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Part I: Quelling Cold Sores and Written by Jacalyn Neceskas, PharmD, BCPS; Stacie Moore, PharmD;
Susan Goodin, PharmD, FCCP, BCOP
Part I I: Relieving Xerostomia
Written by Fiona M. Collins, BDS, MBA, MA
A Peer-Reviewed Publication
Published: August 2010 Go Green, Go Online to take your course
Expiry: July 2013 This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a ful refund by contacting PennWel in writing.
Part I: Quel ing cold sores and aphthous ulcers Table 1. Implicated factors and associations for RAU The overall goal of this article is to provide the reader with in- Sensitivity to sodium lauryl sulfate formation on the etiology, pathophysiology, and treatment of Iron, folate, zinc or vitamin B12 deficiency recurrent aphthous ulcers and recurrent herpes labialis. Upon Systemic diseases completion of this course, the reader will be able to: Immune system involvement 1. List and describe the etiology and pathophysiology related Hypersensitivity to dairy and gluten-containing foods to recurrent aphthous ulcers and recurrent herpes labialis.
2. List and describe the general recommendations specific to RHL, in contrast, are caused by a prior primary infection with patients experiencing recurrent herpes labialis.
herpes simplex virus type 1 (HSV-1). RHL are transmitted by di- 3. List and describe the treatment options available for recur- rect contact with the secretions from herpetic lesions, resulting in a rent aphthous ulcers and recurrent herpes labialis.
primary infection that is often asymptomatic. Once acquired, the infection lies dormant in the peripheral sensory neurons (trigeminal ganglia) until periodic reactivation is induced by a particular trigger Recurrent aphthous ulcers (RAU) and recurrent herpes labialis or stressor (Table 2). Exposure to a trigger then precipitates viral (RHL) are two of the common oral/peri-oral lesions experienced migration along sensory neurons to the epithelium where the virus in the general population. Treatment options include over-the- replicates and, upon recognition by the immune system, prompts counter and prescription products. the release of inflammatory mediators fol owed by a clinical y evi-dent RHL outbreak.
Introduction
Recurrent herpes labialis (cold sores) and recurrent aphthous
Table 2. Triggers and stressors for periodic reactivation of HSV-1 ulcers (canker sores) are common conditions that can be treated to relieve discomfort and, with some treatments, aid healing. Infection (e.g., the common cold) Between 15% and 40% of people experience a cold sore in their Ultraviolet light lifetime, and it has been estimated that up to 80% of adults carry the herpes virus latently by age 30.1 Forty percent of carriers in the United States are under age 20.2 In addition, the age at which the virus is acquired and seropositivity vary by geography and socioeconomic status, with a greater incidence in younger Ultra-violet (UV) light as a trigger has been wel -studied in patients in developing countries.3 Recurrent aphthous ulcers clinical trials. Rooney et al. investigated the effect of sunscreen (RAU) are distinct from recurrent herpes labialis (RHL) in (SPF-15) application compared to use of a placebo in a random- presentation and etiology. Although RAU are believed to be less ized, double-blind crossover study. No patients developed active prevalent than RHL, affecting around 1% of the population ac- lesions while using SPF-15 sunscreen and only one had asymp- cording to NHANES III, other studies have found an incidence tomatic viral shedding, while during the placebo phase there were 27 reactivations of lesions, suggesting not only that UV light acts as a trigger but also that sunscreen can play an important role in Etiology and Pathophysiology of RAU and RHL
The precise precipitating events and mechanisms for the occur-rence of RAU are as yet not ful y explained. A wide range of factors Clinical Presentation of RAU and RHL
have been implicated in RAU (Table 1), with nonsmokers more RAU are classified as minor, major, and herpetiform recurrent affected than smokers.5,6 Hypersensitivity to dairy and gluten, as aphthous ulcers. These differ in size (<1 mm to >10 mm in diam- wel as sensitivity to sodium lauryl sulfate, are considered etiologi- eter), number and severity of the outbreak. RAU may first cause cal factors, and medications implicated in RAU include cardiovas- a tingling sensation before the red raised area at the ulcer site ap- cular drugs, interferon, certain antibiotics, and anti-inflammatory pears prior to ulceration and the appearance of a flat or cratered, drugs.7,8,9 In addition, a higher incidence and severity of RAU grayish-yel ow area surrounded by a ring of inflamed tissue. RAU have been reported in patients with diseases that include Celiac typical y occur on nonkeratinized surfaces of the oral mucosa, disease, ulcerative colitis, Behçet's syndrome, and HIV infection. including the tongue and palate. Al 3 types can cause moderate No consistent association has been found with bacterial or viral to severe pain, and result in difficulty in eating, drinking, speak- factors.10 Based on research there is involvement of the immune ing, and swal owing. Minor and herpetiform RAU typical y heal system, with the presence of increased levels of circulating and within 7-10 days. The most severe are major RAU; these can cause inflammatory mediators including TNF-α, interleukin-2, natural severe debilitating pain, take up to several weeks or months to kil er cel s, and antiendothelial cel autoantibodies.10 heal, and heal with scarring.
