10 - Dental Conditions Flashcards
What are symptoms of teething pain?
- Gum redness, swelling, or tenderness
- Drooling, flushed cheeks b/c of mild increase of body temperature
- Irritability, restlessness, crying, insomnia
What ARE NOT symptoms of teething pain?
Fever, diarrhea, vomiting, or common cold symptoms
What are some non-pharms for teething pain?
- Massage baby’s gums w/ clean finger or damp washcloth
- Cool affected area w/ frozen face cloth, or cold pacifier/teether (avoid exposure to extreme cold)
- Wipe baby’s face often w/ cloth to remove drool and prevent rashes
When is pharmacological treatment used for teething pain?
When non-pharms don’t work
What pharmacological treatment is recommended for teething pain?
- Oral analgesics
- Acetaminophen – 10-15 mg/kg/dose every 4-6 hours PRN (max 65 mg/kg/day)
- Ibuprofen – 5-10 mg/kg/dose every 6-8 hours PRN (max 40 mg/kg/day)
When do you refer teething pain?
No relief w/ treatment for 3-5 days
What pharmacological treatment is not recommended for teething pain and why?
- Topical anesthetics
- Provide relief for maximum 45 minutes and can inactivate the gag reflex if swallowed or cause methemoglobinemia
What are can a toothache?
- Cracked tooth syndrome
- Post-dental procedure discomfort
What is cracked tooth syndrome?
Abrupt pain w/ biting but resolves w/ removal of pressure
When do you refer a toothache?
Always, but can offer pharmacological treatment until they can see a dentist
What treatment can be offered for a toothache?
- Oral analgesics (NSAIDs, acetaminophen)
- Local anesthetics (benzocaine)
What is tooth hypersensitivity?
Short, quick, sharp dental pain due to exposure to a stimulus on exposed dentin
What can cause tooth hypersensitivity?
- Tooth decay
- Fractured teeth
- Worn fillings
- Gum disease
- Worn enamel
- Exposed root from gum recession
When do you refer tooth hypersensitivity?
Always
What are some non-pharms for tooth hypersensitivity?
- Soft-bristled toothbrush and proper tooth brushing
- Decrease acidic foods and drinks
- Avoid brushing w/in 2 hours of acidic foods and drinks
What is a pharmacological option for tooth hypersensitivity?
Desensitizing toothpaste (potassium nitrate most common)
What is the most common cause of oral candidiasis?
C. albicans
What are the 2 major forms of oral candidiasis?
- Pseudomembranous – most common, appears as white plaques on oral mucosa that are easily wiped off w/ cotton-tipped applicator
- Atrophic – common in elderly w/ dentures, erythema w/o plaques
What are risk factors for oral candidiasis?
- Diseases that affect immune system and medications that suppress immune system
- Xerostomia
- Use of systemic or inhaled corticosteroids
- Infants and children
- Use of broad-spectrum antibiotics
- Local mucosal trauma
- Poor dental/denture hygiene
- Pregnant
- Smoking
What are signs and symptoms of oral candidiasis?
- “Cottage cheese” soft plaques that are white or cream/yellow on buccal mucosa, tongue, gums, and throat
- Plaques removed w/ vigorous rubbing but can leave red or bleeding sites
- Red, flat lesions on mucosa under dentures
- May cause cracked, red, moist areas on skin at corners of mouth
What are some red flags for oral candidiasis?
- Atypical symptoms of mild oral thrush
- Px on chemotherapy or immunocompromised from drug therapy
- Systemic symptoms (unexplained weight loss or thirst)
- Other organ involvement
- Any lesion lasting longer than 3 weeks
- Possible symptoms of adverse drug reaction
- Suspect another type of infection
- Unable to confirm oral thrush infection
- Treatment unsuccessful after 14 days
Would you refer oral candidiasis if the patient is on an inhaled corticosteroid?
No, just counsel them on the importance of rinsing their mouth after every use
What are the goals of therapy for oral candidiasis?
- Eradicate infection
- Prevent complications
- Prevent recurrence
What are some non-pharms for oral candidiasis in infants?
- Sterilize toys, soothers, and feeding bottles/nipples
- If breastfed, mother may have candidal infection on nipples and requires treatment
What are some non-pharms for oral candidiasis in px w/ dentures?
- Remove dentures overnight
- Wear dentures only for 6 hours
- Soak and clean dentures when not using
- Clean oral cavity w/ soft toothbrush
- Make sure dentures fit properly
What is the pharmacological therapy for oral candidiasis?
Prescription = nystatin (for mild cases) or oral azole antifungals
What is the OTC treatment for oral candidiasis and why is it no longer recommended?
- Gentian violet
- Can cause mucosal irritation, ulceration, and staining; also has been linked to carcinogenicity
What treatment can pharmacists prescribe for oral candidiasis?
Nystatin oral suspension
Is nystatin fungistatic or fungicidal?
Both
What are the directions of use for nystatin oral suspension?
