l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Tablets may be prescribed as Sodium Fluoride Tablets.
Oral drops may be prescribed as Sodium Fluoride Oral
Mouthwashes may be prescribed as Sodium Fluoride
Mouthwash 0.05% or Sodium Fluoride Mouthwash 2%.
Fluoride mouthwash, oral drops, tablets and toothpaste
are prescribable on form FP10D (GP14 in Scotland, WP10D
There are also arrangements for health authorities to
supply fluoride tablets in the course of pre-school dental
schemes, and they may also be supplied in school dental
Fluoride gels are not prescribable on form FP10D (GP14
COLGATE DURAPHAT ® 5000PPM FLUORIDE
TOOTHPASTE DENTAL PRACTITIONERS’ FORMULARY
May be prescribed as Sodium Fluoride Toothpaste 1.1%.
COLGATE DURAPHAT ® 2800PPM FLUORIDE
TOOTHPASTE DENTAL PRACTITIONERS’ FORMULARY
May be prescribed as Sodium Fluoride Toothpaste 0.619%.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Endekay (Manx Healthcare Ltd)
Sodium fluoride 1.1 mg Endekay Fluotabs 3-6 Years 1.1mg tablets |
Sodium fluoride 2.2 mg Endekay Fluotabs 6+ Years 2.2mg tablets | 200 tablet p £2.38 DT = £2.38
▶ Colgate Duraphat (Colgate-Palmolive (UK) Ltd)
Fluoride (as Sodium fluoride) 2.8 mg per 1 gram Colgate Duraphat
2800ppm fluoride toothpaste sugar-free | 75 ml P £3.26 DT =
Fluoride (as Sodium fluoride) 5 mg per 1 gram Colgate Duraphat
5000ppm fluoride toothpaste sugar-free | 51 gram P £6.50 DT =
▶ Fluor-a-day (DHP Healthcare Ltd)
Sodium fluoride 1.1 mg Fluor-a-day 1.1mg chewable tablets sugarfree | 200 tablet p £3.38 DT = £3.38
Sodium fluoride 2.2 mg Fluor-a-day 2.2mg chewable tablets sugarfree | 200 tablet p £3.38 DT = £3.38
▶ Sodium fluoride (Non-proprietary)
Sodium fluoride 500 microgram per 1 ml Sodium fluoride 0.05%
mouthwash sugar free sugar-free | 250 ml G s DT = £1.51
▶ Colgate FluoriGard (Colgate-Palmolive (UK) Ltd)
Sodium fluoride 500 microgram per 1 ml Colgate FluoriGard 0.05%
daily dental rinse sugar-free | 400 ml G £2.99
▶ Endekay (Manx Healthcare Ltd)
Sodium fluoride 500 microgram per 1 ml Endekay 0.05% daily
fluoride mouthrinse sugar-free | 250 ml G £1.51 DT = £1.51
Oral ulceration and inflammation
Ulceration of the oral mucosa may be caused by trauma
(physical or chemical), recurrent aphthae, infections,
carcinoma, dermatological disorders, nutritional
deficiencies, gastro-intestinal disease, haematopoietic
disorders, and drug therapy (see also Chemotherapy induced
mucositis and myelosuppression under Cytotoxic drugs
p. 888). It is important to establish the diagnosis in each case
as the majority of these lesions require specific management
in addition to local treatment. Local treatment aims to
protect the ulcerated area, to relieve pain, to reduce
inflammation, or to control secondary infection. Patients
with an unexplained mouth ulcer of more than 3 weeks’
duration require urgent referral to hospital to exclude oral
A saline mouthwash may relieve the pain of traumatic
ulceration. The mouthwash is made up with warm water and
used at frequent intervals until the discomfort and swelling
Secondary bacterial infection may be a feature of any
mucosal ulceration; it can increase discomfort and delay
healing. Use of a chlorhexidine mouthwash p. 1211 is often
beneficial and may accelerate healing of recurrent aphthae.
Topical corticosteroid therapy may be used for some forms of
oral ulceration. In the case of aphthous ulcers it is most
effective if applied in the ‘prodromal’ phase.
Thrush or other types of candidiasis are recognised
complications of corticosteroid treatment.
Hydrocortisone oromucosal tablets p. 1216 are allowed to
dissolve next to an ulcer and are useful in recurrent aphthae
and erosive lichenoid lesions.
