Exam 2

Pharmacotherapy of Minor Oral Mucosal Injury/Irritation: when to refer patient?

-Sx persist after 7 days treatment or 10 days of initial injury -Sx worsen during treatment -Sx of infection develop (fever, redness, swelling)

Cheilitis: prevention and treatment - 5 steps (Refer if severely cracked or swollen OR doesn't improve with above steps)

1. Avoid licking/peeling/biting/exfoliating lips or surrounding skin 2. Protect lips with quality lip balm (+ sunscreen if outside) prior to lipstick/gloss • Ingredients a. Best = beeswax or petroleum jelly b. Dimethicone: seals off cracks in lips • Apply 6-8 coats during day 3. Hydrate: drink water, humidify air 4. Avoid irritants 5. Breathe through nose rather than mouth

Minor Oral Mucosal Injury/Irritation: goals of therapy

1. Control discomfort 2. Aid healing 3. Prevent secondary bacterial infection

Cheilitis: Etiology

1. Dry or cold weather 2. Excessive sun exposure 3. Frequent licking of lips 4. Food sensitivity 5. Personal care products: lip balm, lipstick, toothpaste, mouthwash, sunscreen 6. Medications: retinoids; Health conditions: eczema, Crohn's disease, nutritional deficiencies,sarcoidosis

Tooth hypersensitivity (oral pain): etiologies

1. Exposure of dentin (erosion, broken tooth, faulty tooth repair) 2. Injury to mouth or lips or with RAS or herpes simplex labialis 3. nerve pain of face, facial herpes zoster, cluster headaches

Goals of therapy - RAS

1. Relieve pain & irritation 2. Heal lesions 3. Be able to eat/drink & do usual oral care 4. Prevent secondary infection 5. Prevent recurrence

Tooth hypersensitivity (oral pain): goals of therapy

1. Repair damaged tooth surface via appropriate toothpaste 2. Correct inappropriate toothbrushing technique

Tooth hypersensitivity (oral pain): dentin/tooth hypersensitivity

2 aspects for development • Exposed dentin • Dentin tubules open to oral cavity on one side and tooth pulp on the other side Symptoms: short & stabbing/sharp (NOT aching) • Thermal, chemical (acid) or physical (pressure) stimulus to exposed dentin or reach open tubule: tubule fluid increased->nerve stimulation-> pain

Which of the following ingredients would be important to look for on the label of a product for someone with cheilitis? Select all that apply: 1. Aloe 2. Beeswax 3. Dimethicone 4. Lanolin 5. Paraffin 6. Petroleum jelly

2. Beeswax 3. Dimethicone 6. Petroleum jelly

Complementary and non-pharmacologic options: caries and gingivitis prevention

Activated charcoal • Limited data to support claims about teeth whitening/absorbing pigments &stains • Novelty Probiotics • Possible benefit for gingivitis Vitamin D • Adequate vit D during pregnancy can reduce caries in children Xylitol • Children: 2017 meta-analysis: no stat sig. benefit

Xerostomia: OTC treatment options & Follow-up recommendations

Artificial saliva products • Sprays • Gels • Gums • Toothpastes Follow-up Recommendations • Re-evaluate after 5-7 days of therapy

Complementary and non-pharmacologic options: caries and gingivitis prevention - Dietary

Avoid highly cariogenic foods • 15% or more sugar • sticks to teeth • can remain in mouth after being chewed Drink adequate water

Herpes simplex labialis (HSL): Docosanol 10% cream (Abreva) - Avoid, dosing

Avoid: placing aspirin tablet on lesions; hydrocortisone; astringents, zinc sulfate

Waxed dental floss may help promote plaque build-up between teeth A. True B. False

B. False

Halitosis: Symptoms

Bad breath caused by volatile sulfur compounds (VSCs)

Topical oral protectants for RAS - MOA

Barrier protectants 1. protect 2. decrease friction 3. provide temporary relief

A 44-year-old adult asks you what they should use for tooth pain. They were diagnosed with tooth hypersensitivity on one occasion several years ago but haven't had any problems since then. They brush their teeth twice daily and are careful not to eat sweets more than a couple times a week.They describe the pain as sharp and stabbing, and it occurs whenever they drink coffee Which of the following options would be the most appropriate recommendation at this time for this person? A. Use a toothpaste containing baking soda & avoid coffee B. Make an appointment with a dentist and take acetaminophen or ibuprofen OTC until then C. Try a soft-bristled toothbrush & standard toothpaste with fluoride for a week D. Use a desensitization toothpaste with soft-bristled toothbrush twice daily for 2 weeks

