Symptoms in the Pharmacy :Gastrointestinal Tract Problems(2)
Medication (mouth ulcer)
The pharmacist should establish the identity of any current medication,
since mouth ulcers may be produced as a side-effect of drug
therapy. Drugs that have been reported to cause the problem include
aspirin and other NSAIDs, cytotoxic drugs and sulfasalazine (sulphasalazine).
Radiotherapy may also induce mouth ulcers. It is worth
asking about
herbal medicines because feverfew (used for migraine)
can cause mouth ulcers.
It would also be useful to ask the patient about any treatments tried
either previously or on this occasion and the degree of relief obtained.
The pharmacist can then recommend an alternative product where
appropriate.
When to refer
Treatment timescale
If there is no improvement after 1 week, the patient should see the
doctor.
Management
Symptomatic treatment of minor aphthous ulcers can be recommended
by the pharmacist, and can relieve pain and reduce healing
time. Active ingredients include antiseptics, corticosteroids and local
anaesthetics. There is evidence from clinical trials to support use of
topical corticosteroids and chlorhexidine mouthwash. Gels and
liquids may be more accurately applied using a cotton bud or cotton
wool, providing the ulcer is readily accessible. Mouthwashes can be
useful where ulcers are difficult to reach.
Chlorhexidine gluconate mouthwash
There is some evidence that chlorhexidine mouthwash reduces duration
and severity of ulceration. The rationale for the use of antibacterial
agents in the treatment of mouth ulcers is that secondary
bacterial infection frequently occurs. Such infection can increase discomfort
and delay healing. Chlorhexidine helps to prevent secondary
bacterial infection but it does not prevent recurrence.
It has a bitter taste and is available in peppermint as well as standard flavour.
Regular use can stain teeth brown – an effect that is not usually
permanent. Advising the patient to brush the teeth before using the
mouthwash can reduce staining. The mouth should then be well rinsed
with water as chlorhexidine can be inactivated by some toothpaste
ingredients. The mouthwash should be used twice a day, rinsing 10 ml
in the mouth for 1 minute.
Topical corticosteroids
Hydrocortisone and triamcinolone act locally on the ulcer to reduce
inflammation and pain, and to shorten healing time. The former is
available as pellets, the latter in a protective paste. To exert its effect, a
pellet must be held in close proximity to the ulcer until dissolved. This
can be difficult when the ulcer is in an inaccessible spot. One pellet is
used four times a day.
The pharmacist should explain that the pellets
should not be sucked, but dissolved in contact with the ulcer. These
treatments are best used as early as possible. Before an ulcer appears,
the affected area feels sensitive and tingling – the prodromal phase –
and treatment should start then. They should be applied 3–4 times
daily. They have no effect on recurrence but should be restarted at the
first signs of a new outbreak.
Local analgesics
Benzydamine mouthwash or spray and choline salicylate dental gel
are short-acting but can be useful in very painful major ulcers. The
mouthwash is used by rinsing 15 ml in the mouth three times a day.
Numbness, tingling and stinging can occur with benzydamine.
Diluting the mouthwash with the same amount of water before use
can reduce stinging. The mouthwash is not licensed for use in children
under 12.
Benzydamine spray is used as four sprays onto the affected
area three times a day. Although aspirin is no longer recommended for
children under 16 years because of possible links with Reye’s syndrome,
choline salicylate dental gel produces low levels of salicylate
and can therefore be used in children.
Carbenoxolone
Available as gel and mouthwash, carbenoxolone was shown in one
small study to relieve pain and reduce healing time.
Local anaesthetics (e.g. lidocaine (lignocaine), benzocaine)
Local anaesthetic gels are often requested by patients. Although they
are effective in producing temporary pain relief, maintenance of gels
and liquids in contact with the ulcer surface is difficult. Reapplication
of the preparation may be done when necessary. Tablets and pastilles
can be kept in contact with the ulcer by the tongue and can be of value
when just one or two ulcers are present. Any preparation containing a
local anaesthetic becomes difficult to use when the lesions are located
in inaccessible parts of the mouth.
Both lidocaine and benzocaine have been reported to produce sensitisation,
but cross-sensitivity seems to be rare, probably because the
two agents are from different chemical groupings. Thus, if a patient
has experienced a reaction to one agent in the past, the alternative
could be tried.