Beclometasone dipropionate inhaler p. 257 sprayed on the
oral mucosa is used to manage oral ulceration [unlicensed
indication]. Alternatively, betamethasone soluble tablets
p. 1216 dissolved in water can be used as a mouthwash to
treat oral ulceration [unlicensed indication].
Systemic corticosteroid therapy (see under
Corticosteroids, inflammatory disorders p. 1153), is reserved
for severe conditions such as pemphigus vulgaris.
Local analgesics have a limited role in the management of
oral ulceration. When applied topically their action is of a
relatively short duration so that analgesia cannot be
maintained continuously throughout the day. The main
indication for a topical local analgesic is to relieve the pain of
otherwise intractable oral ulceration particularly when it is
due to major aphthae. For this purpose lidocaine
hydrochloride 5% ointment p. 1214 or lozenges containing a
local anaesthetic are applied to the ulcer. Lidocaine
hydrochloride 10% solution as spray can be applied thinly to
the ulcer [unlicensed indication] using a cotton bud. When
local anaesthetics are used in the mouth care must be taken
not to produce anaesthesia of the pharynx before meals as
Preparations on sale to the public: many mouth ulcer
preparations, throat lozenges, and throat sprays on sale to
the public contain a local anaesthetic. To identify the active
ingredients in such preparations, consult the product
literature of the manufacturer— the correct proprietary
name should be ascertained as many products have very
similar names but different active ingredients.
Benzydamine hydrochloride p. 1215 and flurbiprofen
p. 1216 are non-steroidal anti-inflammatory drugs (NSAIDs).
Benzydamine hydrochloride mouthwash or spray may be
useful in reducing the discomfort associated with a variety of
ulcerative conditions. It has also been found to be effective
mouthwash causes some stinging and, for them, it should be
diluted with an equal volume of water. Flurbiprofen lozenges
are licensed for the relief of sore throat.
Choline salicylate p. 1217 is a derivative of salicylic acid
and has some analgesic action. The dental gel may provide
relief for recurrent aphthae, but excessive application or
confinement under a denture irritates the mucosa and can
Doxycycline p. 564 rinsed in the mouth may be of value for
recurrent aphthous ulceration.
Low-dose doxycycline (Periostat ®) is licensed as an adjunct
to scaling and root planing for the treatment of
periodontitis; a low dose of doxycycline reduces collagenase
activity without inhibiting bacteria associated with
For anti-infectives used in the treatment of destructive
(refractory) forms of periodontal disease, see under
Oropharyngeal infections, antibacterial therapy p. 1217. See
also Mouthwashes and other preparations for oropharyngeal
use p. 1210 for mouthwashes used for oral hygiene and
▶ BY BUCCAL ADMINISTRATION USING OINTMENT
▶ Adult: Rub gently into dry gum
Relief of pain in oral lesions
▶ TO THE LESION USING OINTMENT
▶ Adult: Apply as required, rub sparingly and gently on
Anaesthesia of mucous membranes of oropharynx,
▶ Adult: 40–200 mg, to be given as a single dose sprayed,
instilled (if a cavity), or applied with a swab (reduce
dose according to size, age and condition of patient);
1214 Oral ulceration and inflammation BNF 78
Bronchoscopy | Laryngoscopy | Oesophagoscopy |
Relief of pain in oral lesions
▶ Adult: Apply thinly to the ulcer using a cotton bud
l UNLICENSED USE Spray not licensed for the relief of pain
l CAUTIONS Avoid anaesthesia of the pharynx before
meals—risk of choking . can damage plastic cuffs of
l INTERACTIONS → Appendix 1: antiarrhythmics
l ALLERGY AND CROSS-SENSITIVITY
▶ Hypersensitivity and cross-sensitivity Hypersensitivity
reactions occur mainly with the ester-type local
anaesthetics, such as tetracaine; reactions are less
frequent with the amide types, such as articaine,
bupivacaine, levobupivacaine, lidocaine, mepivacaine,
prilocaine, and ropivacaine. Cross-sensitivity reactions
may be avoided by using the alternative chemical type.
l PREGNANCY Crosses the placenta but not known to be
harmful in animal studies—use if benefit outweighs risk.
