Dental Conditions Flashcards
Symptoms of teething
gum redness swelling tenderness drooling rubbing the gum irritability crying etc.
NOT symptoms of teething
fever
diarrhea
vomiting
common cold symptoms
Non-pharmacological treatment of teething
- rub baby’s gums
- cool affected area
- wipe baby’s drool with cloth to prevent rashes from developing
Pharmacological treatment of teething
Oral analgesics:
- acetaminophen
- ibuprofen
Dose for acetaminophen
10 to 15 mg/kg/dose every 4 to 6 hours PRN
max dose = 65-75 mg/kg/day
Dose for ibuprofen
5 to 10 mg/kg/dose every 6 to 8 hours PRN
max dose = 40 mg/kg/day
When do you refer?
if no relief with treatment after 3-5 days
How long to topical anesthetics provide relief for?
max of 45 mins
What is the potential harm caused by topical anesthetics for teething?
if baby swallows some, it can numb their throat/gag reflex
Would you ever recommend a topical anesthetic for teething?
personally, no
a oral analgesic is much more effective for pain relief, provides longer duration and does not pose the certain health risks that topical anesthetic does
What can a toothache be caused by?
- cracked tooth syndrome - abrupt pain with biting, resolves with removal of pressure
- this requires referral to dentist
- post-dental procedure discomfort
Toothache treatment options for temporary relief until dentist can be seen include:
- oral analgesics: NSAIDS, acetaminophen
- local anesthetics: benzocaine
Is a local anesthetic still an issue for adults?
yes - can numb throat and you may burn yourself without even knowing it
AGAIN - local anesthetic is not the best choice
Dentin hypersensitivity = ?
sensitive teeth
Describe dentin hypersensitivity
short, quick, sharp dental pain due to exposure to a stimulus (thermal, chemical, osmotic or physical) on exposed dentin
Is a dental referral necessary for dentin hypersensitivity?
yes - to determine the underlying cause
Non-pharmacological treatment for tooth hypersensitivity
- soft-bristled toothbrush
- proper tooth brushing
- reduce acidic foods and drinks
- avoid brushing within 2 hours after acidic foods/drinks
Pharmacological treatment for tooth hypersensitivity
-desensitizing toothpaste works by blocking the repolarization of the nerve fibre membranes thereby decreasing the pain
most common = potassium nitrate
product examples include: sensodyne F, crest pro-health, colgate sensitivity
Is using a potassium nitrate a long-term or short-term treatment?
long-term because you have to continuously use the product to continuously block the repolarization of nerve fibres
oral candidiasis known as?
oral thrush
oral stomatitis
oral candidiasis (thrush) most commonly caused by ?
C. Albans
There are 2 major forms of oropharyngeal candidiasis:
1) pseudomembranous form
2) atrophic form
describe them
1) the pseudomembranous form is the most common and appears as white plaques on oral mucosa
2) the atrophic form (denture stomatitis) appears as erythema without plaque. common in elderly with dentures
1 - plaque
2 - no plaque
Are the white plaques removable?
yes
Risk factors for oral candidiasis
- diseases that affect immune system (diabetes, HIV)
- medications that suppress immune system (chemo)
- xerostomia (dry mouth/lack of saliva)
- use of corticosteroids (either systemic or inhaled)
- recent use of broad spectrum antibiotics
- infants and children - put things in their mouths
- local mucosal trauma
- poor dental or denture hygiene
- pregnant women
- smokers
Signs and symptoms for oral candidiasis
- “cottage cheese” soft plaques that are white or creamy yellow
- plaques are easily removed with rubbing
- red, flat lesions on mucosa under the denture
- can cause cracked, red, moist areas on the skin at the corners of the mouth
- symptoms are varied and may range from none to sore, painful mouth, burning tongue, metallic taste, and dysphagia
Red flags for oral candidiasis
- Pt on chemo or immunocompromised
- Pt has systemic symptoms such as unexplained weight loss or thirst which could indicate diabetes
- other organ involvement such as conjunctivitis, uveitis or accompanying genital ulcers
- any lesion present for 3 weeks or longer should be referred
- symptoms of an adverse drug rxn
- if you suspect another type of infection
- unsuccessful treatment after 14 days
If red flags are not present - you can ??
prescribe for it! yay! (jk the thought of prescribing scares the shit outta me)
Goals of treatment for oral candidiasis ?
