When should I consider referring a patient with oral thrush to a specialist?

Consider referring a patient with oral thrush to a specialist if:

• The infection is severe or extensive, or the patient is markedly immunocompromised, with a low threshold for early referral in these cases.
• There is breakthrough candidiasis while the patient is on preventive antifungal treatment, suggesting possible resistance.
• The patient experiences recurrent episodes of oral candidiasis.
• There is doubt about the diagnosis of oral thrush.
• The patient has chronic plaque-like oral candidiasis that is unresponsive to treatment, due to the risk of malignancy and the need for biopsy.
• The infection persists despite an extended course of fluconazole treatment (beyond 14–21 days).
• There is evidence of systemic illness or widespread infection such as oesophageal candidiasis, especially in immunocompromised patients, which may require admission and specialist input.

Referral or seeking specialist advice should also be considered if initial treatment fails, or if the patient has risk factors such as diabetes with poor control, or if there are concerns about drug interactions or complications.

In summary, use clinical judgement considering severity, immunocompromise, treatment response, and diagnostic uncertainty to decide on referral to an oral surgeon or specialist.

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