When used as a local anaesthetic, large doses can cause
fetal bradycardia; if given during delivery can also cause
neonatal respiratory depression, hypotonia, or bradycardia
after paracervical or epidural block.
l BREAST FEEDING Present in milk but amount too small to
l HEPATIC IMPAIRMENT Caution—increased risk of sideeffects.
l RENAL IMPAIRMENT Possible accumulation of lidocaine
and active metabolite; caution in severe impairment.
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Lidocaine ointment 5% may be prescribed. Spray may be
prescribed as Lidocaine Spray 10%
XYLOCAINE ® DENTAL PRACTITIONERS’ FORMULARY
May be prescribed as lidocaine spray 10%.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Xylocaine (Aspen Pharma Trading Ltd)
Lidocaine 10 mg per 1 actuation Xylocaine 10mg/dose spray sugarfree | 50 ml p £6.29 DT = £6.29
▶ Lidocaine hydrochloride (Non-proprietary)
Lidocaine hydrochloride 50 mg per 1 gram Lidocaine 5% ointment
ANALGESICS › NON-STEROIDAL ANTIINFLAMMATORY DRUGS
Painful inflammatory conditions of oropharynx
▶ TO THE LESION USING MOUTHWASH
▶ Child 13–17 years: Rinse or gargle 15 mL every
1.5–3 hours as required usually for not more than
7 days, dilute with an equal volume of water if stinging
▶ Adult: Rinse or gargle 15 mL every 1.5–3 hours as
required usually for not more than 7 days, dilute with
an equal volume of water if stinging occurs
▶ TO THE LESION USING OROMUCOSAL SPRAY
▶ Child 1 month–5 years (body-weight 4–7 kg): 1 spray every
1.5–3 hours, to be administered onto the affected area
▶ Child 1 month–5 years (body-weight 8–11 kg): 2 sprays
every 1.5–3 hours, to be administered onto the affected
▶ Child 1 month–5 years (body-weight 12–15 kg): 3 sprays
every 1.5–3 hours, to be administered onto the affected
▶ Child 1 month–5 years (body-weight 16 kg and above):
4 sprays every 1.5–3 hours, to be administered onto the
▶ Child 6–11 years: 4 sprays every 1.5–3 hours, to be
administered onto affected area
▶ Child 12–17 years: 4–8 sprays every 1.5–3 hours, to be
administered onto affected area
▶ Adult: 4–8 sprays every 1.5–3 hours, to be
administered onto affected area
l INTERACTIONS → Appendix 1: NSAIDs
▶ Rare or very rare Photosensitivity reaction .respiratory
▶ Frequency not known Angioedema
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Benzydamine Oromucosal Spray 0.15% may be prescribed.
Benzydamine mouthwash may be prescribed as
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Benzydamine hydrochloride (Non-proprietary)
Benzydamine hydrochloride 1.5 mg per 1 ml Benzydamine 0.15%
oromucosal spray sugar free sugar-free | 30 ml p £4.24 DT = £3.46
▶ Difflam (Meda Pharmaceuticals Ltd)
Benzydamine hydrochloride 1.5 mg per 1 ml Difflam 0.15% spray
sugar-free | 30 ml p £4.24 DT = £3.46
▶ Benzydamine hydrochloride (Non-proprietary)
Benzydamine hydrochloride 1.5 mg per 1 ml Benzydamine 0.15%
mouthwash sugar free sugar-free | 300 ml p £7.95 DT = £7.25
▶ Difflam (Meda Pharmaceuticals Ltd)
Benzydamine hydrochloride 1.5 mg per 1 ml Difflam Oral Rinse
0.15% solution sugar-free | 300 ml p £6.50 DT = £7.25
Difflam 0.15% Sore Throat Rinse sugar-free | 200 ml p £4.64
Painful inflammatory conditions of the oral cavity and
throat and/or following dental treatment or dental
▶ Adult: Rinse or gargle 15 mL 2–3 times a day for 7 days,
treatment may be extended to 6 weeks in mucositis
l INTERACTIONS → Appendix 1: NSAIDs
l PREGNANCY Manufacturer advises avoid unless essential.
l BREAST FEEDING Manufacturer advises avoid unless
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
mouthwash may be diluted with a little water.
