Thrush

What is thrush?

Thrush is a yeast infection that causes white patches in the mouth and on the tongue. Thrush is most common in babies and older adults, but it can occur at any age.

What causes thrush?

You get thrush when a yeast called candida, normally found on the body, grows out of control.

In babies, candida causes thrush because babies' immune systems are not yet strong enough to control the growth of the yeast. Older people get thrush because their immune systems can weaken with age.

Some people get thrush when they take certain medicines, such as antibiotics or inhaled corticosteroids. People who have health problems, such as diabetes or HIV, are also more likely to get thrush.

What are the symptoms?

The most common symptoms of thrush are white patches that stick to the inside of the mouth and tongue. See a picture of thrush .

In babies, it is easy to mistake thrush for milk or formula. It looks like cottage cheese or milk curds. Don't try to wipe away these patches, because you can make them red and sore. Some babies can be cranky and do not want to eat.

How is thrush diagnosed?

In most cases, doctors can diagnose thrush just by looking at the white patches. Your doctor will also ask you questions about your health. If your doctor thinks that a health problem, such as diabetes, may be causing thrush, you may also be tested for that condition.

How is it treated?

Thrush in babies is usually not serious, and you can treat it with antifungal medicine such as nystatin liquid. In most cases, you will put the medicine directly on the white patches. When a baby has thrush, the yeast can cause a diaper rash at the same time as thrush. Your baby may need nystatin cream or ointment for his or her diaper area.

To treat thrush in adults, at first you will probably use medicine that goes directly on the white patches, such as a liquid or a lozenge. If these medicines don't work, your doctor may prescribe an antifungal pill.

How can you manage thrush?

If your baby has thrush, it may help to:

• Clean bottle nipples and pacifiers regularly using hot water.
• Clean your nipples with medicine, such as nystatin, if you breast-feed your baby. Breast-feeding mothers and babies can pass a yeast infection back and forth.
• Dry your nipples and apply lanolin lotion after breast-feeding.

If you wear dentures and have thrush, be sure to clean your mouth and dentures every night. You can soak them overnight in a denture cleaner that you buy at the store. Rinse your dentures well after soaking them.

Frequently Asked Questions

Candida, the yeast that causes thrush, is normally present in small amounts in the mouth and on other mucous membranes. It usually causes no harm. However, when conditions are present that allow the yeast to grow uncontrolled, it invades surrounding tissues and becomes an infection.

Thrush is most commonly caused by the yeast Candida albicans. Less frequently, other forms of candida can lead to thrush. These include Candida tropicalis, Candida krusei, Candida parapsilosis, and Candida glabrata.¹

There are many types of bacteria in your mouth that normally control the growth of candida. Sometimes a new type of bacteria gets into your mouth and disrupts the balance of the organisms already there, allowing candida to overgrow. Health conditions and other factors may also be involved.

• An impaired ability to fight infection (weakened immune system) increases your risk for thrush. A normal immune system is usually strong enough to prevent candida from overgrowing.
  • Infants are more prone to thrush because an infant's immune system is not fully developed. Thrush is a common condition in infants during the first few weeks of life.
  • Older adults are more likely to develop thrush because they may have weaker immune systems.
  • People with human immunodeficiency virus (HIV) infection have a high likelihood of developing thrush. About 90% of people with HIV develop thrush at some point during the course of their disease.²
  • People with diabetes are more prone to thrush because high blood sugar levels promote overgrowth of the candida fungus.
• Having a dry mouth (xerostomia) can lead to thrush. Dry mouth can result from overuse of mouthwashes or from certain conditions such as Sjögren's syndrome.
• Pregnancy increases your risk for thrush. Hormone changes during pregnancy can lead to thrush by altering the balance of bacteria in the mouth.
• Not caring for your teeth can make thrush more likely to develop. This is especially true in people who have false teeth (dentures).
• Taking antibiotic or inhaled corticosteroids medications may lead to thrush. These medicines may upset the balance of bacteria in the mouth.

How thrush spreads

The yeast causing thrush can pass from one person to another in different ways.

