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Oral thrush (oral moniliasis or oral candida albicans infection)

Oral Thrush (Oral Moniliasis or Oral Candida Albicans infection)
Copyright 2010 South Florida Institute for Post-Graduate Health Education, Inc. All rights reserved.
No part of this workbook may be used or reproduced in any manner whatsoever without written permission.
Course developed by: Reda A Abdel-Fattah, BDS, MS, MPS and Mervat Alattar, BDS
C E Credit: 3 CreditsTest time limit: Unlimited within the course time limitCourse time limit: 30 days from the date of purchaseCourse fees: $29.95 Definition
Oral thrush (Oral Moniliasis, Oral Candidiasis, or Oral Candida Albicans infection)
is a fungal infection of the oral mucosa and tongue with Candida albicans fungus.
It causes a whitish lesion that adheres to an underlying erythematous area. The
lesion may slightly bleed and become painful when it is scraped. Occasional y,
oral thrush may spread to the palate, gingiva, or tonsil ar and oropharyngeal
Oral thrush may affect any person, however, it's more likely to affect infants,
denture wearers, chemotherapy and or radiation cancer patients or patients who
take corticosteroids medications or having compromised immune system such as
HIV positive.
Symptoms and Signs
Signs and symptoms may arise abruptly and continue for an extended period of
time. Signs and symptoms of oral thrush may include:
• A whitish lesion that adheres to an erythematous area located on the tongue, inner cheeks, palate, gingiva, or tonsillar and oropharyngeal areas. • The lesions may be described as cottage cheese-like or curdled milk.
• Pain may be felt and slight bleeding may occur when the lesion is scraped or • A feeling of cottony sensation on the dorsal surface of the tongue or in other area of the mouth that may be associated with loss of or diminished taste.
• The presence of angular cheilitis as fissured and cracked angles of the • In advanced cases, the lesions may extend downward to the esophagus causing Candida esophagitis. When this occurs, the patient may suffer from difficulty swallowing. Infants and breast-feeding mothers
In infants the distinctive white oral lesions causes trouble feeding, discomfort or
irritability. The Candida albicans infection may be passed to the mother during
breast-feeding and then back to the infant. Mothers whose breasts are infected
with Candida albicans may suffer from one or more of the following:
• Unusual y erythematous, sensitive or itchy nipples.
• Glossy or peeling skin on the areola.
• Remarkable pain when nursing or painful nipples between feedings.
• Deep stabbing pains within the breast.
Causes of oral thrush
Oral thrush or Candida albicans infections occurs when immune system is
compromised by disease or drugs that disturb the natural balance of the body’s
microorganisms. Generally, the immune system resists the invasion of pathologic
organisms such as bacteria, fungi and viruses through maintaining a balance
between beneficiary and harmful microorganisms that naturally present in the
body. However, when this resistance is compromised through il ness or certain
drugs, the fungus infection occurs.
The following illnesses cause the body to be susceptible to oral thrush:
• Human immunodeficiency virus (HIV) infection damages CD4 lymphocytes of the immune system, making the body more susceptible to opportunistic infections. Frequent attacks of oral thrush may be the initial sign of an HIV infection.
• Malignancy is likely to weaken the body due to the disease itself as well as the effects of chemotherapy or radiation. • Diabetes mel itus causes the presence of excess glucose in blood and saliva. This promotes the growth of Candida Albicans fungus.
• Taking antibiotic agents suppresses natural y occurring bacterial flora leading to overpopulation of the Candida Albicans fungus.
• Taking corticosteroids enhances the infection with Candida Albicans fungus. The mechanism of action in unclear, but may be related to decreasing tumor-related edema or inhibition of synthesis of prostaglandin and leukotriene.
• Vaginal yeast infections are caused by the same Candida Albicans fungus that causes oral thrush. There is a probable co-existence of the fungus in the oral cavity as well as the vagina. Predisposing factors
Candida Albicans can infect any person with a compromised or weakened
immune system such as:
• Having conditions that cause dry mouth (xerostomia).
