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omed
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  1. corticosteroids Secretion follows a diurnal pattern highest plasma concentration occurs at
    8 AM
  2. Corticosteroids Anti-Inflammatory Effects
    anti-H2, PGI, leukocyte adhesion/migration, macrophage exudation, fibroblast
  3. immunnophilin
    • x DNA transcription during T-cell activation
    • use: GVH, transplant, low-dose: AI
    • SE: nephro/neurotoxic
    • examples: cyclosprine, tacrolimus, sirolimus
  4. cytotoxic
    • MOA: x DNA synth esp immune cells, bone marrow
    • use: cancer, transplant rejection, AI
    • examples: azathioprine (6-MP, purine), mycophenolate motefil (purine), MTX (folic acid)
  5. thalidomide
    • class: immune mod
    • use: leprosy, Behçet's syndrome, HIV wasting syndrome, and GVHD
    • MOA: anti-TNF
  6. Anti-TNF agents
    • Etanercept (Enbrel) SubQ,
    • Adalimumab (Humira) SubQ,
    • Infliximab (Remicade) I.V
  7. IL-1 receptor antagonist
    • Anakinra (Kineret) SubQ
    • SE: TB reactivation, lymphoma & other malignancies
  8. Sulfasalazine
    • Class: DMARDs
    • MOA: AntiPG
    • Use: UC, RA, psoriasis, ankylosing spondilitis
  9. Gold
    • Class: DMARD
    • MOA: macrophage interfere, dec RF
  10. Dapsone
    • AB
    • use: malaria, leprosy, dermatitis herpetiformis, toxoplasmosis, PCP prophylaxis
  11. Recurrent Aphthous Stomatitis
    • lesions: defined, round, necrotic center, yellow-gray pseudomembrane, raised margins erythematous haloes
    • symptoms decrease w age, familial
    • prodrome: burning, pain
  12. RAS etiology
    • mechanical
    • emotional
    • hormonal: menstruation, oral contraceptives
    • nutrition
    • allergies: cinnamic aldehyde, sodium lauryl sulfate
    • infections: S. sanguis, adeno, HSV1
    • tobacco LOWERS RAS frequency
  13. RAS types
    • A: few days, infrequent tx: ID etiology
    • B: painful 3-10 days alter habits tx: topical
    • C: chronic tx: systemic
  14. RAS tx
    • Topical chlorohexidine gluconate and topical corticosteroids are both effective in reducing pain & severity but ineffective in frequency of eruptions
    • corticosteroids: prevent ulcer during prodromal
  15. Anesthetic Agents RAS
    • OTC Benzocaine  (anbesol)
    • Rx lidocaine (Xylocaine) viscous 2%
    • Rx compounded anesthetics
    • Dyclonine HCL( Dyclone) gel
    • 0.5%
    • Diphenhydramine, tetracaine, prilocaine, lidocaine in a gel
  16. Covering agents
    • orabase
    • RX: caphasol
    • kaopectate
  17. RAS tx
    • OTC Antibacterial Products
    • Ora 5
    • (cupper sulfate, iodine)

    • Oralief
    • (zinc chloride, phenol, CPT, alcohol)

    • nPovidone
    • Iodine

    • nDebacterol
    • (sulfuric acid, sulfonated phenolics)

    • nCarbamide
    • peroxide (Gly-Oxide,
    • Cankaid
    • rinse)

    nHydrogen peroxide

     Rx Antibacterial Agents

    • nTetracycline
    • suspension (250mg/5ml)

    • nChlorhexidine
    • gluconate
    • (0.12%)

    Herbal Remedies

    • nChickweed and violet:
    • anti-inflammatory

    nRockrose: reduce anxiety!
  18. amlexanox
    • x leukotriene, hist from mast cells
    • limit RAS duration
  19. Topical Dermatologic Glucocorticoids
    • Clobetasol Propionate (Temovate 0.05%)
    • Halobetasol(Ultravate 0.05%)
    • Fluocinonide (Lidex 0.05%)
    • Halcionide(Halog 0.1%)                              Betamethasone
    • dipropionate                                            (Diprosone
    • 0.05%)
    • Triamcinolone acetonide (Kenalog
    • 0.1%)
    • Betamethasone valerate (Valisone
    • 0.1%)

    • Hydrocortisone (several 1% preparations;
    • i.e., Anusol
  20. Corticosteroid applications
    • Intermediate Potency: Betamethasone (Celestone) syrup w/ 0.6 mg/5ml -one tsp swish & expectorate tid
    • High Potency: Dexamethasone (Decadron) elixir w/ 0.5 mg/5 ml - one tsp swish & expectorate tid
    • Ultra potency: Prednisolone (Prelone) syrup w/ 5 mg or 15 mg/5ml - best reserved for systemic use; doses vary from 5 to 60 mg/day
  21. systemic corticosterioids can cause adrenal
    suppression if used for more than
    2 weeks
  22. Continuous CS use:
    • reduces effectiveness
    • withdrawal for 2 to 4 days restores their action
    •  may lead to opportunistic Candida infection
  23. Systemic conditions w RAS
    • 1.Behçet’s
    • syndrome (eyes, joints, neurological systems and skin)

    2.Chronic GI absorption problems

    • Crohn’s
    • disease & ulcerative colitis

    • Celiac
    • Disease; gluten sensitive enteropathy       (4% of some RAS)

    3.Immune disturbances

    Agranulocytosis

    • Cyclic
    • neutropenia

    • HIV
    • positive patients especially when CD4              T-lymphocyte count is fewer than
    • 100/mm3
  24. Systemic RAS Tx
    Systemic

    Prednisone

    Thalidomide

    Etanercept (Enbrel)

