CASE 1: Canker Sores
MM is a 32-year-old man presenting to the pharmacy with a painful canker sore on the left side of his mouth. He complains of discomfort primarily when he eats or drinks and is requesting a consultation with the pharmacist for OTC products or other strategies to soothe the irritation. He is worried that it might be contagious and his partner may get it.
Q: What recommendations should the pharmacist make for MM?
A: Recurrent aphthous stomatitis, or canker sores, appear as epithelial ulcerations on movable mouth parts, such as the tongue, lips, and cheeks. MM should be educated that canker sores are not contagious. MM should be counseled on available OTC products for relief of canker sore discomfort as well as nonpharmacologic management strategies. Local anesthetic gels and creams containing lidocaine or benzocaine can be used to numb the area and relieve discomfort. Additionally, MM should be counseled to avoid foods that irritate canker sores, such as acidic, spicy, or salty foods, and carbonated beverages. Soups and soft foods help to protect the mucous membrane and limit irritation to the ulcerated area. If symptoms persist or worsen, MM should consult his physician for consideration of oral anti-inflammatory medications or medical mouthwashes to soothe the area.1
CASE 2: Dry Mouth
KO is a 45-year-old woman with a past medical history significant for major depressive disorder and hypothyroidism. Her home medications include paroxetine (Paxil;GSK) and levothyroxine (Synthroid;AbbVie). However, when prompted, she explains that this month, she has been taking diphenhydramine (Benadryl;Johnson & Johnson) as needed for hay fever. When asked if she is tolerating her medications, she expresses that she feels they are very effective, although she has been especially thirsty over the past month. KO would like to consult with the pharmacist to inquire whether this could be related to any of her medications and whether there are any OTC products that could provide relief for her dry mouth.
Q: What counseling points should the pharmacist provide?
A: Dry mouth is a known adverse effect of anticholinergic medications, including paroxetine and diphenhydramine. This adverse effect can be managed with OTC lubricants as well as nonpharmacologic strategies to help moisturize the mouth. The pharmacist should recommend saliva substitutes to help KO maintain moisture in her mouth while taking these anticholinergic medications.2,3 Artificial saliva products contain blends of glycerin, water, and sugar alcohols and are available in many formulations including moisturizing sprays, rinses, toothpastes, and lozenges. In addition, the pharmacist should counsel KO on nonpharmacologic strategies such as using sugar-free chewing gum or sucking candy to promote saliva production as well as staying hydrated with sugar-free and caffeinefree beverages. KO should limit intake of products containing ingredients that can worsen dry mouth, including caffeine and alcohol.3,4
CASE 3: Tooth Decay Prevention
IB is a 46-year-old man who comes to the pharmacy to pick up a new toothpaste that was recommended by his dentist. At his most recent appointment, his dentist told him that he has some enamel breakdown. IB wants to know whether there are other ways he can prevent enamel breakdown in addition to using the new toothpaste.
Q: What nonpharmacological options can the pharmacist educate IB on?
A: Various foods and beverages can wear away tooth enamel, resulting in less protection for the teeth and increasing the risk of developing cavities, discoloration, and tooth pain and sensitivity. Foods and drinks that are acidic in nature, such as citrus fruits and tomato products, can increase tooth enamel decay. Additionally, sugary and carbonated beverages such as soda or sports drinks can affect tooth enamel. The best way to prevent tooth enamel decay is to limit foods and drinks that are acidic in nature. Other strategies to prevent tooth enamel erosion include waiting an hour after eating or drinking an acidic product before brushing teeth to allow for the saliva in the mouth to wash away acids. Additionally, rinsing the mouth with water or consuming calcium-rich foods after the ingestion of an acidic food or beverage can help maintain tooth enamel by neutralizing the acidic environment. Lastly, when drinking acidic beverages, avoid swishing the beverage in the mouth.5
CASE 4: Oral Hygiene
RF is a 40-year-old woman who calls the pharmacy and asks to speak with the pharmacist about oral hygiene. She just got home from a dental appointment during which she found out she has a cavity. She is very upset because she has never had a cavity before. RF is inquiring about general oral hygiene management to help prevent cavities.
Q: What oral hygiene counseling points should the pharmacist provide RF with?
A: Good oral health is needed to properly chew, speak, and smile, and is associated with a person’s overall health. Poor oral health has been connected to chronic conditions such as diabetes and heart disease. The risk of cavities and gum disease can increase as adults age because of changes in saliva production, receding gums that allow for an entrance of decay-causing bacteria, or difficulty brushing teeth.6,7 To maintain good oral hygiene, the CDC recommends brushing teeth twice daily and flossing once daily to limit plaque buildup. Drinking water containing fluoride and using fluoridecontaining toothpaste can help strengthen the tooth enamel and prevent cavities. Additionally, a dentist visit is recommended every 6 months to maintain good oral hygiene.8
ABOUT THE AUTHORS
Deanna Fox, PharmD, is a PGY-2 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Kylie Helfenbein, PharmD, is a PGY-1 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Rupal Patel Mansukhani, PharmD, FAPHA, is a clinical associate professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.