Prescribing Antifungals as a GDP – Diagnosis and Management – PDP151

Jaz’s Introduction:
Look, if you’re anything like me and every time you even suspect fungal infection your patient, you are thinking, whoa. When I even begin what I prescribe, I haven’t done this in ages because you see this is something that, unlike a lot of other things in dental school, this is probably actually taught well, but the frequency of how often you actually see patients with fungal infections is not very common.

Therefore, we kind of forget what is the best to prescribe at the best time. So unless you’ve done it a few times, you’re probably going to gain a lot from this episode like I did with our guest all medicine specialist, Dr. Amanda again from Perth, Australia. Now Protruserati, I know you’re going to love Amanda because she is so straight talking.

I know you love our straight talking guests and she’s just absolutely brilliant. We have a fantastic infographic for you to download as well. And a lovely episode summary for you to sink your teeth into. Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of Protrusive Dental Podcast. If you’re new to the podcast, hello.

Thanks for joining us on this oral medicine topic. Very rare for an oral medicine podcast. Perhaps we should do more. I don’t know. Let me know in the comments if you think I should be doing more of these. It’s maybe not as sexy as composites and adhesion. That is bloody well important, isn’t it? Every episode I give you a Protrusive Dental Pearl, and today is like a philosophical motivational one.

If there’s something in your life that you’ve been holding off, that you’ve been putting off, right? This could be like adding meditation to your life. This could be exercise. This could be improving your diet. This could be something business related, something, or even work related, a habit that you want to pick up.

Remember that the best time to do it was some years ago, right? The best time to do it was some years ago. But you know what? The second best time is today. And I’m saying this, even if it helps one person, then this Protrusive Dental Pearl was well worth it, right? So if there’s something they’ve been holding it off, what are you waiting for?

Right? Today is the best day. Yesterday was a better day, but that’s not going to happen. So why not do it today? Why not write down right now? Write on a piece of paper, write on one of those apps, write on Google Docs, WhatsApp, someone, voice note your spouse, what it is that you’re going to do, starting from today, that you should have started yesterday or many years ago, but today is a damn good day to do it.

So you go ahead and do it. And if you want to message me on Instagram to let me know what that thing was, @protrusivedental, I’d like to hear. It’d be cool. Anyway, I’ll catch you in the outro. Enjoy this episode. Now, there’s a lot going on, right? You’ll get lots of helpful advice about what to prescribe, the different conditions, so it’s going to lend itself, like I said, very well to the notes and the infographic, and I’ll let you know how to get your hands on those. But I’ll catch you in the outro.

Main Episode:
Dr. Amanda Phoon Nguyen and welcome to the Protrusive Dental Podcast. How are you?

[Amanda]
I’m great, thank you. Thank you so much for having me. I’m very excited.

[Jaz]
I’m stoked to have an oral medicine guest finally on the podcast. This will be some new stuff for the Protruserati and something that’s really relevant for all general dentists. Now, before we dive into antifungals, what to look for, what to prescribe, just tell us about yourself. Why did you fall in love with oral medicine? How bizarre is that?

[Amanda]
To be honest, when I was going through dental school, I, A, didn’t think I would ever specialize. I thought like why would anyone ever want to narrow themselves to one field? But then I think as I became a dentist and I had more and more experience, I actually found general dentistry quite overwhelming because there was so much to know about so much. And then I started to think about specializing. I did some further study and the two that I actually was very interested in was pediatric dentistry, because I quite enjoyed, like treating kids and then oral medicine and in the end oral medicine one out.

And I’ve been a oral medicine specialist for a while now and I love it. I think the bit that is so interesting about oral medicine is that every patient that walks through the door, Is something different. Like there’s a lot of like differential diagnoses, diagnostic sieve trying to put together like puzzle pieces almost to get to the right diagnosis and treatment plan. And I think that is what I find the best part about oral medicine is that it’s so interesting.

[Jaz]
It reminds me of, I treat a lot of TMD, and the more I read about TMD, TMD is a thinker’s game. Right. It’s very much thinker’s game. Oral medicine is very much a thinker’s game. And just like you said, like yes, you do lots of investigations as a general dentist, but general dentistry, you’re getting your handpiece out, you’re doing something, whereas you are working with your mind and really trying to nail that diagnosis, which sometimes probably can be one of the most challenging parts, I imagine.

[Amanda]
Yes, I think so. So, sometimes when I talk about oral medicine or I speak to people about oral medicine, sometimes even with patients, there’s very much a tendency to jump into how do we manage this? But actually, the main goal is to actually get the right diagnosis first, and I think that’s where a lot of the art and sciences of oral medicine comes into play.

[Jaz]
Well, in the UK, Amanda, I might be wrong, but I think in the UK you have to do medicine. You have to be duly qualified to then become an oral medicine specialist. Is that the case in Australia as well?

[Amanda]
Yes. So in the UK, you had to be dually qualified, I think, until very recently. And in oral medicine in Australia it’s a dental specialization.

In oral medicine, I think you have to be dual qualified. So there’s a couple of places that are still dual qualified, but most places now are moving towards singly qualified.

[Jaz]
Fine. And so the topic, I mean, there’s so much we could talk about in all medicine, but just a little bit more about you. Where do you actually practice you? Are you in a hospital setting? Are you in a private practice setting? How does it work there?

[Amanda]
Yes. So I work in a bunch of different places actually. Cause I quite like the variety. So I work in private practice three to four days a week. And then I am at the university. So I’m an adjunct senior lecturer, at the University of Western Australia. And I also have a consultant’s position at the Perth Children’s Hospital. So I do a mix of public and private.

