Oral Fungal Infection

• Clinical Definition: Overgrowth of Candida causing cream-colored or reddish colored patches on oral tissues.

• Urgency Indicators: Painful swallowing (dysphagia), fever, lesions extending from the oral mucosa into the esophagus, and bleeding mucosal erosions.

• Primary Treatment Options for Oral Candidiasis: Topical antifungal therapy, systemic oral antifungal therapy, and strict adherence to oral hygiene.

• White Creamy Plaque: Raised white patches that resemble cottage cheese on your tongue, cheeks, roof of your mouth and gums. When you scrape the plaque off, it leaves behind an area of redness and irritation.

• Red Erythematous Patch: Flat, bright red patch on the top of your tongue, back side of your tongue and/or inside of your cheek. The red patch may be tender to touch and can cause you to feel a burning sensation in the affected area. This is most commonly found under upper denture wearers.

• Cheilitis Angularis: Severe cracking, redness and flaking skin around the outside edges of your lip and at the corners of your mouth.

• Distorted Taste: A metallic or altered taste may occur during the active infection, but this sensory change typically resolves once the fungal infection is successfully treated and the mucosa heals. Many people also report a temporary loss or reduction in their sense of taste while experiencing this infection.

• Velvet/Cottony Feeling: This infection causes a subjective sensation as though there is cotton or velvet in your mouth. This uncomfortable sensory disturbance and associated dryness can make eating and speaking feel awkward until the infection clears.

• If you are experiencing symptoms that include odynophagia (painful swallowing), immediate medical attention is required. 

• Odynophagia indicates that the infection has spread into the esophagus and requires prompt medical evaluation. 

• If you have been diagnosed with cancer and are receiving chemotherapy; or you have either uncontrolled diabetes, or you are taking medication to suppress your immune system (HIV/AIDS); or you fall into one of these categories, see a doctor immediately upon the appearance of the lesions.

• Antibiotic-related Dysbiosis: Antibiotics kill the good bacteria that protect our mouths from bad bacteria by killing the "good guys," thus creating an opportunity for fungi to take over.

• Hyposecretion of Saliva: A decrease in saliva production reduces the amount of the body's own defense mechanisms against infections.

• Steroid-induced Immune suppression: Inhaled corticosteroids used for asthma management deposit drug residue on the oral mucosa; failing to rinse and gargle with water immediately after inhalation leads to localized suppression of cell-mediated mucosal immunity.

• Mechanical Trauma from Dentures: Ill-fitting removable dentures cause repetitive micro-trauma and trap tissue fluids and debris beneath the base, creating a sheltered reservoir that fosters fungal biofilm adhesion and colonization

• Poor Metabolic Balance: When high blood sugar is poorly managed, it increases the amount of sugar in the saliva where fungi can feed on this directly available nutrient.

• Age: Elderly persons have reduced mucosal immunity, while newborns are still developing their immune system to fight off infections.

• Malnutrition: Lack of adequate amounts of iron, Vitamin B12 and/or Folate will compromise mucosa integrity.

• Local Dietary Habits: Frequent consumption of refined carbohydrates, simple sugars, and high-glycemic foods provides readily available substrate that promotes fungal proliferation and mucosal adhesion.

To self-check for an Oral Candidiasis diagnosis, you will need to stand before a well-lit mirror. 

• First, wash your hands thoroughly. Next, retract your lips and gently pull back on your cheeks to evaluate the white spots or red areas that are located inside of your cheeks. 

• Extend your tongue and look at the upper side as well as both sides of your tongue to see if there are any white coatings present. 

• Gently use a clean cotton swab to wipe away one of the white patches. If wiping away the white coating leaves behind an underlying red surface that may bleed slightly, this suggests Thrush (a Candida infection). In contrast, Leukoplakia consists of fixed white patches that cannot be wiped or scraped away. 

A formal clinical examination by a dental professional is necessary to confirm the diagnosis.

• An Oral Clinician/Physician uses high intensity clinical lighting along with magnification loupes to examine the patient's oral cavity. 

• The diagnosis of an Oral Candidiasis is primarily based upon a clinical evaluation; however, the clinician also scrapes a swab across the lesion for a KOH (Potassium Hydroxide) slide preparation. This slide preparation is used to observe yeast cell buds and pseudo hyphae under a microscope. 

• Additional testing including cultures or biopsies may be necessary for patients who have developed Chronic Candidiasis or whose condition is resistant to therapy to determine what Non Albicans Candida Species they are infected with.

• Treatment for Mild Cases: Topical antifungals include Nystatin oral suspension (used via the swish-and-spit method 4 times a day) for 7–14 days, or Clotrimazole lozenges which dissolve slowly in the mouth to maintain direct contact with the oral tissues.

