Written by Vicki McManus, RDH & Jennifer Pittman, RDH Wednesday, 31 December 2003 19:00
Two frantic calls from patients. When will it ever end? The first patient, Jamie, is getting married Saturday and has a huge cold sore on her lip. The second patient, Andrew, is giving the presentation of his career and has a mouthful of painful ulcers. They are both depending on you to relieve their pain. Do you ever wish you had the answers to these types of problems? We've all seen patients who suffer from recurring oral ulcerations. In the past, our abilities to relieve their pain quickly and effectively has been limited. Today, that has all changed. This article will highlight new products and techniques to help your patients who suffer from these painful outbreaks.
Outbreaks of oral ulcerations can be a small annoyance or a painful experience that can interrupt your patient's otherwise normal life. Managing these episodes comes with understanding what these lesions are, what causes them, and how to treat them. The 2 primary oral lesions that affect the general population are recurrent minor aphthous ulcers (canker sores) and herpetic oral lesions (cold sores).
RECURRENT APHTHOUS STOMATITIS
It is estimated that 80% of the population have recurrent aphthous ulcers. They occur between 10 to 20 years of age, most often in women. The occurrence is thought to be related to an individual's immune system. In the event of an unrecognized chemical in the body, types of white blood cells known as lymphocytes are activated to attack. The result of the attack is a mouth ulcer. There are many factors that trigger this reaction. Following is a discussion of some of these factors.
Sodium Lauryl Sulfate (SLS)
Sodium Lauryl Sulfate, or SLS as we know it, is a foaming agent found in most toothpaste and mouthwash formulations. Foaming agents fill the mouth with suds, sending a signal to users that their mouths are clean. Ulcers may be aggravated or caused by SLS. It causes excessive sloughing of the oral mucosa in a majority of people. Because of its drying effect on the protective layer of oral tissues, SLS causes underlying tissues to become more susceptible to oral irritants. Some mouthwashes and toothpastes are formulated without SLS. People who suffer from canker sores report fewer outbreaks and less pain from developed lesions when using SLS-free products.
There are only several companies that manufacture oral care products that do not contain SLS. Rowpar Pharmaceuticals is one such company. Rowpar's CloSYSII brand is an entire line of products that is primarily marketed to combat oral malodor. However, as an added benefit, these products do not contain SLS. CloSYSII products contain a unique combination of chlorine dioxide and phosphate to neutralize odor-causing compounds on contact plus a special combination of silica polishers to help whiten teeth with regular brushing. CloSYSII toothpaste is one of the lowest in abrasivity of any toothpaste on the market, so it's safe for daily use. These products are professionally dispensed and are easily incorporated into a daily oral hygiene regimen. Other products that do not contain SLS are Rembrandt Extra Whitening Toothpaste Formulated for Cold Sore Sufferers, Tom's of Maine, Oxyfresh, TheraBreath Products, and Squigle Enamel Saver Mouth Friendly Toothpaste.
Nutrition - The Effect on Canker Sore Formation
Diet and vitamin supplements may influence viral replication. A total approach to nutrition should be used. A lack of specific vitamins in the diet has been credited with the presence of canker sores. The lack of nutrients such as vitamins B1, B2, B6, B12, and C as well as zinc, folic acid, iron, selenium, and calcium are cited. Some foods can trigger an outbreak of canker sores. Some examples are fruits and vegetables such as lemons, figs, oranges, tomatoes, apples, pineapples, and strawberries. Cereal grains like buckwheat, oats, rye, and barley also can be allergens, as well as glutens found in grains. Nuts, chocolate, shellfish, and soy vinegar are also noted.
Tissue irritations as a result of extensive dental work, cheek bites, a broken tooth, or scrapes from hard food are all things that could precipitate an ulcer. Medical conditions and medications are a consideration in diagnosing the occurrence of aphthous ulcers. The persistence of aphthous ulcers may be an indication of some disease that has gone undiagnosed. NSAIDs (Nonsteroidal Anti-inflammatory Drugs), beta blockers, and some chemotherapeutic agents have been linked to episodes of outbreaks. Other influences researchers have identified as causative factors include hormonal changes, genetics, food allergies, and bacterial or viral agents.
Aphthous ulcers are most often found on nonkeratinized oral tissue. The most common sites are lips and cheeks, floor of the mouth, soft palate, tonsilar area, and the underside of the tongue. The initial stage of an ulcer appears as a raised, slightly red area that generally tingles. The basic characteristics of aphthous ulcers are the following: round or oval, no more than one-quarter inch in diameter; a grey or whitish membrane covering; regular borders surrounded by a reddish halo; a duration of 4 to 14 days.
