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Sample Chapter - Drugs in Dentistry  by Mosby, 10/e Sample Chapter - Drugs in Dentistry by Mosby, 10/e Document Transcript

  • Based in Part on Material from the American Academy ofOral Medicine (AAOM) Clinician’s Guide to Treatment of THERAPEUTIC MANAGEMENT OF COMMON ORAL LESIONSCommon Oral ConditionsThis is a summary of the etiologic condition so that the managementfactors, clinical description, approach is not masking ancurrently accepted therapeutic underlying condition or to evaluatemanagement, and patient education the individual for drug protocols thatfor the more common oral are beyond the expertise of theconditions. Some of the clinician.recommended treatments have been In addition to the diagnosis,investigated more thoroughly than patient management should beothers, but all have been reported to governed by the natural history ofbe of clinical value. Many oral the oral condition and whether aconditions described here have no palliative, supportive, or curativecure, but are managed by a variety of treatment exists. Referrals oftreatment modalities for the purpose patients should be made when theof relieving discomfort, shortening patients’ problems are beyond thetheir clinical duration and frequency, scope of the clinician, including theand minimizing recurrences. The use of more aggressive drugultimate goal is to provide the protocols for improved outcome.individual with some control over Furthermore, when healing of athe severity of their condition, lesion or an anticipated response tothereby improving their quality of treatment is not achieved within anlife. expected period of time, a biopsy or Clinicians are reminded that an other laboratory studies areaccurate diagnosis is imperative for recommended.clinical success. Every effort should All drugs require a prescriptionbe made to determine the diagnosis unless identified as over-the-counterbefore initiating treatment. It is (OTC) drugs. Please note that incritical to confirm that an individual recent years, the Food and Drugdoes not have a serious infection, an Administration (FDA) has beenunderlying systemic disease, or a active in allowing OTC statuspotentially malignant or malignant for drugs formerly available bylesion. When signs, symptoms, prescription only. Be sure to checkmicroscopic diagnosis, and other the dosages of the newly releasedlaboratory evidence elude a OTC drugs because they usuallydefinitive diagnosis, empirical are of a different strength thantreatment may be initiated and those available by prescription.evaluated on a therapeutic, trial In addition, these OTC drugsbasis. Although empiric treatment or supplements may containmay be of short-term benefit to the ingredients, preservatives, andpatient, certain drugs may mask dyes that may cause irritating-to-or alleviate some of the disease life-threatening adverse effects,features. Therefore, it is also due to relatively minor formularyimportant to make appropriate changes. As with any recommendedand timely referrals in order to therapeutic agent, patients should beobtain a definitive diagnosis when advised of potential side effects anddealing with a persistent oral drug interactions.
  • 2 Therapeutic Management of Common Oral LesionsSUPPORTIVE CARE sucralfate coat the ulcerated lesionsManagement of oral mucosal and may allow the patient to eatconditions may require topical and more comfortably. For specificsystemic interventions. Therapy details, refer to “Herpes Simplex,should address patient nutrition and Topical Anesthetics and Coatinghydration, oral discomfort, oral Agents.”hygiene, management of secondary Meticulous oral hygiene isinfection, and local control of the important in patients who havedisease process. Depending on the multiple areas of erosion orextent, severity, and location of oral ulceration. Mucosal lesionslesions, consideration should be contacting bacterial biofilm on thegiven to obtaining a consultation dentition are more likely to becomefrom a dentist who specializes in secondarily infected. Patients shouldoral medicine, oral and maxillofacial be seen by the dentist or dentalpathology, or oral and maxillofacial hygienist for scaling and rootsurgery. When a question arises planing, under local anesthesia,involving a medical condition, a when necessary, in all cases inphysician should be consulted. which oral hygiene is suboptimal. Temporary, symptomatic relief Patients must be encouraged toof painful conditions can be brush and floss their teeth afterprovided with topical preparations, meals in a gentle yet efficientsuch as 2% viscous lidocaine manner. This may be enhanced byhydrochloride or OTC products placing a soft toothbrush under hotcontaining less potent aesthetics in water to further soften the bristles.gel, ointment, liquid, spray, and The use of fluoride toothpaste islozenge forms. Topical anesthetics strongly encouraged but somecan be used as a rinse in adults patients with widespread mucosalto cover a wide surface area, but lesions prefer toothpastes that areshould be applied with a cotton- not highly flavored and do nottipped applicator or other soft contain foaming, whitening, andapplicator in a young child or adult anti-tartar agents.who is unable to expectorate, inorder to limit the amount of HERPES SIMPLEX INFECTIONmedication that is swallowed. Common viral infection causes twoSwallowing these topical anesthetics types of disease patterns: a primaryis not recommended because it may or acute infection and a secondaryinterfere with the patient’s gag reflex or recurrent infection.and increase the risk for choking, Primary Herpeticaspiration, and drug toxicity. GingivostomatitisSymptomatic relief also can be Etiology:obtained by mixing equal parts A transmissible infection withof diphenhydramine hydrochloride herpes simplex virus, usually type Ielixir and magnesium hydroxide/ or, less commonly, type II.aluminum hydroxide. Children’s Clinical description:formula diphenhydramine Clear-yellowish vesicles develophydrochloride elixir does not contain intraorally and extraorally. Thesealcohol. Sucralfate suspension also vesicles rupture rapidly and coalescecan be used before meals. The to form shallow, irregular, painfuldiphenhydramine mixture and the ulcers. The symptomatic lesions are
  • Therapeutic Management of Common Oral Lesions 3widespread but the gingivae are Although these medications areaffected primarily and are OTC, it is recommended that aerythematous, enlarged, pharmacist compound this oralhemorrhagic, and ulcerated. The suspension. Examples of aluminumpatient may have systemic signs and hydroxide, magnesium hydroxidesymptoms including anterior oral suspension are Maalox andcervical lymphadenopathy, fever, Mylanta—they are common OTCanorexia, and malaise. Adults may brands and are available in a numberdevelop pharyngotonsillitis that is of flavors. Children younger thancharacterized by vesiculo-ulcerative 6 yr should not swallow this orallesions, severe sore throat, and suspension.difficulty swallowing. Usually it is Rxself-limiting, with healing in 7–14 Diphenhydramine hydrochloridedays. liquid 12.5 mg/5 ml lidocaineRationale for treatment: viscous 2% oral solution/aluminumEarly treatment to promote healing, hydroxide, magnesium hydroxiderelieve symptoms, prevent secondary oral suspension. Compound to ainfection, and support general health 1:1:1 mixture by volume.are goals. Supportive therapy Disp. 200 mlincludes plenty of fluids, protein, Sig. Rinse with 1–2 teaspoonsvitamin and mineral food (5–10 ml) every 4 hr for 1 min andsupplements, and rest. Systemic spit out excess. Shake well beforeacyclovir is effective when use and store suspension at roomadministered in the first 48 hr of temperature.symptoms. Topical steroids should Compounded by pharmacy andbe avoided because they tend to stable for approximately 60 days. Dopermit spread of the viral infection not use 2% lidocaine hydrochlorideon mucous membranes, particularly in children who cannot expectorateocular membranes. Nutritional liquid because of potential for aspiration.supplements, pain, and fever control Rxmay be needed. Patients should be Carafate, generic (sucralfate)cautioned to avoid touching the suspension 1 g/10 mlherpetic lesions and then touching Disp. 200 mlthe eyes, genitals, or other body Sig. Rinse with 1 teaspoon (5 ml) 4areas because of the possibility of times a day. Rinse for 1 min and spitself-inoculation. out excess.Topical Anesthetics and In children younger than 6 yr,Coating Agents who cannot expectorate, the amountRx should be limited to 0.5 g, fourDiphenhydramine hydrochloride oral times a day (2 g/day) in case thesolution 12.5 mg/5 ml mixed with suspension is swallowed. Safety andaluminum hydroxide, magnesium efficacy has not been established inhydroxide oral suspension. children.Compound to a 1:1 mixture by Rxvolume. Children’s Benadryl Allergy Liquid,Disp. 200 ml others (diphenhydramineSig. Rinse with 1–2 teaspoons hydrochloride) oral solution(5–10 ml) every 2 to 4 hr for 1 min; 12.5 mg/5 ml (OTC)swish and spit out. Disp. 8 oz bottle
