antibiotik for dental uses
TRANSCRIPT
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Dentists prescribe several categories of medications to manage a variety of diseases and
conditions associated with the oral cavity. Among these conditions are bacterial, fungal and
viral infections, pain, and caries prevention. The prescription of medications is more
complicated than in the past with clinicians dealing with an increasing number of issues
such as microbial resistance to prescribed antibiotics and drug interactions within the
increased number of medications used by both adult and pediatric patients. Theadministration of drugs to pediatric patients is further complicated by the necessity to
adjust the dosages of medications to accommodate their lower weight and body size. In
this course the reader will find descriptions of the most commonly used medications used in
dental care with emphasis on the pediatric patient. As you review the medications you will
see that the dose and instructions on how to take them will vary from patient to patient,
depending on the patients age, weight and other considerations. The categories of
medications covered by this course are antimicrobials, which include antibiotics, antifungals,
and antivirals, analgesics, and fluorides.
In general, pediatric patients cannot be given adult dosages of drug. The primary reasonfor this is the difference in body size. !hile the drugs discussed in this course provide the
drug dosage for pediatric patients, the clinician may be faced with the need to prescribe adrug not listed that does not provide that information. "everal rules e#ist to compute thedosage of a drug for a child, the most common $larks rule. $larks rule determines the
dose suitable for a child based on the typical adult weight of %&' lb (or )' kg*. $larks rule+
Childs weight lb (or kg)
X adult dose =
childs dose
150 lb (or 70 kg)
or e#ample, if the adult dose of -enicillin / is &''mg every 0 hours, the dose for a 1' lb(%2 kg* pediatric patient would be calculated as+
40 lb (18 kg)
X 500 mg = 133 mg
eer! " hours
150 lb (or 70 kg)
$larks rule may also be used to calculate dosages for underweight, ill or elderly patients.
In general, pediatric patients cannot be given adult dosages of drug. The primary reasonfor this is the difference in body size. !hile the drugs discussed in this course provide the
drug dosage for pediatric patients, the clinician may be faced with the need to prescribe adrug not listed that does not provide that information. "everal rules e#ist to compute the
dosage of a drug for a child, the most common $larks rule. $larks rule determines the
dose suitable for a child based on the typical adult weight of %&' lb (or )' kg*. $larks rule+
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Childs weight lb (or kg)
X adult dose =
childs dose150 lb (or 70 kg)
or e#ample, if the adult dose of -enicillin / is &''mg every 0 hours, the dose for a 1' lb(%2 kg* pediatric patient would be calculated as+
40 lb (18 kg)
X 500 mg = 133 mg
eer! " hours150 lb (or 70 kg)
$larks rule may also be used to calculate dosages for underweight, ill or elderly patients.
Infections of the teeth and oral cavity can increase in severity and develop into life
threatening situations if not properly managed. Infection management can consist of a
combination of dental or surgical procedures and the use of antimicrobials. Antimicrobials
are drugs that suppress or kill the growth of microbes 3 bacteria, viruses, fungi or
parasites. Antimicrobial activity is ma#imized when the specific microbe causing the
infection is identified by culture or serologic testing and the antimicrobial most active
against that microbe is administered in appropriate doses. The most common
antimicrobials used in dentistry are antibiotic agents, antifungal agents and antiviral agents.
Antibiotics are drugs that are produced by microbes or by chemical methods to produce an antibacterial action.Antibiotics are the second most prescribed group of drugs in dentistry, after local anesthetics. The widespread use
of antibiotics has resulted in common bacteria developing resistance to drugs that once controlled them. To reduce
the resistance rate, health care providers must prescribe antibiotics judiciously. Antibiotics should be prescribed as
soon as possible for optimal healing. If the infection does not respond to the initially prescribed drug, a culture from
the infected site is indicated. The duration of drug therapy should extend at least 5 days past the point of substantial
improvement or resolution of symptoms. The importance of completing a full course of antibiotic therapy must beemphasized to the patient. hould the antibiotic be discontinued prematurely, the surviving bacteria can restart an
infection that may be resistant to the original antibiotic.
ituations that may necessitate the prescription of antibiotics are!
