Recommendations for the assessment and treatment of oral candidal infection are in line with expert opinion from a textbook [Hay and Moore, 2004] and narrative reviews [Akpan and Morgan, 2002; Gonsalves et al, 2007; Samaranayake et al, 2009].

First line treatment

• Miconazole
• Miconazole has a broad spectrum of activity against fungal and yeast species, and has some additional activity against some Gram-positive bacteria, making it useful in the treatment of angular cheilitis (which is sometimes caused by Staphylococcal aureus) [Pappas et al, 2009; Samaranayake et al, 2009].
• There is a lack of direct evidence from randomized controlled trials (RCTs) to support the use of topical miconazole in the treatment of oral candidiasis in otherwise healthy adults. However, its use is supported by pharmacological principles, historical use, and extrapolation of clinical data from trials in other groups (such as infants and people who are immunosuppressed).
• Nystatin
• There is a lack of evidence from RCTs to support the effectiveness of nystatin suspension in the treatment of oral candidal infection in otherwise healthy adults. However, data extrapolated from trials in infants and immunosuppressed people suggest it is not as effective as topical miconazole or fluconazole, and therefore not suitable as first-line treatment.
• Fluconazole
• Fluconazole has a broad range of antifungal activity, including against candida species [Pappas et al, 2009; Samaranayake et al, 2009]. Although there is a lack of evidence from RCTs to show the efficacy of oral fluconazole in otherwise healthy people, data extrapolated from trials in infants and immunosuppressed people suggest it is an effective option. Fluconazole is not routinely recommended for first-line treatment of mild and localized candidiasis because:
• It is systemically absorbed, and may cause adverse effects.
• Its use is associated with increasing levels of candidal resistance (especially Candida glabrata or C. krusei) [Laudenbach and Epstein, 2009].

Dental hygiene and smoking

• Poor dental hygiene has been identified as a risk factor for oral candidal infection [Samaranayake et al, 2009], although there is a lack of evidence to show improved hygiene is beneficial.
• Smoking is regarded as a significant cause of oral candidal infection, particularly median rhomboid glossitis. Smoking cessation alone may clear infection in these people [Akpan and Morgan, 2002].

Diabetes and oral candidal infection

• There is conflicting evidence from several observational studies as to whether diabetes is a cause of oral candidal infection.
• The presence of Candida has been associated with poor glycaemic control by some studies [Hill et al, 1989; Aly et al, 1992; Guggenheimer et al, 2000]. However, other studies found no relationship between oral candidal carriage/growth and antidiabetic therapy or glycaemic controls [Bartholomew et al, 1987; Belazi et al, 2005; Kumar et al, 2005].
• The discrepancies between studies may reflect differences in methodology, such as variation in sampling techniques and selection of control populations [Soysa et al, 2006].
• It is generally accepted that an association between diabetes and oral candidal infection is plausible, and most experts agree that good control of blood glucose is important in the long-term management of oral candidiasis [Soysa et al, 2006]. This will also have other wide-reaching benefits.

Drugs not recommended for initiation in primary care

• Oral itraconazole should be reserved for people with fluconazole-resistant candidiasis [BNF 57, 2009]. Specialist advice should be obtained before initiating itraconazole therapy because of the increased risk of drug interactions and adverse effects.
• Oral ketoconazole should only be prescribed for the treatment of chronic mucocutaneous candidiasis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].
• Oral amphotericin is not recommended as there is a lack of trial evidence to show its efficacy in the treatment of oral candidal infection. It is sometimes used as adjunct to other systemic antimycotic drugs.