I have oral thrush, which treatment is best for me?

oral thrush 3

Oral thrush is an infection caused by a fungus called Candida, which can occur in the mouth and the throat. This fungus, or yeast, is the same one which causes nappy rashes in babies, rashes between skin folds, and vaginal thrush.

Anyone can be infected with oral thrush, but certain people are more likely to contract it. For example, it is more common in babies, older adults, people taking antibiotics, people with diabetes, or people with a weakened immune system such as those with cancer, HIV, or who have poor nutrition.

Candida is a naturally occurring fungus in the mouth, and is reported to be present in 30-40% of the general healthy population.1 It becomes an infection, and causes symptoms, when Candida grows quickly and gets out of control, which may happen when the normal environment in the mouth changes. This is why people who are taking antibiotics are more likely to get oral thrush, as the antibiotic kills off “normal” bacteria, leaving less competition for Candida for food, and space in the mouth, leading to Candida overgrowth.

Symptoms of oral thrush

Many people with thrush have no symptoms, and may not even be aware they have it, and this is harmless. However, when people do get symptoms these can include white or yellow patches on the inside of the cheeks, tongue, or at the back of the throat. These white patches are the actual fungus, and can also stick onto the tongue, affecting the taste buds and making your mouth feel a bit like it is filled with cotton.

Oral thrush can also appear as redness in the mouth without any patches. This is when there is not as much thrush as to appear as white plaques, but the Candida causes an inflammation in the inside of the mouth — the yeast irritates the delicate oral lining and therefore the mouth appears red.

When people do get symptoms of oral thrush these can include white or yellow patches on the inside of the cheeks, tongue, or at the back of the throat.

If you have symptoms of thrush, or are unsure what your symptoms are a sign of, you should go and see your GP as there are many effective treatments available on prescription for oral thrush, and your GP may be able to diagnose the thrush just by looking at it.

As with lots of conditions, there are many different treatments for oral thrush, and which treatment works best for you may depend on your personal circumstances and the nature of your thrush.

Treatment for mild oral thrush

If oral thrush is mild, with no white plaques and only mild redness, this may sometimes just go away by itself without any treatment. It is important to maintain good mouth hygiene (such as using mouthwash and regular teeth brushing), eat well, and get adequate sleep, which would help the immune system fight oral thrush.

If the thrush persists for weeks then it can also be treated with a prescription mouth rinse (for example nystatin or fluconazole oral suspension), a lozenge that has a medicine to kill the yeast, or an oral gel, such as Daktarin, which contains miconazole. Daktarin oral gel can be brought over the counter, while nystatin and fluconazole oral suspension are available on prescription only.

The active agents in these preparations are antifungals, which work to kill fungus and yeast. Nystatin does this by interfering with the cell membranes of the fungus by binding to a fatty acid on the cell wall called ergosterol. This makes holes appear in the cell wall and the fungus dies because the components within the cells leak out. If you are using one of these suspensions, try to keep the solution in the mouth for as long as possible to ensure that there is enough contact between the active ingredients and the Candida plaques before swallowing.

If the thrush persists for weeks then it can also be treated with a prescription mouth rinse (for example nystatin or fluconazole oral suspension), a lozenge that has a medicine to kill the yeast, or an oral gel.

The usual dose for nystatin suspension is 1 ml, four times a day, to be taken after food. Treatment is usually for seven days, but some people may need longer if they have a weakened immune system, with resistant thrush. Thrush generally clears up quite quickly with treatment — within a few days. However, keep taking the suspension for 48 hours after symptoms have cleared to ensure that all the fungus is killed.

Different studies suggest that the effectiveness of the different types of suspensions (nystatin, amphotericin, and fluconazole) are similar.2 However, nystatin and amphotericin have an unpleasant taste, and some people may find that fluconazole is better tolerated than amphotericin.3

Miconazole gels like Daktarin can interact with some drugs such as Warfarin, so check with your doctor to ensure that you are getting a treatment that is safe for you.

Severe oral thrush

When oral thrush occurs in people with a weakened immune system, where the oral thrush is widespread across the mouth, when thrush causes people to feel very unwell (for example when the Candida goes into the bloodstream which may cause collapse, fever, and low blood pressure) or where oral suspensions have failed, then taking anti-fungal tablets would be needed.

Fluconazole, which is available on prescription, is the drug most often used to treat severe thrush because it is effective and well tolerated, and people find it easy to take as it is a once a day dose. It usually starts to work in just one day, but it may take up to a week for symptoms to disappear.