- eradicate infection
- prevent complications
- prevent recurrence
Non-pharmacological suggestions for infants with oral candidiasis?
- sterilize toys, soothers, feeding bottles/nipples
- if breastfed, mother may have candidiasis on nipples - will require treatment
Non-pharmacological suggestions for people with dentures with oral candidiasis?
- remove dentures overnight
- wear dentures for only 6 hours
- soak and clean dentures when not using
- clean oral cavity with soft toothbrush
-correct underlying risk factors:
rinse mouth after inhaled corticosteroid and stop smoking
Pharmacological therapy for oral candidiasis ?
Rx:
- Nystatin
- Oral Azole Antifungals (fluconazole, itraconazole, ketoconazole, etc.)
Non-Rx:
-gentian violent (no longer recommended)
Nystatin is NAPRA schedule __
1
it is Rx only
Nystatin is ?
- fungi-static and tidal
- considered 1st line for mild disease
- comes as a liquid
Nystatin oral suspension dose for adults/children
4 to 6 mL of 100,000 unit/mL suspension QID for 7-14 days
Nystatin oral suspension dose for infants
1 to 2 mL of 100,000 unit/mL suspension QID for 7-14 days
when should treatment continue until?
treatment should continue for at least 48 hours after symptoms resolved
Do you recommend to swallow Nystatin
yes
- put part of the mL’s in one side of mouth and the other part in the other side of the mouth and swish around
- it is recommended to swallow this because it is not absorbed and will not enter the systemic circulation and won’t contribute to drug interactions
After prescribing nystatin, follow up with the patient should occur in _ days
7
If symptoms are resolved in 48 hours can you discontinue medication?
yes
cold sores are primarily caused by?
HSV-1
Triggers for cold sores?
stress sun exposure trauma hormonal changes fever viral infection fatigue cold weather windburn
cold sores last ?
7-14 days
Describe the prodromal phase and how long does it last
pain, itching, tingling at site
lasts < 24 hours
Describe the erythema phase and how long does it last
red and inflamed area
lasts 24-48 hours
Describe the papule phase and how long does it last
small, raised lesions
lasts 24-48 hours
Describe the vesicle phase and how long does it last
clear, fluid in lesion, swollen with red halo
within 1-3 days
Describe the ulcer phase and how long does it last
yellow, weeping, moist and painful
1-3 days
Describe the crusting phase and how long does it last
hard crust, inflamed, red, some swelling
day 5-8
Red flags for cold sores
- lesion not healed in 14 days (w or w/o treatment)
- systemic symptoms (fever, swollen glands)
- lesion shows signs of infection (excessive redness, swelling, pus)
- more than 6 outbreaks/yr
- pregnant
- pt immunocompromised
Treatment goals for cold sores
- relieve discomfort
- reduce duration and severity
- prevent secondary infection (yellow pus)
- prevent spread to others
- prevent recurrences - reduce triggers
OTC treatment for cold sores:
Docosanol 10% (Abreva)
Docosanol 10% (Abreva)
- topical antiviral
- prevents viral migration and replication
- apply 5 times daily at first sign (max 10 days)
- for >12 yrs old
OTC treatment for cold sores:
Heparin sodium and Zinc sulfate (Lipactin)
Heparin sodium and Zinc sulfate (Lipactin)
-no safety or efficacy evidence published
OTC treatment for cold sores: Hydrocolloid patch (Polysporin Cold Sore Healing Patch)
Hydrocolloid patch (Polysporin Cold Sore Healing Patch) -one study published - small sample size, based results of the participants assessment, manufacturer involved
OTC treatment for cold sores: Local anesthetics (benzocaine, lidocaine)
Local anesthetics (benzocaine, lidocaine) reduce pain for only a short time (30-45 minutes) -risk of choking and being burned
OTC treatment for cold sores:
Protectants
Protectants
-may reduce cracking and drying of cold sore
-hydroxypropyl cellulose (zilactin cold sore gel - benzyl alcohol 10%)
petrolatum, cocoa butter, allantoin
OTC treatment for cold sores:
Topical analgesics
Topical analgesics
- camphor, menthol, phenol
- may reduce pain for a short time
OTC treatment for cold sores:
Oral analgesics
Oral analgesics
- acetaminophen, ibuprofen, naproxen
- can be used to treat pain for up to 3 days
Rx treatment for cold sores
Rx antivirals
-can be used for treatment of prophylaxis
Non-pharmacologic treatment for cold sores
- lip conditioners/proctectants: petrolatum, cocoa butter, allantoin, SPF 30 to prevent sun damage
- keep area clean (warm water and soap) to prevent infection
- avoid direct contact with others
- wash hands often, avoid touching lesion
- avoid sharing objects
- stress reduction and rest
aphthous ulcers are known as?