[Jaz]
Brilliant, brilliant. So it keeps you busy. Very busy. It seems so amazing. Well, thanks for making time for this podcast episode on fungal infections and antifungals so we could start anywhere. Now I’m going to help get your advice on terms of which is the best way to lead the show. But one idea I had was to break it down in terms of sometimes patients come in without any symptoms and it’s the signs that we spot, and then sometimes they come in with symptoms, which helps us.

I think the best way to start would be perhaps the symptomatic patient who’s prompting us, oh, I have an issue with my tongue. Oh, I’ve got some white flecks or whatever. And then it’s up to us and use that information, the symptoms and the signs to come up with a diagnosis, and then we can get our prescription pad out.

So maybe the first half, let’s talk about diagnosis, signs, symptoms, diagnoses, and then we can talk about the management. So perhaps you can tell us what are the most common fungal issues that a dentist might encounter and how to even begin diagnosing them.

[Amanda]
Yeah, so fungal infections is a very broad category of infections that may occur in the oral cavity. By far and large, the most common causative organism is Candida. So that’s a group of yeast so Candida albicans is actually the one that is most commonly implicated. And the reason why I’m sort of bringing that up is that we can’t look at it as a broad thing, we need to think about, are we just talking about candidosis, which in this case we are.

Because there’s a bunch of other infections that can occur in the mouth that are fungally caused. But the one that a general dentist, or that a dentist would most commonly see would be one that was caused by oral, that it’s caused by Candida. Actually this brings me to my first point. Do you call it candidiasis or candidosis?

Because in Australia we, some people say candidiasis, I think it should be candidosis. And I think sometimes getting that out of the way is probably the best thing for us. What do you guys do over there?

[Jaz]
From my lectures in Sheffield, we had Candidosis.

[Amanda]
Very good. So I say Candidosis too because that is more in line with all the other fungal infections, which actually end with ‘Osis’.

So, candidiasis kind of doesn’t make too much sense. But anyway. So let’s say we’re talking about oral candidosis. It’s important to recognize, aswell that it is actually a commensal. So if you look at the studies, it exists on us, in a large percentage. So between 40 and 80% of people actually have Candida on them already.

And then some of the newer studies can say that it is as high as a hundred percent. So when we are talking about candidosis, is it actually the presence of the fungus that we are concerned about? Does that actually need treating or is it actually when it becomes an infection and causes a problem and that’s when we should treat it?

And that will come down to how we actually diagnose it. So, First of all, looking at clinical signs and symptoms, I think it’s fairly reasonable to diagnose based on a clinical appearance, and that is what I would do most of the time. So when we talk about primary oral candidosis, we can have the pseudomembranous candidosis, chronic hyperplastic candidosis, and erythematous candidosis.

Now, a pseudomembranous candidosis is the easiest one to recognize. Pardon this. If you are having your dinner or if you’re listening to this while you’re eating, it looks like cottage cheese in the mouth, basically, right? So you look at it, it looks like cottage cheese. Now, when I tell people about doing a head and neck examination, I always talk about palpating and feeding lesions as well.

So the first thing you should do if you see cream cheese in the mouth or cottage cheese in the mouth, give it a little bit of a wipe. Is it food debris? In infants is very common. Sometimes they have milk debris as well and people start to worry is that actually candidosis.

So give it a little bit of a wipe first. See what is left behind. If there is a very erythematous base behind, then you probably do have pseudomembranous candidosis. Do you need to do any additional testing to diagnose it? I don’t really think so. So in most cases, if that is what I see that looks at pseudomembranous candidosis and I will proceed to treat that.

Now, the other ones that we talked about, chronic hyperplastic candidosis actually looks a lot like leukoplakia, so it can be non homogenous or homogenous. It’s basically a white patch in the oral cavity, most common locations, buccal commissures, ventral tongue Now, if you see a white patch that cannot be wiped away and you don’t really know what it is and you don’t think that it is related to trauma, I think that should be further investigated.

There are some studies out there that show that upon biopsy, chronic hyperplastic candidosis lesions ahead of a higher degree of dysplasia and things like that. So I think those ones should be treated with suspicion and you may want to consider maybe referring it to someone who could manage the patient long term if it does turn out to be dysplastic. Erythema can-

[Jaz]
So pseudomembranous, which is the cottage cheese one and the chronic hyperplastic, they can both be wiped away. Is that correct? Yeah?

[Amanda]
No. So chronic hyperplastic cannot be wiped away, but pseudomembranous can. Yes.

[Jaz]
Okay.

[Amanda]
Yes. And then erythematous candidosis, which is the other one, you can get the acute or chronic forms of it. But the first thing that I do when I look in a patient’s mouth is very red. Acute erythematous candidosis is actually usually painful and actually it’s usually most associated with someone who has recently been on a broad spectrum antibiotic. So if they’ve been on antibiotic, their mouth is suddenly red and pretty painful.

I will be happy to treat that as well as candidosis. So I think candidosis, there are a lot of different presentations, but if it’s a fairly classical form and it fits, I think having a clinical diagnosis and in considering management, I think is adequate. Where we would do like further investigations like biopsies or swabs or things like that? I think the role-

[Jaz]
Oh, blood tests even?

