Treatment of Oral Diseases
Oral Ulcers
Relief of Pain
Non-Steroidal Anti-Inflammatory Drugs (NSAID’s).
Paracetamol. 1g. QDS.
Codeine. 30 – 60 mg. 4 hourly.
Merocaine / Dequacaine (Benzocaine) lozenges.
Xylocaine 2% gel.
Lidocaine 5% ointment / lozenges or 10% solution spray.
Difflam (Benzydamine) M/W. 0.15%. 4 – 8 sprays onto affected area. 1.5 – 3 hourly.
Flurbiprofen lozenges. 8.75 mg. Allow 1 tablet to slowly dissolve in mouth. For maximum of 3 days.
Bonjela (Choline Salicylate) Dental Gel. 8.7%. Apply gel to area & gently massage. 3 hourly at most.
Healing of Ulcers
Tetracycline 250 mg capsules QDS M/W. Dissolve in 10 mls water and hold in mouth > 2 mins. Also used for herpetiform oral ulceration.
Doxycycline 100 mg capsules QDS M/W. Dissolve in small amount of water and gargle for 2 – 3 minutes, repeat QDS for 3 days.
Mysteclin analogue: 1 Tetracycline capsule in 10 mls water + 1 ml Nystatin suspension.
Corsodyl (Chlorhexidine) M/W. 10 mls. TDS. Stains teeth & prolonged use can affect sense of taste.
Prevention of New Ulcers
Corlan (Hydrocortisone) 2.5 mg lozenges. Sucked QDS. Initially for 2 – 3 months.
Adcortyl in Orabase (Triamcinolone). Applied to individual ulcers & nocté. Best anteriorly.
Betnesol (Betamethasone) 0.5 mg tablets dissolved in water & hold in mouth > 3 mins. QDS.
Bextasol (Betamethasone valerate) spray & Becotide (Beclomethasone) inhaler. 1 puff TDS / QDS to affected area.
Prednesol (Prednisolone) Soluble 5 mg tablets dissolved in water & hold in mouth > 3 mins. QDS.
Prednisolone 5 mg tablets. Start at 40 mg for 4/7 and reduce over 2/52 to a maintenance dose of 10 mg. Steroid screen at 1/7, 1/12 & 3/12.
Azathioprine 50 mg tablets. In combination with Prednisolone. 100 mg OD. Hæmatological screen 1/7, 2/12 & every 3/12.
Miscellaneous
Carbenoxolone 20 mg. OD / BD.
Ciclosporin 100 – 1500 mg / ml mouthwash. TDS / QDS.
Cimetidine 200 – 400 mg. BD.
Colchicine 500 μg. OD – TDS. 2/52, reduce to 250 μg. FBC after 1/12; then every 3/12.
Dapsone 1 – 2 mg / kg body weight. OD. Given also with vitamin E.
Disodium chromoglygate 100 mg capsules as rinse for > 3 mins & then swallowed.
Levamisole 50mg TDS. For 3 days only.
Pentoxifylline 400mg BD.
Salazopyrin (Sulphasalazine) 250 – 500 mg (up to 1000 mg) daily.
Synalar (Fluocinolone) gel. 0.25%. Apply to ulcers. Nocté.
Tacrolimus 100 μg / kg. OD.
Clobestasol. 0.05%. Apply to ulcers. Nocté.
Gengigel
Soluble Aspirin tablets 300 mg (1 – 2 tablets dissolved in small amount of water). Used as M/W. QDS. If not contra-indicated can be
swallowed.
Gelclair. Use 30 – 60 minutes before eating or drinking. Use 3x daily or PRN. Also used for Oral Mucositis.
Orabase (Carboxymethylcellulose). Powder / paste used to protect ulcers from further trauma (when eating for example).
Clobestasol 0.05% cream (for anterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
No laboratory monitoring needed.
Fluticasone nasules 400mcg (multiple areas of the oral cavity affected). Dissolve in water and used as mouthwash.
Fluticasone spray 50mcg.
No laboratory monitoring needed.
Tacrolimus 0.1% ointment (for posterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
Tacrolimus 0.5mg capsules (multiple areas of the oral cavity affected). Dissolved in water and used as mouthwash. FBC, LFT, kidney function test, blood glucose, BP (base line & repeated if treatment longer than 3 months). Monitoring at outpatient clinics.
Systemic medications:
Prednisolone, Doxycycline, Mycophenolate, Dapsone, Hydroxychloroquine, Colchicine, Pentoxifyline
Clinical and laboratory monitoring. Antifungal prophylaxis recommended for long term use of topical steroid (nystatin, chlorhexedine, miconazole)
Lichen Planus
Betnesol (Betamethasone) 0.5 mg tablets dissolved in water & hold in mouth > 3 mins. QDS.
