Oral Candidiasis

Background

• Oral candidiasis, also called thrush, is the most common fungal infection in humans.
• Risk factors associated with thrush include immunocompromise, particularly HIV infection, corticosteroid use, antibiotic use, nutritional deficiencies, denture use, and extremes of age.
• Oral candidiasis most often presents as thrush (acute pseudomembranous candidiasis).
• Signs and symptoms associated with thrush include oral discomfort and the development of whitish plaques on the tongue or oral mucosa.
• Less common presentations of oral candidiasis include erythematous forms (acute or chronic atrophic candidiasis), angular cheilitis (perlèche), and chronic hyperplastic candidiasis.

Evaluation

• Diagnosis is typically made based on compatible clinical features.
• Findings characteristic of thrush include:
  • whitish plaques on the tongue or oropharyngeal mucosa
  • lesions that easily bleed and can be scraped away with a tongue depressor
• When needed, clinical diagnosis can be confirmed by:
  • potassium hydroxide (KOH) or methylene blue stain of swab or scraping from affected area
  • periodic acid-Schiff staining of cytology smear
  • fungal culture of swab, scraping, or oral rinse
• Consider susceptibility testing for recurrent or refractory disease.
• Biopsy may be needed for atypical or difficult to diagnose cases.

Management

• Consider topical agents for patients with mild disease (Weak recommendation):
  • clotrimazole 10 mg troches 5 times daily
  • nystatin suspension (100,000 units/mL) 4-6 mL orally 4 times daily (with half dose placed in each side of the mouth, swish and swallow)
• Systemic therapy is recommended for all moderate and severe cases.
  • Fluconazole 100-200 mg orally once daily is the first-line therapy (Strong recommendation).
  • For fluconazole-refractory disease, consider:
    • itraconazole 200 mg orally once daily
    • voriconazole 200 mg twice daily
    • posaconazole 400 mg/day orally
• The recommended duration of therapy is 7-14 days (Strong recommendation).
• Encourage oral hygiene such as toothbrushing, routine dentistry, and denture care.
• Consider advising patients to wash dentures in an antiseptic such as chlorhexidine.