White patches in the mouth, sometimes painful, often painless, are most commonly symptoms of thrush, and less commonly symptoms of oral hairy leukoplakia.
Thrush-Thrush is a common infection of the mouth caused by the fungus Candida albicans. Candida albicans is found in the mouths of most people; thrush occurs only when the fungus begins growing out of control. Symptoms include white or grayish-white patches that look a little like cottage cheese along the gums, along the inside of the cheeks, or on the tongue. Thrush can be unnoticeable, or it can cause pain severe enough to interfere with chewing or swallowing. Thrush does not cause fever, malaise, fatigue, tooth loss, or headache. Since most people have the fungus in their mouths, thrush is not considered contagious.
What appear to be patches of thrush can also simply be food particles in the mouth. The distinction is easily made by rinsing the mouth to remove food particles. Thrush cannot be removed without direct scraping, and scraping will leave an inflamed spot where the white patch was. A physician can usually verify the diagnosis by simply inspecting the mouth. Microscopic examination of the patch to identify the fungus can be done but is usually not necessary.
Thrush can result from taking antibiotics, which inhibit the bacteria in the mouth that seem to control the growth of Candida albicans. People with HIV infection are therefore more prone to thrush when taking trimethoprim-sulfamethoxazole, tetracycline, ampicillin, amoxicillin, erythromycin, ciprofloxacin, or other antibiotics.
Thrush is commonly viewed more as a nuisance than as a serious problem. Symptoms are often trivial, and even when severe, they are easily corrected with medication. Thrush becomes more serious when it extends to the back of the throat to the esophagus: the pain from
swallowing might cause people to stop eating, and the treatment given may be somewhat different than for thrush that is restricted to the mouth. The diagnosis of thrush in the esophagus can be made only with an endoscope, which is a tube put through the mouth by a medical specialist (gastroenterologist), or with an x-ray called a barium swallow. In many cases, these diagnostic procedures are unnecessary: the existence of thrush in the mouth, accompanied by painful swallowing, is enough to make the diagnosis.
About 80 to 90 percent of people with HIV infection eventually develop thrush; it is often the first condition indicating that the immune system is weakening. The CD4 count is usually around 100 to 400. Thrush is not an AIDS-defining diagnosis, but it does imply that AIDS is likely to occur within two or three years, unless treatment slows the progression of HIV infection. Thrush occurring in the esophagus, however, is an AIDS-defining diagnosis.
Common treatments for thrush include gargling with and then swallowing nystatin solution; sucking clotrimazole troches; or taking such pills as ketoconazole (Nizoral) or fluconazole (Diflucan). All of these are prescription drugs. If any of the drugs fails, another will usually work. Thrush is generally controlled after one or two weeks of treatment.
Occasionally people do not do well with any of these treatments, either because the diagnosis was wrong to begin with or because the infection has extended to the esophagus. In the latter cases, treatment with such drugs as amphotericin B, given intravenously, may be required for a few days.
In people with HIV infection, thrush tends to recur once treatment is discontinued. As a result, it is common practice to give these drugs for a long time, initially to control the infection and then to prevent its recurrence. Or people keep on hand the drugs prescribed for their original infection and use them intermittently whenever symptoms recur.
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