Treatment of Oral Candidiasis

Treatment of Oral Candidiasis

Nelson L. Rhodus, D.M.D., M.P.H., F.IC.D.*:
 
Oral candidiasis (thrush) is a common problem encountered in dental patients. The severity of the infection is highly variable from patient to patient and even in the same patient over time. Effective treatment, on-going management, and maintenance therapy are often elusive and frustrating for dentist and patient alike. 
 
There are many contributing causes for oral candidiasis, which is caused by an infection (or overabundance of Candida albicans or other Candida species) as well as many reasons why  oral candidiasis may recur or only partially resolve with treatment. Among these are: decreased salivary flow (and changes in salivary composition), immunosuppression (both  systemically and/or locally within the oral cavity), and gastrointestinal problems. Although there are several effective treatments for oral candidiasis, often the choice as to which  agents to use is a difficult and confusing one for the dentist. Another consideration is recurrence, which is also common as long as etiological factors persist. So effective treatment  may only be achieved by treating the underlying etiology (i.e., stimulating salivary flow). 
 
The purpose of this article is to review the etiologies, clinical presentation, and treatment strategies for oral candidiasis. 
 
Signs and Symptoms
• oral tissue burning
• bad (metallic-acidic) taste
• white film on oral mucosa 
 
Clinical Appearance 
Erythematous candidiasis (atrophic):
• Looks red and “raw”
• Most common — 60 % of cases
 
Pseudomembraneous candidiasis:
• White plaques
• 35 % of cases 
 
Hyperplastic white plaques:
• Looks like leukoplakia
• Five percent of cases
 
Treatment
Treatment has several approaches and contingencies.
 
Level 1: For a mild oral-only infection with few underlying contributing factors:
• Clotrimazole troches, 100 mg; dissolve 1 troche tid for 7 days, or
• Nystatin rinse, 100,000 IU/5cc; 100cc; 5 cc tid for 7 days, or
• Mycostatin cream (ointment); apply tid for 7 days, or
• Mycolog II ointment; apply tid for 7 days. (This contains triamcinolone acenatate, which can help inflammation as well.)
 
Level 2: For more severe clinical manifestations having more systemic disease contributors and which have failed previous Level 1 treatment:
• A combination of two of the above — i.e., clotrimazole troches, 100 mg; dissolve 1 troche tid for 7 days ± Nystatin rinse, 100,000 IU/5cc; 100cc; 5 cc tid for 7 days.
 
Level 3: For much more severe clinical manifestations with many more systemic disease contributors and which have failed previous Level 1 or 2 treatment:
• Diflucan (fluconazole) 100 mg qd for one, two, three, or four days or
• Ketoconazole 400 mg qd for one, two, three, or four days 
 
Level 4: For very severe clinical manifestations:
• A combination of Levels 2 and 3 treatment
 
Conclusion
In all cases, as long as the patient continues to have a contributing condition (xerostomia, diabetes, etc.), he or she will continue to be susceptible to recurrences and exacerbations  of oral candidiasis.  Therefore, the following recommendations should apply for maintenance therapy:
• Regular professional care and follow-up
• Treat the underlying contributing conditions (i.e., xerostomia)
• Use a magic mouthwash with diphenhydramine, nystatin, and Maalox, frequently for maintenance
• Use chlorhexidine gluconate rinses or maintenance (also a good way to clean dentures)
 
If a patient continues to be immunosuppressed or have xerostomia, he or she will have recurrences of oral candidiasis. 
 
 
*Dr. Rhodus is professor and Director, Division of Oral Medicine, School of Dentistry, and adjunct professor, Department of Otolarygnology, School of Medicine, University of Minnesota, Minneapolis, MN 55455. Email is rhodu001@umn.edu.

A patient with pseudomembranous candidiasis beneath a denture. This patient was one year post-renal transplant.