Dental Health (Parts 1-2, COMBINED)

Question 1

Which 2 viruses are SK pharmacists heavily involved in?

Answer 1

1) Cold Sores (Herpes Labialis)
2) Oral Thrush (Oral Candidiasis)

Question 2

Toothaches

Answer 2

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!

Question 3

As pharmacists, what is our role in toothaches?

Answer 3

Treatments ONLY!

• Do not deal with differential or diagnosis of toothaches.

Question 4

Jaw Aches

Answer 4

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.

Question 5

Teething

Answer 5

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

Question 6

Cold Sores (Herpes Labialis)

Answer 6

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

Question 7

Canker Sores

Answer 7

Painful ulcers that develop inside the mouth, often on the inner cheeks, gums, or tongue.
- Self-limiting in most cases within 1-2 weeks

Question 8

Oral Thrush (Oral Candidiasis)

Answer 8

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)

Question 9

Condition characterized by a decrease in saliva production, leading to dryness in the mouth.

Answer 9

Dry Mouth (Xerostomia)

Question 10

Inflammation or irritation of the corners of the mouth, often due to fungal or bacterial infection.

Answer 10

Angular Cheilitis

Question 11

Gingivitis

Answer 11

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

Question 12

TMJ (Temporomandibular Joint) Disorders

Answer 12

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

Question 13

What 3 drugs/drug Classes of antibiotics are contraindicated for pregnant women?

Answer 13

• Fluoroquinolones,
• Tetracyclines (including tetracycline, minocycline, doxycycline, etc) and
• Clarithromycin are not recommended for use during pregnancy

Question 14

Tetracyclines and Teeth

Tetracyclines are not recommended for pregnant women; but which trimesters are most notable?

Answer 14

2nd and 3rd Trimesters

Question 15

Besides pregnant women, who else are tetracyclines NOT recommended for?

Answer 15

Children under the age of 8.

Question 16

What are the implications of using tetracyclines when pregnant, or for children under the 8?

Answer 16

Cosmetic staining on permanent teeth.
- Children might require veneers as a result.

Question 17

List 4 general red flags if a person is complaining of either toothaches or jaw aches that we should always keep in mind.

Answer 17

• Fever
• Pus
• Swelling
• Headaches

Question 18

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.

Answer 18

• 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

Question 19

Bruxism

Answer 19

Grinding of the teeth

Question 20

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?

Answer 20

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.

Question 21

Toothaches

List the Medications can use for Toothaches.

Answer 21

• Acetaminophen (including T1s to T3s)
• NSAIDs (Ibuprofen, Naproxen, Aspirin)

Question 22

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

Answer 22

b) NSAIDs (Naproxen, Ibuprofen, and Aspirin)

Question 23

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

Answer 23

C) Codeine

Question 24

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

Answer 24

B) 1200 mg of Ibuprofen (OTC)

Question 25

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

Answer 25

D) Inhibition of COX-1 and COX-2 enzymes

Question 26

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

Answer 26

E) 4000mg (OTC maximum dosing of Acetaminophen)

Question 27

Why do many dentists recommend the combination use of both ibuprofen and acetaminophen?

Answer 27

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.

Question 28

# 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...

Answer 28

A) Take ibuprofen 400-600mg every 4-6 hours

Question 29

# 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. ## Footnote Not Canada's OTC max or Canada's max RX daily dosing.

Answer 29

B) 2400 mg ## Footnote Canada's Max OTC Dosing = 1200mg; Canada's Max RX Dosing is: 3200mg; THIS dosing in USA by Dionne for these purposes was 2400mg.

Question 30

# 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

Answer 30

C) Take acetaminophen 625-1000mg every 6 hours

Question 31

# 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

Answer 31

c) 4000mg | Same as daily max dosing for normal acet use

Question 32

# 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?

Answer 32

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.

Question 33

# Managing Post-Operative Dental Pain (2017) USA What is the "2 - 4 - 24" Rule addressed by Dionne (2017)?

Answer 33

- 2 Drugs = Ibu and Acet - 4 Doses = Q6H - (Per) 24 Hours

Question 34

Dosages in Advil Dual Action are almost ____ but they are good agents.

Answer 34

Sub-Therapeutic

Question 35

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.

Answer 35

TRUE!!!!!

Question 36

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

Answer 36

C) NSAIDs help reduce inflammation, which is usually involved in toothaches

Question 37

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?

Answer 37

400mg QID ## Footnote This is to just prove the point that technically can go over OTC maximums to a point and remain safe.

Question 38

# 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.

Answer 38

Ibuprofen + Acetaminophen - Ibuprofen = 125mg - Acetaminophen = 250mg ## Footnote Note: This Advil product contains more acetaminophen (# wise - not necessarily potency level) than ibuprofen.

Question 39

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 ____

Answer 39

Helps to relieve pain associated with inflammation.

Question 40

# 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.

Answer 40

Acetaminophen is likely working **CENTRALLY** on the **PROSTAGLANDINS**.

Question 41

# 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 ____.

Answer 41

Ibuprofen is likely to be working **PERIPHERALLY** on the **PROSTAGLANDINS**.

Question 42

# Combogesic Combogesic: What are the two analgesics in this product? | Be sure to indicate the concentration of each analgesic per tablet.

Answer 42

Ibuprofen + Acetaminophen - Ibuprofen = 97.5mg - Acetaminophen = 325mg | Same active ingredients as Advil Dual BUT different concentrations ## Footnote 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...

Question 43

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

Answer 43

B) Every 8 hours | 2 Caplets Q8H

Question 44

T/F: Acetaminophen is more commonly recommended for toothaches than NSAIDs.

Answer 44

False. NSAIDs are commonly more recommended over acetaminophen.

