Oral Thrush

Introduction

Oropharyngeal candidiasis (oral thrush) is an opportunity mucosal infection that is unusual in healthy adults; however, it occurs relatively common in neonates.

  • A healthy adults with no risk factors (e.g. diabetes, xerostomia, immunocompromised, inhaled corticosteroids, broad-spectrum antibiotics, ill-fitting dentures) generally requires referral to the doctor.
  • In neonates, spontaneous resolution can occur but can take a few weeks.

NOTE: Any lesion lasting more than 3 weeks must be referred to exclude sinister pathology.



Clinical Features

Oral Thrush

The classic presentation of oral thrush is with creamy white, soft, elevated patches that can be wiped off (although not easy), revealing underlying erythematous mucosa.

  • Lesions can occur anywhere in the oral cavity but usually affect the tongue, palate, lips and cheeks.

Burning or irritation is associated with the infection, rather than true pain.



Management

Miconazole oral gel and nystatin suspension is available OTC to treat oral thrush.

  • Successful treatment relies on adequate contact time between the antifungal and the affected mucosa, so advise patients not to eat or drink directly after administration.
  • Treatment should be continued for 2 further days, after the symptoms have apparently gone, to ensure that all infection is eradicated.
  • In comparative trials, miconazole oral gel appears to have superior cure than the nystatin suspension.
  • Miconazole may be systemically absorbed, so drug interactions are possible (e.g. with warfarin). Topical nystatin has negligible systemic absorption.
  • Nystatin liquid is not preferred because it contains a high concentration of sucrose, which can promote accumulation of plaque on the teeth and dental caries (tooth decay).

Miconazole oral gel

  • The dosage of the miconazole oral gel is 4 times a day in all age groups (licensed for children >4 months of age), although the volume administered varies, depending on the age of the patient.
  • Patients should be advised to hold the gel in the mouth for as long as possible to increase contact time between the medicine and the infection.
  • For denture wearers, application of miconazole gel to the fitting surface of the dentures is recommended at least twice a day. Dentures should be removed from the mouth at night, then cleaned and stored in a dry environment overnight.
Nystatin suspension
  • Shake well before using.
  • Swish in the mouth and retain for as long as possible (several minutes) before swallowing.
  • Patients should avoid taking food or drink earlier than one hour after a dose.
  • In infants, apply one half of dose in each side of mouth. Avoid feeding for 5 to 10 minutes.

NOTE: Nystatin suspension is not indicated for oesophageal candidiasis.

Mucocutaneous Candidiasis Antifungal Treatment



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