• Undergoing chemotherapy or radiation treatment for cancer.
• Uncontrolled health conditions, such as diabetes mellitus or anemia.
• Certain medications, such as antibiotics, or oral or inhaled corticosteroids.
Rarely, oral thrush is a problem for healthy children and adults. Even though, the
infection may be recurring. On the other hand, patients with compromised
immune systems may suffer serious complications from Candida Albicans
infection. For example, HIV infected patients may have particularly severe oral and esophageal symptoms causing difficult chewing and swallowing. In some cases, the infection spreads to the intestines causing interference with adequate nutrition. Additional y, Candida Albicans infection is more likely to spread to other parts of the body such as digestive tract, lungs and liver in cancer or HIV infected patients.
A number of questions may be implemented in the overal health questionnaire
as follows:
• When did you first start noticing symptoms? • Have you recently taken antibiotics for an infection? • Have you recently used a steroid inhaler? • Do you have any chronic health conditions? • Do you have any other recent symptoms of illness? Tests and diagnosis
Oral thrush is usually diagnosed by direct visual inspection of the oral mucosa to
recognize the lesions. Occasional y, a small sample of the lesion is taken to be
examined under a microscope to confirm the presence of the fungus.
Additionally, local and systemic possible causes are to be ruled out one by one
through comprehensive health history. A referral to a family physician is to be
made when a systemic disease is suspected. When the infection spreads to the
oropharynx a referral to a physician becomes very necessary to perform a throat
culture to confirm the presence of the fungus, prescribing systemic anti-fungal
medication and manage any underlying systemic disease. Moreover, an
Endoscopic examination may be necessary to rule out or confirm the spread of
the infection to the esophagus and or stomach. Other blood analysis may be
ordered to rule out the presence of any potential immune compromising factor.
Treatments and drugs
The treatment goal for oral thrush is to prevent the fast spread of the fungus.
However, the treatment protocol depends on the patient’s age and health
condition. For example:
• Treating infants and nursing mothers; Infant’s oral thrush is usually benign and does not necessitate treatment as it general y resolves by itself within two weeks. However, when persistent it necessitates treating both infant and the breast-feeding mother. Otherwise, it is more likely to pass the infection back and forth between the two individuals. o When using a pacifier, breast pump or a bottle, it is important to rinse them daily in a solution of equal parts water and vinegar and al ow them to air dry to avoid fungus growth. o A mild antifungal medication such as Nystatin may be prescribed for the infant and an antifungal cream for the mother’s breasts. The infant treatment may be better managed by a pediatrician while the mother gets treatment from her obstetrician. The dosage for up to 30 days old infant is usually 0.5 ml to each side of the mouth and 1ml to each side of the mouth for older infants. The treatment continues for 7 to 10 days. This medication may be rubbed on the oral lesions using a piece of sterile gauze soaked with medication. o Some of the home remedies for the mother may include: Eating a non sweetened yogurt to enhance the body’s natural y occurring bacterial flora, taking lactobacil us acidophilus and probiotics as an alternative to yogurt, and stop taking any nutritional yeast supplements such as brewers yeast. Direct application of diluted tea tree oil as an antiseptic or garlic as an antibacterial antifungal agent may be of benefit. It is suggested that a dose between 1 billion to 10 billion viable (live) lactobacil us acidophilus bacteria taken daily in divided doses is adequate for most patients. Larger doses may cause slight abdominal discomfort, and smal er doses may not be adequate to build a stable bacterial floral population in the intestine. For vaginal infections, a dose of 1 to 2 capsules containing 1.5 grams of Lactobacillus acidophilus are suggested.
