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Flashcards in Dental Conditions Deck (76):
1

What are different dental conditions?

Teething
Oral Pain
Oral Candidiasis
Cold Sores
Aphthous Ulcer
Dry Mouth
Periodontal Disease
Mouth Rinses
Halitosis

2

What are the symptoms of teething pain?

Gum redness, swelling or tenderness
Drooling, rubbing the gum, flushed cheeks because of mild increase in body temperature
Irritability restlessness, crying, insomnia, decreased appetite, increased thirst

3

What are NOT symptoms of teething pain?

Fever (although there may be slight elevation of temperature)
Diarrhea (although there may be loose stools)
Vomiting
Common cold symptoms

4

When do teething symptoms begin?

Symptoms can begin up to 4 days prior to the eruption of the tooth

5

What are some non pharmacological treatments for teething?

Rub the baby's gums by using a clean finger or a damp washcloth to massage the gums
Cool the affected area by letting the chew on a frozen facecloth or a cold pacifier/teether (avoid contact with extreme cold; don't freeze pacifiers)
Wipe the baby's face often with a cloth to remove the drool and prevent rashes from developing

6

What are some pharmacological options for teething pain?

Acetaminophen 10-15 mg/kg/dose q4-6h prn (max 65 mg/kg/day)
Ibuprofen 5-10 mg/kg/dose q6-8h hours prn (max 40 mg/kg/day)
Refer if no relief with treatment after 3 to 5 days

7

What are some topical anesthetic products that can be used for teething pain?

Benzocaine gel (Baby Orajel 7.5%, Baby Orajel Night time 10%, Baby Anbesol 7.5%)

8

Should topical anesthetics be used for teething pain?

They only provide relief for a maximum of 45 minutes
They are controversial due to potential harm. They inactivate the gag reflex, which increases the risk of choking. They are a sensitizers. In some cases, they can cause Methemoglobineia; the benzocaine can prevent oxygen from binding to the blood cells (requires a genetic polymorphism). This can cause shortness of breath, blue lips and even death

9

What causes symptoms of a toothache?

Symptoms that may be due to a variety of causes.
Cracked tooth has abrupt pain with biting and resolves with removal of pressure (requires a referral to the dentist for assessment and treatment)
Post-dental procedure discomfort

10

What are pharmacological treatment options for a toothache?

NSAIDs
Acetaminophen
Benzocaine (OraJel regular (10%), Maximum strength (20%), PM (20%), Anebsol Liquid/gel (20%)

11

What is tooth hypersensitivity?

Short, quick sharp dental pain due to exposure to a stimulus (thermal, chemical, osmotic, physical) on exposed dentin
A dental referral is necessary to determine (and potentially treat) the underlying cause

12

What does tooth hypersensitivity result from?

May result from: "tooth decay, fractured teeth, worn fillings, gum disease, worn tooth enamel or an exposed tooth root due to gum recession"

13

What are some non-pharmacological suggestions for tooth hypersensitivity?

Soft-bristled toothbrush
Reduce acidic foods and drinks

14

What are pharmacological options for tooth hypersensitivity?

Desensitizing toothpaste work by blocking the repolarization of the nerve fibre membranes, thereby decreasing the pain
Key ingredient: potassium nitrate
Product examples: Sensodyne F, Crest-Pro Health, Colgate Sensitivity

15

What is oral candidiasis?

Also known as thrush
Most commonly caused by C. albicans

16

What are the two major forms of oropharyngeal candidiasis?

The pseudomonas form is the most common and appears as white plaques on oral mucosa
The atrophic form (denture stomatitis) appears as erythema without plaque. Common in elderly with dentures

17

What are risk factors for oral candidiasis?

Diseases that affect the immune system (e.g., diabetes, HIV infection) and medications that suppress the immune system (e.g., chemotherapy)
Xerostomia (dry mouth)
Use of systemic corticosteroids or corticosteroid inhalers
Recent use of broad spectrum antibiotics
Infants and children
Local mucosal trauma
Poor dental or denture hygiene
Pregnant women
Smoking

18

What are signs and symptoms of oral candidiasis?

"Cottage cheese" soft plaques that are white or creamy-yellowish on the buccal mucosa, tongue, gums and throat
Plaques are easily removed by vigorous rubbing but can leave red (erythema) or bleeding sites when removed
Red, flat lesions on the mucosa under the denture
May cause cracked, red, moist areas on 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

19

What are red flags for oral candidiasis?

