Minor Oral disorder

Identify common causative factors and triggers of xerostomia

For xerostomia, identify common medications that may cause dry mouth.

What is it?	Risk Factor	Potential causes
Dry Mouth; condition where salivary flow is limited or completely arrested,  Presentation: Stomatitis Burning tongue Halitosis Difficulty talking/swallowing	Certain disease states: diabetes, depression, crohn’s disease Radiation to head/neck Older age Consumption of alcohol, tobacco, caffeine, or spicy foods	Anticholinergic and other meds that reduce salivary flow Sjogren’s syndrome Salivary gland stones causing blockages  Excessive mouth breathing  Gland atrophy

Medications examples: 

• Antihistamines

• Decongestants

• Antihypertensives

• Antidepressants 

• Diuretics

• Antipsychotics

• Sedatives

•  Inhaled meds

Identify common causative factors and triggers of canker sores

Canker sores

Risk factors/causes 

• Local trauma

  • Smoking, biting inside lip.cheek, braces, toothbrush 

• Streptococci and varicella zoster virus 

• Autoimmune disease

• Chemo

• Nutritional conditions/deficiencies

• Genetic

• Stress

• Hormonal changes 

Identify common causative factors and triggers of cold sores

Transmission and activation

How does it spread?	Modes of transmission	Reactivation caused by	Other triggers
Passed through direct contact with fluid from vesicles containing live virus	Kissing  Sharing cups/utensils Sexual contact towels	Uv exposure Stress  Fatigue Cold Windburn	Fever Injury Menstruation Dental work Infection Immune system suppression

Compare and contrast the presentation of canker sores versus cold sores.

Canker sores (recurrent aphthous stomatitis) 

• Age of onset: 10-19

• Location: oral, nonkeratinised mucosa

  • Common sites: inside lips, cheeks, tongue, floor of mouth, soft palate 

• Characteristics: 

  • round/oval

  • flat/crateriform

  • Gray or gray/yellow with halo of inflammation 

  • Heals spontaneously in 7-14 days 

• Symptoms:

  • Pain, especially when eating, drinking, performing daily oral hygiene

  • Prodrome 

Cold sores (herpes simplex labialis, fever blisters)

• Patho: primarily herpes simplex virus type 1 (HSV-1), but sometimes HSV-2

• May also be caused by other human herpes viruses such as EBV or CMV

• Locations:

  • Lips or area around lips

  • Junction between lips and skin or skin and nasal mucosa

  • May also occur intraorally (hard palate) 

• Characteristics

  • Recurrent 

  • Crusty

  • Red inflamed border

  • Lesions often coalesce to form larger lesion 

• Symptoms 

  • Pain

  • Prodrone (burning, itching, tingling, numbness)

  • Other possible symptoms: fever, tiredness, swollen lymph nodes, localized bleeding 

Nonpharm for Xerostomia

• Reduce intake of alcohol, tobacco (all types), and caffeine 

  • Avoid alcohol containing mothwashes

• Chew sugar free gum

• Increase water intake 

• Suck on ice chips or sugar free candy 

• Take meds associated with dry mouth 1 hr bf eating 

• Use a humidifier at night

• Cavity prevention 

  • Reduce intake of sugar, starch, spicy, and acidic foods

  • Use very-soft bristle toothbrush 

Pharm of Xerostomia

Over the counter → Artificial saliva products

• Active ingredients: carboxymethyl or hydroxyethylcellulose +/- fluoride 

• Available as different formulations: lozenges, gels, liquids, mouth sprays, gum, and toothpaste

• Ex: 

  • aCT dry mouth lozenge

  • Biotene dry mouth oral balance gel, moisturising spray, and gum 

• Use (at min) after all meals and before bed 

Prescription meds →Pilocarpine and cevimeline 

• Class: cholinergic agonist

• For treatment of xerostomia as result of radiation and sjogren’s syndrome

• ADE: cholinergic associated effects, like sweating, indigestion, nausea, and rhinitis 

Nonpharm of canker sores

• Treat nutrient deficiencies

• Avoid spicy/acidic foods

• Avoid sharp foods 

• Apply ice directly to lesion and avoid heat

• Wax on braces

• Adhesive buccal patches

• Oral saline rines 

  • Avoid antiseptic rinses as this delays healing 

Pharm of canker sores

First-line:

• High potency topical steroid (Rx)

  • Dexamethasone elixir (rinse), clobestasol gel/cream, flucinonide cream

    • Risk of candidiasis 

Other therapies

• Antimicrobials

  • Topical tetracyclines (doxycycline)

  • Chlorhexidine rinse 

• Antiinflammatories

  • Amlexanox paste or patches (Rx)

• Tissue denaturants

  • Debacterol prefilled swb (Rx)

• Protectants  

  • Sucralfate (Rx)

Oral debriding and wound cleansing agents

• Hydrogen peroxide (1.5%)

• Carbamide peroxide (10-15%)

• Directions:

  • Apply drops directly or swish gently in mouth for 1 minute, then rinse

    •  Avoid prolonged rinsing → tissue/enamel damage and bacterial overgrowth

  • Use after meals up to 4 times daily

    • Avoid eating for 30 minutes after application

  • Do not use longer than 7 days

Topical oral anesthetics

• For age ≥ 2 years

• Options: benzocaine 5-20%, benzyl alcohol 0.05-0.1%, dyclonine 0.05-0.1%, hexylresorcinol 0.05-0.1%, salicylic alcohol 1-6%

  • Brand names: Anbesol, Blistex, Orajel

  • Applied directly to lesion for temporary relief

  • Gels preferred, longer acting

Systemic analgesics

• OTC options: acetaminophen, naproxen, ibuprofen,aspirin

• Do not hold aspirin in mouth, may burn or cause tissue damage

Nonpharm of cold sores

• Keep clean with mild soap and water

• Wash hands often (and perform other infection control measures) to prevent spread of infection

• Keep moisturized

• Avoid excessive wind/sun exposure, local trauma (ex. Hard bristle toothbrush), and stress

• Cool foods, cool wash clothes, or ice to affected area for pain management

• Avoid spicy/acidic food

OTC pharm of cold sores

• Lip protectant with SPF 15 or higher

• Topical skin protectants

  • Creams and ointments with dimethicone, pretolatum, and/or zinc oxide

  • Protection from infection and relieve dryness

  • Directions: use after meals 3-4x daily. Avoid eating/drinking for 30 minutes after use 

• Topical anesthetics or analgesics 

  • Ex: benzocaine 5-20%, dibucaine 0.25-1%, dyclonine hcl 0.5-1%, benzyl alcohol10-33%, camphor <3%, menthol <1%

• OTC systemic analgesics - if needed for pain
  

• Docosanol 10% (Brand name: AbrevaCream)

  • Only FDA approved, non-prescription products that can reduce duration and severity of symptoms

  • MOA: Prevents viral replication by blocking fusion of HSV to and the human cell plasma membrane

  • Start applying at first sign of cold sore and apply 5 times daily until lesion is healed

    • Max: 10 days

Cold sores prescription

• Examples: Acyclovir (not preferred), vanacyclovir, and famiciclovir

• Roles:

  • Primary infection presenting within 72 hours, recurrent infection 

  • Typically preferred over OTC products due to increased efficacy 

• MOA: inhibits DNA synthesis and viral replication by competing for DNA polymerases of the virus and being incorporated into HSV DNA 

• ADE:

  • tiredness, nausea/vomiting, rash, hematologic abnormalities, increased SCr andBUN (risk for AKI), CNS symptoms- agitation, confusion, dysarthria,hallucination, and impaired consciousness (risk of neurotoxicity), risk of rare blood disorders (thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS))

Natural

• Tea tree oil

• Lysine (for prevention)

• Zinc-base creams

• Aloe vera gels

• Supplementation with zinc, vitamin c, and vitamin d

Recognize exclusions for self-treatment xerostomia and oral lesions (canker sores and cold sores).

Xerostomia 

• Tooth erosion, decalcification, and decay

• Signs of or diagnoses infection: candidiasis, gingivitis, and periodontitis

• Reduce denture wearing time or mouth soreness associated with poor fitting dentures 

• Fever

• Swelling 

• Loose teeth

• Broken or knocked out teeth 

• Bleeding gums

• Severe tooth pain 

• Trauma to the mouth 

• Sjogren’s syndrome 

• Salivary gland stones 
  

Canker

• Lesions associated with underlying pathology 

• Lesion presentation for > 14 d

• Symptoms of systemic illness

• Frequent recurrence 

• Failure to prior appropriate self-treatment 

Cold Sores

• Lesions present >14 days

• Increase frequency of outbreaks

• Compromised immunity 

• Symptoms of infection (fever, swollen, lymph nodes, rash)

• No previous diagnosis of cold sore

• Recurrence 

Counsel a patient on strategies for treating and preventing xerostomia

• Nonpharm 

Follow-up

• Time frame: 5-7 days

• Worsening symptoms and/or complications: refer

• Improved symptoms: continue using products 

Counsel a patient on strategies for treating and preventing canker sores

Non-pharm

Follow-up 

• Seek medical care if:

  • Lesion does not heal in 14 days

  • Symptoms continue after 7 days of treatment with debriding/cleansing agents

  • Symptoms worsen

  • There are signs of infection (fever, rash, swelling)

Counsel a patient on strategies for treating and preventing cold sores

• Avoid steroid containing products as cold sores will not respond 

• Take steps to avoid transmission of infection: Do not share cups or utensils. Wash hands frequently and after touching/applying medication.

• Follow-up

  • Should resolve within 10-14 days

  • Seek additional care if :

    • Lesions do not heal within 14 days

    • Lesions reoccur despite self-care measures

    • No relief of discomfort with self-care measures

    • Signs of systemic infection (fever, malaise,rash, swollen lymph nodes)

    • Symptoms change or worsen