Figure 1a. Major recurrent aphthous ulcers Figure 2b. Crusted recurrent herpes labialis lesion Figure 2b: Courtesy of Wil iam L. Balanoff, DDS, MS, FICD Figure 1b. Minor recurrent aphthous ulcer RHL are self-limiting and typical y heal without scarring; nonetheless, they can significantly affect the patient's quality of life during outbreaks by resulting in pain, embarrassment, and tem-porary cosmetic disfigurement. They may also cause uncertainty about the frequency of recurrence. Treatment is most effective if initiated during the initial 48 hours of the recurrence. General Considerations for Patients
It is important to enquire about the occurrence of RAU and RHL
Figures 1a,b: Courtesy of HIVdent with al dental patients, particularly since both occur episodical y and may or may not be present at the time of the initial dental visit. RHL proceed through 8 stages of forming and healing: By doing so, patients can be proactively counseled on treatment Prodrome; erythema; papule formation; vesicle formation; ulcer- options and care of RAU and RHL, if required. This is especial y ation/soft crust; hard crust; desquamation (dry flake); residual important for patients suffering from RHL, since treatment is best swel ing.12 During the prodromal phase, patients may experience initiated during the early (prodromal) phase to reduce the severity tingling, numbness, pain or itching associated with the initial of the recurrence. viral replication in the nerve endings.3,5,12 After the papules have Patients should be advised to keep the area adjacent to RHL formed, these coalesce into fluid-fil ed vesicles that form a crust lesions clean by using a mild antibacterial soap and water and then and heal in 14-21 days during the first occurrence and within dabbing the area dry. Patients with RHL should also be advised 7-10 days during recurrences.5 It is during the vesicle stage that to wash their hands frequently to prevent the transmission of viral the patient experiences the highest viral load,3 and when the secretions and infection, and to avoid triggers such as sunlight by vesicle bursts the patient is also at risk for bacterial superinfec- using sunscreen. Patients experiencing RAU should be advised to tion, which would present with pus formation and may require avoid spicy and/or acidic foods and drinks, as these may exacer- the use of topical antibiotics.5 Along with their classical signs and bate discomfort associated with RAU present at that time. symptoms, RHL can be definitively detected and identified using In recommending treatment for RAU and RHL, it is essential DNA amplification tests or by swabbing the lesion and culturing to stress the importance of visiting (or returning to) the dentist or the virus.1 The most common location for RHL to occur is at the physician if lesions do not heal within 14 days. Patients should also junction of the oral mucosa and the lip at the vermilion border. be referred to their physician for further evaluation if the severity or frequency of recurrences increases, or if they experience other signs Figure 2a. Intraoral recurrent herpes labialis at vesicle stage and symptoms of infection such as a fever, as these may indicate an underlying systemic condition that needs to be investigated and addressed. If hypersensitivity to a particular food ingredient or chemical is suspected, patients can be advised to avoid these and encouraged to discuss this with their physician. Immunocompro-mised patients should also be referred to their primary care physi-cian or specialist. Treatment and Care of RAU
Over-the-counter products
The mainstay of palliative care, aimed at relieving symptoms until
Figure 2a: Courtesy of Diane M. Daubert, RDH, MS RAU resolve, is over-the-counter (OTC) oral pastes and rinses. Wound-cleansing and debriding rinses are also available that can used in pregnant women or women who may become pregnant.18 be applied directly to the lesion or used as a rinse in accordance With both topical and systemic higher potency corticosteroids, with the recommendations of the clinician and product labeling. consideration must be given to adrenal suppression, which would Pain-relieving topical analgesic pastes typically contain 20% require tapering off of their use. benzocaine or 2% lidocaine, and barrier creams are also available that help prevent irritation. A mucosal adhesive patch (Canker Table 3. Treatment options for RAU Cover™) has been shown to help relieve pain, and forms a bar- rier over the lesion to help protect it from foods, drinks, and other Pain-relieving topical analgesic pastes irritants. This patch contains citrus oil, which has demonstrated Barrier creams and liquid antiseptic and anti-inflammatory properties.13 The combination of citrus oil and magnesium chloride has been found in a double- Mucosal barrier adhesive patch (Canker Cover) blind, placebo-controlled clinical trial to result in a shorter heal- Bioadherent barrier rinse (Rincinol) ing time of 1.5 days, versus 6 days for placebo (hydroxycellulose Bioadherent barrier analgesic rinse (Kank-A) base tablets containing no magnesium chloride or citrus oil) and Prescription - topical
Prescription - systemic
10 days for untreated patients. The mean time for the elimina- Viscous lidocaine rinse (2%) tion of pain was also reduced (5 hours versus 48 hours and 134 Tetracycline rinse (5%) hours, respectively).14 A separate study in subjects 18 years of Corticosteroid creams age and older compared the use of the same patch with use of a bioadhesive oral solution (Kank-A®) containing benzocaine and compound benzoin tincture as the active ingredients. It was Bioadherent barrier rinse found that the mucoadhesive patch reduced healing time—mean Prescription - systemic healing time was 36 hours versus 134.7 hours with the oral solu- * Must never be used in women who are/may become pregnant tion, there was greater pain reduction at 24 and 48 hours, and the patch was well-tolerated.15 If lesions are widespread, a bioadher- Treatment and Care of RHL
ent barrier rinse (Rincinol®) can be considered and will coat all Major goals of treatment of RHL include pain relief, reduction of of the oral mucosa.