    Dapsone
  25. RAS ABs
    OTC Abx

    Ora 5

    Oralief

    Povidone Idodine

    Carbamide Peroxide

    Hydrogen Peroxide

    Rx Abx

    Tetracycline

    Chlorhexidine Gluconate

    Dexamethasone

    Triamcinolone
  26. RAS, OLP, GCs
    Glucocorticoids

    Clobetasol Propinate

    Halobetasol

    Fluocinonide

    Halcionide

    Betamethasone

    Triamcinolone

    Hydrocortisone
  27. RAS, OLP GCs
    Glucocorticoids

    Clobetasol Propinate

    Halobetasol

    Fluocinonide

    Halcionide

    Betamethasone

    Triamcinolone

    Hydrocortisone
  28. Pemphigoid Cicatricial, Bullous TX
    • Cases Confined to Gingival Tissues
    • Ultra-Potent Topical Agents
    • (Clobetasol Propinate, Halobetasol)
    • Short Course of Systemic Corticosteroid (Methyl Dose-Pack or Pure Prednisone)
  29. For Severe Cases:
    • Long Course systemic Agents (1mg/Kg Prednisone)
    • Azathioprine w/ corticosteroids
    • Methotrexate
    • Cycline Drugs w/ Niacinamide
  30. Pemphigus Vulgaris, Foliaceus, Paraneoplastic TX
    • Systemic Tx ALWAYS Required w/
    • Adjunctive Topical Agents
    • Corticosteroids (Prednisone 1mg/Kg)
    • Azathioprine w/ corticosteroids
    • Mycophenolate Mofetil
    • IVID injections for severe cases
    • Other Agents: Cyclophophamide, Clyclosporine, dapsone, methotrexate,
    • Gold
  31. OLP TX
    • Glucocorticoids
    • Clobetasol
    • Propinate
    • Halobetasol
    • Fluocinonide
    • Halcionide
    • Betamethasone
    • Triamcinolone
    • Hydrocortisone
    • W/O Corticosteroids
    • Tacrolimus (Protopic) 0.03% or 0.1% in Orabase, tid
    • Cyclosporin (Sandimmune oral soln 100mg/mL) 1tsp swish tid
    • Refractory Cases
    • Azathioprine
    • Levamisole
    • Retinoids
    • Dapsone
    • Systemic Glucocorticoids
    • Prednisone (20-30mg tabs 1w)
    • Methylprednisolone (Medrol dose pack)
    • Dexamethasone (1.5mg/day 1w)
  32. RAS Topical
    • Topical Steroids:
    • Tiamcinolone Acetonide (0.1%)
    • Rx: Kenalog in Orabase 0.1%
    • Disp: 15g
    • Sig: Apply to lesion tid
  33. Betamethasone
    • Rx: Valisone Cream 0.1%
    • Disp: 15g
    • Sig: Apply to lesion tid
  34. Fluocinonide (0.05%)
    • Rx: Lidex 0.05% Gel
    • Disp: 15g
    • Sig: Apply to lesion tid
  35. Clobetasol Propionate 0.05%
    • Rx: Temovate 0.05% Cream
    • Disp: 15g
    • Sig: Apply to lesion bid
  36. Acyclovir (Zovirax)
    • Recurrent genital herpes, VZV
    • Capsules 400mg
    • Disp 60 Capsules
    • Sig 1 capsule tid 7-10 days
    • Acyclovir (Zovirax) Ointment 5%
    • Disp 3g
    • Sig: Apply to lip 5x/day
  37. Valcyclovir (Valtrex)
    • HSV 1,2>VZV
    • Caplets 1g
    • Disp 40 Cpalets
    • Sig 1 caplet bid 7-10 days
  38. Famciclovir (Famvir)
    • Acute Shingles (VZV) and HSV 1,2
    • 250mg
    • Disp 30 tabs
    • Sig 1 tab tid 7-10 days
  39. Topical Penciclovir (Denavir)
    • Herpes labialis
    • Cream 1 %
    • Disp 3g
    • Sig Apply to lesion 5x/day
    • PreSun Lip Gel OTC 15oz
    • Sig Apply to area 1hr prior to sun exposure (For Herpes Labialis)
  40. Ganvivlovir (Cytovene)
    CMV in HIV infected patients (Sometimes Acyclovir-resistant HSV infections)
  41. Foscovir (Foscarnet)
    CMV retinitis and mucocutaneous-Acyclovir-Resistant HSV in HIV patients
  42. Cidofovir (Vistide)
    IV preparation for CMV retinitis in HIV patients
  43. TX for Pseudomembranous Candidiasis
    Erythematous Candida
    Angular Chelitis
    Hyperplastic Candidia
    Linear Gingival Erythema (HIV-Related)
    • Nystatin (Topical);
    • Amphotericin B (IV/PO Systemic)

    • Clotrimazole (Topical);
    • Miconazole (Topical);
    • Keteoconazole (Topical, PO; OTC not for oral use)