• A newborn can get thrush during birth, especially if his or her mother had a vaginal yeast infection during labor and delivery. Symptoms of thrush generally appear 3 to 7 days after birth. Newborns and infants have an immature immune system and have not fully developed a healthy balance of bacteria and fungus in their mouths. Because of this, thrush is common during the first few months of life.
• In otherwise healthy toddlers and older children, thrush is usually not contagious. However, a child with a weakened immune system may develop thrush by sharing infected toys or pacifiers with a child who has the infection. A child with thrush spreads the thrush fungus onto anything the child puts in his or her mouth. Another child may then get thrush by putting an infected object into his or her mouth.
• Adults who wear false teeth (dentures) are at a higher risk for developing thrush and spreading it to others. This may happen when another person touches something with the yeast on it and then touches his or her mouth.

Thrush can be a mild infection that causes no symptoms. If symptoms develop, they may include the following.

In infants

Symptoms of thrush in an infant may include:

• White patches inside the mouth and on the tongue that look like cottage cheese or milk curds. Thrush is often mistaken for milk or formula. The patches adhere to the mouth and tongue and cannot be easily wiped away. When rubbed, the patches may bleed.
• A sore mouth and tongue and/or difficulty swallowing.
• Poor appetite. The infant may refuse to eat, which can be mistaken for lack of hunger or poor milk supply. If the infant is unable to eat because of a sore mouth or throat, he or she may act fussy.
• Diaper rash. Diaper rash may develop because the fungus that causes thrush will be in the baby's stool.

In adults

Symptoms of thrush in an adult may include:

• A burning feeling in the mouth and throat (at the start of a thrush infection).
• White patches that adhere to the mouth and tongue. The tissue around the patches may be red, raw, and painful. If rubbed (during tooth brushing, for example), the patches and the tissue of the mouth may bleed easily.
• A bad taste in the mouth or difficulty tasting foods. Some adults say they feel like they have cotton in their mouth.
• Sore, red nipples in a breast-feeding mother. She may also have a severe burning pain in the nipples during and after breast-feeding. Her baby (who spreads thrush to the mother's nipples) may not have any symptoms.

Most cases of thrush are mild and clear up with the use of an antifungal mouth rinse or lozenges. Very mild cases of thrush may clear up without medical treatment. It usually takes about 14 days of treatment with an oral antifungal medication to cure more severe thrush infections. In some cases, thrush may last several weeks even with treatment.

If thrush goes untreated and does not go away by itself, it can spread to other parts of the body.

• Thrush can spread to the throat (esophagus), the vagina, or the skin. It rarely spreads to other organs of the body.
• Infants can develop a diaper rash because the yeast that causes thrush is in the infant's stool.

Thrush is more likely to recur in:

• People who use inhaled corticosteroids to treat asthma.
• People who take antibiotic medications for a long time.
• People who have false teeth.
• People who have a weakened immune system.
• Children who put objects contaminated with the thrush-causing yeast into their mouths.

Complications

Complications related to thrush are rare in healthy people but may include:

• Poor nutrition for infants who have trouble eating because of thrush.
• Infection of the throat.

There are several factors that can increase your risk of developing thrush.

Age

• Newborns and infants don't have fully developed immune systems, which increases their risk of developing infections, including thrush.
• Newborns are also in the process of developing a healthy balance of bacteria and fungi in their mouths. If this balance is upset, the child may develop thrush.
• Older adults, especially those who have serious health problems, are more likely to develop thrush because their immune systems are likely to be weaker.

Behavior

• The yeast that causes thrush can be spread by oral sex.
• Heavy smoking can lower the body's ability to fight off infections, making thrush more likely to develop.

Other conditions

• False teeth (dentures), braces, or a retainer that irritates the mouth make it hard to keep the mouth clean and can increase your risk of developing thrush. An unclean mouth is more likely to develop thrush than is a clean mouth.
• People with a weakened immune system, such as those who have diabetes or human immunodeficiency virus (HIV) or who are undergoing chemotherapy, have an increased risk for developing thrush.

Medications

Some medications can allow the fungus that causes thrush to grow uncontrolled.

• Antibiotics, especially those that kill a wide range of organisms (broad-spectrum antibiotics), such as tetracycline
• Birth control pills (oral contraceptives)
• Medications that weaken the body's immune system, such as corticosteroids

Environment

Exposure over time to certain environmental chemicals, such as benzene and pesticides, can weaken the body's immune system, increasing your risk for developing infections, including thrush.

If you think you may have thrush but it has not been diagnosed, see the topic Mouth Problems, Noninjury to evaluate your symptoms.

