Dental Health (Parts 1-2, COMBINED) Flashcards
2024 --- General, Jaw Aches, Toothaches, Teething, Cold Sores, Canker Sores, Oral Thrush (Oral Candidiasis), Dry Mouth (Xerostomia), Angular Cheilitis, Gingivitis, TMJ, etc.,
Which 2 viruses are SK pharmacists heavily involved in?
1) Cold Sores (Herpes Labialis)
2) Oral Thrush (Oral Candidiasis)
Toothaches
Pain in or around a tooth, typically caused by dental decay, infection, or trauma (among other causes).
- Symptoms: Sharp or throbbing pain in the affected tooth or area, sensitivity to hot or cold foods/drinks, swelling around the tooth, fever or headache if infection present
Pharmacists should NOT try to determine the causes!
As pharmacists, what is our role in toothaches?
Treatments ONLY!
- Do not deal with differential or diagnosis of toothaches.
Jaw Aches
Pain or discomfort in the jaw region, often due to muscle tension, injury, or temporomandibular joint (TMJ) issues.
- Symptoms includes: Pain or tenderness in the jaw, difficulty chewing, clicking or popping sounds in the jaw joint, jaw stiffness or locking
Pharmacists should NOT try to determine the causes of Jaw Pain.
Teething
The process by which an infant’s teeth erupt through the gums
- Symptoms may include: Irritability, drooling, swollen or tender gums, increased biting/chewing behavior, disrupted sleep
- Typically occurs between 6 months and 3 years of age, can vary in intensity and duration
Cold Sores (Herpes Labialis)
Viral infection caused by herpes simplex virus type 1 (HSV-1), characterized by fluid-filled blisters on or around the lips.
- Symptoms may include: Tingling or burning sensation before blisters appear, clusters of small fluid-filled blisters, crusting over of blisters, itching or pain in the affected area
- Triggers include stress, sunlight exposure, fever, hormonal changes; can recur periodically;
- There’s no cure but antiviral medications can help manage outbreaks
Canker Sores
Painful ulcers that develop inside the mouth, often on the inner cheeks, gums, or tongue.
- Self-limiting in most cases within 1-2 weeks
Oral Thrush (Oral Candidiasis)
Fungal infection caused by Candida yeast, characterized by creamy white patches on the tongue and oral mucosa (mouth and/or throat).
- Common, especially in infants (lack of fully functional immune system, acquired from their mothers from things like recent antibiotic use, etc) and older adults (inhaled corticosteroids for asthma or rhinitis; dentures; and suppressed immune systems (disease or drug) or certain health conditions like diabetes)
Condition characterized by a decrease in saliva production, leading to dryness in the mouth.
Dry Mouth (Xerostomia)
Inflammation or irritation of the corners of the mouth, often due to fungal or bacterial infection.
Angular Cheilitis
Gingivitis
Early stage of gum disease characterized by inflammation and bleeding gums.
- Swollen, tender, or bleeding gums, bad breath, receding gums, loose teeth, changes in bite alignment
TMJ (Temporomandibular Joint) Disorders
Conditions affecting the jaw joint and surrounding muscles, often causing pain and dysfunction.
- Jaw pain/Jaw aches
- Difficulty opening/closing the mouth, clicking or popping sounds in the jaw joint, headaches, neck or shoulder pain
What 3 drugs/drug Classes of antibiotics are contraindicated for pregnant women?
- Fluoroquinolones,
- Tetracyclines (including tetracycline, minocycline, doxycycline, etc) and
- Clarithromycin are not recommended for use during pregnancy
Tetracyclines and Teeth
Tetracyclines are not recommended for pregnant women; but which trimesters are most notable?
2nd and 3rd Trimesters
Besides pregnant women, who else are tetracyclines NOT recommended for?
Children under the age of 8.
What are the implications of using tetracyclines when pregnant, or for children under the 8?
Cosmetic staining on permanent teeth.
- Children might require veneers as a result.
List 4 general red flags if a person is complaining of either toothaches or jaw aches that we should always keep in mind.
- Fever
- Pus
- Swelling
- Headaches
List some of the possible causes/etiology of toothaches (4)
Pharmacists’ role is about Treatment and not about finding the cause of things… But need to still know.
- Tooth decay
- Abscess/Infected Gums
- Damaged fillings
- Repetitive motions (e.g., Chewing gum, grinding teeth)
There are other possible causal links associated to experiencing toothaches that are non-dental related such as sinus infections.
