Chapter 3:
Antifungals
Overview
Fungal infections encountered in dental practice can vary from being superficial to deep. Whether presenting as a local manifestation, or as a symptom of a systemic infection, it is important for all dental clinicians to familiarize themselves with the common presentations and treatment alternatives for oral fungal infections.
NOTE: The sample prescriptions in this handbook represent a general recommendation. Clinicians are responsible to adjust the prescription dose, frequency and length of treatment based on the procedure performed, the medicine prescribed, and the patient conditions such as age, weight, metabolism, liver and renal function.
1 | Oral Candidiasis
Candida is a dimorphic organism normally found in the gastrointestinal and vaginal tracts of humans. The fungus is dimorphic, existing in a yeast as well as a hyphal phase. The presence of Candida in and on the human body is typically well tolerated, and the organism is not normally viewed as being pathogenic.
The situation can change when the normal environment is interrupted from conditions and practices such as: immune system compromise, a breach in the mucosa or skin, decreases in salivary flow (xerostomia), the introduction of dental prostheses such as acrylic dentures, nutritional deficiencies, the use of broad-spectrum antibiotics and the intake of other medications, such as chronically-administered steroids.
It is important to replace contaminated oral hygiene devices (toothbrushes, denture brushes) to prevent relapse of the infection after successful treatment. It is highly recommended for patients on continuous positive airway pressure (CPAP) therapy to follow strict hygiene guidelines to prevent fungal contamination, and further systemic infection. Oral fungal infections can be localized or associated with systemic infection.
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Table 1. Superficial Oral Fungal Infections |
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Pseudomembranous Candidiasis (Thrush) |
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Clinical Picture |
• Most commonly seen form of oral fungal infection caused by Candida (35%) •Clinical predictor of HIV disease progression •Presents with a white, “cottage cheese” appearance that often, when scraped off, typically leaves a raw, erythematous surface that can bleed easily •Can present with oral burning sensation and/or sense of taste abnormalities |
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Affected Populations |
• The very young and the very old (populations having immune system deficiencies) •People who are immunocompromised, often as resulting from disease or certain medications such as: – Broad-spectrum antibiotics – Prednisone – Inhaled corticosteroids – Drugs that cause dry mouth |
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Drugs of Choice* |
• Clotrimazole troche – Disp: 70 troches – Sig: Dissolve 1 troche in the mouth 5 times/day until gone – Advise the patient to allow the troche 15-30 minutes to dissolve in the mouth – Troches contain sucrose and can increase caries risk with prolonged use (> 3 months) and dry mouth conditions •Nystatin tablets – Disp: 30 tablets – Sig: Dissolve 1 tablet in the mouth, 4 times/day •Nystatin suspension – Disp: 300 mL – Sig: Swish with 1 tsp 4 times/day and expectorate – Suspension vehicle contains 50% sucrose and can increase caries risk with prolonged use (>3 months) and/or dry mouth conditions •Fluconazole – to be used only if infection does not respond to the Clotrimazole or Nystatin – Disp: 16 tablets – Sig: Take 2 tablets on day one and 1 tablet/day thereafter until resolved – Take for 14 days |
* Also, see the drug monograph for Clotrimazole, Nystatin, and Fluconazole at the end of the chapter.
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Table 1. Superficial Oral Fungal Infections |
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Erythematous Candidiasis (Atrophic) |
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Clinical Picture |
• Absence of a pseudomembranous coating •Areas most affected: – Palate – erythematous patches – Dorsum of the tongue (median rhomboid glossitis), results in depappillation, and affects 3 times more men than women – Corners of the mouth •Most often associated with the use of broad-spectrum antibiotics or corticosteroids •Raw-looking appearance •Painful |
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Chronic Hyperplastic Candidiasis |
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Clinical Picture |
• Also known as candida leukoplakia since there is a white plaque present •Areas most affected: – Commissural region of the buccal mucosa – Palate – Tongue •Cannot be readily wiped away •Is often associated with a diagnosis of epithelial dysplasia •Close follow-up is advised, especially if the lesions are recalcitrant to therapy, and a tissue biopsy may be indicated to determine if dysplasia is present |
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Table 1. Superficial Oral Fungal Infections |
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Angular Cheilitis (Perleche) |
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Clinical Picture |
•A form of chronic atrophic candidiasis • A mixed bacterial-fungal infection •Erythematous fissures develop at the commissures, often covered with a pseudomembranous coating and/or a crusting/scaling appearance •May also affect the anterior portion of the nares •Requires a moist environment •Symptoms can range from asymptomatic to severe discomfort, itching, burning, irritation •Contributing factors include: – Reduced vertical dimension of occlusion – ill-fitting dentures – Facial wrinkling along nasolabial folds or corners of the mouth – Thumb sucking – Tobacco smoking – Down syndrome – Hypersalivation – HIV – Solid organ cancer (pancreas, kidney, liver) – Medical conditions: anemia, diabetes – Nutritional deficiencies: iron, thiamine, riboflavin, folic acid |
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Affected Populations |
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