• Moderate to Severe Cases: The most effective treatments for moderate to severe cases include systemic fluconazole (oral dose of 100-200mg/daily) for 10-14 days or itraconazole for 10-14 days, which allow for greater tissue penetration.

• Oral Antimicrobial Rinsing: Use chlorhexidine gluconate (0.12%) oral rinses separate from your antifungal therapy for additional control of secondary bacterial plaque.

• Sanitizing Prosthetics: Soak removable dentures nightly in dedicated prosthetic cleansing solutions, such as alkaline peroxide or dilute sodium hypochlorite solutions (for non-metallic appliances), to eliminate fungal biofilm without staining the acrylic material.

Kerala's treatment costs will depend on the type of health care facility and how severe the case is:

• Government or Primary Health Centre (PHC) clinics; consultations are free up to low cost (₹10-₹50). Basic topical antifungals are subsidized through KASP (statewide health program) by government sponsored health programs.
  Private dental offices/polyclinics; general consultation fees can range from ₹300 to ₹700.

• Medication: 10-14 day courses of topical nystatin or oral fluconazole can range from ₹150 to ₹600.

• Diagnostic Microbiology / KOH mount: ₹300 to ₹800 at private diagnostic facilities in major cities including Kochi, Thiruvananthapuram and Kozhikode.

• General Dentist: Manages mild to moderate initial cases of primary candidiasis (thrush), denture stomatitis; prescribes most common anti-fungal medications for simple oral infections.

• Oral Medicine/Radiology Specialist: Assesses recalcitrant, recurrent or more serious forms of hyperplastic oral candidiasis (thrush) and may perform biopsies on affected mucosa.

• Physician/Endocrinologist: Diagnoses and manages systemic diseases that are causing the patient's thrush; examples include poorly controlled type 1 or type 2 diabetes or other autoimmune conditions.

• For mild cases of thrush, patients should schedule a routine evaluation with their dentist within a few days to a week to initiate therapy and re-evaluate mucosal response after completing the initial course of treatment.

• For more acute cases where the patient has been experiencing severe difficulty swallowing due to pain, a very high fever and/or significant dehydration resulting from pain while eating, the patient should be evaluated at an emergency department or tertiary center as soon as possible, usually in less than 2-4 hours.

1. How do I get rid of oral thrush once and for all?

When you treat the symptoms of oral thrush but don't address the cause, then this fungus will continue to grow back. Some common causes are uncontrolled diabetes, dirty dental appliances which have fungal colonies growing on them, contaminated inhaler equipment used for treating asthma, or consistently having your mouth too dry.

2. What's the likelihood of getting oral thrush from someone who has it by kissing, shaking hands, holding hands, etc.?

It's rare to contract oral thrush from kissing or passing something while sharing food. 

3. Will using yogurt or coconut oil help heal my oral thrush for good?

You may use yogurt (with its high concentration of beneficial bacteria), virgin coconut oil (which contains lauric acid), or other forms of oil pulling to help restore your mouth's microbiome. These home remedies may help support your oral health, but you need to take prescription antifungals to completely kill the fungi causing your oral thrush.

• Denture Stomatitis: Inflammation and chronic redness of the area under a removable denture.

• Oral Lichen Planus: Autoimmune inflammatory condition that can look similar to or coexist with red/white fungal infections of the mucosa.

• Oral Leukoplakia: White patches that resemble thrush but are precancerous; you cannot wipe these away with a cotton swab.

• Replacing Worn Denture Plates with New Acrylic Resins: Eliminate micro-trauma from a poorly fitting prosthesis and replace degraded, porous acrylic surfaces to prevent the accumulation of fungal and bacterial biofilms.

• Prescription Saliva Stimulants (Sialogogues) and Artificial Saliva: Use these products to maintain hydration of the oral mucous membranes.

• Properly Performed Professional Dental Cleanings (Scaling): Remove plaque and calculus from teeth, which can harbor Candida and act as sites for colonization.

To manage the clinical condition of oral candidiasis effectively, one must look beyond just the surface manifestations of this disease and treat any related systemic or local factors which may have triggered it. Dentists commonly encounter patients who are experiencing recurrent episodes of oral candidiasis when managing this infection in clinics throughout Kerala. The primary reasons include poor management of type-2 diabetes mellitus and failure to properly rinse the mouth after inhalation of medications. It is also essential for all patients to take their prescribed antifungal medication until completion regardless of whether they see resolution of the obvious white plaques. This will ensure eradication of deep-seated hyphae from within the epithelial layers. To ultimately prevent recurrence of oral candidiasis, patients should follow established procedures for proper care of their prosthetics, obtain optimal control over their metabolic diseases, and preserve natural salivary flow.