• Treatment of healthy adults and children; this regimen may include eating unsweetened yogurt or taking lactobacil us acidophilus capsules or liquid. Yogurt and lactobacillus acidophilus do not destroy the fungus, but they help restoring the normal bacterial flora in the body. If infection persists, a prescription of an antifungal medication may be necessary. • Treatment of adults with weakened immune systems; in these conditions and in addition to managing the underlying medical systemic problem, a recommendation may be made for an antifungal medication, which may come in one of several forms, including lozenges, tablets or a liquid that is used to swish in the mouth and then swallow. Examples of these medications: o Nystatin Lozenge (pastille) of 200,000 to 400,000 units taken 3 to 5 times a day that dissolves slowly in the mouth for adults and children. They should not be chewed or swallowed. Hence lozenges should not be given to children under 5 years of age.
o Nystatin Oral Suspension of 400,000 to 600,000 units for adults and children four times a day that is held in the mouth for as long as possible then swallowed. Infants are treated with 200,000 units three times a day.
o Nystatin (Mycostatin) topical powder contains 100,000 Nystatin units per gram dispersed in talc. It is to be applied on the lesion 2 to 3 times a day until healing is completed. o Nystatin (Mycostatin) cream is supplied in 100,000 units per gram and is to be applied to the affected area twice a day until healing is completed.
o Fluconazole (Diflucan™) a synthetic antifungal agent in a regimen of 150 mg every other day for 3 doses, fol owed by weekly 150-200 mg for 6 months,  Amphotericin B ( Amphcin or Fungizone) may be used when other medications are not effective as in HIV infected patients. It is given in an injection dose not to exceed 1.5 mg/kg and primarily for progressive and potential life threatening infection.
Lifestyle and home remedies
These suggestions may facilitate treatment during an eruption of oral thrush:
• Performing good oral hygiene. This is achieved by brushing at least twice a day and flossing at least once before bed time. Replacing the toothbrush frequently until the infection is cleared. An electric toothbrush can make brushing easier for people with manual dexterity problems. Mouthwashes should be avoided during this time. • Warm saltwater rinses. This is made by dissolving 1/2 teaspoon of salt in 1 cup of warm water. The patient is to swish the rinse and then spit it out, but not to swallow.
To reduce and possibly prevent developing oral thrush especially in high risk
individuals the following may be followed:
• Use of oral rinse when using a corticosteroid inhaler.
• Practicing regular oral hygiene.
• Regular cleansing of dentures or oral appliances in antifungal solution. • Eating unsweetened fresh-culture yogurt containing lactobacillus acidophilus or bifidobacterium regularly. Alternatively, lactobacillus acidophilus capsules are taken when taking a long course of antibiotics.
• Treating any vaginal yeast infections that develop as soon as possible.
• Visiting the dentist regularly especially when having a weakening or compromising disease such as diabetes mellitus. • Limiting the amount of sugar and yeast-containing foods as they promote the • Controlling any underlying systemic diseases such as diabetes mellitus.
Additional reading sources
1. http:/ 7. Budtz-Jörgensen E, Löe H. Chlorhexidine as a denture disinfectant in the treatment of denture stomatitis. Scand J Dent Res. 1972; 80(6):457-64. 8. Allen CM. Diagnosing and managing oral candidiasis. J Am Dent Assoc. 1992 9. Lewis MA, Samaranyake LP, Lamey PJ. Diagnosis and treatment of oral candidosis. J Oral Maxillofac Surg. 1991 Sep; 49(9):996-1002. 10. Samaranayake LP, Fidel PL, Naglik JR, Sweet SP, Teanpaisan R, Coogan MM, Blignaut E, Wanzala P. Fungal infections associated with HIV infection. Oral Dis. 2002;8 Suppl 2:151-60. 11. Samaranayake LP, Holmstrup P. Oral candidiasis and human immunodeficiency virus infection. J Oral Pathol Med. 1989 Dec;18(10):554-64. 12. Samaranayake LP, Keung Leung W, Jin L. Oral mucosal fungal infections. Periodontol 2000. 2009 Feb;49:39-59.



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