  • 4 Therapeutic Management of Common Oral LesionsSig. Rinse with 1 teaspoon (5 ml) The protocol is based on thefor 2 min every 2– 4 hr and spit out CDC’s recommended dosage forexcess. primary genital herpes in the If swallowed, for adolescents and immunocompetent patient. The drugadults, the maximum amount is should be taken within the first300 mg in 24 hr. For children 48 hr of the initial signs and6–12 yr, the maximum is 150 mg in symptoms.24 hr. Children younger than 6 yr Recurrent (Orofacial) Herpesshould not swallow this drug. Simplex InfectionRx Etiology:Sucrets (dyclonine HCl) throat There is reactivation of the latentlozenges (OTC) virus that resides within the sensoryDisp. 1 package ganglion of the trigeminal nerve.Sig. Slowly dissolve one lozenge Precipitating factors include fever,in mouth every 2 hr as needed for stress, exposure to sunlight, trauma,pain. Do not take more than 10 and hormonal alterations.lozenges a day. Clinical description: The strength of dyclonine HCl Intraoral presentation consists ofranges from 3 mg (maximum single or small clusters of vesiclesstrength) to 1.2 mg for children’s that quickly rupture, forming painfulformula. ulcers. The lesions usually occur onSystemic Antiviral Therapy the keratinized tissue of the hardAcyclovir and valacyclovir may palate and attached gingiva.relieve and decrease the duration of Labial presentation consists ofsymptoms, but the medications must clusters of vesicles on the vermilionbe initiated at the earliest signs border of the lips that rupture withinand symptoms for maximum hours and then crust.effectiveness. Rationale for treatment:Rx Treatment should be initiated asZovirax, generic (acyclovir) capsules early as possible in the prodromal400 mg stage, with the goal of reducing theDisp. 30 (or 50) capsules duration and symptoms of theSig. Take 1 capsule 3 to 5 times a lesion. Oral and topical antiviralday for 10 days or until lesions treatment, prophylactically andresolve. therapeutically, can be considered The Centers for Disease Control when frequent recurrent herpeticand Prevention (CDC) recommends episodes (greater than 6 episodes athis dosage for severe cases of year) interfere with daily functionstomatitis or pharyngitis. Current and nutrition.FDA-approved indication is that Preventionsystemic acyclovir be used to Rxtreat oral herpes only in Suncreen lip balm, SPF 30 (OTC)immunocompromised patients. Disp. 1 tubeRx Sig. Apply to susceptible area 1 hrValtrex, generic (valacyclovir) tablet before sun exposure and every hour1g thereafter.Disp. 20 tablets There are several lip balms orSig. Take 1 tablet twice daily for gels that are available that contain10 days. an SPF of 30 or higher. Several of
  • Therapeutic Management of Common Oral Lesions 5these agents contain sensitizers that Sig. Dab on lesion 5 times a daymay result in irritation of the lips during waking hours for 5 days,and surrounding skin. For maximum beginning when symptoms firstprotection, concurrent use of a occur.sunscreen on the face and This topical agent reduces theother sun-exposed areas is likelihood of ulcerative lesionsrecommended. A wide-brimmed hat developing.or visor is also recommended when Rxexcessive sunlight exposure is a Abreva (docosanol) cream 10%triggering factor. Sharing of these (OTC)lipsticks should be strongly Disp. 2-g tubediscouraged because of the potential Sig. Dab on lesion 5 times a dayrisk of infection in a susceptible during waking hours for 4 days,individual. beginning when symptoms firstTopical Antiviral Agents occur.Topical antiviral medications are Systemic Antiviral Therapymost effective when initiated in the Systemic antiviral medications areearly stages of lesion formation. most effective when initiated in thePatients should be instructed to prodrome or early stages of lesiongently apply the medication to the development. The duration ofaffected site or where the prodromal treatment is convenient becausesymptoms are noted. Aggressively the medication is only taken forrubbing the affected site is not 1 day. Studies have evaluated therecommended because it can cause effectiveness of systemic antiviraltissue trauma and the spread of medications for herpes labialis, butthe infection. In order to prevent not intraoral lesions.autoinoculation of the virus to the Rxfingers or other sites, the topical Valtrex, generic (valacyclovir)agent should be placed on the tablets 1 glesion using a cotton-tipped Disp. 4 tabletsapplicator, and hands should be Sig. Take 2 tablets twice daily, 12 hrthoroughly washed. apart, when symptoms first occur.Rx The CDC recommends 1 g PODenavir (penciclovir) cream 1% every 12 hr for 5–10 days forDisp. 2-g tube immunocompromised individuals.Sig. Dab on lesion every 2 hr while Rxawake, for 4 days, beginning when Famvir, generic (famciclovir) tabletssymptoms first occur. 500 mgRx Disp. 3 tabletsZovirax (acyclovir) cream 5% Sig. Take 3 tablets as a single doseDisp. 2- or 5-g tube at the first sign or symptom of theSig. Dab on lesion 5 times a day infection.during waking hours for 4 days, The CDC recommends 500 mgbeginning when symptoms first PO twice daily for 5–10 days foroccur. immunocompromised individuals.Rx RxXerese (acyclovir 5%; Zovirax, generic (acyclovir) capsuleshydrocortisone 1%) cream 400 mgDisp. 5-g tube Disp. 15 capsules
  • 6 Therapeutic Management of Common Oral LesionsSig. Take 1 capsule 3 times a day for older. Length of treatment with5 days. these antiviral agents increases when The CDC recommends this herpes zoster develops in HIV-dosing schedule for infected individuals.immunocompetent individuals. If the Rxpatient is HIV-positive, then the Famvir, generic (famciclovir) tabletsduration of use is increased. 500 mg Disp. 21 tabletsHERPES ZOSTER (SHINGLES) Sig. Take 1 tablet every 8 hr for 7Etiology: days.Herpes zoster represents the Rxreactivation of latent varicella-zoster Zovirax, generic (acyclovir) tabletsvirus following a previous infection 800 mgwith chickenpox. Precipitating Disp. 50 capsulesfactors include immunosuppressive Sig. Take 1 tablet every 4 hr, 5 timesand cytotoxic drugs, therapeutic a day for 7–10 days.radiation, old age, alcohol abuse, Rxmalignancies, and trauma, including Valtrex, generic (valacyclovir)dental treatment. tablets 1 gClinical description: Disp. 21 tabletsThe classic signs and symptoms Sig. Take 1 tablet 3 times a day forinclude painful segmental eruption 7 days.of small vesicles that later ruptureto form punctate or confluent RECURRENT APHTHOUSulcers or crusts. Fever, headache, STOMATITISlymphadenopathy, and referred pain Etiology:may precede or accompany the An altered local immune response islesions. When the head and neck the predisposing factor. Patients witharea is involved, one or more of the frequent recurrences should bebranches of the trigeminal nerve are screened for diseases such asaffected. anemia, allergies, vitamin deficiency,Rationale for treatment: inflammatory bowel disease, andPrompt initiation of antiviral therapy immunosuppression. Precipitatingis recommended to reduce duration factors include stress, trauma,and symptoms of the lesions. salivary gland hypofunction, certainPatients older than 60 yr are medications, allergies, endocrineespecially prone to developing alterations, smoking cessation,postherpetic neuralgia. Systemic dietary components, includingantiviral medications are most cheese, chocolate, cow’s milk,effective if initiated within 48 hr of gluten, nuts, strawberries, and acidiclesion formation. The treatment of foods and juices. Inspect the oralacute herpes zoster with famciclovir cavity closely for sources of trauma.significantly decreases the incidence Clinical description:and duration of postherpetic Minor aphthous ulcerations (cankerneuralgia. Recently, the herpes sores) are the most common clinicalzoster virus vaccine, Zostavax, a variation. These lesions are smallerlive, attenuated vaccine, has been than 1 cm, shallow, round to oval,developed for the prevention of this and painful. They are covered by ainfection in adults who are 60 yr or cream-colored membrane and
  • Therapeutic Management of Common Oral Lesions 7surrounded by an erythematous topical steroid may prolong tissuehalo. They usually occur on contact of the medication and makenonkeratinized (moveable) oral the patient more comfortable.mucosa and usually heal in 7 to 14 Multiple topical over-the-counterdays without scarring. anesthetics or protective bioadhesive Major aphthous ulcerations are agents are available for patientlarger lesions that range from 1 to comfort.3 cm in size and very painful. These Topical Steroidsulcerations are not only larger in Prolonged use of topical steroidssize but may be deep with irregular (longer than 2 wk of continuousborders. They are often multiple and use) may result in mucosal atrophypersistent, taking 2 to 6 wk and and secondary candidiasis and maylonger to heal. Mucosal scarring increase the potential for systemicmay be extensive. These ulcerations absorption. It may be necessary tomay mimic other persistent diseases, prescribe antifungal therapy withsuch as deep mycotic infection, steroids use in some patients.granulomatous diseases, or For Mild-to-Moderate Cases:malignant lesions. Rx Herpetiform aphthous Triamcinolone acetonide in dentalulcerations appear as crops of small, paste 0.1%shallow, painful lesions. They Disp. 5-g tubeusually occur on nonkeratinized oral Sig. Coat the lesion with a thin filmmucosa, but any mucosal surface after each meal and at bedtime.may be involved. These ulcerations Rxtypically heal within 7 to 10 