Question 45

T/F: Ibuprofen 400mg taken four times a day is within the safe prescription range, although it exceeds the over-the-counter limit.

Answer 45

True. | But legally, we cannot recommend patients to dose off-label.

Question 46

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

Answer 46

B) Central inhibition of prostaglandins

Question 47

How do we feel about using Aspirin for toothaches?

Answer 47

It can be used for toothaches technically but not very common to see people use. - Can use a combo of ibuprofen plus acetaminophen.

Question 48

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

Answer 48

A) Peripheral inhibition of prostaglandins

Question 49

List 3 Possible Treatments of Toothaches. | Besides oral analgesics.

Answer 49

**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.

Question 50

If a person is suffering from toothaches, when would topical benzocaine provide some pain relief?

Answer 50

If the pain originates from the gums.

Question 51

If a person is suffering from toothaches, when would topical benzocaine **not** be likely provide pain relief?

Answer 51

If the pain originates from a tooth (instead of the gums). | ... It will not have analgesic benefits

Question 52

What age groups is benzocaine **NOT** safe for?

Answer 52

Infants/Children under the age of 2. | Always make sure to look at ingredients list. ## Footnote 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.

Question 53

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?

Answer 53

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.

Question 54

Clove Oil has been used for a long time as a topical agent to treat toothaches. How effective is Clove Oil?

Answer 54

Minimal effects on teeth pain.

Question 55

Heat and Cold Packs can also be used for a variety of dental pain... How does this work?

Answer 55

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.

Question 56

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?

Answer 56

Absolutely no PM/HS impacts. - Completely a marketing tactic.

Question 57

Which of the Orajel products has benzocaine (7.5 to 10%) for infants teething?

Answer 57

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.

Question 58

What is considered to be both the mainstay non-pharmacological option and also the most effective form of treatment for teething?

Answer 58

Teething Rings (teething toys, or anything that goes in place with them)

Question 59

Why is benzocaine not authorized to be used in children under the age of 2?

Answer 59

Might cause a rare but serious condition called **methemoglobinemia**, - which reduces the amount of oxygen carried in the blood.

Question 60

At what age does the average infant start teething?

Answer 60

~ 6 months of age. | Each child is different.

Question 61

Teeth often come in first in the front of the mouth. Which section usually erupts 1 to 2 months earlier than their matching counterpart?

Answer 61

**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. ## Footnote Minimal pain at this stage... More like mild discomfort

Question 62

Around what age range do most infants develop their upper central incisors (i.e., front upper teeth)?

Answer 62

~ 8-12 months of age ## Footnote Mild discomfort at most. As far as we know, very minimal pain at this stage.

Question 63

At around what age do our first molars start to appear?

Answer 63

~ 1 year old ## Footnote Molar development is where pain sets in

Question 64

Around what age do our second molars start to appear?

Answer 64

~ 2-3 years old. (or 25-33 months of age)

Question 65

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

Answer 65

c) Bite on fingers or toys

Question 66

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

Answer 66

c) Symptoms of ear infection or respiratory virus - Ear Infections -- Pain would be more intense - Respiratory viruses -- runny nose, congestion, cough

Question 67

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?**

Answer 67

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.

Question 68

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?

Answer 68

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.

Question 69

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

Answer 69

b) 6-10 months - This refers to the lower front tooth/teeth.

Question 70

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

Answer 70

c) Corners of the mouth

Question 71

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

Answer 71

d) 25-33 months

Question 72

T/F: Teething can cause children to be more irritable and uncomfortable.

Answer 72

True.

Question 73

During teething, children may experience symptoms such as irritability, facial rash, extra drooling, and a mild increase in temperature above _____________°C

Answer 73

38°C ## Footnote If above 38c, should start to consider other symptoms that might not be associated with teething.

Question 74

At what age do most children develop a full set of 20 baby teeth?

Answer 74

~ 3 years old.

Question 75

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.

Answer 75

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

Question 76

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?

Answer 76

Yes, benzocaine is safe to use | ... But we still prefer oral analgesics (acet or ibupr) over benzocaine

Question 77

T/F: Cold Sores are the #1 most common prescribing conditions that pharmacists in SK are involved in.

Answer 77

True.

Question 78

Cold sores often become small fluid-filled ____ that break open and release a clear, sticky fluid.

Answer 78

Blisters.

Question 79

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

Answer 79

a) HSV-1

Question 80

Cold Sores are also known as: - __ - ____ - ____

Answer 80

- Fever blisters, - Oral herpes, - Herpes Labialis

Question 81

What primarily causes cold sores?

Answer 81

Herpes simplex virus type 1 (HSV-1) | Oral Herpes

Question 82

# 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

Answer 82

c) Facial nerve pathways

Question 83

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

Answer 83

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

Question 84

# Cold Sores By early adulthood, most people have become

Answer 84

HSV Positive ## Footnote 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.

Question 85

The HPV-1virus lies latent in

Answer 85

Facial nerve pathways

Question 86

T/F: Cold sores are only caused by the HSV-1 pathogen

Answer 86

**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.

Question 87

# 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?**

Answer 87

- Stress - Trauma - Sunlight

Question 88

Once you have the herpes virus in your body, **what is the likely outcome - long-term? **

Answer 88

... You may get cold sores occasionally for the rest of your life.

Question 89

# Cold Sores ____% experience recurring infections (2-6 per year)

Answer 89

20-40%

Question 90

When are cold sores considered to be infectious?

Answer 90

Any open sores = Infectious

Question 91

What fluid do cold sores typically release when they break open? a) Blood b) Pus c) Clear, sticky fluid d) Yellow fluid

Answer 91

c) Clear, sticky fluid

Question 92

What are two things people can implement into their daily skin care routines to help reduce triggers and/or severity of cold sores?

