Responding to symptoms

in community pharmacy

Mouth ulcersDr. : Siham Gafer Altayib BSc. Khartoum University

MSc. Queen’s University Belfast -

Gastroenterology

Anatomy of the digestive system :

Introduction :The main function of gastrointestinal tract is to break down of food into a suitable energy source to allow normal physiological function of the cell

General Overview of the anatomy of GI tract:

1- Oral cavity :Tongue and cheeks , Function is to crush large pieces of food into smaller particles Saliva moisten , lubricate and begins the process of digesting carbohydrates ( by secreting amylase enzymes ) prior to swallowing

2- stomach : it is a J shape , receive food & fluids from the esophagus .it empties into duodenum

3- liver : Liver performs many functions including carbohydrates , lipid and protein metabolism . Also the process of many medicines

4- gallbladder :It is a pear-shaped sac that lies deep into the liver and hang from the lower margin of the liver Its function is to store and concentrate bile made by the liver

5- pancreas:Lies behind the stomach. It is essential for producing digestive enzymes transported to the duodenum via the pancreatic duct and secretion of hormones such as insulin

Mouth ulcers :-

Mouth ulcers :-

Mouth ulcers extremely common , affecting as many as one in five of the population and they are recurrent problem in some people

They are classified as aphthous (minor or major) or herpetiform ulcers.

Most cases are minor aphthous ulcers, which as self-limiting. causes including :

infection, trauma and drug allergy. However, occasionally mouth ulcers appear as a symptom of serious disease such as carcinoma.

The pharmacist should be aware of the signs and characteristics that indicate more serious conditions.

Information to be collected:

1- Age:- Minor ulcers :common between the age 10-40 Uncommon in young children

2- Nature of the ulcers minor ulcers the lesions may be up to 5 mm in diameter and appear as a white or yellowish center with an inflamed red outer edge.

Common sites are the tongue margin and inside the lips and cheeks.

The ulcers tend to last from 5 to 14 days

Major ulcers are uncommon, severe variants of the minor ones.

The ulcers which may be as large as 30 mm in diameter can occur in crops of up to 10. Sites involved are the lips, cheeks, tongue, pharynx and palate. They are more common in sufferers of ulcerative colitis.

Herpetiform ulcers are more numerous, smaller and, may affect the floor of the mouth and the gums. Associated with herpes viruses

Healing generally occurs 1-2 weeks

Table 1 summaries the features of the three main types of ulcers.

 minor  major Herpetiform  affects 80 % 0f the patients 

2-10 mm in diameter ( usually 5-6 mm) 

Round or oval 

Usually not very painful 

 10-12% of patients 

Usually over 10 mm in diameter but may be smaller ( usually 10-20mm)

Round or oval 

Prolonged and painful ulceration Eating is difficult 

 8-10% of patients 

0.5-3 mm in diameter 

Round or oval may form irregular shape as they enlarge 

May be very  painful 

Minor ulcers

Major ulcer

Herpetiform ulcer

3- Duration

Minor ulcers usually heal in less than 1 week;major ulcers take longer (10–20 days). herpetiform ulcers occur, fresh crops of ulcers tend to appear before the original crop has healed, which may lead patients to think that the ulceration is continuous.

Oral cancerAny mouth ulcer that has persisted for longer than 3 weeks requiresimmediate referral to the dentist or doctor because an ulcer of such long duration may indicate serious pathology, such as carcinoma.

carcinoma may present as a single ulcer with a raised and indurated(firm or hardened) border. The key point to raise suspicion would be a lesion that had lasted for several weeks or longer. Oral cancer is more common in smokers than non-smokers.

4- previous history :1- family history : one in 3 cases

2- ulcers with irregular shapes may be due to trauma such as bitting one side of the cheek while chewing food

fitting dentures may produce ulceration and, if this is a suspectedcause, the patient should be referred back to the dentist so that thedentures can be refitted.

