Oropharyngeal candidiasis (thrush) occurs commonly in seriously ill and dying patients.

Risk factors:
- defects of cell-mediated immunity: acquired (HIV-AIDS) or drug-induced (chemotherapy, inhaled or systemic glucocorticoids)
- disruption of the oropharyngeal mucosa by cytotoxic chemotherapy or irradiation that includes the oropharynx
- xerostomia (dry mouth) from any cause
- diabetes mellitus
- recent antibiotic use
- dentures
- advanced age

Diagnosis
Thrush is often asymptomatic but can lead to oral pain, oropharyngeal dysphagia, halitosis, alterations in taste, diminished appetite, and reduced oral intake.
Thrush may or may not be present in cases of esophageal candidiasis that presents as odynophagia and esophageal dysphagia.
Most cases of thrush are caused by Candida albicans; C. krusei, glabrata, or tropicalis.

Diagnosis is made on clinical findings: white, cottage-cheese-like plaques on the buccal mucosa, tongue, or palate. The plaques are easily removed, leaving a red or bleeding and often painful base. A less common presentation involves red, edematous, and sometimes eroded mucosal lesions, but without plaques. Confirmation can be made by KOH staining a wet-prep of a plaque scraping, revealing pseudohyphal Candidal forms.

Treatments include either systemic or topical antifungal drugs. All regimens should be continued for 7-14 days. Meticulous attention to denture cleaning is important to prevent recurrence. If esophageal candidiasis is suspected, systemic therapy is necessary as topical treatment is ineffective.

Topical drugs are the most commonly.
- Nystatin suspension (“swish and swallow”) - 200,000-500,000 units 4 - 5 times a day.
- Clotrimazole - 10 mg troches 5 times a day. The first line therapy if the troches are tolerable and dosing is acceptable.

Systemic drugs are more effective than the topicals.
- Fluconazole is the systemic treatment of choice - 200 mg once, then 100 mg daily for 14 days total. It should be used with recurrent thrush.
- Itraconazole suspension (200 mg daily) is an alternative to fluconazole.

Itraconazole, IV or oral amphotericin, voriconazole, and caspofungin have been used with fluconazole resistant candidiasis.

See reference for more information.

Adapted from von Dosielle DA and Hoff AM. Palliative Care Network of Wisconsin. Fast facts and concepts #147. Oropharyngeal candidiasis. Internet. Accessed on June 21, 2016.