Oral yeast infection or oral thrush is an infection of the mouth (tongue, inner cheek, lip, gums) or throat caused by the candida group of yeasts. This infection also goes by names such as “oral candidiasis/candidosis” and “oropharyngeal candidiasis”. Candida is normally present in the mucus lining of the mouth in small numbers without causing any harm. However, under certain conditions there is candida overgrowth in the mouth causing the infection. This article will take you through the details about this infection, what puts you at a greater risk for getting it and how can you prevent it, and the treatment options out there.
Major Causes and Risk Factors
Candida is a part of our normal flora, and it is only a few who develop an oral candida infection. According to CDC (Centers for Disease Control and Prevention), the infection is uncommon in general population and is largely considered a disease of immune-compromised people. It is the disturbance in the immune status of a person that allows candida to become infectious. This could be accompanied by other factors such as disturbance of oral normal flora, changes in the quality and quantity of saliva produced, or any lacerations on the epithelial cells that line the mouth cavity. However, it is also possible for someone with a normal immunity to get oral candida when candida enters the tooth or colonizes the surface of teeth along with caries causing Streptococcus bacteria.
The following factors, some of which could be interconnected, increase your risk for developing this infection:
- Reduced immunity: People with AIDS, cancer patients on chemo- or radio-therapy, and diabetics are more prone to oral thrush due to chronically reduced immunity. In AIDS patients, oral candida infection is one of the most common (and earliest) fungal infections. According to CDC, between 9-31% of AIDS patients are currently estimated to get this infection. Nearly 20% of cancer patients also get affected by oral thrush. People who use immunosuppressive corticosteroid inhalers to control their asthma or seasonal allergies are also at an increased risk for getting oral thrush if they do not rinse their mouth properly after using an inhaler. This is because the corticosteroid, when it gets deposited in the oral cavity, reduces the local immunity in the mouth allowing candida to grow.
- Antibiotic use: In a brief 2008 review, Soysa, Samaranayake and Ellepola from Sri Lanka, Hong Kong and Kuwait respectively have discussed scientific research showing the relationship between antibiotics and oral candidiasis. They present evidence which shows that antibiotics promote candida growth in the oral cavity by reducing the bacterial population in the oral microflora which otherwise keeps candida population in check. Read more about antibiotics and candida connection.
- Dentures: Use of dentures is associated with local changes in the mucosal membranes which could promote candida colonization and growth. Additionally, as described in a 1990 review by Budtz-Jörgensen from Switzerland, dentures may increase the acidity and the flow-rate of the saliva which would reduce the clearing of the tissue surfaces by the tongue. Budtz-Jörgensen also discussed in another 1990 review article how trauma induced by dentures can increase the permeability of the epithelium to candida toxins and antigens and make you more susceptible to candida infections. It is also well established now that denture surfaces can support the growth of candida biofilms. Using dentures and not taking enough precautions (improving oral hygiene, thoroughly cleaning the dentures, using properly fitting dentures, removing dentures before going to bed, etc.) can predispose you to oral thrush.
- Dry mouth: This condition, also known as xerostomia can be due to autoimmune or metabolic diseases (for example Sjögren’s syndrome or uncontrolled diabetes) that affect the salivary gland, or due to certain medical treatments and drugs. There is reduced functioning of salivary glands which, may cause dysbiosis. Dysbiosis in turn would lead to candida overgrowth in the oral cavity. A 2008 research study by Leung and colleagues from Hong Kong found that patients with Sjögren’s syndrome had candida overgrowth in their mouths despite good oral hygiene. Another study by Radfar and colleagues from the USA found that reduced salivary flow in Sjögren’s syndrome is associated with increased levels of candida in the mouth. Saliva by itself also has antimicrobial activity, so a lack of it would directly promote the growth of microbes such as candida.
- Smoking: In 2005, Soysa and Ellepola from Srilanka reviewed and analysed the scientific literature on smoking and its association with oral candidiasis. They found plenty of studies showing a link between smoking, either by itself or together with other factors, with risk of developing oral candidiasis. Arendorf and Walker suggested in 1980 that smoking causes many changes locally in the mouth which promote candida colonization. Macgregor in 1989 found through a literature review that smoking depresses the oral immune system and could thus lead to candida infection.
