What is the treatment for oral thrush?

Treatment of Oral Thrush

For oral thrush (oral candidiasis), first-line treatment is oral fluconazole 100-200 mg daily for 7-14 days for moderate to severe cases, or topical antifungal agents such as clotrimazole troches or miconazole buccal tablets for mild cases. 1

Treatment Algorithm Based on Severity

Mild Oral Thrush

• First-line options:

  • Clotrimazole troches: 10 mg 5 times daily for 7-14 days 1
  • Miconazole mucoadhesive buccal 50-mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1

• Alternative options:

  • Nystatin suspension (100,000 U/mL): 4-6 mL 4 times daily for 7-14 days 1, 2
  • Nystatin pastilles (200,000 U each): 1-2 pastilles 4 times daily for 7-14 days 1

Moderate to Severe Oral Thrush

• First-line treatment:

  • Oral fluconazole: 100-200 mg daily for 7-14 days 1

• For fluconazole-refractory disease:

  • Itraconazole solution: 200 mg once daily for up to 28 days 1
  • Posaconazole suspension: 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 1
  • Voriconazole: 200 mg twice daily 1
  • Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 1

For Severe Refractory Cases

• Intravenous echinocandin (caspofungin, micafungin, or anidulafungin) 1
• Intravenous amphotericin B deoxycholate: 0.3 mg/kg daily 1

Special Populations

HIV-Infected Patients

• Same treatment regimens as above
• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• For recurrent infections, fluconazole 100 mg three times weekly can be used as suppressive therapy 1

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy 1
• Remove dentures before performing oral care 1
• Soak dentures in antimicrobial solution (e.g., chlorhexidine 0.2%) for 10 minutes before reinsertion 1

Supportive Measures

• Maintain good oral hygiene with soft toothbrush 1
• Use alcohol-free mouthwash 1
• Avoid irritants such as smoking, alcohol, spicy foods, and hot drinks 1
• Ensure adequate hydration to keep mouth moist 1

Treatment Efficacy and Monitoring

• Most patients show improvement within 48-72 hours of starting treatment 1
• Clinical cure rates are significantly higher with fluconazole (100%) compared to nystatin (32%) 3
• Single-dose fluconazole 150 mg has shown 96.5% improvement in palliative care patients 4

Common Pitfalls and Caveats

1. Failure to identify underlying causes: Persistent oral thrush may indicate underlying conditions such as undiagnosed HIV, diabetes, or immunosuppression 5

2. Inadequate denture care: Failure to properly disinfect dentures can lead to treatment failure and recurrence 1

3. Liver function monitoring: For prolonged azole therapy (>21 days), periodic monitoring of liver function tests is recommended 1

4. Resistance development: Long-term prophylactic use of azoles may lead to resistant Candida strains; therefore, chronic suppressive therapy is usually unnecessary unless recurrences are frequent 1

5. Misdiagnosis: If no improvement occurs after 4 weeks of treatment, the diagnosis should be reviewed 6

Oral thrush is typically caused by Candida albicans and affects the mucous membranes of the oral cavity, including the tongue, palate, cheeks, and lips 7. With appropriate treatment following the above algorithm, most cases resolve completely with minimal risk of complications.