inflammation, improved (faster) healing, avoidance of secondary bacterial infections, and prevention of transmission of viruses to others or self (e.g., autoinoculation to the eyes, which can result Prescription products have also been utilized for the treatment of in severe infections and blindness). To date no cure is available. RAU. Five percent tetracycline rinse has been found to reduce A number of controlled clinical trials have demonstrated the ef- healing time and duration of lesions, and to be well-tolerated ficacy of oral and topical antiviral agents for the prevention and when used 4 times daily for 5 days or less.10 It should be noted treatment of RHL.12,19,20,21 that this is contraindicated during tooth development due to the risk of tetracycline staining. Corticosteroid rinses may be effec- tive in reducing the duration of lesions when used 3-4 times daily, A number of OTC products are available for the relief of pain especially where multiple larger ulcers are present and topical associated with RHL, thereby offering palliative care. These application of pastes is impractical. Viscous lidocaine rinse (2%) contain topical analgesics such as benzocaine and camphor, li- may be prescribed for pain relief, for rinsing and expectoration, or docaine, or pramoxine. In addition, some contain an antiseptic direct application to the lesion. A bioadherent barrier rinse is also ingredient such as benzalkonium chloride and some contain available (Gelclair®). Corticosteroid creams of various potencies sunscreen, skin softener (to soften the crust), and skin protec- have also been investigated for their ability to reduce inflamma- tants. Most of these OTC products are safe for use in young tion and relieve pain, including medium-potency triamcinolone children—the indications and directions on the product labeling acetonide paste (Kenalog in Orabase®), which has been shown should be followed. Nonprescription 10% docosanol cream (Ab- to reduce pain, inflammation, and ulceration when applied 2 reva®) is FDA-approved for the treatment of RHL in patients or 3 times daily for 5 days.16 One topical cream containing 5% 12 years of age or older,22 and works by inhibiting viral fusion to amlexanox (Aphthasol®) has been found in a placebo-controlled, the host cell. In a randomized, double-blind, placebo-controlled double-blind clinical trial with 1335 subjects to increase the rate study of 743 patients age 18 or over who experience more than 2 of healing while reducing the duration of pain, when applied 4 recurrences of RHL per year, the application of 10% docosanol times daily.17 It is indicated for use in patients 18 years of age cream 5 times daily resulted in a reduced healing time and time and older. A number of systemic treatments have been tested to cessation of pain, but did not reduce lesion formation. Patients for severe RAU, including the use of thalidomide, orally admin- were included only if their lesions had not progressed beyond istered corticosteroids, and levamisol. Due to their toxicity and the erythema phase. The median reduction in healing time was contraindications, these are reserved for only the most severe 17.5 hours and the median reduction in time to pain cessation cases of RAU; thalidomide is teratogenic and must never be was 13.4 hours.19 blind, placebo-controlled multicenter studies with a total of 2537 A number of natural products have efficacy claims for treating or patients demonstrated the efficacy of penciclovir in reducing preventing RHL. These include tannic acid, tea tree oil, lemon healing time when applied within 1 hour of the onset of symp- balm and rhubarb-sage topical cream. Tannic acid has been toms. A difference was also found when the cream was used at found to be ineffective, and there is insufficient data to determine the papule stage; its use did not prevent lesions from progressing the efficacy of tea tree oil;23 limited data is available to show ef- to the vesicle stage.32 A separate small study also demonstrated ficacy for lemon balm and rhubarb-sage topical cream.
reduced time to healing by 1 day compared to use of acyclovir.33 Lysine has also been used to treat RHL. After it was found that arginine deficiency suppressed HSV growth in the labora- Table 4. Clinical results of treatments for RHL tory, lysine—an analog of arginine—was investigated for the treatment of RHL with the hypothesis that it would prevent the Median pain cessation time reduced by 13.4 hours utilization of arginine by HSV.24 Lysine can be given orally or applied topically. Studies on orally administered lysine, which is Median reduction in healing time of 17.5 hours sold as a dietary supplement, have produced conflicting results. Lesion resolution in 86% of patients by day 4 One crossover study in 65 patients receiving either 500 mg ly- (Lip Clear® Lysine+) sine or placebo for 12 weeks found no reduction in the number Median reduction in healing time of 1.5 days of recurrences of RHL with either treatment.25 A separate ran- glycine (Novitra®) domized study found no differences in recurrence rates whether Reduced length of time to healing patients were taking 624 mg or 1248 mg of lysine daily, but did find significant reductions in recurrences compared to use of Reduced duration of pain placebo.26 Topical lysine (e.g., Lip Clear® Lysine+) has been Penciclovir cream Median reduction in healing time of 0.7 - 1 day shown to reduce healing time and to provide relief. An open label trial with 30 patients found that 40% of patients reported a full Median pain cessation time reduced by 0.6 days cure (complete disappearance and resolution of the eruption) by Valacyclovir tablets Median reduction in healing time of 0.8 days day 3 and 86% by day 4.27 Finally, an over-the-counter homeopathic formulation of Median pain cessation time reduced by 0.5 - 0.7 days zinc oxide with glycine (Novitra®) was studied in a randomized, Famciclovir tablets Median reduction in healing time of 1.8 - 2.2 days double-blind clinical trial with 46 patients, where it was used every 2 hours during waking hours. The investigators found that Systemic orally administered tablets containing acyclovir have it reduced mean healing time by 1.5 days compared to placebo been found to reduce time to healing when given as 400 mg 5 (based on patient diaries and telephone interviews) and was well- times per day in a subset of patients, but not at doses of 200 mg, 5 times per day for 5 days.34,35 Valacyclovir is approved by the FDA for the treatment of RHL, administered as a dose of 2000 mg given twice for 1 day, which has been shown to decrease the FDA-approved prescription products for the treatment of RHL median time to healing by 0.8 days and to decrease the median include topical treatments and orally administered systemic number of days of pain by 0.5-0.7 days. There was no effect on treatments. Topical agents include acyclovir cream (Zovirax®) lesion progression.36 Oral famciclovir is also approved for the and penciclovir cream (Denavir®). Acyclovir is applied as a treatment of RHL. Famciclovir as 1500 mg in a single dose or cream and works by interfering with the replication of the herpes 750 mg given twice for 1 day have both been found to reduce the simplex virus; it is recommended for use in patients age 12 years median time to healing by 1.8-2.2 days, based on a double-blind, and older and should be used for 4 days, 5 times a day, as soon as randomized trial of 701 patients age 18 or older who experienced the prodromal (initial) phase begins.29 In 2 randomized, double- at least 3 episodes of RHL annually. However, the single dose blind, placebo-controlled clinical trials with Zovirax®, reduced of 1500 mg was found to offer greater reduction in the time to length of time to healing and reduced duration of pain were resolution of pain or discomfort.37 found, but acyclovir did not prevent the progression of lesions to the vesicular phase.30 Penciclovir (1%) is available for use in people age 12 and older Recurrent aphthous ulcers and recurrent herpes lesions occur and should be applied every 2 hours for 4 days (while awake) as frequently in the general population. After a diagnosis has been soon as symptoms occur. The efficacy of penciclovir was demon- made, patients should be given general advice regarding care strated in a randomized, double-blind, placebo-controlled trial of these and, in the case of RHL, avoiding transmission of the with 1573 patients 18 years of age and older who experienced at herpes virus to others. When recommending or prescribing me- least 3 RHL per year. The median time to healing was reduced dicaments and drugs, the severity and frequency of the lesions, by 0.7 to 1 day, and the time to loss of pain was reduced by a health status of the individual patient and clinical efficacy of the median of 0.6 days.31 Two other identical, randomized, double- product should be considered.
