Symptoms of Oral Candida
Oral candidiasis presents in three distinct clinical patterns: pseudomembranous (creamy white, plaque-like lesions that can be scraped off), erythematous (red patches without white plaques on the palate or tongue), and angular cheilitis (inflammation at the corners of the mouth). 1
Primary Clinical Presentations
Pseudomembranous Candidiasis (Classic Thrush)
- Creamy white, plaque-like lesions on the buccal mucosa, oropharyngeal mucosa, or tongue surface that can be readily scraped with a tongue depressor 1
- These lesions are typically painless in early stages 2
- Most recognizable form of oral candidiasis 3
Erythematous Candidiasis
- Red patches without visible white plaques on the anterior or posterior upper palate or diffusely distributed on the tongue 1
- In HIV-infected patients, both erythematous and pseudomembranous forms are predictive of progressive immunodeficiency 1
Angular Cheilitis
- Inflammation and cracking at the corners of the mouth 1, 3
- May occur independently or alongside other oral candidiasis forms 1
Symptoms When Disease Progresses to Esophagus
If oral candidiasis extends to esophageal involvement, additional symptoms emerge:
- Retrosternal burning pain 1
- Altered taste 1
- Odynophagia (painful swallowing) 1
- Endoscopic examination reveals whitish plaques similar to oral lesions that may progress to superficial ulceration of the esophageal mucosa with central or surface whitish exudates 1, 3
Important Clinical Pitfall
Ulceration is NOT a primary feature of oral candidiasis itself - if ulcers are present without characteristic white plaques or red patches, consider alternative diagnoses and obtain a biopsy to exclude other etiologies 3. Ulceration only develops when the infection progresses from the oropharynx to the esophagus 3.
Systemic Impact in Immunocompromised Patients
- Relapse of oral and esophageal candidiasis is common and often associated with recurrence of intense pain that contributes to weight loss due to poor nutrition 1
- In patients with advanced immunosuppression (CD4 counts <50 cells/μL), episodes may be more severe and more frequently recurrent 4
Risk Factors to Assess
When evaluating a patient with suspected oral candidiasis, identify these predisposing conditions:
- HIV/AIDS with low CD4 counts (particularly <50 cells/μL) 4
- Diabetes mellitus 2, 5
- Denture use (denture-related candidiasis) 6
- Inhaled or systemic corticosteroid use 6
- Broad-spectrum antibiotic use 6
- Hematologic malignancies 6, 2
Diagnostic Approach
- Diagnosis is usually made on clinical grounds based on the characteristic appearance of lesions 1
- For first episodes with typical presentation, empiric treatment is appropriate 1
- Culture with species identification and susceptibility testing is recommended for recurrent cases or patients repeatedly exposed to fluconazole 1, 4
- Fungal selective media should be used to avoid bacterial overgrowth 1