days, Dexamethasone oral solution orbut closely spaced recurrences are elixir 0.5 mg/5 mlcommon. Because multiple small Disp. 240 mlulcers develop suddenly, these Sig. Rinse with 1 teaspoon (5 ml)lesions resemble recurrent intraoral for 2 min four times a day andherpes simplex, clinically. expectorate. Do not eat or drink forRationale for treatment: 30 min after rinsing.Treatment options involve mucosal Rxbarriers, topical anesthetics, Fluocinonide 0.05% gelcauterization, laser therapy, topical Disp. 15-g tubeor systemic corticosteroids, and Sig. Apply a thin layer to the ulcerimmunosuppressant or combination after meals and at bedtime.therapy, when indicated. Treatment Discontinue use of topicalshould be initiated as early as steroids when lesions becomepossible in the course of lesions. asymptomatic.Identification and elimination of Other topical steroidprecipitating factors may minimize preparations (cream, gel, rinse,recurrent episodes. Medications ointment) are available. In general,such as mycophenolate mofetil, creams are not used intraorallypentoxifylline, colchicine, and because of very poor mucosalthalidomide are used to treat patients adherence. Many topical steroidswith severe, persistent, recurrent come with a warning that they areaphthous ulcers, but should not be for external use only. However,routinely used. Placing a dissolvable several of these agents have beenor bioerodible mucosal patch over a used successfully for managing
  • 8 Therapeutic Management of Common Oral Lesionsrecurrent aphthous ulcerations. Directions for usingExamples of some of the topical dexamethasone oral solution:steroid medications are listed below Rinse for 1 min, four times daily,according to potency. after meals and before bedtime. DoSuper-High Potency: not drink or eat for 30 min after Betamethasone dipropionate rinsing. (augmented) 0.05%, gel, 1. For 3 days, rinse with 1 ointment tablespoon (15 ml) times a day Clobetasol propionate 0.05%, gel, and swallow. Then, ointment 2. For 3 days, rinse with 1 Halobetasol propionate 0.05%, teaspoonful (5 ml) 4 times a day ointment and swallow. ThenHigh Potency: 3. For 3 days, rinse with 1 Betamethasone dipropionate teaspoonful (5 ml) 4 times a day 0.05%, gel, ointment and swallow every other time. Fluocinonide 0.05%, gel, Then ointment 4. Rinse with 1 teaspoonful (5 ml) Dexamethasone 0.5 mg/5 ml oral 4 times a day and expectorate. solution, elixir Discontinue medication when Desoximetasone 0.05%, gel; mouth becomes comfortable. 0.25% ointment RxMedium Potency: Prednisone tablets 5 mg Betamethasone valerate 0.1%, Disp. 40 tablets ointment Sig. Take 5 tablets in the morning Triamcinolone acetonide 0.1%, for 5 days, then 5 tablets in the ointment morning every other day untilLow Potency: asymptomatic. Alclometasone dipropionate For Very Severe Cases 0.05%, ointment Rx Hydrocortisone acetate 1%, gel, Prednisone tablets 10 mg ointment Disp. 26 tabletsOral candidiasis may develop from Sig. Take 4 tablets in the morningtopical steroid use and, therefore, for 5 days, then decrease by 1 tabletperiodic monitoring for a candidal on each successive day.infection is recommended. Therapy with medications,Prophylactic antifungal therapy such as systemic steroids,should be initiated in patients with a immunosuppressants, andhistory of fungal infections during immunomodulators are presentedprevious steroid administration (see to inform the clinician that such“Candidiasis”) modalities have been reportedSystemic Steroids and effective for patients suffering fromImmunosuppressants for Severe severe, persistent, recurrent aphthousCases stomatitis. Medications such asRx azathioprine, pentoxifylline,Dexamethasone (Decadron) elixir levamisole, colchicine, dapsone, and0.5 mg/5 ml thalidomide are used to treat patientsDisp. 320 ml with severe, persistent recurrentSig. As directed in writing, not to aphthous stomatitis, but should notexceed 2 continuous wk. be routinely used because of the
  • Therapeutic Management of Common Oral Lesions 9potential for serious adverse effects. necessary to eliminate a potentialClose collaboration with the source of fungal infection.patient’s physician is recommended Medication for the management ofwhen these medications are oral candidal infection should beprescribed. continued for 48 hr after the disappearance of clinical signs toCANDIDIASIS prevent immediate recurrence. It isEtiology: also important that salivary flow beCandida albicans and other species evaluated and managed to preventare opportunistic fungal organisms recurrences (see “Xerostomia”).that tend to proliferate with the use Topical Antifungal Agentsof broad-spectrum antibiotics, Rxcorticosteroids, medications that Nystatin oral suspension 100,000reduce salivary output, and cytotoxic units/mlagents. Conditions that contribute Disp. 280 mlto candidiasis include xerostomia, Sig. Rinse with 1 teaspoon (5 ml) 4poorly controlled diabetes mellitus, times a day. Rinse for 2 min andanemia, poor oral hygiene, expectorate or swallow.prolonged use of prosthetic Nystatin suspension has a highappliances, and suppression of the sugar content; therefore, good oralimmune system (i.e., AIDS or the hygiene should be reinforced. A fewside effects of some medications). drops of nystatin oral suspensionIt is important to determine the can be added to the water used forpredisposing factors prior to soaking acrylic prostheses.initiating therapy. RxClinical description: Oravig (miconazole) buccal tabletsThe disease is characterized by soft, 50 mgwhite, slightly elevated plaques Disp. 14 tabletsthat usually can be wiped away, Sig. Place one tablet above the upperleaving an erythematous area front teeth once daily for 14 days.(pseudomembranous form). Alternate sides that you place theCandidiasis also may appear as tablet.generalized erythematous, sensitive Rxareas (atrophic or erythematous Clotrimazole lozenge 10 mgform) or as confluent white areas Disp. 70 lozengesthat are adherent (hyperplastic Sig. Let 1 troche dissolve in mouthform). Angular cheilitis, which is 4–5 times a day for 14 days.also described in this chapter, is Rxfrequently associated with this oral Nystatin vaginal tablet 100,000 unitsdisease (see “Angular Cheilitis”). Disp. 56 tabletsRationale for treatment: Sig. Let tablet dissolve in mouth 4The goal of treatment is to times a day for 14 days. Do notreestablish a normal balance of oral rinse for 30 min after use.flora and improve oral hygiene. If concern exists about sugarThe disinfection of all removable content of the clotrimazole lozenges,prostheses with antifungal vaginal tablets can be substituted.denture-soaking solutions and the In general, lozenges may not beapplication of antifungal agents on well tolerated when a patient has athe tissue-contacting surfaces are dry mouth because of the inability
  • 10 Therapeutic Management of Common Oral Lesionsto dissolve this dosage form. function tests should be performedConsider a course of systemic periodically and/or monitored byantifungal therapy in these cases. the patient’s physician whenRx ketoconazole is prescribed for anNystatin ointment 100,000 units/g extended period of time. SeveralDisp. 15-g tube important drug interactionsSig. Apply a thin coat to inner have been reported withsurface of prosthesis and to the ketoconazole.affected area after each meal. RxRx Ketoconazole tablets 200 mgNystatin topical powder 100,000 Disp. 14 tabletsunits/g Sig. Take 1 tablet a day with a mealDisp. 15 g or orange juice. Do not take withSig. Apply a thin layer under the buffered medications or with gastricprosthesis after each meal. acid blockers.Rx RxKetoconazole topical cream 2% Fluconazole tablets 100 mgDisp. 15-g tube Disp. 15 tabletsSig. Apply a thin coat to inner Sig. Take 2 tablets stat, then 1 tabletsurface of prosthesis and to the a day until complete.affected area after each meal. Systemic Antifungal Agents forRx Refractory OropharyngealClotrimazole topical cream 1% CandidiasisDisp. 15-g tube RxSig. Apply a thin coat to inner Itraconazole oral solutionsurface of prosthesis and to the 10 mg/1 mlaffected area after each meal. Disp. 150 ml This product may be obtained Sig. Rinse and swallow 2 teaspoonsover-the-counter. (10 ml) 2 times a day for 14 days.Rx This antifungal medication is forMiconazole nitrate cream 2% those patients who are unresponsiveDisp. 15-g tube or refractory to fluconazole tablets.Sig. Apply a thin coat to inner Serious adverse heart and drugsurface of prosthesis and to the reactions have been associated withaffected area after each meal. itraconazole. This product may be obtainedover-the-counter.Systemic Antifungal Agents ANGULAR CHEILITISWhen topical therapy is not practical Etiology:or is ineffective, ketoconazole and Fissured lesions in the corners offluconazole are effective, well- the mouth are caused by a mixedtolerated, systemic drugs for infection of the microorganismsmucocutaneous candidiasis. They C. albicans, Staphylococcus, andshould be used with caution in Streptococcus. Predisposing factorspatients with impaired liver function include excessive licking, drooling,(i.e., with history of alcoholism or a decrease in intermaxillary space,hepatitis) and in patients taking anemia, vitamin deficiency,drugs metabolized by the immunosuppression, and ancytochrome P450 isoenzyme. Liver extension of oral infections.