BNF 78 Oral ulceration and inflammation 1215
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Sorbitol
▶ Diclofenac (Non-proprietary)
Diclofenac.74 mg per 1 ml Diclofenac 0.74mg/ml mouthwash sugar
free sugar-free | 200 ml P £12.95 DT = £12.95
Diclofenac 0.074% mouthwash sugar free sugar-free | 200 ml P £12.95 DT = £12.95
▶ Child 12–17 years: 1 lozenge every 3–6 hours for
maximum 3 days, allow lozenge to dissolve slowly in
the mouth; maximum 5 lozenges per day
▶ Adult: 1 lozenge every 3–6 hours for maximum 3 days,
allow lozenge to dissolve slowly in the mouth;
l INTERACTIONS → Appendix 1: NSAIDs
l SIDE-EFFECTS Oral ulceration (move lozenge around
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Strefen (Reckitt Benckiser Healthcare (UK) Ltd)
Flurbiprofen 8.75 mg Strefen Honey and Lemon 8.75mg lozenges |
Beclometasone dipropionate 04-Jan-2016
▶ Adult: 50–100 micrograms twice daily, administered
l UNLICENSED USE Use of soluble tablets and inhaler
unlicensed in oral ulceration.
l INTERACTIONS → Appendix 1: corticosteroids
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. For
preparations, see inhaled beclometasone, p. 257
l DRUG ACTION Betamethasone has very high glucocorticoid
activity and insignificant mineralocorticoid activity.
▶ TO THE LESION USING SOLUBLE TABLETS
▶ Child 12–17 years: 500 micrograms 4 times a day, to be
dissolved in 20 mL water and rinsed around the mouth;
▶ Adult: 500 micrograms 4 times a day, to be dissolved in
20 mL water and rinsed around the mouth; not to be
▶ With oral (topical) use in children Betamethasone soluble
tablets not licensed for use as mouthwash or in oral
l CONTRA-INDICATIONS Untreated local infection
l INTERACTIONS → Appendix 1: corticosteroids
l PATIENT AND CARER ADVICE Patient counselling is advised
for betamethasone soluble tablets (administration).
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary Betamethasone Soluble
Tablets 500 micrograms may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 10, 13, 21 (not for use as
mouthwash for oral ulceration)
▶ Betamethasone (Non-proprietary)
Betamethasone (as Betamethasone sodium phosphate)
500 microgram Betamethasone 500microgram soluble tablets sugar
free sugar-free | 100 tablet P £65.18 DT = £58.15
l DRUG ACTION Hydrocortisone has equal glucocorticoid
and mineralocorticoid activity.
▶ TO THE LESION USING BUCCAL TABLET
▶ Child 1 month–11 years: Only on medical advice
▶ Child 12–17 years: 1 lozenge 4 times a day, allowed to
dissolve slowly in the mouth in contact with the ulcer
▶ Adult: 1 lozenge 4 times a day, allowed to dissolve
slowly in the mouth in contact with the ulcer
▶ With buccal use in children Hydrocortisone mucoadhesive
buccal tablets licensed for use in children (under 12 years—
MHRA/CHM ADVICE: HYDROCORTISONE MUCO-ADHESIVE BUCCAL
TABLETS: SHOULD NOT BE USED OFF-LABEL FOR ADRENAL
INSUFFICIENCY IN CHILDREN DUE TO SERIOUS RISKS (DECEMBER
The MHRA has received reports of off-label use of
hydrocortisone muco-adhesive buccal tablets for adrenal
insufficiency in children. Healthcare professionals are
. hydrocortisone muco-adhesive buccal tablets are
indicated only for local use in the mouth for aphthous
ulceration and should not be used to treat adrenal
. substitution of licensed oral hydrocortisone
formulations with muco-adhesive buccal tablets can
result in insufficient cortisol absorption and, in stress
situations, life-threatening adrenal crisis;
. only hydrocortisone products licensed for adrenal
replacement therapy should be used.
l CONTRA-INDICATIONS Untreated local infection
l INTERACTIONS → Appendix 1: corticosteroids
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Mucoadhesive buccal tablets may be prescribed as
Hydrocortisone Oromucosal Tablets.