Call your doctor today if you or your child has been diagnosed with thrush and:

• You have symptoms of spreading infection, such as white patches on the skin outside of the mouth.
• Your symptoms are getting worse or are not improving within 7 days of starting treatment.

Thrush in an infant's mouth can cause redness and pain in the breast of the nursing mother. Contact your doctor if you have redness and pain in the nipples in spite of home treatment or if you have burning pain in the nipple area when you nurse. Your baby's mouth should be examined to determine whether thrush is causing your symptoms.

Watchful Waiting

If you have previously been diagnosed with thrush and you believe you may have another thrush infection, home treatment may help. Very mild cases of thrush may clear up without medical treatment. Seek your doctor's advice if:

• Your symptoms are getting worse or are not improving in spite of home treatment.
• Your symptoms recur frequently.
• You have HIV infection, cancer, or another condition that weakens your immune system.

Who To See

The following health professionals can diagnose and treat thrush:

• Pediatrician
• Nurse practitioner
• Physician assistant
• Family medicine doctor
• Internist

Other specialists may be required if other organs become infected or other conditions develop. The type of specialist depends on the organs affected and may include the following:

• Gastroenterologist
• Dermatologist
• Gynecologist
• Infectious disease specialist

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Thrush is a yeast infection that can develop in the mouth and throat and on the tongue. Thrush is most common in newborns, infants, and older adults, but it can occur at any age. In healthy newborns and infants, thrush is usually not a serious problem and is easily treated and cured.

A visual examination is usually all that is needed to diagnose thrush. In addition to looking in your mouth, your doctor will ask you questions about your medical history.

In rare cases, your doctor may order a KOH prep test in which one of the white patches is scraped and examined. A KOH prep test is used only in cases when thrush is not clearly evident on visual examination or when a diagnosed case of thrush is not responding to prescribed medications.

Thrush is a yeast infection that can develop in the mouth and throat and on the tongue. Thrush is most common in newborns, infants, and older adults, but it can occur at any age. In healthy newborns and infants, thrush is usually not a serious problem and is easily treated and cured.

Except for the mildest cases, you should treat thrush to keep the infection from spreading. Antifungal medications, which inhibit the growth of yeast, are the standard treatment for thrush. Thrush is most commonly treated with medications that are either applied directly to the affected area (topical) or swallowed (oral).

• Your or your child's general health, the severity of the infection, and the persistence or recurrence of the infection determine how the medication will be given.
• Infants are nearly always treated with topical antifungal medications. Topical medications don't work as well in adults because they have bigger mouths and it is hard to cover the affected areas.

Mild thrush

In adults, mild cases of thrush may clear up with simple treatment that can be done at home. This treatment usually involves using an antifungal mouth rinse or lozenges. Treatment usually lasts about 14 days.

Mild thrush in infants is usually treated with topical medications until at least 48 hours after the symptoms have gone away.

Moderate to severe thrush

More severe thrush infections that have spread to the esophagus are treated with an oral antifungal medication. A topical antifungal medication may also be used.

For some severe infections, a treatment period longer than 14 days may be needed.

Oral antifungal medications are almost never used during pregnancy because the fetus may be harmed. However, if a pregnant woman has a rare, severe thrush infection that has spread to her blood, oral antifungal medications may be used. In this case, the risk of harm to the mother and fetus from the severe thrush infection may be greater than the risk posed by the use of antifungal medications.

Persistent or recurrent thrush

Persistent or recurrent cases of thrush may:

• Need to be treated twice as long as the symptoms last.
• Require treatment with both oral and topical antifungal medications.

People with weakened immune systems can take an antifungal medication on a continuous basis to prevent thrush infections.

It is very important to get rid of any sources of infection, or thrush will continue to come back. Do this by cleaning toys, pacifiers, bottles, and other items a child may put in his or her mouth or share with another child. For more information, see the Prevention section of this topic.

It is important to treat conditions that make you more likely to get thrush, such as diabetes, human immunodeficiency virus (HIV), or cancer. For more information, see the Prevention section of this topic.

Thrush is a yeast infection that can develop in the mouth and throat and on the tongue. Thrush is most common in newborns, infants, and older adults, but it can occur at any age. In healthy newborns and infants, thrush is usually not a serious problem and is easily treated and cured.

