Oral Aphthous Ulcer - Guidelines for Prescribing Triamcinolone Dental PasteThe introduction of topical steroid for mouth into oral medicine heralded esteroides como funcionan therapeutic advance, and substantial benefits have occurred from their use. Three topical steroids are topical steroid for mouth used currently in oral diseases, i. The efficacy of these agents can be increased markedly if they are administered during the prodromal phase of ulceration, i. Therapeutic doses of all of them can be exceeded three times without impairing adrenal function. Nevertheless some of these preparations, as exemplified by topical medication, induced an unfortunate acute pseudomembranous candidiasis without any alteration in the plasma cortisol level.
Treatment of complex oral lesions | Learning article | Pharmaceutical Journal
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I completed my pharmacy degree with the University of Brighton and my diploma with the University of Bath. Currently senior house officer in paediatric dentistry at Bristol Dental Hospital. I completed my dental degree at Cardiff University and have since worked in both primary and secondary care. Patients with complex oral lesions are often prescribed treatments off-label. Pharmacists can assist in the care of these patients by counselling them on appropriate use of topical preparations.
Oral medicine often requires the use of off-label treatments to manage complex conditions such as recurrent aphthous ulceration, oral lichen planus and mucous membrane pemphigoid. Pharmacists need to be aware of the main counselling points for patients, particularly around the use of topical corticosteroids.
The management of oral medical conditions can be complex. Although they may be managed in primary care by a dentist, more commonly patients are referred to an oral medicine specialist centre and their treatment requires a multidisciplinary approach.
An ulcer is a break in the oral epithelium. This exposes the nerve endings present in the underlying connective tissue,  which can often lead to pain and discomfort.
There are numerous causes of oral ulceration. Oral malignancy may also present as persistent ulceration, and any ulcer that lasts for more than three weeks with no sign of resolution requires referral to a GP or dentist for further investigation. RAU is more common during periods of stress, during and after stopping smoking, and in higher socio-economic populations. RAU is characterised by recurrent episodes of single or multiple mouth ulcers with no identifiable cause, and therefore diagnosis can only be made following exclusion of local or medical causes.
Barrier agents eg, Orabase are useful in the management of minor ulceration. The mucosa should be as dry as possible before application. This ensures the agent will adhere to the mucosa, protecting the specific area of the mouth. Topical anti-inflammatories, such as benzydamine 0. The mouthwash should be used undiluted, but can be diluted with water if stinging occurs. Topical corticosteroids are considered the main treatment for aphthous ulceration.
They help reduce the inflammatory response, which in turn helps to reduce pain. Topical corticosteroids suppress the local flora and can cause an overgrowth of Candida spp, which can complicate therapy.
Candidiasis can be managed by reducing or stopping the corticosteroid treatment if appropriate and applying a topical antifungal, such as miconazole gel, to help control the infection. Systemic corticosteroids, dapsone and colchicine can be prescribed for more severe cases of RAU that are unresponsive to topical therapy. The Cochrane Collaboration has conducted a review of systemic interventions for aphthous ulceration.
For some patients, OLP can be asymptomatic and treatment is not necessary. OLP tends to last for several years, with periods of symptoms and remission. Although the exact disease process is not fully understood, it is known to be immune-mediated. Patients need to be aware that they require regular follow-up with a dentist or specialist.
Treatment is based on the severity of symptoms. Analgesic and antiseptic mouthwashes can be used to reduce soreness and prevent secondary infection. Typically, patients with mild inflammation who present with localised atrophic or erosive lesions will respond to topical corticosteroids.
The Cochrane reviews on OLP treatments could find no evidence that one topical steroid is better than another. Patients with severe OLP may not respond to topical treatment. Treatments prescribed in specialist oral medicine units may include the calcineurin inhibitor tacrolimus in an adhesive base, applied topically. The Medicines and Healthcare products Regulatory Agency MHRA  has issued a warning about using tacrolimus topically because post-marketing surveillance data suggest there is an increased risk of developing malignancy.
There is no strong evidence that use of topical tacrolimus in the mouth carries a similar risk. Mucous membrane pemphigoid MMP is an uncommon auto-immune blistering condition that can affect the mouth. It usually occurs in middle-aged or elderly patients and is more common in women. It is characterised by blistering, ulceration, erosions and soreness affecting any mucous membrane eg, mouth, eyes and genitals.
If a diagnosis of MMP is suspected, the patient should be referred to an ophthalmologist because scarring of membranes in the eye can occur, leading to blindness. Patients with MMP should be managed by a multidisciplinary team including dermatology, oral medicine and ophthalmology specialists.
Although mild-to-moderate MMP can be managed with topical corticosteroids, moderate-to-severe MMP is unlikely to be controlled sufficiently with topical treatment alone and immunosuppressants such as azathioprine and mycophenolate mofetil are often prescribed. The use of these immunosuppressants is off-label but widely accepted in oral medicine specialist practice. A Cochrane review of treatment for MMP suggests that more trials are needed to determine which therapy is the most effective.
Patients should mix the clobetasol with Orabase in a 1: The lesion should be as dry as possible before application to ensure the mixture adheres. Corticosteroid inhalers are often used to deliver steroids to the mucosa.
Patients should be advised to direct the inhaler toward the lesion and deliver a dose. Hydrocortisone mucoadhesive buccal tablets can be held by the tongue against the affected area and allowed to dissolve in the mouth.
Soluble betamethasone can be used as an oral rinse, with one tablet dissolved in 20ml of water. Patients should be told not to swallow the solution. Oral Medicine —— update for the dental practitioner.
Aphthous and other common ulcers. British Dental Journal ; Referral guidelines for suspected cancer. June modified April www. Systemic interventions for recurrent aphthous stomatitis mouth ulcers. Cochrane Database of Systematic Reviews. Recurrent aphthous stomatitis recurrent mouth ulcers. Interventions for treating oral lichen planus.
Cochrane Database of Systematic Reviews , Issue 7. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database of Systematic Reviews , Issue 2. Reminder of a possible risk of malignancies including lymphomas and skin cancers. Interventions for mucous membrane pemphigoid and epidermolysis bullosa acquisita.
Cochrane Database of Systematic Reviews , Issue 4. Patricia Hollingsworth 24 JUN 2: Taking Azathioprine 50 mg on Sunday and Thursday. My doctor is in Dallas, Tx at Southwestern Medical. I'm also a type 2 diabetic, 3 kinds of arthitis, heart problems. The golden years suck. I still have a lot of things that I want to do. At this time I'm dealing with a broke back.
It has a crack that can't be fixed. I have trouble walking and keeping up with my housework. Trying to lose weight 72 years old lbs and 5 ft 3 in. For commenting, please login or register as a user and agree to our Community Guidelines. You will be re-directed back to this page where you will have the ability to comment.
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