CASE 1: ORAL ULCERATION
JB is a 29-year-old male inquiring about a pain reliever for a bothersome oral ulceration. JB thinks he has a canker sore on the inside of his lower lip. He recently visited the dentist for a routine dental cleaning and swapped out his old toothbrush for one with harder bristles at the recommendation of his hygienist a week ago. Since using the new toothbrush, the sore developed and is most painful when he eats. He has had similar symptoms in the past but can’t recall the name of the product he used for relief. He has no chronic medical conditions, takes no daily medications, and has no known allergies. How can you educate JB on the self-care of his symptoms?
Canker sores, also known as recurrent aphthous stomatitis or aphthous ulceration, are characterized by their presentation as ulcerations in the epithelial skin on the tongue, soft palate, inside lining of the lips, and cheeks of the mouth.1
These lesions more often occur in women and more often affect younger individuals. These lesions are attributed to stress and local trauma to the affected area and may be associated with an immunologic defect; in the case of JB, his recent dental visit coupled with his change in toothbrush likely contributed to lesion development.1
Symptoms may include between 1 and multiple oval erythematous ulcerations on the mouth structures, coupled with pain that can be severe. Self-treatment modalities (eg, oral wound-cleansing agents, topical oral anesthetics, oral rinses, systemic analgesics) can offer symptomatic relief and promote healing.1
JB can be informed that his dental visit and new toothbrush likely contributed to the formation of his ulcer. Suggesting a toothbrush with softer bristles may be warranted. JM can apply an oral topical anesthetic containing the active ingredient benzocaine (eg, Anbesol Liquid or Maximum Strength Gel, Zilactin-B Gel, Kank-A Liquid) to the affected area to protect it from further injury during meals. These products can be reapplied frequently throughout the day and, along with avoidance of spicy, acidic, or otherwise irritating foods, can help to promote wound healing and prevent reinjury.
CASE 2: FUNGAL INFECTION
JM is a 67-year-old male complaining of painful white lesions in his mouth and on his tongue that occasionally bleed when he pokes or scrapes them with his toothbrush. He first noticed symptoms several days after starting a new inhaler medication to control his chronic obstructive pulmonary disease (COPD). He has never experienced symptoms like this in the past and would like a recommendation for an OTC product to get rid of them. He has a history of diabetes, hypertension, chronic kidney disease, and COPD, for which he takes aspirin 81 mg, atorvastatin 20 mg, lisinopril 20 mg daily, amlodipine 5 mg daily, glipizide XL 10 mg once daily, tiotropium 18 mcg once daily, fluticasone/ salmeterol 250/50 mcg twice a day, and albuterol 2 puffs every 4 hours as needed for shortness of breath; he has no known medication allergies. Is JM a candidate for self-care? What treatment options can you recommend?
JM’s symptoms are consistent with the presentation of oral thrush, which is characterized by overgrowth of Candida albicans fungal species in the mouth. This condition is likely to affect individuals who are immunocompromised, wear dentures, or use inhaled corticosteroids.2
Symptoms of thrush can include cottage cheese–like, white discolorations or plaques on the mouth structures, oral pain, minimal bleeding with irritation, taste disturbances, or difficulty swallowing if the lesions have spread and have affected the esophagus.2
JM’s risk factors for developing thrush may include recently starting a combination inhaled corticosteroid/long-acting beta2
-agonist for the treatment of COPD and having diabetes, poor control of which may result in this infection.
Counsel JM to avoid self-care at this time and to follow up with his primary care provider, as JM will likely need a topical oral antifungal agent, such as clotrimazole troches, available by prescription only to cure this condition. Salt water gargles are the safest remedy for providing some symptomatic relief while waiting to see his physician. Take this opportunity to reinforce proper inhaler technique, including the importance of rinsing the mouth after each use.
CASE 3: IMMUNIZATION NEEDS FOR A PATIENT RECEIVING CORTICOSTEROID THERAPY
AR is a 61-year-old woman who comes to the pharmacy for her shingles vaccine. She has a history of hypertension, osteopenia, chronic back pain, and COPD, for which she is prescribed valsartan/hydrochlorothiazide 160/25 mg once daily, alendronate 35 mg once weekly, meloxicam 15 mg once daily, budesonide/formoterol 160/4.5 mcg 2 inhalations twice daily, and albuterol 2 puffs every 6 hours as needed. She reports that she was recently hospitalized for an exacerbation of her lung disease and is finishing up treatment with an antibiotic (whose name she can’t recall) and a taper of prednisone, which she is now taking at a dosage of 30 mg per day for the next 3 days. Is AR eligible for her zoster vaccine at this time?
