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Oral & Dental Health

Oral Candidiasis

Fungal infection of the oral mucous membranes, most commonly caused by Candida albicans, an opportunistic yeast.

Also known as: Oral Thrush, Yeast Infection Mouth

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Referral and warning signs

When to refer

Refer if: Diagnosis uncertain. Poor response to topical therapy. Suspected oesophageal involvement. Recurrent episodes requiring investigation of underlying cause. Need for systemic antifungals.

Red flags

  • Difficulty or pain on swallowing (suggests oesophageal extension).
  • Lesions unresponsive to standard topical treatment.
  • Signs of severe immunosuppression or uncontrolled systemic disease.

Signs and symptoms

  • Pseudomembranous Candidiasis (Classic Thrush): Creamy white, curd-like plaques or patches on tongue, buccal mucosa, palate, or pharynx. Plaques can often be wiped off, leaving a red, raw, or bleeding surface underneath.
  • Erythematous (Atrophic) Candidiasis: Red, raw-looking patches, often on palate (especially under dentures) or dorsal tongue (loss of papillae). May cause burning sensation.
  • Angular Cheilitis: Soreness, redness, and cracking at the corners of the mouth. Often associated with intraoral candidiasis.
  • Hyperplastic Candidiasis (Candida Leukoplakia): Persistent white plaques that cannot be wiped off (less common).
  • Symptoms: May be asymptomatic, or cause soreness, burning sensation, altered taste, difficulty swallowing (if extending to pharynx/oesophagus).

Risk factors

  • Immunosuppression (HIV/AIDS - common OI, Chemotherapy, Long-term steroids).
  • Infancy and old age.
  • Use of broad-spectrum antibiotics (alters oral flora).
  • Use of inhaled corticosteroids (without rinsing mouth after).
  • Poorly controlled Diabetes Mellitus.
  • Xerostomia (dry mouth).
  • Wearing dentures (especially if poor hygiene or worn overnight).
  • Malnutrition / Nutritional deficiencies.
  • Smoking.

Diagnosis

Clinical assessment

Diagnosis usually based on characteristic clinical appearance (white plaques that wipe off, erythematous patches, angular cheilitis). Consider risk factors.

Differential diagnosis

  • Leukoplakia / Erythroplakia (cannot be wiped off, potentially pre-malignant).
  • Lichen Planus (reticular white lines or erosive).
  • Geographic tongue.
  • Traumatic lesions / Burns.
  • Aphthous ulcers.
  • Secondary Syphilis (mucous patches).

Investigations

  • Clinical appearance often sufficient.
  • Smear/Scraping from lesion for microscopic examination (KOH prep): Shows yeast cells and pseudohyphae.
  • Culture (less commonly needed, identifies species).
  • Biopsy (if hyperplastic type or diagnosis uncertain/suspicion of malignancy).
  • Consider investigations for underlying risk factors (HIV test, blood glucose).

Diagnostic criteria

Clinical appearance +/- confirmation by microscopy showing Candida.

Management

Non-pharmacological management

  • Improve oral hygiene.
  • Denture hygiene (remove at night, soak in antiseptic, clean thoroughly).
  • Rinse mouth with water after using inhaled corticosteroids.
  • Address underlying risk factors (control diabetes, manage xerostomia, treat immunosuppression - e.g., start ART for HIV).

Pharmacological treatment

  • Topical Antifungals (First line for mild-moderate oral thrush):
  • - Nystatin Oral Suspension 100,000 IU/mL: 1-2 mL (infants), 4-6 mL (older children/adults) held in mouth/swished for few minutes then swallowed, QID for 7-14 days. (LOC: HC2)
  • - Nystatin Pastilles/Tablets 500,000 - 1,000,000 IU dissolved slowly in mouth QID for 7-14 days (for adults). (LOC: HC2)
  • - Miconazole Oral Gel (applied to affected areas QID).
  • - Clotrimazole Troches (dissolved slowly in mouth).
  • Systemic Antifungals (For severe, refractory, or oropharyngeal/oesophageal candidiasis, or immunocompromised):
  • - Fluconazole PO: Loading dose 200-400mg, then 100-200mg daily for 7-14 days (oral) or 14-21 days (oesophageal). (Child: 6mg/kg load, then 3mg/kg daily). (LOC: HC3+)
  • - Alternatives (Itraconazole, Voriconazole, Amphotericin B) - specialist use.
  • Angular Cheilitis: Treat intraoral Candida + Apply topical antifungal cream (Miconazole, Clotrimazole) +/- mild steroid cream to corners of mouth.

Monitoring

Monitor resolution of lesions and symptoms. Address underlying factors to prevent recurrence.

Complications

  • Discomfort, altered taste, poor feeding.
  • Extension to pharynx/oesophagus (dysphagia, odynophagia).
  • Systemic candidiasis (rare, only in severely immunocompromised).

Prevention

  • Good oral and denture hygiene.
  • Rinsing mouth after inhaled steroid use.
  • Control of diabetes.
  • Prophylactic antifungals in certain high-risk immunocompromised patients (specialist decision).
  • Early initiation of ART in HIV.

Patient education

  • Explanation of thrush as a yeast infection.
  • Importance of oral/denture hygiene.
  • Correct use of antifungal medication (hold suspension in mouth, dissolve lozenges slowly).
  • Need to complete full course.
  • Addressing underlying risk factors (dentures, inhalers, diabetes, HIV).

Uganda-specific notes

Very common opportunistic infection, especially in HIV/AIDS patients (often presents as pseudomembranous or erythematous type). Nystatin suspension widely available. Fluconazole used for more severe/refractory cases or oesophageal involvement. Consider underlying HIV status.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.3.1

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 7 (HIV Care - OIs)

For learning and professional reference. Use current local guidance and clinical judgement.

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