    • Topical Antifungals: Polyenes<Imidazoles
    • Systemic Antifungals: Imidazoles<Polyenes<Triazoles<Echinocandins
  44. Topical Antifungals:
    Polyenes<Imidazoles
  45. Systemic Antifungals:
    Imidazoles<Polyenes<Triazoles<Echinocandins
  46. Systemic Fungal Infections
    • Fluconazole (PO, IV)
    • Itraconazole (PO, IV)
    • Voriconazole/Posaconazole (PO, IV)
    • Caspofungin, Micafungin, Amydulafungin (IV)
  47. Intermediate Topical
    • Nystatin Oral Suspension 100,000 u/mL
    • Disp 60mL
    • Sig: 2mL swish 2min, quid
    • Nystatin Pastilles 200,000 U
    • Disp 70 Pastilles
    • Sig: Dissolve 1 in mouth 5x/day
    • Nystatin Vaginal 100,000 U
    • Disp 40
    • Sig: Dissolve 1 in mouth quid
    • Nystatin Cream (Denture Candidiasis)
    • Disp 15g tube
    • Sig: Apply thin coat to inner surface of denture after meals
  48. Potent Topical
    • Mycelex Trouches 10mg
    • Disp 70
    • Sig: Dissolve 1 in mouth 5x/day
    • Ovig 50mg B Tablets
    • Disp 14 tablets
    • Sig: Place 1 tablet in upper gum region 1x/day 14 days
  49. Combination Topical
    • Mycolog II Ointment
    • Disp 15g tube
    • Sig: Apply to corners of the mouth after meals and at bed time
    • Lotrisone Cream
    • Disp 15g
    • Sig: Apply to the corners of the mouth after meals and at bed time
  50. Systemic Antifungal
    • Nizoral Tablets 200mg
    • Disp 14 Tabs
    • Sig Take 1 tab daily w/ meal (Don’t take with buffered meds or gastric acid blockers)
    • Diflucan Tablets 100mg
    • Disp 15 tabs
    • Sig: 2 Tabs to start, then 1 tab daily until finished
    • Itraconazole Oral Solution 10mg/mL
    • Disp 100mL
    • Sig: 1 tsp swish and swallow bid
  51. Odontogenic Infection/ Pulpal Infection AB
    Narrow Spectrum Antibiotics: PCN V, Amoxicillin, Clarithromycin
  52. Facial Space Infections
    PCN V, Amoxicillin, Clindamycin, Metronidazole, First Generation Cephalosporins (Cefazolin, Cefriaxone)
  53. Periodontal Therapy
    Tetracycline, Doxycycline, Metronidazole, Clindamycin
  54. Acute Salivary Gland Infections
    Broad Spectrum Antibiotics: Tetracycline, Cephalexin
  55. ANUG
    • Debridement w/ 3% H2O2;
    • Chlorhexidine Gluconate (0.12%), Povidone Iodine (10%)
    • Metronidazole for Systemic tx if evidence of gingival destruction, masticatory dysfunction and palpable nodes
  56. Halitosis
    • Reduce bacterial reservoir (Cetylpyridium chloride, Benzethonium chloride, chlorine dioxide, mechanical removal)
    • Restore normal salivary flow
    • Zn Salts, avoid high protein diets
  57. Xerostomia TX
    • Salivary Substitutes: Carboxy Methyl Cellulose, Hydroxymethyl Cellulose (Sal-ese, Moi-stir, Optimoist), Mucopolysaccharide (Mouth-Kote), Glycerate Polymer (Oral Balance gel), Mucin (Orthana)
    • Salivary Stimulants: Chloinergic herbal remedies (Pilocarpus jaborandi, daffodil), Bile secretion-stimulant (Anethole Trithione), Rx for Severe Cases (Pilocarpine-Salagen and Cevimeline HCL-Evoxac)
  58. Burning Mouth Syndrome TX
    • Benzodiazapines: Clonazepam (Klonopin), Chlordiazepoxide (Librium)
    • Tricyclic Antidepressants: Amitriptyline (Elavil), Nortriptyline (Pamelor)
    • Anticonvulsants: Gabapentin (neurotin)
    • OTC Capsaicin: Dilute w/ water
  59. Glucocorticoids
    • Prednisone
    • -Produce a dose-dependent exaggerated physiological effect
    • -Interfere with metabolic functions
    • -NOT stored in the body, produced throughout the day
    • -Can be structurally modified w/ F- or Me to enhance or suppress specific activities -Antagonize histamine release
    • -Inhibit prostaglandin synthesis
    • -Reduce leukocyte migration and adhesion
    • -Reduce macrophage exudation
    • -Decrease fibroblast proliferation (esp. fluoridated cmpds)
    • -Wide range of uses w/ autoimmune diseases
    • -Must take the drug in the morning
  60. Immunophilin Ligands
    • Cyclosporine
    • Tacrolimus
    • Sirolimus
    • Interfere w/ DNA txn involved in T-lymphocyte activation (cell-mediated immunity)
    • -Used in high doses to prevent graft rejection during organ transplantation
    • -Can lead to nephrotoxicity and neurotoxicity
    • -Low dose used to treat autoimmune disorders
  61. Cytotoxic Drugs
    • Azathioprine (Imuran)
    • Methotrexate (Rheumatrex)
    • Mycophenolate
    • -Interfere with DNA Synthesis of rapidly dividing cells
    • -Nucleotide formation or incorporation into DNA
    • -Cancer treatment
    • -Prevention of solid organ transplant rejection
    • -Autoimmune disorders
    • -Can cause BM suppression
    • -Risk of infections/ malignancies
    • -Tx of pemphigus, pemphigoid, LP
  62. Azathioprine:
    • cytotoxic drug converted to active form in the body
    • Risks: toxic in thiopurine methyltransferace deficiency, inhibition of Coumadin, hepatotoxicity, BM suppression, increased rate of malignancy, caution w/ EtOH
  63. Methotrexate:
    • cytotoxic drug Folic acid antagonist, good for tx of pemphigoid
    • Risks: BM suppression, hepatic and renal toxicity, CNS effects (seizures), GI and BM toxicity enhanced with NSAIDs
  64. Immune Modulators
    • Thalidomide
    • Biological Agents:
    • Etanercept (Enbrel)
    • Infliximab (Remicade)
    • Adalimumab (Humira)
    • Anakinra (Kineret)
    • -Thalidomide: anti-tumor necrosis factor (TNF) action
    • -Taken off market for teratogenic effects
    • -Bio Agents: Cytokine regulatory fxn