canker sores
Describe aphthous ulcers
- painful, recurrent lesions
- not contagious
- unknown cause
- found on inner lip, inner cheek, soft palate, undersurface of tongue, floor of mouth
- appear first in childhood
characteristics of canker sores
- crater/indent
- white (white part is not removable - distinguishes it from thrush)
- red halo
symptoms of aphthous ulcers
- symptoms last 5-14 days
- burning, tingling, intense persistent pain
- four appearance-related factors - roundish, shallow-cratered, red halo, white-yellow interior covering
- may feel some pain in area prior to outbreak
when do you refer for aphthous ulcers?
- 5 or more ulcers
- if they are over 1 cm
- if it lasts longer than 14 days
Predisposing factors for aphthous ulcers
- stress and anxiety
- local trauma
- genetic predisposition
- allergies/ food sensitivities
- nutritional deficiencies
- systemic diseases
- medications (NSAIDs, ACE inhibitors, beta-blockers, opioid analgesics)
red flags for aphthous ulcers
- severe pain
- diameter of ulcer > 1 cm
- > 5 ulcers present
- duration of ulcer > 14 days
- history of recurring aphthous ulcers (6-12x/yr)
- systemic disease (HIV, inflammatory bowl disease, diabetes)
- fever or other systemic symptoms present
- ulcer first occurring later in life (>30 yrs old)
- pregnant
- nutritional deficiency suspected (vitamin or iron)
goals of therapy for aphthous ulcers
- relief from pain
- decrease duration of ulcer
- ensure normal oral function and adequate nutrition intake
- decrease frequency and severity of recurrences
Non-pharmacological suggestions
-avoid foods that cause pain
when aphthous ulcer present
-avoid oral trauma (use a soft bristled toothbrush, oral wax on braces that may rub or irritate the cheek, have irregular dental surfaces repaired)
-avoid oral products that contain sodium laurel sulphate
-avoid foods that trigger flares
-treat nutritional deficiencies
-dental hygiene (brush teeth and floss 2x/day, routine dental cleaning)
-warm saline rinses
OTC treatment for aphthous ulcers:
Oral analgesics
Oral analgesics
- ONLY acetaminophen
- never NSAIDs b/c they can cause aphthous ulcers
OTC treatment for aphthous ulcers:
Protectants
Protectants
- may offer short term relief and protection
- hydroxypropyl cellulose, carboxymethyl cellulose (Orabase)
OTC treatment for aphthous ulcers:
Topical analgesics
Topical analgesics
-camphor, menthol, phenol, (Canker Cover)
OTC treatment for aphthous ulcers:
Local anesthetics
Local anesthetic -may provide short term relief of pain -risk of choking or being burned -benzocaine (10-20% strength) (anbesol, oracle, kank-A)
What can a Mb Pharmacist prescribe for aphthous ulcers
triamcinolone 0.1% in orabase
What are some Rx product options (can only be prescribed by a physician or a dentist)
- antibiotic therapy (tetracycline mouth rinse)
- pain relief (ex. benztdamine topical solution)
- other agents: dapsone, colchicine, dexamethasone ointment, prednisolone, infliximab, thalidomide, etc.
