Oral candidiasis

Oral candidiasis is a fungal infection of the oral mucosa mainly caused by Candida albicans.It occurs when normal oral flora balance and host immunity are disrupted, allowing Candida to overgrow and invade mucosal surfaces.

It is common in:

• Infants

• Elderly

• Immunocompromised patients

• People using antibiotics or inhaled steroids

Predisposing Factors

• HIV/AIDS

• Diabetes mellitus

• Pregnancy

• Prolonged antibiotic therapy

• Corticosteroid use (especially inhaled steroids)

• Chemotherapy / immunosuppressive therapy

• Denture use (especially poorly fitted dentures)

• Malnutrition

• Xerostomia (dry mouth)

• Neonates (immature immunity)

Pathophysiology

Candida normally exists in the mouth as a commensal organism.

When immunity declines or oral flora changes:

1. Candida multiplies rapidly

2. Converts from yeast → hyphal invasive form

3. Invades epithelium

4. Causes inflammation and pseudomembrane formation

The white plaques consist of:

• Fungal hyphae

• Desquamated epithelial cells

• Keratin

• Debris

Removing plaques leaves a bleeding erythematous base.

Clinical Presentation

A. Classical Pseudomembranous Thrush

• White, creamy plaques on:

  • Tongue

  • Buccal mucosa

  • Palate

  • Oropharynx

• Plaques easily scraped off

• Leaves red bleeding surface

• Burning mouth sensation

• Bad taste (dysgeusia)

• Feeding difficulty in infants

B. Erythematous (Atrophic) Candidiasis

• Red shiny mucosa

• Painful tongue

• Burning sensation

• Common in denture wearers

C. Angular Cheilitis

• Cracks at mouth corners

• Painful fissures

• Secondary bacterial infection common

D. Severe Disease (Immunocompromised)

• Dysphagia

• Odynophagia

• Suggests esophageal candidiasis

Diagnostic Criteria

Diagnosis is mainly clinical.

Typical Findings

• White removable plaques

• Erythematous mucosa underneath

• Burning sensation

• Risk factors present

Investigations

Differential Diagnosis

• Leukoplakia (cannot be scraped off)

• Oral lichen planus

• Aphthous ulcers

• Chemical burns

• Oral hairy leukoplakia

• Diphtheria membrane (rare)

Treatment

A. Non-Pharmacological Treatment

• Maintain oral hygiene

• Clean tongue daily

• Remove dentures at night

• Disinfect dentures (chlorhexidine/boiling water where safe)

• Rinse mouth after inhaled steroid use

• Reduce sugar intake

• Treat underlying disease (HIV, diabetes)

B. Pharmacological Treatment

First-Line Therapy

Nystatin oral suspension — gurgle and swallow 4 times daily

Dosage:

• Newborns: 200,000–400,000 units/day

• <2 years: 400,000–1,000,000 units/day

• 2 years & adults: 1,000,000–2,000,000 units/day

Continue for 7–14 days and at least 48 hours after symptoms resolve.

Alternative Therapy

Miconazole 2% oral gelApply every 8 hours for 7 days

Severe / Recurrent Disease

Fluconazole oral therapy (systemic) may be required especially in:

• HIV

• Cancer

• Esophageal involvement

Special Populations

Infants

• Treat both baby and breastfeeding mother

• Sterilize feeding bottles and pacifiers

Denture Wearers

• Remove dentures at night

• Apply antifungal gel to denture surface

HIV Patients

• Often recurrent

• May require prolonged or prophylactic therapy

Complications

• Esophageal candidiasis

• Feeding difficulty in infants

• Malnutrition

• Chronic pain

• Systemic candidiasis (rare but serious)

Prevention

• Good oral hygiene

• Control diabetes

• Rinse mouth after steroid inhaler use

• Avoid unnecessary antibiotics

• Proper denture hygiene

• Sterilize infant feeding equipment

• Nutritional support in elderly

Prognosis

• Excellent in immunocompetent patients

• Recurrent in HIV/diabetes

• Rapid response within 3–5 days of therapy