To prevent thrush from developing:

• Practice good oral hygiene, including brushing and flossing your teeth daily and using an antiseptic mouthwash. If you have had a previous thrush infection, replace your toothbrush to help prevent another infection. If you wear dentures, soak them each night in a chlorhexidine gluconate solution you can get from your pharmacist. You can also use a denture cleaner (such as Polident or Efferdent) that is sold in most drug or grocery stores. Scrub your dentures with water both before and after soaking them.
• Practice good hand-washing.
• If you are taking a liquid antibiotic, rinse your mouth with water shortly after taking it.
• Get treatment for conditions that increase your risk for thrush, such as diabetes, human immunodeficiency virus (HIV), or cancer.
• Use a spacer when taking inhaled corticosteroids, and rinse your mouth with mouthwash after inhaling the dose.
• For people with acquired immunodeficiency syndrome (AIDS), Listerine mouthwash may be particularly helpful.

To reduce the risk of spreading thrush to infants:

• Treat vaginal yeast infections, especially during the last 3 months of pregnancy. This will decrease your baby's risk of getting thrush during delivery. It also helps prevent spreading the infection through oral sex.
• Wash bottle nipples and pacifiers daily, and keep all prepared bottles and nipples in the refrigerator to decrease the likelihood of yeast growth.
• Do not reuse a bottle more than an hour after the baby has drunk from it because yeast may have had time to grow on the nipple.
• Boil for 20 minutes all objects that the baby puts in his or her mouth, or run them through the dishwasher.
• Change your baby's diaper soon after it is wet. A wet diaper area provides a good environment for the yeast that causes thrush to grow.
• Breast-feed your baby if possible. Breast milk contains antibodies that will help build your baby's natural defense system (immune system) so he or she can resist infection.
• Contact your doctor if you are breast-feeding and your nipples become red and sore or you have a burning pain throughout your breasts during or after nursing your baby. This may be a sign of a thrush infection in your baby.

If your baby is taking antibiotic medication for a different infection, such as an ear infection, rinse his or her mouth out with water after each dose. Antibiotic medications can disrupt the balance of bacteria in the mouth and allow growth of the yeast that causes thrush. Rinsing the mouth with water after taking an antibiotic can prevent disrupting the normal environment in the mouth.

If your baby needs medication to treat thrush, don't put the medicine dropper in the baby's mouth. Drop the medicine on a cotton swab and swab it on the affected area. Throw away the swab, and don't put anything back into the medicine bottle that could be contaminated with the yeast.

Thrush is a yeast infection that can develop in the mouth and throat and on the tongue. Thrush is most common in newborns, infants, and older adults, but it can occur at any age. In healthy newborns and infants, thrush is usually not a serious problem and is easily treated and cured.

If your child only has mild thrush, you may only need to clean bottle nipples and pacifiers regularly and massage the inside of your child's mouth with a clean moist cloth. If you are breast-feeding, you should clean your nipples with an antifungal medication, such as nystatin (Mycostatin). You should also dry your nipples after breast-feeding. Applying lanolin-containing body lotion may help relieve nipple soreness.

If you develop thrush and have false teeth (dentures), it is important to clean your mouth and dentures every night.

• Remove your dentures before going to bed.
• Scrub them well with a clean toothbrush and water.
• Soak them overnight in chlorhexidine gluconate, which you can get from a pharmacist. Or you can use a denture cleaner (such as Polident or Efferdent) that is sold in most drug or grocery stores.
• Rinse the dentures well in the morning. If you used chlorhexidine gluconate to soak your dentures, don't use fluoride toothpaste for at least 30 minutes after putting your dentures back in your mouth. (Fluoride can weaken the effect of chlorhexidine gluconate.)

Gentian violet (1%), which is a dye that kills bacteria and fungi, sometimes works as treatment for thrush. It is available without a prescription. Gentian violet should only be used on adults. Talk to your doctor before using it to treat a child with thrush. If gentian violet does not work, talk to your doctor about other treatments to try.

Comfort measures

Measures can be taken to reduce the discomfort of thrush:

• Drink cold liquids, such as water or iced tea, or eat flavored ice treats or frozen juices.
• Eat foods that are easy to swallow such as gelatin, ice cream, or custard.
• If the patches are painful, try drinking from a straw.
• Rinse your mouth several times a day with a warm saltwater rinse. You can make the saltwater mixture with 1 tsp (5 g) of salt in 8 fl oz (0.2 L) of warm water.