#ral $ou%d &a%ageme%t
"ral wounds are associated with an increased ris# of bacterial contamination. $xamples of oral wounds are soft
tissue laceration, complicated tooth fracture %pulp exposure&, severe tooth displacement %including avulsion&,gingivectomy, and severe ulcerations. If the oral wound seems to have been contaminated by extraoral bacteria,
antibiotics therapy should be considered.
'e%tal %ectio%
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'acteria can gain access to pulpal tissue through caries, exposed dentin tubules and defective restorations resulting
in acute dental infection. Treatment of acute dental infection is accomplished by immediate dental treatment%pulpotomy, pulpectomy or extraction&. Antibiotic therapy is usually not indicated if the infection is contained
within the pulpal tissue or the immediately surrounding tissue and the patient does not exhibit systemic signs ofinfection %fever and facial swelling&.
(atients presenting with facial swelling secondary to a dental infection receive dental treatment accompanied byantibiotic therapy. If the clinician is able to achieve ade)uate local anesthesia, the dentist may render immediate
treatment followed by a regimen of antibiotics. If the infection is of such severity that achievement of ade)uate
local anesthesia is )uestionable, then prescription of antibiotics for a period of 5*+ days should be considered
before rendering treatment. -hile oral antibiotics may be the simplest route of administration, in cases of severe
infection hospitalization and intravenous administration may be necessary.
*ediatric *eriodo%tal 'iseases
(rolonged antibiotic therapy may be prescribed for the management of chronic periodontal disease, especially in
patients with an immunodeficiency disease. In pediatric periodontal diseases %neutropenias, (apillon*evere
syndrome, leu#ocyte adhesion deficiency& the immune system is unable to control the growth of periodontal
microbes. As this is a chronic rather than an acute condition, effective drug selection may be accomplished byculture and susceptibility testing.
+iral 'iseases
Antibiotics should not be prescribed for viral conditions %acute primary herpetic gingivostomatitis& unless there is
strong evidence to suggest that a secondary infection exists.
#ral Co%trace,tie -se
It is not uncommon for oral contraceptives to be prescribed for adolescent females to prevent pregnancy. -henantibiotics are prescribed in concurrence with oral contraceptives, the patient must be advised to use additional birth
control techni)ues as antibiotics may render the oral contraceptive ineffective for at least + wee# beyond the lastdose.
Antibiotics can be categorized by the bacteria they target. They are either narrow or wide spectrum. /arrowspectrum antibiotics are effective specifically against either gram*positive or gram*negative antibiotics. 'road
spectrum antibiotics are effective against a wider range of bacteria. The efficacy of an antibiotic against a particular
bacteria is determined by culturing the pathogen and testing its susceptibility to a particular antibiotic.
0nfortunately, culturing and susceptibility testing may ta#e 12 hours to several days resulting in a delay in initiation
of antimicrobial therapy. Thus, until culturing and susceptibility results are available a best guess is made for
determining the most effective antibiotic for a specific clinical situation.
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Causes and Treatment of Odontogenic Infections
3ost orofacial infections are of odontogenic origin. 4ental pulp infection, as a result of caries, is the leading cause
of odontogenic infection. The major pathogens identified in dental caries are members of the viridens %alpha*hemolytic& streptococci family including Streptococcus mutans, Streptococcus sobrinisand Streptococcus milleri.
"nce bacteria invade the dental pulp an inflammatory reaction results in necrosis and a lower tissue oxidation*reduction potential. At this stage, the bacterial flora changes from predominately aerobic to more anaerobic flora.
Anaerobic gram*positive cocci (Peptostreptococcus)and anaerobic gram negative rods %'acteroides, (revotella,(orphromonas and usobacterium& predominate. The infection progresses forming an abscess at the apex of the
root, resulting in bone destruction. 4epending on host resistance and bacteria virulence the infection may spread
into the marrow, perforate the cortical plate and spread to the surrounding tissues.
