Oral Thrush Causes, Symptoms and Treatment

Authored By: Allison DiMatteo Reviewed By: Mahnaz Fatahzadeh, DMD Oral thrush or oral pseudomembranous candidiasis is a fungal infection of the mouth common among denture wearers, infants and people with weakened immune systems. The most common human fungal infection, oral thrush presents as slightly raised removable plaques (resembling cottage cheese) on the tongue or inner cheek. Thrush can also affect the roof of the mouth, gums, tonsils or back of the throat. There are three other forms of oral candidiasis infections:

Erythematous candidiasis appears as red patches on the roof of the mouth and tongue. Hyperplastic (chronic) candidiasis resembles the more common type, but cannot be scraped off. Angular cheilitis looks like red sores that develop in the corners of the mouth.

Causes of Oral Thrush

Teeth Grinding How much is bruxing costing you?

Oral thrush is caused primarily when there is an overgrowth of Candida albicans, a yeast normally present in the mouth in small quantities and kept in balance by helpful bacteria in the body. Less frequently, oral thrush may also be caused by an overgrowth/infection of the Candida glabrata or Candida tropicalis yeasts, which also are present in the mouth. Dry mouth, high blood and salivary sugar levels (diabetes), and prolonged use of certain antibiotics or corticosteroid therapy (asthma inhalers) can upset the body's natural balance of friendly bacteria that would otherwise fight off a yeast infection. This allows overgrowth of Candida and leads to oral thrush.

Oral Thrush Symptoms

There are several symptoms associated with the development of the fungal infection. In addition to having a white, yellow or cream-colored curd-like appearance, oral thrush can cause a burning sensation in the mouth, soreness and/or sensitivity to acidic and spicy foods, an unpleasant taste in the mouth and bad breath (halitosis). Scraping the white lesions from the soft tissues (mucosa) of the mouth may cause bleeding and a painful sensation, revealing red and inflamed surfaces underneath. Candidal infections can lead to a diaper rash in infants that does not heal with the use of ointments (yeast passes through the baby's stool), in addition to a rash in the infant's mouth.

Mothers and their infected infants can pass oral thrush back and forth. For a breastfeeding mother, Candidal infection could result in burning, painful nipples. Candidal infections can also cause vaginal yeast infections in women. Candidiasis is not limited to the mouth and, if left untreated, can spread to other parts of the body (throat, vagina, skin). Although rare, oral thrush can spread to other organs of the body, but this is usually limited to immunocompromised individuals. Your dentist can diagnose oral thrush by examining your mouth and brushing the lesions away. If necessary, microscopic testing can be used for confirmation.

Oral Thrush Considerations and Risk Factors

A number of factors can put an individual at higher risk for an oral thrush or candidiasis infection. Women who are pregnant, women taking birth control pills and those who experience persistent dry mouth (caused by systemic conditions or medications such as antidepressants) are more likely to develop a candidal infection. Other at-risk individuals include: Newborns/Nursing Mothers: Babies and nursing mothers must both be properly treated to prevent passing the Candidal infection back and forth. Dentists or healthcare providers can prescribe mild antifungal medications to treat oral infections, and an antifungal cream may be needed for treating the breasts. Diabetics: Individuals with diabetes have a reduced resistance to infection, so they may experience an increased incidence of oral thrush. To prevent oral infections, dentists may recommend medicated mouth rinses or more frequent dental hygiene appointments. People with Asthma/Chronic Obstructive Pulmonary Disease (COPD): The use of inhaled corticosteroids has been shown to increase an individual's risk for oral thrush. This risk can be reduced by using a spacer and rinsing the mouth after using the inhaler. Denture Wearers: A common contributor to oral thrush is denture stomatisis, which occurs when the gums and soft tissue of the mouth are irritated and inflamed from wearing a denture that doesn't fit well or hasn't been properly cleaned on a regular basis. This condition creates an environment that is ideal for Candida growth. Smokers: The use of tobacco has been identified as a contributing factor in oral thrush infection. Immune deficiencies (HIV, Chemotherapy/Cancer Patients): Deficiencies in the immune system that result from chemotherapy, radiation treatments or HIV infection can dramatically change the balance of the protective mechanisms in the body that would otherwise fight off an oral thrush infection. An individual's ability to fight infection determines the severity of oral thrush and the fungal infection overall. Individuals with HIV are prone to severe forms of oral thrush in their mouth or esophagus, as well as spread of the infection to the intestines. Prolonged antifungal treatment may be necessary for individuals with severe infections and/or those who are immunocompromised.