Herpes zoster, or shingles, is a condition associated with the reactivation of latent varicella zoster virus from the dorsal root ganglia of the spinal nerves. Upon reactivation, patients usually develop a localized, painful or irritated rash with clusters of clear vesicles along dermatomes, or neuronal cell axons, on the trunk and extremities. Complications of this condition can include postherpetic neuralgia, scarring of the affected areas, secondary bacterial infections, and complications of the eye.3
The herpes zoster vaccine, a live attenuated virus vaccine, has been shown to prevent shingles and reduce the incidence of postherpetic neuralgia and pain associated with this condition. As a live attenuated vaccine, this product has several important contraindications; notably, it should not be administered to individuals (1) with malignancies affecting the bone marrow or lymphatics, (2) receiving immunosuppressive therapy (including ≥20 mg/day of prednisone or equivalent for more than 2 weeks), (3) with cellular immunodeficiency disorders, (4) receiving treatment with recombinant human immune mediators and immune modulators (eg, adalimumab, infliximab, etanercept), or (5) who are pregnant.4
In the case of AR, it would be prudent to evaluate her prednisone prescription and instruct her that the use of corticosteroids, such as prednisone, at a dosage greater than 20 mg/day for 2 or more weeks is a contraindication to receiving the zoster vaccine. Reevaluation in 1 month after completion of her steroid taper would likely be the best approach at this time.
CASE 4: SELF-CARE FOR DRY MOUTH
KM is a 45-year-old female who is suffering from chronic dry mouth secondary to an autoimmune disease known as Sjögren’s syndrome. She would like a pharmacist’s recommendation for an OTC product that she can use in conjunction with her prescriptive therapies to provide additional relief of her symptoms. She has no known medication allergies but reports having a history of lupus and hypertension, for which she takes hydroxychloroquine and prednisone as needed for flares, and amlodipine and lisinopril, respectively. She has additionally been taking prescription cevimeline (Evoxac) for treatment of her dry mouth since her physician gave her a diagnosis of Sjögren’s syndrome. Her physician indicated it was okay to pick up a mouth rinse or lozenge, but KM is unsure of what product to select. What product(s) can you recommend at this time?
Sjögren’s syndrome is an autoimmune, inflammatory condition that often affects the tear and salivary glands. Symptoms of this condition often include burning, irritated eyes and dry mouth that can make food consumption difficult. Other symptoms may include dryness of the mucous membranes of the nose, throat, and vagina.5
In the case of KM, this is likely an example of secondary Sjögren’s syndrome, as she is suffering from symptoms consistent with Sjögren’s but is also suffering from lupus, another rheumatologic disorder; primary Sjögren’s syndrome occurs in individuals who do not have another rheumatologic disease.5
The symptoms of this condition can result in disease complications, as chronic dry eye may result in ocular infections or corneal damage. Chronic dry mouth, although a seemingly benign condition, can result in poor dentition, tooth decay, gingivitis, and thrush. Treatment modalities are focused on patient’s symptoms; eyedrops and ocular lubricants can be used to treat dry eyes, and prescription cholinergic medications (eg, cevimeline, pilocarpine) can increase saliva production. Adjuncts to the prescription-only products include lifestyle modifications (drinking water, chewing gum, sucking on hard candy) and OTC saliva substitutes.5
In the case of KM, consider recommending a product based on her preferences. An artificial saliva spray, such as Biotene Moisturizing Mouth Spray or Entertainer’s Secret, is a portable option that can be frequently reapplied as needed for symptomatic relief.
Dr. Bridgeman is an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, New Brunswick, New Jersey, and clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University.
Dr. Mansukhani is a clinical pharmacist at Morristown Medical Center in Morristown, New Jersey, and clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University.
Albanese NP. Oral pain and discomfort. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011.
Oral thrush. Mayo Foundation for Medical Education and Research website. www.mayoclinic.org/diseases-conditions/oral-thrush/basics/causes/con-20022381. Accessed January 10, 2014.
Clinical overview: shingles (herpes zoster). Centers for Disease Control and Prevention website. www.cdc.gov/shingles/hcp/clinical-overview.html. Accessed January 13, 2014.
Guide to vaccine contraindications and precautions. Centers for Disease Control and Prevention website. www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf. Accessed January 13, 2014.
Sjögren’s syndrome. American College of Rheumatology website. www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Sj%C3%B6gren_s_Syndrome/. Accessed February 14, 2014.