  • Therapeutic Management of Common Oral Lesions 11Clinical description: This topical agent is used whenThe commissures may appear secondary bacterial and candidalwrinkled, red, fissured, cracked, or infections are suspected.crusted. Scarring may develop in Rxpersistent cases. Recurrences are Clotrimazole cream 1%common if the underlying problem Disp. 1 tubeis not managed. Sig. Apply small dab to corner ofRationale for treatment: mouth after meals and beforeIdentification and correction of bedtime. Use for 2 wk andpredisposing factors, elimination re-evaluate.of the primary and secondary This product may be obtainedinfections, and decrease of over-the-counter.inflammation are the management Rxapproaches. Recurrences are Miconazole nitrate antifungal creamcommon. 2%Rx Disp. 1 tubeNystatin/triamcinolone acetonide Sig. Apply small dab to corner ofointment 100,000 units/g 0.1% mouth after meals and beforeDisp. 15-g tube bedtime. Use for 2 wk andSig. Apply to lips after each meal re-evaluate.and at bedtime. Use for no longer This product may be obtainedthat 2 wk. over-the-counter. This is the preferred topical Rxagent when secondary candidal Bacitracin zinc 500 U; Polymyxin Binfection is suspected. Concomitant 10,000 U ointment 2% (OTC)intraoral antifungal treatment may Disp. 1 tubebe indicated. Sig. Apply small dab to corner ofRx mouth after meals and beforeKetoconazole cream 2% bedtime. Use for 1 wk andDisp. 15-g tube re-evaluate.Sig. Apply a small dab to corners This OTC topical antibacterialof mouth after meals and before agent may be associated withbedtime. Use for 2 wk and allergic reactions because of itsre-evaluate. frequent use for skin irritation. This topical agent is used whensecondary candidal infection is ACTINIC (SOLAR) CHEILITISsuspected. Concomitant intraoral Etiology:antifungal treatment may be This precancerous lesion is causedindicated. by prolonged exposure to sunlightRx that results in irreversibleHydrocortisone-iodoquinol 1%-1% degenerative changes in thecream vermilion of the lips, especially theDisp. 15-g tube lower lip.Sig. Apply small dab to the corners Clinical description:of mouth after meals and bed The normal appearance of thebedtime. Use for 2 wk and vermilion border with regularre-evaluate. vertical fissuring of a smooth surface is replaced by a white plaque or an irregular scaly surface
  • 12 Therapeutic Management of Common Oral Lesionsthat may exhibit periodic erythema that are surrounded by a slightlyand ulceration. There is often an raised white border. The primary siteindistinct margin between the of involvement is the dorsal andperioral skin and lip vermilion. ventrolateral tongue but other oralRationale for treatment: mucosal sites may be affected. ThePrevention of the solar-induced pattern of these lesions frequentlychanges is recommended. For changes and ranges from solitary tomaximum protection, concurrent multiple affected areas.use of sunscreen should be used on Rationale for treatment:the face and other sun-exposed Generally, no treatment is necessaryareas. If exposure to the ultraviolet because most patients arelight in the sun’s rays is allowed asymptomatic. When symptoms areto continue, the degenerative present, they may be associated withchanges may progress to a acidic or spicy foods and beverages.malignancy. Sunscreens with a sun In addition, tender lesions may beprotection factor (SPF) of 30 or associated with secondary candidalhigher and protection from both infection. Although there is noUVA and UVB should be well-documented treatment for thisrecommended. condition, symptoms can beRx improved temporally with topicalSeveral OTC sunscreen preparations anesthetics or coating agents. Forfor the lips are available. For those persistent and tender lesions, topicalpatients who are allergic to steroids, especially in combinationparaaminobenzoic acid (PABA), with topical antifungal agents, arePABA-free sunscreens should be the treatment of choice. Patientsrecommended. For patients with a should be informed that thishistory of lip cancer, a zinc oxide condition does not suggest a moreproduct should be used. Regular and serious disease and is notrepeated use of these products is contagious. In most cases, a biopsycritical for sun protection. is not indicated because of the pathognomonic clinical appearance.GEOGRAPHIC TONGUE (BENIGN However, solitary lesions of theMIGRATORY GLOSSITIS; lateral tongue that do not resolveERYTHEMA MIGRANS) should be biopsied to excludeEtiology: epithelial dysplasia or squamous cellAlthough a common condition, the carcinoma.etiology of geographic tongue is Rxunknown. Although not supported Nystatin/triamcinolone acetonideby large epidemiologic studies, this ointment 100,000 units/g 0.1%tongue condition has been associated Disp. 15-g tubewith atopic conditions and pustular Sig. Apply to affected area afterpsoriasis. each meal and at bedtime.Clinical description: RxGeographic tongue is a benign Lotrisone (clotrimazole/inflammatory condition caused by betamethasone dipropionate) creamdesquamation of superficial keratin 1%–0.05%and filiform papillae. It is Disp. 15-g tubecharacterized by both red, denuded, Sig. Apply to affected area afteroval to irregularly shaped patches each meal and at bedtime.
  • Therapeutic Management of Common Oral Lesions 13Rx traumatically-induced mucosalFluocinonide gel 0.05% lesions. For patients with removableDisp. 15-g tube prosthetic appliances, the applicationSig. Apply to affected areas after of an artificial saliva or oral lubricantmeals and at bedtime. gel to the tissue contact surface of the If there is a secondary candidal prosthesis reduces frictional trauma.infection, the symptoms may worsen Saliva Substituteswith a topical steroid. RxRx Sodium carboxymethylcelluloseBetamethasone valerate ointment 0.5% aqueous solution (OTC)0.1% Disp. 8 fl ozDisp. 15-g tube Sig. Use as a rinse as frequently asSig. Apply to affected areas after needed. Solution may be preparedmeals and at bedtime. by the pharmacist. If there is a secondary candidal Sipping on plain water orinfection, the symptoms may worsen crushed ice is often used with somewith a topical steroid. success in patients with dry mouth. There are several OTC salivaXEROSTOMIA (REDUCED substitutes and oral moisturizingSALIVARY FLOW AND DRY gels that are commercially availableMOUTH) and patients may need to evaluateEtiology: which product best meets theirAcute or chronic salivary flow specific needs and preferences.alterations or xerostomia may result Relief from oral dryness andfrom drug therapy, mechanical accompanying discomfort can beblockage, dehydration, emotional achieved conservatively by thestress, bacterial infection of the following:salivary glands, local surgery, • Sipping water frequently all dayavitaminosis, diabetes, anemia, longconnective tissue diseases, Sjögren’s • Letting ice melt in the mouthsyndrome, radiation therapy, viral • Restricting caffeine intakeinfections, and congenital disorders. • Avoiding mouth rinses, drinks, andClinical description: medications containing alcoholThe saliva may be ropey with a film • Avoiding tobacco productsforming over the teeth. The tissues • Humidifying the sleeping areamay be dry, pale or red, and • Coating the lips (see “Chapped/atrophic. The tongue may be devoid Cracked Lips”)of papillae, atrophic, fissured, and Saliva Stimulantsinflamed. Multiple carious lesions The use of sugar-free gum, candy, ormay be present, especially at the mints is a conservative method togingival margin and on exposed root temporarily stimulate salivary flowsurfaces. The quantity and quality of in patients with medication-inducedsaliva may be altered. xerostomia or with salivary glandRationale for treatment: dysfunction. Patients should beSalivary stimulation or replacement cautioned against using productstherapy is important to keep the that contain sugar or have a low pH.mouth moistened and comfortable Rxand for the prevention of caries, Salagen, generic (pilocarpine HCl)candidal infection, and tablets 5 mg