- Shake well
- Swish and swallow product
- Instill 1/2 dose into each side of mouth and ensure contact w/ lesions for as long as possible before swallowing
- Do not eat 5-10 minutes after dose is given
What are some side effects of nystatin?
- Nausea, vomiting and diarrhea w/ high doses
- Rarely rash or irritation
What is the dosing of nystatin for adults and children?
4-6 mL of 100,000 unit/mL suspension QID for 7-14 days
What is the dosing of nystatin for infants?
1-2 mL of 100,000 unit/mL suspension QID for 7-14 days
How long should treatment w/ nystatin continue once symptoms have cleared?
48 hours
What are the monitoring procedures for oral candidiasis?
- After prescribing nystatin, follow up in 7 days
- Can discontinue medication if symptoms have been resolved for 48 hours
What should be done if the px experiences improvement but not resolution of sx w/ nystatin?
Continue nystatin for 7 more days
What should be done if px does not experience improvement w/in 14 days while using nystatin?
Refer
Which organism is the primary cause of herpes labialis?
HSV-1
What are some symptoms of the primary infection of herpes labialis?
- May be asymptomatic
- May have fever, chills, sore throat, ulcerations on lip, malaise
What are triggers for herpes labialis?
- Stress
- Sun exposure
- Hormonal changes
- Trauma
- Viral infection
- Fever
- Cold weather
What are the various stages of herpes labialis?
- Prodromal (less than 24 h) - pain, itching, tingling at site
- Erythema (24-48 h) - red, inflamed area
- Papule (24-48 h) - small, raised lesions
- Vesicle (1-3 days) - clear, fluid in lesion, swollen w/ red halo
- Ulcer (1-3 days) - yellow, weeping, moist and painful
- Crusting (day 5-8) - hard crust, inflamed, some swelling
How long can healing take for herpes labialis?
7-10 days
What are red flags for herpes labialis?
- Lesion not healed w/in 14 days w/ or w/o tx
- Systemic symptoms
- Lesion appears infected
- More than 6 outbreaks per year
- Pregnant
- Immunocompromised
What are the goals of treatment for herpes labialis?
- Relieve discomfort
- Reduce duration and severity
- Prevent secondary infection
- Prevent spread
- Prevent recurrences
- Reduce triggers
What is the OTC treatment for herpes labialis?
- Docosanol 10% (Abreva)
- Local anesthetics (Anbesol, Orajel, Kank-A)
- Protectants
- Topical analgesics
- Oral analgesics
What does docosanol do and what is the dosing?
- Prevent migration and replication
- Applied 5 times/day at first sign (max. 10 days)
- For 12 years old and over
Should heparin sodium/zinc sulfate and hydrocolloid patches be recommended for herpes labialis?
Both are lacking safety and efficacy evidence
What is a disadvantage to using local anesthetics for herpes labialis?
Risk of choking and being burned
What do protectants do and what are some examples that can be used for herpes labialis?
- May help decrease cracking and drying of lesion
- Petrolatum, cocoa butter, allantoin
What are examples of topical analgesics used for herpes labialis?
Camphor, menthol, phenol
Which oral analgesics can be used for herpes labialis and for how long?
- Acetaminophen, ibuprofen, naproxen
- Up to 3 days
What are some Rx treatments for herpes labialis?
Rx antivirals, either oral or topical
What are some non-pharms for herpes labialis?
- Lip conditioners and protectants
- Keep area clean w/ warm water and soap to prevent infection
- Avoid direct contact w/ others
- Wash hands often and avoid touching lesion
- Avoid sharing objects (straws, glasses, cutlery, razors, towels)
- Stress reduction and rest
What are symptoms of aphthous ulcers?
- Last 5-14 days
- Burning, tingling, intense persistent pain
What are the 4 appearance related factors for aphthous ulcers?
- Roundish
- Shallow-cratered
- Red halo
- White-yellow interior covering
Are aphthous ulcers contagious?
No
What are common precipitating factors of aphthous ulcers?
- Local trauma
- Stress
- Genetic predisposition
- Medications (NSAIDs, ACE inhibitors, beta-blockers, opioid analgesics)
What are red flags for aphthous ulcers?
- Severe pain
- More than 5 ulcers present
- Ulcer greater than 1 cm diameter
- Lasts more than 14 days
- Recurring 6-12x per year
- Systemic disease (HIV, inflammatory bowel disease, diabetes, TB)
- Fever or other systemic symptoms
- First ulcer later in life (> 30 y/o)
- Pregnant
- Vitamin or iron deficiency suspected
What are the goals of therapy for aphthous ulcers?
- Relieve pain
- Decrease ulcer duration
- Ensure normal oral function and adequate nutrition intake
- Decrease frequency and severity of recurrences
What are some non-pharms for aphthous ulcers?