Oral Thrush Treatments

Oral thrush treatment starts with the management of the conditions that caused development of the fungal infection. For example, if you have developed oral thrush as a result of using a particular antibiotic, you should speak with your physician immediately about getting an alternative medication. If you wear dentures, they should be removed from the mouth at bedtime and thoroughly cleaned. An antimicrobial mouth rinse may also be recommended by your dentist for use as a denture disinfecting agent. If you are diabetic, you must carefully monitor and control your blood glucose levels. Those who are immunocompromised may need oral or IV antifungal medications to control the Candidal infection on an ongoing basis. Practicing good oral hygiene is also important, as well as limiting the amount of sugary and yeast-containing foods that you eat. Treatment of oral thrush depends on the severity of the condition. Mild cases may be managed without medications. Drinking acidic liquids such as orange juice and eating yogurt can help to rebalance the natural bacteria that keep the Candida yeast in check. Your dentist will develop a treatment plan for you based on your specific condition and the nature of your oral thrush infection. Medications used in the treatment of oral thrush include antifungal mouth rinses, lozenges, creams and oral tablets. In some cases, a combination of oral tablets and lozenges are used to treat severe oral thrush infections. As many as 14 days of treatment with antifungal medications may be necessary to treat severe oral thrush infections. In some instances, generic brands of the medications are available, which will help to lessen the cost of any treatment regimen prescribed for you by your dentist. Dental insurance will cover the cost of prescription medications to treat oral thrush, and some medications are available over-the-counter. Topical medications used to treat oral thrush include nystatin (creams, ointments, powder and oral solution) or clotrimazole lozenges. Nystatin powder or ointments may be applied to the affected mucosa and/or inside the thoroughly cleaned dentures and worn. Nystatin solution is used to rinse the mouth. It is safe to swallow for treatment of candidiasis affecting the throat. Oral tablets of fluconazole may also be used to treat oral thrush (with an estimated wholesale price of $104.00 for treatment). Other antifungal medications are also available and may be prescribed by your dentist depending upon your condition and diagnosis.

Angular cheilitis Its not just thumb-sucking kids who have it

by John Kraft, MD and Charles Lynde, MD Vol.17, No.03, March 2009 A 46-year-old gentlemen presents with a 2-month history of burning and redness at the commissures of the lips. He admits to licking his lips. Hes a borderline diabetic controlled with diet and exercise alone. He isnt on any medications. Angular cheilitis, also known as perleche, is a chronic inflammatory condition of the angles of the mouth. Its often multifactorial with many triggers and aggravating factors. Mechanical reasons for excessive wetness or dryness of the lips are very common. Habits such as frequent lip licking, or thumb sucking in children promote angular cheilitis. Other mechanical causes include flossing teeth, denture use, sagging skin leading to overhanging cheeks or lips, and too little or too much saliva. Alternating wetting and drying of the lips disrupts the barrier function and promotes cracking and fissures. Infectious agents such as yeast and bacteria grow very well in moist environments such as wet angles of the mouth. Candida albicans and Staphylococcus aureus are common colonizers that promote angular cheilitis. Angular cheilitis can also be associated with nutritional and systemic diseases. These include iron deficiency anemia, riboflavin, folate and B12 deficiencies. Systemic diseases associated with this skin condition include diabetes mellitus, Crohns disease, Sjgrens syndrome, HIV and Downs syndrome. Dermatological conditions such as eczema, perioral dermatitis and orofacial granulomatosis can also be predisposing. Clinical findings The commissures (corners) of the lips show erythema, scaling, maceration, atrophy, crusting and fissures. The fissures radiate down and away from commissures. Patients usually complain of soreness. Lesions can be unilateral or bilateral. Unilateral lesions resolve quicker than bilateral ones, and tend to be due to trauma. Bilateral lesions are more chronic and are more likely associated with an underlying disease. Differential diagnosis Consider the following conditions in anyone who presents with scaly lips. Actinic cheilitis is a reaction to excessive sun exposure analogous to actinic keratoses of the skin. It often involves only the lower lip with scale, fissures and erosions. Allergic contact dermatitis (ACD) is much more prominent over the vermillion border and angular cheilitis is usually also present. Common triggering allergens of lip ACD include lip balms, lipsticks, topical medicines and toothpastes especially cinnamon-flavoured varieties. Cheilitis can also be secondary to seborrheic dermatitis, atopic dermatitis, psoriasis and retinoids.