  • 14 Therapeutic Management of Common Oral LesionsDisp. 90 tablets RxSig. Take 1 tablet 3 times a day, PreviDent 5000 Plus, generic30 min prior to meals. (neutral NaF) 1.1% dental cream Dosage may be titrated to 2 Disp. 1 tubetablets (10 mg) 3 times a day. An Sig. Place 1-inch ribbon on aalternative is 1 tablet (5 mg) 4 times toothbrush; brush teeth for 2 mina day. twice daily and expectorate. AvoidRx rinsing or eating for 30 minEvoxac (cevimeline HCl) capsules following application.30 mg In general, the use of stannousDisp. 90 capsules fluoride gels is not recommendedSig. Take 1 capsule 3 times a day. because of the high acidity and Some patients benefit from lower fluoride concentration oftaking 1 capsule 4 times a day. 1000 ppm, in contrast to the sodiumRx fluoride gels that have a neutral pHUrecholine, generic (bethanechol and contain 5000 ppm. Also,chloride) tablets 25 mg stannous fluoride gels may etchDisp. 90 tablets ceramic and glass ionomerSig. Take 1 tablet 3 to 5 times a day. restorations and cause extrinsic tooth Not FDA-approved for this staining.indication. Note that FDA regulations have Cholinergic drugs should be limited the size of bottles of fluorideprescribed in consultation with the because of toxicity, if ingested bypatient’s physician because of the infants. Because most preparationsside effects. The pilocarpine and do not come in childproof bottles,cevimeline dosage should be the sizes of topical fluorideadjusted to increase saliva while preparations vary; 24 ml isminimizing the adverse side effects approximately a 2-wk supply for(sweating, stomach upset, etc.). application to a full dentition inPatients should be warned that there custom carriers.is a wide range of sensitivity and Reduced salivary flow providesthat the adverse side effects may an excellent environment foroutweigh the benefit of increased overgrowth of C. albicans. Thesalivation. If this occurs, then the patient is likely to require treatmentcholinergic drug should be for candidiasis, along with treatmentdiscontinued. for dry mouth (see “Candidiasis”).Caries Prevention In a dry oral environment, plaqueRx control becomes more difficult.PreviDent, others (neutral NaF) Scrupulous oral hygiene is essential1.1% gel to prevent dental and periodontalDisp. 1 tube disease.Sig. Place 1-inch ribbon on atoothbrush; brush teeth for 2 min LICHEN PLANUSdaily and expectorate. Avoid rinsing Etiology:or eating for 30 min following Lichen planus is an immunologicallyapplication. mediated, chronic, mucocutaneous As an alternative, place a 1-inch disorder. Although many casesribbon in a custom tray; apply for develop without a known cause,5–10 min daily. some lesions are triggered by
  • Therapeutic Management of Common Oral Lesions 15emotional stress, hypersensitivity to when these medications aredrugs, dental products, foods, and a prescribed. These modalities aregenetic predilection. beyond the scope of the clinicalClinical description: experience of general dentists, andLichen planus varies in clinical referral to a dental specialist or toappearance. Oral forms of this an appropriate physician isdisorder include lacy white lines recommended.representing Wickham’s striae Topical Steroids(reticular), an erythematous form Prolonged use of topical steroids(atrophic), and an ulcerating form (for a period longer than 2 wk ofthat often is accompanied by striae continuous use) may result inperipheral to the ulceration (erosive). mucosal atrophy and secondaryThe lesions are commonly found on candidiasis and may increase thethe buccal mucosa, gingiva, and potential for systemic absorption.tongue, but they can be found on The prescribing of antifungalthe lips and palate. Lichen planus therapy with steroids may belesions are chronic and also may necessary. Therapy with topicalaffect the skin. The dental and steroids, once the lichen planus ismedical literature remains under control, should be tapered tocontroversial as to whether lichen alternate day therapy or lessplanus undergoes malignant depending on control of thetransformation. Therefore, any disease and the tendency forpersistent or refractory lesion should recurrence.be biopsied to establish a diagnosis Rxand to rule out a malignancy. Fluocinonide gel 0.05%Rationale for treatment: Disp. 30-g tubeSince this is a chronic disease, Sig. Coat the lesion with a thin filmmanagement of the disease focuses after each meal and at bedtime.on providing oral comfort, if the Rxlesions are symptomatic. Dexamethasone elixir, solutionSystemic and local relief with 0.5 mg/5 mlantiinflammatory and Disp. 240 mlimmunosuppressant agents is Sig. Rinse with 1 teaspoon (5 ml)indicated. Identification of any for 2 min 4 times a day anddietary component, dental product, expectorate. Discontinue whenor medication (lichenoid drug lesions become asymptomatic.reaction) should be undertaken to Other topical steroidensure against a hypersensitivity preparations (cream, gel, rinse,reaction. Treatment or prevention of ointment) are available. In general,a secondary fungal infection with a creams are not used intraorallysystemic antifungal agent also because of very poor mucosalshould be considered. adherence. These topical steroids Therapies with steroids and come with a warning that they areimmunomodulating drugs are for external use only. However,presented to inform the clinician several of these agents have beenthat such modalities are available. used successfully for managingBecause of the potential for side lichen planus. Examples of some ofeffects, close collaboration with the the topical steroid medications arepatient’s physician is recommended listed below according to potency.
  • 16 Therapeutic Management of Common Oral LesionsExcept when lichen planus occurs depending on disease control andon the lips, low-potency topical tendency to recur.steroids are generally not effective Systemic Steroids andfor intraoral lesions. Immunosuppressants forSuper-High Potency: Severe Cases Betamethasone dipropionate Rx (augmented) 0.05%, gel, Dexamethasone elixir or solution ointment 0.5 mg/5 ml Clobetasol propionate 0.05%, gel, Disp. 320 ml ointment Sig. As directed in writing not to Halobetasol propionate 0.05%, exceed 2 continuous wks. ointment 1. For 3 days, rinse with 1High Potency: tablespoonful (15 ml) 4 times a Betamethasone dipropionate day and swallow. Then, 0.05%, gel, ointment 2. For 3 days rinse with 1 Fluocinonide 0.05%, gel, teaspoonful (5 ml) 4 times a day ointment and swallow. Then, Dexamethasone 0.5 mg/5 ml oral 3. For 3 days, rinse with 1 solution, elixir teaspoonful (5 ml) 4 times a day Desoximetasone 0.05%, gel; and swallow every other time. 0.25% ointment Then,Medium Potency: 4. Rinse with 1 teaspoonful (5 ml) 4 Betamethasone valerate 0.1%, times a day and expectorate. ointment Rx Triamcinolone acetonide 0.1%, Prednisone tablets 10 mg ointment Disp. 26 tabletsLow Potency: Sig. Take 4 tablets in the morning Alclometasone dipropionate for 5 days, then decrease by 1 tablet 0.05%, ointment on each successive day. Hydrocortisone acetate 1%, gel, Rx ointment Prednisone tablets 5 mgProlonged use of topical steroids Disp. 40 tabletsmay result in mucosal atrophy and Sig. Take 5 tablets in the morningsecondary candidiasis and increase for 5 days, then 5 tablets in thethe potential for systemic morning every other day until gone.absorption. It may be necessary to If oral discomfort recurs, theprescribe antifungal therapy with patient should return to the cliniciantopical steroids. The oral cavity for reevaluation.should be monitored for emergence Rxof fungal infection in patients who Protopic (tacrolimus) ointment 0.1%are placed on therapy. Prophylactic Disp. 30-g tubeantifungal therapy should be Sig. Apply to the affected sites twiceinitiated in patients with a history daily. Use for 2 wk and re-evaluate.of fungal infection with previous Rxsteroid administration (see Protopic (tacrolimus) ointment“Candidiasis”). Therapy with topical 0.03%steroids, once the lichen planus is Disp. 30-g tubeunder control, should be tapered to Sig. Apply to the affected sites twicealternate-day therapy or less daily. Use for 2 wk and re-evaluate.