Additionally, the anaerobic bacteria inhabiting the periodontal tissues may provide an additional source of
odontogenic infection. The most common anaerobes are Actinobacillus actinomycetemcomitans, (revotellaintermediud, (orphyrommonas gingivalis, usobacterium nucleatum, and $i#enella corrodens.
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3ost odontogenic infections %6& contain mixed aerobic and anaerobic bacteria. (ure aerobic infections have less
than a 56 incidence. (ure anaerobic infections have a 156 incidence. The consensus by researchers is that in earlyodontogenic infections, bacteria are aerobic with gram*positive, alpha*hemolytic streptococci (S.
viridens)predominating. As the infection matures and increases in severity the microbial flora becomes a mix ofaerobes and anaerobes. The anaerobes found are determined by the site of origin7 pulpal or periodontal. As the host
defenses begin to control the infection process the flora becomes predominately anaerobic.
Thus, the choice of antibiotic is influenced by a number of factors! tage of infection development and the ability of
the patient to ta#e the antibiotic 8 medical conditions or allergy.
Antibiotics may also be categorized by their method of attac#. 'actericidal antibiotics actually #ill microorganisms,
while bacteriostatic antibiotics slow bacterial growth and depend on the host immune system to eliminate the
microorganism. An antibiotic may be bactericidal for one microorganism and bacteriostatic for another.
'actericidals are preferable over bacteristatics in most situations. 'acteriostatics should not be administered to
immunocompromised patients whose compromised immune system may be unable to assist in clearance of the
microorganism. 9ommon bactericidals used in dentistry are the penicillins and cephalosporins. 9ommon
bacteristatics are the macrolides, tetracyclines and sulfonamides.
The ideal antibiotic for treating dental infections would be bactericidal against gram positive cocci and the majorpathogens of mixed anaerobic infections. It would cause minimal adverse effects and allergic reactions and be
relatively low in cost.
.able 1/ m,iric %tibiotics o Choice or #do%toge%ic %ectio%s/
.!,e o %ectio% %tibiotic o Choice
$arly %first : days of
infection&
(enicillin ;
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.able 2/ m,iric %tibiotics o Choice or #do%toge%ic %ectio%s/
%tibiotic'osage
Childre% dults
(enicillin ;#g body
weight in e)ually divided
doses )=*Eh for at least days7
maximum dose! : g>day
+1 years! 5 mg )=h for at
least days
9lindamycinE*15 mg>#g in :*2 e)ually
divided doses
+5*25 mg )=h for at least
days7 maximum dose! +.E
g>day
9ephalexin %#g>day in divided
doses )=h
evere infection! 5*+
mg>#g>day in divided doses
)=h7 maximum dose : g>12h
15*+ mg )=h7 maximum
dose 2 g>day
Amoxicillin
F 2 #g! 1*2 mg>#g>day in
divided doses )Eh
2 #g! 15*5 mg )Eh or
E5 mg )+1h for at least
days7 maximum dose 1 g>day
2#g! 15*5 mg )Eh or
E5 mg )+1h for at least
days! maximum dose! 1 g>day
Amoxicillin>clavulani
c acid %Augmentin?&
F 2 #g! 1*2 mg>#g>day individed doses )Eh
2 #g! 15*5 mg )Eh or
E5 mg )+1h for at least
days! maximum dose 1 g>day
2 #g! 15*5 mg )Eh or
E5 mg )+1h for at least
days7 maximum dose! 1g>day
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Penicillin VK
-enicillin / is a beta4lactam antibiotic and is bactericidal against gram4positive cocci andthe major microbes of mi#ed anaerobic infections. Adverse drug reactions include mild
diarrhea, nausea and oral candidiasis. There is a '.) to %'5 allergy rate among patients.