    • -Thalidomide: rheumatic diseases (off label)
    • -Restricted approval for leprosy, Behcet’s, HIV wasting syndrome, GVHD
    • -Bio Agents: Rheumatic and Connective tissue diseases
    • -Risk of TB reactivation, lymphoma and other malignancies
  65. Glucocorticoids in order of decreasing potency
    • Clobetasol Propinate
    • Halobetasol
    • Fluocinonide
    • Halcionide
    • Betamethasone Dipropriante
    • Triamcinolone Acetonide
    • Betamethasone Valerate
    • Hydrocortisone
    • Can be used BEFORE the active ulcer surfaces, use strongest indicated for case
    • Gels and creams are best for wet mucosa
  66. Recurrent Aphthous Stomatitis (RAS) Minor Major Herpetic
    • -Recurring oral ulcers
    • -Painful w/ eating, swallowing, speaking
    • -May have + family hx
    • -Onset later in life suggests more complex disorder
    • -Lesions clearly defined, raised margins w/ red halo, shallow necrotic center covered w/ yellow-gray pseudomembrane
    • 1. Preulcer Phase:
    • Lymphocytic cell infiltrate into epithelium
    • 2. Papular swelling w/ red halo
    • Localized keratinocyte vacuolization
    • 3. Ulceration
    • Erosion of papule
    • Ulcer gets covered w/ fibrinous membrane and infiltrated w/ immune cells
    • 4. Healing w/ epithelial regeneration
    • -Childhood onset, frequency and severity decreases w/ age
    • -80% of cases before age 30
    • -Prodrome of burning/pain 24-48hrs prior
    • -Precipitating Factors: Emotional stress, mechanical trauma, dietary deficiencies (B-vitamins, Fe, folic acid), food allergies (gluten, tomatoes, milk, nuts, chocolate), habits, pathogens/chemicals
    • -Biopsy MAY BE NECESSARY
    • -NO-If can make the dx clinically
    • -Dry mouth increases chance of developing ulcers
    • -Chemicals like toothpaste (SLS) or mouthwash, cinnamon flavoring, S. sanguis, adenovirus, HSV-1
    • -Smoking has a NEGATIVE effect
    • -Female hormones and BCP increases recurrence -Tx depends on which stage the ulcer is in
    • Steroids: Antigen processing
    • Au: TNF/IL-1
    • Type A: episodes last a few days, few times per year, pain is tolerableidentify precipitating factors
    • Type B: painful RAS lasting 3-10 days causing patient to alter diet or OH habitsIdentify precipitating factors, use topical and prophylaxis
    • Type C: painful, chronic courses of RASRefer to an OM specialist, need systemic management w/ potent cmpds
  67. Oral Lichen Planus
    • -Erosive Lichen Planus: epithelial sloughing and erosion
    • -Plaque-Form Lichen Planus: thick adherent plaques associated with the classic reticular LP on the buccal mucosa
    • -Etiology unknown
    • -Pathogenesis involves a cell mediated cytotoxic process
    • Langerhans cells recognize unknown Ag and stimulate T lymphocytes
    • Lymphocytes cytotoxic to epithelial cells are produced
    • -Epithelium undergoes degeneration -Systemic Aspects of LP:
    • Skin lesions (popular lesions, Wickham’s Striae, VB type blisters)
    • Vulvovaginal Lesions
    • Penile and Anal lesions
    • Scalp lesions
    • Nail involvement
    • -Hair loss, hearing loss, vaginal problems, itching and burning skin
    • -Biopsy is almost ALWAYS indicated
    • All clinical types test NEGATIVE for IgG, IgM and IgA antibodies and POSTIVE for fibrinogen along BM zone -Hydrocortisone is NOT a good tx -Tx reserved for atrophic and ulcerated lesions
    • Identify triggers (foods, stress, xerostomia)
    • Corticosteroids (anti-inflammatory properties)
    • Other immunosuppressants (topica) (modulate immune system, used for patients that can’t tolerate corticosteroids like severe DM)
  68. Pemphigoid
    • -Chronic bullous mucocutaneous disease
    • -Cicatricial Pemphigoid-mucous membranes, scarring (MMP)
    • -Bullous Pemphigoid- skin (BP)
    • MMP: IgG autoantibodies against at least 10 components of hemidesmosome apparatus;
    • possible malignant potential for antiepiligrin MMP -POSITIVE Nikolsky Sign (blister forms within 2 minutes after pushing with a blunt instrument)
    • -Untreated cases can progress to involve other mucosal sites like eyes
    • -SYSTEMIC CONDITION
    • -Biopsy is ALWAYS indicated
    • -Light microscopy on oral biopsies detect epithelial separation
    • -DIF on tissue sample
    • -IIF NOT usually used
    • -MUST treat! Will not resolve on its own
    • -For cases confined to gingival tissues: apply ultra-potent or potent topical agents or a short course of systemic corticosteroid are adequate
    • Clobetasol (0.05%) cream 2x/day in trays for 2w; Methyl pack dose or prednisone
    • -Severe Cases: long course systemic agents; 1mg/Kg Prednisone
    • Azathiorpine w/ corticosteroids, Methotrexate, Cycline drugs w/ niacinamide
  69. Pemphigus
    • -Pemphigus Vulgaris: MOST COMMON, blisters
    • -Pemphigus Foliaceus: crusted sores or fragile blisters on face and scalp
    • -Paraneoplastic Pemphigus: LEAST COMMON, occurs in patients already dx with hematologic malignancies
    • -Autoantibodies against epithelial adhesion components
    • Desmoglein 3 in the mucosal dominnt type
    • Desmoglein 1 mostly in mucocutaneous variant -Pemphigus Vulgaris: POSITVE Nikolsky sign, PAINFUL sores
    • -Pemphigus Foliaceus: NOT PAINFUL
    • -Paraneoplastic Pemphigus: PAINFUL sores on mouth
    • -Biopsy and serologic testing is ALWAYS indicated
