|Year : 2016 | Volume
| Issue : 2 | Page : 77-80
Antifungal-prescribing pattern and attitude toward the treatment of oral candidiasis among dentists in and around Kothamangalam in Kerala: A survey
Asha S Anand1, Majo Ambooken1, Jayan Jacob Mathew1, KS Harish Kumar2, KC Vidya2, Linu Sara Koshy1
1 Department of Periodontics, Mar Baselios Dental College, Ernakulam, Kerala, India
2 Department of Microbiology, Mar Baselios Dental College, Ernakulam, Kerala, India
|Date of Web Publication||6-Jan-2017|
Asha S Anand
Department of Periodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala
Source of Support: None, Conflict of Interest: None
Context: Dentists come across various clinical entities of candidiasis and prescribe antifungals for its treatment.
Aims: The aim of this study was to evaluate the attitude of dentists in and around Kothamangalam in Kerala toward the treatment of oral candidiasis and their current antifungal-prescribing pattern.
Settings and Design: A questionnaire-based survey was conducted among the dental surgeons working in and around Kothamangalam, a small town in Ernakulam district, Kerala.
Participants and Methods: The potential participants of the survey were identified from the faculty list of the three dental colleges as well as from the general practitioners list of Kothamangalam. A total of 150 questionnaires were distributed among dentist practitioners in Kerala. Of the 122 dentists responded, 22 were rejected due to insufficient data. The data from the remaining 100 questionnaires were entered for analysis.
Statistical Analysis Used: The data were manually entered for analysis in the online portal - http://www.SurveyMonkey.com, and the analysis was performed.
Results: Clotrimazole was the most common (71%) antifungal prescribed by the practitioners. Only 13% of the dentists prescribed antifungals systemically.
Conclusions: Most dentists preferred topical treatment for the management of candidiasis. Clotrimazole is the most popular choice of antifungal employed followed by nystatin.
Keywords: Antifungals; oral candidiasis; prescription; survey
|How to cite this article:|
Anand AS, Ambooken M, Mathew JJ, Harish Kumar K S, Vidya K C, Koshy LS. Antifungal-prescribing pattern and attitude toward the treatment of oral candidiasis among dentists in and around Kothamangalam in Kerala: A survey. Indian J Multidiscip Dent 2016;6:77-80
|How to cite this URL:|
Anand AS, Ambooken M, Mathew JJ, Harish Kumar K S, Vidya K C, Koshy LS. Antifungal-prescribing pattern and attitude toward the treatment of oral candidiasis among dentists in and around Kothamangalam in Kerala: A survey. Indian J Multidiscip Dent [serial online] 2016 [cited 2017 Nov 23];6:77-80. Available from: http://www.ijmdent.com/text.asp?2016/6/2/77/197759
| Introduction|| |
Candida species are opportunistic pathogens that can cause disease in immunocompromised host.  Risk factors for opportunistic infections caused by Candida species include diabetes mellitus, broad-spectrum antibiotics, immunosuppressants, and certain immunodeficiency states.  One consequence of the widespread use of antibiotics both in general medicine and in dentistry is superinfections by yeasts. This may warrant antifungal agents in the management of oral fungal infection. Inappropriate use of antifungal drugs may contribute to the worldwide increase in antifungal resistance. ,
The aim of this study was to evaluate the attitude of dentists in and around Kothamangalam in Kerala toward the treatment of oral candidiasis and their current antifungal-prescribing pattern.
| Participants and Methods|| |
A questionnaire-based survey was conducted from January to March 2016.
The survey was conducted among the dental surgeons working in and around Kothamangalam, a small town in Ernakulam district, Kerala. Along with the resident population, Kothamangalam depends on by a major part of the population of the high ranges of Idukki district for their medical needs. Furthermore, Kothamangalam has three dental colleges located in its periphery. Therefore, patient care is distributed among general practitioners as well as specialists working in the dental colleges. Hence, in spite of the survey being carried out in a small geographic area, there existed diversity in the nature of the participants.
A questionnaire in English was developed based on earlier studies by Oliver et al.,  Al-Shayyab et al.,  and Martínez-Beneyto et al.  to meet the local requirements. The questionnaire consisted of socioprofessional details, their current prescribing habits of the available antifungal drugs, and their attitude toward the treatment of oral candidiasis. The questionnaire was piloted and tested for clarity and simplicity of questions by distributing among dentists with postgraduate qualifications. Based on their comments and suggestions, the questionnaire was modified and adjusted to make it easier for participants to understand and respond. The potential participants of the survey were identified from the faculty list of the three dental colleges as well as from the general practitioners list of Kothamangalam. The final questionnaire was then hand distributed among dental practitioners. The participants were first informed of the purpose of the study, and after obtaining their consent, it was asked to fill up the questionnaire. Completed questionnaires were collected in person, and the data were analyzed. The study was approved by the Institutional Ethical Committee of Mar Baselios Dental College.
| Results|| |
A total of 150 questionnaires were distributed among dentist practitioners in Kerala. Of the 122 dentists responded (81.34% response rate), 22 were rejected either due to insufficient data. The data from the remaining 100 questionnaires were manually entered for analysis in the online portal - http://www.SurveyMonkey.com, and the analysis was performed.