- Avoid foods that cause pain when ulcer present
- Avoid oral trauma (use soft bristled toothbrush, oral wax on braces that rub or irritate cheek, repair irregular dental surfaces)
- Avoid oral products w/ sodium lauryl sulfate
- Avoid foods that may trigger a flare
- Treat nutritional deficiencies
- Dental hygiene
- Warm saline rinses
What is the OTC treatment for aphthous ulcers?
- Oral analgesics - acetaminophen (NSAIDs may cause or worsen sx)
- Protectants (hydroxypropyl cellulose, carboxymethyl cellulose)
- Topical analgesics (camphor, menthol, phenol)
- Local anesthetics (benzocaine 10-20%)
How can the duration of local anesthetics be increased?
Combine w/ oral analgesics and protectants
What can pharmacists prescribe for aphthous ulcers?
Triamcinolone 0.1% in orabase
What are the prescription products available for aphthous ulcers that can be prescribed by doctors or dentists?
- Antibiotics
- Pain relief
- Other agents - dapsone, colchicine, dexamethasone ointment, prednisolone, infliximab, thalidomide
What is the benefit of traimcinolone?
- Delivers protective local coating and enables local anti-inflammatory effect of the corticosteroid
- May be helpful to speed healing and relieve sx of recurrent minor aphthous ulcers
- Early initiation may result in a more rapid response
What is the dosing of triamcinolone 0.1%?
- Apply to ulcer 2-4 times per day until healed
- Press small dab (~1/4 inch) to lesion until thin film develops
- For optimal results, use only enough to coat lesion w/ a thin film and do not rub in
- Apply at bedtime or after meals (do not eat or drink for 30 minutes after application)
What are some side effects of triamcinolone?
- Potential development of oropharyngeal candidiasis (b/c of corticosteroid)
- Burning
- Irritation
What is the monitoring for aphthous ulcers?
- If no significant healing in 7 days or if ulcer worsens refer
- Refer if ulcer doesn’t heal w/in 14 days
- Pharmacist should monitor for pain every 3 days for first week, then again in 1 week
What is xerostomia?
- Dry mouth
- Not a disease, but a manifestation secondary to a medical condition, drug, or radiation to salivary glands
What is xerostomia usually associated w/?
- Hyposalivation
- The 2 are not synonymous b/c xerostomia is subjective but hyposalivation is objective and they don’t always occur together
What are some complications associated w/ xerostomia?
- Increase risk of dental caries
- Tooth decay and loss
- Difficulty speaking
- Decreased ability to chew and swallow
- Decreased taste sensation
- Decreased nutritional status
- Oral conditions (candidiasis, gingivitis)
What are the goals of therapy for xerostomia?
- Prevent complications
- Relieve symptoms
- Improve mouth comfort
What are some non-pharms for dry mouth?
- Dental care
- Suck on ice chips
- Frequent sips of water
- Hard, sugarless candies or gum
- Humidifier at night
- Avoid/reduce caffeine intake
- Avoid tobacco and alcohol
What are some OTC products for xerostomia?
Salivary substitutes and lubricants (Biotene, Oral Balance, Moi-Stir, Oramoist)
What do salivary substituents and lubricants do?
- Replace moisture and provide lubrication
- Mimic natural saliva, but do not provide all benefits of saliva
- *Do not stimulate saliva production
What is an advantage to Biotene products?
Help replace missing salivary enzyme activity in px w/ decreased saliva production
What is gingivitis?
- Chronic inflammation of gums
- Swelling and discolouration of gums, bleeding gums when brushed
- First stage of peridontal disease
- Reversible!
What causes gingivitis?
Build-up of bacterial plaque from insufficient brushing and flossing
What are risk factors for gingivitis?
- Medical conditions
- Medications
- Poor nutrition
- Infections
- Hormonal changes
What is periodontitis?
- Progression of gingivitis
- Loss of connective tissue attachment => resorption of tooth-supporting bone
- Plaque has spread to roots
- Gums may pull away from teeth
What are symptoms of periodontitis?
- Pain
- Bleeding of gingival tissue
- Halitosis
- Foul taste
- Increased salivation
What are the screening questions for periodontal disease?
- BUG questions (bleeding gums, unsteady/loose teeth, gum recession) – yes to any = refer
- Signs of infection, bad breath, bad taste, ulcers, pain
- Ask when last dental visit was
What is the pharmacological treatment for periodontal disease?
Chlorhexidine 0.12% (Peridex)
What schedule is chlorhexidine?
1
What does chlorhexidine do?
Decreased periodontal pathogens in saliva
What is the dosing indication for chlorhexidine?
- Swish and spit 10-15 mLs for 30 seconds BID
- Use 5-7 days for mild gingivitis and up to 31 days for chronic periodontitis
What are possible side effects of chlorhexidine?
- Tooth and tongue staining
- Taste disturbances
What are some non-pharms for periodontal disease?
- Adhere to daily oral hygiene practices
- Healthy balanced diet
- Avoid sipping or frequent intake of acidic food/drink
- Quit smoking and decrease alcohol consumption
- Regular dental visits
