Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants. Management of the Oral Infection: Part 2 A Peer-Reviewed Publication Written by Ian Shuman, DDS, MAGD, AFAAID © Stiggdriver | Dreamstime.com © Stiggdriver Abstract Educational Objectives Author Profile This is the second of a two-part course on oral At the conclusion of this educational Ian Shuman DDS, MAGD, AFAAID maintains a full-time general, infection. It includes the clinical and diagnostic activity participants will be able to: reconstructive, and aesthetic dental practice in Pasadena, Maryland. features of infections that clinicians are most likely to 1. Identify clinical features associated with Since 1995 Dr. Shuman has lectured and published on advanced, encounter: fungal, viral and bacterial. Published clinical different viral, fungal and bacterial minimally invasive techniques. He has taught these procedures to recommendations and current scientific literature are infections thousands of dentists and developed many of the methods. Dr. Shuman reviewed and management strategies are discussed. In 2. Describe the various strategies for has published numerous articles on topics including adhesive resin den- tistry, minimally invasive restorative, cosmetic and implant dentistry. addition, scientifically supported alternative therapies treating acute fungal and viral infection He is a Master of the Academy of General Dentistry, an Associate Fellow are mentioned where applicable. The reader should 3. Implement appropriate medication of the American Academy of Implant Dentistry, a Fellow of the Pierre refer to current pharmacology and dosing information management of fungal, viral and Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in prior to prescribing any antifungal therapy.1 bacterial infections. Continuing Education since 2005, by Dentistry Today. Author Disclosure Dr. Shuman has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. INSTANT EXAM CODE 15154 Go Green, Go Online to take your course Publication date: Mar. 2017 Supplement to PennWell Publications Expiration date: Feb. 2020 This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15154 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives Figure 2. At the conclusion of this educational activity participants will be able to: 1. Identify clinical features associated with different viral, fungal and bacterial infections 2. Describe the various strategies for treating acute fungal and viral infection 3. Implement appropriate medication management of fungal, viral and bacterial infections. Abstract This is the second of a two-part course on oral infection. It in- cludes the clinical and diagnostic features of infections that cli- Figure 3. nicians are most likely to encounter: fungal, viral and bacterial. Published clinical recommendations and current scientific lit- erature are reviewed and management strategies are discussed. In addition, scientifically supported alternative therapies are mentioned where applicable. The reader should refer to current pharmacology and dosing information prior to prescribing any antifungal therapy.1 Oral Fungal Infection Figure 4. Fungi are commonly found in the oral cavity (oral mycoses) and in healthy individuals do not pose a threat of infection. How- ever, in a conducive environment, infection can occur for a mul- titude of reasons. These include but are not limited to aging,2 xerostomia,3 organ transplants,4 HIV and AIDS,5 and systemic diseases such as diabetes mellitus.6 There over 15 distinct Can- dida species that can cause human disease with Candida albicans the most common oral fungal organism7 associated with infec- tion.8 (Figure 1) Superficial mucosal infection caused by this organism is classified as acute pseudomembranous candidiasis, (Figure 2) acute erythematous candidiasis or chronic atrophic (erythematous) candidosis (or chronic hyperplastic candidosis). Infection caused by C. albicans also includes angular cheilitis (Figure 3) (formed at the commissure of the lips), rhomboid Other, species in the genus Candida that can cause oral in- glossitis (on the dorsum of the tongue) (Figure 4) and ‘pros- fection includes C. glabrata, C. tropicalis, C. parapsilosis, and thetic’ stomatitis (commonly found on the palate). C. krusei.9,10 Candida Glabrata a common cause of oral thrush is now estimated to be involved in about 15 to 30 percent of yeast Figure 1. infections.11 It is very common in AIDS patients, and involves white, cheese-like lesions on the inside of the cheeks, the gums and the tongue. C. glabrata infections have a higher mortality rate than most other yeast species. Another species present in otherwise healthy people, Candida dubliniensis, has been re- covered primarily from the oral cavities of human immunode- ficiency virus (HIV)-infected individuals and AIDS patients.12 The duration of fungal infection is dependent on variables such as immune suppression, and long-term antibiotic or cor- ticosteroid use, among others.13,14 Symptoms associated with candidiasis can include taste disturbance, dry mouth, oral burning,15 oral ulcers16 and difficulty swallowing.17 The diag- nosis of candidiasis is primarily clinical, based on observable lesions that vary in their presentation:18 2 www.DentalAcademyOfCE.com • Pseudomembranous candidosis presents with white identifying tests does not imply infection. It is the invasion of the plaques on the mucosa and tongue resembling milk mucosa by the fungal organism that is definitive with respect to curds.19 Wiping them exposes an underlying erythematous the diagnosis. Microbiological identification techniques incor- epithelium that may bleeds. porating biopsy and DNA testing may be necessary in question- • Erythematous candidosis is generally found as red areas able clinical diagnosis, resistance to treatment with antifungal on the palate, depapillated areas on the dorsum of the medication, or determination of the responsible organism.24 tongue, and on the buccal mucosa.20 It should be noted that there are several noncandidal oral • Chronic hyperplastic candidosis (candidal leukoplakia) mycoses and include histoplasmosis, blastomycosis, aspergil- usually occur on the buccal mucosa and less commonly on losis, paracoccidioidomycosis, cryptococcosis, and zygomycosis the tongue. They present as raised lesions that may vary from (mucormycosis).25 This group is far less common than oral can- small, palpable, translucent, or whitish, to large, dense, opaque didiasis, producing subclinical infection, especially pulmonary plaque-like lesions that are hard and rough to the touch.21 infections. Immunocompromised persons (including those with • Denture-related stomatitis is a typically asymptomatic, leukemia, leukopenia, solid tumors,