Thrush is a yeast infection that can develop in the mouth and throat and on the tongue. Thrush is most common in newborns, infants, and older adults, but it can occur at any age. In healthy newborns and infants, thrush is usually not a serious problem and is easily treated and cured.

Both nonprescription and prescription medications that inhibit the growth of yeast (antifungals) are available for treating thrush. If nonprescription medications do not cure thrush, you will need to see a doctor for a prescription medication.

In infants, treatment is continued for at least 48 hours after the symptoms have gone away. Most adults need treatment for 14 days. In more severe or persistent infections, treatment may be continued beyond the normal treatment period.

Antifungal medications are either applied directly to the affected area (topical) or swallowed (oral) so the medication affects the whole body.

Topical antifungal medications

Topical antifungal medications are applied to the affected area and are available in a variety of forms, such as rinses and lozenges.

Topical antifungal medications need to be in contact with the affected area long enough to stop the growth of the fungus. Lozenges are preferred because they take longer to dissolve. Because the lozenges need moisture to dissolve, sipping water while using them may increase their effectiveness.

Because several of the topical antifungal medications contain sugar, there is an increased risk of cavities when the medications are used for long periods of time. Using a topical fluoride rinse or gel (if you are not already obtaining fluoride through other means) during treatment may help prevent cavities from forming.

Oral antifungal medications

Unlike topical antifungal medications, oral antifungal medications affect the whole body. Oral medications are used alone to treat mild thrush infections, but they also may be combined with topical antifungal medications to treat more severe thrush infections.

Oral antifungal medications are used to prevent thrush in certain people with conditions that weaken the body's immune system.

Oral antifungal medications should not be used during pregnancy because the fetus may be harmed. However, oral antifungal medications may be used in pregnant women who have a rare, severe infection that has spread to the blood.

In rare cases, an antifungal medication will need to be injected into a vein (intravenous, or IV).

Medication Choices

Nonprescription medications

• Gentian violet (1%) is a dye that kills bacteria and fungi, including the yeast that causes thrush.
• Listerine mouthwash has been recommended to help prevent thrush in people with acquired immunodeficiency syndrome (AIDS).

Prescription medications

• Polyenes (such as Mycostatin and Fungizone)
• Azoles (such as Diflucan, Monistat, Mycelex, Nizoral, and Sporanox)
• Chlorhexidine (such as Peridex)

What To Think About

• Both polyenes and azoles cure thrush most of the time.
• Nystatin (a polyene) is the medication used most often to treat infants with thrush.
• Although azoles have been shown to be safe for babies and children in a few limited studies, more research is needed.³ Polyenes are usually the first medicine tried for babies and children. Relapse rates are about the same for both medicines.³

There is no surgical treatment for thrush at this time.

There is no other treatment for thrush at this time.

Organizations

• Mouth Problems, Noninjury
• Vaginal Yeast Infections

Citations

1. Weinberg A, Levin MJ (2003). Infections: Parasitic and mycotic. In WW Hay Jr et al., eds., Current Pediatric Diagnosis and Treatment, 16th ed., pp. 1240–1243. New York: McGraw-Hill.

2. Darouiche RO (1999). Oropharyngeal and esophageal candidiasis in immunocompromised patients: Treatment issues. Clinical Infectious Diseases, 26: 250–274.

3. American Academy of Pediatrics (2003). Candidiasis. In LK Pickering, ed., Red Book: 2003 Report of the Committee on Infectious Diseases, 26th ed., pp. 229–232. Elk Grove Village, IL: American Academy of Pediatrics.

Other Works Consulted

• American Public Health Association (2004). Candidiasis. In DL Heymann, ed., Control of Communicable Diseases Manual, 18th ed., pp. 84–86. Washington, DC: American Public Health Association.

• Hughes WT, Flynn PM (2004). Candidiasis. In RD Feigin et al., eds., Textbook of Pediatric Infectious Diseases, 5th ed., vol 2, pp. 2569–2579. Philadelphia: Saunders.

• Rex JH, et al. (2000). Practice guidelines for the treatment of candidiasis. Clinical Infectious Diseases, 30: 662–678.

Author:	Amy Fackler, MA Merrill Hayden	Last Updated March 30, 2006
Medical Review:	Kathleen Romito, MD - Family Medicine Michael J. Sexton, MD - Pediatrics Emmett Francoeur, MDCM, CSPQ, FRCPC - Pediatrics
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