  • Therapeutic Management of Common Oral Lesions 17 Many studies suggest that oral when the gingival tissues arelichen planus has an intrinsic affected. Patients with gingivalproperty predisposing to malignant involvement are at increased risk fortransformation. However, the gingival recession and periodontitis.etiology is complex, with interactionamong genetic, infectious agents, PEMPHIGUS VULGARIS ANDenvironmental, and lifestyle factors. MUCOUS MEMBRANEProspective studies have PEMPHIGOIDdemonstrated that lichen planus Pemphigus vulgaris and mucouspatients have a slightly increased membrane pemphigoid are relativelyrisk to develop oral squamous cell uncommon lesions. They should becarcinoma. All patients exhibiting suspected when chronic, multiplelichen planus, intraorally, oral ulcerations and a history of oralparticularly those who have had the and skin blisters exist. Often, theyulcerative form, should receive may occur only in the mouth.periodic follow-up. Diagnosis is based on history Therapy with medications and on microscopic andsuch as systemic steroids, immunofluorescence studies of aimmunosuppressants, and biopsied sample adjacent to a lesion.immunomodulators is presented to Etiology:inform the clinician that such Both of these chronicmodalities have been reported mucocutaneous diseases areeffective for patients suffering from autoimmune disorders witherosive lichen planus. Medications autoantibodies against antigenssuch as azathioprine, mycophenolate appearing in different areas of themofetil, tacrolimus surface epithelium or lining mucosa.hydroxychloroquine sulfate, In pemphigus vulgaris, the antigensacitretin, and cyclosporine are used are within the epitheliumto treat patients with severe (desmosomes), whereas inpersistent erosive lichen planus, but pemphigoid, the antigens are locatedshould not be routinely used because at the base of the epithelium in theof the potential for side effects. hemidesmosomes.Close collaboration with the Clinical description:patient’s physician is recommended In pemphigus vulgaris, the lesionwhen these medications are may stay in one location for a longprescribed. period of time with small placid Topical tacrolimus has been bullae. The bullae may rupture,associated with neoplastic disease, leaving areas of ulceration.such as lymphoma and skin cancers, Approximately 80%–90% of patientsand, therefore, should not be used have oral lesions. The oralindiscriminately for long periods of manifestations are the first signstime. This medication is indicated of the disease in approximatelyfor patients who cannot tolerate or two-thirds of patients. All parts ofare refractory to topical or systemic the mouth may be involved. Thesteroid therapy. bullae rupture almost immediately in In addition, periodic scaling and the mouth, but may stay intact forprofessional dental cleanings every some time on the skin. One of the3 to 4 months, are important for classic signs, the Nikolsky signcontrolling this chronic disease (blister formation induced with
  • 18 Therapeutic Management of Common Oral Lesionsgentle rubbing of an affected Therapy with medicationsmucosal site), is positive in such as systemic steroids,pemphigus, but is not immunosuppressants, andpathognomonic, because it is also immunomodulators are presentedpositive in other disorders. Because to inform the clinician that suchthe vesicles or bullae are modalities have been reportedintraepithelial, they often are filled effective for patients suffering fromwith clear fluid. Microscopically, vesiculobullous disorders such asTzanck cells or acantholytic cells pemphigus vulgaris and mucousare observed within the spinous cell membrane pemphigoid. Therapieslayer of the epithelium. such as dapsone, methotrexate, In pemphigoid, the cleavage or mycophenolate mofetil,split is beneath the epithelium, cyclosporine, or niacinamide withresulting in bullae that are often tetracycline are used to treat patientsblood filled. Mucous membrane with vesiculobullous disorders suchpemphigoid is usually limited to as pemphigus vulgaris and mucousthe oral cavity, but some patients membrane pemphigoid, but theyhave ocular lesions (symblepharon) should not be routinely used becausethat must be evaluated by an of the potential for serious adverseophthalmologist. The gingiva is the effects. Close collaboration with themost common oral site involved. patient’s physician is recommendedPemphigoid may appear clinically as when these medications area red, nonulcerated or ulcerated prescribed.gingival lesions with a positive Rx:Nikolsky sign. Topical and Systemic Steroids (SeeRationale for treatment: Lichen Planus)Because both pemphigus andpemphigoid are autoimmune ORAL ERYTHEMA MULTIFORMEdisorders, the primary treatment is Etiology:topical or systemic steroids or other Oral erythema multiforme is aimmunomodulating drugs. Custom blistering and ulcerativetrays can be used to localize topical mucocutaneous disease that issteroid medications on the gingival immunologically mediated. It cantissues (occlusive therapy). Because occur at any age. Drug reactions tothey can resemble other ulcerative- medications such as penicillin andbullous diseases, a biopsy is sulfonamides may play a role innecessary for a definitive diagnosis. some cases. In a few patients whoSpecimens should be submitted develop oral erythema multiforme, afor light microscopic and herpetic infection occursimmunofluorescence studies. immediately before the onset ofBecause of the potentially serious clinical signs. Other infectiousnature of these diseases, referral to diseases have also been implicated.a specialist in oral medicine, Clinical description:dermatology, and ophthalmology Signs of oral erythema multiformemust be considered. When eye include “blood-crusted” lips,lesions are present, an “targetoid” or “bull’s-eye” skinophthalmologist must be lesions, and a nonspecific mucosalconsulted immediately to prevent erythema, ulceration, and necrosis.blindness. The name multiforme is used
  • Therapeutic Management of Common Oral Lesions 19because its appearance may take Rxdifferent forms. A severe form of Diphenhydramine hydrochlorideerythema multiforme is called liquid 12.5 mg/5 ml/lidocaineStevens-Johnson syndrome, viscous 2% oral solution/aluminumor erythema multiforme major. hydroxide, magnesium hydroxideErythema multiforme, as a skin oral suspensiondisease, occurs most frequently Compound to a 1:1:1 mixture bybecause of an allergic reaction. volume.Rationale for treatment: Disp. 200 mlTreatment is primarily directed at Sig. Shake well before use. Rinsepatient comfort, using topical with 1–2 teaspoons (5–10 ml) everyanesthetics and coating agents. 3– 4 hr for 1 min and spit outBecause of the possible relationship excess. Store suspension at roomof oral erythema multiforme with temperature.herpes simplex virus, suppressive It is compounded by pharmacyantiviral therapy may be indicated to and stable for approximately 60 days.prevent lesion recurrences. Patients Do not use 2% lidocaineshould be questioned carefully about hydrochloride in children who cannota previous history of recurrent expectorate because of potential forherpetic infections and prodromal aspiration or swallowing.symptoms that might have preceded Rxthe onset of erythema multiforme. It Carafate, generic (sucralfate)is also important to take a thorough suspension 1 g/10 mldrug history to determine if that is Disp. 200 mlthe cause. Sig. Rinse with 1 teaspoon (5 ml) 4Topical Anesthetics and times a day. Rinse for 1 min and spitCoating Agents out excess.Rx In children younger than 6 yr,Diphenhydramine hydrochloride oral who cannot expectorate, the amountsolution 12.5 mg/5 ml mixed with should be limited to 0.5 g, fouraluminum hydroxide, magnesium times a day (2 g/day) in case thehydroxide oral suspension suspension is swallowed. Safety and Compound to a 1:1 mixture by efficacy has not been established involume children.Disp. 200 ml RxSig. Rinse with 1–2 teaspoons Children’s Benadryl Allergy Liquid,(5–10 ml) every 2 to 4 hr for 1 min; others, (diphenhydramineswish and spit out. hydrochloride) oral solution Although these medications are 12.5 mg/5 ml (OTC)OTC, it is recommended that a Disp. 8 oz bottlepharmacist compound this oral Sig. Rinse with 1 teaspoon (5 ml)suspension. Examples of aluminum for 2 min every 2– 4 hr and spit outhydroxide, magnesium hydroxide excess.oral suspension are Maalox and If swallowed, for adolescents andMylanta—they are common OTC adults, the maximum amount isbrands and are available in a number 300 mg in 24 hr. For childrenof flavors. Children younger than 6–12 yr, the maximum is 150 mg in6 yr should not swallow this oral 24 hr. Children younger than 6 yrsuspension. should not swallow this drug.
  • 20 Therapeutic Management of Common Oral LesionsRx should be idealized, and mechanicalSucrets (dyclonine HCl) throat irritation should be ruled out.lozenges (OTC) Clinical description:Disp. 1 package The tissue covered by the appliance,Sig. Slowly dissolve one lozenge in especially if the appliance is mademouth every 2 hr as needed for pain. of acrylic, is erythematous andDo not take more than 10 lozenges a smooth or granular. It may be eitherday. asymptomatic or associated with a The strength of dyclonine HCl burning sensation.ranges from 3 mg (maximum Rationale for treatment:strength) to 1.2 mg for children’s Therapy is directed towardformula. controlling all possible causes andSuppressive Antiviral Therapy improving oral comfort. If therapy isRx ineffective, consider underlyingZovirax, generic (acyclovir) tablets systemic conditions such as diabetes400 mg mellitus and poor nutrition.Disp. 60 tablets Treatment:Sig. Take 1 tablet 2 times daily. Take 1. Institute appropriate antifungaldrug for up to 12 months and medication (see “Candidiasis”);re-evaluate. 2. Improve oral and applianceRx hygiene. The patient may have toValtrex, generic (valacyclovir) leave the appliance out fortablets 1 g extended periods of time andDisp. 30 tablets should be instructed to leave theSig. Take 1 tablet a day. Take drug denture out overnight. Thefor up to 12 months and re-evaluate. appliance should be soaked in a Because of the long-term use of commercially available denturethese antiviral agents, patients may cleanser or soaked in a 1%be best monitored by a dental sodium hypochlorite solution (1specialist or physician. teaspoon of sodium hypochlorite in a denture cup of water) forDENTURE SORE MOUTH 15 min and thoroughly rinsed forEtiology: at least 2 min under runningDiscomfort under oral prosthetic water;appliances may result from 3. Reline, rebase, or construct a newcombinations of candidal infections, appliance;poor denture hygiene, an occlusal 4. Apply an artificial saliva or oralsyndrome, overextension, or lubricant gel to the tissue contactexcessive movement of the surface of the denture to reduceappliance. This condition may be frictional trauma.erroneously attributed to an allergy If all the above actions fail toto denture material, which is a rare control symptoms, a biopsy or shortoccurrence. This condition may trial of topical steroid therapy can berepresent a pressure neuropathy due used to rule out contact mucositisto advanced atrophy of the alveolar (an allergic reaction to denturebone and trauma to the nerves materials). If a therapeutic trial failsemanating from the mental foramen to resolve the condition, a biopsyand the incisive foramen. The should be performed to establish theretention and fit of the denture diagnosis.