Also need to know the RED FLAGS
Bruxism
Grinding of the teeth
A 25-year-old man comes to the pharmacy and tells you they have been experiencing toothaches for the past few days and is hoping you can help them.
As a pharmacist, what is my next move? What am I allowed to do?
As a pharmacist, we are NOT to try to figure out the possible causes to the aching teeth. We do NOT dive into this. This is DENTIST territory.
- As a pharmacist, I can just make sure to ask the right questions to see if I can show them my OTC analgesics to hold them down until they can see their dentist, and be sure to counsel them on safety and dosing.
- Advise patient to consult a dentist as soon as they can if the pain is bothersome.
Toothaches
List the Medications can use for Toothaches.
- Acetaminophen (including T1s to T3s)
- NSAIDs (Ibuprofen, Naproxen, Aspirin)
Which OTC analgesic is a more favourable option to recommend to those suffering from toothaches?
a) Acetaminophen (including T1s to T3s)
b) NSAIDs (Naproxen, Ibuprofen, and Aspirin)
c) Codeine
d) Both a and b
e) Topical analgesics
b) NSAIDs (Naproxen, Ibuprofen, and Aspirin)
Which of the following medications is not considered a great analgesic but is often prescribed for pain?
A) Acetaminophen
B) NSAIDs
C) Codeine
D) Aspirin
C) Codeine
What is the maximum daily limit for over-the-counter Ibuprofen in Canada (for any use)?
A) 800 mg
B) 1200 mg
C) 2100 mg
D) 3200 mg
E) 4000mg
B) 1200 mg of Ibuprofen (OTC)
What is the main mechanism of action of ibuprofen (in general)?
A) Inhibition of COX-1 enzymes
B) Inhibition of COX-2 enzymes
C) Central inhibition of prostaglandins
D) Inhibition of COX-1 and COX-2 enzymes
D) Inhibition of COX-1 and COX-2 enzymes
What is the maximum daily limit for over-the-counter Acetaminophen in Canada (for any use)?
A) 800 mg
B) 1200 mg
C) 2100 mg
D) 3200 mg
E) 4000mg
E) 4000mg (OTC maximum dosing of Acetaminophen)
Why do many dentists recommend the combination use of both ibuprofen and acetaminophen?
Because a lot of people who only use one agent often find themselves maxing out on one analgesic without even getting adequette pain relief that is needed.
- Want to try to match up while trying not to exceed either agents’ daily max dosings.
Managing Post-Operative Dental Pain (2017) USA
Before the introduction of drug combinations containing both NSAIDs and acetaminophen in the USA, what was the proposed dosing regimen suggested by Dionne (2017) for post-dental surgery?
A) Take ibuprofen 400-600mg every 4-6 hours
B) Take ibuprofen 400-600mg every 6-8 hours
C) Take ibuprofen 400-600mg every 2-3 hours
D) Take ibuprofen 400-600mg every 12 hours
If chose to spread out the ibuprofen and acetaminophen dosings…
A) Take ibuprofen 400-600mg every 4-6 hours
Managing Post-Operative Dental Pain (2017) USA
According to Dionne’s proposed dosing regimen of the combination uses for dental surgery pain, what is the maximum daily dosage limit for ibuprofen?
A) 1600 mg
B) 2400 mg
C) 3200 mg
D) 4000 mg
This is in regards to THIS scenario in USA by Dionne.
Not Canada’s OTC max or Canada’s max RX daily dosing.
B) 2400 mg
Canada’s Max OTC Dosing = 1200mg; Canada’s Max RX Dosing is: 3200mg; THIS dosing in USA by Dionne for these purposes was 2400mg.
Managing Post-Operative Dental Pain (2017) USA
Before the introduction of drug combinations containing both NSAIDs and acetaminophen in the USA, what was the proposed dosing regimen suggested by Dionne (2017) for post-dental surgery?
A) Take acetaminophen 325-500 mg every 4-6 hours
B) Take acetaminophen 500-625mg every 6-8 hours
C) Take acetaminophen 625-1000mg every 6 hours
D) Take acetaminophen 325-1000mg every 6 hours
if chose to spread out the acetaminophen and ibuprofen dosings
C) Take acetaminophen 625-1000mg every 6 hours
Managing Post-Operative Dental Pain (2017) USA
What is the maximum daily dosage limit for acetaminophen according to Dionne (2017) ‘s proposed dosing regimen for post-dental surgery?
A) 2000 mg
B) 3000 mg
C) 4000 mg
D) 5000 mg
c) 4000mg
Same as daily max dosing for normal acet use
Managing Post-Operative Dental Pain (2017) USA
Ultimately, how has Dionne (2017) indicated ibuprofen and acetaminophen can be administered at the same time without exceeding the daily max doses of both analgesics?