About 2&5 of allergic reactions are delayed and take greater than 6 days to develop. The
usual allergic responses e#hibited are skin rashes that usually respond to antihistamine
therapy (diphenhydramine, 7enadryl8*. "evere reactions of angioedema have occurred,
characterized by severe swelling of the lips, tongue, face, and periorbital tissues. -atients
reporting a history of penicillin allergy should never be given -enicillin /. The alternative
antibiotic is clindamycin. If the allergy reaction is of the delayed type and not
anaphylactoid, a first generation cephalosporin may used as an alternative.
-enicillin / may be given with meals, however blood concentrations are slightly higher
when given on an empty stomach. The preferred dosing is one hour before meals or twohours after meals.
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Contraindications:9ypersensitivity to penicillin or any component of the formulation.
Warnings/Precautions::se with caution in patients with severe renal impairment
(modify dosage*, history of seizures, hypersensitivity to cephalosporins.
The usual daily dose of enicillin VK for treating odontogenic infections is:
$hildren ; %6 years of age+ 6&4&' mg
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gram positive cocci and similar in efficacy against anaerobes. Thus penicillin ;< is the drug of choice for treating
odontogenic infections.
Co%trai%dicatio%sCypersensitivity to amoxicillin, penicillin or any component of the formulation.
$ar%i%gs*recautio%s0se with caution in patients with severe renal impairment %modify dosage&7 low incidenceof cross*allergy with other beta*lactams and cephalosporins exists.
.he usual dail! oral dose or treati%g odo%toge%ic i%ectio%s i% childre% is
9hildren under +1 years! 1*2 mg>#g divided in 1*: doses daily for + days.
9hildren over +1 years and adults! 15 85mg : times>day, maximum 1*: gm>day for + days.Amoxicillin is supplied as a +15, 1, 15, 2 mg>5ml solution or chewable tablets7 15 or 5mg capsules.
am,le amo6icilli% ,rescri,tio% or a 3 !ear old ,atie%t weighi%g 12 kg (25 lb) with acial swelli%g
Rx:Amoxicillin +15mg>5ml
Disp:+5 mlSig:Ta#e + teaspoon every E hours for + days
In situations when amoxicillin is ineffective due to possible bacterial resistance to the drug and the patient cannottolerate the adverse gastrointestinal side effects of clindamycin, clavulanate potassium can be administered in
conjunction with amoxicillin %Augmentin?&. 9lavulonic acid binds and inhibits beta*lactamases that inactivate
amoxicillin. It is recommended that it be ta#en with food to increase absorption and decrease HI intolerance.
Co%trai%dicatio%sCypersensitivity to amoxicillin, clavulanic acid, penicillin or any component of the
formulation7 history of hepatic dysfunction.
$ar%i%gs*recautio%s(rolonged use may result in superinfection. 0se with caution in patients with severe renal
impairment %modify dosage&. Incidence of diarrhea is higher than with amoxicillin alone.
.he usual dail! oral dose o ugme%ti%?or treati%g odo%toge%ic i%ectio%s i% childre% is
9hildren : months and F 2 #g! 1*2 mg>#g>day in : divided doses.
9hildren 2 #g and adults! 15*5 mg every E hours or E5 mg every +1 hours.
Augmentin?is supplied as +15, 1, 15 2 mg >5ml solution, chewable tablets and tablets.
am,le amo6icilli%claula%ate (ugme%ti%?) ,rescri,tio% or a 3 !ear old ,atie%t weighi%g 12 kg (25 lb) with
acial swelli%g
Rx:Augmentin?+15 mg>5ml solution %or chewable tablets&
Disp:+5 ml %or : chewable tablets&
Sig:+ tsp %or tablet& every E hours for + days
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Page , of 25
-irst .eneration Cehalosorins
The first generation cephalosporins are alternatives to penicillin / for the treatment of
odontogenic infections. The oral dosage forms of this class are cefadro#il (Duracef8*,
cephale#in (/efle#8*, and cephradine (elosef8*. They are indicated as alternatives to
penicillin / in early infection because they are bacterially effective against aerobes but not
anaerobes. They are active against gram4positivestaphylococciand streptococci, but
ineffective against enterococci. The rate of cross reactivity between cephalosporins and
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penicillins is %5 when the allergic reaction to penicillin is delayed. It should be used with
caution in those patients e#hibiting anaphylactoid reactions.
