1. Antifungals and antivirals
LO 12
Chapter 8
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Antifungals
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Fungal infections
Oral candidal infections; caused by Candida Albicans.
Usually superinfection after antibiotic treatment for a primary infection.
Under dentures, esp. ill fitting dentures
In immune-compromised patients: due to corticosterids, immuno-suppressants, chemotherapy
Treatment:
-nystatin (Candistatin, Mycostatin)(oral suspension)
-ketoconazole (Nizoral) tablets
-clotrimazole troches (Canesten)
-fluoconazole (Diflucan) tablets
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Nystatin
Fungicidal and fungostatic against a variety of fungi, including Candida albicans
Not absorbed if administered orally or applied topically. Safe to use for infants and during pregnancy. First choice in antifungal therapy.
Treatment and prevention of oral candidiasis:
Aqueous suspension containing sucrose(OHI): U/ml.
Rinse for 2 min. and spit, with 5ml(1tsp) qid.
For children use 2.5 ml
For 2 weeks, longer if immunocompromised
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5. Imidazoles:Ketoconazole(Nizoral)
Wide spectrum antifungal
needs acidic environment for its absorption (do not administer in same time with acid blocking medication)
Adverse reactions: nausea, vomiting, hepatotoxicity
Teratogenic, excreted in the breastmilk
Drug interactions: acid reducing drugs(wait 2 hours), alcohol(disulfiram-like reaction), contraceptives
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6. Imidazoles:Ketoconazole
Dental use: in treatment and prophylaxis of oral candidiasis.
Because of its side effects should be used only after topical antifungal agents have been ineffective or are believed to be ineffective
Dose: 200 mg qd, for at least 2 weeks
Topical : 2% cream, applied 1 or 2 times daily for 2 weeks
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7. Imidazoles:Clotrimazole
Synthetic antifungal agent, primarily against Candida species
Oral use:
Lozenges: dissolve in saliva in ~15-30 min
maintain a salivary concentration sufficient to inhibit Candida for 3 hrs.
Side effects: xerostomia: difficulty dissolving
Contains sucrose: OHI
Dose: 1 lozenge(10mg) 5 times daily for 2 weeks
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8. Imidazoles: Fluconazole
Treatment of oropharingeal and esophageal candidiasis and serious systemic candidal infections
Prophylaxis of candidiasis in immunocompromised patients
Treatment of candidal infections that do not respond to other agents.
Dose: 200mg first day, then 100mg daily.
Tablets.
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Anti-virals
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10. Viral infections in dentistry
Herpex Simplex:
Acyclovir Penciclovir Famciclovir Abreva
AIDS(aquired immunodeficiency syndrome):
-Nucleoside reverse transcriptase inhibitors(NRTIs)
-Nonnucleoside reverse transcriptase inhibitors(NNRTIs)
-Protease inhibitors
-combinations
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Definitions
Nucleoside:result from the breakdown of the nucleotides
Nucleotides: A,G,C,T; are the building blocks for synthesis of DNA
Reverse transcriptase=DNA polymerase
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Herpex simplex
Type 1: “cold sores” Type 2:herpes genitalis
Recurrent infection that might be triggered by factors that reduce general immunity: common cold, dental appointments, menstrual cycle, hot/cold weather, fever, sun exposure, etc.
Treated with antiviral agents.
Most antiviral agents act on viral DNA and inhibit DNA synthesis.
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Acyclovir
Spectrum:
herpex simplex type 1(HSV-1)
type 2(HSV-2)
varicella-zoster
Epstein-Barr (infectious mononucleosis)
Cytomegalovirus
Routes of administration:
Topical
Oral
Parenteral
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Acyclovir
Adverse reactions:
topical use: local burning, stinging, itching or skin rash
oral use:
CNS: headache, vertigo, fatigue, dizziness, insomnia, irritability
GI tract: Nausea, vomiting, diarrhea, funny taste
parenteral use: irritation at injection site, symptoms of encephalopathy: lethargy, seizures, confusion
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Acyclovir
Uses: Topical and oral acyclovir
The available data does not support the use of acyclovir for management of herpes labialis in dentistry in immunocompetent patients.
No acyclovir products are approved for treatment of recurrent herpes labialis in the immunocompetent patient.
Cream can be used to treat herpetic whitlow.
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AIDS
Produced by the human immunodeficiency virus (HIV)
Patients usually are prone to opportunistic infections like:
-tuberculosis, herpes infections, Candida infections, pneumonia.
They might be taking also antiinfective agents for treatment of these infections
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AIDS
Treatment:
Several drugs“cocktails” usually one from each of the following groups:
-nucleoside reverse transcriptase inhibitors(NRTIs): AZT
Adverse reactions: . Nausea, bone marrow depression leading to anemia, granulocytopenia and thrombocytopenia=> Transfusions are often required.
*Oral effects: taste alteration, edema of the tongue, bleeding gums, mouth ulcers, pigmentation.
-non-nucleoside reverse transcriptse inhibitors(NNRTIs):
if used alone will develop resistance easily.
-protease inhibitors: less general adverse reactions than older agents.
* oral effects: buccal mucosa ulcerations.
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Other antiviral drugs
amantadine, rimantadine:
-prevention of influenza A or treatment to reduce the symptoms of influenza A.
-in institutionalized patients (nursing homes) to prevent spread of infection during outbreaks
-Side effects: nausea, dizziness, insomnia
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19. Other antiviral agents
Interferons:
large group of endogenous proteins with antiviral, cytotoxic and immuno-modulating actions.
Are now produced by recombinant DNA technology.
There are several types, classified as: alfa, beta, gamma.
Only parenteral administration
They interact with cells through cell surface receptors.
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Interferons
They have the following effects:
-induction of gene transcription,
-inhibition of cellular growth,
-altered cellular differentiation,
-interference with oncogene expression.
Mainly in hepatitis C, multiple sclerosis.
Oral side effects:
-taste changes
-reactivation of herpes labialis
-excessive salivation
Adverse reactions: flu-like syndrome, CNS effects, G.I. effects.
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