[Amanda]
Oh, blood tests even. Yeah. So I think the role for that comes, so blood test is more to see if there’s an underlying systemic contributor. So we can talk about that when we come into management. But say you see a patient with all of these clinical signs and symptoms and you think that it is oral candidosis, I think it is reasonable to go ahead and manage the patient. And we can talk about management in the-

[Jaz]
But sounds like the second one, the chronic hyperplastic sounds like the advice here is because it is a patch that can’t be rubbed away, that as a general dentist perhaps you are good. You’re correct to refer,.

[Amanda]
Yeah.

[Jaz]
As a rule of thumb.

[Amanda]
Yeah, that’s it.

[Jaz]
Okay.

[Amanda]
So because chronic hyperplastic candidosis, I would say that most people will not be able to differentiate it from a leukoplakia just by looking at it. So I think in this case, when I say you can go ahead and treat, I will be thinking more about the erythematous candidosis or the pseudomembranous candidosis, because-

[Jaz]
Very helpful.

[Amanda]
Like realistically, if you see a white patch on the side of the tongue, on the ventral surface of the tongue, that doesn’t wipe away. A patient doesn’t know how long it’s been there. That’s pretty much a referral I think in most Australian dental professional books

[Jaz]
As a general dentist and a restorative dentist, I treat patients with their denture dermatitis. And that is often linked to fungal infections candida now, does that fall into either of those categories, or is that an entirely new category?

[Amanda]
Yes, that’s an excellent question. So the three that we just talked about there, pseudomembranous, chronic hyperplastic, and erythematous candidosis, they are your primary oral candidosis.

Now you do have, Candidal associated lesions, which is a different category. And the reason why there is a different category of these, of which denture dermatitis fits into there is that it is usually thought to be a polymicrobial infection. So not only related to Candida or the evidence isn’t strong and Candida is the only causative fact.

So those ones would be your angular cheilitis. And we can talk about that because that’s very common. A lot of people have that. Median Rhomboid Glossitis, where you have a deep populated area in the dorsal surface. So the tongue looks a little bit like a diamond. And then you have sometimes called Linear Gingival Erythema, where you get basically a red band along the interdental papilla.

Now if you do see a patient with linear gingival erythema, not to say that it doesn’t happen in people who don’t have an underlying medical problem, but it’s seen in a lot higher numbers in people who do have HIV. And then the denture stomatitis.

[Jaz]
But that must be so difficult to diagnose Amanda, because it just, you might think that that’s just gingivitis.

[Amanda]
Yes. So the hallmark feature of that actually is something that is not responsive to plaque management. So if you see a patient and you think that they’ve got gingivitis, you do plaque control, you do debridement, scaling cleans. You increase the oral hygiene, but it still remains, and I think that’s when it’s worthwhile considering referral either to a oral medicine or a periodontist.

[Jaz]
Okay, so if you’re enjoying this episode and you know about the different conditions, and we’re going to get into what to prescribe if you want it all nicely and neatly presented to you in an infographic, so it’s easy for you know what to prescribe when, and the different diagnoses, like a cheat sheet, right?

An antifungal dentistry cheat sheet that you wish. Then school have given to you or you wish was in a textbook somewhere. But don’t worry, I got you covered. If you want this, you head over to protrusive.co.uk/antifungals. That’s protrusive.co.uk/antifungals and I will email to you personally. So back to the episode.

Got it. So in terms of you break it up, because now we branching into two areas. Let’s finish up and wrap up the first part, the three primary diagnosis we make.

[Amanda]
Yeah.

[Jaz]
And we talk about their management before we talk about the denture and the angular cheilitis, which I think I’d like to because it’s just so common that we see it actually.

[Amanda]
Yes, yes. So with all of the candidal presentations, if you suspect a fungal infection, and we’ve talked about how the most likely ones that you will probably suspect is the pseudomembranous and the erythematous candidosis, the general treatment will be with via an antifungal medication. And there are different types of antifungal medications that we can consider for patients.

Equally as important as starting your patient on these medications is considering what are the modifiable factors there are. Because we’ve talked about how candida is something that is present in a large percentage of patients. There is something that has changed. So something in the environment that has changed or something in the host factor that has changed, that has caused the candida to become more active and more invasive and basically start to cause a problem.

So classy things will be, have they recently started a new medication? Have they recently got a denture? Have they recently changed their diet? If they do have things like diabetes and stuff like that, it’s always worthwhile, I think, to ask the patient, how because we see lots of patients with diabetes, how well controlled is it?

When did you last check? Are they checking themselves at home? Did their doctors check it? How their denture hygiene is as well, I mean, It’s not uncommon that I have patients come to see me with these types of candidal infections, but they are not aware of denture hygiene or they have been told, but they just don’t listen to it.

So reinforcing all of that’s important. If they have anemia, that’s a pretty common one as well. So that’s where the blood test will come in. So if I see a patient and they have a history of anemia or anything like that, or if they’re sometimes they’re female or they’ve been bit rundown, I would generally do a general blood screen.

So I would do a full blood count. I would do vitamin b12, folate, and iron studies cuz these are the things that sometimes are well, that are used for mucosal healing. So if there’s any sort of deficiency in them, there’s a defect in the mucosa and that’s how candida can sometimes be a little bit more active as well.

We don’t see this as much as anymore, but back to dental school days, up to the people who are listening. You might remember like hearing about red, beefy tongue where the tongue looks very red and very smooth and things like that. So if you see any of those sort of signs, I think is a good idea to investigate what’s underlying it because-

[Jaz]
What about dry mouth xerostomia is that a cause as well?