    • Light microscopy (H&E) to detect the epithelial cells separation
    • DIF to detect desmoglein antibodies
    • IIF to detect circulation antibodies (MUST DO)
    • Antibody titer test
    • ELISA for identification of desmoglein
    • Systemic Tx is ALWAYS Required, Topical agents used in adjunctive therapy
    • Corticosteroids (1mg/Kg Prednisone)
    • Other Immunosuppressants: Azathoprine w/ corticosteroids, Mycophenolate mofetil, IVID Injections for severe cases
    • Other Agents: Cyclophosphamide, clyclosporine, dapsone, methortrexate, Gold
    • -Prior to tx, PV was 99% fatal
  70. Disease Modifying Anti-Rheumatic Drgus (DMARDs)
    • Sulfasalazine, Au, Anti-malarials, penicilinamine, levamisole, minocycline
    • -Sulfasalazine: anti-prostaglandin synthesis
    • -Gold: Interferes with macrophage fxn, decreases Rheumatoid Factor
    • -Dapsone: Antibiotic -Sulfasalazine: ulcerative colitis, RA, psoriasis, ankylosing spondilitis
    • -Dapsone: leprosy, malaria, dermatitis herpetiformis, proph against toxoplasmosis and PCP (AIDs patients)
  71. OLP TX
    • Typical Treatment
    • Glucocorticoids in order of decreasing potency
    • Clobetasol Propinate, Halobetasol, Fluocinonide, Halcionide, Betamethasone Dipropriante, Triamcinolone Acetonide, Betamethasone Valerate
    • NO Hydrocortisone
    • Topical Treatments without Corticosteroids
    • -Tacrolimus (Protopic) 0.03% or 0.1% in orabase, apply tid
    • -Cyclosporine (Sandimmune oral soln 100 mg/ml) 1 tsp swish tid
    • Severe or Refractory Cases
    • Azathioprine (used in combo with corticosteroids)
    • Levamisole (used in combo with corticosteroids)
    • Retinoids
    • Dapsone (antibiotic)
    • Systemic Glucocorticoid Cmpds
    • Low Doses for less severe cases
    • Prednisone (20-30mg tablets for 1w)
    • Methylprednisolone (Medrol dose pack of tablets- 6 day course, 24mg tirtrated down to 4mg)
    • Dexamthasone (1.5mg/dayx1w)
    • Severe Cases: max daily dose 1mg/Kg
    • Follow-Up
    • 1.7% malignant transformation
    • Transformation more likely to occur in atrophic, erosive and ulcerative lesions
  72. RAS Associated with Systemic Conditions
    • Drug Exposure (NSAIDs), Behcet’s syndrome (eyes,
    • joints, neurological systems and skin), Chronic GI absorption problems
    • (Chron’s, ulcerative colitis, Celiac’s), Immune disturbances (Agranulocytosis,
    • cyclic neutropenia, HIV+
  73. OTC mouthwashes
    • 1. Antibacterial and Antifungal agents: Reduce the number of microorganisms
    • a. Phenols, essential oils, halogens, biguinides, quaternary ammonia
    • 2. Oxygenating Agents: Active against anaerobic bacteria of the mouth
    • 3. Astringents: Cause local vasoconstriction and reduce tissue edema
    • a. Alcohol, zinc chloride, zinc acetate, alum, tannic acid, acetic acid, citric acid
    • 4. Anodynes: Alleviate pain and soreness
    • a. Phenol derivatives, oil of wintergreen, and eucalyptus oil
    • 5. Buffers: Maintain the pH and counteract the acidic pH produced from bacterial metabolism
    • a. Na perborate, Na bicarbonate
    • 6. Deodorizing Agents: Neutralize odor from decomposing oral debris
    • a. Chlorophyll
    • 7. Detergents: Degrade bacterial cell walls, causing the bacteria to lyse; foaming action washes the microoransims away
    • a. Sodium Laurel Sulfate (SLS)-in a lot of toothpastes
    • 8. Inactive Ingredients:
    • a. Water (largest by percentage), sweeteners (glycerol, sorbitol, sucralose, saccharin, aspartame, xylitol), coloring agents, flavorings (wintergreen, spearmint oil, peppermint oil, eucalyptus oil, orange oil)
  74. OTC Anesthetics
    (Benzocaine, lidocaine, dyclonine)
  75. OTC Lubricants
    (Sodium carboxymethyl cellulose, propylene glycol, hydroxypropyl cellulose, glycerin)
  76. OTC Antiseptic: ethyl alcohol, salicylic acid, benzyl alcohol, phenol, K iodine, povidone iodine, benzalkonium chloride, benzethonium chloride, searyl alcohol, cetyl pyridium chloride (CPC), benzoin incture)
  77. OTC Astringent
    (Sugar gum, tannic acid, ZnCl)
  78. Anestheics OTC
    • Benzocaine Alcohol Free
    • a. Baby Anbesol (7.5%)
    • b. Baby Orajel (7.5%)
    • c. Baby Zilactin (7.5%)
    • d. Hurricaine (20%)
    • e. SensoGARD Canker Sore (20%)
    • Benzocaine and Alcohol
    • a. Anbesol Max Strength Gel or Liquid (20% B, 50% benzyl alcohol)
    • b. Orabase-B (20% B, 57% ethyl alcohol)
    • c. Orajel Max Strength (15% B, 67% ethyl alcohol)
    • d. Zilactin B (10% B, 70% benzyl alcohol)
    • Benzocaine & Eugenol; Benzocaine & Menthol; Benzocaine & Phenol
    • 4. Dyclonine (Children’s Maximum and Regular strength sucrets)
    • 5. Lidocaine
    • a. Xylocaine Viscous (2%)
    • b. Zilactin-L (2.5%)
  79. Covering Agents OTC
    • 1. Orabase: an emollient paste composed of Na carboxymethyl cellulose in a plasticized hydrocarbon gel
    • 2. Zilactin: a film-forming liquid composed of a hydroxypropyl cellulose and benzyl alcohol
    • 3. Orabase Soothe-N-Seal: A mucoadherent cmpd with Na hyaluronate, glycyrrhetinic acid and aloe vera
    • 4. GelClair oral gel: an new Rx mucoadherent formula targeted to cancer tx mucositis
    • 5. Debacterol: sulfuric acid and phenol (burns the surface of the tissue to form cauterized seal)
  80. Saliva Stimulants
    • 1. Parasympathomimetic
    • a. Cholinergic herbal remedies
    • b. Pilocarpus jaborandi