Both medications [Ibuprofen 600mg + Acetaminophen 1000mg] could be administered every six hours (i.e., four times daily) for 24 hours without exceeding the maximum daily doses of either drugs.
- This is what they called the “2-4-24” rule.
Managing Post-Operative Dental Pain (2017) USA
What is the “2 - 4 - 24” Rule addressed by Dionne (2017)?
- 2 Drugs = Ibu and Acet
- 4 Doses = Q6H
- (Per) 24 Hours
Dosages in Advil Dual Action are almost ____ but they are good agents.
Sub-Therapeutic
T/F: Advil Dual Action & Combogesic contains both acetaminophen and ibuprofen. Both of which has a larger concentration (# wise) of ibuprofen in comparison to acetaminophen.
TRUE!!!!!
Why are NSAIDs more commonly recommended for toothaches than acetaminophen products?
A) NSAIDs have fewer side effects
B) Acetaminophen is not effective for toothaches
C) NSAIDs help reduce inflammation, which is usually involved in toothaches
D) The kind of acetaminophen needed to treat toothaches are not available over-the-counter
C) NSAIDs help reduce inflammation, which is usually involved in toothaches
Legally, pharmacists are not permitted to recommend dosing beyond the OTC daily maximums.
Approved daily max dosing of Ibuprofen as OTC is 1200mg. Theoretically, what is a dosing is often prescribed by MDs and dentists?
400mg QID
This is to just prove the point that technically can go over OTC maximums to a point and remain safe.
Advil Dual Action
Advil Dual Action:
What are the two analgesics in this product?
Be sure to indicate the concentration of each analgesic per caplet.
Ibuprofen + Acetaminophen
- Ibuprofen = 125mg
- Acetaminophen = 250mg
Note: This Advil product contains more acetaminophen (# wise - not necessarily potency level) than ibuprofen.
While Advil Dual Action contains ibuprofen [NSAID], the OTC dosage in each dose (ibu 125mg x 2) does not treat the inflammation… Instead, the OTC dosing of Ibuprofen ____
Helps to relieve pain associated with inflammation.
Advil Dual Action
Even though the concentrations of acetaminophen and ibuprofen might seem lower in dosage, when taken together like this, it is likely that the acetaminophen is probably working ____ on the _____; while the ibuprofen is likely to be working peripherally on the prostaglandins.
Acetaminophen is likely working CENTRALLY on the PROSTAGLANDINS.
Advil Dual Action
Even though the concentrations of acetaminophen and ibuprofen might seem lower in dosage, when taken together like this, it is likely that the acetaminophen is probably working centrally on the prostaglandins; while the ibuprofen is likely to be working _____ on the ____.
Ibuprofen is likely to be working PERIPHERALLY on the PROSTAGLANDINS.
Combogesic
Combogesic:
What are the two analgesics in this product?
Be sure to indicate the concentration of each analgesic per tablet.
Ibuprofen + Acetaminophen
- Ibuprofen = 97.5mg
- Acetaminophen = 325mg
Same active ingredients as Advil Dual BUT different concentrations
Note: Combogesic also contains more acetaminophen compared to ibuprofen (# wise - not necessarily potency level). BUT Combogesic has LESS ibuprofen than Advil Dual & has MORE acetaminophen than Advil Dual…
What is the recommended adult dosing frequency for Advil Dual Action?
A) Every 6 hours
B) Every 8 hours
C) Every 12 hours
D) Every 24 hours
B) Every 8 hours
2 Caplets Q8H
T/F: Acetaminophen is more commonly recommended for toothaches than NSAIDs.
False.
NSAIDs are commonly more recommended over acetaminophen.
T/F: Ibuprofen 400mg taken four times a day is within the safe prescription range, although it exceeds the over-the-counter limit.
True.
But legally, we cannot recommend patients to dose off-label.
What is the main mechanism of action for acetaminophen in Advil Dual Action?
A) Peripheral inhibition of prostaglandins
B) Central inhibition of prostaglandins
C) Blocking of histamine receptors
D) Activation of opioid receptors
B) Central inhibition of prostaglandins
How do we feel about using Aspirin for toothaches?
It can be used for toothaches technically but not very common to see people use.
- Can use a combo of ibuprofen plus acetaminophen.
What is the main mechanism of action for ibuprofen in Advil Dual Action?
