Oral Candidiasis (Thrush)

Risk Factors

• Local

  • Dentures (especially if ill-fitting or poor hygiene)

  • Salivary gland hypofunction (dry mouth)

  • Smoking

  • Corticosteroid inhalers (especially without a spacer or mouth rinse)

  • Poor oral hygiene

• Systemic

  • Immunocompromised states (poorly controlled diabetes, HIV/AIDS, chemotherapy, radiotherapy)

  • Broad-spectrum antibiotics or prolonged systemic steroid use

  • Nutritional deficiencies (iron, vitamin B)

  • Recent PPI use or malnutrition

• Neonates

  • Immature immune system

  • Frequent in breastfeeding infants if maternal nipple candidiasis present

Clinical Forms

• Pseudomembranous (Thrush)

  • Creamy white plaques that can be scraped off, revealing erythematous or bleeding mucosa underneath

  • May cause a cottony sensation or taste disturbance

• Erythematous (Atrophic) Candidiasis

  • Diffuse erythema on the tongue or palate, often with depapillation

  • Can cause soreness and burning

• Denture-Associated Stomatitis

  • Erythema under denture surfaces

  • Related to poor denture hygiene or overnight denture use

• Median Rhomboid Glossitis

  • Rhomboid-shaped depapillated erythematous patch on the dorsal tongue

• Angular Cheilitis

  • Cracks or erythema at the corners of the mouth, often with staphylococcal co-infection

Diagnosis

• Usually clinical based on characteristic lesions

• White plaques that scrape off to reveal a raw base

• Differentiate from leukoplakia or lichen planus (non-scrapable)

• Swab for fungal culture or microscopy (KOH prep) if uncertain

• Consider HIV testing or evaluation for immunodeficiency in recurrent or persistent cases

Treatment

• Topical Antifungal Therapies (7–14 days, continue 2–3 days post-resolution)

  • Nystatin Liquid (100,000 units/mL)

    • 1 mL QID after meals, includes sugar so monitor for caries

  • Miconazole Oral Gel (2%)

    • 1.25 mL QID, caution in patients on warfarin (bleeding risk)

    • Rinse mouth and hold gel before swallowing

  • Amphotericin B Lozenges (10 mg)

    • Suck 4 times/day if aged ≥2 years

    • May be unsuitable if dry mouth is significant

• Neonates & Children <2 years

  • Miconazole gel 1.25 mL QID or nystatin oral suspension 1 mL QID post-feeding

• Severe or Refractory Cases

  • Consider systemic antifungal (e.g., fluconazole)

  • Monitor liver function if prolonged fluconazole courses

• Denture Management

  • Clean dentures thoroughly and soak overnight

  • Remove dentures at bedtime

  • Apply topical antifungal to the fitting surface if stomatitis persists

Adjunctive Measures

• Rinse mouth after inhaled corticosteroids

• Optimise glycaemic control in diabetics

• Address nutritional deficiencies (iron, B vitamins)

• Manage dry mouth (artificial saliva, hydration)

• Reduce or stop smoking and limit alcohol intake

• Promptly treat any co-existing bacterial infections in angular cheilitis

Complications

• Recurrent or chronic oral candidiasis if underlying factors remain unaddressed

• Oesophageal candidiasis in immunocompromised individuals, presenting with dysphagia, odynophagia, or retrosternal pain

• Secondary bacterial infection in angular cheilitis

• Risk of candidaemia in severely immunosuppressed patients

Notes:

• Oral candidiasis is unusual in otherwise healthy adults, prompting consideration of immunosuppression or local risk factors

• Continue topical antifungal therapy for at least 2–3 days after clinical resolution to prevent relapse

• Check denture hygiene and overnight removal to avoid persistent denture stomatitis

• Early recognition and treatment can prevent progression to more severe infection, especially in immunocompromised patients