    • c. Narcissus pseudonarcissus (daffodil)
    • 2. Bile secretion-stimulating drug (cholagogue)
    • a. Anethole Trithione (Sialor)
    • 3. Most patients with severe xerostomia require a Rx
    • a. Pilocarpine (Salagen) 5mg
    • b. Cevimeline HCL (Evoxac) 30mg
  81. Saliva Substitutes
    • 1. Carboxy methyl cellulose and Hydroxymethyl cellulose
    • a. Sal-ese, Saliment aerosol, Moi-stir spray and liquid, Optimoist spray and drops which also contain fluoride, Ca and P
    • 2. Mucopolysaccharide (Mouth-kote liquid)
    • 3. Glycerate Polymer (Oral Balance gel w/ lactoperoxidase enzyme system)
    • 4. Mucin containing saliva (Orthana spray and lozenges)
  82. Burning Mouth Syndrome
    • 1. Burning sensation in the tongue or other oral sites, Absence of clinical and laboratory findings
    • 2. Patients often present with multiple oral complaints (burning, dryness, taste alterations)
    • 3. Reported more often in women, especially after menopause, Sometimes associated with DMII, anxiety & depression, deficiencies in vitamins and nutrients
    • 4. Supertasters are more prone to BMS (taste inhibits oral pain, if taste is damaged, the associated pain inhibition is damaged)
    • 5. Damage to chorda tympani (ant 2/3 of tongue)
    • a. Release of pain inhibition and intensification of sensations of the trigeminal (V) and glossopharyngeal (IX) nerves (phantom senses)
    • b. One-sided burning could be damage to chorda tympani in ear
    • 6. Causes of Taste Loss
    • a. Aging, menopause (estrogen maintains steroids, onset associated with climacteric symptoms)
    • b. Oral diseases (Lichen Planus, Candida, viruses, periodontitis)
    • c. Nutritional deficiencies (B vitamins, Zn, Cu), Medications (ACE Inhibitors)
    • d. Dry Mouth (Sjogren’s, chemo, radiation), Systemic Conditions (Liver disease, chronic renal failure), Cranial Nerve Injury (Trauma, neoplasms, Bell’s Palsy)
    • e. Psychiatric conditions (depression, eating disorders)
  83. BMS Management
    • 1. Benzodiazepines
    • a. Clonazepam (Klonopin) 0.25-2mg/day (has peripheral effect)
    • b. Chlordiazepoxide (Librium) 10-30mg/day
    • 2. Tricyclic Antidepressants
    • a. Amitriptyline (Elavil) 10-150mg/day
    • b. Nortriptyline (Pamelor)
    • 3. Anticonvulsants
    • a. Gabapentin (Neurontin) 300-1600mg/day
    • 4. Capsaicin (OTC)
    • a. 1:2 dilution of hot pepper and water
    • b. Rinse w/ 1 teaspoon, increase strength to 1:1 dilution with time
  84. Supplements
    • Most commonly Used:
    • 1. 10 multivitamins and minerals
    • a. Vit E, C, B12, A, D, Ca, Mg, Zn, Folic Acid
    • 2. 10 herbal supplements
    • a. Echinacea, ginseng, gingko biloba, garlic, st. Jonh’s wort, peppermint, ginger, soy, chamomile, kava kava
    • 3. Adverse reactions realted to herbs are due to inherent toxicity, overdose, drug-herb interactions and allergic responses
    • 4. Patients must be asked if they are taking any dietary supplements or herbal rememdies along with their prescription drugs
    • 5. Potential drug interactions should be identified
  85. Gingko Biloba
    • -Effective against dementia, leg claudication
    • -Anti-platelet activity causing spontaneous bleeding, GI complaints, headaches, allergies
    • -Interacts with MAOI, ASA, anti-PLT drugs and thiazide diuretics
  86. Garlic
    • -Used for hyperlipidemia
    • -Increased risk for bleeding, GI symptoms, be careful with anti-platelet drugs
    • Ginger
    • -Used for nausea
    • -Caution with anti-platelet drugs St. John’s Wort
    • -Used for mild-moderate depression
    • -Causes GI symptoms, dizziness, confusion, tiredness, sedation, photosensitivity, inhibition of sperm motility, Many drug interactions due to liver drug metabolism
  87. Soy
    • -Tx of menopausal symptoms and lowering cholesterol
    • -Concern for long-term estrogen effects Kava Kava
    • -Used as a sedative, relaxant
    • -Small benefit for anxiety
    • -Severe hepatotoxicity possible, combination with benzodiazepines may cause semicomatose state
  88. Echinacea
    • -Immune stimulant
    • -Contraindicated in multiple sclerosis, HIV infection and TB
  89. Ginseng
    • -Physical and cognitive performance
    • -Interacts with Warfarin, MAO inhibitiors
    • -Don’t use with stimulants, anti-psychotic drugs or hormones
  90. Peppermint
    -Tx of IBS
  91. Chamomile
    -Sleep disorders, anxiety and GI problems
  92. Drugs interactions
    • Pharmaceutical Interactions
    • Drug incompatibilities of a physical or chemical nature - mixing of in the same bottle, tubing, syringe or IV drip
    • Usually involves drugs that are given parenterally for sedation (i.e., barbiturates and opioid analgesics)  
    • Pharmacokinetic Interactions
    • When one drug affects the absorption, distribution, biotransformation or excretion of another drug
    • Many possible interaction with OTC drugs, antibiotic and antifungal agents
    • Pharmacodynamic Interaction
    • Modifications in the pharmacologic effects of one drug in the presence of another
    • Analgesics and epinephrine
  93. ›Antacids and H2 blockers increase the
    gastric absorption of
    enteric coated medications
  94. ›Antacids and H2 blockers prevent absorption
    of pH sensitive drugs like
    PCN,  ketoconazole ,digoxin
  95. ›Antacids that contain  Ca++,
    Mg++, Fe++, Al+++ and calcium enriched products interfere with