Describe Triamicinolone 0.1% in Orabase
- product delivers a protective local coating and enables a local anti-inflammatory effect of the corticosteroid
- RCT demonstrated effective to decrease pain
- may be helpful to speed healing and relieve symptoms for recurrent minor aphthous ulcers
- early initiation of this treatment may result in a more rapid response
*it is a topical steroid product - brings down redness and inflammation
Dosing of Triamicinolone 0.1% in Orabase
apply to aphthous ulcers 2-4 times a day until ulcer healed
Application of Triamicinolone 0.1% in Orabase
Press a small dab (1/4 inch) to the lesion until a thin film develops.
Use only enough to coat the lesion with a thin film, do not rub in.
Apply at bedtime or after meals if applications are needed throughout the day.
Don’t eat or drink for 30 mins after applying.
Side effects of Triamicinolone 0.1% in Orabase
potential development of oropharyngeal candidiasis (thrush), burning, irritation, etc.
Describe the monitoring of Triamicinolone 0.1% in Orabase
- if there is no significant healing in 7 days or if ulcer worsens, refer
- ulcer should heal within in 14 days, if not - refer
- pharmacists should monitor pain every 3 days for first week then again in 1 week
Xerostomia
dry mouth - hyposalivation
Causes of xerostomia
- medical conditions (sjogre’s syndrome, addison’s disease, depression, cystic fibrosis, HIV)
- medications (anticholinergics, antidepressants)
- radiation therapy
- trauma or tutors involving the salivary glands
Complications involved with xerostomia
- increased risk of dental caries
- tooth decay and loss
- difficulty in speaking
- decreased ability to chew and swallow
- decreased taste sensation
- decreased nutritional status
- oral infections (candidiasis, gingivitis)
Non-pharmacological treatment for xerostomia
- ensure proper dental care (because they are at a higher risk of developing cavities)
- sucking on ice chips
- frequent sips of water
- hard sugarless candies or gum (containing alcohol sugars)
- humidifer at night
- avoid or reduce caffeine intake
- avoid tobacco and alcohol
OTC pharmacological options for xerostomia:
Salivary substitutes and lubricants
Salivary substitutes and lubricants:
- replace moisture
- provide replication
- mimic natural saliva
- does not stimulate salivary glands to produce more saliva
OTC pharmacological options for xerostomia:
Biotene products
Biotine products:
- toothpaste, mouthwash, gum
- help to replace missing salivary enzyme activity in patients with decreased saliva production
OTC pharmacological options for xerostomia:
Oral balance
Oral balance:
- oral moisturizer
- lasts an hour in daytime
- lasts 4 hours at nighttime
OTC pharmacological options for xerostomia:
Moi-Stir
Moi-Stir:
- spray or swabs
- contains electrolytes found in saliva
OTC pharmacological options for xerostomia:
OraMoist
OraMoist:
-patch placed on the hard palate or inside of cheek dissolves slowly over 2-4 hours
What are 2 types of periodontal disease?
- gingivitis
- periodontitis
Describe gingivitis
- inflammation of the gums
- result of build-up of bacterial plaque
- swelling and discolouration of gums (red or red/blue)
- bleeding of gums when brushed
Risk factors for gingivitis
- medical conditions
- medications
- poor nutrition
- infections
- hormonal changes
Describe periodontitis
- progression of gingivitis
- plaque has spread to the roots
- gums may pull away from teeth
- pain, bleeding of gingival tissue, halitosis, foul taste, increased salivation
- pain may occur
- may cause damage to the bone
List the Periodontal Screening questions
BUG
Bleeding gums
Unsteady (loose) teeth
Gum recession
*also ask when was last dental visit
Other symptoms of periodontal disease
- signs of infection
- bad breath
- bad taste
- ulcers
- pain
Periodontal disease pharmacological treatment
Chlorhexidine 0.12% (Peridex)
- schedule 1 (Rx only)
- decreases periodontal pathogens in saliva
- swish and spit 10 to 15 mLs twice daily for 30 seconds
- 5-7 days for mild gingivitis
- up to 31 days for chronic periodontitis
- possible side effects include: tooth staining, taste disturbances, tongue discolouration