Part II: Relieving Xerostomia Oral Signs and Symptoms
The overall goal of this article is to provide the reader with infor- Individual patients may experience the signs and symptoms of mation on xerostomia and treatments for the relief of dry mouth. xerostomia to varying degrees depending on the residual level Upon completion of this course the reader will be able to: of function of the salivary glands. Symptoms associated with 1. List the etiological factors for xerostomia.
xerostomia include a sticky and/or dry feeling in the mouth, a 2. List and describe the signs and symptoms of xerostomia. sensation of pain and burning mouth, alterations in taste, stringy 3. List and describe the treatment options available for the or ropey saliva, difficulty speaking, and a reduced ability to chew relief of dry mouth.
and swallow a bolus of food due to a (relative) lack of saliva. Signs of xerostomia include an increased level of carious lesions, the appearance of dryness of the oral mucosa intraorally, increased Xerostomia (dry mouth) affects a significant number of adults levels of plaque, bad breath, and oral irritations including and its prevalence increases with age, primarily as the result angular cheilitis, dry and cracked lips. In addition, xerostomia of the increased use of medications and an increased risk and patients are at increased risk for candidal and other oral infec- incidence of diseases/conditions associated with xerostomia. tions. The chief complaints of patients with xerostomia are the The symptoms of xerostomia can be debilitating and result in feeling of dryness in the mouth and difficulties experienced with a reduced quality of life. Treatment options for the relief of dry swallowing and speaking.7 mouth include prescription and over-the-counter products, and recommendations should be tailored for the individual patient.
Figure 1. Dry appearance of oral mucosa Introduction
Xerostomia, or dry mouth, is a common affliction in the general
population. An extensive and increasing number of medica-
tions are associated with xerostomia, including antidepressants
and psychotropics, antihistamines, antihypertensives, and
cardiovascular drugs. Estimates on the number of medications
with xerostomia as a side effect range from more than 500 to
more than 1500.1,2,3 Diseases associated with xerostomia include
Sjögren's syndrome, diabetes, AIDS, and Parkinson's disease.4
While chemotherapy can also result in xerostomia and changes
to the consistency of saliva, head and neck radiation results in
severe xerostomia and, as with nerve damage, can completely
Figure 2. Angular cheilitis in patient with xerostomia destroy functioning of the salivary glands. Tobacco and alcohol use also result in a dry mouth. In addition, breathing through the mouth (and snoring) result in dry mouth – this, however, is of a temporary nature and resolves once nose breathing re-sumes. There is an increased prevalence of xerostomia with age, and it has been estimated that around 25% of adults in the over-65 age group experience xerostomia and at least 10% of all adults are affected.5 While older patients experience dry mouth more frequently, this is related to medication use or other con-ditions rather than aging itself.6 Figures 1 and 2: Courtesy of Sandra L. Boody, RDH, MEd Table 1. Factors in xerostomia Detecting and Diagnosing Xerostomia in the
Auto-immune diseases Patients should be screened for xerostomia. The medical and dental history forms used in the dental office should include Parkinson's disease questions on medication use, diseases, and medical conditions, Head and neck radiation therapy and should be reviewed for any present that may result in xero-stomia. The medical and dental history forms should also include specific questions on symptoms related to dry mouth, including whether the patient has the sensation of dryness in the mouth, chief symptom and complaint with xerostomia – the sensation of dry lips, or difficulty speaking, chewing, or swallowing. Asking dryness and the discomfort this brings. A number of treatment whether the patient has to sip water to chew and swallow helps options are available for xerostomia relief, including prescription elucidate problems. Detecting xerostomia is best accomplished and over-the-counter products. in the dental office. The oral mucosa may be observed to be dry and parched in appearance, there may be dry or cracked areas Dry Mouth Relief
on the lips or at the corners of the lips, and an increased caries experience may also indicate xerostomia. Clinical assessment should include placing the mirror against Prescription products used to treat xerostomia include those the buccal mucosa to see if it sticks to the mucosa (indicative of that stimulate salivary production and those that relieve symp- inadequate salivary flow). If it is suspected that a patient may toms. Oral y administered systemic treatments that stimulate have xerostomia, unstimulated and stimulated salivary flow tests the production of saliva include pilocarpine hydrochloride will help objectively determine if xerostomia is present and to (Salagen) and cevimeline hydrochloride (Evoxac). Side effects what degree. In both cases the patient salivates for five minutes can include dizziness, alterations in vision, stomach upset, and, and expectorates his or her saliva into a cup or other vessel. A rarely, rapid or slowed heart rate and breathing trouble.10 Ca- recent protocol for collecting unstimulated saliva recommends phasol is a unit-dose prescription rinse containing calcium and that the patient refrain from eating, drinking anything (except phosphate ions and has been clinical y proven to lubricate dry water), smoking, chewing gum, and consuming caffeine for one mouth and to reduce the occurrence and severity of mucositis hour before the test is conducted, and that the patient sit still associated with head and neck radiation.11 A second prescription while saliva is collected. For stimulated saliva, the standardized rinse, Numoisyn Liquid, is indicated for relief of dry mouth, has protocol recommends that the patient chew gum in time with a similar viscosity to saliva, and produces a barrier bioadhesive a metronome prior to collection of saliva.8 It should be noted film on the dentition and oral mucosa.12 The linseed extract con- that while an objective salivary flow test could indicate that a tained in Numoisyn has been found to relieve the symptoms of patient has mild, moderate, or severe xerostomia, the patient may subjectively experience this differently (better or worse). When assessing xerostomia prior to and after initiation of dry mouth–relief treatment, subjective assessment by the patient is a Over-the-counter products available for relief of dry mouth key factor and is performed using either a specific questionnaire include mouthwashes, liquids, sprays, gums, lozenges, and designed for the purpose or a visual analog scale (VAS). a patch. Mouthwashes are formulated to help relieve dry mouth, soothe the oral mucosa, help cleanse the oral cavity, Treatment Options for Xerostomia
