Therapeutic Agents for Common Mucosal Diseases

What are the two most common types of oral non-microbial mucositis?

Aphthous Stomatitis

Lichen Planus

What is Lichen Planus?

White lacy patches or sores in the mouth

Three types

• Reticular → lacy white lines

• Erosive → ulcers/erosions with reticular pattern

• Plaque → solid white patches

Commonly found on buccal mucosa

What is aphthous stomatitis?

Canker sores

Classic findings are pain greater than expected for lesion size

Occurs on non-keratinized mucosa → buccal vestibule, ventral tongue, floor of mouth

What are baseline activities that are essential for therapeutic success in the mucosa?

Avoid common intra-oral irritants

Maintain salivary pellicle

Maintain saliva production

Manage microbes

What drugs commonly cause non-microbial mucositis?

ACE-I

Beta blockers

Diuretics

Allopurinol → for gout

AEDs → carbamazepine

Statin drugs → for hyperlipidemia

Oral hypoglycemic drugs → ex; glimepiride

Precipitating factors for non-microbial mucositis?

Genetics, Systemic diseases, Microelement deficiencies, Stress, Estrogen shifts, Medications, Minor oral trauma, Toothbrushing, Dental treatment, Orthodontic bands, Popcorn, Sharp/hard devices or Foods

What topical chemicals can contribute to non-microbial mucositis?

Pyrophosphates / Polyphosphates

Flavoring agents

Cocamidopropylamine → CAPB

Sodium lauryl sulfate → SLS

How do aphthous stomatitis and lichen planus differ?

Aphthous stomatitis → painful recurrent ulcers/canker sores

Lichen planus → chronic inflammatory condition with white lacy lesions (reticular), plaques, or erosive ulcerations; commonly on buccal mucosa

What is the treatment of non-microbial mucositis?

Topical corticosteroids

Triamcinolone rise → cornerstone therapy but must be compounded

Dexamethasone solution → commercially available

Neither are “cures” → palliative care

Dexamethasone 0.5mg/5ml oral solution?

Available in 500ml bottle

Half the potency of triamcinolone

Covered by insurance → reasonable initial choice

Dexamethasone 0.5mg/5ml oral solution counseling points?

Must be held in mouth for 1-2 minutes

DO NOT Swallow → can cause adrenal suppression → 3 weeks

Triamcinolone acetonide rinse?

Compounded suspension → $$$

Disped as 240ml

Never should be flavored

Triamcinolone acetonide rinse counseling points?

Rinse 5 mL for 1 minute up to 4 times daily PRN

Spit out after rinsing (do not swallow)

Avoid food or drink for 30 minutes after use

Triamcinolone + antifungal suspensions?

Combination of triamcinolone with an antifungal to help prevent/treat Candida overgrowth during steroid therapy

Nystatin suspension → less consistent Candida coverage; contains high sucrose

Amphotericin B suspension → better activity against Candida krusei and Candida glabrata

How are topical corticosteroid ointments used for oral lesions?

High potency → Clobetasol 0.05%, Fluocinonide 0.05%

Apply thin film to dentures/medication trays

Hold ~30 minutes, then rinse mouth

When are corticosteroid ointments used in mucositis?

For localized, non-microbial inflammatory mucositis

When lesions are persistent, painful, or not responding to basic care

Used to reduce inflammation directly at specific lesion sites

What are the most common types of oral microbial mucositis?

Candidosis

Herpes simplex virus → HSV

Angular cheilitis?

Infected painful, red, cracked sores at one or both corners of the mouth

Usually Candida, sometimes mixed with Staph bacteria

Common in denture wearers

Linked to dry mouth and loss of vertical face height (mouth “collapses”)

How is angular cheilitis treated?

Ketoconazole 2% cream

Apply → 2–3 times daily to corners of mouth

Can be used with dentures as a delivery method

Sometimes compounded with high-potency steroids

Off-label use → not officially approved for intraoral use

How are clotrimazole and miconazole used for angular cheilitis?