The pharmacist should establish the identity of any current medication,
since mouth ulcers may be produced as a side-effect of drug
therapy. Drugs that have been reported to cause the problem include
aspirin and other NSAIDs, cytotoxic drugs and sulfasalazine (sulphasalazine).
Radiotherapy may also induce mouth ulcers. It is worth
asking about
herbal medicines because feverfew (used for migraine)
can cause mouth ulcers.
It would also be useful to ask the patient about any treatments tried
either previously or on this occasion and the degree of relief obtained.
The pharmacist can then recommend an alternative product where
appropriate.
When to refer
- Duration of longer than 3 weeks
- Associated weight loss
- Involvement of other mucous membranes
- Rash
- Suspected adverse drug reaction
- Diarrhoea
Treatment timescale
If there is no improvement after 1 week, the patient should see the
doctor.
Management
Symptomatic treatment of minor aphthous ulcers can be recommended
by the pharmacist, and can relieve pain and reduce healing
time. Active ingredients include antiseptics, corticosteroids and local
anaesthetics. There is evidence from clinical trials to support use of
topical corticosteroids and chlorhexidine mouthwash. Gels and
liquids may be more accurately applied using a cotton bud or cotton
wool, providing the ulcer is readily accessible. Mouthwashes can be
useful where ulcers are difficult to reach.
Chlorhexidine gluconate mouthwash
There is some evidence that chlorhexidine mouthwash reduces duration
and severity of ulceration. The rationale for the use of antibacterial
agents in the treatment of mouth ulcers is that secondary
bacterial infection frequently occurs. Such infection can increase discomfort
and delay healing. Chlorhexidine helps to prevent secondary
bacterial infection but it does not prevent recurrence.
It has a bitter taste and is available in peppermint as well as standard flavour.
Regular use can stain teeth brown – an effect that is not usually
permanent. Advising the patient to brush the teeth before using the
mouthwash can reduce staining. The mouth should then be well rinsed
with water as chlorhexidine can be inactivated by some toothpaste
ingredients. The mouthwash should be used twice a day, rinsing 10 ml
in the mouth for 1 minute.
Topical corticosteroids
Hydrocortisone and triamcinolone act locally on the ulcer to reduce
inflammation and pain, and to shorten healing time. The former is
available as pellets, the latter in a protective paste. To exert its effect, a
pellet must be held in close proximity to the ulcer until dissolved. This
can be difficult when the ulcer is in an inaccessible spot. One pellet is
used four times a day.
The pharmacist should explain that the pellets
should not be sucked, but dissolved in contact with the ulcer. These
treatments are best used as early as possible. Before an ulcer appears,
the affected area feels sensitive and tingling – the prodromal phase –
and treatment should start then. They should be applied 3–4 times
daily. They have no effect on recurrence but should be restarted at the
first signs of a new outbreak.
Local analgesics
Benzydamine mouthwash or spray and choline salicylate dental gel
are short-acting but can be useful in very painful major ulcers. The
mouthwash is used by rinsing 15 ml in the mouth three times a day.
Numbness, tingling and stinging can occur with benzydamine.
Diluting the mouthwash with the same amount of water before use
can reduce stinging. The mouthwash is not licensed for use in children
under 12.
Benzydamine spray is used as four sprays onto the affected
area three times a day. Although aspirin is no longer recommended for
children under 16 years because of possible links with Reye’s syndrome,
choline salicylate dental gel produces low levels of salicylate
and can therefore be used in children.
Carbenoxolone
Available as gel and mouthwash, carbenoxolone was shown in one
small study to relieve pain and reduce healing time.
Local anaesthetics (e.g. lidocaine (lignocaine), benzocaine)
Local anaesthetic gels are often requested by patients. Although they
are effective in producing temporary pain relief, maintenance of gels
and liquids in contact with the ulcer surface is difficult. Reapplication
of the preparation may be done when necessary. Tablets and pastilles
can be kept in contact with the ulcer by the tongue and can be of value
when just one or two ulcers are present. Any preparation containing a
local anaesthetic becomes difficult to use when the lesions are located
in inaccessible parts of the mouth.
Both lidocaine and benzocaine have been reported to produce sensitisation,
but cross-sensitivity seems to be rare, probably because the
two agents are from different chemical groupings. Thus, if a patient
has experienced a reaction to one agent in the past, the alternative
could be tried.
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