C. Try a soft-bristled toothbrush & standard toothpaste with fluoride for a week D. Use a desensitization toothpaste with soft-bristled toothbrush twice daily for 2 weeks depending on toothpaste - fluoride (C or D)

Recurrent Aphthous Stomatitis

Canker sore or aphthous ulcer Etiology • Unknown for most patients • Triggers: stress, local trauma, food allergy/gluten sensitivity, hormonal changes, genetic predisposition • Systemic diseases (e.g. SLE, allergies, IBD, nutritional deficiencies, HIV)

RAS: pharmacologic therapies: Oral debriding and wound cleansing agents - Dosage/Admin

Carbamide peroxide: • Drops of carbamide peroxide or hydrogen peroxide applied x 1 min • Rinse: carbamide peroxide drops on tongue, mix with saliva, swish x 1 min Hydrogen peroxide • (DIY) 50:50 mix of hydrogen peroxide 3% & water: swish x1 min Sodium perborate • Sodium perborate monohydrate powder:dissolve in 1 oz water & use right away Sodium bicarbonate • DIY: Sodium bicarbonate paste • Expectorate!

Caries (cavities) etiology

Carbohydrates in diet Oral bacteria Host resistance alterations • Orthodontic appliances • xerostomia (oral dryness) • Medications • Radiation therapy • Tobacco product use • Alcohol use • Immune system dysregulation (chemo, Sjogrens, HIV/AIDs)

Topical oral protectants for RAS - products

Coat ulcers with topical oral protectants • Orabase®, Zilactin® • denture adhesive • Dissolvable patch: hold on lesion x 10-20 seconds to adhere; dissolves over 8-12 hours

Poisoning: definition and routes

Definition: use of a substance harmful to the body Routes: Oral, inhaled, injected, topical (absorbed through skin)

Tooth hypersensitivity (oral pain): Potassium nitrate 5% + fluoride (in toothpaste) - DDI; Avoid; Dosing; Preg/lac

Drug interactions: • Sodium or stannous fluoride: calcium in foods/supplements Avoid: high abrasion toothpastes, whitening toothpastes Dosing: brush with 1 inch strip BID

Minor Oral Mucosal Injury/Irritation: etiology and Do not self-treat

Etiology • Dental procedures • Accidental injury: biting tongue/cheek, abrasion from sharp foods Do NOT self-treat: same list as tooth hypersensitivity

Caries & gingivitis: OTC treatment options - Chemical plaque management

Fluoride Dentrifrices (toothpastes) • Fluoride-containing • Tartar control • Antiplaque/antigingivitis • Whitening • Botanical-based Mouthrinses

Tooth discoloration & staining self-care: Nonprescription options - Nonbleaching ingredients/products=whitening toothpastes

Ingredients: sodium bicarbonate, hydrated silica May be combined with peroxides • Lightens stains & prevent new stains See required reading article in Canvas about • Side effects & their symptoms (including duration) • How to manage side effects

Tooth discoloration & staining: etiology

Intrinsic: within tooth structure • Causes: aging, health conditions, damage, tetracycline antibiotics Extrinsic: surface of tooth • Causes: tobacco, foods (coffee & tea)

Dentrifrice abrasive categories & ingredients

Low abrasion: 10-25% silica abrasives Mild abrasion: baking soda High abrasion: 40-50% • Dicalcium phosphate • Calcium pyrophosphate • Calcium carbonate • Alumina trihydrate

Plaque control with gum

MOA • Increased saliva flow • Mechanical removal of FOOD/PLAQUE Use • Chew after eating as well as other times of day • Sugarless gum only

Prevention of caries & gingivitis: Pharmacologic Methods - Dentrifrices (fancy name for toothpaste)

MOA: act directly on oral bacteria or disrupt plaque components to aid in mechanical removal 3 functions: 1. Help remove plaque, stain 2. Reduce mouth odors 3. Enhance personal appearance Products: Powders, Gels, pastes

Tooth hypersensitivity (oral pain): Arginine 8% + calcium carbonate - MOA & indication

MOA: depolarizes nerves in tubules & pulp to block perception of stimuli Indication: tooth sensitivity

Tooth hypersensitivity (oral pain): Potassium nitrate 5% + fluoride (in toothpaste) - MOA, Indication, PD

