What is the recommended rinse and spit treatment for oral thrush?

Recommended Rinse and Spit Treatment for Oral Thrush

For oral thrush treatment, the recommended rinse and spit regimen is nystatin oral suspension (100,000 U/mL) 4-6 mL four times daily for 7-14 days. 1

First-Line Treatment Options

Topical Antifungal Rinses (Mild Disease)

• Nystatin suspension (100,000 U/mL): 4-6 mL swished in mouth for approximately 1 minute and then spit out, 4 times daily for 7-14 days 2, 1, 3
• Administration technique: Vigorously swish the solution around the mouth, ensuring contact with all affected areas before spitting out
• Timing: After meals and before bedtime to maximize contact time with oral tissues

Alternative Topical Options (Mild Disease)

• Clotrimazole troches: 10 mg 5 times daily for 7-14 days 2, 1
• Miconazole mucoadhesive buccal tablet: 50 mg applied to the mucosal surface over the canine fossa once daily for 7-14 days 2, 1
• Nystatin pastilles: 1-2 pastilles (200,000 U each) 4 times daily for 7-14 days 2, 1

Systemic Options (Moderate to Severe Disease)

• Oral fluconazole: 100-200 mg daily for 7-14 days 2, 1
  • Particularly effective with 96.5% of patients showing >50% improvement in a palliative care population 4
  • Single-dose fluconazole 150 mg has shown effectiveness in hospice patients 4

For Fluconazole-Refractory Disease

• Itraconazole oral solution: 200 mg once daily for up to 28 days 2, 1, 5
  • Should be vigorously swished in the mouth (10 mL at a time) for several seconds and then swallowed 5
• Posaconazole suspension: 400 mg twice daily for 3 days then 400 mg daily for up to 28 days 2, 1
• Voriconazole: 200 mg twice daily 2, 1
• Amphotericin B deoxycholate oral suspension: 100 mg/mL 4 times daily 2, 1

Treatment Algorithm Based on Severity and Response

1. For initial mild oral thrush:

   • Start with nystatin suspension 4-6 mL 4 times daily for 7-14 days
   • If not tolerated, switch to clotrimazole troches or miconazole buccal tablet

2. For moderate to severe disease or if topical therapy fails:

   • Switch to oral fluconazole 100-200 mg daily for 7-14 days

3. For fluconazole-refractory disease:

   • Try itraconazole solution 200 mg daily (swish and swallow)
   • Alternative: posaconazole suspension or voriconazole

4. For severe refractory cases:

   • Consider intravenous echinocandins or amphotericin B 2, 1

Special Considerations

For Denture Wearers

• Remove dentures before performing oral care 2
• Brush dentures with toothpaste and rinse with water 2
• Soak dentures for 10 minutes in antimicrobial solution (e.g., chlorhexidine 0.2% if available) 2
• Disinfection of dentures is essential in addition to antifungal therapy 2

For Recurrent Infections

• For patients requiring chronic suppressive therapy: fluconazole 100 mg three times weekly 2, 1
• For HIV-infected patients: antiretroviral therapy is strongly recommended 2, 1

For Non-albicans Candida Species

• C. glabrata infections may require alternative treatments as they often don't respond to azoles 2
• Boric acid in gelatin capsules may be considered for resistant cases 2

Supportive Measures During Treatment

• Rinse mouth with an alcohol-free mouthwash upon awakening and at least four times daily after brushing 2
• Avoid potential irritants: smoking, alcohol, spicy foods, citrus fruits, hot drinks 2
• Maintain adequate hydration to keep the mouth moist 2
• Use a soft toothbrush for oral hygiene 2
• Inspect oral mucosa daily for improvement or worsening 2

Monitoring and Follow-up

• Continue treatment for at least 48 hours after symptom resolution 1
• Schedule follow-up within 7-10 days to assess response to treatment 1
• Monitor for hepatotoxicity if treatment with azoles extends beyond 7-10 days 1

Fluconazole rinse-and-spit (2 mg/mL solution used 3 times daily) has shown 94% clinical relief in one study 6, but this formulation is not standard and would need to be compounded, making nystatin suspension the more practical and widely available first-line rinse-and-spit option.