Answer 92

SPF and hydration - Hydration applies to both sufficient fluid intake, as well as application of protectants on the lips.

Question 93

Is there a preference between using OTC products vs. RX products when treating cold sores?

Answer 93

Yes, there are preferences. RX > OTC | Prefer RX products over OTCs for cold sore treatment.

Question 94

How many stages are there for Cold Sores?

Answer 94

There are **5 Stages** of Cold Sores.

Question 95

# 5 Stages of Cold Sores. Stage 1 of Cold Sores: **"Prodrome Stage" or "Prodromal Stage"** | Duration, Symptoms, Presentation, and any other important details.

Answer 95

- **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. ## Footnote 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.

Question 96

# RX Oral Anti-Viral Agents for Cold Sores. Valtrex (Valacylovir) - Dosing, Frequency, Duration of Treatment [for Cold Sores]

Answer 96

2000mg (i.e., 2 g) po BID x 1 day - Prodrug is acyclovir. When body converts it to that, works by inhibiting viral DNA replication. ## Footnote Valacyclovir 500mg caplets are the only ones that are covered under the formulary (no other strength pills are covered) therefore usually will dispense dosing using 500mg caplets and dispense the proper amounts based on that.

Question 97

# 5 Stages of a Cold Sore. Stage 2 of Cold Sores | Time of Onset, Symptoms, Presentation, and any other important details.

Answer 97

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.

Question 98

Is it wise or beneficial to start valacyclovir during Stage 2 (and beyond)?

Answer 98

Not usually... Valacyclovir is considered to only be benficial *before* lesions/blisters are present. - Pharmacists cannot prescribed Valtrex once blisters or lesions are present

Question 99

# RX Topical Anti-Viral Agents for Cold Sores. Zovirax (Acyclovir) 5% Ointment (or Cream) - Dosing, Frequency, Duration of Treatment [for Cold Sores]

Answer 99

AAA 5x per day x 4 days (RXFiles says 5-6x/day x 5-7d) - Approved for individuals ≥ 18 years - Less effective than oral antivirals; ointment may not be as effective as cream (RXFiles says ointment is ineffective) - Inhibits viral DNA replication towards surrounding cells - Topical helps is likely to just be more for TLC purposes by alleviating symptoms such as pain, itching, and tingling at most. - We don't like this product, even if trying to choose a topical for cold sores.

Question 100

# RX Topical Anti-Viral Agents for Cold Sores. Xerese (Acyclovir 5% / HC 1%) Cream - Dosing, Frequency, Duration of Treatment [for Cold Sores]

Answer 100

AAA 5x / day x 5 days - Approved for ≥ 12 yo (FDA USA has approved for people ≥ 6 yo) - Addition of hydrocortisone may reduce the risk of ulcerative lesions - Cream improves healing by ~0.5 days and reduces lesion size by 50% - For this reason, we don't mind this product as the HC can help (but we don't really recommend Zovirax ointment) - Still less effective than valacyclovir

Question 101

# 5 Stages of Cold Sores. Stage 3 of Cold Sores. | Time of Onset, Symptoms, Presentation, and any other important details.

Answer 101

- 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)

Question 102

# 5 Stages of Cold Sores. Stage 4 of Cold Sores. | Time of Onset, Symptoms, Presentation, and any other important details.

Answer 102

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.

Question 103

# 5 Stages of Cold Sores Stage 5 of Cold Sores

Answer 103

Healing Stage

Question 104

Do all cold sore cases require treatment?

Answer 104

No. If a person is experiencing their first cold sore, or has a mild case of a cold sore, or only has occassional episodes, treatment is not usually required.

Question 105

What are some (4) Non-Drug recommendations for cold sores?

Answer 105

- Reduce stress [prevention]... but that's easier said than done. - Protect from the sun [prevention]... Use SPF. - Don't pop or squeeze the blister - Use lip balm (to keep soft and hydrated)

Question 106

Use an ointment (such as Vaseline) on the cold sore to keep it from cracking and drying. This helps prevent getting an _____ in the cold sore

Answer 106

Infection

Question 107

# OTC Lip Treatments for Cold Sores... Abreva

Answer 107

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 ## Footnote Generic equivalent now available in Canada!

Question 108

Mechanism of Action: **Abreva (docosanol 10%)**

Answer 108

Disrupts viral entry process, which limits the spread of the HSV. - Not considered as an antiviral BUT has antiviral properties since it also** inhibits the fusion of HSV's viral envelope with host cell which prevents entry of the cell and therefore prevents or inhibits the HSV replication process**. ## Footnote By blocking this critical step in the viral life cycle, docosanol helps limit the spread of the virus and reduce the severity of cold sore outbreaks.

Question 109

# 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.

Answer 109

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.

Question 110

Anbesol, Kank-A Mouth Pain, Orajel, Zilactin-B are all products that contains what active ingredient?

Answer 110

Benzocaine

Question 111

# OTCs for Cold Sores **ColdSore-FX...** What is in this product? - Is this effective for cold sores?

Answer 111

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.

Question 112

# OTC Products for Cold Sores **Camphor/Phenol/Menthol Products (example: Camex, Blistex, Lip Medex) ** - What does it do? - How effective is it?

Answer 112

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. ## Footnote Camphor at a concentration >3% OR menthol >1% can cause irritation and inflammation and are therefore CONTRAINDICATED in treatment of cold sores.

Question 113

# OTC Cold Sore Products in Canada. **Lipactin** (heparin/ZnSO4) - What are their effects? - Do we recommend for cold sores?

Answer 113

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. ## Footnote Do not like Lipactin for cold sores!!

Question 114

# OTCs for Cold Sores **Zilactin**. - What is the main ingredient? - Effects? - Recommend?

Answer 114

- 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.

