What is the treatment for oral thrush?

Treatment for Oral Thrush

For oral thrush, first-line treatment is clotrimazole troches (10 mg) five times daily or miconazole buccal tablets (50 mg) once daily for 7-14 days for mild disease, while moderate to severe cases should be treated with oral fluconazole 100-200 mg daily for 7-14 days. 1

Treatment Algorithm Based on Disease Severity

Mild Oral Thrush

• First-line options:

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

• Alternative options:

  • Nystatin oral suspension: 100,000 units/mL, 4-6 mL 4 times daily for 7-14 days 1, 2
  • Nystatin pastilles: 1-2 pastilles (200,000 units each) 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
  • This regimen has demonstrated superior efficacy and better patient compliance compared to topical agents 3, 4

Fluconazole-Refractory Disease

• First-line options:

  • 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

• Alternative options:

  • Voriconazole: 200 mg twice daily 1
  • Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 1
  • For severe refractory cases: IV echinocandin or IV amphotericin B deoxycholate 1

Special Considerations

Denture-Related Candidiasis

• Disinfection of dentures is essential in addition to antifungal therapy 1
• Remove dentures before performing oral care 1
• Brush dentures with toothpaste and rinse with water 1
• If hospitalized, soak dentures in antimicrobial solution (e.g., 0.2% chlorhexidine) for 10 minutes before reinserting 1

Recurrent Oral Thrush

• For patients with recurrent infections requiring chronic suppressive therapy:
  • Fluconazole: 100 mg three times weekly 1
• For HIV-infected patients:
  • Antiretroviral therapy is strongly recommended to reduce recurrence 1

Supportive Care Measures

• Maintain good oral hygiene 1
• Use a soft toothbrush after meals and before sleep 1
• Rinse with alcohol-free mouthwash 1
• Avoid irritants such as smoking, alcohol, spicy foods, and hot drinks 1
• Apply white soft paraffin to lips regularly 1

Important Clinical Pearls

1. Single-dose fluconazole (150 mg) has shown 96.5% efficacy in palliative care patients with oral thrush, offering a convenient option for patients with difficulty adhering to multiple daily doses 4

2. Diagnostic pitfall: Failure to recognize denture-related candidiasis. Always check for and address denture hygiene issues, as this is a common cause of treatment failure 1

3. Treatment failure considerations:

   • Secondary bacterial or viral (HSV) infection may cause slow healing 1
   • Consider taking oral swabs if secondary infection is suspected 1
   • For persistent cases, evaluate for underlying conditions like undiagnosed HIV or diabetes

4. Fluconazole has demonstrated superior efficacy compared to nystatin in comparative studies, with clinical cure rates of 100% vs 32% in one study 5

5. Topical agents like clotrimazole and nystatin require multiple daily applications, which can lead to poor compliance compared to once-daily oral fluconazole 3

By following this treatment algorithm based on disease severity, most cases of oral thrush can be effectively managed with excellent outcomes in terms of morbidity and quality of life.