and combat halitosis. These typical y contain a base of water Dental professionals are oral care experts and thus positioned to and either hydroxyethylcel ulose (Biotene Dry Mouth and PBF detect, diagnose and recommend primary treatment for xerosto- Mouthwashes) or carboxymethylcel ulose (Oasis Moisturizing mia.9 Patients should be counseled on the importance of home Mouthwash). Natural-based mouthwashes containing plant care – extra thorough brushing and flossing to remove plaque is extracts and essential oils are also available. Over-the-counter necessary to help prevent caries and periodontal disease and to saliva substitute gels and liquids are also available. The primary reduce halitosis. Patients with xerostomia are at increased risk goals for these are rapid relief of dry mouth and soothing of the for caries; professional fluoride therapy is indicated as is home oral mucosa. Oral Balance Gel (Biotene) contains protective en- use of fluoride toothpaste. Toothpastes formulated for dry- zymes as the active ingredient in a hydroxyethylcel ulose base. mouth patients containing lower levels of sodium lauryl sulfate It has been found to be effective in relieving dry mouth, includ- (SLS), or without SLS, and with low foaming activity to reduce ing in head-and-neck-radiation patients and patients who had the possibility of irritation are available (Biotene Dry Mouth received whole-body irradiation and chemotherapy.14,15 Biotene Toothpaste; Biotene PBF Fluoride Toothpaste). As appropri- saliva substitute has also been shown to be effective in elderly ate, patients can be advised to use prescription level paste/gel or patients for relief of dry mouth.16 The use of Oral Balance Gel over-the-counter alcohol-free adjunctive fluoride rinses. Patients and Dry Mouth Toothpaste has been clinical y shown to provide should also be advised to avoid consumption of sugar-containing greater relief and pal iative care in head-and-neck-radiation foods, drinks, and snacks and other fermentable carbohydrates patients than use of a carboxymethylcel ulose gel and regular in order to reduce caries risk, as well as to avoid tobacco, caffeine, toothpaste.17 A second saliva substitute containing the same alcohol, and alcohol-containing rinses due to their drying effect. enzymes is available as a liquid in a smal portable bottle (Oral Sipping water and sleeping with a humidifier have also been Balance Liquid), while another product (Numoisyn Liquid) shown to help relieve the symptoms of dry mouth. Palliative care contains linseed extract. Another option is office-dispensed GC of oral irritations can be achieved using topical analgesic pastes Dry Mouth Gel which can be applied with a finger. Over-the- containing 20% benzocaine or 2% lidocaine, or using a barrier counter spray and atomizer saliva substitutes have also been cream or rinse. The main focus of this article is on the relief of the found to provide relief from xerostomia.7 Figure 3. Mouthwashes, chewing gums and patch Patch during dissolution position with finger for xerostomia relief Intraoral devices have recently also been investigated for the re-lief of xerostomia. One study found that a night guard fabricated as an ethylene vinyl acetate sheet covering the palate and dental arches, without any reservoir, provided relief from nocturnal xerostomia (assessed using a visual analog scale);24 replacement full dentures with reservoirs containing saliva substitute may also provide relief.25 Summary
Xerostomia is a debilitating condition that affects a significant
These may contain glycerin, glycerol, mucin, or carboxymeth- percentage of the population and results in reduced quality ylcellulose in the base formulation (Salivart; Biotene and Oasis of life. Treatment is aimed at relieving dry mouth through the Moisturizing Mouth Sprays; Mouth-Kote; Moi-Stir). Spray stimulation of saliva and use of oral moisturizing products, saliva substitutes have been found to be effective and their ap- and at helping to reduce the risk of conditions associated with plication easy and acceptable to patients.18 xerostomia. Once a patient has been diagnosed with xerostomia, Sugar-free lozenges and chewing gums are available that can treatment planning and recommendations can be made for its be used ad libitum to stimulate saliva if salivary gland function is management. When making recommendations on products for still present19,20 (Wrigley chewing gums). These may also con- the relief of dry mouth, the patient's preferences and subjective tain xylitol (SalivaSure lozenges, Epic chewing gum, Biotene Dry assessment of relief attained should be explored – taste, vehicle, Mouth Gum), or casein phosphopeptide-amorphous calcium ease-of-use and portability, and perceived relief are all factors in phosphate (CPP-ACP) (Trident Extra chewing gum), which patients' acceptance and use of these treatments.26 Dry mouth can has been shown to help reduce demineralization.21 One brand be relieved using a number of vehicles that include toothpastes, of lozenge contains essential oils and zinc gluconate and claims mouthwashes, saliva substitutes, chewing gums, lozenges, or a to impede biofilm and to kill bacteria associated with halitosis mucoadhesive patch, and combinations of these can be used for (Salese with Xylitol).22 In addition to stimulating saliva, chew- effective relief of dry mouth.
ing gum may also help remove plaque and debris through the process of mastication; for many patients chewing gum is a habit References Part I
they already enjoy and can modify simply by changing to the Vestly JP, Norval M. Mucocutaneous infections with herpes simplex virus and their management. Clin Exp Dermatol. 1992;17:221-37.
recommended gum for dry mouth. Patients should be cautioned Xu F, Schillinger JA, Sternberg MR, et al. Seroprevalence and coinfection with against using chewing gums containing sugar, which would fur- herpes simplex virus type I and type 2 in the United States, 1998-1994. J Infect ther increase their high risk for caries.
Esmann J. The many challenges of facial herpes simplex infection. J An innovative patch has been introduced for dry mouth relief Antimicrob Chemother. 2001;47:17-27.
Chattopadhyah P, Chatterjee S. Risk indicators for recurrent aphthous ulcers (OraMoist Dry Mouth Patch). Using a finger, this small muco- in the US. Community Dent Oral Epidemiol. 2007;35:152-9.
adhesive patch is applied to the side of the palate, or in denture/ Oral pain and discomfort. In: Allen LV, Berardi RR, DeSimone EL, et al, eds. Handbook of Nonprescription Drugs. 12th ed. Washington, D.C.: American appliance wearers to the cheek, and dissolves over the course of Pharmacists Association; 2000:585-609.
