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Pharm 129 > Oral Aphthous Ulcers > Flashcards

Oral Aphthous Ulcers Flashcards

1
Q

What are other names for AU

A
  • Canker Sores
  • Aphthous Stomatitis
  • Recurrent Aphthous Stomatitis
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2
Q

What are AU

A

Recurrent, painful, inflammatory, noninfectious, non-vesicular, immunologically-mediated mucosal disease

  • White centre, red inflammed halo
  • Occur on nonkeratinized oral mucosal surfaces (not on hard palate or lips)
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3
Q

When are AU most common

A

in childhood to early adulthood

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4
Q

Impact of AU

A

pain
weight loss (avoid eating, lose appetite)
decrease in QOL

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5
Q

What are precipitating factors for AU

A

Local trauma (mucosal injury) - biting cheek, braces, dentures
Stress
Food - salty, acidic, coffee
Immunologic states
Systemic conditions
Nutritional deficiencies - Vit B, iron, zinc, folic acid
Allergy or sensitivity - celiac disease
Cessation or restarting tobacco use - causes changes to mucosa
Genetic predisposition
Medications - like NSAIDS
Hormonal changes

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6
Q

Risk factors

A

Family history
Female
Age less than 40
Immunocompromised
individuals in middle and upper-middle class socioeconomic groups (more stressful jobs)
Vitamin and mineral deficiencies (B1, B2, B6, B12, zinc, iron, folic acid)

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7
Q

What is the clinical presentation

A
  • One or more shallow sores with a white or cream-coloured coating
  • Erythematous “halo” of inflamed tissue surrounds the ulcer
  • Painful
  • History of recurrent episodes
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8
Q

What are the 3 types of AU

A

minor
major
herpetiform

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9
Q

what are minor AU

A 
2-10 mm
Occur singly or in clusters ≤5
Oval shape 
7-10 days (self-limiting)
No Scarring
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10
Q

What are major AU

A 
>10 mm, deeper
Occur in clusters of 2 or more
Irregular shape
May persist for weeks
Scar potential
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11
Q

what are herpetiform

A 
2-3 mm
Occur in clusters of 10-100
Irregular shape 
7-30 days
Scar Potential
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12
Q

what AU can RPhs treat

A

only minor

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13
Q

DD: Behçet syndrome

A

Blood vessel inflammation

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14
Q

DD: Inflammatory bowel disease (Crohn’s)

A

other symptoms will be related to GI

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15
Q

DD: Lupus erythematosus

A

blistering

on lips, extend inwards

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16
Q

DD: Leukoplakia

A
  • white lesion
  • on tongue/cheeks
  • usually males <30, smokers or ex-smokers
  • precancer
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17
Q

DD: Viral infections (cold sores)

A
  • additional symptoms like fever
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18
Q

DD: Treponemal infection (syphilis)

A
  • will appear on tongue
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19
Q

DD: Fungal infections (thrush)

A
  • white coating
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20
Q

DD: Hematologic diseases (cyclic neutropenia)

A
  • can cause ulcerations

- often on tongue

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21
Q

DD: Neoplasms (squamous cell carcinoma)

A
  • on lips

- usually on areas exposed to sun (skin cancer)

22
Q

How do drug-induced oral ulcers occur

A
  1. direct trauma - direct application of essential oils or effervescent tablet
  2. long-term medication use (Isotretinoin/accutane, histamine-2 receptor antagonists)
  3. direct association of oral ulcerations (NSAIDs, immunosuppressants, etc)
23
Q

Red flags that indication another condition

A
  • 1st aphthous ulcer was after the age of 30
  • Systemic illness symptoms
  • Immunocompromised due to medication or disease state, or immunodeficiency disorder
  • Behcet’s, SLE, IBD, HIV
  • Lesions present elsewhere on the body
  • hard palate, gums, genitals, lips
  • Severe pain
  • Radiation therapy
  • Recurrences > 6 times per year
24
Q

Red flags that indicate major or herpetiform ulcers (require referral)

A
  • Ulcer diameter >10 mm
  • Ulcer duration >14 days
  • > 5 ulcers present
  • multiple clusters of ulcers that may have coalesced
  • difficulty chewing or swallowing due to pain
  • History of having ulcers that last >14 days, heal with scarring and recur 6-12 times/year
25
Q

