White, flaky, curd-like plaques covering the tongue and buccal mucosa with an erythematous base are typical of thrush. These lesions tend to be painless, although some patients experience a burning sensation. Painful inflammatory erosions or ulcers may be noted, particularly in adults. Predisposing factors include antibiotic use, inhaled and oral corticosteroids, radiation to the head and neck, extremes of ages, patients with immunologic deficiencies, and chronic irritation (eg, denture use and xerostomia). Colonization of surface epithelium by Candida occurs due to altered oral microflora. Hairy leukoplakia, lingual lichen planus, flecks of milk or food debris, and liquid antacid adhering to the tongue may be confused with candidiasis. Hairy leukoplakia cannot be removed with a tongue depressor (note Fig. 20.4). This helps differentiate this process from thrush or residue from ingested materials. Microscopic examination of the removed specimen for the presence of hyphae in potassium hydroxide mount will aid in the identification of Candida.
Oral Candidiasis (Thrush). Whitish plaques are seen here on the buccal mucosa. These plaques are easily removed with a tongue blade, differentiating them from lichen planus or leukoplakia. (Photo contributor: James F. Steiner, DDS.)
Management and Disposition
Nystatin oral tablets or swish and swallow suspension, fluconazole, or clotrimazole oral troches are therapeutic. Topical analgesic cocktails may provide comfort for patients (eg, liquid antacid with diphenhydramine, viscous lidocaine).
Thrush is most common in premature infants and immunosuppressed patients.
In young adults, thrush may be the first sign of AIDS; a history of HIV risk factors should be elicited.
Failure of oral candidiasis to respond to topical antifungal agents may suggest an underlying immune deficiency.
Oral Candidiasis (Thrush). Extensive thrush is seen on the hard and soft palate and uvula of this immunocompromised patient. (Photo contributor: Lawrence B. Stack, MD.)