    tetracycline absorption
  96. Oral anticoagulants are highly protein bound in plasma - easily displaced from their plasma protein binding site by:
    • certain antibiotics (sulfonamides)
    • analgesics/anti-inflammatory agents (aspirin)
    • Extended use of high dose aspirin (more than 4 days and more than 3 g/day) causes an increase in warfarin (Coumadin) potency and increases bleeding
  97. _____ enhances the hepatic breakdown of a host of substances and it especially makes the standard dose of Coumadin ineffective
    Phenobarbitol
  98. ____ reduces plasma levels of protease inhibitors (HIV progression), cyclosporine (immune suppression), Coumadin (bleeding) and oral contraceptives (unwanted pregnancy)
    St. John’s Wort
  99. _____ which interferes with hepatic clearance of Coumadin (bleeding) and Lithium (renal toxicity)
    • Metronidazole
    •  
    • __________ interfere with clearance of digoxin (causing bradycardia), theophylline (causing tachyarrhythmia), carbamazepine (causing CNS effects), prednisone (causing steroid toxicity), Coumadin (causing bleeding), cyclosporine (causing severe immune suppression & nephrotoxicity), terfenadine (causing severe tachycardia) 
    • Erythromycin (and macrolides in general), azole antifungal drugs (Ketoconazole and Itraconazole) [and grapefruit juice]
  100. ______ can reduce digoxin metabolism in the gut causing toxicity (cardiac arrhythmia)
    Tetracycline
  101. ____ alters GI flora and reduces the absorption of the oral contraceptives (reduced birth control effect)
    • Rifampin
    • Rifampin is also a strong Cytochrome P450 inducer leading to rapid clearance of estrogen and progesterone
  102. ____ have a major inhibitory effect on hepatic clearance of sensitive drugs
    Antifungals
  103. ___ & administration of exogenous epinephrine in local anesthetics can cause increased cardiac rate and output w/out the compensatory vasodilitation and an increase in patient’s blood pressure
    Non-selective B-blockers block cardiac B1-adrenergic & and vascular B2-receptors;
  104. ___ anticoagulant effect is enhanced by the use of NSAIDs and ASA leading to upper GI bleeding
    Heparin and Coumadin
  105. Halothane(a general anesthetic) has a CNS depression effect that is enhanced by the use of
    opioid analgesics (i.e., Morphine & Meperidine)
  106. ____ most likely inhibits serotonin reuptake so concomitant use with SSRIs (i.e., sertraline or Zoloft) can lead to serotonin toxicity
    St. John’s Wort
  107. Nabumetone (Relafen) and Naproxyn Sodium (Naprosyn
    • COX1 and COX2 inhibitors
    • suitable for joint inflammation without seriously impacting the stomach lining
    • Naproxyn seems to have a more salutary effect on headache than the other NSAID’s.
  108. Flexeril (cyclobenzaprine)
    • analogue of the tricyclic antidepressants and has similar side effects.
    • myalgia, myofascial pain and muscle spasms
    • Sedation?
    • Side Effects: sedation, postural hypo-tension and fainting.
    • Contraindications: liver or kidney disease alcoholism, near-term pregnancy.
    • Cross Rxn’s: Other TCA’s or SSRI, any drug which is hypotensive inducing, any sedating medication drug.
  109. Tizanidine (Zanaflex)
    • Alpha 2 Agonist
    • Dose range 2-8 mg tid
    • Increases synaptic inhibition of motor nuerons
    • Similar to Clonidine but 1/10 to 1/50 as potent on lowering blood pressure.
    • Useful for CTTH
    • Useful for MFP
    • Follow liver enzymes
  110. Skelaxin (metaxalone)
    • Require Glucose-6-phosphate dehydrogenase to metabolize
    • Cannot use with any history of anemia (G6PD deficiency – the most common inherited enzyme pathology affecting more than 400 mil people).
    • Blacks>Caucasians; Male>Female
    • Can cause oxidative damage to RBCs in G6PD deficient individuals.
  111. In order to determine if a toothache is peripheral or central, the tooth and area around the tooth
    should be thoroughly anesthetized.
  112. Peripheral Sensitization
    • Pain is continuous
    • Pain is aching and burning
    • Pain usually associated with static mechanical allodynia.
    • Pain responds to somatic blocking
  113. chronic peripheral trigeminal neuropathy
    persistent idiopathic facial pain of neuropathic origin that is characterized as aching or burning, a lowered response to neurosensory stimulation, is blocked by topical and or local anesthetics and is not due to another cause.
  114. Topical Medications and Stents
    • Instruct patient to mix in equal portions:
    • Orabase Paste ( mucoadhesive with 20% benzocaine)
    • 0.025% capsaicin
    • Apply to affected area 4-6x/day
    • If this shows any benefit, make stent.
    • If this procedure is helpful with stent but only partially, add other medications to the mixture
    • Other topical agents
    • Gabapentin up to 10% if being mixed with Orabase due to thickness and other agents.
    • 2% carbamazepine
    • 5% Ketoprophen
    • 0.1% clonidine
    • 1% Ketamine
    • Note: Use compounding pharmacist who uses a mill. Mortar and pestle processing will not make a powder fine enough.
  115. Trigeminal Neuralgia:
    • Often triggered by chewing and swallowing.
    • Refractory to all conventional analgesics
    • Opiates only effective at high doses where patient is significantly sedated.
    • Sharp stabbing paroxysms of pain