  • Therapeutic Management of Common Oral Lesions 21BURNING MOUTH SYNDROME Disp. 1 bottleEtiology: Sig. Rinse with 1–2 teaspoonsBurning mouth syndrome is a (5–10 ml) for 2 min before eachcommon dysesthesia that has been meal and spit out.associated with a variety of local When the burning mouth isand systemic factors. Current considered psychogenic orliterature supports a neurogenic idiopathic, a tricyclic antidepressantcause with psychological or benzodiazepine in low dosescomponent. However, other exhibits the properties of analgesiaconditions, such as xerostomia, and sedation and frequently iscandidiasis, referred pain from the successful in reducing or eliminatingtongue musculature, chronic the symptoms after several weeks orinfections, gastrointestinal reflux months. The dosage is adjusteddisease, medications, blood according to patient reaction anddyscrasias, nutritional deficiencies, clinical symptoms. The followinghormonal imbalances, and allergic systemic therapies for burningand inflammatory disorders, must mouth disorder are best managedalso be considered. by appropriate specialists or theClinical description: patient’s physician, due to theBurning mouth syndrome is protracted nature of this therapy.characterized by persistent Rxtenderness of usually the tongue, Clonazepam orally disintegratingfollowed by the lips and anterior hard tablets 0.25 mgpalate in the absence of clinical signs. Disp. 60 tabletsRationale for treatment: Sig. Take 1 tablet nightly, then adjustIf an underlying local or systemic dose after 7 days.cause is not identified, then This therapy probably is besttreatment approaches focus on managed by an appropriate specialistreducing discomfort. Either topical or the patient’s physician at thisanesthetics or mood-altering drugs time. Due to the sedative affects,are prescribed. patients may wish to take thisTreatment: medication only at night andIt is important to reassure the patient increase the dosage to 2 tabletsthat this disorder is not infectious (0.50 mg). Other patientsand does not progress to a malignant experience more improvementcondition. On the basis of the when they take 1–2 tablets 3 timeshistory, physical evaluation, and a day.specific laboratory studies, it is Rximportant to exclude all local and Amitriptyline tablets 25 mgsystemic causes. Minimal blood Disp. 50 tabletsstudies should include complete Sig. Take 1 tablet at bedtime forblood count and differential, fasting 1 wk, then increase to 2 tabletsglucose, iron, ferritin, folic acid, and every night for the next week.vitamin B12 levels, and thyroid Increase to 3 tablets every nightprofile (TSH, T3, T4). after 2 wk and maintain at thatRx dosage or titrate as appropriate.Benadryl Children’s Allergy Rx(diphenhydramine) solution Chlordiazepoxide capsules 5 mg12.5 mg/5 ml (OTC) Disp. 50 capsules
  • 22 Therapeutic Management of Common Oral LesionsSig. Take 1 capsule 3 times a day, xerostomia, and secondary candidalthen adjust after 1 wk to 2 capsules infection.3 times a day as appropriate. Clinical description:Rx The surface of the vermilion isXanax, generic (alprazolam) tablets rough, scaly, and peeling and may0.25 mg be ulcerated with bleeding andDisp. 50 tablets crusting. In severe and chronicSig. Take 1 tablet 3 times a day. cases, the lips are tender, slightly The rationale for use of tricyclic swollen, and deep fissures andantidepressants and other scarring may be detected.psychotropic drugs should be Rationale for treatment:thoroughly explained to the patient, An interrupted and chronicallyand the patient’s physician should be inflamed surface is at increased riskconsulted. These medications have for scarring and secondary infection.a potential for addiction and Eliminating the cause, especiallydependence. if the chapped lips are due to aRx factitial habit or contact allergy, isTabasco sauce (capsaicin) (OTC) important. A protective lipDisp. 1 bottle emollient, a topical antiinflammatorySig. Place one part Tabasco sauce in agent with or without antimicrobial2 to 4 parts of water. Rinse with 1 agents, aids in the healing of theteaspoon (5 ml) 4 times a day and lips, but recurrences are common.expectorate. RxRx Aquaphor Healing Ointment, othersZostrix, generic (capsaicin) cream (OTC)0.025% (OTC) Disp. 1 tubeDisp. 1 tube Sig. Apply to lips after each mealSig. Apply sparingly to affected and at bedtime.site(s) 4 times a day. Avoid flavored products because Wash hands after each they tend to promote increasedapplication and do not use near the licking of the lips. Althougheyes. medicated products may be soothing Topical capsaicin may produce initially, they should not be useda burning sensation in some because they can cause increasedindividuals. An increase in drying of the lips. Some patientsdiscomfort for a 2- to 3-wk period respond better to lanolin cream orshould be anticipated. ointment than petroleum-based products.CHAPPED OR CRACKED LIPS Rx(EXFOLIATIVE CHEILITIS) Nystatin/triamcinolone acetonideEtiology: ointment 100,000 units/g 0.1%Chapped lips are due to increased Disp. 15-g tubekeratinization with subsequent Sig. Apply to lips after each mealdesquamation of the vermilion and at bedtime. Use for no longerborder that is often secondarily that 2 wk.inflamed. Repeatedly licking, Rxpicking, and biting the lips are Triamcinolone acetonide ointmentaggravating factors. Other causes 0.1%include eczema, contact allergies, Disp. 15-g tube
  • Therapeutic Management of Common Oral Lesions 23Sig. Apply to lips after each meal enlargements originate in theand at bedtime. Use for no longer interdental papillae.that 2 wk. Rationale for treatment:Rx Local factors, such as plaque andBetamethasone valerate ointment calculus accumulation, contribute to0.1% secondary inflammation and theDisp. 15-g tube hyperplastic process. This furtherSig. Apply to lips after each meal interferes with plaque control.and at bedtime. Use for no longer Specific drugs tend to deplete serumthan 2 wk. folic acid levels, which result in Prolonged use of corticosteroids compromised tissue integrity.can result in thinning of the tissue, Treatment:so their use should be closely Management approaches consists ofmonitored and for a limited period (1) meticulous plaque control; (2)of time. For maintenance, the gingivectomy or other gingivalfrequent application of lip care surgery when indicated; (3) whenproducts that are hypoallergenic possible, replace the causative drugshould be suggested. Avoid products with an equivalent substitute; andwith desiccants, such as phenols and (4) test for serum folate level andalcohols and those with flavoring supplement folic acid, if necessary.agents. In severe cases with swelling Use of folic acid rinse, topicalof the lips, systemic antibiotics may antimicrobial mouth rinse, andbe needed, along with topical agents. systemic antibiotics may be effective in some cases. Specifically,DRUG-INDUCED GINGIVAL metronidazole and azithromycinOVERGROWTH have been successful in resolvingEtiology: some cases.Certain drugs, such as phenytoin Rxsodium, calcium channel blocking Folic acid oral rinse 1 mg/mlagents (nifedipine, diltiazem, Disp. 16 ozverapamil, amlodipine and others), Sig. Rinse with 1 teaspoonful (5 ml)and cyclosporine therapy are known for 2 min twice a day andto predispose some individuals to expectorate.persistent gingival enlargement. RxChronic hyperplastic gingivitis, Peridex, PerioGard, genericsgingival fibromatosis, and (chlorhexidine gluconate) oral rinsegranulomatous gingivitis should be 0.12%ruled out by clinical history, family Disp. 16 ozhistory, biopsy, and other indicated Sig. Rinse with 15 ml twice dailylaboratory tests. for 30 seconds and expectorate.Clinical description: Rinse after breakfast and beforeThe gingival tissues, especially in bedtime.the anterior region, are firm,stippled, nontender, and enlarged. TASTE DISORDERSDepending on the degree of Etiology:inflammation, the gingival tissues Taste acuity may be affected byvary from normal in color to dark medications and by neurologic andred and hemorrhagic. Especially in physiologic changes. Clinicaldrug-induced examples, the examination and diagnostic