Goals of therapy

A
  1. Relieve local pain & discomfort
  2. Restore function & oral hygiene practices (speaking, swallowing)
  3. Ensure adequate nutritional intake
  4. Reduce duration of ulcer(s)
  5. Decrease frequency & severity of recurrences (AU cannot be cured!)
  6. Prevent complications
26
Q

Prevention Measures

A 
Avoid Local Trauma
• Avoid self-biting
• Avoid sharp-edged foods
• Replace toothbrush heads early
Avoid allergens
Avoid dehydration (makes AU very uncomfy)
Avoid nutritional deficiencies 
Avoid/minimize emotional stress
Manage drug-induced causes
Manage underlying systemic disease causes
27
Q

Nonpharm Treatment

A

• Repair or remove oral trauma-causing agent
• Avoid food & drinks that cause pain (alcohol, caffeine, salty, spicy)
• Avoid using harsh toothpastes and mouthwashes with SLS
• Maintain regular daily oral hygiene
• Ice application (short increments: 10-20 mins PRN)
• Cleanse the lesion:
Rinse the mouth with salt water (2.5-5 mL table salt per 250 mL warm water) several times a day, especially after meals

28
Q

Should cleaning rinses and antiseptics be used

A

NO evidence that benefit over saline rinses

29
Q

How to determine treatment approach

A

the choice of agent will depend on severity of pain, number of ulcers, frequency of episodes and patient’s tolerance to treatment.

30
Q

What is the 1st line treatment

A

topical agents:
• Anesthetics (local)
• Anti-inflammatories
• Mucosal Protectants

31
Q

Mucosal Protectants and dosing

A
  • Hydroxypropyl cellulose, carboxymethyl cellulose (Orabase Paste®)
  • Protective layer over lesion = temporary pain relief
  • To be applied PRN (often TID - QID)
32
Q

Local oral anesthetics and dosing

A

• Benzocaine (Orajel®, Anbesol®), lidocaine (Xylocaine Viscous®)
<20%
• Short duration of action; may be used with protectants or oral analgesics
• MAX QID for <1 week; apply with cotton swab
apply ice before using a gel formulation (since there is a high alcohol concentration, can be painful)
• Avoid eating, drinking, speaking for 30 min post-application (do not swallow)

33
Q

Local Oral Anesthetic + Mucosal Protectant

A

combination: numbs and protects (more expensive)

Orabase with benzocaine ®, Kank-a ®, Zilactin-B

34
Q

Which oral analgesics can be used?

A

Acetaminophen; AVOID NSAIDS

35
Q

Which vitamins to supplement with

A

Vitamin B1, B2, B6, B12, Iron, Folic Acid, Zinc

- studies show shortens episodes, reduces number of ulcers, and reduces pain

36
Q

Milk of Magnesia & Diphenhydramine Allergy Liquid (mixed 1:1)

A

Swish 5mL in mouth for 1 minute then spit Q4-6 hours to help pain

37
Q

Is canker cover effective?

A

does not have evidence to support

38
Q

Should baking soda, witch hazel, raw egg, etc be used?

A

No

39
Q

Avoid or use: menthol and camphor

A

counterirritants should be avoided

worsen disease state

40
Q

How to use ASA

A

do not place directly over lesion

41
Q

Avoid or use: dentrifrices with SLS

A

Avoid

42
Q

Avoid or use: benzocaine/lidocaine

A

Avoid -caines in patients with hypersensitivity

43
Q

What causes black hairy tongue

A

swallowing oral debriding and wound cleansing agents

44
Q

When to follow up

A

Assess benefits and AE of treatment
Patient: daily
RPh: 3-7 days x 1st week then 1 week later

45
Q

What to do if the ulcer is still present or worsened after 14 days

A

refer

46
Q

What is LESS

A

Non pharm strategies to lessen duration of ulcer

47
Q

What is L in LESS

A

Local trauma: avoid sharp, spicy, acidic foods. Avoid SLS

48
Q

what is E in LESS

A

Emotional and environmental stress management

49
Q

what is S in LESS

first S

A

Supplementation: increase foods in iron, folate, B12 or B6 if suspected deficiency

50
Q

what is S in LESS

second S

A

Start Ice: apply in 10 min increments

51
Q

ON vs SK (medSask)

A

Both can assess patient to determine if minor AU present

- SK can prescribe treatment for minor AU, ON cannot

Pharm 129 (14 decks)

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