Bextasol (Betamethasone valerate) spray & Becotide (Beclomethasone) inhaler. 1 puff TDS / QDS to affected area.
Prednesol (Prednisolone) Soluble 5 mg tablets dissolved in water & hold in mouth > 3 mins. QDS.
Corlan (Hydrocortisone) 2.5 mg lozenges. Sucked QDS. Initially for 2 – 3 months.
Adcortyl in Orabase (Triamcinolone). Applied to individual ulcers & nocté. Best anteriorly.
Prednisolone 5 mg tablets. Start at 40 mg for 4/7 and reduce over 2/52 to a maintenance dose of 10 mg. Steroid screen at 1/7, 1/12 &
3/12.
Azathioprine 50 mg tablets. In combination with Prednisolone. 100 mg OD. Hæmatological screen 1/7, 2/12 & every 3/12.
Clobestasol 0.05% cream (for anterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
No laboratory monitoring needed.
Fluticasone nasules 400mcg (multiple areas of the oral cavity affected). Dissolve in water and used as mouthwash.
Fluticasone spray 50mcg.
No laboratory monitoring needed.
Tacrolimus 0.1% ointment (for posterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
Tacrolimus 0.5mg capsules (multiple areas of the oral cavity affected). Dissolved in water and used as mouthwash. FBC, LFT, kidney function test, blood glucose, BP (base line & repeated if treatment longer than 3 months). Monitoring at outpatient clinics.
Systemic medications:
Prednisolone, Doxycycline, Mycophenolate, Dapsone, Hydroxychloroquine, Colchicine, Pentoxifyline
Clinical and laboratory monitoring. Antifungal prophylaxis recommended for long term use of topical steroid (nystatin, chlorhexedine, miconazole)
Behçet’s Syndrome
Colchicine 500 μg. OD. 2/52, reduce to 250 μg. FBC after 1/12; then every 3/12.
Prednisolone 5 mg tablets. Start at 40 mg for 4/7 and reduce over 2/52 to a maintenance dose of 10 – 20 mg. Steroid screen at 1/7,
1/12 & 3/12.
Azathioprine 50 mg tablets. In combination with Prednisolone. (Prednisolone 10 mg alternate days, Azathioprine, 50 mg OD). 50 –
100 mg OD. Hæmatological screen 1/7, 2/12 & every 3/12.
Pemphigus, Pemphigoid & Erythema Multiforme
Prednisolone 5 mg tablets. Start at 40 mg for 4/7 & reduce over 2/52 to a maintenance dose of 10 – 20 mg. Steroid screen at 1/7, 1/12 & 3/12.
Azathioprine 50 mg tablets. In combination with Prednisolone. (Prednisolone 10mg alternate days, Azathioprine, 50 mg OD). 50 –
100 mg OD. Hæmatological screen 1/7, 2/12 & every 3/12.
Oral Crohn’s
Salazopyrin (Sulphasalazine) 250 – 500 mg (up to 1000 mg) daily.
Clobestasol 0.05% cream (for anterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
No laboratory monitoring needed.
Fluticasone nasules 400mcg (multiple areas of the oral cavity affected). Dissolve in water and used as mouthwash.
Fluticasone spray 50mcg.
No laboratory monitoring needed.
Tacrolimus 0.1% ointment (for posterior oral lesions / localised area of the oral cavity affected). Can be used in specially constructed trays.
Tacrolimus 0.5mg capsules (multiple areas of the oral cavity affected). Dissolved in water and used as mouthwash. FBC, LFT, kidney function test, blood glucose, BP (base line & repeated if treatment longer than 3 months). Monitoring at outpatient clinics.
Systemic medications:
Prednisolone, Doxycycline, Mycophenolate, Dapsone, Hydroxychloroquine, Colchicine, Pentoxifyline
Clinical and laboratory monitoring. Antifungal prophylaxis recommended for long term use of topical steroid (nystatin, chlorhexedine, miconazole)
Antifungals
Fluconazole. 50 – 100 mg. OD. 10 – 14/7.
Miconazole gel. 25 mg / ml. QDS. 10 – 14/7. Apply to lip / denture / tongue. Useful if combined with Amphoteracin.
Nystatin pastilles. 100k units. QDS. 10 – 14/7.
Nystatin suspension. 100k units / ml. 1ml QDS. 10 – 14/7.
Amphoteracin 10mg lozenge, 100 mg / ml suspension.
Saliva Substitutes & Sialogogues
Saliva Orthana. Spray & lozenges. Spray onto tongue & buccal mucosa PRN.