  • 24 Therapeutic Management of Common Oral Lesionsprocedures may identify potential Disp. 100 capsulescauses such as nasal and sinus Sig. Take 1 capsule with food ordisease, viral infection, oral after meals once a day for 1 month.candidiasis, neoplasia, malnutrition, Rxmetabolic disorders, trauma, illicit Zinc acetate capsules 50 mg (OTC)drug use, autoimmune diseases Disp. 100 capsulesaffecting salivary glands, and Sig. Take 1 capsule a day with foodradiation sequelae. In addition, or after meals for 1 month.individuals with anxiety disorders Rxand depression may complain Zinc gluconate tablets 50 mg (OTC)about changes in taste. Laboratory Disp. 100 capsulestests for trace elements may be Sig. Take 1 capsule a day with foodnecessary to identify any existing or after meals for 1 month.deficiencies.Rationale for treatment: MANAGEMENT OF PATIENTSA reduction in salivary flow may RECEIVING ANTINEOPLASTICconcentrate the electrolytes in the AGENTS AND RADIATIONsaliva, resulting in a salty or metallic THERAPYtaste (see “Xerostomia”). Numerous Etiology:medications have dysgeusia as a Cancer chemotherapy and radiationreported side effect. Antibiotics, to the head and neck cause directantihypertensives, antifungals, and and indirect effects on the oralantiretrovirals are examples of tissues. Chemotherapy results inclasses of drugs that have been direct cytotoxic effects that mayimplicated. Rarely, a deficiency of result in mucositis and ulceration ofzinc has been associated with a loss the mucosa. In addition, there areof taste and smell sensation. To indirect effects of myelosuppressionprevent deficiency, the current resulting in anemia,recommended dietary allowance for thrombocytopenia, and leucopenia.zinc is 10 mg for men and 12 mg Both local and disseminatedfor women. Additional zinc infection may develop includingsupplementation should be reserved fungal, viral, and bacterialfor individuals with true deficiency infections. Besides odontogenic andstates and in consultation with the periodontal infections, candidal andphysician. recurrent herpes simplex infectionsTo Ensure Dietary Allowance are among the most commonfor Zinc infections in the mouth. BleedingRx problems, especially due toZ-BEC tablets (OTC) decreased platelets, may result inDisp. 60 tablets mucosal and gingival bleeding. TheSig. Take 1 tablet daily with food or use of intravenous bisphosphonatesafter meals. may increase the risk for This supplement also contains osteonecrosis of the jaws. Thevitamin B complex, vitamin C, and effects of radiation treatmentVitamin E, along with zinc. directly affect the targeted tissues.For Zinc Deficiency in Patients When the head and neck is thewith Proven Zinc Deficiency targeted site, mucositis, tasteRx alterations, salivary glandZinc sulfate capsules 220 mg (OTC) hypofunction, dysphagia,
  • Therapeutic Management of Common Oral Lesions 25osteoradionecrosis, trismus, Mouth Rinses (See “Xerostomia”)periodontal disease, and dental Rxcaries are potential complications. Alkaline saline (salt/bicarbonate)Clinical description: mouth rinseDue to the wide range of potential Disp. Mix 1 4 teaspoon each ofcomplications, the oral findings are salt and baking soda in 16 oz glassdiverse in appearance. The more of water.common findings include red, Sig. Rinse for 1 min with copiousinflamed, and/or ulcerated mucosa amounts at least 5 times a day andand chapped lips. The saliva may be spit out.viscous or absent. If too irritating, may switch to 1Rationale for treatment: 2 teaspoon baking soda in 16 oz ofThe treatment of these patients is water.symptomatic and supportive. It Rxshould be aimed at patient comfort Caphosol (calcium phosphate)and education, maintenance of solutionproper nutrition and oral hygiene, Disp. 60 ampulesand prevention of opportunistic Sig. Mix 2 ampules in a clean glassinfection. Frequent monitoring and and swirl contents of glass to mix.close cooperation with the patient’s Rinse and gargle with 1 2 of thephysician are important. In order to solution for 1 min and expectorate.prevent potentially serious oral Repeat with the remaining solution.complication, all patients who Do not eat or drink for 15 min afterundergo chemotherapy and/or use. Use up to 4 times a day.radiation therapy should have a This solution may be helpful forthorough oral evaluation to eliminate patients with both dry mouth andany source of infection. In patients mucositis.who will receive radiation treatment Gingivitis Controlto the head and neck region, oral Rxsurgical procedures should be Peridex, PerioGard, genericperformed 14 days prior to the (chlorhexidine gluconate) rinsetreatment for optimal healing. Oral 0.12%hygiene is of paramount importance Disp. 16 ozprior to, during, and after radiation Sig. Rinse with 1 2 oz (15 ml) twicetreatment. a day for 1 min and spit out. Avoid The oral discomfort may be rinsing or eating for 30 minrelieved by periodically using following treatment. Rinse afterneutral or saline mouth rinses and breakfast and at bedtime.topical anesthetics and coating In xerostomic patients,agents. Artificial saliva and mouth chlorhexidine rinse should be usedmoisturizing gels aid in reducing concurrently with artificial saliva tooral dryness. Antifungal and provide the needed protein-bindingantiviral agents are needed to agent for efficacy and substantivity.manage specific infections. The use Because of the alcohol content, thisof fluorides is recommended for rinse may be too irritating to use.caries control and root sensitivity. In A pharmacy can compound ansome patients, chlorhexidine rinses alcohol-free, 2% aqueous solution.help control plaque when oral It is important to note that bothhygiene is poor. toothpaste and nystatin reduce the
  • 26 Therapeutic Management of Common Oral Lesionseffectiveness of chlorhexidine rinse, Disp. 200 mlso it is important to allow 30 min Sig. Rinse with 1–2 teaspoonsbefore using these agents. (5–10 ml) every 2– 4 hr for 1 min;Caries Control (See “Xerostomia”) swish and spit out.Rx Although these medications arePreviDent, others (neutral NaF) gel OTC, it is recommended that a1.1% pharmacist compound this oralDisp. 24 ml suspension.Sig. Place a thin ribbon in custom Rxtrays. After inserting trays in the Diphenhydramine hydrochloridemouth, bite on them to create a liquid 12.5 mg/5 ml/lidocainepumping action. Keep in the mouth viscous 2% oral solution/aluminumfor 5–10 min and spit out excess. hydroxide, magnesium hydroxideAvoid rinsing or eating for 30 min oral suspension.after treatment. Compound to a 1:1:1 mixture by An alternative is to brush on volumeNaF gel twice daily for 2 min and Disp. 200 mlspit out excess. Both of these Sig. Shake well before use. Rinsetechniques should be supplemented with 1–2 teaspoons (5–10 ml) everywith conventional 1100 ppm sodium 4 hr for 1 min and spit out excess.fluoride toothpaste twice daily. Store suspension at room The use of SnF2 gels such as temperature.Gel-Kam is not recommended It is compounded by pharmacybecause of the high acidity and and is stable for approximately 60lower fluoride concentration of days. Do not use 2% lidocaine1000 ppm, in contrast to the NaF hydrochloride in children or adultsgels that have a neutral pH and who cannot expectorate because ofcontain 5000 ppm. potential for aspiration orTopical Anesthetics swallowing.Rx RxLidocaine hydrochloride viscous Children’s Benadryl Allergy Liquid,solution 2% others, (diphenhydramineDisp. 200 ml hydrochloride) oral solutionSig. Rinse with 2–3 teaspoons 12.5 mg/5 ml (OTC)(10–15 ml) every 3– 4 hr for 1 min; Disp. 8 oz bottleswish and spit out. Sig. Rinse with 1–2 teaspoons Do not use 2% lidocaine (5–10 ml) for 2 min every 2– 4 hrhydrochloride in children or adults and spit out excess.who cannot expectorate because of If swallowed, for adolescents andpotential for aspiration or adults, the maximum amount isswallowing. 300 mg in 24 hr. For childrenRx 6–12 yr, the maximum is 150 mgDiphenhydramine hydrochloride in 24 hr. Children younger thanoral solution 12.5 mg/5 ml mixed 6 yr should not swallow thiswith aluminum hydroxide, drug.magnesium hydroxide oral Rxsuspension Sucrets (dyclonine HCl) throat Compound to a 1:1 mixture by lozenges (OTC)volume Disp. 1 package
  • Therapeutic Management of Common Oral Lesions 27Sig. Slowly dissolve one lozenge in Saliva Stimulantsmouth every 2 hr as needed for pain. (See “Xerostomia”)Do not take more than 10 lozenges aday. Bibliography The strength of dyclonine HCl Neville BW, Damm DD, Allen CM,ranges from 3 mg (maximum Bouquot JE, editors: Oral andstrength) to 1.2 mg for children’s maxillofacial pathology, ed 3, St. Louis, 2009, Saunders, Elsevier.formula. Rankin KV Jones DL, Redding SW, , In general, when topical editors: Oral health in canceranesthetics are used, patients should therapy. A guide for health carebe warned about a reduced gag professional, ed 3, Dallas, TX, 2008,reflex and the need for caution while Dental Oncology Education Program.eating and drinking to avoid possible Siegel MA, Silverman S Jr, Sollecito TP,airway compromise. Allergies are editors: American Academy of Oralrare but may occur. Medicine clinician’s guide. Treatment of common oral conditions, ed 6,Antifungal Agents Hamilton, Ontario, 2006, BC Decker.(See “Candidiasis”)