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Oral medicine prescription guide Flashcards

1
Q

What investigations do you do for Burning Mouth Syndrome/Oral dysaesthesia?

A
  1. Bloods
    a. FBC
    b. Haematinics (Vit B12/F/F)
    c. TFTs (thyroid function tests)
    d. Resting glucose
    e. AIP (autoimmune profile)
    f. (Zinc if altered taste)
  2. Microbial swab
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2
Q

Treatment for Burning Mouth Syndrome/Oral Dysaesthesia

A
  1. Difflam (benzydamine hydrochloride 0.15%)
    > 30ml oral spray PRN
    > 300ml mouthwash PRN
  2. Vitamin B Co-Strong, 2 tds for 6/52.
  3. Solvazic tabs (zinc sulphate 125mg) mouthwash, 1 tab tds
  4. Others as appropriate
    > Antifungals
    > Ferrous sulphate 200mg tds
    > Ferrous fumerate 210mg tds
    > Folic acid 5mg od
  5. Neuropathic meds (see facial pain box)
    > Nortriptyline 20mg on
    > Amitriptyline 20mg on
    > Pregabalin 75mg bd
    > Gabapentin 300mg tds over 3d
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3
Q

Investigations for oral lichen planus?

A
  1. Bloods
    a. FBC
    b. Haematinics
    c. Random glucose
    d. AIP (autoimmune profile)
    e. (Pemphigoid and pemphigus antibodies if desquamative gingivitis)
    f. (Hep C antibody if risk factors)
  2. Biopsy
    a. Request separate /second sample if DG (desquamative gingivitis)/suspected MMP (mucous membrane pemphigoid) to sent for direct IF (immunofluorescence) - best results from punch biopsies of normal perilesional tissues (usually buccal mucosal tissue)
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4
Q

Treatment of oral lichen planus?

A
  1. Aloe vera (if they want natural)
  2. Difflam spray or mouthwash (Benzydamine hydrochloride 0.15%) - 30ml oral spray, 300ml mouthwash.
  3. Betnesol mouthwash (0.5mg betamethasone soluble tabs, 2 tabs dissolved in 10-15ml water and used as mouthwash for 2-3 mins, then spat out. Use PRM up to bd).
  4. Beclometasone dipropionate aerosol inhaler 100-200mcg/puff) 1 qds
  5. Prednisolone 5mg soluble tabs, 1 in 10-15ml water for 2-3 min used PRN up to qds.
  6. Flixonase nasal spray (fluticasone propionate 50mcg/spray) 1 spray PRN up to qds.
  7. Flixonase nasules (fluticasone propionate 400mcg) 1 in 10-15ml as m’wash for 2-3 min PRN up to bd.
  8. Dermovate cream (clobetasol propionate 0.05%) PRN up to bd. NB advise to ignore advice on container re not using in the mouth.
  9. Synalar GEL (fluocinolone acetonide 0.025%) PRN up to bd.
  10. Protopic ointment (tacrolimus 0.03% or 0.1% strength), prn up to bd.
  11. Intralesional triamcinolone 40mg/ml for stubborn localised atrophic/erosive areas.
  12. Knox formula (only from BRI pharmacies - GPs can’t prescribe). Prescribe as ‘triamcinolone acetonide 40mg/ml 1.25ml and erythromycin suspension 125mg/5ml to 100ml, please supply 200ml. Use bd as m’wash’.
  13. Systemics
    > prednisolone
    > hydroxychloroquine
    > mycophenolate mofetil
    > azathioprine
    > dapsone
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5
Q

Investigations for fungal infections?

A
  1. Microbial swabs
  2. Bloods if resistant to treatment
    a. FBC
    b. Haematinics
    c. Random glucose
    d. Consider HIV testing
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6
Q

Treatment for fungal infections?

A
  1. Nystatin oral suspension 100,000 nits/ml, 1ml qds for 2-3/52
  2. Miconazole oral gel 24mg/ml, 5-10ml qds for 2-3/52 (STATINS)
  3. Fluconazole 50-100mg od po for 2/52 (STATINS)
  4. Fucidin cream (fusidic acid 2%)
  5. Fucidin ointment (sodium fusidate 2%) qds
  6. Daktakort cream or ointment bd (hydrocortisone plus miconazole - (STATINS))
  7. Fucidin H cream bd (hydrocortisone plus fusidic acid)
  8. Timodine cream bd (hydrocortisone plus nystatin)
  9. Trimovate cream bd (clobetasone, oxytetracycline, nystatin).
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7
Q

What is the normal unstimulated flow rate of saliva?

A

Normal is 0.3-0.4ml/min

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8
Q

What is the abnormal unstimulated flow rate of saliva?

A

<0.1ml/min (<1ml in 10 mins)

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9
Q

Investigations for xerostomia?

A
  1. Bloods
    a. FBC
    b. Haematinics
    c. AIP incl Ro/La (Autoimmune profile
    d. ESR (erythrocyte sedimentation rate)
    e. Random glucose
    f. (consider ACE/HIV in sialosis)
  2. Salivary flow rates of 10 mins
  3. USS - ultrasound
  4. Sialography
  5. Labial gland biopsy
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10
Q

What does a positive RO antibody mean?

A

Anti-Ro antibodies can be found in patients with a variety of autoimmune conditions including Lupus, Sjögren’s syndrome and rheumatoid arthritis. It can also be found in a small number of asymptomatic women who don’t have an associated medical disorder.