Contraindications:9ypersensitivity to cephale#in, any component of the formulation, or
other cephalosporins.
Warnings/Precautions:>odify dosage in patients with severe renal impairment?
prolonged use may result in superinfection. :se with caution in patients with a history of
penicillin allergy. >ay cause antibiotic associated colitis.
$ephale#in (/efle#8* is the first generation cephalosporin most often used to treat
odontogenic infections.
The usual daily oral dose for treating odontogenic infections in children is:
$hildren under %6 years+ 6&4&' mg#g>day divided every E*+1 hours with a maximum dose of 1 g>day.
9hildren over +1 years and adults! 15*5 mg divided every E*+1 hours.9efaclor and cefuroxine are supplied as +15, +E, 15, :5 mg>5ml suspensions and 15 and 5 mg capsules.
am,le ceaclorceuro6i%e ,rescri,tio% or a 3 !ear old ,atie%t weighi%g 12 kg (25 lb) with acial swelli%g
Rx:9eflacor +15 mg>5ml
Disp:+5ccSig:+ teaspoon every E hours for + days
(revious
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*age 10 o 25
/ext
acrolides &0rythromycin1 Clarithromycin1 *ithromycin(
The macrolides are antibiotics with a spectrum of coverage similar to penicillin, with the
addition of some penicillanase4producing staphylococci, chlamydiae,
Legionella,mycoplasma and others. rythromycin is the most popular macrolide. In its
free base form it is unstable at gastric p9 so it is administered as a salt form (stearate or
estolate* or with an enteric coating. (Bote+ Due to differences in absorption the three forms
have different dosages*. Its most common side effect is gastrointestinal upset.
$larithromycin and azithromycin are structural derivates of erythromycin with a broader
spectrum of activity and increased bioavailability. 7oth agents e#hibit less gastrointestinal
upset than erythromycin. >acrolides are bacteriostatic rather than bacteriocidal and thus
are not recommended in immuno4compromised patients.
In the past, macrolides were considered highly effective antibiotics for treating dentalinfections and freCuently substituted in penicillin allergy. $urrently, however, the high
resistance rates of oral streptococciand oral anaerobesto the macrolides has reduced their
use in dental infections. or patients with a penicillin allergy clindamycin is the preferred
alternative antibiotic for treating dental infections.
Contraindications:9ypersensitivity to erythromycin or any component of the formulation.
Warnings/Precautions::se with caution in patients with hepatic impairment.
Administration may be accompanied by malaise, nausea, vomiting, abdominal colic and
fever. Discontinue use if these occur. Avoid using erythromycin lactobionate in neonates
since formulations may contain benzyl alcohol which is associated with to#icity in neonates.
:se in infants has been associated with infantile hypertrophic pyloric stenosis. Interactswith numerous other drugs increasing the serum levels of the drugs. $onfirm patients
medical history before prescribing.
The oral dosages and dosage forms of the macrolides are:
Erythromycin
Infants and children 3 $2 years
7ase+ @'4&' mg
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!amle erythromycin estolate rescrition for a " year old atient #eighing $2 %g
&25 l'( #ith facial s#elling:
Rx:rythromycin estolate %6& mg
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'acterial endocarditis is much more li#ely to result from fre)uent exposure to random bacteremias
associated with daily activities than form bacteremia caused by dental, HI tract, or H0 tract
procedures.
(rophylaxis may prevent an exceedingly small number of cases bacterial endocarditis, in individuals
who undergo dental, HI tract or H0 tract procedures.
The ris# of antibiotic associated adverse events exceeds the benefit from prophylactic antibiotic
therapy.
3aintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily
activities and is more effective than prophylactic antibiotics for a dental procedure for reducing the
ris# of bacterial endocarditis.
The revised guidelines clarified when antibiotic prophylaxis is>is not recommended, i.e.
+. "nly an extremely small number of cases might be prevented by antibiotic prophylaxis.
1. Antibiotic prophylaxis for dental procedures is recommended only for patients with underlying cardiacconditions associated with the highest ris# of adverse outcomes from bacterial endocarditis.
:. or patients with these underlying cardiac conditions, prophylaxis is recommended for all dental
procedures that involve manipulation of gingival tissues or the periapical region of teeth or perforation
of the oral mucosa.
2. (rophylaxis is not recommended based solely on an increased lifetime ris# of ac)uiring bacterial
endocarditis
pecific recommendations from the 1 ACA guidelines on prevention of bacterial endocarditis are included in the
following tables. 9onsultation with the patientJs physician is recommended to determine the patientJs susceptibility
to bacterial endocarditis.
.able 3/ Cardiac Co%ditio%s ssociated with the ighest isk o derse #utcomes rom %docarditis or
$hich *ro,h!la6is *rior to 'e%tal *rocedures is ecomme%ded/
(rosthetic cardiac valve
(revious bacterial endocarditis
9ongenital heart disease %9C4&
0nrepaired cyanotic 9C4, including palliative shunts and
conduits
9ompletely repaired congenital heart defects with prosthetic
material or devices, whether placed by surgery or catheter intervention
within the first = months after the procedure
Bepaired 9C4 with residual defects at the site or adjacent to
the site of a prosthetic patch or prosthetic device %which inhibit
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endothelialization&
9ardiac transplantation recipients who develop cardiac
valvuopathy
.able 4/ 'e%tal *rocedures or $hich %docarditis *ro,h!la6is isis %ot ecomme%ded or *atie%ts i% .able
3/
ecomme%ded
All dental procedures that involve manipulation of gingival
tissue or the periapical region of the teeth or perforation of the oralmucosa
9ot recomme%ded
Boutine anesthetic injections through no infected tissue
4ental radiographs
(lacement of removable prosthodontic or orthodontic
appliances
Adjustment of orthodontic appliances
(lacement of orthodontic brac#ets
hedding of deciduous teeth
'leeding from trauma to the lips and tongue
.able 5/ egime%s or 'e%tal *rocedures/
dmi%ister si%gle dose 30 to "0 mi%utes beore ,rocedure
ituatio% ge%t dults Childre%
"ral Amoxicillin 1 gm 5 mg>#g
0nable to ta#e oral
medication
Ampicillin
"B
1gm I3 or I; 5 mg>#g I3 or I;
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9efazolin or
ceftriaxone+gm I3 or I; 5 mg>#g I3 or I;
Allergic to
penicillins or
ampicillin*oral
9ephalexin
"B9lindamycin
"B
Azithromycin or
clarithromycin
1 gm
=mg
5mg
5 mg>#g
1 mg>#g
+5 mg>#g
Allergic to
penicillin or
ampicillin and
unable to ta#e oral
medication
9efazolin or
ceftriaxone
"B
9lindamycin
+ gm I3 or I;
=mg I3 or
I;
5 mg>#g I3 or I;
1 mg>#g I3 or I;
(revious
*age 12 o 25
/ext
*ntifungals
"ral fungal infections occur from alterations in oral flora as a result of the extensive use of broad spectrum
antibiotics, steroids, chemotherapy immunosuppression, and inade)uate oral hygiene and nutrition. The mostcommon fungal infection found in children is candidiasis. The clinical variations of candidiasis most commonly
found in children are pseudomembranous candidiasis, angular cheilitis, erythematous candidiasis and
mucocutaneous candidiasis.
Treatment of candidiasis is accomplished through the topical application of nystatin, clotrimazole and amphotericin
and systemic administration of #etoconazole, fluconazole, itraconazole when topical treatment is ineffective. -hen
prescribing antifungals, the clinician must closely monitor and re*evaluate the patientJs response every two wee#s.
