MUDr. Hana Poskerová, Ph.D. Stomatologická klinika FN u sv. Anny a LF MU v Brně General principles of treatment of mucosal diseases Indication of local antiseptics Systemic treatment - causal treatment against microbes (antibiotics, antifungals, antivirotics) - analgetics, antipyretics - antihistaminics, (corticosteroids, immunosupresives) - immunomodulators - to increase the immunity - removal of irritation factors - improvement of OH (precaution against secondary bacterial infection), soft diet - antiseptics, antiflogistics - antibiotics, antifungals, antivirotics - adstringent agents, epitelization agents - local anesthetics for topical use Solutions (mouthwash, spray), gels, mucosal adhesive ointments (orabase), ointments (lip vermilion) Local treatment Local treatment - Local antiseptics • Disinfectant (skin) - Antiseptics (mucous) • When topically applied, they kill bacteria (the possible antifungal and antiviral effect) • Attention in children! (avoid swallowing cotton ball on a stick) • Beware of large mucosal lesions! (large wound area, KI of alcohol solutions) • Scale efficiency of mouthwashes Indication of Local antiseptics • Mucosal diseases • Infectious diseases of oral membrane mucous • Symptomatic treatment • Prevention in certain patient groups (HIV+...) • Perio diseases • Initial phase of perio treatment • Maintenance phase • People with difficult conditions • People with mental or physical disabilities • Perio surgery • Infectious diseases of oral membrane mucous ANUG Oral candidiasis Primary HGS and intraoral herpes • Initial phase of perio treatment • „Full mouth desinfection“ • Maintenance phase • People with difficult conditions • People with mental or physical disabilities • Perio surgery - before (bacteriemia) - after (sec. infection) • High risk of caries Sjögren sy After radiotherapy Side effects - dysgeusia, dark coloration of dorsum of the tongue and of fillings - epithelial desquamation - allergies - poisoning if ingested (children) Local antiseptics • Chlorhexidinum • Hexetidinum • Cetylpyridinium • Benzoxonium • Benzalconium • Benzydaminum • Iodium • Triclosanum • Hydrogen Peroxide Chlorhexidinum • Gold standard • Antibacterial, antifungal, antiviral effect • Bacteriostatic - germicid (bactericid) effect • Chemical inhibitor of plaque • The ability to adhere to the oral mucos (depot) CHX – mouthwash 0,05%..... 0,2% – 2 times a day for 1 min CHX - toothpastes, gels, sprays, paints, pastils, varnishes, Perio chip Chlorhexidinum • 0,05% - 0,1% - 0,12% - 0,2% 2 times a day (once per 12 hours) • side effects - dysgeusia, dark coloration of dorsum of the tongue and of fillings, epithelial desquamation • Chlo-site® gel (fy Ghimas, Italy) • 1,5% CHX gel • chlorhexidin digluconate a chlorhexidin dihydrochlorid 1:2 • Perio Chip® (Dexcel Pharma) • 2,5 mg CHX (34%) Octenidolhydrochloridum • Octenidolhydrochlo ridum in aqueous solution • A very good bactericid, antifungal effect • Less side effects than CHX/more expensive Cetypyridinium • The broad antimicrobial spectrum, but does not reach the efficacy of chlorhexidine • 0,05 - 0,1% • Less side effects than CHX • Combination with s CHX • Usually not for treatment of oral membrane mucous Calgel • Cetylpyridinium, lidocainum • Mild antiseptic and anesthetic effect • Aroma chamomile • Up to 6 times a day Essential oils • Antibacterial effect • Antiinflammatory • Thymolum, eucalyptolum, mentolum, metylsalicylate • Solution in alcohol – 25% (unsuitable for children) • Not suitable for treatment of mucosal lesions !!! CPC propylen glykol ZnCl NaF ↑ Listerne professional Gum therapy -ethyl-lauroyl- -argináthydrochlorid (LAE) Fluoride plus - NaF 450ppm - xylitol Sensitivity therapy - calcium oxalate NaF 220ppm Jodine preparations • Strong broad-spectrum antiseptic • Strong immediate effect without prolonged exposure • Allergic reactions to iodine in the population Hexetidinum Hexetidinum 0,1%, in alcohol • Mild antibacterial, antifungal effect • Mild local anesthetic effect • Antinflammatory effect • It does not bind to the mucosa, concentration decreases rapidly • Undiluted rinses 3-5 times a day Benzydaminum • Nonsteroidal antiinflammatory solution • Anti-inflammatory, anesthetic effect • Only mild antibacterial and antifungal • 0,15%, in alcohol • 4 - 6 times a day • Sol, spray, pastils Hydrogen peroxide • Treatment of ANUG • Deep tissue oxygenation • Short antibacterial effect • Treatment of ANUG - Dentist‘s office: 10 - 30% H2O2 topical 3% H2O2 irrigation - At home: 6% H2O2 topical application