Clinician's Guide Pharmacology in Dental Medicine

Caution: Ketaconazole and fluconazole are potent inhibitors of the hepatic microsomal enzyme system CYP3A4. As such, drug interactions must be anticipated in patients concurrently taking anticoagulant, antihistamine, antianxiety, and cholesterol-lowering medications. If patients fail to respond to systemic therapy, they should be referred to an infectious disease specialist for evaluation of resistant strains or the diagnosis must be reevaluated

These medications (caspofungin, micafungin, anidulafungin) are not currently recommended

Nystatin with triamcinolone acetonide or clotrimazole with betamethasone dipropionate preparations are quite useful for this purpose. Patients should be encouraged not to lick the lesions because this will serve to further superinfect the cheilosis with salivary bacteria. If the combination of medications is not readily available, the patient can be prescribed the two creams and mix a small amount of each in the palm of the hand before applying to the area.
In cases of refractory or mucocutaneous candidosis, patients in whom compliance is a problem, or women who have a concurrent candidal vaginitis, systemic antifungal therapy with ketaconazole or fluconazole is recommended. If either of these medications is used for longer than 2 weeks, liver function tests should be performed to monitor potential hepatotoxicity. A new class of antifungal medications known as echinocandins is available to treat resistant fungal infections

Angular cheilosis is a mixed infection of Candida albicans and salivary species of streptococci. These lesions respond very well to combination therapy containing an antifungal and a topical steroid in a cream or ointment vehicle

Patients who wear dentures must remove the dentures prior to using an antifungal rinse or troche unless it is treated with ointment applied to the denture itself. When treating cases of erythematous candidosis under a denture, the prosthetic appliance must be addressed, as well as the oral infection. Patients should be reminded to remove their dentures at bedtime and soak them overnight in an antifungal solution. Most commercially available denture soaking tablets are fungicidal; it should not be necessary to prescribe nystatin suspension specifically for this purpose. However, it is also possible to soak dentures in chlorhexidine or a dilute solution of bleach (1 tsp for 8 oz of water) for the duration of antifungal therapy. The use of even a mild bleach solution for soaking dentures may affect the color of the prosthesis, and the prosthesis must be thoroughly rinsed before replacing it in the mouth

For rinses to be effective, they must contact the affected mucosal surfaces for a period of 3 minutes four times daily for the entire duration of therapy

Oral hygiene must be reinforced when prescribing oral antifungal troches because they contain sucrose. The

Oral candidosis is most often treated with topical antifungal agents such as troches

The two most common oral presentations are pseudomembranous candidosis and erythematous candidosis (denture sore mouth). Pseudomembranous candidosis is characterized by the presence of white curd-like lesions that can be easily removed with an instrument or gauze to expose an erythematous, eroded surface underneath. Erythematous candidosis is frequently noted in patients who wear maxillary complete or partial dentures, especially in cases in which the prosthesis is not removed prior to bedtime. Clinically, erythematous candidosis appears as red, atrophic lesions. Hyperplastic candidosis is unlike the pseudomembranous and erythematous forms in that it cannot be wiped off the mucosa. Lesions of hyperplastic candidosis that do not respond to a trial of antifungal medication must be biopsied to establish a diagnosis. Finally, angular cheilosis is due to candidal infection of the labial commissures. It is characterized by redness and/or fissures radiating from one or both corners of the mouth and is often associated with small white plaques. Angular cheilosis has long been associated with vitamin B deficiency and decreased vertical dimension of occlusion.

HSV-1 and HSV-2 are the most common viruses in the oral cavity. HSV-1 infects 70% of the population and produces symptomatic recurrent lesions in 25% of those infected. Recurrent infections occur after stress or trauma and typically present as painful vesicles and ulcers of the lips, attached gingiva, and palate. Treatment of primary HSV-1 infection, in otherwise healthy patients, requires the use of topical and systemic analgesics and antiviral agents. Dyclonine, viscous lidocaine, Benadryl Elixir, and Benadryl with Kaopectate are effective topical anesthetics when used as a rinse for 2 minutes every 2 hours. Antiviral drugs are most effective if used early in the course of the infection (first 2 days) and are provided systemically. Topical antiviral drugs do not penetrate well and are generally recommended for recurrent episodes. Antiviral agents are beneficial when used prophylactically and intermittently by those suffering from frequent and predictable recurrences