[Amanda]
Definitely, yeah. So that would be one of the things that can alter the, is a host factor that has altered so I think paying attention to all of these factors is quite important as well. Steroid puffers as well.

If you do have patients that are using steroid asthma puffers, reminding them that they should rinse their mouth out after using it. It’s also important because sometimes they sort of were told by their dentist or they read it on the packet, but then they forgot all about it and they’re wondering why they’re getting this candidal infection in their mouth.

So I think spending a little bit of time seeing if the patient’s systemically well, if anything has changed oral appliance wise, checking their saliva. Checking the control of their systemic conditions. I think it’s basically really important because in the past, candida used to be called like, the disease of the disease.

That’s actually what they used to call it. So, that’s like the hallmark sign. Like you’ve got to check out if anything else is going on, if they are immunocompromised, if they’re on long-term corticosteroids, that’s another one as well. See if maybe that is something that they are doing if they recently had antibiotics.

[Jaz]
This is what, I mean you mentioned the antibiotics and you’re quite right. That’s a common one. But what becomes difficult for the general dentist, and one of the reason I got you on is that you’re a general dentist. You busy list and suddenly you have to switch on your oral medicine hat on and become this investigator, quite rightly so, but this is where general dentistry struggle because you’ve got a queue of waiting patients, you just diagnosed fungal infection and now to do the entire medical history so exhaustively to figure out exactly what’s changed the environment.

That can be a tricky thing. So hopefully we’re going to give you a few tips to make it more efficient and better. So, two questions I have based on when all the wonderful said you said that is, let’s talk about anemia being either suspected or in the medical history. Would you expect the general dentist to refer to oral medicine or to the GP to get bloods? You think?

[Amanda]
That is an excellent question. And you know, to be honest, I don’t really know the answer. Like, okay. I know what my answer would be, but I don’t think it is always correct. I think it depends on the patient’s general practitioner, because I’ve had multiple cases where the patient is sent to the doctor and the doctor hasn’t really known what blood test to order, or they’re unsure about potential systemic contributors to oral candidosis.

And then the patient just ends up going round and round in circles for a little bit. I think this will have to be up to the person that is listening to like whoever’s listening to the podcast to maybe have a chat with their patients about, do they have a regular GP, has their GP been pretty thorough. Because a good GP I think would be very adequate at managing this. But then at the same time, GPs are also very busy, so they need to know a little bit about everything. So it’s sometimes very difficult to expect them to know how to manage oral candidosis systemic conditions.

They may not know necessarily what to look for when they start to order blood tests, and then even then they may not know what to prescribe. And actually, one really big thing that we’ve not really talked about as well is that I’ve set the cases where Oral Candidosis is very obvious. Pseudomembranous Candidosis being the example.

But there are many times where these signs and symptoms are sort of nebulous or not very obvious, and then the patients are misdiagnosed and they’re sort of going to a merry-go-round. So a classic example will be burning mouth syndrome, which is otherwise known as oral dysesthesia. I’ve recently just done a lecture on that as well, and and I looked at this paper that was done in Italy.

And the number of burning mouth syndrome cases that were misdiagnosed as oral candidosis is actually quite high. So, would you necessarily expect a patient’s GP to be able to know the differential diagnoses of oral burning or potential oral infections? I think that is really difficult as well. Because GPs are very busy, so they may not know.

[Jaz]
Are they always segregated, the burning? I mean, is any evidence that everyone in burning mouth syndrome has a candle infection same time or vice versa? The candidate is what set off the BMS, is there anything linked or are they very much different entities?

[Amanda]
Yeah, so there have been a couple of studies that looked at Candidal carriage in people who do have burning mouth syndrome. But unfortunately I don’t think we can put much stock into that because Candidal carriage is something that we know doesn’t necessarily mean infection. So I think it’s probably easier to think of it as being separate because burning mouth syndrome is meant to be a diagnosis of exclusion, where we’ve wrote everything out.

Then we diagnose the patient with burning mouth syndrome. So, If they do have signs of oral candidal infection, then we would diagnose them as having a oral candidal infections first, and then see how they respond to management. And if we are sure that there’s no longer any other infection or any other problem, and we think it’s burning mouth, like, it’s a diagnosis of exclusion essentially. So I think it’s easier to think of it separately.

[Jaz]
Okay. Well the second question I wasn’t asked then is, let’s say we’ve looked for the signs and we’ve either diagnosed the cottage cheese appearance or the chronic hyperplastic when get a referral out to get it investigated because of the risk of dysplasia or we’ve got the erythematous one and from this podcast, we think, okay, I think I’ve diagnosed a fungal infection.

Now something as you said, quite beautifully, something has changed in the host and we’re going to discuss and have a chat with the patient, look at their medical history, take a close look. What is the recommended pathway? Is there a school of thought that actually we shouldn’t pick up the referral pad?

How about we listen to the patient, we’ll figure out what’s changed, and try and see if possible if within our powers we reverse that. Or should we also prescribe antifungals and investigate what’s changed. So what I’m trying to say is, a pans off approach, no prescription, but let’s just drink more water, stay more hydrated, figure out what’s causing the xerostomia speak to your GP about changing that medicine, clean your denture better, and not giving the antifungals. Is there a place for that?

[Amanda]
So I have to caveat this by saying that you have to look at the therapeutic guidelines of your own country, where you’re from, who are wherever. Cuz I know people from all around the world listen to this podcast.

But what I would do in Australia is that with the people that I work with, I would actually encourage doing both. So if you have a reasonable suspicion that it is an oral fungal infection, like oral candidosis, modify any risk factors that is possible or densely related, or talk to the patient’s GP if there’s anything there.

