Oral Thrush

Oral thrush, medically known as oral candidiasis, is a fungal infection of the mouth and throat caused by an overgrowth of Candida species, particularly Candida albicans. While Candida organisms are normally present in the oral cavity, an imbalance can lead to infection. This condition is common among infants, the elderly, and individuals with weakened immune systems, but it can affect anyone.

Oral thrush is characterised by creamy white lesions, usually on the tongue or inner cheeks. It can also spread to the roof of the mouth, gums, tonsils, or the back of the throat. The lesions may be painful and may bleed slightly when scraped. In severe cases, the infection can spread to the oesophagus, causing difficulty swallowing. 

India

In India, the prevalence of oral candidiasis varies among different populations. Reports show its prevalence in HIV-positive and diabetic patients.

Worldwide

Globally, oral candidiasis affects approximately 2 million people annually . It is particularly prevalent among individuals with HIV/AIDS, with many cases worldwide. 

Oral thrush can present in several forms:

• Pseudomembranous Candidiasis: The most common type, characterised by white, creamy plaques that can be wiped off, leaving a red, inflamed surface.
• Erythematous (Atrophic) Candidiasis: Red, inflamed areas, often on the tongue and palate, without the white plaques.
• Hyperplastic (Chronic) Candidiasis: White plaques that cannot be wiped off, often associated with smoking.
• Angular Cheilitis: Cracks and redness at the corners of the mouth.
• Median Rhomboid Glossitis: A smooth, red, flat or raised area on the midline of the tongue.

Oral thrush, also known as oral candidiasis, is caused by an overgrowth of the fungus Candida albicans, which is naturally present in the mouth. While it typically exists in harmless amounts, certain factors can disturb the microbial balance and lead to fungal overgrowth.

1. Weakened Immune System

People with compromised immunity—such as individuals undergoing chemotherapy, organ transplant recipients, or those with HIV/AIDS—are at increased risk. Their bodies are less equipped to keep fungal populations in check.

2. Antibiotic or Corticosteroid Use

Broad-spectrum antibiotics can destroy helpful bacteria that normally suppress Candida. Similarly, inhaled corticosteroids for asthma or COPD can alter the oral environment, especially if users don’t rinse their mouths after use.

3. Diabetes and High Blood Sugar Levels

High blood sugar levels create an ideal environment for Candida to thrive. People with uncontrolled diabetes often have a higher prevalence of oral thrush.

4. Poor Oral Hygiene

Improper brushing, irregular flossing, or not cleaning dentures can allow fungal colonies to grow unchecked.

5. Dry Mouth (Xerostomia)

Saliva helps control microbes in the mouth. Reduced saliva due to dehydration, medication side effects, or certain health conditions can contribute to thrush.

6. Smoking and Alcohol Use

Tobacco alters the natural flora of the mouth and weakens mucosal defences. Alcohol, particularly in mouthwashes, may also disrupt the oral environment.

7. Hormonal Changes

Pregnancy, menstrual cycles, or use of oral contraceptives can impact fungal growth due to hormonal fluctuations.

8. Age

Infants and elderly individuals are more prone to oral thrush due to underdeveloped or declining immune systems.

Symptoms can vary depending on the individual and the severity of the infection:

• White, creamy lesions on the tongue, inner cheeks, gums, tonsils, or throat.
• Redness or soreness causing discomfort during eating or swallowing.
• Cracking and redness at the corners of the mouth (angular cheilitis).
• A cottony feeling in the mouth.
• Loss of taste.
• In severe cases, difficulty swallowing or a feeling of food being stuck in the throat.

Diagnosing oral thrush is generally straightforward and is often based on a physical examination and medical history.

1. Clinical Examination

A healthcare provider will inspect the mouth and tongue for characteristic signs—white, creamy patches on the inner cheeks, tongue, gums, and sometimes the throat. When scraped, these patches may bleed slightly.

2. Microscopic Testing

To confirm the diagnosis, a swab of the affected area may be taken and examined under a microscope. A KOH test (potassium hydroxide smear) can identify fungal elements.

3. Culture Tests

If necessary, a sample can be cultured in a lab to identify the specific species of Candida and check for resistance to antifungal drugs.

4. Blood Sugar Testing

In adults with recurrent oral thrush, checking for undiagnosed diabetes is common. Elevated blood sugar levels can explain persistent Candida infections.

