OTCs Today
Daniel L. Krinsky, BS, MS, RPh, FAPhA
Whether it’s to help a parent looking for a product for their teething infant or a college-aged student interested in options to manage cold sores, we have pharmacologic and nonpharmacologic options to help patients with oral disorders.
Teething discomfort
Teething is the eruption of the deciduous (primary or baby) teeth through the gingival tissues. During this, mild pain, irritation, reddening, excessive drooling, mouth biting, gum rubbing, low-grade fever, or slight swelling of the gums may precede or accompany sleep disturbances or irritability. The goal of self-care for teething discomfort is to relieve gum pain and irritation, thereby reducing the child’s distress and sleep disturbances.
Nonpharmacologic options include massaging the gums and using a cold teething ring. Pharmacologic management includes the use of pediatric doses of certain systemic analgesics. Be sure to review product details such as dosing and frequency of use with parents and caregivers. Topical oral anesthetics containing benzocaine carry strict warnings from FDA against their use for teething. In April 2011, FDA released a safety alert that warned health care providers of the reports linking benzocaine use and methemoglobinemias.
Canker and cold sores
Recurrent aphthous stomatitis (RAS), also known as canker sores or aphthous ulcers, are a fairly common occurrence. Most patients will have a mild form of the disease, and lesions will usually spontaneously heal in 10 to 14 days. While the cause of RAS is unknown in most patients, various precipitating factors—such as local, systemic, immunologic, genetic, allergic, and nutritional issues—have been proposed. RAS occurs in 3 clinical forms: minor, major, and herpetiform. RAS forms can be distinguished primarily by the number of lesions, the size of the ulcer, and the number of days that the lesion persists.
While not curable, some nonprescription medications can provide symptomatic relief of pain and irritation. Nonpharmacologic therapy options include addressing any nutritional deficiency, avoiding spicy or acidic foods until the lesions heal, and applying ice directly to the lesions in 10-minute increments but for no longer than 20 minutes in a given hour.
Pharmacologic options to address symptomatic relief include oral debriding and wound-cleansing agents, topical oral anesthetics, topical oral protectants, oral rinses, and certain systemic analgesics. It’s important to evaluate each patient and the duration of their symptoms upon presentation to determine the potential benefit of pharmacologic options.
Herpes simplex labialis, better known as cold sores or fever blisters, is a disorder caused by a virus of the Herpesviridae family. Herpes simplex virus type 1 (HSV-1) is primarily associated with oral and labial lesions, while herpes simplex virus 2 (HSV-2) usually produces genital sores. However, predilection of a specific HSV infection for an anatomic site is changing, in part because of variability in sexual practices.
Any human herpes virus can cause oral lesions. HSV infection is for life, contagious, and is transmitted by direct contact. Reactivation can be triggered by several factors, such as ultraviolet radiation, stress, fatigue, cold, windburn, fever, injury, menstruation, dental work, and infectious diseases.
This condition commonly affects the lip or areas bordering the lips, and lesions are recurrent, painful, and cosmetically objectionable. Onset of HSV is often preceded by a prodrome in which the patient notices burning, itching, tingling, or numbness in the area of the forthcoming lesion, usually 2 to 48 hours before the lesion actually appears.
Nonpharmacologic options include handwashing, keeping lesions clean, keeping the affected areas moist, and reducing sun exposure. Pharmacologic therapy includes topical skin protectants, externally applied analgesics or anesthetics, and docosanol 10%. Docosanol is the only FDA-approved nonprescription product proven to reduce the duration and severity of symptoms. It inhibits direct fusion between the herpes virus and the human cell plasma membrane, thereby preventing viral replication. Patients should apply at the first sign of an outbreak (prodromal stage), then 5 times a day until the lesion is healed, but for no more than 10 days. Evidence suggests it reduces the median time to healing by approximately 1 day (18 hours) compared with placebo. It delivers a significant reduction in the duration of symptoms, including pain and/or burning, itching, or tingling, compared with placebo. ■