- Age: Newborns and older people are more susceptible to oral candida infections. This is because of the immature immune system in newborns and the risk of them contracting the infection during the birth process from their mother if she has vaginal candida infection. Immunity in older people is generally reduced; they have age-related changes in oral mucosa and reduction in saliva production which puts them on the risk for getting this infection. In addition, if they use dentures, they are even more likely to develop the condition.
- Diet: Malnutrition is one of the factors that can lead you to developing oral candidiasis. A study by Paillaud and colleagues from France which was done in 2004 and involved elderly patients with and without oral thrush showed that those with oral thrush were more likely to have protein-energy imbalance, and a deficiency of zinc and vitamin C. Deficiency of nutrients by itself causes lowered immunity as has been shown in a review article published by Cunningham-Rundles, McNeeley and Moon from USA in 2005. This reduction in immunity makes you a direct target for the pathogens including candida as described in the “reduced immunity” subsection above.
Signs & Symptoms
What are the signs and symptoms that you have oral yeast infection (what are some early signs of it?)
You may or may not be able to notice the symptoms of oral thrush immediately. It depends on the underlying cause whether it develops gradually over time or suddenly. The symptoms may persist for days, weeks or months – also depending on the underlying cause.
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The signs and symptoms of oral candidiasis are different based on the type of infection. Basically, oral candida infections are of two types: primary, which involves mouth and surrounding tissues; and secondary, which involves other parts of the body and shows up also as candida infection of the mouth.
The following table compares different forms of oral candida infections within the two basic types.
|Type||Forms||Chronic/Acute (who gets it)||Part affected||Symptoms|
|Primary||Pseudomembranous||Generally acute (in infants due to immature immune system, in older people due to nutritional deficiency, local immune suppression or underlying disease like HIV infection and AIDS). Sometimes chronic (in AIDS patients)||Usually tongue and lining of the mouth||Coating or white patches (cottage cheese like) that can be wiped off to reveal redness and/or mild bleeding|
|Primary||Erythematous||Acute (usually in people on antibiotics)|
Chronic (prevalent in HIV positive people and AIDS patients)
|Usually on the tongue and palate, but can also occur on the other mucosal linings of the mouth.||Red lesions, pain, if associated with antibiotics, stopping antibiotics heals the lesions once the normal flora of the mouth is back to the state before antibiotic treatment.|
|Primary||Hyperplastic (candida leukoplakia)||Chronic (prevalent in middle aged men who smoke)||Any mucosal surface of the mouth. Frequently on both the corners of the lips or on both sides where the jaws meet.||Smooth or nodular white lesions that cannot be wiped or scraped off|
|Primary||Candida associated lesions:|
1. Angular chelitis
|1. Acute (prevalent in patients who already have oral candidiasis)||1. Corners of mouth||1. Lesions and fissures in corner of mouth;|
Soreness; tests show presence of candida along with Staphylococcus aureus
|Primary||Candida associated lesions:|
2.Median rhomboid glossitis
|2. Chronic (more common in males)||2. Tongue||2. Red, usually smooth, rhomboid shaped lesion on the central part of the top of the tongue; often asymptomatic but may cause soreness on taking spicy food|
|Primary||Candida associated lesions:|
3. Denture stomatitis
|3. Chronic (denture wearers)||3. Mucosa of the gums||3. Mild inflammation and redness of the mucosa under the dentures; rarely any pain|
|Primary||Candida associated lesions:|
4. Linear gingival erythema
(HIV positive people and immunocompromised people.
|4. Gums||4. Inflammation of gums – a fiery red band along the margin of gums; not related to plaque; bleeding is rare; does not respond to plaque control or root planning and scaling|
|Secondary||Chronic mucocutaneous candidosis||Chronic (people with disorders of immune cell function)||Different parts of the body||Superficial candida infection of the skin, nails and mucosal membranes including of the mouth|
Diagnosis & Tests
It is usually diagnosed just by observing the type of lesions; however, sometimes microscopic examination of a scraping is done to check for presence of candida. If the doctor suspects an underlying condition (if not already known) additional tests may be done to find the source of the problem.
If the infection has extended to the throat, a throat swab sample is taken and cultured to check for presence of candida. If candida leukoplakia is suspected, a biopsy may be taken and examined by staining and studying the appearance of the cells.