Question 115

# OTCs for Cold Sores. **Zilactin-B** - What is the main ingredient? - Effects? - Recommend?

Answer 115

- 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. ## Footnote May offer temporary relief of pain and itching. More likely to cause sensitization than lidocaine

Question 116

# 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?

Answer 116

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??

Question 117

# Non-RX Options for Cold Sores. **Ice.** - What is its "Mechanism"?

Answer 117

Anti-inflammatory

Question 118

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.

Answer 118

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 ## Footnote 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.

Question 119

A father comes to the pharmacy with his 10-year-old son asking for help as he suspects his son is dealing with another cold sore. Father reports that this is the 4th time this year that his son is experiencing the exact same symptoms and presentations. Father is worried because his son had them last year but mostly in the spring and summer and we are only in the month of March. What would you tell them?

Answer 119

Refer to MD - Pharmacists in SK cannot do minor ailments for <12 years old - If suspicions are correct [cold sore diagnosis], the boy might benefit from preventative or prophylactic medication options for the future plus treatment for the current episode. In the mean time, can suggest the use of lip balms that contain camphor for example to help with irritating symptoms.

Question 120

Why should all topical products used for things like cold sore recommended to use Q-Tips for each application?

Answer 120

Reduces the chances of auto-inoculation (i.e., spreading to other parts of body).

Question 121

Does Abreva (docosanol 10%) cure cold sores?

Answer 121

No, it does not cure cold sores. - While Abreva does **not** cure cold sores or significantly alter the duration of symptoms or the course of the condition, it **can provide some benefits for individuals experiencing cold sore outbreaks such as improve healing time and/or reduce the severity of symptoms. **

Question 122

Which active ingredient is found in Zilactin (regular) for the treatment of cold sores? a) Benzoyl peroxide b) Benzoyl alcohol c) Benzocaine d) Lidocaine

Answer 122

b) Benzoyl alcohol

Question 123

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

Answer 123

c) Drying effect | Might have WEAK anesthetic properties, too.

Question 124

Which active ingredient is found in Zilactin-B for the treatment of cold sores? a) Benzoyl peroxide b) Benzoyl alcohol c) Benzocaine d) Lidocaine

Answer 124

c) Benzocaine | Benzocaine 10% = Anesthetic ## Footnote Recommended option for irritation if wanted.

Question 125

When is cold sore treatment recommended?

Answer 125

- Recurrent cases (3+ cases per year) - Moderate to severe cases - Immunocompromised - If there are complications or no improvements (regardless of how many times has had cold sores)

Question 126

How long after starting treatment for cold sores should we refer patient to see an MD or authorized health care provider?

Answer 126

- If symptoms not resolved 7 days after treatment. - If lesion appears infected - excessively red, swollen, or contain pus. - If lesion is still present after 14 days (or 7 days if attempted treatment)

Question 127

If someone comes to the pharmacy with an open lesion on their lip that looks similar to a cold sore but indicates it has not shown any improvements or any changes since it started 10 days ago, we refer. What is one possible differential assessment we are concerned about for this case?

Answer 127

Basal or Squamous Cell (Basal Cell Carcinoma) - We are always concerned when lesions last for 2+ weeks and/or if no changes occur after the blister appears over a span of 10 days. - Refer because one possibility could be basal cell carcinoma

Question 128

Impetigo and Cold Sores can sometimes look very similar at times. What are some of the things to consider when making a differential assessment between the two?

Answer 128

- Impetigo is more common in kids - Impetigo does not have any vesicle (cold sores have vesicles) - Impetigo usually stays on the skin (whereas cold sores are usually bordering around the lips and such) - Impetigo reports less pain compared to cold sores - Impetigo can take up to 2 weeks to clear - Cold sores usually takes 7-14 days to heal

Question 129

T/F: Canker Sores are cold sores that present themselves inside of the lips.

Answer 129

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.

Question 130

Are children equally likely to get cold sores and impetigo?

Answer 130

No, children are more likely to contract impetigo than they are cold sores. However, cold sores are possible in children.

Question 131

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?

Answer 131

- 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

Question 132

Although very rare, shingles can occur in children. However, not likely to have rash in the same regions of the body. What regions of the body are kids and adults likely to have their rash present themselves when suffering from shingles?

Answer 132

Kids = Face (this is still rare regardless so REFER) Adults = Back

Question 133

Which antiviral medication is the only approved oral treatment for cold sores in Canada? a) Acyclovir b) Famciclovir c) Valacyclovir d) Penciclovir

Answer 133

c) Valacyclovir - Even though valacyclovir is a prodrug that gets converted to acyclovir, Health Canada has only approved Valacyclovir as the only oral anti-viral drug to be used for cold sore treatment. - Acyclovir and Famciclovir are sometimes used for cold sore RX treatment but when it is prescribed for cold sores, it is considered to be "off-label".

Question 134

Valtrex is believed to reduce the healing time of cold sores by how long?

Answer 134

Faster healing by 1-2 days (but needs to be started BEFORE lesions/blisters appear)

Question 135

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

Answer 135

b) On the outer edge of the lip or near the nostrils

Question 136

Zovirax vs. Xerese Topical Antivirals - Which one do we like more?

Answer 136

**Xerese! ** Acyclovir + HC! :) - Anti-viral plus Anti-Inflammatory - Added benefit with using acyclovir in combo with HC, plus having HC can reduce risks of developing ulcers - Cream improves healing by ~0.5 days and reduces lesion size by 50% - Zovirax only has acyclovir and comes in ointment form only. Zovirax topical is considered to be ineffective.

Question 137

How long do symptoms of cold sores typically last for?

Answer 137

7-10 days

Question 138

T/F: Cold sores usually heal within 1–2 weeks even without treatment

Answer 138

**True! ** - Cold sores usually heal in 1–2 weeks without treatment; however, treating them with things like antivirals may shorten the healing time.