MOA: depolarizes nerves in tubules & pulp to block perception of stimuli;seals exposed dentin Indication: tooth hypersensitivity Pharmacodynamics: • Onset: 2 weeks; may need 4 to 6 weeks • Duration: duration of use & beyond

Misuse: definition and 3 types

Medication used for medical purposes but used incorrectly 3 types • Taking a dose or taking differently other than as directed • Taking the medication for an effect it can cause (e.g., to get high) • Mixing OTC meds together to create new products

Presenting symptoms - caries (cavities)

No initial symptoms Progressive lesion on tooth • Visualize • Sensitive to stimuli (heat, cold, sweetness, chewing) • Continuous pain ± difficulty chewing if lesion invades dental pulp • Can progress to abscess and tooth loss

Mouthrinse cautions: AE

Occasional burning, irritation of oral mucosa; may cause sloughing of oral epithelium

Tooth hypersensitivity (oral pain): Arginine 8% + calcium carbonate - PD, Avoid, Dosing

Pharmacodynamics: • Onset: 2 weeks • Duration: same as potassium nitrate 5% Avoid: using fluoride toothpaste at same time Dosing: brush with 1 inch strip BID

RAS: OTC treatment options

Pharmacologic therapy • Topical 1. Oral debriding & wound cleansing agents 2. topical oral anesthetics 3. topical oral protectants 4. oral rinses • Systemic: analgesics

What is the difference between plaque & calculus?

Plaque: • Fresh/soft deposit • Removed by toothbrush Calculus • Harder form of plaque • Removed by professional cleaning

Goals of therapy - caries prevention

Prevent or control dental plaque

Caries & gingivitis: Follow-up recommendations

Professional dental cleanings every 6 months

Topical oral rinses for RAS

Rinses • Listerine® • Saline rinse (1 to 3 tsp salt in 4 to 8 oz warm tapwater)

Pharmacotherapy of Minor Oral Mucosal Injury/Irritation

Same as RAS: 1. Topical analgesics and anesthetics 2. Oral protectants 3. Oral debriding/wound cleansing Astringents: tissue contraction, stop secretions

RAS: pharmacologic therapies: Oral debriding and wound cleansing agents - SE & Avoid

Side effects • Mouth tissue irritation • Short-term tooth hypersensitivity • Black hairy tongue Avoid: toothpastes containing sodium lauryl sulfate

Minor Oral Mucosal Injury/Irritation: nonpharmacologic therapy

Sodium bicarbonate • Baking soda ½ to 1 tsp in 4 oz water; swish x 1 minute then expectorate Saline rinse • MOA: debride, clean wound, stimulate health • Salt 1 to 3 tsp in 4 to 8 oz warm water Ice x 10 minutes (max 20 min in an hour)

Tooth hypersensitivity (oral pain): follow-up recommendations

Standard toothpaste with fluoride & soft bristled brush Resolved? • Yes: continue regimen • No: see 14 days as below 14 days of desensitization toothpaste Resolved? • Yes: switch to fluoride toothpaste • No: dental referral

Caries (cavities): do not self-treat

Symptoms of toothache • pain with or without chewing difficulty • Localized swelling • Hot or cold sensitivity • Fever or headache • Visualized lesion • Entire tooth discoloration • Bleeding, swelling or reddened gums (*if very extensive) • Persistent mouth odor despite regular use of fluoride toothpaste

Complementary and non-pharmacologic options: caries and gingivitis prevention - Plaque removal - Dental floss

Types • Dental floss • Dental tape • Tapered picks Waxed vs unwaxed (no difference)

Topical Anesthetics for RAS

don't memorize 3 starred=most common

American Association of Poison Control Centers

memorize the phone number!

Fluoride: anticaries agent

removed at professional cleaning fluoride: personal oral hygiene in the absence of fluorides has failed to show a benefit in terms of reducing the incidence of dental caries

Cheilitis: S/Sx

severe dry skin on or around lips Signs & symptoms • Dry • Scaly • Cracking (lip, corner of mouth) • Irritated, painful

Abuse: definition

use of OTC medications for non-medical purposes

RAS: follow-up recommendations

• 7 days of treatment or 14days since lesion/s first appeared • Side effects of topicals: see medical provider

Prevention of caries & gingivitis: Pharmacologic Methods - categories of ingredients

• Abrasive • Humectant • Sweetener • Surfactant • Binder/thickener • Flavor • Anticaries activity agent (often)