Of the 100 respondents, 75% had postgraduate qualification and 25% were undergraduates. [Figure 1] shows the details of academic qualifications of the dentists. The majority of the respondents were qualified after 2000, and also majority were employed in private (38%), academic (38%), or both (22%). Almost 92% of the respondents came across candidal infection in their practice, the rest 8% (four undergraduates and four postgraduates) responded negatively.
[Figure 2] illustrates the antifungal prescription pattern among dentists of various specialties. Clotrimazole was the most common (71%) antifungal prescribed by the practitioners, of which 98.59% preferred the liquid form. Nearly 23% prescribed nystatin as oral suspension (47.83%), ointment (43.48%), or pastille (21.74%). About 15% prescribed chlorhexidine mouthwash. The other antifungals prescribed included fluconazole (13%), ketoconazole (13%), miconazole oral gel (5%), miconazole and hydrocortisone cream (2%), amphotericin (2%), and itraconazole (1%). One respondent, though he came across Candida in practice, did not prescribe antifungals. Only 13% of the practitioners responded to have been using systemic antifungals [Figure 3].
| Discussion|| |
The present study investigated the antifungal prescription pattern of dental practitioners in and around Kothamangalam municipality in Kerala, in relation to the socioprofessional details as described in a study by Martínez-Beneyto et al.  The treatment of oral candidiasis depends on its early diagnosis, the correction of facilitating factors or underlying diseases, and the clinical type (pseudomembranous, atrophic, hyperplastic, etc.). Dentists may need to treat immunocompetent and immunocompromised patients who have different types of oral candidiasis. Management of oral candidiasis entails identification and correction of predisposing factors wherever possible and selecting the antifungal agent suitable for the patient and the lesion. Furthermore, weighing the risk and benefits of the use of specific antifungal agent has to be taken into consideration. In this regard, dentists should have sufficient knowledge on the diagnosis of oral candidal lesions to permit prescription of the appropriate antimicrobial therapy. However, it has been reported that this knowledge and attitude may be influenced by the practitioners' socioprofessional factors, including work setting and experience. ,
The experience of dentists is known to have a significant association with their attitude and prescribing habits, particularly of systemic antifungal agents. , In our study, we did not find any significant association with experience, work setting, and qualification of practitioners to diagnose and treat oral candidiasis. However, practitioners with postgraduate qualification used significantly more systemic antifungals (87%) than practitioners with a graduate degree. This might be due to the better understanding of different clinical types of oral candidiasis as well as the underlying predisposing factors.
Clotrimazole was the most preferred antifungal (71%) irrespective of qualification, work setting, and experience among dentists, which is in contrast to studies by Martínez-Beneyto et al.  (8%), Al-Shayyab et al.,  and Oliver et al.  The reason for such a huge difference in percentage between the above-mentioned studies and our study might be due to the fact that those study had respondents who were mainly educated in the European Union countries (The UK and Spain) where clotrimazole is not available.  However, our study is in accordance with the Infectious Disease Society of America, which recommends clotrimazole for the treatment of mild (pseudomembranous) oral candidiasis.
Miconazole and nystatin were the commonly employed antifungals in the above three studies ,, as they may cause less intestinal irritation and other side effects. The topical formulations of nystatin and clotrimazole have high sucrose content, and thereby limiting its use in diabetes, steroid use, or an immunocompromised state.  Nystatin was the second commonly prescribed antifungal (23%), of which majority (43.75%) was prescribed by prosthodontists.
Chlorhexidine mouth rinse formulations are widely used for reducing the microbial burden in the oral cavity. For instance, chlorhexidine gluconate at a concentration of 0.2% is used in clinical practice as an antiseptic oral rinse due to its activity against a wide range of oral microbial species including Candida.  It is recommended as a useful adjunct to the antifungal agents although it should not be used simultaneously with nystatin as they interact and render each other ineffective.  In this study also, chlorhexidine was prescribed by dental practitioners (16%) along with other antifungal agents as an adjunctive therapeutic agent.