Patients with signs and symptoms not typical of mild oral thrush
Patient is on chemotherapy or is immunocompromised due to drug therapy
Patient 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 to physician as it may require biopsy and/or systemic antifungal treatment
Possible symptoms of an adverse drug reaction. If a prescription medication is suspected, refer to physician for evaluation and possible change in medication
Suspect another type of infection (e.g., viral herpes infection)
Unable to confirm diagnosis of oral thrush. Refer for further evaluation and/or physician-supervised therapy
Treatment unsuccessful after 14 days

20

Can oral candidiasis be treated by a pharmacist?

Only in Manitoba
Patients with mild signs and symptoms can be treated by a pharmacists (only when you feel very comfortable)
Patients with atypical symptoms should be referred

21

What are the goals of treatment of oral candidiasis?

Eradicate infection
Prevent complications
Prevent recurrence

22

What are non-pharmacological suggestions for oral candidiasis for infants?

Sterilize toys, soothers, and feeding bottles/nipples
If breastfed, the mother may have candidal infection on the nipples and require treatment

23

What are non-pharmacological suggestions for oral candidiasis for those with dentures?

Remove dentures overnight
Wear dentures only for 6 hours
Soak and clean dentures when not using
Clean oral cavity with soft toothbrush and investigate if dentures fit properly

24

What are prescription options for oral candidias?

Pharmacist options: Nystatin (for mild disease)
Physician/dentist options: Oral azole antifungals (fluconazole tablets or suspension, itraconazole, ketoconazole, posaconazole, voriconazole)

25

Why is gentian violet (OTC) not used anymore?

In the past, Gentian Violet (OTC) was applied to affected area. Difficult to determine therapeutic progress and decreased compliance as it can cause mucosal irritation, ulceration and staining. Safety is questionable (linked to carcinogenicity)
Required longer treatment, stains skin and clothing, should not be swallowed, NAPRA schedule II (may have to dilute appropriate concentration)

26

What is nystatin oral suspension?

Fungi-static and cidal
Effective for candidal infections, considered first line for mild disease

27

How is the liquid nystatin used?

Shake well before using, need to swish and swallow. Recommend instilling half of the dose in each side of the mouth to ensure contact with lesions for as long as possible before swallowing
Infants: do not feed for 5-10 minutes after dose is given

28

What are the side effects of nystatin?

Considered well tolerated. In high doses: nausea, vomiting and diarrhea.
Rarely: rash, irritation, urticaria and Stevens-Johnson syndrome

29

What is the dosing for nystatin oral suspension?

Adults and children: 4 to 6 ml of 100 000 unit/ml suspension QID 7 to 14 days
Infants: 1 to 2 ml of 100 000 unit/ml suspension QID for 7 to 14 days
Note: treatment should continue for at least 48 hours after symptoms have resolved

30

What are the monitoring parameters for oral candidias?

After prescribing nystatin, follow up with the patient should occur in 7 days
If symptoms resolved for 48 hours, can discontinue medication
If improvement but not resolution of symptoms ensure the patient continue nystatin for another 7 days
If no improvement, refer to physician or dentist for assessment

31

What causes herpes labialis (cold sores aka fever blisters)? What are the symptoms?

Primarily caused by HSV-1
Primary infection is caused by direct contact
May be asymptomatic or have fever, chills, sore throat, ulcerations on the lips and malaise

32

What are triggers for a flare of herpes labialis?

Stress, sun exposure, trauma, hormonal changes, fever, viral infection, fatigue, cold weather, windburn

33

What are the stages of cold sore development?

Stages last 7-14 days
Prodromal: pain, itching, tingling at site (

34

What are red flags for cold sores?

Lesion not healed within 14 days (with or without treatment)
Systemic symptoms (fever, swollen glands)
Lesion show signs of infection (excessive redness, swelling, pus)
Over 6 outbreaks per year
Under the age of 12
Pregnant
Patient is immunocompromised

35

What are the goals of treatment?

Relieve the discomfort
Reduce the duration and severity
Prevent secondary infection (yellow pus)
Prevent spread to others

36

How do we prevent recurrences of cold sores?

Decrease stress, avoid prolonged sun exposure, lip sunscreen, lots of rest

37

What are OTC options for cold sores?

