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Palliative cancer care - oral problems - Management
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What are the risk factors for oral candidiasis?

  • Local factors:
    • Poor oral hygiene.
    • Wearing dentures.
    • Dry mouth.
    • Alteration of saliva composition (e.g. when levels of salivary glucose are high owing to diabetes).
    • Damage to the oral mucosa from radiotherapy, chemotherapy, surgery, or cancer. 
    • Alterations in mouth flora (e.g. levels of competitive bacteria in the mouth are reduced after treatment with antibiotics).
    • Reduced mechanical debridement (e.g. comatose, enterally or parenterally fed people, trismus).
  • Systemic factors:
    • Diabetes.
    • Immunosuppression.
    • Drugs (e.g. corticosteroids).
    • Malnutrition.

What assessment do I need to make?

  • Perform a full history and examination. Assess concurrent symptoms, psychological state, social needs, and spiritual needs. See the CKS topic on Palliative cancer care - general issues.
  • Assess the person's:
    • Understanding of the diagnosis and their current problems, and how they and their family/carer are coping.
    • Nutritional status and whether their fluid intake is adequate.
    • Level of oral hygiene, and whether they can carry out routine oral care.
  • Estimate the likely prognosis, if possible. For further information, see Prognostic Indicator Guidance (pdf).

In depth

What is the first-line treatment for oral candidiasis?

  • In immunocompetent people, use topical nystatin, or miconazole for first-line treatment.
  • In immunocompromised people, high-dose oral fluconazole is generally preferred for first-line treatment.
  • Predisposing local and systemic risk factors for oral candida should be managed in conjunction with anticandidal treatment.
  • Chlorhexidine should be used to clean dentures and may be used as an adjunct to topical or oral treatment.
  • Note: the choice of anticandidal drug treatment may be dictated by local policy or based on advice from a local microbiologist.

How should I manage treatment failure of oral candidiasis?

  • Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
  • Fluconazole is the preferred oral antifungal drug, except when fluconazole-resistant infections are present.

What other advice should I give?

  • Encourage regular oral hygiene. See Self care.

What follow-up is recommended?

  • Review if the person does not respond to first-line topical antifungal treatment within 7 days.
    • Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
  • If there is evidence of persistent oral candidiasis after initial topical treatment, consider prescribing oral fluconazole.
  • If oral candidiasis persists, seek specialist advice.

When is referral indicated?

  • If oral candidiasis:
    • Persists, despite specialist advice.
    • Is interfering with oral intake and nutrition.

Prescriptions

1st-line topical antifungals

Age from 16 years onwards
Nystatin 100,000units/ml s/f susp: use 1ml four times a day
Nystatin 100,000units/ml oral suspension sugar free
Using the oral dispenser provided, place 1 ml in the mouth and hold near the affected area(s) four times a day.
Supply 30 ml.
Age: from 16 years onwards
NHS cost: £1.91
Licensed use: yes
Patient information: Use after food or drink. Hold the liquid near the affected area for as long as possible before swallowing. Remove dentures before use. Continue treatment for 48 hours after lesions have healed. Consult your doctor if condition has not improved after 7 days of treatment.
Miconazole 20mg/g oromucosal gel 5ml to 10ml 4 times a day.
Miconazole 20mg/g oromucosal gel sugar free
Place 5ml to 10ml in the mouth and hold near the affected area(s) four times a day.
Supply 160 grams.
Age: from 16 years onwards
NHS cost: £9.30
Licensed use: yes
Patient information: Use after food and drink. Try to keep the gel in the mouth for a few minutes in the area affected before swallowing. If there are separate lesions, a small amount of gel can be smeared on to the affected area four times a day with a clean finger. Remove dentures before use. At bedtime, the dentures should be removed and brushed with a small amount of the gel. Continue treatment for 48 hours after lesions have healed. Consult your doctor if condition has not improved after 7 days of treatment.

2nd-line oral fluconazole

Age from 16 years onwards
Fluconazole capsules: 50mg once a day
Fluconazole 50mg capsules
Take one capsule once a day for 7 days.
Supply 7 capsules.
Age: from 16 years onwards
NHS cost: £2.07
Licensed use: yes
Fluconazole suspension: 50mg once a day
Fluconazole 50mg/5ml oral suspension
Take one 5ml spoonful once a day for 7 days.
Supply 35 ml.
Age: from 16 years onwards
NHS cost: £16.61
Licensed use: yes
Patient information: The oral suspension should be swished around the oral cavity and swallowed. There should be no rinsing after swallowing.

Immunocompromised: oral fluconazole

Age from 16 years onwards
Fluconazole capsules: 100mg once a day for 7 days
Fluconazole 50mg capsules
Take two capsules once a day for 7 days.
Supply 14 capsules.
Age: from 16 years onwards
NHS cost: £4.14
Licensed use: yes
Fluconazole capsules: 100mg once a day for 14 days
Fluconazole 50mg capsules
Take two capsules once a day for 14 days.
Supply 28 capsules.
Age: from 16 years onwards
NHS cost: £8.28
Licensed use: yes
Fluconazole suspension: 100mg once a day for 7 days
Fluconazole 50mg/5ml oral suspension
Take two 5ml spoonfuls once a day for 7 days.
Supply 70 ml.
Age: from 16 years onwards
NHS cost: £33.22
Licensed use: yes
Patient information: The oral suspension should be swished around the oral cavity and swallowed. There should be no rinsing after swallowing.
Fluconazole suspension: 100mg once a day for 14 days
Fluconazole 50mg/5ml oral suspension
Take two 5ml spoonfuls once a day for 14 days.
Supply 140 ml.
Age: from 16 years onwards
NHS cost: £66.44
Licensed use: yes
Patient information: The oral suspension should be swished around the oral cavity and swallowed. There should be no rinsing after swallowing.

Oral candidiasis: Chlorhexidine mouthwash

Age from 16 years onwards
Chlorhexidine mouthwash: rinse with 10ml twice a day
Chlorhexidine gluconate 0.2% mouthwash
Rinse the mouth with 10ml for about 1 minute twice a day. Continue use for 48 hours after symptoms have resolved.
Supply 300 ml.
Age: from 16 years onwards
NHS cost: £1.94
OTC cost: £4.45
Licensed use: yes
Patient information: When used regularly, this mouthwash may stain teeth brown but this is not usually permanent. Brushing the teeth before using the mouthwash can minimize the staining but make sure that you rinse your mouth well with water before you rinse with the mouthwash. Do not use this mouthwash continuously for more than 1 month.

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