Clotrimazole 1% or Miconazole 2% cream

Apply to affected area (OTC or Rx)

Treats Candida-related infection

Also used for other superficial fungal skin infections

Why is nystatin + triamcinolone cream not recommended for angular cheilitis?

Poor antifungal effectiveness for Candida

Steroid can worsen infection by suppressing immune response

Not recommended for routine use

When is fluconazole used for angular cheilitis?

Used for more severe or resistant Candida infections

Oral systemic therapy

Significant drug interactions → CYP3A4 inhibition

Use short course → 7–14 days depending on severity

What is Herpes Simplex Virus?

Most common cause of oral and ocular herpes

HSV-1 → causes most oral disease (HSV-2 can also cause ~20%)

Very common

Primary infection often occurs in childhood and may be asymptomatic

What are the different types of oral herpes simplex?

Primary herpes gingivostomatitis → First infection

Recurrent intraoral herpes → Reactivation inside the mouth, localized ulcers (often hard palate/gingiva)

Herpes labialis → cold sores, reactivation on the lip

What is the course of herpes labialis?

Prodrome → pain, itching, burning, tingling for 6 hours

Vesicle formation erythematous base, may merge

Ulcers/crust → develop within 72–96 hrs

Pain → worst early, then improves over 4–5 days

Healing → fully resolves in 8–10 days

What is the abortive therapy of choice for herpes labialis?

Valacyclovir → 1000 mg

Take 2 tablets at first sign → tingle/buzz

Then 2 tablets 12 hours later

Most effective if started within 6–8 hours of prodrome

Maintain good hydration

Supply of 16 tablets = about 4 treatment episodes

What are some possible reactivation triggers for herpes labialis?

Dental procedures if lip trauma

Physical or emotional stress

Fever, upper respiratory infections

Menstruation

Immunosuppression → due to drugs, disease or idiopathic

When are treatments for herpes labialis most effective?

Most effective if started within 48 hours of prodrome

Little benefit once lesions fully develop

Supportive options → ice applied frequently (about every 20 min)

Corticosteroids may reduce inflammation but are controversial

How are HSV infections different in immunosuppressed patients?

Harder to treat than in healthy patients

Require higher doses and longer treatment duration

Often need suppressive/prophylactic antivirals to prevent spread to organs/CNS

Lesions near the nose can signal eye involvement → ophthalmic emergency

How is topicals for herpes labialis?

Rx → Penciclovir 1% cream

OTC → Docosanol 10% cream

Apply thin film every 2 hours at onset of prodrome

Valacyclovir for primary HSV?

1g BID x 10 days

Valacyclovir for recurrent HSV?

2g BID once a day

FDA approved regimen

Acyclovir for primary HSV?

400mg TID x 10 days

Must remain hydrated to avoid renal problems

Acyclovir for recurrent HSV?

400 mg TID x 5 days

Must remain hydrated to avoid renal problems

What are HSV prophylaxis options and when are they used?

Used for frequent recurrences (≥6 episodes/year) or predictable triggers (e.g., sun exposure)

Acyclovir 400 mg BID (also 400 mg BID for 7 days before sun exposure)

Valacyclovir 500 mg daily (increase to 1 g daily if ≥9 episodes/year)

Therapy options for dry lips?

Chapped lips → moisturizer → Hydrous lanolin 3-4x a day

Lip balm → use when in sun 1-2x, put on after lanolin

How to treat angular cheilitis + staph?

Ketoconazole 2% cream and Bactroban 2% ointment in 1:1 ratio

Apply to lip first thing morning and last at night

After application → wait 30min before any other lip treatments

Do not use other steroids without further consultation

What are 3 topical and 1 systemic drug options for oral mucosal candidiasis?

Topical →

• Ketoconazole

• Clotrimazole

• Miconazole

Systemic →

• Fluconazole

Fluconazole dosing for angular cheilitis?

200 mg day 1

Then 100 mg daily for 7–14 days