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Therapeutic Agents for Oral Candidiasis, Thrush, Candida, Oral Thrush

last modified on: Thu, 04/18/2024 - 18:29

return to: Therapeutic Agents for Oral Mucosal Disease Treatment Strategies

Therapeutic Agents and Treatment Strategies for the Management

of Selected Oral Mucosal Diseases

September 2018

Cindy Marek, PharmD & Faculty, Dept. of Oral Pathology, Radiology & Medicine

The University of Iowa College of Dentistry

see footnote key at bottom of page below (e.g.3)

Topical Suspensions 3

RX:          Nystatin oral suspension 100,000 U/ml

Disp:       12 day supply (240 ml)

Sig:         Rinse with 5 ml for 1 minute and expectorate P.C.

                (after meals) and HS (before retiring) NPO 1/2 hr.
  • Poor antifungal
  • Commercial products contain 33-50% sucrose, not recommended for this reason, especially in chronic/recurrent cases like Sjögren’s, medicament xerostomia or post radiation xerostomia, ($60+)

äRX:      Nystatin oral suspension 100,000 U/ml Sugar-Free

Disp:       12 day supply (240 ml)

Sig:         Rinse with 5 ml for 1 minute and expectorate P.C.

                (after meals) and HS (before retiring) NPO 1/2 hr.
  • Viscous, will coat tissue
  • Compounded at Dental Pharmacy ($35)
  • Must be refrigerated, shorter shelf life than commercial, but not cariogenic

äRX:      Amphotericin-B oral suspension 25mg/ml

Disp:       14 day supply (280 ml)

Sig:         Rinse with 5 ml for 1 minute and expectorate P.C.

                (after meals) and HS. (before retiring) NPO 1/2 hr.
  • Much more effective than nystatin suspension
  • Of use for fluconazole-refractory infections or when C. krusei or C. glabrata are suspected
  • May use 15mg/ml strength when combining with triamcinolone acetonide

 

Ointment 3

RX:          Nystatin ointment 100,000 U/g

Disp:       15 gm

Sig:         Apply thin film to inner surfaces of dentures and

                 angles of mouth QID, PC & HS.  NPO 1/2 hr.
  • Poor antifungal
  • Works OK under dentures, but not first line agent
  • Bright yellow color may be objectionable for angular cheilitis, ($24)

äRX:      Clotrimazole 2% in Jelene ointment

Disp:       30 g

Sig:         Swab or apply thin film onto affected area QID, PC

                 and HS, NPO 1/2 hr.
  • Useful for debilitated patients who cannot rinse
  • Higher concentration (2%) and more occlusive than commercial creams (no commercial oint. available)
  • Compounded at Dental Pharmacy

 

Cream 3

RX:          Clotrimazole 1% cream (Rx, OTC as Lotrimin AFâ, g)

Disp:       15 gm Rx or 12 gm OTC

Sig:         Apply thin film to inner surface of denture and

                angles of mouth QID.  NPO 1/2 hr. after use.
  • Has slight anti-staph activity
  • Available OTC ($7) but labeled for athletes foot and jock itch which may cause some patients to hesitate. 
  • Identical to Rx version ($28)

 

Troches 3

RX:          Clotrimazole 10 mg oral troches

Disp:       70 troches

Sig:         Dissolve 1 troche in mouth every 3 hours while awake

                (5 tabs per day).  NPO 1/2 hr. after use.

  • Patients with decreased salivary flow should rinse mouth with water prior to use to enhance dissolution
  • Compliance problems with 5X daily therapy
  • 1-2 troches QD HS is useful for maintenance or prevention. ($120)
  • Can also dissolve 2 troches in am, 1 in afternoon and 2 HS to improve compliance
  • Contains sucrose, FDA pregnancy category: C

 

Buccal Tablet

RX:          Miconazole 50mg buccal tablet (Oravig®)

Disp:       14

Sig:         Apply tablet to canine fossa once daily for 14 days
  • Approved for patients 16 years and older
  • Cost  >$900/14 tablets, insurance usually will not cover

 

Angular Cheilitis

  • OTC clotrimazole 1% cream works – patient must understand that even though it is marketed for athlete’s foot
  • RX for clotrimazole 2% ointment (Jelene) – doubles the strength of clotrimazole

*RX:        Clobetasol 2% in mupirocin 2% ointment

Disp:       #20 g

Sig:        Apply thin film to corners of mouth three times daily (after breakfast, mid-day and at bedtime. NPO for 30 min. after use
  • This combination works well if the problem has been persistent or there is redness (secondary to skin staph and strep)
  • Use until clear plus 4 days

*RX:        Clotrimazole 1% cream 1:1  mupirocin ointment

                 (Bactroban®)

Disp:       #15 g

Sig:         Apply thin film to angles of mouth 3 times daily (after breakfast, in pm & HS). NPO 30 min. after use. Apply with cotton-tip applicator.

