THE ROLE OF ANTIFUNGAL AND ANTIVIRAL AGENTS IN PRIMARY DENTAL CARE - PowerPoint Presentation

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THE ROLE OF ANTIFUNGAL AND ANTIVIRAL AGENTS IN PRIMARY DENTAL CARE

Matt

Dickie

Significantly limited spectrum of antifungal and antiviral drugs when compared to the range of antibiotics.

Essentially there are three antifungal agents and 2 antiviral agents.

Introduction

Two main types:Polyenes

1950s

Interacts with fungal cell wall causing loss of cytoplasmic content.Poorly absorbed in the gut- (topical use required)

Lozenge or oral suspension

Poor compliance due to tasteNYSTATIN ORAL SUSPENSION (100,000 units/ml)

Anti Fungals

Azoles1970s+1980s

Inhibits biosynthesis of

ergosterol (Component of cell wall)Fungistatic

action

Underlying cause needs addressed at the same timeMiconazole is poorly absorbed- topical useMICONAZOLE OROMUCOSAL GEL 20mg/g

Fluconazole is well absorbed- systemic useFLUCONAZOLE CAPSULES 50mg

Anti

Fungals

Interactions

Things to look out for

Pseudomembranous

Acute Erythematous

Chronic Erythematous (Denture Stomatitis)

Chronic Hyperplastic

Angular

Cheilitis

Candidosis

“ The disease of the diseased”

White plaque like lesion- can be wiped offSoft palate and buccal

mucosa most frequent

Most likely cause in primary care is use of a Corticosteroid inhaler Advise to rinse mouth following use.

If no resolution following local measures then:

Fluconazole 50mg capsule, once daily for 7 days.If Fluconazole contraindicated then:Nystatin

(100,000units/ml) 1ml after food, 4 times daily for 7 days

Pseudomembranous

Uncomfortable erythematous patches on oral mucosa

Typically dorsum of tongue

Frequently related to broad spectrum antibiotics

Resolution on completion of antibiotic course

Alternatively fluconazole can be prescribed as before.

Fluconazole 50mg capsule, once daily for 7 days.Miconazole can also be prescribed and used topically

Miconazole

oromucosal

gel 20mg/ml, pea sized amount 4 times dailyAgain if azoles contraindicated then Nystatin.Acute Erythematous

Most frequent form in primary careErythema of mucosa beneath partial or complete denture.

Most

pt’s unaware of signsPredisposing factors include nocturnal wear and/or poorly fitting appliances

Local measures include improving denture hygiene

Immersion in dilute sodium hypochlorite for 15mins twice dailyAlternatively Chlorhexidine 0.2% if any metal components.

Removal of denture as much as possible during the process.

Chronic Erythematous

“Denture Stomatitis”

Miconazole gel can be applied to the fitting surface of the denture 4 times/day

A new denture maybe require if there has been

hyphal infiltration into the fitting surface of the acrylic.

Why this patient?

Why now?Has then been any changes that might need investigated?Poorly controlled or undiagnosed diabetes for example

Chronic Erythematous

“Denture Stomatitis”

Most prevalent in middle aged men that are smokers.Generally asymptomatic

If untreated then 5-10% undergo malignant change

Clinically: bilateral white patch at the commissures of the mouth.Histologically: hyphal

invasion of epithelium

Systemic FluconazoleSmoking cessation required. Recurrence common with continued smokingRefer for specialist assessment (Incisional biopsy)

Chronic Hyperplastic

Corners of the mouth Typically candidal

and bacterial infection

Related to intra-oral infectionElimination of intra-oral

candidal

infectionTopical application of miconazole gel, which has dual action on candida and gram positive bacteriaIf a lack of response then refer

? Haematinic deficiency or diabetes issueAngular

Cheilitis

Drug therapys are a great adjunct to treatment

However, main focus must be to identify and eliminate the underlying predisposing factors to prevent reoccurrence.

On many occasions primary dental care may be the patients initial presentation.

Opportunistic Infections

3 groups to consider in primary care

Herpes

HSV-1: primary herpetic gingivostomatisRecurrent herpes

labialis

Varicella Zoster: ShinglesHPVOrofacial warts or papiloma

Oropharyngeal SCCCoxsachieHand foot and Mouth

Herpangina

However, antivirals

arent

prescribed for HPV or coxsachieViral Infections

Aciclovir and penciclovir

are the drugs of choice.

Work by inhibiting the replication of the virus.Therefore needs to be taken as early as possible.

Furthermore, they need to be taken frequently due to the short half life inside the cells.

Anti Virals

Young childrenNo antivirals routinely prescribed

Importance placed on

maintance of fluid levels, analgesics and a soft diet.Furthermore chlorhexidine can be utilised to help with plaque control.

Typical resolution in 10-14 days.

Primary Herpetic Gingivostomatitis

(PHGS)

30% of pt's

who have had PHGS will suffer from this.

Most commonly lipsCan affect any part of the face

Typical cycle:

Prodomal tingleBlisterErosionCrusting

Healing within 7-14 days

Secondary Herpes Simplex Infection

"

Cold sore

"

Topical Aciclovir 5%, 5 times daily on affected area.

Is still effective in the blister stage.

If pt very susceptible then prophylactic systemic Aciclovir 200mg

can be prescribed.

3 time daily for 3 monthsSecondary Herpes Simplex Infection

"

Cold sore"

Affect Sensory NervesCan affect the Trigeminal Nerve (CN5)

If

mand or max branch then ? Tooth ache like symptoms

May present before mucosal or cutaneous lesions.

Lack of obvious pathology then consider shinglesTreatment:AnalgesicsAciclovir 800mg, 5 times daily, 7 days

Zaricella

Zoster Reactivation

"Shingles"

Thanks for listening