A) Peripheral inhibition of prostaglandins
B) Central inhibition of prostaglandins
C) Blocking of histamine receptors
D) Activation of opioid receptors
A) Peripheral inhibition of prostaglandins
List 3 Possible Treatments of Toothaches.
Besides oral analgesics.
**Heat or Cold Packs ** (placed outside of the cheeks)
**Topical Benzocaine **
- If pain originates from a tooth, topical benzocaine will not give any pain relief.
- If pain is from the gums, will see some relief when using topical benzocaine.
- Can be safe as long as for minor toothache and for minor canker sores
- Unsafe for severe or persistent pain which might end up masking the bigger issue. Should not be overused or misused.
- Health Canada does not approve the use of benzocaine for any infants under the age of 2
**Clove Oil **
- Long history for topical use for toothaches; however there is minimal value to use this for toothaches.
If a person is suffering from toothaches, when would topical benzocaine provide some pain relief?
If the pain originates from the gums.
If a person is suffering from toothaches, when would topical benzocaine not be likely provide pain relief?
If the pain originates from a tooth (instead of the gums).
… It will not have analgesic benefits
What age groups is benzocaine NOT safe for?
Infants/Children under the age of 2.
Always make sure to look at ingredients list.
Benzocaine should not be used in infants under 2 years old, as it may cause a rare but serious condition called methemoglobinemia, which reduces the amount of oxygen carried in the blood.
Prior to 2012 (and Health Canada’s 2018 modifications), there were topical benzocaine options available for infants to use when teething…
What concentrations of benzocaine were previously available for infants to use while teething?
7.5 to 10% (7.5% was “regular strength” and 10% was “extra strength”)
prev. warning was that any benzocaine above 10% was not considered safe for infants to use). In 2018, they were taken off the shelves.
- Now discontinued version of Baby Orajel was in grape flavour and was advised that could apply a thin layer to the gums up to QID and to avoid feedings for 1 hour after application.
Clove Oil has been used for a long time as a topical agent to treat toothaches. How effective is Clove Oil?
Minimal effects on teeth pain.
Heat and Cold Packs can also be used for a variety of dental pain… How does this work?
We don’t really know how this works for pain itself or the cause behind its effects exactly.
- Place the pack on the side of the cheek and it helps reduce the swelling.
Lots of adults will try Orajel Maximum Strength PM Toothache & Gum Relief Paste. This contains 20% benzocaine in it. What is the significance in HS or PM usage?
Absolutely no PM/HS impacts.
- Completely a marketing tactic.
Which of the Orajel products has benzocaine (7.5 to 10%) for infants teething?
None of them!
- As of 2018, Health Canada prohibits benzocaine to be used for infants who are under the age of 2 so none of the products for teething has benzocaine anymore.
- Any Baby Orajel products currently available on the market is non-medicated and does not contain any traces of benzocaine.
What is considered to be both the mainstay non-pharmacological option and also the most effective form of treatment for teething?
Teething Rings (teething toys, or anything that goes in place with them)
Why is benzocaine not authorized to be used in children under the age of 2?
Might cause a rare but serious condition called methemoglobinemia,
- which reduces the amount of oxygen carried in the blood.
At what age does the average infant start teething?
~ 6 months of age.
Each child is different.
Teeth often come in first in the front of the mouth.
Which section usually erupts 1 to 2 months earlier than their matching counterpart?
Lower Central Incisors = Lower teeth (front part of the mouth) before their matching upper teeth. Usually takes place between ages 6-10 months of age.
- Lower teeth usually erupt 1 to 2 months earlier than their matching upper teeth.
Minimal pain at this stage… More like mild discomfort
Around what age range do most infants develop their upper central incisors (i.e., front upper teeth)?
~ 8-12 months of age
Mild discomfort at most. As far as we know, very minimal pain at this stage.
At around what age do our first molars start to appear?
~ 1 year old
Molar development is where pain sets in
Around what age do our second molars start to appear?
~ 2-3 years old.
(or 25-33 months of age)
What may children often do to relieve the pressure in their gums during teething?
a) Become dependent on their pacifiers
b) Suck on ice cubes
c) Bite on fingers or toys
d) Drink warm milk
c) Bite on fingers or toys
If a child’s temperature is above 38°C (100.4°F) during teething, what should parents look for to determine if it’s related to an infection or illness?
a) Runny nose
b) Extra drooling
c) Symptoms of ear infection or respiratory virus
d) None of the above
c) Symptoms of ear infection or respiratory virus
- Ear Infections – Pain would be more intense
- Respiratory viruses – runny nose, congestion, cough
A mom comes to the pharmacy and feels helpless as her 7-month-old is having trouble sleeping for the last 2 weeks. She explains her daughter is drooling a lot more as of late, more irritable, has a rash on her face, feel slightly hot at the touch but fever is minimal.
