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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).

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.

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.

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.

Biotène products.

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

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.

Valproate.

Clonazepam.

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.