Manage the patient with their oral fungal infection. And then if it doesn’t get any better or something’s a little bit unusual, or if you think it is chronic hyperplastic is a leukoplakia, you don’t know if it’s leukoplakia or not. Those ones I think you should refer, but if not, if it’s a fungal infection, I think dentists should be able to manage that.

And certainly I think it’s a good idea because I’m sure in the UK as well, in the same is same here in Australia. The wait list for an oral medicine specialist or like a specialist is quite long. You don’t necessarily need-

[Jaz]
Massive.

[Amanda]
Yeah.

[Jaz]
And they’re few and far between. The oral medicine specialists only work in certain tertiary centers if you like. So, usually the only option we have is to refer to Max Fax, which may, which is similar, but not the same.

[Amanda]
Mm-hmm. Yeah, no, I agree. So I think it, I think general dentists or dental professionals are well within their capability to manage this. And then if it’s recalcitrant or anything’s a little bit unusual, then I think that is worth a referral.

[Jaz]
Okay. Brilliant. Well, let’s talk about my medicines, I guess. The management as a general dentist that is accepted before we then talk about the angular cheilitis and median rhomboid glossitis. Yes. So please tell us.

[Amanda]
Yes. So there are different types of antifungals. So the earlier ones are actually the polyenes which is the Nystatin and the amphoterecin. Now Nystatin in Australia comes in Nils stat oral drop form. And I think when I looked it up online, what they had it in the UK, I think it comes in a suspension. Some places may have it in pastels. Nystatin is something that has been shown to be not particularly effective in the oral cavity.

Now obviously the efficacy depends on which formulation you’re using. But in general, they’re not amazing. In Australia it is a little bit of an issue because that seems to be very widely prescribed, and I don’t know why the most weak one is the most commonly prescribed, probably for ease of use.

But the problem with the nilstat that oral drops or the suspensions, is that we have issues with making sure that they stay in the mouth for long enough. Because if it’s an oral drop or suspension, it kind of doesn’t really hang in there that much. And also it doesn’t taste very nice or in some formulations they don’t taste very nice and it actually increases salvation in which further dilutes the Nystatin

so I think a Nystatin is probably one that I wouldn’t recommend because it’s not particularly effective unless for some reason you decide to get it compounded at a compound chemist and they can do different things, like different suspensions, different coating agents to make it stay in the oral cavity a little bit longer.

But why would you do that when there are other things? So the most common one would be miconazole oral gel. The brand name here in Australia is Daktarin Oral Gel. That is-

[Jaz]
Yes. Same.

[Amanda]
Yes. Yeah. So that’s pretty easy to find. You can get it from the pharmacy and then that is what I would get patients to apply in their mouth four times daily for about four weeks. It is generally well tolerated. There are a few significant interactions which we will get into that I think people should be aware about. But in general, it’s-

[Jaz]
Can you just describe the general dentist, when they’re explaining to their patients maybe the first time they’re prescribing this, and yes, you can read it, but how should they instruct their patients to wear it and how might it differ if the patient’s got a denture?

[Amanda]
Yes. So I get this question all the time, so I actually even made a video about it. So with the Daktarin oral gel in Australia, you don’t need a script for it. So I write the name down on a piece of paper, and I give it to the patients, and I tell them that they can buy it from the pharmacy.

Now, Daktarin Oral Gel here comes with a spoon. I tell them that the spoon is actually too much. All they really need to do is apply a pea size amount into their oral cavity. So depending on where I think the infection is the worst, I will tell them to put it on there. But generally I always tell them to put it on the dorsal tongue because that’s where the IT candida likes to hide.

So I tell them to apply a pea size amount in their four times daily, for about four weeks. Now, the official guidelines is that they should be doing it for seven to 14 days and then continue for another seven days after the infection has cleared up. Now, I don’t know about you, but there are not many patients I know that can accurately identify when the infection is cleared up and continue for another seven days after.

So just at ease. I usually tell them just do it for about four weeks. Now when they put the gel in their mouth, I tell them to leave the gel in there for their mouth as long as possible. I tell them not to eat, drink, or rinse or swallow for about 30 minutes after. So I generally tell them-

[Jaz]
No swallowing for 30 minutes? How? How do they do that?

[Amanda]
So if you have like a little bit you can, but I try to get them, cuz some people would try to get rid of the gel taste and things like that. I’ll be like, no, it should stay in there for as long as possible. A little bit of swallowing is fine, but they shouldn’t like try and actively swallow all of the gel. So I explained-

[Jaz]
Should they try and keep their tongue out? Like should they try and keep, stick their tongue out and leave it there? Or just, close their mouth. Okay.

[Amanda]
Yeah. So what I tell them to do is that, when you wake up in the morning, have your breakfast, brush your teeth, or whatever order you want to do that in, put a piece ice in your mouth, put it rub it around your oral cavity, and then just go about your day.

Don’t worry about rinsing it out, leave it alone for about 30 minutes and you should be fine. Now, sometimes you may have patients who do struggle with doing it four times a day, but I sort of explained to them that candida is pretty good at hiding. You need to keep using it long enough. You need to apply it often enough for it to actually work.

And most patients are fairly compliant. Now, if they do have a denture, I tell them to put it to the fitting surface of the denture. As well as a little bit on their tongue. And then at night when they sleep, because we’ve talked to them about denture hygiene already, they take it out at night so they can just apply it directly into the oral cavity. So that’s typically how-

[Jaz] So just before you sleep is a good time to also apply. Maybe that fourth time should be just before they sleep.