She thinks her daughter is teething. She grabs a box of topical benzocaine and is asking how should she give this to her daughter.
What are you going to tell her?
Health Canada does not authorized the use of any benzocaine-containing products for children under 2 years of age…
- Consider safe and clean teething toys (can put them in the freezer for a few minutes at a time to provide some relief.
- Instead of benzocaine, can consider infant acetaminophen or ibuprofen that is dosed based on the child’s weight.
A grandfather comes to the pharmacy looking for a product for his teething grandson. He asks if Baby Orajel™ Natural Source Homeopathic Teething Gel is a good option to use… Are you going to recommend this product to him?
No! We don’t like this product.
- It’s just dental gel
- Minimal relief and poor value.
- It’s “natural” but does absolutely nothing and a waste of money.
- Cooling effects not from the gel but from the drying effects of it.
At what age do lower central incisors typically emerge in infants?
a) 2-3 months
b) 6-10 months
c) 8-12 months
d) 25-33 months
b) 6-10 months
- This refers to the lower front tooth/teeth.
Angular cheilitis is characterized by inflammation at which part of the mouth?
a) Roof of the mouth
b) Inner cheeks
c) Corners of the mouth
d) Gum line
c) Corners of the mouth
When do upper second molars usually appear in children?
a) 2-3 months
b) 6-10 months
c) 8-12 months
d) 25-33 months
d) 25-33 months
T/F: Teething can cause children to be more irritable and uncomfortable.
True.
During teething, children may experience symptoms such as irritability, facial rash, extra drooling, and a mild increase in temperature above _____________°C
38°C
If above 38c, should start to consider other symptoms that might not be associated with teething.
At what age do most children develop a full set of 20 baby teeth?
~ 3 years old.
Why is benzocaine not recommended for children under 2 years old?
a) It may cause temporary numbness in the mouth.
b) It could lead to gastrointestinal discomfort if ingested.
c) It may disable the infant’s gag reflex if swallowed.
d) It carries a risk of causing a rare, acute blood disorder known as methemoglobinemia.
d) It carries a risk of causing a rare, acute blood disorder known as methemoglobinemia.
- Old concern was about the disabling of the gag reflexes
- Current concern: methemoglobinemia
If we had a 3-year-old who is on the last stages of teething and developing their second molars, is benzocaine now okay to use it?
Yes, benzocaine is safe to use
… But we still prefer oral analgesics (acet or ibupr) over benzocaine
T/F: Cold Sores are the #1 most common prescribing conditions that pharmacists in SK are involved in.
True.
Cold sores often become small fluid-filled ____ that break open and release a clear, sticky fluid.
Blisters.
Which herpes simplex virus type is most commonly transmitted via saliva and causes the majority of oral herpes infections?
a) HSV-1
b) HSV-2
c) Both HSV-1 and HSV-2
d) Neither HSV-1 nor HSV-2
a) HSV-1
Cold Sores are also known as:
- __
- ____
- ____
- Fever blisters,
- Oral herpes,
- Herpes Labialis
What primarily causes cold sores?
Herpes simplex virus type 1 (HSV-1)
Oral Herpes
Cold Sores
Where does the herpes simplex virus type 1 (i.e., HSV-1) primarily lie latent in the body?
a) Salivary glands
b) Lymph nodes
c) Facial nerve pathways
d) Respiratory tract
c) Facial nerve pathways
When is the risk of transmission highest for herpes simplex virus type 1 (HSV-1)?
a) During asymptomatic periods
b) During symptomatic periods
c) Equally during symptomatic and asymptomatic periods
d) Risk is negligible for HSV-1
b) During symptomatic periods (highest transmission shedding)
As long as the lesions are not crusted over, you are symptomatic.
BUT can still spread the virus while asymptomatic
Cold Sores
By early adulthood, most people have become
HSV Positive
By the time individuals reach early adulthood, a significant portion of people have been infected with the herpes simplex virus (HSV), specifically HSV-1, which is responsible for cold sores.
The HPV-1virus lies latent in
Facial nerve pathways
T/F: Cold sores are only caused by the HSV-1 pathogen
**False! **
- HSV-1 is a more dominant causal pathogen for cold sores BUT is NOT the only pathogen to blame.
- Cold sores can also be caused by HSV-2, as well.
Cold Sores
Virus lies latent in facial nerve pathways as most of us are HSV positive by early adulthood…
What factors are likely to re-activate cold sores?
