Thrush (Oral Candidiasis)

Thrush is a superficial infection of the oral epithelium by the Candida albicans. It appears as a white papules and patches that are said to sometimes resemble "cottage cheese". The lesions can be scraped off to reveal an erythematous, inflamed mucosa. The tongue, buccal (cheek) mucosa, and angles of the mouth are most frequently involved. It occurs in the following settings:

Neonates. Many neonates are affected by thrush within the first week of life. Mothers of affected infants often report a history of vaginal candidiasis during pregnancy.

Immunosuppression. Thrush occurs in patients immunosuppressed due to disease (e.g. HIV, cancer) or due to the use of immunosuppressive medications, either topical (e.g. inhaled steroids for asthma) or systemic (e.g. steroids and other drugs for transplant patients).

Antibiotic use. The use of broad spectrum systemic antibiotics changes the balance of flora in the mouth and can allow Candida albicans to thrive.

Dentures. The wearing of dentures predisposes to thrush in older patients. In this case, it is the area underlying the dentures that is affected.

Chronic mucocutaneous candidiasis. This is an uncommon disorder caused by a deficiency in cellular immunity to Candida albicans. It is marked by mucous membrane, skin and nail candidal infection.

With what can thrush be confused?

Other white lesions of the oral mucosa can be confused with thrush, including lichen planus, leukoplakia, and squamous cell carcinoma. Thrush is easily distinguished form other conditions in that the white material can be easily scraped off.

How is thrush diagnosed?

A KOH preparation form a scraping will reveal hyphae and pseudohyphae. Culture is not useful because Candida albicans (yeast form) can be part of the normal mouth flora; the invasive hyphae must be visualized. Thrush in adults without a predisposing factor (dentures, antibiotic use, steroid use), should trigger a search for immunosuppressive conditions such as HIV infection. For physical examination, remember to remove dentures in denture-wearing patients.

How is thrush treated?

Thrush is treated with antifungal drugs with activity against Candida albicans. Infants are treated with topical nystatin, while adults can use a nystatin suspension or itraconazole (Sporanox) for "swish and swallow" or clotrimazole troches (Mycelex). Systemic regimens of fluconazole (Diflucan) or ketoconazole (Nizoral) can be used as well. Elimination or treatment of underlying predisposing factors is required. In the case of dentures, the prostheses must be disinfected with bleach (Clorox) or other solutions.

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What is the prognosis for thrush?

In neonates, thrush will usually clear even without therapy. In adults with underlying risk factors, such as immunosuppression, the condition can become chronic or recurrent; this is especially the case for chronic mucocutaneous candidiasis. In severe immunosuppression the disease can spread to the esophagus. Rarely, the organism can spread systemically, which usually results in death.

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