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Emergency and Acute Medicine – Oral Candidiasis
Overview and Definitions
Oral candidiasis is an infection of the oral mucosa caused by species of Candida. Although Candida albicans accounts for up to 80% of cases, other species such as Candida glabrata and Candida tropicalis may be involved, particularly in immunocompromised patients. Candida organisms are part of the normal oral flora in approximately 60% of healthy individuals.
Clinical variants include pseudomembranous candidiasis (thrush), acute and chronic atrophic candidiasis, angular cheilitis, and hyperplastic candidiasis. The condition is more common in neonates, the elderly, and immunocompromised individuals. In otherwise healthy patients, oral candidiasis typically follows a benign, localized course. In immunocompromised patients, infections are more likely to be recurrent, caused by non-albicans species, and may represent an early manifestation of HIV infection. Although usually localized, certain populations are at risk for progression to systemic infection.
Etiology and Pathophysiology
Oral candidiasis most commonly results from overgrowth of Candida albicans due to alterations in the intraoral environment. Medication-induced changes are frequent, particularly with antimicrobial use, inhaled or systemic corticosteroids, chemotherapy, and immunosuppressive agents. Impaired immune function significantly increases susceptibility.
Reduced salivary flow also predisposes to infection and may occur with anticholinergic or psychotropic medications, Sjögren disease, or head and neck radiation. Denture use and orthodontic appliances are common contributing factors and account for a large proportion of chronic atrophic candidiasis cases. Disruption of the epithelial barrier, endocrinopathies such as diabetes or hypothyroidism, and mechanical trauma may also contribute.
In infants, immune immaturity and lack of established oral flora predispose to thrush. In the elderly, denture use and age-related changes increase colonization, and angular cheilitis is more common due to facial wrinkling.
Diagnosis
Signs and Symptoms
Pseudomembranous candidiasis presents with painless, white, adherent plaques that can be scraped off to reveal an erythematous base. Lesions may become confluent and curdlike and may be associated with anorexia or dysphagia.
Acute atrophic candidiasis presents as erythematous mucosa with a burning sensation, typically involving the palate or tongue, which may appear bright red. Chronic atrophic candidiasis, also known as denture stomatitis, causes irritation and erythema beneath dentures. Angular cheilitis presents as cracking, erythema, or pain at the corners of the mouth and is often complicated by bacterial superinfection. Hyperplastic candidiasis manifests as chronic, adherent plaques or ulcers, usually on the lateral tongue or buccal mucosa, and carries a risk of malignant transformation, especially in tobacco users.
Essential Workup
In otherwise healthy infants, minimal evaluation is required and diagnosis is usually clinical. In adults or older children without clear risk factors, evaluation for underlying immunodeficiency or diabetes should be considered. Systemic infection should be excluded in high-risk patients.
Diagnostic Tests and Interpretation
Diagnosis is most often clinical. Laboratory testing may include CBC and serum glucose in patients with suspected systemic disease. Fungal staining or culture may reveal branching hyphae or pseudohyphae and is recommended in refractory cases or high-risk patients such as those with HIV, neutropenia, or transplant history.
Differential Diagnosis
Hairy leukoplakia, lichen planus, squamous cell carcinoma, and adherent food or milk residue.
Management
Emergency Department Management
Supportive care includes IV fluids if dehydration is present and topical analgesia for pain control. “Magic mouthwash,” consisting of viscous lidocaine, antacid, and diphenhydramine, may provide symptomatic relief. Topical antifungal therapy is first-line treatment, while systemic therapy is reserved for severe, recurrent, or refractory disease.
Patient education regarding oral hygiene is essential, including rinsing the mouth after inhaled steroid use and proper denture care.
Medications
First-line therapy includes topical antifungals such as nystatin oral suspension, nystatin pastilles, or clotrimazole troches administered for 7–14 days. Second-line therapy includes systemic azoles such as fluconazole or itraconazole for patients who fail topical therapy or have severe disease. Amphotericin B is preferred during pregnancy when systemic therapy is required.
Disposition and Follow-Up
Patients may be discharged if hydration and oral intake are adequate. Admission is indicated for inability to tolerate oral intake, newly diagnosed immunocompromised states, or evidence of systemic infection. Persistent or unexplained oral candidiasis warrants further evaluation for immunodeficiency.
Clinical Pearls and Pitfalls
Failure to recognize underlying immunodeficiency can delay diagnosis of serious systemic illness. Persistent oral lesions should prompt evaluation for alternative diagnoses, including squamous cell carcinoma.
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