Polyethylene Oxide (Polyox) tablets. 150 mg lozenges. Suck one PRN.
Hypromellose M/W. 500 ml. 5 mls PRN.
Glandosane. Aerosol spray. Spray onto tongue & buccal mucosa PRN.
Luborant. Oral spray. 2 – 3 sprays onto oral mucosa, up to 4x daily.
Salinum. Liquid. 2 ml rinsed around mouth & swallowed. PRN.
Saliveze. Oral spray. PRN.
Salivix. Pastilles. PRN.
SST. Tablets. Allow 1 tablet to slowly dissolve in mouth. PRN.
Pilocarpine. 15 – 30 mg daily (normally 5 mg TDS).
Cevimeline. 30 mg. TDS.
Anethole trithione. 75 mg. TDS.
Human Interferon alpha (IFN-α) lozenges. 150 IU. TDS.
Aquoral products.
Caphosol products.
Carboxymethyl / hydroxy-ethylcellulose solutions: Entertainer’s Secret spray; Moi-Stir Oral Rinse / Spray; Optimoist spray; Saliva Substitute liquid; Salivart ærosol; Oralube Salivary Substitute liquid; Xero-Lube spray / rinse.
Mucopolysaccharide Solutions (novel thickening agents in hopes of providing longer retention on the mucosal surface): MouthKote spray; Linseed Polysaccharide (Salinum); Xanthan Gum Polysaccharide; Natrol Dry Mouth Relief (anhydrous crystalline maltose).
Atypical Facial Pain & Burning Mouth Syndrome
Dothiepin (Dosulepin). 25 – 75 mg. Nocté.
Nortriptyline 30 mg & Fluphenazine 1.5 mg. 2 tablets. Nocté.
Nortriptyline 10 mg & Fluphenazine 0.5 mg. 2 – 3 tablets. Nocté. Minimum of 6 – 8/52.
SSRI’s. Sertraline (50 mg OD) & Paroxetine (20 mg OD).
Topical local anaesthetics. Merocaine / Dequacaine (Benzocaine) lozenges, Xylocaine 2% gel, Lidocaine 5% ointment / lozenges or 10% solution spray.
Gabapentin. 100 mg before bed & increasing as tolerated or required (up to 2400 mg / day).
Baclofen (see below)
Lamotrigine (see below)
Capsaisin. 0.025% or 0.075% strength cream.
Clonazepam. Systemic (0.25mg – 3mg / day) or topical (1mg TDS sucked / dissolve on tongue).
Zinc (see below)
Antifungals (see above)
Salivary Substitutes (see above)
α-Lipoic Acid. 600g OD 3/52; 200mg OD 1/52
Post-Herpetic Neuralgia
Axsain (Capsaicin). 0.075% & 0.025% creams. TDS – QDS. Apply to affected area.
Lidocaine 5% medicated plasters. Cut to desired shape & apply to area. Can be kept on for 12 hours & then needs 12 hours uncovered.
Antidepressants (Nortryptiline 10 – 125mg / day & Duloxetine 60 – 120mg / day).
Anticonvulsants (Gabapentin 300 600mg mg TDS & Pregabalin 150 – 300mg / day).
Tramadol. 50 – 100 mg 4 – 6 hourly.
Amantidine. 100 mg BD for 2/52 to be continued for another 2/52 if necessary.
Trigeminal Neuralgia
Tegretol (Carbamazepine). 800 – 1200 mg daily (200 mg QDS). Monitor plasma levels 4 – 12 mg / l. Start at 100 mg BD & increase slowly until best result achieved.
Phenytoin. 2nd line therapy. 300 – 600 mg / daily.
Gabapentin (see above)
Baclofen. 2nd line therapy. 60 – 80 mg / daily. The starting dosage is 10 mg / daily, which can be increased, if needed, to 60 – 80 mg / daily administered 3 – 4 x per day (it has a short half-life of 3 – 4 hour). The dose of carbamazepine can be reduced to 500 mg / daily to maintain a putative synergistic effect.
Oxcarbazepine. 150 mg BD. The dose can be increased as tolerated in 300 mg increments every third day until pain relief occurs. Maintenance doses range between 300 – 600 mg BD. The maximum suggested total dose is 1800 mg/d
Valproate. 400 – 800mg BD
Lamotrigine. 2nd line therapy. 100 – 400 mg / daily. The dosage should be increased slowly for better tolerance (eg 25 mg daily dose each week; up to 250 mg BD).
Antidepressants (see above).
Iron & Vitamins
Ferrous Sulphate. 200 mg. BD. 4 – 6/52.
Ferrous Fumarate. 200 mg. BD. 4 – 6/52.
