💡 Key Point: Oral candidiasis is frequently over-diagnosed — if there’s no pain and it’s limited to the tongue, it’s often just overgrown papillae (“hairy tongue”). True candidiasis typically causes discomfort, erythema, and bleeding when the plaques are wiped away.

🧠 About

Pathogen: Candida albicans — a commensal yeast that becomes pathogenic with host or local immunity changes.
Predisposed mucosa + impaired local defences → opportunistic overgrowth.
Common, especially in the elderly, denture-wearers, and immunocompromised patients.

⚠️ Risk Factors

💉 Diabetes mellitus and other causes of hyperglycaemia.
💊 Broad-spectrum antibiotics or cytotoxic therapy.
🦷 Poor oral hygiene, reduced oral intake, or dentures.
🫗 Salivary gland dysfunction / Sjӧgren’s syndrome (dry mouth).
🎯 Immunosuppression — HIV, malignancy, corticosteroids (especially inhaled without mouth rinsing).
🍼 Neonates and the malnourished.

🩺 Clinical Features

Superficial white, curd-like plaques on buccal mucosa, palate, or tongue.
When scraped off → raw, erythematous surface that may bleed.
Soreness, altered taste, and pain when eating or brushing.
Extensive or recurrent disease → consider HIV or immunosuppression.
Oesophageal involvement → odynophagia or dysphagia.

🔬 Investigations (If Indicated)

🧪 Blood glucose — screen for undiagnosed diabetes.
📈 Full Blood Count and White Cell Count.
🧫 HIV testing if severe, recurrent, or systemic features.
🧬 Biopsy / culture if atypical appearance or non-response to therapy.

💊 Management

🎯 Topical antifungals (first-line):
- Nystatin oral suspension (1 mL qid; hold before swallowing).
- Amphotericin B lozenges (e.g. Fungilin®).
- Miconazole oral gel (e.g. Daktarin®) — also active against S. aureus.
🧴 Systemic therapy: Fluconazole 50 mg od for 7–14 days if extensive, refractory, or immunocompromised.
🪥 Address predisposing factors:
- Optimise diabetes control.
- Rinse mouth after inhaled steroids.
- Clean dentures thoroughly and leave out overnight.
📋 Follow-up: Re-examine to ensure resolution and check for underlying disease.

🧩 Conclusion

Oral candidiasis represents an imbalance between host defence and microbial flora. Painful white plaques that scrape off to reveal erythema are diagnostic. Treat locally when mild, systemically if severe, and always seek the underlying cause (especially HIV or diabetes). Avoid over-diagnosis of benign tongue coating from not eating or antibiotic-related dysbiosis.

📚 References

NHS – Oral Candidiasis
Mayo Clinic – Oral Thrush
AAD – Oral Candidiasis Overview
WHO – Candida Infections Fact Sheet
Flickinger JC et al. Oral Candidiasis: Clinical Presentation, Diagnosis and Management. J Clin Microbiol 2017.

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Oral Candidiasis