[Amanda]
Mm-hmm. Yep. So dinner, brush your teeth, apply, you can go to bed if you want.

[Jaz]
And do other, there any studies looking at their efficacy of Daktarin? I mean, how effective is it in terms of as a medicine?

[Amanda]
Yep. So Daktarin Oral Gel is actually pretty good. So there are other ones that we can talk about, which will include the fluconazole mouth washes and the amphotericin B lozenges. Those ones are actually better for adults, but Fluconazole mouth washes in Australia has to be compounded, so that’s quite a bit of an expense to get a compounded fluconazole mouthwash.

The amphotericin B lozenges is great, however, so amphotericin B is a lozenge. Amphotericin B is called Fungilin 10 milligrams and it comes in a little pastel that the patients suck on, and they do that again four times a day. I usually tell them to do it for about four weeks. It can leave a bit of a yellow stain on the teeth, but it’s temporary that will come out.

And amphotericin B is my choice. If cost is not an issue because it’s only covered partially here by the government, so in terms of costs, I generally will go Daktarin oral gel unless there’s a reason for them to go to amphotericin B. The other thing as well, which sometimes patients don’t, like it’s obvious to us, but not really to the patient.

They don’t take their denture out when they’re sucking the Fungilin lozenge. So you have to make sure that they are happy to actually have their denture out when they’re sucking it, cuz the lozenge takes about 30 minutes to dissolve. So we all have our those patients who won’t sleep without their dentures.

Their partners have never seen them without their dentures. Sometimes it’s a bit of a big ass to get them to take it out so often during the day. So in those cases, I’ll just do Daktarin Oral Gel cuz they will be a little bit more compliant for it. In infants though, in studies, the Miconazole Oral Gel is actually shown to be the most effective.

[Jaz]
Is that concern is, you say that Candida is a disease of the diseased and a child having it and diagnosing it. Is that a reason for referrals of GP to get investigated for a child? I mean, I’m thinking like leukemia, I’m thinking things like that, or is it a common thing that it’s not worth worrying about too much?

[Amanda]
I think it’s worthwhile to treat first and see how they respond. If it’s recurrent or coming very frequently, then definitely investigation is needed. But they used to call it the disease of the diseased, but we know that it happens in higher numbers in the very young and the very old as well. So I think if it’s just a once off or not happening too often, I don’t think it’s too bad, but if it keeps coming back, then it needs to be investigated.

[Jaz]
Okay. Any other medicines that you think are worth mentioning for GDPs? Like the fluconazole you said is a mouthwash, right?

[Amanda]
Mm-hmm.

[Jaz]
But you has to be compounded, you mentioned that one already. So it’s a bit trickier if, are those all in terms of GDPs needing to know?

[Amanda]
You can do fluconazole capsules, so you can give them 50 milligrams of fluconazole that they can swallow and they can do that for up to a week. I think if you’re getting to the stage where giving them systemic fluconazole. I think that one you’ll have to do a little bit of reading up. Like I still think it’s fine for general dentists to prescribe it, but obviously giving something systemic versus giving something topical, there will be more interactions. Actually, we need to talk about the interactions for miconazole and I suppose for fluconazole as well. Mm.

[Jaz]
Let’s do that.

[Amanda]
Because one of the things before you give the patient Daktarin Oral Gel and this is the time where it is definitely worth spending going through their medical history with a fine tooth comb as well.

So if they are on a statin, you need to be a little bit wary. And if they are on warfarin or even some of the newer anticoagulants, you have to be a bit wary as well. So, miconazole can potentiate the action of warfarin. So patients can actually bleed a lot more even with the newer noac. So Rivaroxaban also has that action.

Sometimes there is a little bit of a concern in the hospital department if you need to treat the patient with an antifungal, are you able to give them miconazole or itroconazole or fluconazole, or do you need to change them on their blood thinning medication? So I think that’s something that needs to be considered.

Not to say that if I have a patient with Warfarin, I would never put them on Daktarin. But I think that’s something that should be done at specialist level. So Warfarin-

[Jaz]
I think, yeah, as a general dentist, I think as a rule of thumb, as a general dentist, anything that ends in -azole if they’re at risk of bleeding or on that kind of medication that makes ’em bleed more, or as you said, they’re on a statin. Is it a rule of thumb? Say avoid miconazole avoid fluconazol?

[Amanda]
Yeah, and also probably your benzodiazepine, cuz it can lead to long lasting sedation.

[Jaz]
Okay.

[Amanda]
So those are probably the ones that I will avoid if the patients is, if you want to put them on Fluconazole or Miconazole or the azoles basically.

[Jaz]
And so maybe go for the Nystatin suspension in that case.

[Amanda]
I would probably go for the amphotericin B lozenges first because I think that they are still more, they are more effective. One of the big issues with Nilstat oral drops, if that’s the formulation that’s available to you, that there were a couple of studies done and it’s about 50% sugar.

So some patients can run into an issue. So say if they have salivary gland, hyper function, maybe they’ve had neck radiotherapy, they need to be on long-term antifungals. And you give them Nilstat oral drops that they use every single day, they’re going to get ringbark caries. They’re very high risk of dental caries. So generally on the whole, I would prefer amphoterecin B rather than your Nystatin oral drops.

[Jaz]
Amazing. We’re going to now do a segment of the podcast where it’s going to be about roughly a minute long, so good luck. Okay. We’re going to make an Instagram reel out of this. Okay? So, I’m going to get you to summarize everything you said.