Question 139

Which of the following is a common treatment for cold sores caused by herpes simplex virus type 1? a) Antibiotics b) Antifungal cream c) Antiviral medication d) Topical steroids

Answer 139

c) Antiviral medication

Question 140

# Cold Sores Mechanism of Action: **Valacyclovir**

Answer 140

- When valacyclovir enters the body, it is **converted into acyclovir** by the enzyme valacyclovir hydrolase. - Acyclovir, the active form of the medication, works by **selectively inhibiting** the** activity of the viral DNA polymerase** enzyme. - This inhibition **prevents** the virus from **replicating its DNA, thereby halting the spread of the virus** and reducing the severity and duration of cold sore outbreaks

Question 141

What triggers cold sores in some people? a) Lack of sleep b) Exposure to cold weather c) Fatigue, stress, bright sunlight, fever, or hormone changes d) Eating spicy food

Answer 141

c) Fatigue, stress, bright sunlight, fever, or hormone changes

Question 142

A 7-year-old child presents with a rash around the mouth and nose. Upon examination, the healthcare provider notes small, fluid-filled blisters on an erythematous base. The child's mother mentions that the rash appeared after the child's friend, who had a cold sore, kissed them on the cheek. Additionally, the child's sibling has developed honey-colored crusts on their face. Does both the child and their sibling likely have the same ailment/infection?

Answer 142

No, one likely has a virus while the other likely has a bacterial infection.

Question 143

A 7-year-old child presents with a rash around the mouth and nose. Upon examination, the healthcare provider notes small, fluid-filled blisters on an erythematous base. The child's mother mentions that the rash appeared after the child's friend, who had a cold sore, kissed them on the cheek. Additionally, the child's sibling has developed honey-colored crusts on their face. What condition does the 7-year-old child likely have? a) Cold sore b) Oral Candidiasis (oral thrush) c) Impetigo d) Contact dermatitis e) Angular Cheilitis

Answer 143

a) Cold sore - Likely transmitted through direct saliva contact with the friend who already had a cold sore at the time of contact.

Question 144

A 7-year-old child presents with a rash around the mouth and nose. Upon examination, the healthcare provider notes small, fluid-filled blisters on an erythematous base. The child's mother mentions that the rash appeared after the child's friend, who had a cold sore, kissed them on the cheek. Additionally, the child's sibling has developed honey-colored crusts on their face. What condition does the sibling in this scenario have? a) Cold sore b) Oral Candidiasis (oral thrush) c) Impetigo d) Contact dermatitis e) Angular Cheilitis

Answer 144

c) Impetigo - Honey-coloured crusts on the face - Not much info to go off of with limited items given about the sibling but cold sores don't usually have yellow crusts like so - Impetigo is a bacterial infection that is also very contageous so should stay away from other people but especially the child who already has a cold sore.

Question 145

# Cold Sores. Mechanism of Action: **Zovirax** (Topical Acyclovir Ointment) | Zovirax 5% (Topical Acyclovir Ointment)

Answer 145

Inhibits viral DNA replication within the infected cells. - When applied to the affected area, acyclovir penetrates the skin and enters the infected cells - Topical acyclovir helps to reduce the severity and duration of cold sore outbreaks, as well as alleviate symptoms such as pain, itching, and tingling... - Ointment is INEFFECTIVE - Cream is MINIMALLY EFFECTIVE - Even oral acyclovir is Minimally effective

Question 146

# Cold Sores. Mechanism of Action: **Xerese** Cream (Topical Treatment) | Xerese (Acyclovir 5% / HC 1%) Topical Cream

Answer 146

Acyclovir: Inhibits replication of the viral DNA to the surrounding cells. HC: Inhibits the production of inflammatory cytokines and suppressing the immune response that contributes to inflammation. This therefore helps reduce swelling, irritation, itchiness, etc.

Question 147

Xerese is said to improve healing time of cold sores by: a) 1-2 day(s) b) 2-4 days c) Approx. 4 days d) Less than a day e) None of the above - we don't like Xerese

Answer 147

d) Less than a day... More specifically **0.5 days**

Question 148

T/F: Xerese is a topical product that can be used for cold sores and we don't mind it even though healing time is not reduced significantly as one of the benefits of using this products includes decreasing size of cold sore lesion by 50%.

Answer 148

True! Still to be used during Stage 1, it will not decrease healing time greatly BUT it is believed that lesions will still decrease by about 50%.

Question 149

"Aphthous ulcers" =

Answer 149

Canker sores

Question 150

# Canker Sores Etiology of canker sores are often unknown... What are some of the known possible etiologies behind these ulcers? (5)

Answer 150

- Local trauma - Stress - Allergies - Nutritional deficiencies - Medicines

Question 151

Describe the presentation or appearance of canker sores.

Answer 151

White or cream-coloured lesions that are situated within red/inflamed borders. - Small... Ulcers' diameters are typically <1cm.

Question 152

What are the 3 Stages of Canker Sores?

Answer 152

1) Prodromal w/ burning or tingling (no ulcer) 2) Small, painful, and shallow ulcers 3) Healing (clearance of ulcer) ## Footnote Duration of ≤ 7-14 days; often resolve spontaneously

Question 153

T/F: Canker sores are typically large, fluid-filled blisters.

Answer 153

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.

Question 154

Hand, Foot, and Mouth Disease (HFMD) is what kind of infection?

Answer 154

Viral

Question 155

T/F: HFMD is a a viral infection that affects only school-aged (or daycare) children.

Answer 155

**False! ** HFMD predominantly impacts children; however, is possible to infect adults, as well! - Depending on the severity, might be asymptomatic but still can be contagious to others.

