What is the recommended treatment approach for a patient presenting with oral thrust?

Oral Thrush Treatment

For oral thrush (oropharyngeal candidiasis), start with clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days for mild disease, or oral fluconazole 100-200 mg daily for 7-14 days for moderate to severe cases. 1

First-Line Pharmacologic Treatment

Mild Disease (Topical Therapy)

• Clotrimazole troches 10 mg dissolved slowly in the mouth 5 times daily for 7-14 days is the preferred topical agent 1
• Alternative topical options include:
  • Miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7-14 days 1
  • Nystatin suspension (100,000 U/mL) 4-6 mL swished and swallowed 4 times daily for 7-14 days 1
  • Nystatin pastilles (200,000 U each) 4 times daily for 7-14 days 1

Moderate to Severe Disease (Systemic Therapy)

• Oral fluconazole 100-200 mg daily for 7-14 days is the recommended systemic treatment 1
• This should be used when topical therapy fails or when disease severity warrants immediate systemic treatment 1

Refractory or Resistant Disease

When fluconazole fails or resistance is suspected:

• Itraconazole solution 200 mg once daily as first alternative 1
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
• Voriconazole 200 mg twice daily or amphotericin B deoxycholate oral suspension 100 mg/mL 4 times daily for additional alternatives 1

Severe Refractory Cases Requiring Hospitalization

• Intravenous echinocandin therapy: caspofungin (70 mg loading dose then 50 mg daily), micafungin (100 mg daily), or anidulafungin (200 mg loading dose then 100 mg daily) 1
• Intravenous amphotericin B deoxycholate 0.3 mg/kg daily as alternative 1

Essential Supportive Oral Care

Daily Oral Hygiene During Treatment

• Rinse mouth with non-medicated saline solution 4-6 times daily to maintain oral hygiene and reduce bacterial load 1
• Use a soft toothbrush or foam swab and brush gently twice daily 2
• Brush after meals and before bedtime using gentle circular motions 2
• Use mild, fluoride-containing, non-foaming toothpaste to minimize irritation 2

Critical Avoidances

• Avoid all alcohol-based mouthwashes as they cause additional pain and mucosal irritation 1
• Avoid tobacco, spicy foods, acidic foods (tomatoes, citrus), hot beverages, and crusty/abrasive foods 3

Hydration and Lip Care

• Drink ample fluids throughout the day to keep the mouth moist 3
• Apply lip balm or petroleum jelly to lips to prevent cracking, but avoid chronic petroleum jelly use as it promotes mucosal dehydration 3

Special Considerations

Denture-Related Candidiasis

• Disinfect dentures in addition to antifungal therapy 1
• Remove dentures before performing oral care 3
• Soak dentures for 10 minutes in chlorhexidine 0.2% solution before reinsertion 3
• Defer wearing dental prostheses as much as possible until oral tissues are healed 3

Recurrent Thrush

• Chronic suppressive therapy with fluconazole 100 mg three times weekly for patients with recurrent infections 1
• For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrence 1

Common Pitfalls to Avoid

• Do not use interdental floss or brushes during acute infection if not previously using them regularly, as these can break the epithelial barrier and cause bleeding in inflamed tissues 2
• Do not assume treatment failure before completing the full 7-14 day course 1
• Do not continue topical therapy alone when moderate to severe disease is present—escalate to systemic fluconazole 1
• Do not overlook denture disinfection in denture wearers, as this is a common source of treatment failure 1

Monitoring and Follow-Up

• Inspect oral mucosa daily for changes, worsening inflammation, or signs of secondary infection 2
• If symptoms persist beyond 14 days of appropriate therapy, consider fluconazole resistance and escalate to second-line agents 1
• Evaluate for underlying immunosuppression (HIV, diabetes, corticosteroid use, chemotherapy) if thrush is recurrent 1