Okay. If the patient has this, you’re going to prescribe miconazole, but weary of this, this, this. Second choice is this, but then watch out for this. So try your best. It’ll be a very fun Instagram reel to make. So, Amanda, over to you for the real guideline for GDPs prescribing antifungals.

[Amanda]
So this is not exhaustive if a patient has oral candidosis. You can put them on Daktarin oral gel, otherwise known as miconazole oral gel. You do have to be careful if the patient’s on a statin. You do have to be careful if the patient’s on Warfarin or Rivaroxaban or if they are on a benzodiazepine. Second option, you can put them on Fungilin 10 milligram lozenges, otherwise known amphotericin B lozenges.

You do have to be where it can cost temporary staining and it’s not safe in pregnancy. And also for denture wearers, they have to take off their denture. Yes, don’t forget to reinforce denture hygiene and keep an eye out of any systemic contributors.

[Jaz]
And then third choice would be the Nystatin but generally you think with the first two, the azoles and the amphotericin B generally we’re going to be okay.

[Amanda]
Yeah, I would put near step pretty low. I don’t know. Can you splice that together into a minute? I hope so.

[Jaz]
Yes. Yes. That was way shorter than a minute. That was perfect.

[Amanda]
Oh, very good.

[Jaz]
That was really good. That was really, that was brilliant, Amanda. I love straight talking guests like you. I love guests like you, who’s like, duh, this is what you need to know. Boom, boom, boom. You’re like an encyclopedia of all medicine. I’m so glad I’ve connected with you. This is amazing.

So, I guess the final part then let’s tell the GDPs about a common thing that I see, well, I say common, but like probably like in the scale of commonality, like more common than a dental trauma, like more common than evulsion coming in, but less common than a lot of the other things we see.

So angular cheilitis and median rhomboid glossitis, what is the thinking? Any difference in terms of what you explained so far when we’re coming across these issues?

[Amanda]
Yeah. So first off, let’s start with angular cheilitis. Cause I think that’s probably going to be the most common one that people see. If you see angular colitis, you need to consider why that has happened. And so I think-

[Jaz]
Can you just describe for the student maybe what it actually is?

[Amanda]
Yes, sorry. So, angular cheilitis is usually crusting erythema or ulceration involving the bilateral commissures of the lip. So you can actually see that they usually have retinas at the corner. Sometimes patients may describe it as a rash or a ulcer.

Sometimes they may even tell you that they keep getting cold sores at the corner of their mouth. But what they’re really describing is angular cheilitis.

[Jaz]
Does it always have to be bilateral?

[Amanda]
No. It can be unilateral as well. Good question. Okay. Yeah. So angular cheilitis is something that we see fairly commonly. I think one of the really great things for a dental professional to pick up is actually if there’s loss of vertical dimension. Have they had dentures for 20 years and is it about time to get them new dentures? But it is thought to be a polymicrobial infection. So the candidal species and also staph aureus and things like that have been thought to be associated.

So first thing I would do is do all of the basic things that we talked about, about making sure that there’s, or identifying any obvious systemic contributors. So, checking are they anemic? Are they taking their denture out at night? Are they rinsing their mouth out after using a steroid puffer?

And then if all of that is maintained and you’ve optimized that well, then you can get them to use a medication that they can apply to the side of their lips on the outside. Now, there are a couple ways to do this. One of it is that if you suspect that they have an oral candidal infection, as well as angular cheilitis.

You can actually try getting them to use something like the Miconazole or Daktarin Oral gel. They can apply it to their tongue four times a day for four weeks that we talked about. They can also put a little bit on the corners of their mouth and they can see if it clears up. Now if it doesn’t clear up, because sometimes, as I say, it could be polymicrobial and obviously the Miconazole only works for fungal infection.

You can apply something like Kenacomb which basically has a mild corticosteroid, a antibiotic as well as an antifungal. So there are similar formulations where you can get these types of medications that have multipurpose, and they can apply a little bit on the corner of their mouth. You can do clotrimazole as well cream which you can apply to the corner of the mouth. Now, I do want to-

[Jaz]
And these are all GDP friendly, you think, or this is something that we should be referring to you guys for okay.

[Amanda]
No, I don’t think so. Yeah, I think, I mean, I think if you do suspect that oral candidal infection, just starting off with the miconazole oral gel is probably the easiest. Sometimes if I do suspect that the patient has nasty or what I think is like not like the angular cheilitis is not going well. Then I might get them to use miconazole oral gel in the mouth and put them on Kenacomb extra orally. But I think, this is something that I think is fairly safe, but there is one word of caution that the patient shouldn’t be using steroids on their skin for too long.

So if you give them Kenacomb which has the antibiotic, the steroid, and the antifungal, you want to make sure that they stop using it after a while because steroid can actually atrophy the skin. So it can actually make it a little bit worse. So if it’s something like Kenacomb I get them to do it two to three times a day for about two weeks.

And then once it clears up, I tell them, make sure you stop. Don’t keep applying a steroid on your skin cuz it can make things worse. So that’s generally how I would approach the angular cheilitis. Median rhomboid glossitis I would approach fairly similarly to how I would with the rest that we just talked about there, they can apply the daktarin oral gel into their oral cavity, same as the denture dermatitis.

But probably one of the things to know about median rhomboid glossitis, and the denture dermatitis, sometimes after treating them, it may not go away completely, so that little diamond shaped erythema on the dorsal surface of the tongue may actually stay there even after you’ve treated the fungal infection.

