Sensitive parameters
Topical
Systemic
Polyenes
Azoles
Azoles
Difficult compliance
−
−
+
Complicating systemic disease/condition
+
+
−
Risk of drug-drug interactions
+
−
−
Azole insusceptibility
+
−
−
Treatment expense
−
−
+
13.4 Specialist Treatment
Second-generation azoles such as voriconazole and posaconazole are spared for specialist settings and selected patients with life-threatening candidiasis or severe immunocompromising conditions. Intravenous antifungal therapy with amphotericin B, echinocandins, and pyrimidines for oral candidiasis may be indicated in seriously medically compromised patients and should only be done in specialist settings.
13.5 Management of Patents with Oral Candidiasis
Management of oral candidiasis depends on several factors; some are host-sensitive and others are infection-sensitive parameters (Table 13.2).
Table 13.2
Relevant factors for management of patents with oral candidiasis
|
Host-sensitive parameters
|
|
|
1. Predispositions for oral candidiasis
|
Local
|
|
Systemic
|
|
|
2. Health and medical status of the patient affecting drug metabolism
|
Chronic diseases
|
|
Drug exposure
|
|
|
Infection-sensitive parameters
|
|
|
1. Classification of infection
|
Duration of infection (acute/chronic)
|
|
Primary/secondary/tertiary infection
|
|
|
Sporadic/recurrent
|
|
|
Clinical manifestations
|
|
|
2. Candida species
|
Susceptibility to antifungals
|
|
Resistance to antifungals
|
|
13.5.1 Host-Sensitive Parameters
Host-dependent parameters are very important factors when managing oral candidiasis. Identification of predisposing factors is crucial for successful treatment outcome (Table 13.3). If the underlying causes are not eliminated or identified, the chance of relapse is high.
Table 13.3
Local and systemic predisposing factors and conditions
|
Background
|
Intervention
|
|
|---|---|---|
|
Local
|
Poor oral hygiene
|
Instruction, motivation, and follow-up of oral hygiene procedures
|
|
High-carbohydrate diet
|
Information, motivation, and follow-up
|
|
|
Salivary gland hypofunction caused by medications, head and neck radiotherapy, or systemic diseases like Sjögren’s syndrome
|
Stimulation of functional salivary gland tissue with sugar-free pastilles or chewing gum, substitution of drug if possible
|
|
|
Mucosal traumas
|
Identify cause and eliminate
|
|
|
Mucosal diseases
|
Diagnostic workup, information, treatment, and follow-up
|
|
|
Topical steroid
|
Instruction in appropriate behaviour
|
|
|
Tobacco
|
Tobacco counselling, smoking cessation
|
|
|
Systemic
|
Immune deficiency (acquired or idiopathic)
|
Diagnostic workup and intervention.
Often need for multidisciplinary cooperation
|
|
Systemic diseases
|
||
|
Nutritional deficiency
|
The drug formulation is relevant in patients with special needs, e.g. topical formulation in patients with dysphagia and capsules in patients with reduced compliance. Patients with hyposalivation cannot dissolve pastilles and lozenges.
The health and medical status of the patient is important as the choice of antifungals depends on whether the patient can eliminate the drug in order to avoid toxic or adverse reactions. Moreover, knowledge of the patient’s drug intake is vital as severe drug-drug interactions with the antifungals can be relevant (Table 13.1 and 13.4).
Table 13.4
Central host- and infection-sensitive parameters regarding the management of patients with chronic oral candidiasis with antifungals
|
Host factors
|
Infection factors
|
|||||||
|---|---|---|---|---|---|---|---|---|
|
Administration
|
Drug
|
Formula
|
Dosage
|
Diseases
|
Drug interaction
|
Classification
|
In-sensitive Candida species
|
Comments
|
|
Topical
|
Clotrimazole
|
Cream 1 %
|
2–3 dailycontinues until 10 days after lesions healed
|
–
|
–
|
Perioral *
|
–
|
>12 years of old
|
|
Miconazole
|
Cream 2 %
|
2 dailycontinues until10 days afterlesions healed
|
–
|
+
|
Perioral *
|
+
|
||
|
Ketoconazole
|
Cream 2 %
|
1–2 dailycontinues untilsome daysafter lesionshealed
|
Liver monitoring
|
+
|
Perioral
|
+
|
||
|
Oral gel
|
2.5 ml × 4daily in 4–6weeks
|
–
|
+
|
Intraoral
|
+
|
Blockage of airway in neonatal children
|
||
|
Nystatin
|
Oral suspension 100,000 IE/ml
|
1 ml × 4 dailyin 4–6 weeks
|
–
|
–
|
Intraoral
|
–
|
||
|
Pastille 100.000 IE/unit
|
After meals x 4 daily 4 weeks
|
–
|
–
|
Intraoral
|
–
|
Not if hyposalivation
|
||
|
Amphotericin B
|
Lozenge 10 mg
|
4 times daily for 4 weeks
|
–
|
–
|
Intraoral
|
–
|
Not if hyposalivation
|
|
|
Fluconazole
|
Oral suspension 10 mg/ml
|
50–100 mg daily for 4 weeks
|
Dosis↓ reduced renal function
|
+
|
Multi-focal infection
|
+
|
||
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