Fluconazole works by stopping Candida from producing the essential component, ergosterol, for the cell membrane. Therefore, the cell becomes leaky and the fungus dies. One study compared fluconazole with another antifungal, itraconazole, and it was found that fluconazole showed improvement in 66% of people compared with 54% for itraconazole. This may be because itraconazole has drug interactions and unpredictable absorption.4

Some strains of Candida are resistant to fluconazole, however, so if your symptoms do not clear after completing your treatment course, you GP may change you to a different antifungal, such as voriconazole. This is a newer drug than fluconazole and as such fewer strains of Candida are resistant to it. It is equally as effective as fluconazole, with 98.3% (voriconazole) compared to 95.1% (fluconazole) in one study when checking clearance of thrush in the gullet by endoscopy (‘camera test’).5

Oral thrush in babies and while breastfeeding

Babies, due their immature immune systems, may be more likely to get oral thrush. This often clears without any treatment and may be prevented by sterilising anything that the baby may put in their mouth, such as feeding bottles and mouth toys.

Babies, due their immature immune systems, may be more likely to get oral thrush. This often clears without any treatment and may be prevented by sterilising anything that the baby may put in their mouth.

If the baby is breastfeeding, however, Candida can spread from the baby’s mouth to the mother’s nipples and vice versa. Infection of the breasts with Candida can present with pain and redness of the nipples. Treatment in this instance would be topical gels of antifungals such as nystatin, ketoconazole, or miconazole, massaged onto the nipples after breastfeeding, and a nystatin suspension for the baby to take. It is best to see your GP to obtain these treatments in order to check that the antifungals are appropriate for you and baby.

If, after two weeks of treatment, the nipple pain does not settle, then taking nystatin or fluconazole may be recommended for the mother. Fluconazole and nystatin are safe to take when breastfeeding as very little passes into the breast milk.

Prevention

In all cases of oral thrush, there are steps that can be taken to prevent it from occurring and hasten recovery. Regular oral and dental hygiene with use of a soft toothbrush and rinsing the mouth often with mouthwash (for example, chlorhexidine) so that it penetrates areas which are not brushed can help.

If you have dentures, make sure that they fit well, and that they are adequately sterilised by submerging them in a disinfectant solution such as chlorhexidine at night.

As poor nutrition and a weakened immune system can make you more likely to have thrush, eating a balanced diet, taking regular exercise, and getting adequate sleep would help fight infection. Any medical condition that predisposes you to thrush should be treated, such as keeping diabetes under good control, and taking antiviral medications for HIV. If thrush is related to antibiotic use, once the course has finished the thrush may go away on its own after the normal bacteria in the mouth regrows.

If you suspect that you have oral thrush or symptoms of thrush, you are unsure about symptoms or if symptoms do not go away with treatment, it is important to seek advice from your GP because there may be other treatments, or it may be something else causing your discomfort.

References

  1. A. Akpan and R. Morgan, ‘Oral candidiasis’, Postgrad. Med. J., Vol. 78, Iss. 922, 2002, pp. 455-459.
  2. J. Taillandier et al., ‘A comparison of fluconazole oral suspension and amphotericin B oral suspension in older patients with oropharyndeal candidosis’, Age and Ageing, Vol. 29, 2000, pp. 117-23.
  3. Ibid.
  4. A.M. Oude Lashof et al., ‘An open multicentre comparative study of the efficacy, safety and tolerance of fluconazole and itraconazole in the treatment of cancer patients with oropharyngeal candidiasis’, Eur J Cancer, Vol. 40, No. 9, 2004, pp. 1314-9.
  5. R. Ally et al., ‘Esophageal Candidiasis Study Group. A randomised double-blind, double-dummy, multicentre trial of voriconazole and fluconazole in the treatment of esophageal candidiasis in immunocompromised patients’, Clin Infect Dis., Vol. 33, No. 9, 2001, pp. 1447-54.

Dr. Diana Chiu MBChB (Hons), MRCP, PGCERT (Med Ed), PhD

Diana received her medical degree, with honours, from the University of Manchester. She then went on to receive basic and specialist medical training within the north west of England. She carried out in-depth research in medicine and was awarded a PhD in 2016. Currently, she is finishing her medical training at a large teaching hospital, and one of her greatest interests is medical education. She is an advanced life support instructor and writes regularly for post-graduate examination websites, and also holds a PGCERT in medical education with distinction.

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