1. THE ROLE OF ANTIFUNGAL AND ANTIVIRAL AGENTS IN PRIMARY DENTAL CARE
Matt Dickie

2. Introduction
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.

3. Anti Fungals Polyenes Two main types: 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)

4. Anti Fungals Azoles 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

5. Interactions

6. Things to look out for

7. Candidosis “ The disease of the diseased”
Pseudomembranous
Acute Erythematous
Chronic Erythematous (Denture Stomatitis)
Chronic Hyperplastic
Angular Cheilitis

8. Pseudomembranous 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.
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

9. Acute Erythematous 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 daily
Again if azoles contraindicated then Nystatin.

10. Chronic Erythematous “Denture Stomatitis”
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.

11. 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

12. Chronic Hyperplastic
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)

13. Angular Cheilitis Corners of the mouth
Typically candidal and bacterial infection
Related to intra-oral infection
Elimination of intra-oral candidal infection
Topical application of miconazole gel, which has dual action on candida and gram positive bacteria
If a lack of response then refer
? Haematinic deficiency or diabetes issue

14. Opportunistic Infections
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.

15. Viral Infections 3 groups to consider in primary care Herpes HPV
HSV-1: primary herpetic gingivostomatis
Recurrent herpes labialis
Varicella Zoster: Shingles
HPV
Orofacial warts or papiloma
Oropharyngeal SCC
Coxsachie
Hand foot and Mouth
Herpangina
However, antivirals arent prescribed for HPV or coxsachie

16. Anti Virals 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.

17. Primary Herpetic Gingivostomatitis (PHGS)
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 days.

18. Secondary Herpes Simplex Infection "Cold sore"
30% of pt's who have had PHGS will suffer from this.
Most commonly lips
Can affect any part of the face
Typical cycle:
Prodomal tingle
Blister
Erosion
Crusting
Healing within 7-14 days

19. 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 months

20. Zaricella Zoster Reactivation "Shingles"
Affect Sensory Nerves
Can 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 shingles
Treatment:
Analgesics
Aciclovir 800mg, 5 times daily, 7 days

21. Thanks for listening