What treatment options are available? (natural and prescription and home remedies if any)
Untreated oral candidiasis can become more severe, hence this should be treated as soon as possible. The treatment will be dependent on the type of candida infection you have, your age, your immune status and the underlying cause of infection. In addition to anti-candida therapy, for HIV patients, antiretroviral therapy is highly recommended for reducing recurrent infections. Disinfection of dentures is similarly recommended to people with denture related candida infections in addition to anti-candida therapy.
Here are some of the available options (both OTC and prescription):
Chlorhexidine: This is a broad spectrum anti-bacterial and antifungal agent. It is available as mouthwash, oral gel and cream. Repeated short-term treatment with chlorhexidine may be recommended in people with poor oral hygiene and those with recurrent oral candida infections. Dentures can also be soaked in chlorhexidine solution (0.2%) to get rid of attached candida biofilms.
At high concentrations, chlorhexidine kills fungi and at low concentrations it prevents the fungus to bind to surfaces (tooth, epithelium, dentures). It is not suitable for long term treatment as there can be adverse reactions like peeling of the oral mucosa, temporary brown discoloration of teeth and dentures, taste disturbances – the higher the dose and the time, stronger are the reactions.
Antifungal antibiotics: According to the guidelines of the Infectious Disease Society of America (IDSA), you may be recommended to use antifungal medication in the form of oral gels, lozenges, sprays or mouthwash. Clotrimazole lozenges may be prescribed for mild disease. Miconazole buccal tablet or alternatively nystatin suspension (swish and swallow) may also be prescribed.
In case the infection has spread to throat and oesophagus (moderate to severe infection) or in cases where the treatment with clotrimazole and nystatin does not work, oral fluconazole or in case of resistance to fluconazole, itraconazole, posaconazole or voriconazole may be prescribed. Amphotericin-B may be prescribed in case candida is resistant to azole antibiotics.
Home and natural remedies:
Salt-wash: If your infection is mild, you can rinse your mouth and gargle with salt-water wash (half tablespoon of salt in warm water). You should repeat this several times a day. It is generally a good idea to use salt water wash even if you do not have candida infection – it is a very good agent for regular oral hygiene.
Baking soda: Baking soda can also be used to rinse your mouth. This will help you maintain the optimal acidity of mouth and also help you reduce the symptoms of oral yeast infection.
Oil pulling: Oil pulling is an ancient Ayurvedic method for maintaining oral health where coconut, sesame or sunflower oil is swished around the mouth and between the teeth for a few minutes and then spat out. This is followed by brushing the teeth normally.
There are not many controlled scientific experiments on oil pulling, but in 2011 a group of researchers from Thailand checked the effects of oil pulling on oral microbes in biofilm models of candida, streptococcus and lactobacillus. They found that different oils (pulled mechanically up and down 20 times for 1 minute) had different effect on the biofilms. Coconut oil killed candida and streptococcus, sesame oil killed streptococcus and sunflower oil killed candida. None of the oils killed lactobacillus. Considering the known antifungal effects of coconut oil and sunflower oil, the evidence seems logical. Additionally, oil pulling does not affect the good bacteria like lactobacillus – which is an added advantage compared to contemporary mouthwashes which indiscriminately kill all bacteria and fungi. It also does not have any side-effects.
So, you can definitely add oil pulling to your oral-hygiene maintenance schedule to reduce the load of candida and in general improve your oral health in a natural manner.
Tea tree oil rinse: Rinsing your mouth thrice a day with tea-tree oil diluted in water (5mL oil in 50mL water) could be a natural remedy for your oral candida infection. There is plenty of evidence showing anti-candida activity of tea-tree oil. But when it comes to oral candida infection, is there any evidence for whether it actually is a reasonable alternative to pharmaceutical antifungals? Maghu, Desai and Sharma from India published their clinical study in 2015, where they compared the efficacy of treatment of tea-tree oil rinse with clotrimazole cream application. They found that tea-tree oil rinse was more effective than clotrimazole treatment in reducing the redness and inflammation and was able to reduce the burning sensation as much as clotrimazole. Although clotrimazole was better at clearing candida hyphae (100% clearance as compared to 89%), tea-tree oil rinse has fewer associated side effects compared to clotrimazole.
