Oral thrush is often over-diagnosed in the immuno-competent. Prescribing is only recommended where symptomatic thrush has been identified. Oral thrush tends to be more problematic in some patients e.g. cancer patients, other immunocompromised patients, and those on corticosteroids.

Failure to respond to treatment (particularly in the immuno-compromised) may indicate mouth ulceration due to herpes. Swabs may be helpful in the case of treatment failure; requests must include details of agents that have not been successful.

Fungal infections of the mouth are usually caused by Candida spp. (candidiasis or candidosis). Underlying conditions, medications or devices which predispose to infection should also be managed in order to optimize the chances of successful treatment.

Acute infections should normally resolve with good oral hygiene and topical treatment.

Managing risk factors for developing oral candidiasis

Dentures or orthodontic braces with plates:

• Good oral hygiene and thorough washing of teeth/brace to eliminate source of infection
• Advise patient to sleep without teeth/brace if possible
• Miconazole gel may be applied to the underside of the plate if patient is unable to go without wearing teeth/brace at any time

Smoking:

• Encourage patients to think about stopping, offer smoking cessation products if needed

Antibacterial therapy:

• Assess continuing need for antibacterial therapy and stop if appropriate

If possible, eliminate or manage any precipitating factors for candidiasis alongside prescribing treatment for the infection.

Mild Acute Infection

Nystatin oral suspension 100 000 units/ml

• 1ml four times daily for 7 days with continuation for at least 48 hours after symptoms have disappeared
• If signs and symptoms worsen or persist beyond 14 days of treatment, the patient should be re-evaluated, and alternate therapy considered
• It is important that the dose remains in contact with the affected area for as long as possible. Divide administration of the dose between both sides of the mouth
• Since the absorption of nystatin from the gastro-intestinal tract is negligible, overdose or accidental ingestion causes no systemic toxicity
• Dentures must be removed when nystatin is used to ensure all of the mouth is coated. Dentures can be soaked in a sodium hypochlorite solution (e.g. Milton® or Dentural®) for 20 minutes, rinsed and air-dried.

Miconazole oral gel 24 mg/ml

• Adults and children 2 years of age and older:
  
  • 2.5ml four times a day after meals
• Infants:
  
  • 4 months – 2 years: 1.25ml four times a day after feeds. The gel should not be applied to the back of the throat due to possible choking. The lower age limit should be increased to 5-6 months of age for infants who are pre-term, or infants exhibiting slow neuromuscular development
• The treatment should be continued for at least a week after lesions have healed or symptoms have cleared
• Each dose should be divided into smaller portions and the gel should be applied to the affected area(s) with a clean finger
• Dental prostheses should be removed at night and brushed with the gel
• The gel should not be swallowed immediately, but retained in the mouth for as long as possible near the lesions

Miconazole greatly enhances the anti-coagulation effect of warfarin, avoid concomitant use. Refer also to MHRA Drug Safety Update (June 2016).

Refer to the BNF or manufacturer's Summary of Product Characteristics (SPC) for a full list of interactions with miconazole.

Severe Acute, or Chronic Infection

Oropharyngeal candidiasis:

Acute oropharyngeal candidiasis presents as a speckled white "cream cheese" deposit on mucosal surfaces around the mouth and throat which may be associated with discomfort or difficulty swallowing.

Fluconazole

• Adults and children over 12 years of age:
  
  • 50mg daily for 7-14 days
• Children under 12 years of age:
  
  • Refer to BNFC

Oesophagitis:

Fluconazole

• Adults and children over 12 years of age:
  
  • 50mg daily for 14-30 days, dose may be increased to 100mg daily for unusually difficult infections
• Children under 12 years of age:
  
  • Refer to BNFC

Notes

1. Usual initial dose then halve subsequent doses if eGFR less than 50 mL/minute/1.73 m²
2. Be aware of potential drug interactions as a result of inhibition of various cytochrome P450 enzymes by azole antifungals
3. Higher doses and longer courses may be needed in immunosuppressed patients, and patients with more severe infections

Simple gingivitis

Temporary pain and swelling relief can be attained with saline mouthwash.

Use antiseptic mouthwash if more severe & pain limits oral hygiene to treat or prevent secondary infection.

The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated.

Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet

Simple saline mouthwash

• Half a teaspoon salt dissolved in a glass of warm water

Chlorhexidine 0.12-0.2%

• Rinse mouth for 1 minute every 12 hours with 5mL diluted with 5-10mL water (do not use within 30 minutes of toothpaste)

Hydrogen peroxide 6%

• Rinse mouth for 2 minute every 8 hours with 15mL diluted in half a glass of warm water

• Always spit out after use. Use until lesions resolve or less pain allows oral hygiene.

Commence metronidazole and refer to dentist for scaling and oral hygiene advice.

Metronidazole

• 400mg every 8 hours for 3 days

Use in combination with antiseptic mouthwash if pain limits oral hygiene.

Chlorhexidine 0.12-0.2%

• Rinse mouth for 1 minute every 12 hours with 5mL diluted with 5-10mL water (do not use within 30 minutes of toothpaste) or hydrogen peroxide 6% rinse mouth for 2 minute every 8 hours with 15mL diluted in half a glass of warm water. Use until oral hygiene possible

Refer to dentist for irrigation & debridement.

Amoxicillin

• 500mg every 8 hours for 3 days

If there is persistent swelling or systemic symptoms use metronidazole.

Metronidazole

• 400mg every 8 hours for 3 days

Use antiseptic mouthwash if pain and trismus limit oral hygiene

Chlorhexidine 0.12-0.2%

• Rinse mouth for 1 minute every 12 hours with 5mL diluted with 5-10mL water (do not use within 30 minutes of toothpaste) or hydrogen peroxide 6% rinse mouth for 2 minute every 8 hours with 15mL diluted in half a glass of warm water. Use until oral hygiene possible

Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection.

Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.

Severe odontogenic infections; defined as:

• Cellulitis plus signs of sepsis
• Difficulty in swallowing
• Impending airway obstruction
• Ludwigs angina

Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics.

The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option.

If pus drain by incision, tooth extraction or via root canal. Send pus for microbiology.

Metronidazole is a suitable alternative for the management of dental abscess in patients who are allergic to penicillin. It can also be used as an adjunct to amoxicillin in patients with spreading infection (lymph node involvement, or systemic signs i.e. fever or malaise) or pyrexia.

Amoxicillin

• 500mg every 8 hours for up to 5 days, review at day 3

Or

Phenoxymethylpenicillin

• 500-1000mg every 6 hours for up to 5 days, review at day 3

True penicillin allergy

Metronidazole

• 400mg every 8 hours for 5 days

Or

Clarithromycin

• 500mg every 12 hours for up to 5 days, review at day 3

NICE CG64: Prophylaxis against infective endocarditis: antimicrobial prophylaxis against endocarditis in adults and children undergoing interventional procedures (July 2016)