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).
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.
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)
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).
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.
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 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)
- 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.