  • Use until clear plus 4 days
  • If applied with finger, wash hands after use.
  • Most pharmacies will combine two commercial products.  Commercial 1% clotrimazole is only available in cream.
  • Combination of ointment & cream is not ideal, but mupirocin cream may cost >$200/15 g while ointment is $20.
  • Better choice  than Mycolog II which is >$100/15 g

 

Systemic 5

RX:          Fluconazole 100 mg tablets

Disp:       #11-15 tabs

Sig:         Take 1 tablet BID for first day, then take 1 tablet daily for 10 –

                  14 days.

  • Loading dose results in steady state concentration in 2 days
  • Price of 15 tablets is approximately $65 without insurance, cheaper to break 200 mg tablets in half
  • Potent CYP2C9 inhibitor, moderate CYP3A4 inhibitor, causes QT prolongation
  • Serious interactions with statin drugs, psych drugs, sulfonylureas, warfarin,  some antihypertensives and many other drug classes –  always check for interactions before prescribing
  • FDA pregnancy category: X Even single doses in 1st or 2nd trimester can cause miscarriage

 

Antibacterial Mouth Rinse 3

RX:          Chlorhexidine 0.12% oral rinse (Peridexâ, g)

Disp:       473 ml

Sig:          10 - 15 ml mouth rinse for 30 seconds and expectorate

                  BID (after breakfast and HS),  NPO 1\2 hr.

RX:          Alcohol-Free Chlorhexidine 0.12% oral rinse (Paroexâ)

Disp:       473 ml

Sig:         10-15 ml mouth rinse 60-90 seconds and expectorate

                 BID, PC, AM & HS. NPO 1/2 hr.

 

 

 

  • 11.6% alcohol content will irritate ulcerations and enhance xerostomia, ($4-14)
  • Due to chemical deactivation, separate from toothpaste by 30 min.
  • FDA pregnancy category: B
  • Non-alcohol formulation – useful for alcoholics, patients with mucositis, xerostomia, ($18)
  • Due to chemical deactivation, separate from toothpaste by 30 min.

Footnote Key:

1.  These medications are all contraindicated in microbial diseases. If given to patients with microbial diseases, microbial proliferation is usually enhanced and systemic dissemination is possible. Candidosis is a common side effect.

2.  Systemic steroids are contraindicated or must be used with caution in a number of systemic conditions. Consultation with the patient's physician is recommended before prescribing. Tapering of prednisone is not necessary with 5-7 day burst therapy. Tapering of prednisone is not necessary with alternate day therapy (QOD) if the dosage does not exceed 20 mg QOD.  In order to reduce the possibility of adrenocortical suppression, it is important that prednisone be taken in harmony with diurnal adrenocortical steroid levels. In order to accomplish this, prednisone should be taken 1-1/2 hours after normal arising time. Alternate day AM (QOD) dosage also reduces the possibility of adrenocortical suppression.

3.  Whenever topical mouth rinses or ointments are prescribed, the manner in which the medication is used is very important. The patient should be advised that the medications are effective on contact and that they should avoid anything by mouth (NPO) for 1/2-1 hour after using them to prolong medication contact time.

4.  Baseline hematology laboratory studies to include platelets are necessary to monitor possible bone marrow suppression.

5.  Hepatotoxicity has been reported.                                                 OPRM Faculty

* Denotes prescription items that must be extemporaneously compounded by a pharmacist. Usually a specialty "compounding pharmacy" is a better choice as they have more experience and knowledge regarding product formulation.

Extemporaneously Compounding Medications for Intraoral Conditions

  • Few products available in the U.S - ?? limited product demand
  • Problems:
    • Difficulty with insurance payments, XIX & Medicare will not reimburse for the full cost
    • Expensive – Dental Pharmacy can mail Rxs to patients living in Iowa – at significantly less cost to patient patients and the products are formulated correctly for improved efficacy
    • “I can do that” - generalized lack of knowledge – many pharmacies incorrectly compound intraoral products causing mucosal irritation, reduced efficacy
  • Make sure products are not flavored or sweetened (especially with sucrose) unless necessary!