Investigations Consider the following investigations in patients presenting with angular cheilitis:

CBC, ferritin, B12, folate, fasting blood sugar, HbA1C swab for bacterial culture and sensitivity, and candidiasis

Consider referral to dermatologist who may biopsy any lesions suspicious of malignancy, e.g. if there is induration or ulceration. The dermatologist may also see about patch testing if its a possible ACD. Treatment The keys to successful management include treating any underlying causes and modifying habits that may worsen the condition. Patients should be instructed to ensure optimal denture fit, and remove dentures nightly with regular cleansing. Tell patients to apply a barrier moisturizer to the lips frequently. Have them try petroleum jelly or zinc oxide ointments, especially before bed and meals. Topical antifungals that are effective against yeasts are the mainstay of therapy. Clotrimazole and nystatin creams are good options. Use topical antibiotics if bacterial superinfection is likely. Fusidic acid, polymyxin B, and mupirocin are possible options. Mild topical corticosteroids and topical calcineurin inhibitors (pimecrolimus, tacrolimus) are additional options if inflammation is obvious. Combinations such as 1% hydrocortisone in clotrimazole cream can also be helpful. If these arent effective, oral antifungals, e.g. fluconazole, should be considered. Mechanical correction of deep folds, such as collagen injection, is rarely done for select cases. Case discussion We discussed the nature of angular cheilitis with our patient, and took swabs for bacterial and fungal culture and sensitivity. Blood work included CBC, ferritin, fasting blood sugar and HbA1C. We instructed our patient to avoid lip licking and cinnamon-flavoured toothpaste, and to apply petroleum jelly to the lips and angles before eating and sleep. We also prescribed clotrimazole cream to use twice daily at the angles of the mouth.

Charles Lynde, MD, FRCP(C) is an assistant professor of dermatology at the University of Toronto. John Kraft, MD, is in his third year of the Dermatology Residency Program at the University of Toronto.

REFERENCES 1. Epstein JB. Antifungal therapy in oropharyngeal mycotic infections. Oral Surg Oral Med Oral Pathol1990;69:3241. 2. Guida RA. Candidiasis of the oropharynx and oesophagus. Ear Nose Throat J1988;67:83240. 3. Odds FC. Candida and candidiasis. 2nd Ed. London: Bailliere Tindall, 1988. 4. Ghannoum MA, Radwan SS. Candida adherence to epithelial cells. Boca Raton, FL: CRC Press, 1990. 5. Abu-Elteen KH, Abu-Alteen RM. The prevalence of candida albicans populations in the mouths of complete denture wearers. New Microbiol1998;21:418. 6. Manning DJ, Coughlin RP, Poskit EM. Candida in mouth or on dummy? Arch Dis Child1985;60:3812. 7. Berdicevsky I, Ben-Aryeh H, Sazargel R, et al. Oral candida in children. Oral Surg Oral Med Oral Pathol1980;57:3740. 8. Lucas VS. Association of psychotropic drugs, prevalence of denture-related stomatitis and oral candidosis. Community Dent Oral Epidemiol1993;21:31316. 9. Arendorf TM, Walker DM. The prevalence and intra-oral distribution of Candida albicans in man. Arch Oral Biol1980;25:110. 10. Aldred MJ, Addy M, Bagg J, et al. Oral health in the terminally ill: a cross sectional pilot survey. Spec Care Dentist1991;11:5962. 11. Cumming CG, Wight C, Blackwell CL, et al. Denture stomatitis in the elderly. Oral Microbiol Immunol1990;5:825.

12. Holbrook WP, Hjorleifsdottir DV. Occurrence of oral Candida albicans and other yeast-like fungi in edentulous patients in geriatric units in Iceland. Gerodontics1986;2;1536. 13. Rodu B, Carpenter JT, Jones MR. The pathogenesis and clinical significance of cytologically detectable oral candida in acute leukaemia. Cancer1988;62:20426. 14. Dupont B, Graybill JR, Armstrong D, et al. Fungal infections in AIDS patients. J Med Vet Mycol1992; 30(suppl 1):1928. 15. Fraser VJ, Jones M, Dunkel J, et al. Candidemia in a tertiary care hospital: epidemiology, risk factors, and predictors of mortality. Clin Infect Dis1992;15:41421. 16. Morgan R, Tsang J, Harrington N, et al. Survey of hospital doctor's attitudes and knowledge of oral conditions in older patients. Postgrad Med J2001;77:3924. 17. Lewis MAO, Lamey P-J. Clinical oral medicine. Oxford: ButterworthHeinemann, 1995. 18. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002; 113(9):7515 (ISSN: 00029343) 19. Abe M, Sogabe Y, Syuto T, Ishibuchi H, Yokoyama Y, Ishikawa O. Successful treatment with cyclosporin administration for persistent benign migratory glossitis. Journal of Dermatology. 2007; 34:340343 20. Sigal MJ. Mock D. Symptomatic benign migratory glossitis: report of two cases and literature review. Pediatric Dentistry. 1992:14:3926. 21. Gonsalves, Wanda C., Chi, Angela C., Neville, Brad W., Common Oral Lesions: Part I. Superficial Mucosal Lesions. American Family Physician, February 15, 2007, vol. 75, no. 4., p. 503 22. 23.