Letters to the Editor - March-April 2013

Letters to the Editor - March-April 2013

The Editors:
Letters to the Editor
Readers of Northwest Dentistry are invited to submit Letters to the Editor on topics related to articles or columns previously published in the journal. Letters written to express viewpoints about current policies or actions of the MDA or other agencies will be referred to an appropriate individual, department, or committee to directly respond to the author. The  views expressed are those of the writers and do not necessarily reflect the opinions or official policies of the Minnesota Dental Association, the Publications Committee, or Northwest Dentistry editorial staff. Letters will be accepted by e-mail at info@mndental.org
 
 
 
January 17, 2013
To the Editors,
I have a couple of comments regarding the brief column titled "Treatment of Oral Candidiasis" by Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D., published in Northwest Dentistry’s March- April 2012 issue (Volume 91, number 2, pages 32-33). 
 
1. "Triamcinolone acenatate" does not exist ... "triamcinolone acetonide" does.
2. This ingredient is not suitable to use in the oral cavity of children. Also, this ingredient may retard the immune system's effectiveness in fighting off the fungal infection.  Triamcinolone is sometimes used with an antifungal agent for just a few days in the treatment of dermatologic (not oral) fungal infections.
3. "Mycostatin cream (ointment)" and "Mycolog II ointment" are not intended for internal or oral use. The FDA indicates that Mycolog-II contains plasticized hydrocarbon gel and is for  "DERMATOLOGIC USE ONLY".  Mycostatin cream (ointment) is "not indicated for systemic, oral, intravaginal or ophthalmic use."
4. Author recommends the use of clotrimazole + nystatin for the treatment of "Level 2" infections. I disagree, since there will be no advantage to this combination over just  clotrimazole monotherapy. Clotrimazole covers the same species of fungus as nystatin and also covers dermatophytes (which nystatin does not cover). So, trying this treatment  would delay the patient from getting a more effective one, thus extending the period of suffering needlessly. 
5. Author recommends oral ketoconazole for "Level 3" disease. Ketoconazole has been replaced pretty much by the less toxic itraconazole and terbinafine. These two agents should be  recommended in place of ketoconazole. 
6. Author recommends two topical agents + systemic fluconazole/ketoconazole for "Level 4" disease. This combo is not expected to be better than just the systemic antifungal. 
 
Thanks.
Sincerely,
Marc Riachi
Pharmacist
Ottawa, Ontario, Canada

February 8, 2013
Dear Dr. Raichi,
 
Thank you for your interest in the paper. I appreciate your comments. In fact, I receive these same questions from pharmacists almost every day when I write these prescriptions. 
This brief paper did not allow for substantial rationale or specific patient types for which these various regimens are indicated. However, I can assure you that these recommendations  are indeed appropriate in many (complex) clinical situations based upon: 
(1) scientific literature (selections of which are referenced), including clinical trials supporting these recommended therapies; 
(2) evidence from several clinical practice guidelines including the American Academy of Oral Medicine; and 
(3) more than 30 years of clinical practice treating many medically complex patients for whom the standard (common monotherapy) is not effective. 
 
Please rest assured that these recommendations are indeed safe and effective when used appropriately, as clearly stated in the paper.
 
Thank you.
Sincerely,
Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D.