Additionally, as shown by Vazquez and Zawai from USA in 2002, tea-tree oil formulations can be effective in the treatment of fluconazole-resistant oropharyngeal candida infection in AIDS patients. Thus tea-tree oil is a good alternative especially considering rising antibiotic resistance.
Probiotics: Probiotics not only restore the microbial balance of the oral cavity, but are also effective in other ways to fight candida:
- They increase immunity against candida: Mendonça and colleagues from Brazil showed in 2012 through their research on 42 healthy aged people that consuming probiotics at least thrice a week for a month increases the antibody levels against candida and reduces the levels of candida colonizing the mouth.
- They help increasing saliva flow: As we have discussed earlier, dry mouth is a risk factor for developing candida infection of the mouth. In 2007, Hatakka and colleagues from Finland did a double blind, randomized controlled trial on 276 elderly people where 136 were given 50g of probiotic and 140 were given control cheese. They found that the salivary yeast count reduced in the probiotic group and on the contrary it increased in the control group. The risk of high yeast numbers in saliva was reduced by 75% by intake of probiotic. They found that probiotics also reduced the risk of dry mouth by 56% which could be the reason for their anticandida effect.
Diet: It can’t be stressed enough that you need to make sure that you have a well-balanced diet that would strengthen your immune system. You need to be sure that your diet does not leave you deficient in any essential component that could lead you to states of suppressed immunity. In case of already reduced immune function due to any reason, you need to be extra cautious with your diet and make sure you are getting all the minerals and vitamins that are so important in maintaining your immune system – take zinc and iron supplements and vitamin A, C and D to support your immune system. With a good diet you also ensure getting rid of candida from elsewhere in your system. You also prevent your oral yeast from getting severe and spreading to other parts of the body.
Natural antifungal pill supplements: You can also use antifungal pills, like CanXida Remove, that are an all-natural supplement for your recovery from oral thrush. CanXida Remove is formulated carefully by Eric Bakker, ND, after years of experience and expertise in treating candida infections. CanXida Restore on the other hand contains a mix of probiotic bacterial species along with digestive enzymes and is meant to restore your normal flora balance and thus fight candida.
How can thrush be prevented?
There are often simple things that solve a problem. However, the issue is that somehow we are not so invested in taking these simple preventive measures. What can be a bigger incentive than not getting one of the most annoying of the infections? If you really want to prevent thrush, you should follow the following simple rules:
- Boost your immunity: A strong immune system will prevent you from getting oral candida infection – any candida infection for that matter. Take a good diet, get enough sleep, drink enough water, stop alcohol and smoking, reduce stress in your life, get enough sunshine, and keep a positive outlook to life! All these boost your immunity and help you keep candida away.
- Avoid getting HIV infection: HIV infection is the biggest risk factor for getting oral thrush. Make sure that you practice safe sex, do not share needles etc. Of course, one may get an HIV infection despite being careful on their part. In case you already are HIV positive, make an effort to not let it turn into AIDS. Take steps to keep your immune system as healthy as you possibly can.
- If you are under radiation therapy, make sure to have immune supportive diet – minerals, good fats, vitamins and probiotics should be provided by your diet.
- If you are using corticosteroid inhalers, make sure that you rinse your mouth well after use. Use a spacer for inhaler if you are using aerosol based inhalers – these reduce the deposition of corticosteroid in the mouth and throat.
- Do not have oral sex if you know that your partner has genital thrush. Similarly, let your partner know if you have genital candida infection.
- Do not resort to antibiotics at every little sign of infection. Give your body a chance to recover by itself. If you are from a country where antibiotics are available over the counter, you need to be especially careful not to self-medicate with antibiotics. If you have had to take antibiotics for any reason, make sure you start probiotics to restore your normal flora.
- If you use dentures, make sure that you take them off before sleep, that they fit you properly and that you regularly clean them.
- Include good probiotics in your regular diet. These could be dairy based or fermented vegetables and fish.
- Maintain good oral hygiene.
What is the difference between oral yeast infection and bacterial infection?