5. HIV Testing (in select cases)

If oral thrush is unusually severe, recurring, or affects the oesophagus, an HIV test may be recommended to rule out immune suppression.

Treatment aims to eliminate the fungal overgrowth and address the underlying cause or contributing factors.

1. Antifungal Medications

These are the primary treatment for oral thrush and come in various forms:

Topical Antifungals:

• Nystatin suspension: Often the first choice, used as a mouth rinse.
• Clotrimazole: Fights infection within the oral cavity. (Brand available: Candid)
• Miconazole gel: Applied directly to the affected areas.
   

Systemic Antifungals:

• Fluconazole tablets: Commonly prescribed for more persistent or widespread infections.
• Itraconazole or ketoconazole: Alternatives for resistant strains or immunocompromised individuals.

Dosage and duration depend on age, overall health, and infection severity.

2. Treatment of Underlying Causes

Managing conditions like diabetes, reviewing immunosuppressive therapy, or switching antibiotics can help prevent recurrence.

3. Improving Oral Hygiene

Patients are advised to:

• Brush teeth twice daily using a soft-bristled brush.
• Floss regularly.
• Rinse the mouth after using inhalers.
• Disinfect and remove dentures at night.

4. Dietary and Lifestyle Changes

• Reduce intake of sugary foods and refined carbs.
• Stay hydrated to prevent dry mouth.
• Avoid alcohol-based mouthwashes.

5. For Infants and Breastfeeding Mothers

• Thrush in infants may require nystatin drops or miconazole oral gel.
• Mothers may need antifungal creams to prevent passing the infection back and forth through breastfeeding.

While antifungal medications are the mainstay of treatment, some individuals explore alternative remedies:

• Probiotics: May help restore the natural balance of bacteria in the mouth.
• Saltwater Rinses: Can provide symptomatic relief.
• Tea Tree Oil: Has antifungal properties but should be used with caution and under professional guidance.

Always consult a healthcare provider before trying alternative treatments.

Certain factors increase the likelihood of developing oral thrush:

• Infancy or old age.
• Wearing dentures, especially if not properly cleaned.
• Use of inhaled corticosteroids.
• Recent antibiotic or chemotherapy treatments.
• Smoking.
• Conditions causing dry mouth.

If left untreated, oral thrush can lead to:

• Spread of Infection: To the oesophagus or other parts of the body.
• Systemic Candidiasis: A serious infection that can affect the heart, brain, eyes, bones, or other parts of the body.
• Recurring Infections: Especially in individuals with underlying health conditions.

• Follow Treatment Plans: Complete the full course of prescribed medications.
• Maintain Oral Hygiene: Brush and floss regularly.
• Stay Hydrated: Drink plenty of water to keep the mouth moist.
• Avoid Irritants: Such as tobacco and alcohol.
• Monitor Blood Sugar Levels: Especially for diabetic patients.

• Only Affects Babies: While common in infants, it can affect individuals of all ages.
• Always Indicates Poor Hygiene: Not necessarily; underlying health conditions often play a significant role.
• Contagious: It's not highly contagious, but precautions should be taken, especially around immunocompromised individuals.

Consult a healthcare provider if: 

• Symptoms persist despite treatment.
• You experience difficulty swallowing or a feeling of food being stuck in the throat.
• You have recurring episodes of oral thrush.
• You are immunocompromised or have underlying health conditions.

• What is the best treatment option for my condition?
• Are there any lifestyle changes I should make to prevent recurrence?
• Could my current medications be contributing to the infection?
• How can I manage side effects of the treatment?

• Encourage Medical Consultation: Gently suggest seeing a healthcare provider to ensure proper diagnosis and treatment.
• Promote Good Hygiene Habits: Remind them to brush and rinse regularly and clean dentures properly if they wear them.
• Assist with Dietary Adjustments: Help them avoid sugary foods and beverages that can worsen fungal growth.
• Monitor for Changes: If symptoms worsen or spread, encourage follow-up care promptly.

Oral thrush, while common, can be distressing and uncomfortable. Whether it occurs in infants, adults, or the elderly, oral thrush typically responds well to treatment. However, recurrent cases may signal underlying health issues that need to be addressed.

Practising good oral hygiene, managing chronic illnesses like diabetes, and being cautious with antibiotics or corticosteroids can significantly reduce the risk of developing oral thrush. With appropriate care, most individuals recover quickly and completely.