Symptoms and Treatment of Oral Thrush
Oral thrush (oropharyngeal candidiasis) presents with characteristic white plaque-like lesions on oral mucosa, often accompanied by pain, altered taste, and difficulty eating or swallowing. Treatment typically involves antifungal medications, with fluconazole being highly effective for most cases 1.
Clinical Manifestations
Three main clinical patterns of oral thrush have been identified:
- Pseudomembranous candidiasis: Characterized by creamy white, plaque-like lesions on the buccal or oropharyngeal mucosa or tongue surface that can be scraped off, leaving an erythematous base 1
- Erythematous candidiasis: Presents as erythematous patches without white plaques, visible on the anterior or posterior upper palate or diffusely on the tongue 1
- Angular cheilitis: Inflammation and cracking at the corners of the mouth 1
Common symptoms include:
- Pain and burning sensation in the mouth 1
- Altered taste sensation 1
- Difficulty eating and swallowing 2
- White patches that may bleed when scraped 1
- In severe cases, weight loss due to poor nutrition 1
Diagnosis
Diagnosis is typically made clinically based on the characteristic appearance of lesions 1. In cases where the diagnosis is uncertain:
- Visual examination of the oral cavity is usually sufficient 1
- Scraping of lesions for microscopic examination or culture may be performed in refractory cases 1
- Response to antifungal therapy can be diagnostic in some cases 1
Treatment Recommendations
First-line Treatment
- Fluconazole 200-400 mg (3-6 mg/kg) daily for 7-14 days is recommended as first-line therapy for most cases of oral thrush 1
- For mild cases or when systemic therapy is contraindicated, topical options include:
For Refractory Cases
- Itraconazole oral solution 200 mg daily for patients with fluconazole-refractory disease (64-80% response rate) 1, 3
- Posaconazole suspension for patients not responding to fluconazole (approximately 75% efficacy in refractory cases) 1
- Voriconazole for fluconazole-refractory infections 1
- For highly resistant cases, intravenous echinocandins (caspofungin, micafungin, or anidulafungin) or amphotericin B deoxycholate may be necessary 1
Special Populations
- For HIV-infected patients: Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
- For denture-related candidiasis: Disinfection of dentures in addition to antifungal therapy is essential 1
- For infants: Fluconazole suspension 3 mg/kg daily for 7 days has shown superior efficacy (100% cure rate) compared to nystatin suspension (32% cure rate) 4
- For palliative care patients: A single dose of fluconazole 150 mg has shown 96.5% improvement in symptoms, reducing pill burden 2
Prevention of Recurrence
- For patients with frequent recurrences, fluconazole 100 mg three times weekly is recommended as suppressive therapy 1
- For HIV-infected patients with recurrent oral thrush, effective antiretroviral therapy is the best prophylaxis 1
- For denture wearers, proper denture hygiene and removal at night is important 1
Common Pitfalls and Caveats
- Failure to identify and address underlying predisposing factors (HIV, diabetes, steroid use, antibiotics) may lead to treatment failure 1
- Prolonged or repeated courses of fluconazole can lead to development of resistance, particularly in immunocompromised patients 1
- Non-albicans Candida species (particularly C. glabrata and C. krusei) may emerge with intrinsic reduced azole susceptibility after repeated antifungal exposure 1
- Persistent or recurrent oral thrush despite appropriate therapy should prompt evaluation for underlying immunodeficiency or systemic disease 5
- Esophageal involvement should be suspected in patients with oral thrush who report odynophagia, retrosternal pain, or difficulty swallowing 1