1216 Oral ulceration and inflammation BNF 78
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Hydrocortisone (Non-proprietary)
Hydrocortisone (as Hydrocortisone sodium succinate)
2.5 mg Hydrocortisone 2.5mg muco-adhesive buccal tablets sugar
free sugar-free | 20 tablet p £7.94 DT = £7.80
SALICYLIC ACID AND DERIVATIVES
Mild oral and perioral lesions
▶ Child 16–17 years: Apply 0.5 inch, apply with gentle
massage, not more often than every 3 hours
▶ Adult: Apply 0.5 inch, apply with gentle massage, not
l CONTRA-INDICATIONS Children under 16 years
CONTRA-INDICATIONS, FURTHER INFORMATION
▶ Reye’s syndrome The CHM has advised that topical oral pain
relief products containing salicylate salts should not be
used in children under 16 years, as a cautionary measure
due to the theoretical risk of Reye’s syndrome.
l CAUTIONS Frequent application, especially in children,
may give rise to salicylate poisoning . not to be applied to
dentures—leave at least 30 minutes before re-insertion of
l INTERACTIONS → Appendix 1: choline salicylate
l PRESCRIBING AND DISPENSING INFORMATION When
prepared extemporaneously, the BP states Choline
Salicylate Dental Gel, BP consists of choline salicylate
8.7% in a flavoured gel basis.
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Choline Salicylate Dental Gel may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Bonjela (Reckitt Benckiser Healthcare (UK) Ltd)
Choline salicylate 87 mg per 1 gram Bonjela Cool Mint gel sugarfree | 15 gram G £3.55 DT = £2.91
Bonjela Original gel sugar-free | 15 gram G £2.91 DT = £2.91
Salicylic acid with rhubarb extract
Mild oral and perioral lesions
▶ Child 16–17 years: Apply 3–4 times a day maximum
▶ Adult: Apply 3–4 times a day maximum duration 7 days
l CONTRA-INDICATIONS Children under 16 years
CONTRA-INDICATIONS, FURTHER INFORMATION
▶ Reye’s syndrome The CHM has advised that topical oral pain
relief products containing salicylate salts should not be
used in children under 16 years, as a cautionary measure
due to the theoretical risk of Reye’s syndrome.
l CAUTIONS Frequent application, especially in children,
may give rise to salicylate poisoning . not to be applied to
dentures—leave at least 30 minutes before re-insertion of
▶ Common or very common Oral discolouration .tooth
l PATIENT AND CARER ADVICE May cause temporary
discolouration of teeth and oral mucosa.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Ethanol
▶ Pyralvex (Meda Pharmaceuticals Ltd)
Salicylic acid 10 mg per 1 ml, Rhubarb extract 50 mg per
1 ml Pyralvex solution | 10 ml p £3.25
Antibacterial required only in presence of systemic features
of infection, or of trismus, or persistent swelling despite
. Metronidazole p. 542, or alternatively, amoxicillin p. 548
▶ Suggested duration of treatment 3 days or until symptoms
Gingivitis (acute necrotising ulcerative)
Antibacterial required only if systemic features of infection.
. Metronidazole, or alternatively, amoxicillin
▶ Suggested duration of treatment 3 days or until symptoms
Abscess (periapical or periodontal)
Antibacterial required only in severe disease with cellulitis or
if systemic features of infection.
. Amoxicillin, or alternatively, metronidazole
▶ Suggested duration of treatment 5 days.
Antibacterial used as an adjunct to debridement in severe
disease or disease unresponsive to local treatment alone.
. Metronidazole, or alternatively in adults and children over
Acute sore throat is usually triggered by a viral infection and
is self-limiting. Symptoms can last for around 1 week, and
most people will improve within this time without treatment
with antibiotics, regardless of the cause.
g Antibacterial therapy is required only in patients
with severe systemic symptoms, signs and symptoms of a
more serious illness or condition, or those at high risk of
complications. Patients with severe systemic infection or
severe suppurative complications such as peri-tonsillar
abscess (quinsy), acute otitis media, acute sinusitis or
cellulitis should be referred to hospital. h
. Phenoxymethylpenicillin p. 548
▶ Suggested duration of treatment 5 to 10 days.
. If penicillin-allergic, clarithromycin p. 538 (or erythromycin
▶ Suggested duration of treatment 5 days.