If the response is inade)uate, the diagnosis, choice of medication and dosage should be reevaluated. The chosen
form of administration is dependent on the childJs ability and maturity to follow directions. The drugs areadministered until 1 days after symptoms disappear.
ample perscriptions!
Topical Antifungals
Rx:/ystatin ointmentDisp:25 gm tube
Sig:Apply locally as directed with a thin coat to the affected area 2*5 times>day
Rx:/ystatin +, units>ml oral suspension
Disp:: mlSig:Binse with + teaspoon %5 ml& for 1 minutes 2*5 times>day and expectorate.
Rx: 9lotrimazole %3ycelex?& + mg trochesDisp: troches
Sig:4issolve + troche in mouth 5 times>day until gone
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Rx:day.
Systemic Antifungals The decision to use systemic antifungals are based on diagnostic culture results.
Rx:day until finished
Angular Cheilitis Treatment
Rx:Iodo)uinol and hydrocortisone creamDisp:25 gm tube
Sig:Apply locally as directed :*2 times>day for + days to 1 wee#s and re*evaluate
Rx:/ystatin and triamcinolone acetonide ointment
Disp:25 g tube
Sig:Apply locally as directed to affected area 2 times>day for + days to 1 wee#s and re*evaluate.
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Page $" of 25
*nti6irals and 7lcerati6e 8esions
Be#t
Advances in the pharmacological treatment of viral infections lag behind the treatment ofbacterial or fungal infections. The reason is due to the difficulty in attaining adeCuate
degrees of selective to#icity. "ince virus replication uses the same metabolic mechanismsessential for the function of normal cells, it was difficult to find drugs that would inhibit viral
growth without killing the host. 9owever recent advances in the research of viral replicationhave lead to discovery of agents useful in antiviral activity in the oral cavity. The agents are
not highly effective and are best used as soon as symptoms first appear. "ystemicsupportive therapy should be administered in conjunction with antivirals which includes
forced fluids, high concentration protein, vitamin and mineral food supplements and rest.iral infections may become secondarily infected with bacteria reCuiring antibiotics.
Gral viral infections are most commonly caused by the herpes simple# virus. The herpeszoster or herpes varicella3zoster virus can cause similar viral eruptions involving the oral
mucosa.
Diagnosis of oral viral infections begins by evaluation of presenting signs and symptoms. A
distinction must be made between lesions associated with herpes and aphthous ulcerswhich do not have a viral etiology.
iral lesions (9erpetic gingivostomatitis* are characterized by an initial acute onset ofvesicular eruptions on the soft tissues that Cuickly rupture into small ulcerations that are
covered by a yellowish gray pseudomembrane surrounded by an erythematous halo. Theulcers may coalesce to form larger irregular ulcerations. The lesions are found on the
gingival, tongue, palate lips (labialis*, buccal mucosa, tonsils and posterior pharyn#. The
ulcers gradually heal over )4%' days without scarring. The disease is accompanied by highfever, malaise, irritability, headache and pain in the mouth during the first three days of
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onset. It usually appears in children between the ages of si# months and four years.
Treatment consists of administration of acyclovir and supportive therapy.
Contraindications:9ypersensitivity to acyclovir, valacyclovir, or any component of the
formulation.
Warnings/Precautions::se with caution in immunocompromised patients. "afety and
efficacy of oral formulations have not been established in pediatric patients H 6years ofage. The ointment is for e#ternal use only to the lips and face. Do not apply to the eye orinside the nose or mouth. Treatment should begin at the first sign of symptoms.
The oral systemic dose of acyclo6ir &only gi6en in se6ere cases of 9!V( is:
$hildren 6 years and ; 1' kg+ 6' mg
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Rx:Diphenhydramine liCuid (7enadryl8< /aopectate or >aalo#* < Jidocaine viscous (mi#
%