2–4 hours to moisturize the mouth and stimulate saliva to provide Natah SS, Konttinan YT, Enattah NS, et al. Recurrent aphthous ulcers today: a review of the growing knowledge. Int J Oral Maxil ofac Surg. 2004;33:221-34.
relief from xerostomia. A recent small study comparing this patch Brokstad B, Barkvol P. The effect of two toothpaste detergents on the frequency with mouthwash found the patch to be more effective in reliev- of recurrent aphthous ulcers. Acta Odontol Scand. 1996;54(3):150-3.
Abdollahi A, Radfar M. A review of drug-induced oral reactions. J Contemp ing dry mouth, based on patient self-reporting. Twice as many Dent Pract. 2003;4:10-31.
subjects reported relief using the patch, and its use resulted in a Tack AD, Rogers RS. Oral drug reactions. Dermatol Ther. 2002;15:236-50.
10 Jurge S, Cuffer R, Scully C, Porter SR. Mucosal disease series number 1.5-fold increase in unstimulated whole salivary flow.23 VI:Recurrent aphthous stomatitis. Oral Dis. 2006;12:1-21.
11 Rooney JF, Bryson Y, Mannix ML, et al. Prevention of ultraviolet-light-induced Managing xerostomia. Vital 6, 32–34 (1 March 2009) doi:10.1038/vital944 herpes labialis by sunscreen. Lancet. 1991;338;1419-21.
Atkinson JC, Grisius M, Massey W. Salivary hypofunction and xerostomia: 12 Woo S, Challacombe SJ. Management of recurrent oral herpes simplex diagnosis and treatment. Dent Clin N Am. 2005;49:309- 26.
infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Vissink A, Panders AK, Gravenmade EJ, Vermey A. Treatment of oral symptoms in Sjögren's syndrome. Scand J Rheumatol Suppl. 1986;61:270-3.
13 Mizrahi B, Shapira L, Dob AJ, Had HY. Citrus oil and magnesium salt as Navazesh M, Kumar SK. Measuring salivary flow: challenges and antibacterial and anti-inflammatory agents. J Periodontol. 2006;77(6):963-8. opportunities. J Am Dent Assoc. 2008;139 Suppl:35S-40S.
14 Mizrahi B, Wolnerman Y, Domb AJ. Adhesive tablet effective for treating Frost PM. Difficulties in dental prescribing of saliva substitutes for xerostomia. canker sores in humans. J Pharm Sci. 2004;93(12):2927-35.
15 Shemer A, Amichai B, Trau H, Nathansohn N, Mizrahi B, Domb AJ. Efficacy of a mucoadhesive patch compared with an oral solution for treatment of 11 Papas AS, Clark RE, Martuscelli G, O'Loughlin KT, Johansen E, et al. A aphthous stomatitis. Drugs R D. 2008;9(1) 29-35.
prospective, randomized trial for the prevention of mucositis in patients 16 Herlofson BB, Barkvoll P. Sodium lauryl sulfate and recurrent aphthous undergoing hematopoietic stem cel transplantation. Bone Marrow Transplant. ulcers. A preliminary study. Acta Odontol Scand. 1994;52(5):257-9.
17 Khandwala A, Waninwegen RG, Alfano MC. 5% Amlexanox oral paste, a 12 Christersson CE, Lindh L, Arnebrant T. Film-forming properties and new treatment for recurrent minor aphthous ulcers. Oral Surg Oral Med Oral viscosities of saliva substitutes and human whole saliva. Eur J Oral Sci. Path. 1997;83(2):222-30. 18 Porter SR. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med. 13 Andersson G, Johansson G, Attstrom R, Edwardsson S, Glantz P-O, et al. Comparison of the effect of the linseed extract Salinum® and a methyl 19 Raborn GW, Chan KS, Grace M. Treatment modalities and treatment cellulose preparation on the symptoms of dry mouth. Gerodontology. recommended by health care professionals for treating recurrent herpes labialis. J Am Dent Assoc. 2004;135:48-54.
14 Shahdad SA, Taylor C, Barclay SC, Steen IN, Preshaw PM. A double-blind, 20 Sacks SL, Thisted RA, Jones TM, et al. Clinical efficacy of topical docosanol crossover study of Biotène Oralbalance and BioXtra systems as salivary 10% cream for herpes simplex labialis: a multicenter, randomized placebo- substitutes in patients with post-radiotherapy xerostomia. Eur J Cancer Care controlled trial. J Am Acad Dermatol. 2001;45:222-30.
21 Gaby AR. Natural remedies for herpes simplex. Altern Med Rev. 15 Sugiura Y, Soga Y, Tanimoto I, Kokeguchi S, Nishide S, et al. Antimicrobial effects of the saliva substitute, Oralbalance, against microorganisms from oral 22 About Abreva: Efficacy and use. Abreva Web site. http://www.abreva.com. mucosa in the hematopoietic cell transplantation period. Support Care Cancer. 23 Carson CF, Ashton L, Dry L, et al. Melaleuca alternifolia (tea tree) oil gel 2008;16(4):421-4. (6%) for the treatment of recurrent herpes labialis. J Antimicrob Chemother. 16 Matear DW, Barbaro J. Effectiveness of saliva substitute products in the treatment of dry mouth in the elderly: a pilot study. J R Soc Promot Health. 24 Griffith RS, DeLong DC, Nelson JD. Relation of arginine-lysine antagonism to herpes simplex growth in tissue culture. Chemotherapy. 1981;27:209-13.
17 Epstein JB, Emerton S, Le ND, Stevenson-Moore P. A double-blind crossover 25 Tomblin FA Jr, Lucas KH. Lysine for management of herpes labialis. Am J trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with Health Syst Pharm. 2001;58:300-4.
xerostomia following radiation therapy. Oral Oncol. 1999;35(2):132-7.
