What are the symptoms and treatment options for oral candidiasis?

Symptoms of Oral Candidiasis

The primary symptoms of oral candidiasis include white or red patches on oral mucosa, burning sensation in the mouth, altered taste sensation, and difficulty eating or swallowing, which can significantly reduce quality of life and oral intake if left untreated. 1

Clinical Presentation

Oral candidiasis manifests with several characteristic signs and symptoms:

• White patches/plaques: Creamy white, curd-like lesions on the tongue, inner cheeks, and other oral surfaces that can be scraped off (pseudomembranous candidiasis)
• Red patches: Erythematous areas with loss of filiform papillae (erythematous candidiasis)
• Burning sensation: Particularly when eating spicy or acidic foods
• Altered taste: Dysgeusia or unpleasant taste in the mouth
• Discomfort: Pain or soreness in the mouth
• Difficulty swallowing: Dysphagia, particularly when esophageal involvement occurs
• Angular cheilitis: Cracking and redness at the corners of the mouth

Risk Factors

Several conditions predispose individuals to oral candidiasis:

• Immunosuppression: HIV/AIDS, chemotherapy, organ transplantation 2
• Medications: Antibiotics, corticosteroids, immunosuppressants 1
• Denture use: Especially ill-fitting dentures or poor denture hygiene 1
• Diabetes mellitus: Particularly uncontrolled diabetes 1
• Age extremes: Infants and elderly individuals 1
• Decreased salivation: Xerostomia from medications or Sjögren's syndrome 3
• Smoking: Alters oral microbiome 3

Types of Oral Candidiasis

1. Pseudomembranous candidiasis (thrush): White, curd-like plaques that can be scraped off
2. Erythematous candidiasis: Red patches, commonly on palate or tongue
3. Hyperplastic candidiasis: White lesions that cannot be scraped off
4. Angular cheilitis: Inflammation at corners of mouth
5. Denture stomatitis: Erythema of palatal mucosa under dentures

Treatment Approach

First-Line Treatment Options

For mild to moderate uncomplicated oral candidiasis:

• Topical antifungals (7-14 days) 2:

  • Clotrimazole troches (10 mg, 5 times daily)
  • Nystatin suspension (100,000 U/mL, 4-6 mL four times daily)
  • Nystatin pastilles (200,000 U, 1-2 pastilles 4-5 times daily)

• Oral azoles (7-14 days) 2:

  • Fluconazole (100 mg daily) - most effective systemic option with excellent bioavailability

For Moderate to Severe or Refractory Cases

• Fluconazole (200-400 mg daily for 14-21 days) 2
• Itraconazole oral solution (200 mg daily for 7-14 days) 2, 4
• Posaconazole suspension (400 mg twice daily) 2
• Voriconazole (200 mg twice daily) 2

For Fluconazole-Resistant Cases

• Itraconazole solution (200 mg daily) 2, 4
• Echinocandins (for severe cases): caspofungin, micafungin, or anidulafungin 2
• Amphotericin B (intravenous, 0.3-0.7 mg/kg daily) - reserved for severe refractory cases 2

Special Considerations

Denture-Related Candidiasis

• Remove and disinfect dentures daily
• Leave dentures out overnight
• Consider denture replacement if ill-fitting 1
• Apply antifungal cream to denture-bearing areas

HIV-Associated Oral Candidiasis

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 2
• For recurrent episodes, chronic suppressive therapy with fluconazole (100-200 mg three times weekly) may be necessary 2

Common Pitfalls to Avoid

• Inadequate treatment duration: Continuing treatment for 7-14 days even if symptoms resolve earlier
• Neglecting underlying factors: Failing to address immunosuppression, diabetes control, or denture issues
• Missing resistant strains: Consider resistance if no improvement after 7-14 days of appropriate therapy
• Relying solely on oral hygiene: Antifungal medication is required; oral hygiene alone is insufficient 1

Monitoring and Follow-up

• Improvement typically occurs within 48-72 hours of starting appropriate therapy 2
• If no improvement after 7-14 days, consider:
  • Medication non-adherence
  • Resistant Candida species
  • Alternative diagnosis
  • Need for systemic rather than topical therapy

Maintaining good oral hygiene and addressing underlying risk factors are essential for preventing recurrence and ensuring successful treatment outcomes.