Gingivitis etiology

• Accumulation of supragingivival bacterial plaque • Medications: Calcium channel blockers, Cyclosporine, Phenytoin • Reduced saliva flow: anticholinergics, Antidepressants (TCAs) • Tobacco (smoked and smokeless) • Pregnancy: Hormones; Connective tissue changes

Toothpaste Use: children

• Age to start brushing? when teeth erupt • Kind of toothpaste: fluoride • Spit but no rinse • Amount: Younger than 3 years: size of rice grain; Older than 3 years: size of pea • Supervise

Plaque control mouthrinses: ingredients & MOA

• Aromatic oils: antibacterial, local anesthesia • Antimicrobials: bactericidal activity • Phenol: local anesthetic, antiseptic, bactericidal activity

Xerostomia: Complementary and non-pharmacologic options

• Avoid tobacco, caffeine, hot spicy foods, alcohol (including mouth rinses) • Adjust or change causative meds if possible • Limit sugary food intake • Limit acidic food intake • Chew gum with sugar alcohol (e.g. xylitol) • Increase water consumption • Cool mist humidifier in home • VERY SOFT bristled toothbrushes

RAS: pharmacologic therapies - Oral debriding and wound cleansing agents

• Carbamide peroxide 10% to 15% in anhydrous glycerin • Hydrogen peroxide 3% (DIY) • Sodium perborate monohydrate • Sodium bicarbonate (DIY)

Complementary and non-pharmacologic options: caries and gingivitis prevention - Plaque removal

• Chewing sugarless gum x 20 min after a meal • Brushing & flossing (adults & childrenolder than 5 years): Manual; Electric-consider battery power • Toothbrushes • Dental floss: at least once daily • Irrigating devices-removes minimal amount of plaque; supplement to brushing & flossing

RAS: Complementary and non-pharmacologic options

• Correct any diagnosed nutritional deficiencies • Avoid food allergy triggers • Avoid spicy/acidic foods if active lesions • Avoid textured foods that can irritate lesions • Apply ice to lesions x 10 minutes; max 20 minutes in an hour • DIY salt water rinses (table salt in tap water, swish then spit)

Tooth discoloration & staining: Do NOT self-treat & Goals of therapy

• Do NOT self-treat: Intrinsic (refer) • Goals of therapy: lighten color/whiten teeth

Xerostomia: presenting symptoms

• Dry mouth (less than 1.5 L saliva in 24 hours) • Difficulty talking, swallowing • Mouth sores (stomatitis) • Halitosis • Altered taste, loss of appetite • Tooth hypersensitivity • Over time: caries

Recurrent Aphthous Stomatitis: S/Sx

• Epithelial, circular ulcer on nonketatinized, movable mouth surfaces • Last 5 to 14 days, 0.5 to 2 cm

Other Dentrifrice Ingredients - Chemotherapeutic agents may be combined in a whitening dentrifrice

• Fluoride • Potassium nitrate • Stanous flouride • Metal salts • Essential oils • Hydrogen peroxide • Sodium bicarbonate

Toothpaste Use: Adults (size of pea)

• Frequency: BID • Type of brush/how often to change: Soft; Change every 3-4 months • Kind of toothpaste: Fluoride-containing • Hold at 45 degree angle • Where to brush: Inner, outer, chewing surfaces • Flossing: at least daily

Herpes simplex labialis (HSL): Causes

• HSV-1 • HSV-2 • CMV • Epstein-barr virus infected for life

Xerostomia etiologies

• Health conditions: Sjogrens, DM, depression, Crohn's disease • Radiation therapy • Medications: first-gen antihistamines, decongestants, diuretics,TCAs, antipsychotics, sedatives • Excessive alcohol consumption • Tobacco use • Excessive alcohol and caffeine use • Mouth-breathing

Recurrent Aphthous Stomatitis: Do not self-treat

• If underlying cause • Lesions present 14 days or more • Frequent recurrence • Sx of systemic illness • Self-care ineffective

Gingivitis: presenting symptoms

• Inflamed gingiva • May progress to periodontal disease

Tooth discoloration & staining self-care: Nonprescription options - Bleaching ingredients/products

• Ingredients: hydrogen peroxide (up to 10%), carbamide peroxide • Product types: strips/dissolving strips, emulsion, brush-on gels, applicator pens, trays with gel • Use for 30 min-2 hours daily for 5-14 days

Herpes simplex labialis (HSL): complementary and non-pharmacologic options

• Keep lesions clean • Handwashing • Avoid sharing utensils, drinking vessels • Moisturize involved skin (petroleum jelly applied with clean fingertip) • Avoid triggers that slow healing (stress, local trauma, wind/sun,fatigue) • Facial/lip sunscreen if sun is trigger • Tea tree oil, lysine, lemon balm

