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Candidal infection (Oral thrush)

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Brief description of the condition

Acute and chronic infection of the oral cavity caused by Candida species (most commonly C. albicans). Several patient groups are predisposed to candidal infection (pseudomembranous candidiasis and erythematous candidiasis infections). These include patients taking certain drugs, (including inhaled corticosteroids, cytotoxic drugs, broad-spectrum antibacterials, DMARDs [Disease-Modifying Anti-Rheumatic Drugs] or biologic medications [see Adverse drug reactions and oral side effects]); people who smoke or wear dentures; patients with diabetes; patients with nutritional deficiencies; or patients with serious systemic disease associated with reduced immunity (such as leukaemia, other malignancies and AIDS).

Key signs and symptoms

  • Pain, burning or itching sensation
  • Altered taste
  • Abnormal appearance:
    • Pseudomembranous candidiasis: White patches on the oral mucosa which become confluent plaques resembling milk curds. The plaques can be removed to reveal a raw erythematous base which may be painful and bleed.
    • Erythematous candidiasis: Red patches on the oral mucosa. Typically involves the dorsal surface of the tongue where it manifests as depapillated smooth areas.

Initial management

If there is evidence of systemic illness or widespread infection, advise the patient to seek emergency medical care, via NHS24/111.51

Otherwise:

If a patient is using a corticosteroid inhaler, in the first instance, advise them to rinse their mouth with water or brush their teeth immediately after using the inhaler. Confirm good inhaler technique and consider the use of a spacer.51

If the patient wears dentures, advise them to leave the dentures out for at least 6 hours in each 24-hour period to promote healing, and to clean the dentures in a disinfectant solution such as chlorhexidine.51

For mild and localised infections, prescribe a topical antifungal agent (see SDCEP Drug Prescribing for Dentistry guidance).51

For extensive or severe infection, consider prescribing oral fluconazole (see SDCEP Drug Prescribing for Dentistry guidance).51

  • Note that fluconazole interacts with many drugs (see BNF for information on drug interactions).

Advise the patient to seek non-urgent dental care.

Subsequent care

Monitor symptoms at follow-up appointments.

If the patient does not respond to appropriate local measures and a course of drug treatment, or there is no identifiable cause, refer the patient to their general medical practitioner or to a dental specialist for further investigation.

Fungal infections in immunocompromised patients with serious systemic disease require assessment by the patient’s general medical practitioner.