Matt Dickie
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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.
Two main types:
Polyenes
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◦ 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 taste
 NYSTATIN ORAL SUSPENSION (100,000 units/ml)
Azoles
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1970s+1980s
Inhibits biosynthesis of ergosterol (Component of cell wall)
Fungistatic action
Underlying cause needs addressed at the same time
◦ Miconazole is poorly absorbed- topical use
 MICONAZOLE OROMUCOSAL GEL 20mg/g
◦ Fluconazole is well absorbed- systemic use
 FLUCONAZOLE CAPSULES 50mg
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Pseudomembranous
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Acute Erythematous
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Chronic Erythematous (Denture Stomatitis)
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Chronic Hyperplastic
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Angular Cheilitis
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White plaque like lesion- can be wiped off
Soft palate and buccal mucosa most frequent
Most likely cause in primary care is use of a Corticosteroid
inhaler
◦ Advise to rinse mouth following use.
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If no resolution following local measures then:
◦ Fluconazole 50mg capsule, once daily for 7 days.
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If Fluconazole contraindicated then:
◦ Nystatin (100,000units/ml) 1ml after food, 4 times daily for 7 days
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Uncomfortable erythematous patches on oral mucosa
Typically dorsum of tongue
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Frequently related to broad spectrum antibiotics
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◦ Resolution on completion of antibiotic course
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Alternatively fluconazole can be prescribed as before.
◦ Fluconazole 50mg capsule, once daily for 7 days.
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Miconazole can also be prescribed and used topically
◦ Miconazole oromucosal gel 20mg/ml, pea sized amount 4 times daily
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Again if azoles contraindicated then Nystatin.
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Most frequent form in primary care
Erythema of mucosa beneath partial or complete denture.
Most pt’s unaware of signs
Predisposing factors include nocturnal wear and/or poorly
fitting appliances
Local measures include improving denture hygiene
◦ Immersion in dilute sodium hypochlorite for 15mins twice daily
◦ Alternatively Chlorhexidine 0.2% if any metal components.
◦ Removal of denture as much as possible during the process.
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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
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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 Fluconazole
Smoking cessation required.
Recurrence common with continued smoking
Refer for specialist assessment (Incisional biopsy)
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Corners of the mouth
Typically candidal and bacterial infection
Related to intra-oral infection
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Elimination of intra-oral candidal infection
Topical application of miconazole gel, which has dual
action on candida and gram positive bacteria
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If a lack of response then refer
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◦ ? Haematinic deficiency or diabetes issue
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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.
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3 groups to consider in primary care
◦ Herpes
 HSV-1: primary herpetic gingivostomatis
 Recurrent herpes labialis
 Varicella Zoster: Shingles
◦ HPV
 Orofacial warts or papiloma
 Oropharyngeal SCC
◦ Coxsachie
 Hand foot and Mouth
 Herpangina
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However, antivirals arent prescribed for HPV or
coxsachie
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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.
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Young children
No 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.
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30% of pt's who have had PHGS will suffer from this.
Most commonly lips
Can affect any part of the face
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Typical cycle:
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Prodomal tingle
Blister
Erosion
Crusting
Healing within 7-14 days
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Topical Aciclovir 5%, 5 times daily on affected area.
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Is still effective in the blister stage.
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If pt very susceptible then prophylactic systemic Aciclovir
200mg can be prescribed.
3 time daily for 3 months
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Affect Sensory Nerves
Can affect the Trigeminal Nerve (CN5)
◦ If mand or max branch then ? Tooth ache like symptoms
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May present before mucosal or cutaneous lesions.
◦ Lack of obvious pathology then consider shingles
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Treatment:
◦ Analgesics
◦ Aciclovir 800mg, 5 times daily, 7 days