fungal infections

Question 1

candidiasis (pseudomembranous and erythematous) - predisposing factors

Answer 1

inhaled corticosteroids, cytotoxic or broad-spectrum antibacterials
diabetics
nutritional deficiencies
serious systemic disease associated with reduced immunity e.g. leukaemia, other malignancies, HIV

Question 2

candidiasis (pseudomembranous and erythematous) - when should you refer to specialist/GP?

Answer 2

if pt doesn’t respond to appropriate local measures and a course of drug tx
no identifiable cause
immunocompromised pt with serious systemic disease - likely to need IV systemic tx

Question 3

candidiasis (pseudomembranous and erythematous) - first tx approach

Answer 3

local measures

Question 4

candidiasis (pseudomembranous and erythematous) - local measures

Answer 4

advise pts who use a CS inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler

Question 5

candidiasis (pseudomembranous and erythematous) - first line drug tx options

Answer 5

fluconazole capsules 50mg

miconazole oromucosal gel 20mg/g

Question 6

candidiasis (pseudomembranous and erythematous) - fluconazole

Answer 6

capsules 50mg
7 capsules x1 daily
can administer for max 14 days for tx of oropharyngeal candidosis

Question 7

candidiasis (pseudomembranous and erythematous) - fluconazole contraindications

Answer 7

warfarin

statins

Question 8

candidiasis (pseudomembranous and erythematous) - miconazole

Answer 8

oromucosal gel (can get SF) 20mg/g
80g tube, apply a pea sized amount after food x4 daily
continue use for 7 days after lesions have healed

Question 9

candidiasis (pseudomembranous and erythematous) - miconazole contraindications

Answer 9

warfarin

statins

Question 10

candidiasis (pseudomembranous and erythematous) - if miconazole and fluconazole contraindicated?

Answer 10

nystatin oral suspension 100000 units/ml

Question 11

candidiasis (pseudomembranous and erythematous) - nystatin

Answer 11

oral suspension 100000 units/ml
30ml
1ml after food x4 daily for 7 days
advise pt to rinse suspension around mouth and then retain suspension near lesion for 5mins before swallowing
advise pt to continue use for 48hrs after lesions have healed

Question 12

denture stomatitis - first line tx

Answer 12

local measures

Question 13

denture stomatitis - local measures

Answer 13

brush palate daily to tx
clean dentures thoroughly (soak in CHX MW or NaOCl for 15mins x2 daily (NaOCl is only for acrylic))
leave dentures out as often as possible during tx period
CHX MW effective
if dentures are identified as contributing to problem - adjust/make new dentures to avoid recurrence

Question 14

denture stomatitis - what can anti fungal agents be used as?

Answer 14

an adjunct

esp to reduce palatal inflammation before taking impressions for new dentures

Question 15

denture stomatitis - first line antifungals

Answer 15

fluconazole capsules

miconazole oromucosal gel

Question 16

denture stomatitis - fluconazole

Answer 16

50mg capsules
7 capsules, x1 daily
max 14 days

Question 17

denture stomatitis - fluconazole contraindications

Answer 17

warfarin

statins

Question 18

denture stomatitis - miconazole

Answer 18

oromucosal gel (can get SF) 20mg/g
80g tube
apply a pea sized amount to fitting surface of upper denture after food x4 daily
advise pt to remove U denture, apply gel sparingly to fitting surface and then reinsert
advise pt to continue use for 7days after lesions have healed

Question 19

denture stomatitis - miconazole contraindications

Answer 19

warfarin

statins

Question 20

denture stomatitis - drug tx if fluconazole and miconazole contraindicated

Answer 20

nystatin oral suspension 100000units/ml

Question 21

denture stomatitis - nystatin

Answer 21

oral suspension 100000 units/ml
send 30ml
1ml after food x4 daily for 7 days
advise pt to remove dentures before using drug, rinse suspension around mouth and then retain suspension near lesion for 5mins before swallowing
advise pt to continue use for 48hrs after lesions have healed

Question 22

angular cheilitis - usual cause if dentures

Answer 22

infection with candida spp and there is an associated denture stomatitis that should be treated concurrently

Question 23

angular cheilitis - usual cause if no dentures

Answer 23

more likely to be caused by infection with streptococcus spp or staphylococcus spp

Question 24

angular cheilitis - what should be done if dentures identified as contributing to problem?

Answer 24

ensure adjusted/new dentures made to avoid problem recurring

Question 25

cream vs ointment

Answer 25

creams normally used on wet surfaces whereas ointments normally used on dry surfaces

Question 26

angular cheilitis - first line treatments

Answer 26

miconazole cream 2% if clearly bacterial in nature - sodium fusidate (fusidic acid) ointment 2%

Question 27

angular cheilitis - miconazole cream

Answer 27

2% 20g tube apply to angles of mouth x2 daily advise pt to continue use for 10 days after lesion has healed

Question 28

angular cheilitis - miconazole contraindications

Answer 28

warfarin | statins

Question 29

angular cheilitis - what is miconazole effective against?

Answer 29

both candida and gram positive cocci

Question 30

angular cheilitis - sodium fusidate (fusidic acid) ointment

Answer 30

``` 2% if clearly bacterial in nature 15g tube apply to angles of mouth x4 daily to avoid development of resistance, don't prescribe for >10days ```

Question 31

angular cheilitis - tx for unresponsive cases

Answer 31

miconazole (2%) and hydrocortisone (1%) cream or ointment 30g tube apply to angles of mouth twice daily don't prescribe if taking warfarin/statins continue use for max 7days / until clinical resolution

Question 32

angular cheilitis - lack of clinical response could indicate?

Answer 32

predisposing factors e.g. concurrent haematinic deficiency/diabetes refer to specialist or GP

Question 33

chronic hyperplastic candidiasis (candidal leukoplakia)

Answer 33

potentially premalignant so refer for tx

Question 34

why are fluconazole/miconazole preferred over nystatin?

Answer 34

topical anti fungal e.g. nystatin effective against superficial infections but compliance poor because of its unpleasant taste so miconazole/fluconazole preferred

Question 35

fungal infections subsequent care

Answer 35

monitor symptoms at follow-up appts if pt does not respond to appropriate local measures and a course of drug tx or no identifiable cause - refer to a GP or a dental specialist fungal infections in immunocompromised pts with serious systemic disease require assessment by GP