Topical antiviral (Docosanol 10%)
Heparin sodium and zinc sulfate (Lipactin)
Hydrocolloid patch (Polysporin Cold Sore Healing Patch
Local anesthetics (benzocaine, lidocaine)
Protectants
Topical analgesics (camphor, menthol, phenol)
Oral analgesics (acetaminophen, ibuprofen, naproxen)

38

How is docosanol 10% used?

Aka Abreva
Prevents viral migration and replication
Applied 5 times daily at first sign (max 10 days)

39

What are some protectants available?

Hydroxypropyl cellulose (Zilactin Core Sore Gel (benzyl alcohol 10%))
Petrolatum, cocoa butter, allantion

40

What are the prescription treatment options for cold sores?

Antivirals may be used for treatment or prophylaxis. Treatment options include oral (systemic) therapy or topical therapy.

41

What are some non-pharmacological therapies available for cold sores?

Lip conditioners/protectants (petrolatum, cocoa butter, allantoin, SPF 30 to prevent sun damage)
Keep area clean (warm water and soap, prevents infection)
Avoid direct contact with others
Wash hands often; avoid touching lesion
Avoid sharing objects (glasses, straws, cutlery, razors, towels)
Stress reduction and rest

42

What are aphthous ulcers?

Aka canker sores
They are painful, recurrent lesions of unknown cause (bacterial or immune)
They are not contagious
They are found on the inner lip, inner cheek, soft palate and undersurface
They first appear in childhood

43

What are the symptoms of aphthous ulcers?

Symptoms last for 5-14 days
There is a burning, tingling, intense persistent pain
Four appearance-related factors: roundish, shallow-crater, red halo, white-yellow interior covering
May feel some pain in area prior to outbreak
Refer is lasts longer than 14 days

44

What are predisposing factors of aphthous ulcers?

Stress and anxiety
Local trauma
Genetic predisposition
Allergies/food sensitives
Nutritional deficiencies
Systemic diseases
Medications (NSAIDs, beta-blockers)

45

What are red flags for aphthous ulcers?

Severe pain
Diameter of ulcer is over 1 cm
Over 5 ulcers are present
Duration of ulcer is over 14 days
History of recurring aphthous ulcer (6-12 times a year)
Systemic disease (HIV, inflammatory bowel disease, diabetes, TB, etc)
Fever or other systemic symptoms present
Ulcer first occuring later in life (over 30 years)
Pregnant
Nutritional deficiency suspected (vitamin or iron)

46

What are the goals of therapy of aphthous ulcers?

Relief from pain
Decrease duration of ulcer
Ensure normal oral function and adequate nutrition intake
Decrease frequency and severity of recurrences

47

What are some non-pharmacological suggestions for aphthous ulcers?

Avoid foods that cause pain (e.g., hard, crusty, sharp, spicy, salty, acidic or difficult to chew)
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 lauryl sulphate
Avoid foods that may trigger a flare (e.g., nuts, acidic food or drinks, salty meals, spices, alcoholic and carbonated beverages)
Treat any nutritional deficiencies

48

What are some OTC products for aphthous ulcers?

Oral analgesics (acetaminophen)
Protectants (hydroxypropyl cellulose, carboxymethyl cellulose (orabase))
Warm saline rinses
Topical analgesics (camphor, menthol, phenol (Canker Cover))
Local anesthetics (benzocaine (10-20% strength))

49

What are some prescription products that pharmacists can prescribe for aphthous ulcers?

Triamcinolone in Orabase

50

What are some prescription products for aphthous ulcers (from physicians and dentists)?

Antibiotic therapy (e.g., tetracycline mouthrinse)
Pain relief (e.g., benzydamine topical solution)
Other agents: dapsone, colchicine, prednisolone, infliximab, thalidomide, etc.)

51

What is triamcinolone 0.1% in orabase do?

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

52

What is the dosing for triamcinolone 0.1% in orabase?

Apply to aphthous ulcers 2 to 4 times a day until ulcer healed
Press a small dab (about 1/4 inch) to the lesion until a thin film develops. For optimal results, 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. Do not eat or drink for 30 minutes after applying

53

What are side effects of triamcinolone 0.1% in orabase?

Potential development of oropharyngeal candidiasis, burning, irritation, etc.

54

What are the monitoring parameters aphthous ulcers?

If there is no significant healing in 7 days or if ulcer worsens, refer to physician or dentist for re-evalution
Ulcer should heal within 14 days, if not then refer patient to physician or dentist
Pharmacists should monitor pain every 3 days for first week, then again in 1 week

55

What is xerostomia?

