Thrush
Jill C. Cash and Kathleen Bradbury-Golas
Definition
A.Thrush is a fungal infection of the oral cavity and/or the pharynx caused by Candida.
Incidence
A.Approximately 9% to 31% of AIDS patients and 20% of patients diagnosed with cancer will have thrush.
B.Healthy adults may also experience an episode of thrush; however, these adults usually have other risk factors, such as the frequent use of inhaled steroids and/or the use of oral antibiotics/steroids.
Pathogenesis
A.Thrush is an overgrowth of yeast cells, Candida albicans, on the oral mucosa, which leads to desquamation of the epithelial cells, creating a pseudomembrane over the normal oral mucosa. Other species of yeast cells may include Candida glabrata, Candida krusei, and Candida tropicalis.
Predisposing Factors
A.Use of broad-spectrum antibiotics.
B.HIV.
C.Prolonged steroid use (systemic or inhaled corticosteroids).
D.Cancer treatments (radiation/chemotherapy).
E.Dentures.
F.Malnutrition.
Common Complaints
A.Soreness, pain of the mouth.
B.White plaque coating the buccal mucosa, palate, tongue, or oropharynx.
Other Signs and Symptoms
A.Erythemic, sore tongue, buccal mucosa, or oropharynx.
Subjective Data
A.Determine onset, duration, and course of illness.
B.Has the patient used antibiotics or other medications in the previous weeks?
C.Does the patient use inhaled or systemic steroid on a daily basis?
D.Has the patient had difficulty swallowing?
E.Does the patient wear dentures?
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Inspect oral cavity for white, curd-like plaques that cannot be removed.
2.Inspect ears, nose, and throat.
Diagnostic Tests
A.Gram stain or KOH performed on scraping specimen of lesions. Confirmed diagnosis with the presence of yeast and pseudohyphae. Gram stain or KOH testing is recommended for recurrent infections.
Differential Diagnoses
A.Thrush.
B.Esophageal candidiasis (hallmark symptom is odynophagia or pain with swallowing).
C.Stomatitis.
D.Aphthous ulcer.
E.Hairy leukoplakia.
Plan
A.General interventions:
1.Instruct the patient/family on proper use and cleaning/rinsing of inhalers/dentures to prevent reoccurrence of thrush.
2.Instruct patient on the use of oral medications to treat thrush.
B. 
See Section III: Patient Teaching Guide Thrush.
C.Pharmaceutical therapy:
1.Oral candidiasis: Nystatin (Mycostatin) oral suspension (400,000–600,000 units) 4 to 6 mL four times a day for 7 to 10 days. Place medication in front of mouth on each side. Rub directly on plaques with a cotton swab. Nystatin pastilles: 200,000 units lozenge four times a day for 7 to 14 days, or swish and swallow 500,000 units four times a day for 14 days or two 500,000 unit tablets three times daily for 14 days.
2.Clotrimazole troche (Mycelex): 10 mg five times daily for 14 days; monitor for side effects.
3.Fluconazole: Adults: 400 mg × 1 (load dose), then 200 mg daily for 14 days.
4.Mary’s magic mouthwash (diphenhydramine, nystatin, Maalox—equal amounts of each) may be used for maintenance once thrush has resolved. Swish and spit this mouthwash one to three times a day as needed. If painful, viscous lidocaine can also be added.
Follow-Up
A.Advise the patient to telephone the office if there is no improvement, if thrush lasts more than 10 days, or if there is unexplained fever.
Consultation/Referral
A.Consult a physician/specialist if thrush does not resolve with adequate antifungal treatment.
B.Immunosuppressed patients are at higher risk for developing systemic dissemination and candidal esophagitis. Consult a physician if this is suspected.
Individual Considerations for Stomatitis and Thrush
A.Geriatrics:
1.Ask elderly patients about their dentures. Adequate fit (looseness or too tight) and if there is any pain.
2.Dentures should be removed and cleaned at least once daily. Encourage patients to remove dentures at night.
3.Oral inflammation and denture-related stomatitis has recently been linked through evidence-based research with the pathogenesis of cardiovascular disease (atherosclerosis and hypertension). Geriatric patients must be screened to denture-related stomatitis and immediate antifungal treatment is advised.
4.Nutritional challenges in the elderly population can lead to stomatitis and aphthous ulcers. Assess chewing ability. Evaluate geriatric patients for iron, B12, and folic acid deficiencies.
5.Certain conditions may cause overgrowth of Candida thrush and/or increase occurrences of aphthous stomatitis in geriatric population, which could include use of steroid inhaler, tobacco use, systemic steroid/antibiotics, radiation/chemotherapy, food allergies, asthma, diabetes or other endocrine disorders, anxiety, and lack of sleep.
6.If pain is involved, evaluate patient’s food/drink intake, weight, and nutritional status.