BNF 78 Oropharyngeal bacterial infections 1217
ANTIBACTERIALS › TETRACYCLINES AND
Treatment of recurrent aphthous ulceration
▶ BY MOUTH USING SOLUBLE TABLETS
▶ Child 12–17 years: 100 mg 4 times a day usually for
3 days, dispersible tablet can be stirred into a small
amount of water then rinsed around the mouth for
2–3 minutes, it should preferably not be swallowed
▶ Adult: 100 mg 4 times a day usually for 3 days,
dispersible tablet can be stirred into a small amount of
water then rinsed around the mouth for 2–3 minutes, it
should preferably not be swallowed
l UNLICENSED USE Doxycycline may be used as detailed
below, although these situations are considered outside
. recurrent aphthous ulceration.
l INTERACTIONS → Appendix 1: tetracyclines
▶ Common or very common Dyspnoea . hypotension . peripheral oedema .tachycardia
▶ Uncommon Gastrointestinal discomfort
(SCARs). skin hyperpigmentation (long term use). tinnitus . vision disorders
l RENAL IMPAIRMENT Use with caution (avoid excessive
l PATIENT AND CARER ADVICE Counselling on
Photosensitivity Patients should be advised to avoid
exposure to sunlight or sun lamps.
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Dispersible tablets may be prescribed as Dispersible
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 6, 9, 11, 13
Doxycycline (as Doxycycline monohydrate) 100 mg Vibramycin-D
100mg dispersible tablets sugar-free | 8 tablet P £4.91 DT = £4.91
Oropharyngeal fungal infections
Fungal infections of the mouth are usually caused by
Candida spp. (candidiasis or candidosis). Different types of
oropharyngeal candidiasis are managed as follows:
Acute pseudomembranous candidiasis (thrush), is usually an
acute infection but it may persist for months in patients
serious systemic disease associated with reduced immunity
such as leukaemia, other malignancies, and HIV infection.
Any predisposing condition should be managed
appropriately. When thrush is associated with corticosteroid
inhalers, rinsing the mouth with water (or cleaning a child’s
teeth) immediately after using the inhaler may avoid the
problem. Treatment with nystatin p. 1219 or miconazole
p. 1219 may be needed. Fluconazole p. 595 is effective for
unresponsive infections or if a topical antifungal drug
cannot be used or if the patient has dry mouth. Topical
therapy may not be adequate in immunocompromised
patients and an oral triazole antifungal is preferred.
Acute erythematous candidiasis
Acute erythematous (atrophic) candidiasis is a relatively
uncommon condition associated with corticosteroid and
broad-spectrum antibacterial use and with HIV disease. It is
usually treated with fluconazole.
Patients with denture stomatitis (chronic atrophic
candidiasis), should cleanse their dentures thoroughly and
leave them out as often as possible during the treatment
period. To prevent recurrence of the problem, dentures
should not normally be worn at night. New dentures may be
required if these measures fail despite good compliance.
Miconazole oral gel can be applied to the fitting surface of
the denture before insertion (for short periods only).
Denture stomatitis is not always associated with candidiasis
and other factors such as mechanical or chemical irritation,
bacterial infection, or rarely allergy to the dental base
Chronic hyperplastic candidiasis
Chronic hyperplastic candidiasis (candidal leucoplakia)
carries an increased risk of malignancy; biopsy is essential—
this type of candidiasis may be associated with varying
degrees of dysplasia, with oral cancer present in a high
proportion of cases. Chronic hyperplastic candidiasis is
treated with a systemic antifungal such as fluconazole to
eliminate candidal overlay. Patients should avoid the use of
Angular cheilitis (angular stomatitis) is characterised by
soreness, erythema and fissuring at the angles of the mouth.
It is commonly associated with denture stomatitis but may
represent a nutritional deficiency or it may be related to
orofacial granulomatosis or HIV infection. Both yeasts
interacting, infective factors. A reduction in facial height
related to ageing and tooth loss with maceration in the deep
occlusive folds that may subsequently arise, predisposes to
such infection. While the underlying cause is being
identified and treated, it is often helpful to apply miconazole
cream or fusidic acid ointment p. 571; if the angular cheilitis
is unresponsive to treatment, hydrocortisone with
miconazole cream or ointment p. 1252 can be used.
