JCDA - Canadian Dental Association

film of tissue fixative (95% ethanol), allow to air dry for
several minutes, label the slide in pencil with the patient’s
name and source of the sample, and place it in a slide
holder. Send the specimen to an oral pathology biopsy
service with a request for fungal evaluation. On staining
Question 4
Once candidiasis has been confirmed but before antifungal
treatment is instituted, an attempt should be made
to identify and, if possible, correct any contributing factors
(outlined in Question 1). In mild cases in nonimmunocompromised
patients, topical preparations are usually best
for initial treatment.
Nystatin, a polyene antifungal agent, interacts directly
with ergosterol, the main sterol component of certain
fungal cell membranes. Its effectiveness depends on direct
contact with the organisms, so multiple daily doses are
needed. Nystatin is generally prescribed in tablet form
(500,000 units/tablet), to be dissolved slowly in the mouth
5 times daily for 10 to 14 days. It can also be administered
as an oral suspension (1–2 mL of a suspension with
100,000 units/mL), to be rinsed slowly in the mouth 4 or
5 times a day and either expectorated or swallowed.
Patients with full or partial dentures should soak their
dentures at night in nystatin oral suspension. Angular
cheilitis is treated with a combination cream containing
100,000 units/g nystatin and 0.1% triamcinolone
(compounded by a pharmacist), or Kenacomb cream
(Westwood-Squibb Canada, Montreal, Quebec), which
contains the antibiotics neomycin and gramicidin in addition
to nystatin and triamcinolone, applied after each meal
and at bedtime.
Clotrimazole, an imidazole-derived antifungal, inhibits
the cytochrome P450 enzyme that converts lanosterol to
ergosterol. Like nystatin, it is poorly absorbed in the
gastrointestinal tract, necessitating prolonged direct
contact with the fungal organisms. Clotrimazole is generally
prescribed as a 10-mg troche, dissolved slowly in the
mouth 5 times daily for 10 to 14 days. Caution must be
exercised in prescribing clotrimazole for patients with
hepatic impairment, as liver enzymes become mildly
elevated in approximately 15% of patients.
Other orally administered antifungal agents include
ketaconazole, fluconazole and itraconazole.
Ketaconazole is not recommended in the dental setting
because of its significant toxicity, including a 1 in 15,000
risk of symptomatic hepatitis.
Fluconazole has a lower risk of side effects and is therapeutically
superior to ketaconazole. A 200-mg oral loading
dose followed by 100 mg/day for 14 days is highly effective
Journal of the Canadian Dental Association
Point of Care
with periodic acid-Schiff (PAS), cylindrical fungal hyphae
(Fig. 6) and ovoid spores can be readily identified. C
Further Reading
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial
pathology. 2nd ed. Philadelphia: WB Saunders Co.; 2002.
What are the best treatment options for a patient with oral candidiasis?
in the treatment of oropharyngeal candidiasis. Fluconazole
oral suspension (10 or 40 mg/mL for a total dose of
100 mg/day) swished for 2 minutes and then swallowed
results in a significantly higher salivary concentration but
plasma levels comparable to the same dose administered in
tablet form. Fluconazole is generally well tolerated, the
most common adverse effects being nausea, vomiting, diarrhea
and abdominal pain in 1% to 4% of patients and
headache and rash in 1% to 2%. Rare cases of serious hepatotoxicity
have been reported. Fluconazole should be
avoided during pregnancy and in patients with severe
hepatic insufficiency. The dosage should be reduced in
patients with renal dysfunction. Fluconazole leads to
increases in the plasma concentrations of several commonly
used medications, including orally administered hypoglycemic
agents, warfarin, cyclosporine, triazolam and theophylline.
Cardiac arrhythmias have been reported in
patients taking fluconazole along with cisapride, terfenadine
or astemizole, and there have been reports of
nephrotoxicity in patients taking both fluconazole and
tacrolimus.
Resistance to fluconazole in the immunocompromised
patient has become a concern. Certain candidal species,
such as C. krusei and C. glabrata, are unresponsive to
fluconazole therapy. However, these species are uncommon
in healthy patients who have not recently received systemic
antifungal treatment.
Itraconazole is a recently introduced triazole antifungal
agent, available in pill form or solution, that is best
restricted to rare clinical situations such as immunocompromised
patients with fluconazole-resistant candidal
infections. It is not recommended for routine antifungal
therapy in an otherwise healthy patient. C
Further Reading
Kauffman CA, Carver PL. Antifungal agents in the 1990s. Current status
and future developments. Drugs 1997; 53(4):539–49.
Terrell CL. Antifungal agents. Part II. The azoles. Mayo Clin Proc 1999;
74(1):78–100.
Wynn RL, Jabra-Rizk MA, Meiller TF. Antifungal drugs and fungal
resistance: the need for a new generation of drugs. Gen Dent 1999;
47(4):352–5.
Dr. Edwards has no declared financial interests in any company
manufacturing the types of products mentioned in Point of Care.
November 2003, Vol. 69, No. 10 681