    • Dull aching background pain.
    • Light touch will trigger the pain, e.g. washing face, brushing teeth, licking lip, talking, eating,
    • Marked by periods of remission.
    • Often pain stops when patient is asleep.
    • Goes into remission for weeks, months or years.
    • 155/1,000,000
    • Most often in individual 50 and older.
    • Female to male prevalence 1.6:1
    • Less than 4% is bilateral
    • Neurological Exam is normal
  116. trigger areas for trigeminal neuralgia
    • perioral region in V2 and V3
    • intraorally in the tooth or gingival regions
    • lateral border of the tongue
  117. Trigeminal imaging
    MRI w contrast, look for notches in trigeminal root where vessel sits on nerve
  118. Medication Management for Trigeminal Neuralgia
    • Oxcarbazepine
    • Carbamazepine
    • Gabapentin
    • Lamotrigine
    • Tiagabine
    • Topiramate
    • Valproic acid
    • Felbamate
    • Zonisamide
    • Phenytoin
    • Baclofen
  119. Trigeminal tx:
    • RF or Glycerol gangliolysis
    • Gamma Knife
    • Microvascular decompression removes the offending blood vessel from the trigeminal root and places a teflon material over the nerve to protect the damaged area.
  120. central neuropathy
    • activating central sensitizing processes that have a tremendous impact on the character of the pain and its response to therapy.
    • Pain is not blockable
    • Dysesthesia
    • Paresthesia
    • Dynamic Mechanical Allodynia
  121. Chronic centralized trigeminal neuropathy
    • pain that is persistent, aching and/or burning, not responsive to topical or local anesthetic blocking and is due to central sensitization,
    • dental analogue = atypical odontalgia
  122. Treatment of Centralized Neuropathic Pain
    • Tricyclic Antidepressants
    • Antiseizure Medications
    • Gabapentin
    • Pregabalin
    • Other AED’s
    • Tramadol
    • Narcotics
    • Surgery
    • Memantine (Namenda)
  123. Sympathetically mediated pain
    • pain that is maintained by sympathetic efferent activity or circulating catecholamine action as determined by pharmacologic or sympathetic nerve blockade.
    • autonomic involvement, motor, cutaneous, sensory and dystrophic changes.
  124. duration of AB therapy
    • Remission of disease + 48 hrs
    • Consider host factors; adjust for renal and hepatic diseases
  125. Beta-Lactam Antibiotics
    • Bacteriocidal
    • penicillins and cephalosporins
    • Good diffusion in organic fluids, infected tissues
    • RENAL Clearance
    • Most cross the placenta; excreted in breast milk
    • Resistance is an issue
    • Hypersensitivity, GI disturbance, anemia, renal damage
  126. Tetracyclines
    • broad - most g+ and g- bacteria including many anaerobes (chlamydiae, rikettsia, spirochetes), even some protozoa
    • Acne, rosacea, intestinal infections, PID, UTI & spirochetal infections (syphilis, lyme disease, periodontitis)
  127. Clindamycin
    • narrow - streptococci, staphylococci, pneumococci and very specific for anaerobes (fusobacterium, bacteroides, porphyromonas, prevotella)
    • Anaerobic dental & periodontal infections, acne, infections of the soft tissues and respiratory tract
  128. Macrolides
    • narrow – streptococci, staphylococci, mycobacteria (M. pneumonia) and some anaerobes (chlamydia, haemophilus, spirochetes)
    • Skin infections, pharyngitis/tonsillitis/sinusitis, bronchitis, pneumonias, chlamydial infections
  129. Metronidazole
    • NA synth inhibitor
    • Spectrum: narrow, strict anaerobes (trichomonal infections, brain & lung abscesses, periodontitis)
    • Crosses placenta & is mutagenic
    • Excretion: renal
    • Interferes w/ anticoagulants, potentiates alcohol
  130. Quinolones
    • NA synth
    • Ciprofloxacin
    • Chlamydial infections, hospital acquired pneumonias
    • Crosses placenta & secreted in breast milk
    • Excretion: renal
  131. Perio AB
    • Tetracyclines
    • Short –acting; drug conc. in GCF is 7x higher than serum
    • Useful for aggressive tx of periodontitis in young pts, Juvenile periodontitis, rapidly advancing disease or those refractory to tx
    • Doxyclycline
    • The greatest anti-collagenase activity
    • Because it is long acting, is used as once daily low dose
    • Metronidazole
    • Narrow spectrum, effective for g- anaerobes, so beneficial in tx of periodontitis in combination w/ conventional tx methods
    • Can cause metallic taste, HA, vertigo and peripheral neuritis
    • Clindamycin
    • Narrow spectrum targeted to g- anaerobes, useful for disease refractory to tetracycline & metronidazole
    • Very good at penetrating bone
  132. Salivary Gland infections
    broad-spectrum antibiotic such as tetracycline or Cephalexin may also be used
  133. Breath Analyses Odor Judge Tests
    • Organoleptic tests
    • Examination of the expired air
    • Wrist-Lick test
    • Spoon test
    • OBJECTIVE:
    • Volatile Sulfur Compounds (VSCs) detection test (Halimeter)
    • Measurement of VSCs in ppb in the air collected from the anterior mouth, posterior tongue and each of the nostrils
    • Gas chromatography
    • Identification and quantification of the specific VSCs in the headspace air sample
    • The electronic nose
    • Identification of the specific odorous bacterial species in the headspace air sample

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