Feeling of dry mouth - usually associated with hyposalivation

56

What are the causes of xerostomia?

Medical conditions (Sjogren's syndrome, Addison's disease, depression, cystic fibrosis, HIV)
Medications (e.g., anticholinergics, antidepressants)
Radiation therapy
Trauma or tumors involving the salivary glands

57

What are complications due to 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 (chronic atrophic), gingivitis)

58

What are non-pharmacological treatment options for dry mouth?

Dental care
Sucking on ice chips, frequent sips of water
Hard sugarless candies or gum (containing alcohol sugars)
Humidifier at night
Avoid or reduce caffeine intake
Avoid tobacco and alcohol

59

What are OTC options for dry mouth?

Salivary substitutes and lubricants (Biotin products, Moi-Stir, OraMoist)

60

What is gingivitis?

Inflammation of the gums
Results of build-up of bacterial plaque
Swelling and redness of gums, bleeding of gums when brushed

61

What are risk factors for gingivitis?

Medical conditions
Medications
Poor nutrition
Infections
Hormonal changes

62

What is periodontitis?

Plaque has spread to the roots
Gums may pull away from teeth
Pain, bleeding of gingival tissue, halitosis, foul taste, increased salivation
May cause damage to the bone

63

What are screening questions for periodontal disease?

"BUG" questions (bleeding, unsteady teeth, gum recession; refer if yes)
Other symptoms (signs of infection, bad breath, bad taste, ulcers, pain)
Ask when was last dental visit

64

What is prescription treatment option for periodontal disease?

Chlorhexidine 0.12% (Peridex)
Prescription only

65

How is chlorhexidine 0.12% used?

Swish and spit 10-15 mL twice daily for 30 seconds (gargle as well)
5 to 7 days for mild gingivitis
Up to 31 days for chronic periodontitis

66

What are side effects of chlorhexidine?

Tooth staining
Taste disturbances
Tongue discolouration

67

What is halitosis?

Bad breath
May significantly impact at patients quality of life
Can be due to ingestion of herbs, spices, garlic, onion, tobacco or alcohol
85% of cases result from poor oral health (example of potential cause is the breakdown of food by microorganism in the mouth release volatile sulphur compounds)

68

What are red flags for patients with halitosis?

Painful, red, swollen areas around the gums or tongue
Signs of infection or gingivitis
Recent dental surgery
Symptoms of respiratory disease or other contributing medical condition
Patient has concerns of bad breath but friends and family do not share this concern

69

What are non-pharmacological options for halitosis?

Practise good oral hygiene (flossing daily, brushing teeth with soft-bristled toothbrush twice daily)
Regular dental appointments for assessment and teeth cleaning
Tongue cleaning
Increase saliva flow and tongue movement by munching on sugarless gum, raw carrots or celery
New toothbrush every 3-4 months
Adjust diet

70

What is the purpose of mouth rinses?

Freshen breath
Cleaning the oral cavity
Anticavity
Antibacterial (may reduce bacteria activity in plaque up to 12 hours after brushing)
Antiplaque/antigingivitis (dependent on correct use, in addition to brushing)

71

What do antiplaque products do?

Inhibit plaque formation
Chlorhexidine is the gold standard
Thymol, eucaplyptus, menthol, methyl salicylate

72

What do plaque inhibitory products do (antibacterial) do?

Used in combination with brushing for plaque control
Chlorhexidine (Peridex), cetyl pyridinium (Cepacol), essential oils, triclosan

73

What do breath fresheners do?

Cosmetic use only
Hexitidine, alcohol, flavours (mint or spicy)

74

How should oral mouth rinses be used?

With for 30 seconds
Avoid eating or drinking after use for 30 minutes
Best effect if used prior to bed

75

What are the monitoring parameters for halitosis?

Improvement after 1 week of good oral hygiene
Remind patients that long therm use of alcohol containing mouthwashes may lead to dry mouth (which could worsen bad breath), therefore recommend use for short term only
Persistent bad breath should be referred to a dental professional or physician

76

What is the role of a pharmacist in oral health?

Importance of adhering to daily oral hygiene practises
Encourage healthy balanced diet
Avoid sipping or frequent intake of acid food/drink
Tobacco cessation and decreased alcohol consumption
Importance of regular dental visits
"BUG" questions