Basics
Description
- Infection of oral mucosa with any species of Candida
- Up to 80% of isolates are Candida albicans (most common), Candida glabrata, and Candida tropicalis.
- Candida normally present as oral flora in 60% of the healthy population.
- Variations include:
- Pseudomembranous (thrush)
- Chronic and acute atrophic candidiasis
- Angular cheilitis
- Hyperplastic candidiasis
- More common in neonates, elderly, and immunosuppressed individuals
- Usually benign course in healthy patients
- In immunocompromised patients, more likely to be recurrent and a non-albicans species
- May represent an early manifestation of AIDS in HIV-infected patients
- Typically localized
- Risk factors for systemic infection:
- AIDS
- Diabetes
- Hospitalization
- Immunosuppressive therapy
- Malignancy
- Neutropenia
- Organ transplantation
- Prematurity
Etiology
- Usually overgrowth of C. albicans from alterations in intraoral environment
- May be medication induced-commonly antimicrobials, inhaled or systemic steroids, chemotherapy, immunosuppressive agents
- Immunocompromised patients
- Alterations or impairment of salivary flow:
- Anticholinergic or psychotropic medications
- Sj ¶gren disease
- Head or neck radiation
- Presence of dentures or other orthodontics:
- Occurs in up to 50-65% of denture wearers
- Common etiology for chronic atrophic candidiasis
- Interruption of epithelial barrier (cheek biting)
- Endocrinopathies (diabetes, hypothyroidism)
- Acute pseudomembranous candidiasis (thrush) is common in infancy likely because of immaturity of their immune system and lack of mature oral flora
- Initial presentation may be feeding difficulty secondary to dysphagia
- May have concurrent Candida diaper rash
- Consider maternal treatment if breastfeeding:
- Maternal breast colonization may be cause for persistent thrush. Query maternal nipple pain, burning, itching, or cracked skin
- Candida organisms are normally present as oral flora from 65-88% of elderly or those in long-term care facilities
- Dentures can lead to Candida overgrowth
- Angular cheilitis more common in the elderly secondary to facial wrinkling
Diagnosis
Signs and Symptoms
- Pseudomembranous candidiasis (thrush):
- Painless white mucosal plaques
- Adherent but removable plaques
- Erythematous base
- May become confluent and curdlike
- Anorexia, dysphagia
- Acute atrophic candidiasis:
- Also referred to as erythematous candidiasis
- Burning sensation in mouth or on tongue
- Erythematous with few, if any white patches usually on the palate or dorsum of tongue
- Tongue may be bright red in color-similar to nutritional deficiency
- Chronic atrophic candidiasis:
- Also referred as denture stomatitis
- Irritation around denture-bearing mucosa
- Angular cheilitis:
- Cracking or erythema at the corners of mouth
- Lesion can be asymptomatic, pruritic, or painful
- Superinfection with Staphylococcus or Streptococcus is common
- Hyperplastic candidiasis:
- Chronic, invasive ulcers
- Typically on lateral borders of tongue or buccal mucosa
- High incidence of malignant degeneration in tobacco users
Essential Workup
- Minimal workup needed in otherwise healthy infant. Diagnosis can be made clinically.
- Determine whether there is a cause for a breakdown of host factors
- If no reason is found, evaluate for possible HIV infection or diabetes
- Exclude a systemic infection
Diagnosis Tests & Interpretation
Lab
- Clinical diagnosis often sufficient
- CBC if suspect severe infection
- Glucose testing
- Periodic acid-Schiff stain/KOH/fungal culture:
- Branching, thread-like hyphae, spores or pseudohyphae may be seen
- Obtain culture and sensitivity if failed first line treatment or high-risk individuals (HIV/AIDs, neutropenic, AIDs, transplant, etc.)
Differential Diagnosis
- Hairy leukoplakia
- Lichen planus
- Squamous cell carcinoma
- Adherent food/milk
Treatment
Ed Treatment/Procedures
- IV fluids if dehydration and/or unable to tolerate PO fluids
- Topical analgesia: "Magic mouthwash":
- Mixture of equal parts of 2% viscous lidocaine, Maalox, and diphenhydramine elixir
- Swish for 1-2 min, then expectorate
- Topical antifungal medications:
- Suspension, troches, lozenges
- Ointments (angular cheilitis)
- Systemic agents reserved for those with severe disease or resistant to topical therapy
- Provide oral hygiene education:
- Instruct those using steroid inhalers to rinse mouth immediately after use
- Denture and orthodontic care
Medication
- Dissolve troche in bottle nipple
- Mix suspensions with fruit juice and freeze into popsicle
- Apply suspensions to affected areas with a cotton-tipped swab
- Instruct parents to disinfect or replace toothbrushes, pacifiers, bottle nipples
- Angular cheilitis: Treat with topical nystatin ointment
- Dentures: Remove, brush, and soak nightly. Consider overnight rinse with 2% chlorhexidine
First Line
- Nystatin: Oral suspension; neonates 100,000 U; older infants: 200,000 U; children/adults: 400,000-600,000 U. Swish and swallow QID for 7-14 days
- Nystatin pastilles: 200,000 U PO QID for 7-14 days
- Clotrimazole troches: 10 mg PO dissolved slowly 5 times per day for 7-14 days (children >3 yr)
Second Line
- Oral fluconazole: Loading dose of 200 mg (peds: 6 mg/kg) on day 1, followed by 100 mg (peds: 3 mg/kg) PO daily for 7-14 days
- Itraconazole solution: 200 mg (peds: >5 yr, 2.5 mg/kg BID, not FDA approved) PO daily for 7-14 days
- Posaconazole 100 mg (peds: >13 yr refer to adult dosing) PO BID on day 1, then 100 mg PO daily for 13 days
- Systemic Amphotericin B (0.3 mg/kg) daily is the treatment of choice for candidiasis in pregnant women
Follow-Up
Disposition
Admission Criteria
- Inability to tolerate oral intake
- Newly diagnosed immunocompromised state
- Systemic infection
Discharge Criteria
If the candidiasis does not threaten patients hydration status, discharge
Followup Recommendations
Additional workup for immunodeficiency is warranted in older children and adults with unexplained candidiasis.
Pearls and Pitfalls
- Failure to recognize immunodeficiency
- Failure to recognize other intraoral pathology such as squamous cell carcinoma
Additional Reading
- Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75:501-507.
- Krol DM, Keels MA. Oral conditions. Pediatr Rev. 2007;28:15-22.
- Kuyama, K, Sun Y, Taguchi C, et al. A clinico-pathological and cytological study of oral candidiasis. Open J Stomatology. 2011;1:212-217.
- Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:503-535.
Codes
ICD9
- 112.0 Candidiasis of mouth
- 771.7 Neonatal Candida infection
ICD10
- B37.0 Candidal stomatitis
- P37.5 Neonatal candidiasis
SNOMED
- 79740000 Candidiasis of mouth (disorder)
- 30799000 neonatal thrush (disorder)