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11
Q

What does positive LA antibodies mean?

A

Antibodies to La are found in 25-80% of patients with primary Sjögrens syndrome particularly those with hyper-gammaglobulinaemia, extra glandular manifestations, especially vasculitis and cytopaenias.

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12
Q

What disease are anti ro anti-la antibodies most often associated with?

A

Anti-Ro/SSA and anti-La/SSB antibodies are among the most frequently detected autoantibodies against ENA and have traditionally been associated with SLE, SS, subacute cutaneous lupus erythematosus (SCLE), and neonatal lupus erythematosus (NLE).

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13
Q

What does it mean to have elevated Sjögren’s antibodies?

A

Elevated Sjögren’s antibodies—anti-SS-A and anti-SS-B—are suggestive of inflammatory connective tissue disease. Elevated results on this test may indicate Sjögren’s syndrome or another autoimmune disease such as lupus or rheumatoid arthritis.

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14
Q

Treatment of xerostomia?

A
  1. Biotene oralbalance gel PRN
  2. Glandosane spray PRN
  3. Salivix pastilles 1 PRN (give 100)
  4. SST tablets 1 PRN (give 100)
  5. Xerontin oral spray PRN
  6. Pilocarpine 1% eye drops on tongue, 2 tds
  7. Systemic pilocarpine hydrochloride 5mg po qds
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15
Q

Investigations for ulcers?

A
  1. Bloods
    a. FBC
    b. Haematinics
    c. TTGs - tissue transglutaminase IgA (tTg-IgA) test
    d. AIP (autoimmune profile)
    e. (consider HLA B5101 if strong suspicion of Behcet)
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16
Q

Treatment for ulcers?

A
  1. Difflam spray or mouthwash
  2. Gelclair sachets 1 tds
  3. Doxycycline mouthwash (100mg capsules dissolved in 10-15ml used for 2-3 min qds)
  4. Knox formula mouthwash
  5. Topical steroids (see OLP box)
  6. Systemics (as OLP however consider colchicine 500mcg gd increasing to tds if needed).
17
Q

Investigations for orofacial granulomatosis?

A
  1. Bloods
    a. FBC
    b. Haematinics
    c. ACE
    d. U+E
    e. LFT
    f. AIP
    g. Total IgE
    h. C3/C4 (if suspect angioedema)
    i. Ca (if suspect sarcoid)
  2. Biopsy (usually swollen labial mucosa or cobble-stoned buccal mucosa)
  3. CXR if resp symptoms or suspect Tb/sarcoid)
18
Q

Treatment of orofacial granulomatosis?

A
  1. Cinnamon/Benzoate free diet
  2. Antihistamines
    a. Cetirizine hydrochloride 10mg od
    b. Chlorphenamine 4mg qds
  3. Aureocort ointment bd (triamcinolone acetonide 0.1%)
  4. Prednisolone 5mg soluble tablets used as mouthwash PRN up to qds (AVOID BETNESOL)
  5. Intralesional triamcinolone 40mg/ml
  6. Minocycline tabs 100mg od po 3/12 then review
  7. Clofazamine 50-100mg od po 3/12 then review
  8. Azathioprine
  9. Dapsone
  10. Sulfasazine
  11. Biologics (liaise with derm/gastro re IV infusions)
  12. Consider referral to dermatology for patch testing
  13. Consider referral to gastro for endoscopy if suspect IBD
19
Q

Investigations for Facial pain (Neuralgia or Neuropathic pain)?

A
  1. Bloods
    a. FBC
    b. Haematinics
    c. ESR
    d. Glucose
    e. AIP
  2. Plain film radiography
  3. CT/CBCT
  4. MRI head +/- neck
20
Q

Treatment of facial pain (neuralgia/neuropathic pain)

A
  1. Simple analgesia (paracetamol/NSAID/Tramadol 50-100mg qds)
  2. 5% lidocaine patch/gel/cream
  3. 0.075% capsaicin cream qds
  4. TCAs
    > amitriptyline 10-20mg on, increased slowly up to 75mg
    > nortriptyline 10-20mg on, increased slowsly up to 75mg
    > imipramine 10mg on, increased slowly up to 50mg
  5. SSRIs
    > citalopram 20mg, increasing to 40mg if needed.
    > sertraline
  6. SNRIs
    > venlafaxine 37.5mg tabs bd increasing to a max of 375mg total daily dose
    > duloxetine 60mg od, if suspect diabetic neuropathy
  7. Anti-epileptics
    > Carbamazepine (Tegratol slow release) 100-200mg bd (usual eventual dose for TN is 200mg tds-qds, max 1.6g total daily dose) TRIGEMINAL NEURALGIA> Oxcarbazepine 300mg bd (usual dose range 600mg-2.4g in divided doses)> Gabapentin caps 300mg tds (day 1: 300mg od, day 2: 300mg bd, day 3: 300mg tds) increasing by 300mg every 3-4 days as needed. Max 3.6g daily in divided doses (900mg tds)> Pregabalin 75mg bd, increasing to 150mg bd after 1 week if needed. Max 600mg daily in divided doses.> Lamotrigine 25mg od, increasing by 25mg every 2/52 to a maximum of 200mg bd.
    1. Indometacin start at 75mg od, if suspect vascular cause ie chronic paroxysmal hemicrania.

Revision (7 decks)

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