Another thing is that it’s actually really common to get erythema of the hard palate based on a poorly fitting denture. So if you’ve treated the patient for an antifungal and the surface of the hard palate still looks very red, you need to consider if the denture is rocking and causing trauma and causing erythema, or if you’ve got something in there that needs referral.

[Jaz]
Very good. I actually remember so random things you remember from Dent School. Remember Prof. Nick Martin telling me that sometimes with a denture and you’ve got patients got recurrent denture dermatitis that they may need the denture rebasing cuz apparently the candida actually goes into the acrylic is from I remember. So how successful is just miconazole And then it gets better with improved oral hygiene or sometimes if it’s persistent, such a thing as rebasing and or replacing the denture. Is that something that’s accepted?

[Amanda]
Yep. So the thing that I would like to bring up there is actually how you’re giving your patient the denture hygiene instructions cuz you may, like in Australia here, there was a little bit of discussion around the fact whether when the denture is removed at night, whether it should be kept in water, whether it should be kept dry.

Cuz some people argue that taking it out and leaving it dry at night will change the dimensional stability of the acrylic. And I think someone then published a paper and said that it was very minimal. So what I tell my patients to do when they take their dentures out at night is to give it a good clean not to use toothpaste cuz it scratches the acrylic and gives more areas for the candida to colonize.

But to use something like dish soap and a very soft brush, give it a really good clean rinse it, leave it dry overnight. Now, in most cases, by leaving it dry overnight, you should be able to reduce colonization of the candida by that. And then also, don’t forget, you’re also applying like the miconazole oral gel directly onto the denture itself.

Now, in some cases, if the patient is due for a new denture, it’s poorly fitting. It’s not up to par. Then I think replacing the denture or relining the denture, if it rocks or if it doesn’t fit well, I think it’s perfectly justifiable.

[Jaz]
Amazing. Wow. So a 40 minute mark and you’ve literally blasted antifungals and all those things. I’m so happy. I think everyone’s going to love this. I think the Protruserati chopping onions right now are going to feel much more confident now about diagnosing and managing of fungal infections of the oral cavity. Is there anything else that you think we need to noteworthy for the general dentists who are tuning in, either on YouTube or the app, or listing in on Spotify?

[Amanda]
No, I think we’ve covered Oral Candida quite well. I mean, there are some things that are out there right now about emerging resistance of bacteria and fungus and medications that we do use. So if something feels a little bit funny, if it’s not going well, or if it doesn’t heal right or it keeps recurring, then I think that’s definitely a good thing to consider referring.

I think this is also dependent on where you are, but I think getting to know your local oral medicine specialist is actually a good idea as well cuz I think it’s very common and I certainly felt it when I was a dentist as well. You don’t know whether these cases need referral or not.

So if you are friendly with your local specialist, you can open up the doors to conversation. You can ask them, hey, I’ve got this patient, do you need to see them? And I think in most cases, if it’s something that we feel that is very, that is completely fine for a dentist to manage. We will talk you through it. So I think, dentistry is all about community, so make connections and get to know your local specialists too.

[Jaz]
Yeah. There’s a shortage of, I don’t know. I feel there’s a short shortage. There they’re few and far between. So it’s good to find these guys and be able to lean on them for advice and guidance.

And I think you have provided so much advice and guidance in just a clear manner. So thank you so much. Where can we learn more from you? What are your channels to follow you on and to absorb all this wonderful helpful content that you’re generating so we can help our patients? That’s ultimately, that’s what it’s about. How can we serve our patients in a predictable manner? How can we learn more from you, Amanda?

[Amanda]
Oh, thank you very much. So, I do have an Instagram page that’s called, Oral Medicine, Oral Pathology, and then on Facebook, it’s a spoonful of oral medicine, so I’m the same as you. I do love talking and educating. So I do put up a few posts on things that I think people will, or hopefully people will find helpful.

[Jaz]
I can vouch for it. When I saw your page, I was like, yes, this is who I want. Come on Protrusive to talk about all these things all medicine. So I mean, thank you so much. I will have to invite you back cuz I loved it so much.

It was so direct. One of my team often worked together and we make these infographics and stuff, so, I’ll be able to short set, send it to you for you to get your seal of approval so you can share it with everyone. It’ll be a nice summary for everyone cuz there’s a lot to grasp. But if you can make it into an infographic, which you will, it’ll be really nice for them to follow and that’ll be yours because that’s your work based in your delivery of the content. And I look forward to making that real and sharing as well. So, Amanda, thank you so much for giving up your time today. We appreciate it.

[Amanda]
Oh, not a problem. Thank you for having me. I had a really good time.

Jaz’s Outro:
Well, there we have it, guys. Straight talking Amanda did a fantastic job at breaking down. I think that’s it, right? We’ve absolutely smashed antifungals. You know what to prescribe now, and you’ll have the infographic, which you’ll download of course. And if you are a Protrusive Premium member, you don’t need to download anything. You don’t need to sign up for anything, you just head over to the app.

The Protrusive Vault Section where we’ll find hundreds of PDFs and goodies. And of course you’ve got a premium monthly content, which I’m adding to, and we’re loving it. And of course now the OBAB, my occlusion course is published and I’m not having to dedicate my entire life to that occlusion project.

I can feed the app a lot more now. So thanks so much for sticking with me, but the best is yet to come. And thank you for listening all the way to the end. I’ll catch you in the next episode.