HIGH PROBABILITY OF RECURRENCE
Treatment of aphthous ulcers
There is no known cure for aphthous ulcers. However, remedies that lessen pain and limit duration are sought by patients and consumers alike. These remedies can range from everyday household products and herbal remedies to OTC products and prescription products. (Chart 1). Debacterol, a recent product introduced by Northern Research Laboratories, is a breakthrough treatment for aphthous ulcers. This semiviscous topical liquid is a chemical cautery agent. Its unique chemical and physical properties are particularly beneficial when performing therapeutic cautery in the oral cavity. Therapeutic cauterization refers to the process of applying a physical or chemical agent to damaged tissues in order to denature the underlying structures in a way that promotes healing. Debridement by cauterization enhances the repair processes. Debacterol treats aphthous stomatitis by stopping oral ulcer pain, sealing damaged oral mucosal tissues, and aiding the natural healing processes. One application is necessary, and can be completed in minutes.1
In order for any ulcerating mucosal lesion to heal, factors contributing to the injury must first be controlled at the ulcer site. Cauterization of necrotic tissue debris in the ulcer bed must be removed so that healthy new cells are able to grow. What distinguishes Debacterol from other agents is the combination of rapid penetration deep into the ulcer bed accompanied by the denaturant activity. Ulcer pain is eliminated immediately and completely at the instant of application. Mucosal healing time is also reduced dramatically.
RECURRENT HERPES LABIALIS
Recurrent herpes labialis lesions, commonly known as either cold sores or fever blisters, are caused by the herpes simplex virus. The virus is actually divided into 2 types. The first, HSV1 (herpes simplex virus type 1), generally affects tissues above the waistline. The second, HSV2 (herpes simplex virus type 2), infects tissues in the genital area. HSV2 is not limited to the genital area.
As societal revolutions take place, we find both virus types in the oral area. Cold sores, unlike other types of infection, are not caused by exposure to germs. They are a result of a reactivation of dormant or "sleeping" viruses living in an individual's body. The dormant virus is a result of an initial primary infection. This primary infection is termed primary herpetic stomatitis. Symptoms can be flu-like with intraoral manifestations of tiny grey blisters throughout the mouth. Approximately 99% of persons do not remember having this episode, since symptoms are often subclinical.
The initial exposure to the herpes simplex virus does not include the common manifestation of the extraoral lesion. Following the initial infection, parts of the virus remain forever. Even though 80% of the population has been exposed, only one third of the infected individuals manifest outbreaks. Dormant viruses "sleep" in trigeminal nerve ganglia. During activation, the virus travels down the nerve to the location, where the lesion develops.
Outbreaks of cold sores are triggered by such factors as emotional stress; physical fatigue or stress; illnesses like colds or flu; lip injuries resulting from severe chapping or trauma; extensive exposure to sunlight or ultraviolet light sources; pregnancy or menstruation; and immune system deficiency. Cold sores are generally found on facial skin around the mouth or on the edge of the lips. The duration is about 8 to 10 days and follows this set pattern of development: Day 1 to 2-Prodromal Stage: possible redness, some swelling, and a tingling sensation are noted. Day 2 to 3-Blister Stage: an outbreak of a cluster of fluid-filled blisters the size of a nickel will form. Day 4-Weeping Stage: blisters rupture, leaving a shallow ulceration. (This is the most painful and most contagious stage.) Day 5 to 8-Crusting Stage: itching or burning occurs. (As the ulcer becomes dry and crusty, the scab may crack, which leads to bleeding.) Day 9 to 12-Healing Stage: a series of scabs form, each flaking off, and smaller scabs reforming until complete healing has occurred.
Treatment of Herpetic Lesions
As with aphthous ulcers, there is no cure for cold sores. There is no set rationale for treating cold sores, save getting rid of the unsightly sore and relieving pain. There are various remedies, including both OTC and prescription alternatives. OTC cold sore medications are palliative in nature. They relieve only the symptoms, inhibit the continued development of the lesion, promote healing, or possess properties that interfere with the actual virus development of cold sores. Prescription medications work via intervention in the replication process of the virus. The latest professionally distributed product to aid in the fight against cold sores is Viroxyn (Quadex Pharmaceuticals). The active ingredient in Viroxyn is 0.13% benzalkonium chloride; the FDA considers this to be safe and effective when used to treat open skin wounds.2 This efficient germicidal is applied topically and is vigorously rubbed into the lesion. The medication acts directly on the mature virus. The combination of incorporating the active ingredient first into the tissues and then into the infected cells disrupts the lipid coating on the virus, resulting in virus death. A unique single-application treatment for cold sores, Viroxyn can shorten outbreaks from 10 days to 3 to 4 days and relieve pain within minutes of application (Chart 2).3
Finding treatment for both aphthous ulcers and cold sores can be extremely difficult. This article is meant to provide new product updates as well as a review of options for treating these lesions.
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