- Stress
- Trauma
- Sunlight
Once you have the herpes virus in your body, **what is the likely outcome - long-term? **
… You may get cold sores occasionally for the rest of your life.
Cold Sores
____% experience recurring infections (2-6 per year)
20-40%
How many stages are there for Cold Sores?
There are 5 Stages of Cold Sores.
5 Stages of Cold Sores.
Stage 1 of Cold Sores:
“Prodrome Stage” or “Prodromal Stage”
Duration, Symptoms, Presentation, and any other important details.
- Duration: Less than a day (half of a day) but at the most 2 days.
- Days 1 to 2.
- Symptoms: Tingling, itching, and/or burning where the cold sore is iminent.
- Presentation: Might have little-to-no visible signs of a cold sore or blister appearing. Maybe some redness.
- Not all people infected with a cold sore will go through Phase 1 and just be asymptomatic before they get to the other stages… BUT Stage 1 is very common.
- This is where we want to introduce antiviral therapies (On Days 1-2)
Stage 1: Prodromal Stage of Cold Sores.
Approx. 50% of cold sore sufferers will experience Stage 1… Prodromal Stage involves lingering symptoms of an inevidable cold sore and occurs approx. 6 to 48 hours before a cold sore appears.
5 Stages of a Cold Sore.
Stage 2 of Cold Sores
Time of Onset, Symptoms, Presentation, and any other important details.
It is too late to introduce antiviral treatments at this point (and going forward)… Now more about TLC.
Time of Onset: On Days 2-3 of cold sore (or one or two days after tingling).
Symptoms/Presentations: Blister formation, Swollen lips (as blister develops), a group of small, fluid-filled bumps surrounded by red, swollen skin.
- Antiviral medications are of little help at this point. Pharmacists cannot prescribe antivirals by Stage 2. Would need MD RX.
Stage 2 of Cold Sores.
5 Stages of Cold Sores.
Stage 3 of Cold Sores.
Time of Onset, Symptoms, Presentation, and any other important details.
- Time of Onset: Day 4
- Ulcer erruption (i.e., blister bursts)
- Can look similar to angular cheilitis
- Probably the most infectious time
- If the rash has been around too long, the antivirals will be far less effective
- Antivirals of any kind likely to be ineffective. More about TLC and can use camphor/phenol products to help with the irritation (but patient decision)
5 Stages of Cold Sores.
Stage 4 of Cold Sores.
Time of Onset, Symptoms, Presentation, and any other important details.
Scab Formation
- Time of Onset: Days 5-8
- Blister that errupted is likely starting to dry
- As scab shrinks, might cause painful cracks on the lips. Might feel itch, burn, or feel tight.
5 Stages of Cold Sores
Stage 5 of Cold Sores
Healing Stage
OTC Lip Treatments for Cold Sores…
Abreva
Abreva (Docosanol 10%)
- Approved for ≥ 12 years
- Recommended OTC product… We like this OTC option.
- Start using Abreva by Stage 1 (Prodromal) tingling phase or else be too late and likely ineffective
- AAA 5x/day until fully healed (max of 10 days) USING A Q-TIP
- When used early enough, it is believed to shorten time by 4 days, vs. later use less than one day
- Doesn’t really cure it… Can maybe shorten the healing time and possibly help reduce the severity of symptoms
Generic equivalent now available in Canada!
OTC Treatment for Cold Sores.
How should Abreva (docosanol 10%) be used for the treatment of cold sores?
a) Use a thin layer of cream and apply it with clean fingers twice a day for a maximum of 7 days.
b) Apply a thick amount of cream with a cotton swab (Q-tip) to the affected area 5 times a day until the cold sore heals, with a maximum duration of 10 days.
c) Apply a thin layer of cream directly from the tube onto the cold sore and rub it in gently for a maximum of 5 days.
d) Use Abreva as a lip balm (while using a cotton swab ideally) throughout the day whenever needed.
b) Apply a thick (or ample) amount of cream with a cotton swab (Q-tip) to the affected area 5 times a day until the cold sore heals, with a maximum duration of 10 days use.
Not necessary to be thick… but ample amount to cover entire area.
OTCs for Cold Sores
ColdSore-FX… What is in this product?
- Is this effective for cold sores?
ColdSore-FX = Propolis
It’s a natural product derived from bees.
- Likely to be ineffective/not helpful for cold sores
- Basically a **lip balm **
- Something to recommend for TLC for instances like when too late to start antivirals or Abreva.