Question 156

# Hand, Foot, and Mouth Disease (HFMD) What are the first round of symptoms experienced by those infected with HFMD?

Answer 156

- Fever - Malaise (exhaustion) - Loss in appetite - Sore throat (older victims report can feel like razor blades) - Flu-like symptoms (body aches) ## Footnote Painful sores might not happen for all victims. If sores do appear, usually occurs 1-2 days after fever presentations.

Question 157

# HFMD In the cases where painful sores in the mouth are to appear for HFMD patients, when do they typically present?

Answer 157

1-2 days after fever.

Question 158

# HFMD Painful mouth sores are common for those who contract HFMD... Where would mucosal ulcers be typically found?

Answer 158

- Anywhere inside the mouth (throat, tongue, tonsils, inside of cheeks, etc.) - Anywhere outside the mouth

Question 159

How can we differentiate between cold sores vs. canker sores vs. HFMD based on their lesions alone?

Answer 159

- Cold Sores: fluid-filled blisters that are usually painful and usually situated on the exterior of lips and around the nasal region - Canker sores: white coloured lesions lacking fluid and only situated inside the mouth - HFMD: multiple lesions and ulcers both inside and outside the mouth, as well as has papules found on the palms of the hands, soles of the feet, genitalia, etc. As well, often comes after fever, and other flu-like symptoms.

Question 160

# HFMD Skin rash is likely to appear over 1-2 days... Are the rashes from HFMD itchy?

Answer 160

Depends on the case and severity. Some will get non-itchy rashes, while others can suffer from itchy rashes.

Question 161

# HFMD Once a person contracts HFMD, how likely is it that these individuals will contract the virus recurrently?

Answer 161

Unlikely to contract again in most cases. - Usually only get HFMD once! We develop an immunity.

Question 162

# HMFD On average, how many days does it usually take for HFMD to completely clear?

Answer 162

7-10 days.

Question 163

# HFMD Is HFMD serious?

Answer 163

No (most cases).

Question 164

T/F: There are antivirals and RX medications available to treat HMDF.

Answer 164

False! - Self-limiting virus (and no antivirals available) - Oral analgesics for the pain and fever only.

Question 165

# Canker Sore Differentials Drug-Induced Ulcers can be caused by which kinds of medications ## Footnote List 3 discussed in lecture

Answer 165

- NSAIDs - Beta-Blockers - Cytotoxic agents (e.g., methotrexate)

Question 166

# Canker Sores - Differentials Stomatitis

Answer 166

Often associated with radiation and chemotherapy treatments. - Patients are usually warned beforehand about this possibility.

Question 167

# Canker Sores - Differentials Mouth Cancer

Answer 167

Appears much different in comparison to canker sores and other differentials. - More commonly be found on the tongue.

Question 168

# Canker Sores What are some Non-Pharmacological way to prevent and/or treat canker sores? (5)

Answer 168

- Try to prevent local trauma (dental procedures, dental devices, biting lip) - Reduce stress (do NOT say this to someone) - Nutritional deficiencies (e.g., iron, folic acid, zinc, vit B - are more commonly associated with mouth ulcers) --- this only really applies to frequent canker sore cases to maybe consider. - Rinse w/ salt water multiple times daily (especially after meals) - Can also use other mouth rinses like hydrogen peroxide

Question 169

Which non-pharmacologic consideration is most effective for canker sores?

Answer 169

Saline Rinses (repeat multiple times daily after meals especially) - Can possibly give temporary relief for sore throat or scratchy throat. ## Footnote Can also use other rinses like hydrogen peroxide but not more-or-less effective to each other.

Question 170

If I were to suggest to patient to try a saline rinse for canker sores, what ingredients would you tell them to use (and how much)?

Answer 170

- 1/4 to 1/2 teaspoon of salt that is dissolved in an 8 oz glass of warm water

Question 171

What do we think about Amosan Oral Antiseptic Rinse? ## Footnote Sodium Perborate

Answer 171

Good... It has the same effectiveness as saline BUT it is more expensive option.

Question 172

# Canker Sores; Pharmacological Therapy Benzocaine - How to use? - Benefits (if any) - What can you use it with? - Methemoglobemia concerns? ## Footnote Kanka, CankAid

Answer 172

- Apply directly to the lesion - Provides short-term relief from pain for 30-45 mins BUT does not actually treat the canker sore - Okay to use w/ oral analgesics for extra pain relief - As long as children <2 yo does **not** use this, we are okay. ## Footnote Anything >5% of benzocaine will have similar impacts ITC.

Question 173

# Canker Sores; Pharmacological Therapy Protectants (e.g., Zilactin and Orabase) - How does it work? - How much to use?

Answer 173

- Acts by **adhering** to the **mucosal tissue** - Can use as much as you want - this provides somewhat of a physical barrier via contact - Just know it will wash away with any food or fluids you take in.

Question 174

# Canker Sores; Pharmacological Therapy Magic Mouthwash - Ingredients - How to use - Benefits - Comparison w/ Orabase (or other protectants)

Answer 174

- Ingredients: Milk of Magnesia + Diphenhydramine (Benadryl) - Swish the contents TID then spit out - Low-level therapy, some antiseptic effects, a small amount of protective effects - Not considered more effective than Orabase, but is commonly used.

Question 175

Styptic Sticks... What are the indications? Do we recommend?

Answer 175

Supposed to be for canker sores - Silver nitrate on the ends and dab on the sores. - We do NOT recommend this as this will hurt a lot!

Question 176

# Canker Sores: Prescription Therapy/Prescribing - Low Levels Oracort (triamcinolone) Paste

Answer 176

Orabase [Protectant] + Steroid - Provides symptomatic relief of oral lesions from trauma - Apply small amount to sore HS (because this allows for max contact time w/ lesion) AND use PRN after meals. (Dab over sore until smooth/slippery... Do NOT rub it in) - Duration of therapy: ~7 days (if no improvement, see MD or dentist)

Question 177

# Oral Thrush (Oral Candidiasis) Which organism is associated with oral thrush?

Answer 177

Candida albicans (or C. albicans) | Same as in infected diaper rashes.

