Management of Acute Dental Problems

Brief description of condition

Acute and chronic infection of the oral cavity caused by Candida species (most commonly C. albicans).

Several patient groups are predisposed to candidal infection (pseudomembranous candidosis and erythematous candidosis infections), e.g. patients taking certain drugs, including inhaled corticosteroids, cytotoxics or broad-spectrum antibacterials, patients with diabetes, patients with nutritional deficiencies, or patients with serious systemic disease associated with reduced immunity such as leukaemia, other malignancies and HIV infection.

Key signs and symptoms

• Pain
• Bleeding
• Abnormal appearance:
  Pseudomembranous candidosis: White patches on the oral mucosa which become confluent plaques resembling milk curds. The plaques can be removed to reveal a raw erythematous base which may be painful and bleed.
  Erythematous candidosis: Red patches on the oral mucosa. Typically involves the dorsal surface of the tongue where it manifests as depapillated areas.

Initial management

If a patient is using a corticosteroid inhaler, in the first instance, advise them to rinse their mouth with water or brush their teeth immediately after using the inhaler. Confirm good inhaler technique and consider the use of a spacer.

For superficial infections, prescribe systemic fluconazole or miconazole oromucosal gel for topical application (see SDCEP Drug Prescribing for Dentistry guidance for doses.

• Note that fluconazole interacts with many drugs. If fluconazole or miconazole are contraindicated, prescribe nystatin.

Advise the patient to seek non-urgent dental care.

Subsequent Care

Monitor symptoms at follow-up appointments.

If the patient does not respond to appropriate local measures and a course of drug treatment, or there is no identifiable cause, refer the patient to the patient's general medical practitioner for further investigation or to a dental specialist.

Fungal infections in immunocompromised patients with serious systemic disease require assessment by the patient's general medical practitioner.

References

1. SDCEP. Drug prescribing for dentistry: dental clinical guidance, 2nd edition. Dundee: Scottish Dental Clinical Effectiveness Programme, 2011.