26 McCune MA, Perry HO, Muller SA, et al. Treatment of recurrent herpes 18 Silvestre FJ, Minguez MP, Suñe-Negre JM. Clinical evaluation of a new simplex infections with L-lysine monohydrochloride. Cutis. 1984;34:366-73.
artificial saliva in spray form for patients with dry mouth. Med Oral Patol Oral 27 Singh BB, Udani J, Vinjamury SP, et al. Safety and effectiveness of an L-lysine, Cir Bucal. 2009 Jan 1;14(1):E8-E11.
zinc, and herbal-based product on the treatment of facial and circumoral 19 Itthagarun A, Wei SH. Chewing gum and saliva in oral health. J Clin Dent. herpes. Altern Med Rev. 2005;10:123-7.
28 Godfrey HR, Godfrey NJ, Godfrey JC, et al. A randomized clinical trial on 20 Bots CP, Brand HS, Veerman EC, Korevaar JC, Valentijn-Benz M, et al. the treatment of oral herpes with topical zinc oxide/glycine. Alter Ther Health Chewing gum and a saliva substitute alleviate thirst and xerostomia in patients Med. 2001;7:49-56.
on haemodialysis. Nephrol Dial Transplant. 2005;20(3):578-84. 29 Zovirax cream 5% (package insert). Glaxosmithkline.
21 Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and 30 Spruance SL, Nett R, Marbury T, et al. Acyclovir cream for treatment of herpes remineralization of enamel lesions by various forms of calcium in a mouthrinse simplex labialis: results of two randomized, double-blind, vehicle-controlled, or sugar-free chewing gum. J Dent Res. 2003;82(3):206-11. ref multicenter clinical trials. Antimicrob Agents Chemother. 2002;46(7):2238-43. 22 Nuvora website. http://www.nuvorainc.com/salese-learn-more.html 31 Spruance SL, Rea TL, Thoming C, et al. Pencyclovir cream for the treatment 23 Afriamian D. Treating Xerostoma Utilizing an Adhesive Oral Tablet As of recurrent herpes simplex labialis: a randomized, multicenter, double-blind, Compared With Biotene Rinses. Data on file.
placebo-controlled trial. J Am Med Assoc. 1997;277:1374-9. 24 Yamamoto K, Nagashima H, Yamachika S, Hoshiba D, Yamaguchi K, et al. 32 Raborn GW, Martel AY, Lasonde M, et al. Effective treatment for herpes The application of a night guard for sleep-related xerostomia. Oral Surg Oral simplex labialis with penciclovir cream: combined results of two trials. J Am Med Oral Pathol Oral Radiol Endod. 2008;106(3):e11-4.
Dent Assoc. 2001;133:303-9.
25 Hirvikangas M, Posti J, Mäkilä E. Treatment of xerostomia through use of 33 Femiano F, Gambos F, Scully C. Recurrent herpes labialis: efficacy of topical dentures containing reservoirs of saliva substitute. Proc Finn Dent Soc. therapy with penciclovir compared with acyclovir (acyclovir). Oral Dis. 26 Momm F, Volegova-Neher NJ, Schulte-Mönting J, Guttenberger R. Different 34 Raborn GW, McGaw WT, Greace M, et al. Oral acyclovir and herpes labialis: saliva substitutes for treatment of xerostomia following radiotherapy. A a randomized, double-blind, placebo-controlled study. J Am Dent Assoc. prospective crossover study. Strahlenther Onkol. 2005 Apr;181(4):231-6.
35 Spruance SL, Stewart JC, Rowe NH, et al. Treatment of recurrent herpes simplex labialis with oral acyclovir. J Infect Dis. 1990;161:185-90.
36 Spruance SL, Jones TM, Blatter MM, et al. High-dose, short-duration, Dr. Jacalyn Neceskas is a pharmacist at the Cancer Institute of New Jersey, and early valacyclovir therapy for episodic treatment of cold sores: results of two graduated with a PharmD. randomized, placebo-controlled, multicenter studies. Antimicrob Agents Dr. Stacie Moore was a pharmacy resident at the Robert Wood Johnson University 37 Spruance SL, Bodsworth N, Resnick H, et al. Single-dose, patient-initiated Hospital in New Brunswick and holds a PharmD. famciclovir: a randomized, double-blind, placebo-controlled trial for episodic Dr. Susan Goodin graduated with a PharmD and is the director in the division of treatment of herpes labialis. J Am Acad Dematol. 2006;55:47-53. pharmaceutical sciences at the Cancer Institute of New Jersey and associate profes- sor of medicine at the Robert Wood Johnson Medical School in New Jersey.
References Part II
Dr. Fiona M. Col ins graduated with a dental degree from Glasgow University and Porter SR, Scully C, Hegarty AM. An update of the etiology and management holds an MBA and MA from Boston University. of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:28- Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth—2nd edition. Gerodontology. 1997;14:33-47.
The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.
Mouly SJ, Orler JB, Tillet Y, Coudert AC, Oberli F, et al. Efficacy of a new oral lubricant solution in the management of psychotropic drug- induced xerostomia: a randomized controlled trial. J Clin Psychopharmacol. We encourage your comments on this or any PennWel course. For your convenience, an online feedback form is available at www.ineedce.com.
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1. It has been estimated that up to _ 11. _ are the mainstay of pal iative care 22. The results of the of xerostomia of adults carry the herpes virus latently by are important to proper treatment of the age 30 and that _ of carriers in the a. Prescription oral pastes and rinses United States are under age 20.
b. Over-the-counter (OTC) oral pastes and rinses a. objective assessment c. Corticosteroids d. none of the above b. subjective assessment 12. A mucosal adhesive patch containing citrus c. objective and subjective assessments oil and magnesium chloride _.
d. none of the above 2. _ is an implicated factor/association a. has been shown to help relieve pain 23. If a mouth mirror sticks when placed against b. forms a barrier over the lesion to help protect it c. has been shown to reduce healing time the buccal mucosa _.
a. Hypersensitivity/sensitivity to foods/chemicals d. al of the above b. Medication use a. this suggests enzymatic activity 13. Pain-relieving topical analgesic pastes used b. this is indicative of inadequate salivary flow d. al of the above for RAU typical y contain _.