Question 178

# Oral Thrush (Oral Candidiasis) How do we refer this kind of fungal infection as being?

Answer 178

An opportunistic fungal infection - Often occurs when normal mouth flora's host defenses are weakened and will disrupt the normal defense mechanisms - Otherwise, can just happen because patient is just unlucky (and can still occur while defenses are still up)

Question 179

What demographics/populations are more susceptible to oral thrush?

Answer 179

- Infants/Children - Denture wearers - Steroid inhaler users (important to rinse mouth after each use) - Immunocompromised (disease state or via immunosupressant therapy) - Broad-Spectrum Antibiotic users

Question 180

How is poor hygiene associated with oral thrush susceptibility?

Answer 180

- Infants... Dirty pacifiers, bottles - Elderly/Seniors... Failure to clean dentures adequately.

Question 181

Symptoms of Oral Thrush (4)

Answer 181

- Creamy white lesions along the tongue and/or cheeks - Can be painful or experience burning sensations - Might bleed slightly when trying to scrape it off (oral thrush cannot be wiped off easily) - Increased fussiness {infants}

Question 182

For infants, oral thrush might be mistaken with what? | And can also be vice-versa - x thing can be can be mistaken for thrush

Answer 182

Milk residue (post-feedings)

Question 183

Infants have a higher susceptibility of getting diaper rash and oral thrush as diaper rash is often due to yeast infection.... What should be considered for treatment of infants who might have a diaper rash for example?

Answer 183

Consider prophylaxis - Give Canesten and antifungal in the mouth at the same time as a precaution as higher chance of diaper rash being yeast infected.

Question 184

T/F: Anemia (B12, iron, folate) is a risk factor of oral thrush.

Answer 184

True! Anemia of various kinds are a form of disease state that can be linked to things like oral thrush, as well as canker sores (as prev. discussed)

Question 185

How can Aerochambers or Spacers make it less likely for asthmatics (and other steroid MDI inhaler users) to get oral thrush?

Answer 185

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. ## Footnote 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.

Question 186

What can elderly people or those who wear dentures do to reduce their chances of getting oral thrush?

Answer 186

Clean their dentures out at night.

Question 187

What can parents/guardians do to lower the chances of infants from getting oral thrush?

Answer 187

- For bottle-feeders, properly clean and sterilize each component of the bottles. - Clean and sanitize pacifiers regularly.

Question 188

# Oral Thrush: Pharmacological Treatment Gentian Violet 1% Solution

Answer 188

- 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.

Question 189

# Pharmaceutical Treatment for Oral Thrush Is Gentian Violet still available?

Answer 189

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.

Question 190

# Therapeutic options for Oral Thrush Probiotics

Answer 190

Purpose: Putting back probiotics into the body - Makes sense - Yogurt might be a good option Problem? Might be difficult to know what is the "right" probiotic(s) to use or need for this. Do we recommend? Meh. Thrush medications are pretty effective so might not even need probiotics!

Question 191

If your baby has a history of oral thrush (or related infections), as your baby gets older, MD might suggest adding which probiotic bacteria to their diet?

Answer 191

Lactobacilli - This acts as "good" bacteria to help get rid of the fungus

Question 192

Which infant probiotics are available at the pharmacy to help reduce the chances of oral thrush?

Answer 192

**None! **- There is NO probiotic in pharmacies to assist with thrush!

Question 193

# Pharmacotherapies for Oral Thrush What is the most commonly used/prescribed product to treat oral thrush for infants and children?

Answer 193

**Nystatin**! - Can use Nystatin for any age demographic - as young as ≤1 year old to adulthood!

Question 194

# Pharmacotherapeutic Options for Oral Thrush: Nystatin Nystatin Dose: Infants (≤1 year old)

Answer 194

100,000 to 200,000 Units QID for 7-14 days * (minimum of 2 days after symptoms resolve). - Place 1/2 the dose in each side of the mouth. - May use cotton swab or finger to apply solution to the inside of the infant's cheeks and on tongue. ## Footnote Symptomatic relief usually within 24- 48 hours... But should continue for another 48 hours after clearning. Total time of therapy is ~7 days.

Question 195

# Pharmacotherapeutic Options for Oral Thrush: Nystatin Nystatin Dose: Children & Adults

Answer 195

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 ## Footnote Symptomatic relief usually within 48 hours... But should continue for another 48 hours after clearning. Total time of therapy is ~7 days.

Question 196

What is the typical duration of therapy for Nystatin when treating oral thrush (even when accounting for the 48h continuance post-symptom clearance)?

Answer 196

7 to 14 days (approx)

Question 197

T/F: Infants, children are to continue Nystatin for oral thrush therapy for 48 hours after symptom clearance; but adults only need 24 hours extra.

Answer 197

**False! **- All Nystatin users for oral thrush should continue for 48h after symptoms clear. - Typical duration of treatment is approx. 7-14 days

Question 198

Your pharmacy only has Nystatin 100,000 Units/mL stock suspension... What is the recommended dosage of Nystatin oral suspension for infants ≤1 year old to treat oral thrush? a) 1 to 2 mL 2 times daily b) 1 to 2 mL 4 times daily c) 2 to 4 mL once daily d) 4 to 6 mL 3 times daily

Answer 198

b) 1 to 2 mL 4 times daily x 7-14 days (use for additional 2 days after symptoms clear) (100,000 to 200,000 Units QID)

Question 199

T/F: Nystatin oral suspension can be used for the treatment of oral thrush in premature or low birth-weight infants.