The triazoles constitute 27% of the total prescription with fluconazole and ketoconazole being most commonly used (13% each) followed by itraconazole (1%). Fluconazole suspension, in a variety of dosages, has been used for the treatment of oropharyngeal candidiasis. , The theoretical benefit of using topical fluconazole is that a higher concentration of the active drug is delivered to the oral mucosa without the untoward systemic side effects.  Ketaconazole is the first oral systemic agent with broad antifungal activity, which is also available in topical form. Ketoconazole is the drug of choice for all forms of mucocutaneous candidiasis in outpatient population. ,,
Less commonly prescribed antifungals in our study were miconazole (7%) and amphotericin B (2%). Miconazole in combination with hydrocortisone was prescribed by 2% of the practitioners.
The systemic use of antifungals is less as majority of respondents (87%) did not use systemic antifungals. Those who prescribed systemic antifungals (92%) had a postgraduate degree; this might be attributed to a better understanding of different clinical entities of oral candidiasis.
Despite the above-mentioned results, this study is not without limitations. The possible improvement in our methodology could be the inclusion of identification of specific oral candidal infection to enable comment on the drugs used in the treatment of such infection. Differentiation between respondents prescribing antifungals for initial first-line treatment or prescribing them after failure to initial therapy was also not investigated in the study. Similarly, the cost of patient care and predisposing factors for oral candidiasis such as denture wearing or other concurrent systemic illness were not investigated. The small sample size was an additional limitation of this questionnaire-based survey. Therefore, future studies with larger sample size covering a wider geographic area and data which has been excluded in our study may provide findings that are able to confirm the results of this survey.
| Conclusion|| |
In general, the attitude of dental practitioners in the state toward the diagnosis and treatment of oral candidiasis is positive among graduates and postgraduates. Most dentists preferred topical treatment for the management of candidiasis. Clotrimazole is the most popular choice of antifungal employed followed by nystatin.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hibino K, Samaranayake LP, Hägg U, Wong RW, Lee W. The role of salivary factors in persistent oral carriage of Candida
in humans. Arch Oral Biol 2009;54:678-83.
Farah CS, Lynch N, McCullough MJ. Oral fungal infections: An update for the general practitioner. Aust Dent J 2010;55 Suppl 1:48-54.
Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida
species to fluconazole. Antimicrob Agents Chemother 1995;39:1-8.
Goldman M, Cloud GA, Smedema M, LeMonte A, Connolly P, McKinsey DS, et al.
Does long-term itraconazole prophylaxis result in in vitro
azole resistance in mucosal Candida albicans
isolates from persons with advanced human immunodeficiency virus infection? The national institute of allergy and infectious diseases mycoses study group. Antimicrob Agents Chemother 2000;44:1585-7.
Oliver RJ, Dhaliwal HS, Theaker ED, Pemberton MN. Patterns of antifungal prescribing in general dental practice. Br Dent J 2004;196:701-3.
Al-Shayyab MH, Abu-Hammad OA, Al-Omiri MK, Dar-Odeh NS. Antifungal prescribing pattern and attitude towards the treatment of oral candidiasis among dentists in Jordan. Int Dent J 2015;65:216-26.
Martínez-Beneyto Y, López-Jornet P, Velandrino-Nicolás A, Jornet-García V. Use of antifungal agents for oral candidiasis: Results of a national survey. Int J Dent Hyg 2010;8:47-52.
Crowley PD, Gallagher HC. Clotrimazole as a pharmaceutical: Past, present and future. J Appl Microbiol 2014;117:611-7.
Akpan A, Morgan R. Oral candidiasis. Postgrad Med J 2002;78:455-9.
Salem AM, Adams D, Newman HN, Rawle LW. Antimicrobial properties of 2 aliphatic amines and chlorhexidine in vitro
and in saliva. J Clin Periodontol 1987;14:44-7.
Barkvoll P, Attramadal A. Effect of nystatin and chlorhexidine digluconate on Candida albicans
. Oral Surg Oral Med Oral Pathol 1989;67:279-81.
Epstein JB, Gorsky M, Caldwell J. Fluconazole mouthrinses for oral candidiasis in postirradiation, transplant, and other patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:671-5.
Martins MD, Rex JH. Fluconazole suspension for oropharyngeal candidiasis unresponsive to tablets. Ann Intern Med 1997;126:332-3.
Graybill JR, Craven PC. Antifungal agents used in systemic mycoses. Activity and therapeutic use. Drugs 1983;25:41-62.
Hay RJ, Clayton YM. The treatment of patients with chronic mucocutaneous candidiasis and Candida
onychomycosis with ketoconazole. Clin Exp Dermatol 1982;7:155-62.
Fazio RA, Wickremesinghe PC, Arsura EL. Ketoconazole treatment of Candida
esophagitis - A prospective study of 12 cases. Am J Gastroenterol 1983;78:261-4.
[Figure 1], [Figure 2], [Figure 3]