Ferrous Gluconate. 300 mg. OD. 4 – 6/52.
Folic Acid. 5 mg. OD. 4 – 6/52.
B12 (Hydroxycobalamin). 1 mg. TDS 2/52; then 1 mg every 2 – 3/12. Given by 3 monthly injection.
Zinc. Adult & child > 30 kg, 1 tablet in water 1 – 3 times daily after food. Effervescent zinc sulphate tablets contain 125 mg of zinc sulphate (45 mg zinc), every 3 – 6 hours. Apply to ulcers. Nocté.
Oral Mucositis
Some of the medications used for Oral Mucositis can be used for Oral Ulceration.
Interventions to reduce the mucosal toxicity of chemotherapy drugs
Allupurinol M/W 1 mg/ml was administered 1, 2 & 3 h after chemotherapy & 3 consecutive nights or 5 mg / ml of allopurinol in water, 2
– 4x daily for the 3 days subsequent to methotrexate administration; 3mg / mL 4 – 6 daily for at least 6 days.
Oral cryotherapy (holding ice water in the mouth) is suggested to be used to prevent oral mucositis in patients receiving high-dose
melphalan / 5 FU.
Mouthwashes with mixed action
Benzydamine hydrochloride, corticosteroids & chamomile
Immunomodulatory agents
Recombinant human Keratinocyte Growth Factor-1 (Palifermin) is recommended to be used to prevent oral mucositis in patients
receiving autologous HSCT.
Topical anaesthetics
Difflam & 5% amlexanox oral paste topical application
Mucain (antacid effect (Aluminium hydroxide & Magnesium hydroxide) with a topical local anaesthetic (Oxethazaine)) QDS.
Swallowed.
Bonjela (Choline Salicylate) Dental Gel. 8.7%. Apply gel to area & gently massage. 3 hourly at most.
“Magic Mouthwash” (diphenhydramine syrup, lidocaine & aluminum hydroxide liquid syrup (Maalox); 1.7 mL each (5.1-mL total
solution) of diphenhydramine (12.5 mg in 5-mL alcohol-free solution), lidocaine (2% viscous solution) & antacid (200 mg of aluminum
hydroxide, 200 mg of magnesium hydroxide & 20 mg of simethicone in 355-mL solution)
Doxepin M/W (25 mg in 5-mL solution). 4 hourly.
Dyclonine 0.1% topical spray: Spray into throat or affected area with up to 4 sprays per use. Use up to 4 times daily or as directed by
physician.
Dyclonine topical 2 mg mucous membrane lozenge: 2 hours as needed. Allow lozenge to dissolve slowly in mouth.
Dyclonine topical 3 mg mucous membrane lozenge. 2 hours as needed (not to exceed 10 lozenges daily). Allow lozenge to dissolve
slowly in mouth.
Antiseptic mouthwashes
Corsodyl (Chlorhexidine) M/W. 10 mls. TDS. Stains teeth & prolonged use can affect sense of taste.
Povidone Iodine 1% M/W. QDS.
Peroxyl (Hydrogen Peroxide) M/W. 10ml. QDS. Keep in mouth for 1 minute before spitting out.
Antibacterial, Antifungal & Antiviral agents
Nystatin, Clotrimazole & PTA lozenges (Polymixin E, Tobramycin & Amphotericin B) QDS.
BCoG (Bacitracin, Clotrimazole & Gentamycin) lozenges. QDS
Mucosal barriers & coating agents
Topical Hyaluronic gel 0.2% act as a barrier
Sucralfate (see above)
Orabase (see above)
Gelclair Bioadherent oral gel (see above)
Cyanoacrylate skin adhesives
Caphosol (see above)
Episil Gel
Oralife Gel
Cytoprotectants
β-carotene (pro-vitamin A), Vitamin E, Oxpentifylline, Azelastine, Prostaglandins E1 & E2
Amifostine
Iseganan. 9 mg / 3 ml was administered as a swish & swallow solution, 6x daily for 21 – 28 days.
Mucosal cell stimulants
Low level laser therapy (at a specific setting: 650nm, 40mW, time required to deliver each cm2 energy of 2J/cm2) is recommended to
be used to prevent oral mucositis in patients treated with high-dose chemotherapy for HSCT.
Glutamine iv / m/w. 4g glutamine dissolved in water & used QDS.
Psychotherapy
Cognitive Behaviour Training, Relaxation & Imagery Training, Hypnosis & Therapist Support
Analgesics
Co-Codamol dispersible tablets 30 / 500mg. QDS.
Soluble Aspirin 300 – 600mg dissolved in water. Used as a M/W 4x daily; for radiation mucositis.
Topical Morphine (0.2% gel). 6x daily.