Yeast infection may cause a thick, white, cottage cheese-like coating on the tongue or other parts of the mouth. In a bacterial infection, there may be white coating, but it is not very thick or cottage-cheese like. Bacterial infections generally affect the gums and the teeth, while yeast infections can affect any part of your mouth (see table in this article). If yeast infects the gums (like in linear gingival erythema), it forms a fiery red band along the margin of the gums and rarely is there any bleeding and is not plaque related. In case of bacterial infection of the gums (ginigivitis), the inflammation of the gums causes redness and swelling of the gums allover(not just a band of redness), the gums may bleed often and can become better by professional dental cleaning and plaque removal. That being said, if you do have bacterial gingivitis or periodontitis, candida can co-establish itself in the gums along with the bacteria causing candida infection.
How to know how bad is your oral yeast?
In a mild infection, you will have almost no symptoms – perhaps just a persistently coated tongue. Sometimes such infection may clear up without any treatment. Moderate infections show up as sores on the tongue or other mouth surface and may be accompanied with pain. Chronic or recurrent oral yeast infections are considered moderately severe. You should get the infection treated to avoid it from becoming severe. In severe form of the infection the infection spreads to other parts. If your infection is starting to travel down your throat or food-pipe (oesophagus), you can be sure that your infection is quite bad and needs immediate attention.
Is it contagious?
In general terms, oral thrush is not contagious – you do not infect people around you like you would in case of cold or flu. However, under certain circumstances, you can pass it on to others. You could, for example, get oral thrush from kissing if your immune status is less than optimal. In situations where an infant has oral yeast infection, it can be passed on to mother’s breast. It can be passed between sexual partners if their immune system is not functioning optimally or is suppressed due to medication, metabolic disease or other reasons.
How common are oral yeast infections?
Oral yeast infections are not very common in general population. However, they are a more common occurrence in immune-compromised people.
Will it go away on its own or do I have to treat it?
Oral candida is not very common and, as we have discussed in this article, generally has an underlying cause. Only once the underlying cause goes away will oral thrush go away. In case of antibiotic based oral thrush, the infection goes away when antibiotics are stopped and the normal flora returns to normal. So, no, it will not go away on its own and you need to find the source of the problem and treat that.
How long does the oral yeast infection pill take to work?
Oral fluconazole can take 7-14 days to work. For fluconazole resistant candida infections, other azole drugs are given orally which need to be taken for up to 28 days. Depending on your infection it can take anywhere from a week to a month after using an oral pill. If you take CanXida Remove, it is recommended that you take it for a month and combine it with other good practices to build up your immunity and natural flora balance to see an effect.
Can it spread to other parts?
Yes, it can. It can spread to different parts of the mouth, or the throat or oesophagus.
Is it always on tongue or can you have it on lips?
As described in this article, you can get it on tongue, lip, inner cheek or gums.
Can I smell bad if I have it?
Yes, you can have bad breath (halitosis) if you have oral thrush.
Is doing a mouthwash good enough?
It depends on the type, severity, your age and your immune system whether mouthwash will be able to rid you of the infection. In cases of mild to moderate infections, mouthwash may help remove the infection – under the condition that your immune system had just suffered a temporary suppression. In case of difficult to reach, severe candida infection of the mouth, or under chronic state of immune suppression due to any reason, a mouthwash will most definitely not be enough and you will need to address the underlying cause of the infection.
As a rule-of-the-thumb, do not depend on single shot, single target “treatment” – these may temporarily relieve you of the symptoms, but will not cure the condition. Try and inculcate a holistic view towards health – find the underlying cause and treat the disease, not just the symptoms; target the disease on multiple possible fronts.
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Who is more likely to get oral thrush?
People who are immune-compromised for one reason or other are more likely to get oral thrush. You can read more details in cause and effect section.
Can you get oral thrush by giving oral to your girlfriend who has vaginal yeast infection?
It is established that one can get vaginal candida infection from oral sex. Conversely, not many studies can be found in the literature about the transmission of candida from the genitals to the mouth. However, a German article by Dr. H. Schofer, published in 2012, definitely says that it is possible to transmit genital candida infection to the mouth. Dr. Schofer says that it is important for a person with oral thrush to take their partner to diagnostics (for vaginal/penile candida infection) if they engage in oral sex. This is important to avoid “ping-pong transmissions” back and forth between the partners. Thus, in the situation where you have an oral- while your sexual partner has genital- candida infection, both of you need to get treatment.