diluted 1:1 mouthwash (3%) Benzoxoniumchlorid • Benzoxoniumchlorid, lidocain • Antiseptic effect (bactericid G+, antifungal, antiviral) local anesthetic (lidocainum) effect • Infection of pharynx and oropharynx • Pas, sol, spr Salicylcholinum Mundisal gel • Salicylcholinum, cetalconium chlorid • Anti-inflammatory, anesthetic effect • 3-4 times a day Solcoseryl dental adhesiv paste • Deproteinized calf blood • 1% polidocanolum • The effect lasts for 1-5 hours • Polymers • Natrium-hyaluronát • Gel, spray Aphtgel, Aftamed, Aloclair Gengigel, Gelclair Herbs • Herbal infusions of rinses • Mild antiseptic, antiinflammatory, adstringent, epithelization effect • Sage, thyme, mint, oregano, agrimony, chamomile… • Several times a day • Watch out for allergies !!! Antiviral drugs - local treatment • Antiseptics with antiviral effects CHX, iodine preparations, Zincum sulfuricum Rp. Sol. Zinci sulfurici 0,25% aquosae • Specific treatment of nucleosids (HSV) aciclovir topical cream for labial herpes simplex - Herpesin Antiviral drugs - systemic treatment • Aciclovir is active against most known species in the herpesvirus family - HSV, VZV (EBV, CMV) • It is inactive against latent viruses in nerve ganglia • HSV - 200 mg 5 times a day (serve every 4th hours + pause to sleep) • VZV - 800 mg 5 times a day • Valaciclovir, ganciclovir, famciclovir Corticosteroids • Dexamethasonum (1 mg in 1 g of paste) (Dexaltin oral paste) • Indication – autoimmune diseases, OLP, major aphtous ulcers, EEM, alergic reactions • Contraindication - acute bacterial, viral, fungal infection, pregnancy, lactation • 1 - 4 times a day in a thin layer Corticosteroids Rp. Dexamethasoní 0,01 Paraffin liq. q.s. Ung. macrogol ad 10,0 M.f.ung. DS: apply to the oral mucosa 3 times a day Treatment of oral candidiasis • Clinical examination, • Microbiological examination • Local Treatment - always, often a combination of drugs (resistance is possible) • Systemic Treatment - extensive involvement, recurrence, resistance, serious general health Local Treatment of oral candidiasis • Antiseptics - CHX 0,1% - 0,2% - hexetidinum 0,1% - iodium - natrium tetraboricum 5% – 20% • Antifungals - nystatinum Rp. Nystatini 2 mil IU Methylcellulosi 0,3 Glyceroli 85% 0,6 Aquae purif. ad 20,0 M.f. suspenzion DS for application to the oral mucosa 4 times a day Local Treatment of oral candidiasis • Azol antifungals - Canesten, Clotrimazol (lips) - suitable pharmaceutical form to oral cavity? - non lege artis - vaginal tablets to dissolve in the mouth • Solutions of triazol antifungals - ketoconazolum, fluconazolum, itraconazolum - not available for dentists (only pediatrician) Systemic Treatment of oral candidiasis • Extensive involvement, recurrence, resistance, serious general health • Prophylaxis (long-term antibiotic therapy, immunodeficiency and immunosuppressive ter, HIV) • Adequate doses for a sufficiently long time (minium 2-3 weeks) Systemic Treatment of oral candidiasis • Triazol antifungals (ketoconazolum - Nizoral, fluconazolum Diflucan, itraconazolum - Sporanox) • KI - pregnancy, liver failure, drug interactions (cyclosporin A, warfarin, ATB) • Caring for dentures • Reduction of predisposing factors Caring for dentures • New denture, relining (rebasing) • Proper cleaning (light, glasses) • Taking of at night • Solution of baking soda (alkaline reaction), 0,2% CHX Lip vermilion • Ointments with antimicrobial effect ATB - Framykoin (Neomycini, Bacitracinum) antifungal effect - Fungicidin, Pevaryl, Batrafen + hydrocortisonum (anti-inflammatory) - Pimafucort • support of epithelization Bepanten (dexpanthenolum with CHX), Calcium pantothenicum, Infadolan Treatment of xerostomia • Sufficient amount of fluid through the day • Protection of lips • Avoidance of drugs that may cause xerostomia, alcohol, smoking, dry or spicy food • Stimulation of salivation - chewing gums diabetic sweets - parasympatomimetics (pilokarpin) Treatment of xerostomia • Substitution of saliva - artificial saliva - mineral water (Vincentka) spray - BioXtra, Biotene, Xerostom gel, mouthwash, spray, toothpaste, chewing gums Treatment of xerostomia • Maintaining perfect oral hygiene prevention of new dental caries • Local fluoridation, careful treatment of caries • Treatment of salivary glands • Treatment of oral mucous • Regular recall • Primary herpetic gingivostomatitis • Herpes labialis, Intraoral herpes • Oral candidiasis • ANUG • Traumatic erosion/ulcer • Aphtous ulcers minor/major • Hyposalivation with Xerostomia Questions for practical exam – Rp.