See advice on prevention of fungal infections in
Immunocompromised patients under Antifungals, systemic
Drugs used in oropharyngeal candidiasis
Nystatin is not absorbed from the gastro-intestinal tract and
is applied locally (as a suspension) to the mouth for treating
local fungal infections. Miconazole is applied locally (as an
oral gel) in the mouth but it is absorbed to the extent that
potential interactions need to be considered. Miconazole
also has some activity against Gram-positive bacteria
including streptococci and staphylococci. Fluconazole is
given by mouth for infections that do not respond to topical
therapy or when topical therapy cannot be used. It is reliably
absorbed and effective. Itraconazole p. 597 can be used for
fluconazole-resistant infections.
1218 Oropharyngeal fungal infections BNF 78
If candidal infection fails to respond to 1 to 2 weeks of
treatment with antifungal drugs the patient should be sent
for investigation to eliminate the possibility of underlying
disease. Persistent infection may also be caused by
reinfection from the genito-urinary or gastro-intestinal
tract. Infection can be eliminated from these sources by
appropriate anticandidal therapy; the patient’s partner may
also require treatment to prevent reinfection.
Antiseptic mouthwashes are used in the prevention of oral
candidiasis in immunocompromised patients and in the
treatment of denture stomatitis.
ANTIFUNGALS › IMIDAZOLE ANTIFUNGALS
▶ Child 2–17 years: 2.5 mL 4 times a day treatment should
be continued for at least 7 days after lesions have
healed or symptoms have cleared, to be administered
after meals, retain near oral lesions before swallowing
(dental prostheses and orthodontic appliances should
be removed at night and brushed with gel)
▶ Adult: 2.5 mL 4 times a day treatment should be
continued for at least 7 days after lesions have healed
or symptoms have cleared, to be administered after
meals, retain near oral lesions before swallowing
(dental prostheses and orthodontic appliances should
be removed at night and brushed with gel)
▶ Child 4 months–17 years: 5 mg/kg 4 times a day (max. per
dose 250 mg) treatment should be continued for at
least 7 days after lesions have healed or symptoms
▶ Adult: 5 mg/kg 4 times a day (max. per dose 250 mg)
treatment should be continued for at least 7 days after
lesions have healed or symptoms have cleared
l CONTRA-INDICATIONS Infants with impaired swallowing
l CAUTIONS Avoid in Acute porphyrias p. 1058
l INTERACTIONS → Appendix 1: antifungals, azoles
▶ Common or very common Skin reactions (in adults)
▶ Frequency not known Angioedema
l PREGNANCY Manufacturer advises avoid if possible—
toxicity at high doses in animal studies.
l BREAST FEEDING Manufacturer advises caution—no
l HEPATIC IMPAIRMENT Manufacturer advises avoid.
l DIRECTIONS FOR ADMINISTRATION Oral gel should be held
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
l PATIENT AND CARER ADVICE Patients or carers should be
given advice on how to administer miconazole oromucosal
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Miconazole Oromucosal Gel may be prescribed.
l EXCEPTIONS TO LEGAL CATEGORY 15-g tube of oral gel can
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 9
▶ Daktarin (Johnson & Johnson Ltd, Janssen-Cilag Ltd)
Miconazole 20 mg per 1 gram Daktarin 20mg/g oromucosal gel
sugar-free | 80 gram P £4.38 DT = £4.38
ANTIFUNGALS › POLYENE ANTIFUNGALS
▶ Child: 100 000 units 4 times a day usually for 7 days,
and continued for 48 hours after lesions have resolved
▶ Adult: 100 000 units 4 times a day usually for 7 days,
and continued for 48 hours after lesions have resolved
l CAUTIONS Contact with eyes and mucous membranes
reactions . Stevens-Johnson syndrome . vomiting
l PATIENT AND CARER ADVICE Counselling advised with oral
suspension (use of pipette, hold in mouth, after food).
Medicines for Children leaflet: Nystatin for Candida infection
www.medicinesforchildren.org.uk/nystatin-candida-infection
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Nystatin Oral Suspension may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, capsule, oral
CAUTIONARY AND ADVISORY LABELS 9
EXCIPIENTS: May contain Ethanol
Nystatin 100000 unit per 1 ml Nystatin 100,000units/ml oral
suspension | 30 ml P £2.43 DT = £2.03
Oropharyngeal viral infections
Viral infections are the most common cause of a sore throat.
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