OTC Products for Cold Sores
**Camphor/Phenol/Menthol Products
(example: Camex, Blistex, Lip Medex) **
- What does it do?
- How effective is it?
Mild anesthetics [Camphor and Phenol]… Offer temporary relief of pain and itching associated with cold sores. Does NOT treat the cold sore, just TLC.
- Okay to use for cold sores… But it’s for the symptoms not for the virus itself.
- Can be applied 3-4x per day
- Okay to use for children 2+ yo
- It’s okay to use technically. But again, TLC to keep things soft.
Camphor at a concentration >3% OR menthol >1% can cause irritation and inflammation and are therefore CONTRAINDICATED in treatment of cold sores.
OTC Cold Sore Products in Canada.
Lipactin (heparin/ZnSO4)
- What are their effects?
- Do we recommend for cold sores?
Heparin is an anti-coagulant… Are there clotting receptors on the lips to be worried about? Not really.
Zinc Sulfate (ZnSO4) is an astringent = Drying
- Be careful to not use too much because it can cause lips to crack
We do NOT recommend for cold sores.
Do not like Lipactin for cold sores!!
OTCs for Cold Sores
Zilactin.
- What is the main ingredient?
- Effects?
- Recommend?
- Benzoyl Alcohol
- It can be drying, but might also act as a weak anesthetic
- NOT generally recommended. It’s drying and the impacts on pain relief are not worth giving a try unless patient wants to.
OTCs for Cold Sores.
Zilactin-B
- What is the main ingredient?
- Effects?
- Recommend?
- Benzocaine (10%)
- Anesthetic (May offer temporary relief of pain and itching)
- Recommend - for TLC but not for treatment.
Zilactin-B = Yes. Zilactin (regular, in red) = Not really.
May offer temporary relief of pain and itching. More likely to cause sensitization than lidocaine
OTCs for Cold Sores.
LipClear Lysine
- Main ingredient is Lysine but also has things like menthol, olive oil and propolis.
Would you recommend this for cold sores?
No. We are already skeptical about the efficacy of using this amino acid, Lysine, orally for other uses… There’s even more skepticism when used topically.
- Menthol is an astringent… Propolis and olive oil basically used as lip balm properties… How would it work to use a product with both a drying agent and ingredients that might hydrate??
Lipivir is
a) a non-drug gel or emollient that prevents cold sore outbreaks and claims to also reduce the frequency of outbreaks when applied before Stage 2
b) a new prescription drug available only in the USA and UK. This topical gel or emollient is a new topical antiviral agent that contains docosanol 10% and HC 1% for cold sores and to be used before Stage 2 of cold sores.
c) a non-drug gel or emollient that is used daily for the prevention of recurrent cold sores and also hydrates the lips (so can also be thought of as a lip balm)
d) a prescription product in Canada that is unique in that is used for cold sore treatment and can be used anywhere from Stages 1-3 and claims to reduce the severity of symptoms and duration of ailment BUT can be quite drying on the skin.
a) a non-drug gel or emollient that prevents cold sore outbreaks and claims to also reduce the frequency of outbreaks when applied before Stage 2
Lipivir does not treat actual cold sores but is said to just prevent outbreaks… We don’t know the frequency of uses and in order for this to work, would need to know the exact spot to treat.
Why should all topical products used for things like cold sore recommended to use Q-Tips for each application?
Reduces the chances of auto-inoculation (i.e., spreading to other parts of body).
Which active ingredient is found in Zilactin (regular) for the treatment of cold sores?
a) Benzoyl peroxide
b) Benzoyl alcohol
c) Benzocaine
d) Lidocaine
b) Benzoyl alcohol
What is the primary function of benzoyl alcohol in Zilactin (regular) for cold sores?
a) Antibacterial action
b) Antifungal action
c) Drying effect
d) Anesthetic effect
c) Drying effect
Might have WEAK anesthetic properties, too.
Which active ingredient is found in Zilactin-B for the treatment of cold sores?
a) Benzoyl peroxide
b) Benzoyl alcohol
c) Benzocaine
d) Lidocaine
c) Benzocaine
Benzocaine 10% = Anesthetic
Recommended option for irritation if wanted.
T/F: Canker Sores are cold sores that present themselves inside of the lips.
False!
Canker sores and cold sores are two different things.
- Canker Sores are not a viral entity. Cold sores are from HSV.
- Canker sores have Gray-white lesions occur on the inside of mouth and not going to form a blister. Cold sores are found usually externally either on the lips or nose area. Usually unilateral vesicle that blisters and bursts.
Acne can present itself in various places on the body, including the face, lip border and nasal regions.