Herpes simplex labialis (HSL): do not self-treat

• Lesions present more than 14 days • Increased outbreak frequency • Symptoms of infection (fever, swollen glands, rash) • No prior cold sore

Herpes simplex labialis (HSL): Docosanol 10% cream (Abreva) - MOA, indication, PD

• MOA: inhibits fusion of virus to cell membrane; prevents viral replication • Indication: reduce duration & severity of HSL symptoms • Pharmacodynamics: decreases time to heal by ~1 day compared to placebo

Xerostomia: OTC treatment options - Artificial saliva - MOA, Indication, PD

• MOA: mimics natural saliva; replacement (not cure) • Indication: dry mouth Pharmacodynamics: • Onset: minutes • Duration: few hours

RAS: pharmacologic therapies: Oral debriding and wound cleansing agents - MOA & duration

• MOA: release of molecular oxygen • Use: up to 4x daily x 7 days

Halitosis: Do not self-treat

• Medical conditions associated with halitosis • Persistent halitosis despite good oral hygiene

Halitosis: causes - systemic

• Medications: TCAs, first-gen antihistamines, oxybutynin,meclizine, Parkinson's meds • Kidney/liver failure • Cancer • Ketosis

Mouthrinse Use

• Most effective prior to brushing except use after if mouthrinse contains fluoride • 1 to 2 times per day • Avoid eating/drinking x 30 min afterward • Supervise children younger than 12 yrs

Mouthrinse cautions

• Mouth ulcers or irritation: only use under dental advice • Keep out of reach of children • Supervise use in children • Alcohol content issues: Poisoning; Oral cancer

Other Dentrifrice Ingredients - whitening dentrifrices

• NOT tooth-bleaching products • Ingredients: baking soda; titanium dioxide; or aluminum oxide + citrate salt + papain;peroxides

Tooth hypersensitivity (oral pain): presenting symptoms

• Pain from hot, cold, sweet or sour liquids • Pain from hot or cold air on teeth • See Table 32-1 to differentiate from toothache

Halitosis: causes - oral

• Poor hygiene • Xerostomia • Foods/beverages: garlic or onions • tobacco

Goals of therapy - gingivitis prevention

• Prevent calculus formation • Remove and control supragingival plaque

Goals of therapy - xerostomia

• Relieve discomfort & any symptoms such as difficulty talking • Reduce risk of dental decay • Prevent & treat associated infections

Herpes simplex labialis (HSL): goals of therapy

• Relieve pain & irritation • Prevent secondary infection • Prevent spread of lesions

Halitosis: prevention

• Remove cause if possible • Mechanical: See caries prevention; Tongue brushing • Chemical: Zinc salts, chlorine dioxide

Xerostomia: OTC treatment options - Artificial saliva - SE, DDI, Avoid

• Side effects: hypersensitivity if preservatives • Drug interactions: NONE • Avoid: sodium-based products if low-salt diet

Tooth hypersensitivity (oral pain): OTC treatment options

• Standard toothpaste with fluoride • Potassium nitrate 5% in fluoride-containing toothpaste

Tooth hypersensitivity (oral pain): Complementary and non-pharmacologic options

• Stop triggers (acidic foods, aggressive toothbrushing) • Avoid toothbrushing within 30-60 min of acidic foods/drinks • Correctly brushing teeth with fluoride toothpaste

Toothpaste Use: children - parent education

• Supervise, esp spitting & amount • Too much fluoride: flecks/stripes or brown spots on teeth, enamel pits

Gingivitis: do not self-treat

• Swollen gums • Gums that bleed with brushing or flossing (*a lot) • Receding gums • Gums that are darker red

Tooth hypersensitivity (oral pain): Do not self-treat

• Toothache • Mouth soreness associated with dentures • Fever or swelling • Loose teeth • Bleeding gums • Broken teeth • Severe tooth pain started or worsened by hot, cold, or chewing • Trauma to the mouth

Herpes simplex labialis (HSL): OTC treatment options & follow-up recommendations

• Topical skin protectants (seeRAS) • External analgesics/anesthetics (seeRAS) • Docosanol 10% Follow-up: 14 days

Halitosis: prevention - Chemical agents - MOA

• Zinc salts: reduce receptor binding for VSCs • Chlorine dioxide: breaks disulfide bonds, oxidizes VSC precursors