Answer 199

True! | But pharmacists CANNOT prescribe for them. MDs only!!

Question 200

How long should Nystatin oral suspension be used to treat oral thrush **in infants**? a) 1-3 days b) 3-5 days c) 7-14 days d) 14-21 days

Answer 200

c) 7-14 days

Question 201

How should Nystatin oral suspension be administered to infants with oral thrush? a) Swallow the entire dose immediately b) Apply the solution only to the tongue c) Place 1/2 the dose in each side of the mouth d) Administer using a syringe e) Administer the solution orally and have them swallow it.

Answer 201

c) Place 1/2 the dose in each side of the mouth *May use cotton swab or finger to apply solution to the inside of the infant's cheeks and on tongue, too.

Question 202

T/F: Nystatin is safe to use during any trimester of pregnancy.

Answer 202

True!

Question 203

T/F: Nystatin is absorbed systemically when taken orally and can enter breast milk, so it should be avoided while breastfeeding.

Answer 203

False! - Nystatin is compatible with breastfeeding/chestfeeding. - It is Poorly absorbed orally and does not enter breast milk = safe!

Question 204

# Your pharmacy only has Nystatin 100,000 Units/mL stock suspension... What is the recommended dosage of Nystatin oral suspension for children and adults to treat oral thrush? a) 1 to 2 mL (100,000 to 200,000 U) 4 times daily b) 2 to 4 mL (200,000 - 400,000 units) twice daily c) 4 to 6 mL (400,000 to 600,000 units) 4 times daily d) 6 to 8 mL (600,000 - 800,000 U) once daily

Answer 204

c) 4 to 6 mL (400,000 to 600,000 units) QID x 7-14 days *

Question 205

How long should Nystatin oral suspension be used to treat oral thrush **in children and adults**? a) 1-3 days b) 3-5 days c) 7-14 days d) 14-21 days

Answer 205

c) 7-14 days | Same as for infants (just diff. dosings)

Question 206

T/F: It is recommended to swallow Nystatin oral suspension immediately after administration.

Answer 206

False! - Children & Adults are to Swish, **retain in mouth for as long as possible (up to a few minutes)** before swallowing. - This is to help get to the throat and GI tract

Question 207

What is the tolerability of Nystatin for users?

Answer 207

It is well-tolerated

Question 208

There are times where there might be a short contact time when using Nystatin... - Does this effect the efficacy of the drug?

Answer 208

Yes, it limits the efficacy of Nystatin [with short contact times] - Regardless, Nystatin is still the drug of choice for oral thrush.

Question 209

Dry Mouth (Xerostomia) is more common among which population?

Answer 209

**Elderly people ** - Medication uses (anti-cholinergics; > 400 possible causes) - Decreased saliva production - Chronic Medical conditions or diseases - Poor hygiene and lifestyle - Short-term causes

Question 210

What are some of the functions (4) of saliva?

Answer 210

- Helps re-mineralize the teeth - Lubricates oral mucosa - Local antimicrobial activity - Part of taste sensation

Question 211

What are (5) Some of the Causes of Dry Mouth?

Answer 211

- Radiation/Chemo - Mouth-breathing (terminal illness, allergic rhinitis) - Chronic Diseases (HIV, Alzheimers, etc.) - Medications (>400 possible causes), and uses of things like diuretics, TCAs, 1st gen antihistamines, opioids, etc., - Short-Term Causes (anxiety, dehydration, viral infections)

Question 212

What are some of the Non-Pharmacological Treatments for Dry Mouth?

Answer 212

- Sipping Water (most or all will do this) - Sugar-Free Gum and/or Hard Candies - Humidifier in the house

Question 213

# Pharmacological Dry Mouth Treatments Moi-Stir, Oralbalance, and Biotene are all examples of what kind of agent?

Answer 213

Saliva Substitutes | Cannot completely replicate saliva, but something has to be tried.

Question 214

Which Saliva Replacements are the best on the market right now?

Answer 214

Don't know... Depends on the person. - trial and error type of thing

Question 215

What is the duration of action of saliva substitutes (Biotene, Moi-Stir, and OralBalance)?

Answer 215

Short-Term - Due to swallowing - Cannot completely replicate saliva, but something has to be tried.

Question 216

How frequent can Saliva Replacements be used in a day?

Answer 216

Apparently as frequently PRN (but GSK recommends do not use more than a full single tube of Biotene - for example - per day)

Question 217

Erythematous fissures at the angles of the mouth

Answer 217

Angular cheilitis | Affects the corners of the mouth

Question 218

What causes angular cheilitis?

Answer 218

Don't know the cause of this.

Question 219

How does one distinguish between cold sores vs. angular cheilitis?

Answer 219

Cold sores (oral herpes) typically holds of the lips, at the edge of the lips or on the face close to the mouth area. Angular Cheilitis affects only the corners of the mouth.

Question 220

What does gingivitis look like?

Answer 220

Gums become red, swollen and might bleed easily (especially during brushing and eating)

Question 221

What can happen if leave gingivitis untreated?

Answer 221

Possible **Periodontitis** - serious gum infection that damages the soft tissue and destroys the bone that supports your teeth

Question 222

Lists 4 causes of Gingivitis.

Answer 222

- Inadequate brushing and/or flossing - Medical disorders - Medications (like **phenytoin**, **cyclosporin**, calcium channel blockers... but this can usually be avoided with good oral hygiene) - Tobacco use

Question 223

What is the most common cause of gingivitis?

Answer 223

Inadequate brushing and/or flossing - Builds up plaque and tartar on teeth and gums

Question 224

What can you expect if you have TMJ?

Answer 224

- Clicking, popping sounds in the jaw joint - Pain and discomfort - temporary or can be for years - Most common for those ages 20-40 years old