- Email: [email protected]
Drug interactions between miconazole oral gel and warfarin
malocclusion with early loss of his upper and lower primary molars. Radiographic images of the lower right second premolar bud showed calcification initiating, but at a significantly slower rate than was occurring in the lower left second premolar (Fig 1). Arrest of the tooth formation process made it difficult to determine its outcome. It was decided to open the space for an implant or prosthesis or for the lower right second premolar. Serial periapical and panoramic radiographs revealed the bud had a good chance to remain in the dental arch, so orthodontic mechanics was initiated. The mechanical approach to increase lower arch length achieved its goal by the time the tooth development was clearly aimed at eruption. Once the tooth was fully erupted, the lower right second premolar was bonded and orthodontic treatment completed. Discussion.—The malocclusion was treated orthodontically in anticipation that the lower right second premolar
would need space to erupt. This space could also have served as a site for an implant or prosthesis had the tooth bud failed to develop further.
Clinical Significance.—Being patient pays off. In this study, space for a late-developing second premolar was maintained orthodontically for 6 years while it caught up with the rest of the dentition.
da Silva Filho OG, Lauris RdMC, Júnior F, et al: Delayed formation of a lower second premolar. J Clin Pediatr Dent 28:299-302, 2004 Reprints available from OG da Silva Filho, Rua Rio Branco, 20-81, 17014-480 Bauru - SP, Brazil; fax: 55 14 3234-3239; e-mail: ortoface @travelnet.com.br
Pharmacology Drug interactions between miconazole oral gel and warfarin Background.—According to a survey of general dental practitioners, as many as one third are unaware of the contraindications or problems accompanying the use of azole antifungal agents. A case was reported to illustrate the impact of miconazole oral gel on warfarin anticoagulation. Case Report.—Man, 62, had a complaint of intermittent soreness of the tongue over a period of 5 months. His general medical practitioner had prescribed miconazole oral gel 3 months previously to be used as needed. Four years ago, the patient had a thrombosis of the large bowel. His current medical condition included irritable bowel syndrome and bladder cancer, and he was taking warfarin regularly. One month after beginning the miconazole oral gel, he reported hematuria on a routine visit to the anticoagulant clinic, prompting a check of his INR, which was 11.9. He was hospitalized and taken off warfarin. His INR was only 3.1 at discharge 1 week later. He returned to taking the 4.5-mg daily maintenance dose of warfarin and symptomatic use of miconazole oral gel. His INR again rose, so his warfarin dosage was reduced to 3.5 mg daily. When he was seen in the oral medicine unit, he was told of the interaction that occurs between miconazole and warfarin. His hematologist was similarly advised so the patient’s INR would be monitored after the miconazole was withdrawn. The hematologist was unaware that the patient was taking miconazole. Once the miconazole was withdrawn, the patient’s INR fell, requiring an increased war-
farin dosage. Because his oral condition showed no evidence of candidiasis or other fungal infection, he was diagnosed with traumatic ulceration. Discussion.—The possible drug interactions with imidazole antifungal agents can be attributed to their inhibition of the cytochrome P-450 enzyme system in the liver, which affects the clearance of various other agents. When given in a gel form, miconazole has the potential to be absorbed, which is most likely what happened in this case. When a drug interaction with warfarin is possible, polyene antifungal agents should be used instead of miconazole. If warfarin and miconazole must be used together, the INR must be closely monitored.
Clinical Significance.—Clinicians need to be aware that miconazole oral gel may have systemic interactions, including that patients on warfarin will exhibit derangement of anticoagulation. Other interactions have also been reported.
Pemberton MN, Oliver RJ,Theaker ED: Miconazole oral gel and drug interactions. Br Dent J 196:529-531, 2004 Reprints available from MN Pemberton, Unit of Oral Medicine, Univ Dental Hosp of Manchester, Higher Cambridge St, Manchester M15 6FH, United Kingdom; e-mail: [email protected]
Volume 50 • Issue 2 • 2005 91
would need space to erupt. This space could also have served as a site for an implant or prosthesis had the tooth bud failed to develop further.
Clinical Significance.—Being patient pays off. In this study, space for a late-developing second premolar was maintained orthodontically for 6 years while it caught up with the rest of the dentition.
da Silva Filho OG, Lauris RdMC, Júnior F, et al: Delayed formation of a lower second premolar. J Clin Pediatr Dent 28:299-302, 2004 Reprints available from OG da Silva Filho, Rua Rio Branco, 20-81, 17014-480 Bauru - SP, Brazil; fax: 55 14 3234-3239; e-mail: ortoface @travelnet.com.br
Pharmacology Drug interactions between miconazole oral gel and warfarin Background.—According to a survey of general dental practitioners, as many as one third are unaware of the contraindications or problems accompanying the use of azole antifungal agents. A case was reported to illustrate the impact of miconazole oral gel on warfarin anticoagulation. Case Report.—Man, 62, had a complaint of intermittent soreness of the tongue over a period of 5 months. His general medical practitioner had prescribed miconazole oral gel 3 months previously to be used as needed. Four years ago, the patient had a thrombosis of the large bowel. His current medical condition included irritable bowel syndrome and bladder cancer, and he was taking warfarin regularly. One month after beginning the miconazole oral gel, he reported hematuria on a routine visit to the anticoagulant clinic, prompting a check of his INR, which was 11.9. He was hospitalized and taken off warfarin. His INR was only 3.1 at discharge 1 week later. He returned to taking the 4.5-mg daily maintenance dose of warfarin and symptomatic use of miconazole oral gel. His INR again rose, so his warfarin dosage was reduced to 3.5 mg daily. When he was seen in the oral medicine unit, he was told of the interaction that occurs between miconazole and warfarin. His hematologist was similarly advised so the patient’s INR would be monitored after the miconazole was withdrawn. The hematologist was unaware that the patient was taking miconazole. Once the miconazole was withdrawn, the patient’s INR fell, requiring an increased war-
farin dosage. Because his oral condition showed no evidence of candidiasis or other fungal infection, he was diagnosed with traumatic ulceration. Discussion.—The possible drug interactions with imidazole antifungal agents can be attributed to their inhibition of the cytochrome P-450 enzyme system in the liver, which affects the clearance of various other agents. When given in a gel form, miconazole has the potential to be absorbed, which is most likely what happened in this case. When a drug interaction with warfarin is possible, polyene antifungal agents should be used instead of miconazole. If warfarin and miconazole must be used together, the INR must be closely monitored.
Clinical Significance.—Clinicians need to be aware that miconazole oral gel may have systemic interactions, including that patients on warfarin will exhibit derangement of anticoagulation. Other interactions have also been reported.
Pemberton MN, Oliver RJ,Theaker ED: Miconazole oral gel and drug interactions. Br Dent J 196:529-531, 2004 Reprints available from MN Pemberton, Unit of Oral Medicine, Univ Dental Hosp of Manchester, Higher Cambridge St, Manchester M15 6FH, United Kingdom; e-mail: [email protected]
Volume 50 • Issue 2 • 2005 91