c. this is indicative of adequate salivary flow 3. RHL is caused by a _with herpes a. 10% benzocaine or 1% lidocaine b. 15% benzocaine or 2% lidocaine simplex virus type 1. c. 20% benzocaine or 2% lidocaine 24. Toothpastes specifical y formulated for a. primary infection d. none of the above dry-mouth patients contain _.
b. secondary infection c. tertiary infection 14. 5% amlexanox has been found to _ a. lower levels of SLS or no SLS d. none of the above , when applied 4 times daily.
b. lower levels of zinc a. increase the rate of healing of RAU 4. RHL is transmitted by _.
c. higher levels of antibacterial agents b. reduce the duration of pain c. provide only pal iative relief d. al of the above b. direct contact with the secretions from herpetic lesions 25. Patients with xerostomia should be advised c. sneezing and coughing d. al of the above 15. 10% docosanol cream _.
a. has been found to reduce healing time a. consumption of sugar-containing foods, drinks, and 5. _ is a potential trigger/stressor for b. has been found to reduce the time to cessation of pain periodic reactivation of HSV-1.
c. is a nonprescription cream snacks and other fermentable carbohydrates d. al of the above b. tobacco, caffeine, and alcohol b. Anxiety/stress 16. Topical lysine has been shown to reduce c. alcohol-containing rinses c. Dental treatment healing time and to provide relief for . d. al of the above d. al of the above 26. Xerostomia associated with mouthbreathing 6. _ can play an important role in preventing recurrences of RHL d. none of the above a. sometimes permanent 17. _ is an FDA-approved prescription b. always permanent product for the treatment of RHL.
c. always debilitating d. al of the above a. Acyclovir cream d. none of the above 7. Recurrent aphthous ulcers _.
b. Penciclovir cream 27. _ has been shown to help relieve a. result in the appearance of a flat or cratered, grayish- c. Fanclover cream yel ow area surrounded by a ring of inflamed tissue the symptoms of dry mouth.
b. occur on nonkeratinized surfaces of the oral mucosa 18. _ are factors in the occurrence of c. can cause moderate to severe pain d. al of the above a. Medication, alcohol and tobacco use c. Sleeping with a humidifier 8. It is during the vesicle stage of RHL that the b. Chemotherapy and head and neck radiation therapy d. al of the above c. Auto-immune diseases patient experiences _.
d. al of the above 28. Mouthwashes for the treatment of xerosto- a. the highest viral load b. bacterial superinfection 19. _ is a symptom of xerostomia. mia are formulated to effectively _.
c. viral superinfection a. A sticky and/or dry feeling in the mouth a. help relieve dry mouth d. the lowest viral load b. Stringy or ropey saliva b. soothe the oral mucosa c. Difficulty speaking, chewing or swal owing 9. Patients with RHL should be advised to d. Al of the above c. help cleanse the oral cavity, and combat halitosis d. al of the above 20. _ can be a sign of xerostomia. a. wash their hands frequently to prevent the transmission a. The appearance of dryness of the oral mucosa and oral 29. A smal mucoadhesive patch used to treat of viral secretions and infection b. avoid triggers such as sunlight xerostomia has been found to _. b. An increased level of carious lesions c. avoid spicy and/or acidic foods and drinks c. An increased level of plaque and bad breath a. effectively relieve dry mouth d. al of the above b. dissolve over 2-4 hours to moisturize the mouth 10. It is essential to stress the importance of 21. If it is suspected that a patient may have c. increase whole salivary flow visiting (or returning to) the dentist or physi- xerostomia, _wil help objectively d. al of the above cian if lesions do not heal within _ determine if xerostomia is present and to 30. Dry mouth can be relieved using _. what degree.
a. toothpastes, mouthwashes and saliva substitutes a. an unstimulated salivary flow test b. a visual analog scale b. chewing gums and lozenges c. a stimulated salivary flow test c. a mucoadhesive patch d. combinations of the above Part I: Quelling Cold Sores and Aphthous Ulcers Part I I: Relieving Xerostomia Telephone: Home ( ) Lic. Renewal Date: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test wil earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWel Corp. For Questions Cal 216.398.7822
If not taking online, mail completed answer sheet to Academy of Dental Therapeutics and Stomatology,
A Division of PennWel Corp.
1. List and describe the etiology and pathophysiology related to recurent aphthous ulcers and recurent herpes labialis.
P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 2. List and describe the general recommendations specific to patients experiencing recur ent herpes labialis.
3. List and describe the treatment options available for ecur ent aphthous ulcers and recur ent herpes labialis.
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1. List the etiological factors for xerostomia.
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2. List and describe the signs and symptoms of xerostomia. Payment of $49.00 is enclosed. 3. List and describe the treatment options available for the relief of dry mouth.
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Objective #2: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personal mastery of the course objectives. 4. How would you rate the objectives and educational methods? 5 5. How do you rate the author's grasp of the topic? 6. Please rate the instructor's effectiveness. 7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate? 9. Would you participate in a similar program on a different topic? 10. If any of the continuing education questions were unclear or ambiguous, please list them. 11. Was there any subject matter you found confusing? Please describe. 12. What additional continuing dental education topics would you like to see? AGD Code 016, 734, 739 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
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COMPOSANTES BIOLOGIQUES Quelques fondements de biologie moléculaire et de génie génétique intéressants pour approfondir le sujet, malgré le parti pris instructionniste qui sous-tend la présentation. Source : Centre Scientifique de la Biotechnologie/Industrie Canada http://strategis.ic.gc.ca/. Qu'est-ce qu'une cellule ? La cellule est l'unité du monde vivant et les millions de types différents d'organismes qui

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Normas Oficiales Mexicanas SSA2 Fuente : Diario Oficial de la Federación Fecha de Publicación: 08 de Enero de 2001 PROYECTO DE NORMA OFICIAL MEXICANA, PARA LA VIGILANCIA EPIDEMIOLOGICA, PREVENCION Y CONTROL DE ENFERMEDADES TRANSMITIDAS POR VECTOR. Al margen un sello con el Escudo Nacional, que dice: Estados Unidos Mexicanos.- Secretaría de Salud.