What are some features that we can use to distinguish acne from a cold sore if a lesion is present on the border of a person’s lips for example?
- Blistering occurs only for cold sores (not acne)
- Assess history of acne (if any) - do they have spots on the face and/or have had acne around the mucosal regions before?
- Acne is never directly on the lip… Can be nearby the border of the lips (but so can cold sores)
- Acne lesions typically appear as comedones (blackheads or whiteheads), papules (small red bumps), pustules (pus-filled lesions), nodules (large, painful lumps), or cysts (deep, inflamed lesions).
- Cold sores usually appear as small, fluid-filled blisters on the outer edge of the lips or around the nostrils. They may occur singly or in clusters and often progress through stages of blistering, oozing, crusting, and healing.
- If there’s discharge, if there’s pus or blood = acne… If the discharge is sticky, fluid = cold sore
Where do cold sores commonly appear?
a) Inside the mouth
b) On the outer edge of the lip or near the nostrils
c) On the chin
d) On the cheeks
b) On the outer edge of the lip or near the nostrils
Describe the presentation or appearance of canker sores.
White or cream-coloured lesions that are situated within red/inflamed borders.
- Small… Ulcers’ diameters are typically <1cm.
What are the 3 Stages of Canker Sores?
1) Prodromal w/ burning or tingling (no ulcer)
2) Small, painful, and shallow ulcers
3) Healing (clearance of ulcer)
Duration of ≤ 7-14 days; often resolve spontaneously
T/F: Canker sores are typically large, fluid-filled blisters.
False.
- Canker sores are typically small in size as their diameter is normally <1cm
- Canker sores are not fluid-filled blisters (that’s cold sores)… Canker sores have white lesion bordering around a red and/or inflammed border.
Hand, Foot, and Mouth Disease (HFMD) is what kind of infection?
Viral
HFMD
Painful mouth sores are common for those who contract HFMD… Where would mucosal ulcers be typically found?
- Anywhere inside the mouth (throat, tongue, tonsils, inside of cheeks, etc.)
- Anywhere outside the mouth
Canker Sores - Differentials
Stomatitis
Often associated with radiation and chemotherapy treatments.
- Patients are usually warned beforehand about this possibility.
Canker Sores - Differentials
Mouth Cancer
Appears much different in comparison to canker sores and other differentials.
- More commonly be found on the tongue.
What do we think about Amosan Oral Antiseptic Rinse?
Sodium Perborate
Good… It has the same effectiveness as saline BUT it is more expensive option.
How can Aerochambers or Spacers make it less likely for asthmatics (and other steroid MDI inhaler users) to get oral thrush?
Aerochambers (spacers) generally are good options to consider since they are made to distribute the inhaled corticosteroid more effectively down to the lungs, which enables better delivery of the drug…
- Beneficial for less chances of oral thrush as this means less likely for more of the medicine to remain in the mouth.
Asthmatics using steroid inhalers should be gargling and rinsing their mouths post-use PLUS Aerochamber/spacer users should also clean the spacer frequently with mild soap and water.
Oral Thrush: Pharmacological Treatment
Gentian Violet 1% Solution
- Effective antiseptic dye used to treat oral thrush.
- Messy = Low compliance
- Causes slight mucosal irritation
- If infant infected is being breastfed, need to treat mother, as well.
- Previously recommended for use but there are safety concerns now.
Pharmaceutical Treatment for Oral Thrush
Is Gentian Violet still available?
No.
Health Canada issued a recall in 2019 and is no longer available on the market in response to a WHO report that stated possible cancer causal link from an unknown amount of exposure to it…
- Concerns is that unable to determine what is considered to be a safe level of exposure before risks of cancer and staining become problematic.
Which infant probiotics are available at the pharmacy to help reduce the chances of oral thrush?
**None!
**- There is NO probiotic in pharmacies to assist with thrush!
Pharmacotherapies for Oral Thrush
What is the most commonly used/prescribed product to treat oral thrush for infants and children?
Nystatin!
- Can use Nystatin for any age demographic - as young as ≤1 year old to adulthood!
Pharmacotherapeutic Options for Oral Thrush: Nystatin
Nystatin Dose:
Children & Adults
400,000 to 600,000 Units PO QID for 7-14 days * (minimum of 2 days after symptoms resolve).
- Children usually is 500,000 Units QID
- Swish, retain in mouth for as long as possible (up to a few minutes), and then swallow
Symptomatic relief usually within 48 hours… But should continue for another 48 hours after clearning. Total time of therapy is ~7 days.
