Fungal Infections

Comments from Expert Advisory Group

  • Clinically oral candida infections can present as four main variants: pseudomembranous, erythematous, denture stomatitis and hyperplastic. Chronic hyperplastic candidiasis may have malignant potential and therefore refer patients with this condition for specialist treatment.
  • N.B. oral candidiasis may be a clinical marker for an underlying pre-disposing condition e.g. diabetes, nutritional deficiencies, immunocompromise, or may be associated with the use of inhaled/systemic corticosteroids, cytotoxics, or broad-spectrum antimicrobials. Unexplained, extensive or recurrent candidiasis should prompt consideration of a GP referral.
  • Fungal infections in immunocompromised patients may need intravenous systemic treatment and should be referred to their GP or secondary care if they fail to respond to first line therapy.
  • If an infant being breast-fed is identified as having an oral candida infection, treatment of the mother also needs to be considered with referral to GP. Further information can be found under nipple/breast thrush management.
  • Note that Nystatin suspension contains 0.5g of sucrose per ml. This should be taken into account in patients with diabetes mellitus or glucose intolerance and the dental effects of sucrose should be considered with prolonged or repeated use.
  • Note that miconazole gel and fluconazole can interact with many drugs such as warfarin and statins – check for drug interactions before prescribing.

Local Measures

  • Denture Care
    • Denture wearers should be instructed on appropriate denture hygiene, such as:
      • Leave the denture out at night time.
      • Soak nightly in a denture cleaning solution according to the manufacturer’s instructions (Note: hypochlorite can only be used for dentures with no metal parts).
    • Leave the dentures out as often as possible during the treatment period.
    • Assess adequacy of denture.
  • Inhaled Corticosteroid Users
    • If oral candida infection is secondary to inhaled corticosteroids, the patient should be reminded to rinse their mouth with water after inhaler use.
  • Infants using soothers and bottles
    • Contaminated soothers and bottles should be cleaned/sterilised.

Treatment

Where antifungal treatment is considered necessary:

DENTAL ANTIMICROBIAL GUIDELINES

ORAL CANDIDA INFECTION TREATMENT TABLE
Drug Dose Duration Notes
1st choice options

Nystatin Oral Suspension

 

 

 

 

Infant: 1 month – 2 years:

1-2mL every 6 hours after feeds

Adult and children > 2 years:

1-6mL every 6 hours  after meals

7-14 days

 

 

 

 

 

Keep suspension in contact with oral mucosa for as long as possible before swallowing or spitting out.

Larger volumes of nystatin may be required to provide adequate coverage of more extensive infections. 

 

 

 
OR

Miconazole 20mg/g oral gel

 

 

 

 

 

 

 

 

 

Infant: 1 - 23 months:

1.25mL (quarter of measuring spoon provided) to be applied four times daily after feeds*

Adults and children ≥ 2 years:

2.5mL (half the measuring spoon provided) to be applied four times a day after meals

 

 

7-14 days

 

 

 

 

 

 

 

 

 

 

*Unlicensed use in infants < 4 months or during first 5-6 months of life of an infant born pre-term due to choking risk. The gel should not be applied to the back of the throat due to possibility of choking.

The dose should be smeared in baby’s mouth after feeds with a clean finger.

The gel should not be swallowed immediately, but kept in the mouth as long as possible.

Dental prostheses and orthodontic appliances should be removed at night and brushed with the gel.

Do not prescribe for patients taking warfarin.

Check for drug interactions before prescribing. 
2nd choice option 
  • Reserve for severe cases or those who are non-responsive to both first-line therapies.
  • All patients who require fluconazole should be seen by their GP for investigation into possible underlying causes.

 Fluconazole

 

 

 

 

 

 

 

 

 

  

1 month–11 years:

3-6mg/kg on day 1, then 3mg/kg every 24 hours from day 2 onwards (max. 100mg daily)

Adults & Children ≥ 12 years:

50mg every 24 hours; increased to 100mg every 24 hours for unusually difficult infections

 

 

  

7 days

(Can be extended up to 14 days)

 

 

 

 

 

 

 

  

Liquid preparation: 50mg/5ml (35ml bottle).

Anticoagulant effect of warfarin & DOACs are enhanced with fluconazole.

Check for drug interactions before prescribing.

Use with caution in patients with hepatic dysfunction.

Avoid fluconazole (and all oral azoles) in pregnancy.

 

 

 

 

 

Patient Information

Safe Prescribing (visit the safe prescribing page)

Reviewed November 2023

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