Oral Thrush

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Introduction

  • A clinical infection of mucous membranes due to the fungus species Candida
  • Candida albicans is the most frequently isolated strain

Classification

  • Acute oral candidosis
  • Chronic oral candidosis
  • Denture association candidosis/denture stomatitis

Pathogenesis/aetiology

  • Immunosuppression results in the Candida albicans (a normal oral commensal) becoming virulent
  • It invades and proliferates in superficial epithelium
  • Results in a thick plaque which is oedematous and not easily rubbed off

Clinical features

  • A creamy/whitish, soft and friable slough located on the soft tissues of the oral cavity: tongue, palate, cheek, pharynx
  • May be asymptomatic, or painful, with difficulty in swallowing

Predisposing factors

  • Denture wearing
  • Reduced salivation (e.g. drug induced)
  • Antibiotic therapy (especially broad spectrum)
  • Poorly controlled diabetes mellitus
  • Steroid therapy (chronic)
  • Salivary gland damage (e.g. post radiation)
  • Malnutrition
  • HIV infection
  • Leukaemia
  • Iron, vitamin B, folic acid deficiency and Agranulocytosis

Investigations

  • Smear of the affected region and Gram staining or PAS with or without potassium hydroxide to demonstrate hyphae
  • Swab sample for microscopy, culture and sensitivity
  • Biopsy and histopathologic examination
  • Identify predisposing factors (including immunosuppression)
  • Define extent of involvement

Non-drug treatment

  • Manage any underlying predisposing factors
  • Replace worn dentures
  • Proper counselling of patients as to use of dentures
  • Diet modification and improvement
  • Chlorhexidine mouthwash three times daily for 1 – 2 weeks

Drug treatment

  • Topical anti-fungal medication
    • Nystatin suspension
    • Adult: 400,000 - 600,000 units/mL 4 times daily, after food (usually for 7 days); Continue for 48 hours after lesions have resolved
    • Child: 1 month - 18 years, prophylaxis and treatment: 100,000 units 6 hourly after food for 7 days; Continue for 48 hours after lesions have healed
    • Immunocompromised children: 500,000 units 6 hourly for 7 days

Or:

  • Miconazole oral gel 2%
  • Adult: place 5 - 10 mL in the mouth after food and retain near lesions 4 times daily
  • Child:
    • under 2 years: 5 mL twice daily; 2 - 6 years: 5 mL twice daily
    • 6 - 12 years: 5 mL four times daily;
    • 12 - 18 years: 5-10 mL four times daily

Leave in the mouth after food and retain near lesions

  • Some patients may require systemic antimicrobial medicines
    • Fluconazole
  • Adult: 50 mg orally daily for 7 - 14 days
  • Child:
    • 3 - 6 mg/kg on the first day, then 3 mg/kg daily for 7 - 14 days
    • For neonates up to 2 weeks old: administer every 72 hours for 7 - 14 days
    • 2 - 4 weeks old: administer every 48 hours for 7-14 days