3- in women minor ulcers may precede menstrual cycle

4- Deficiency of iron, folate, zinc or vitamin B12 may be a contributory Factor in mouth ulcers ( sore red & smooth tongue )

Duration > 14 days

< 14 days

Refer

Paine full

yes

Trauma related yes

No

More than 10 ulcer present

No

Yes

No Lesion size 1cm

Minor ulcer , symptomatic relief

No Yes

Refer ( esp. if more than50 years )

symptomatic relief

Refer 3

Major ulcer or candidiasis 4

Management :minor aphthous ulcers : Symptomatic treatment can be recommendedby the pharmacist and can relieve pain and reduce healing time.

include :1- antiseptics2- corticosteroids 3- local anaesthetics

1- Chlorhexidine gluconate 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 infectionbut 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 canreduce 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 mouthfor 1 min and continued for 48 h after symptoms have gone.

2- Topical corticosteroids:

Hydrocortisone and triamcinolone act locally on the ulcer to reduceinflammation and pain and to shorten healing time.

The former is used as pellets, the latter as 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.

They should be applied three to four times daily.They have no effect on recurrence, but should be restarted at the first signs of a new outbreak.

3- Local anaesthetics (e.g. lidocaine (lignocaine) and benzocaine):

Local anaesthetic gels are often requested by patients. Although theyare effective in producing temporary pain relief, maintenance of gelsand liquids in contact with the ulcer surface is difficult.

Reapplication of the preparation may be done when necessary.

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 thetwo agents are from different chemical groupings. Thus, if a patient hasexperienced a reaction to one agent in the past, the alternative couldbe tried.

Mouth ulcers in practice

Case 1Ahmed , a man in his early fifties, asks you to recommend something for painful mouth ulcers. On questioning, he tells you that he has two ulcers at the moment and has occasionally suffered from the problem over many years. Usually he gets one or two ulcers inside the cheek or lips and they last for about 1 week. Mr Ahmed is not taking any medicines and has no other symptoms. You ask to see the lesions and note that there are two small white patches, each with an angry looking red border. One ulcer is located on the edge of the tongue and the other inside the cheek. Mr Ahmed cannot remember any trauma or injury to the mouth and has had the ulcers for a couple of days. He tells you that he has used pain-killing gels in the past and they have provided some relief.

The pharmacist’s viewFrom what he has told you, it would be reasonable to assume that Mr Ahmed suffers from recurrent minor aphthous ulcers. Treatment with hydrocortisone pellets (one pellet dissolved in contact with the ulcers four times a day), with triamcinolone dental paste, or with a local anaesthetic or analgesic gel applied when needed, would help to relieve the discomfort until the ulcers healed. Mr Ahmed should see his doctor if the ulcers have not healed within 3 weeks.

The doctor’s viewMr Ahmed is most likely suffering from recurrent aphthous ulceration.

As always, it is worthwhile enquiring about his general health, checking, in particular, that he does not have a recurrent bowel upset or weight loss. These ulcers can be helped by a topical steroid preparation.

Case 2One of your counter assistants asks you to recommend a strong treatment for mouth ulcers for a woman who has already tried severaltreatments. The woman tells you that she has a troublesome ulcer that has persisted for a few weeks. She has used some pastilles containing a local anesthetic and an antiseptic mouthwash but with no improvement.

The pharmacist’s viewThis woman should be advised to see her doctor for further investigation.

The ulcer has been present for several weeks, with no sign ofimprovement, suggesting the possibility of a serious cause.

The doctor’s view

Referral is correct.It is likely that the doctor will refer her to an oral surgeon for further assessment and probable biopsy as the ulcer could be malignant.

Cancer of the mouth accounts for approximately 2% of all cancers of the body in Britain. It is most common after the sixth decade and is more common in men, especially pipe or cigar smokers.

Cancer of the mouth is most often found on the tongue or lower lip. Itmay be painless initially.

Oral thrush :

It is unusual infection in healthy adults More common in very young and very old people (5% of infant and 10 % of elderly )

40% of people carry candida albican in the oral cavity it can make infection when there is change in the environment of the oral cavity

Differential diagnosis:Size and shape of the lesions :Patches with irregular shape and vary in size suggests oral thrush

Associated pain :White painless patches

Location of lesions;Oral thrush often affect the tounge and cheek If precipitated by inhaled steroids the lesions appear in the pharynx

When to refer:

1- diabetes 2- duration greater than 3 weeks3- immuno compromise patients

Treatment : miconazole oral gel

Advices on application :Patients should be advised to hold the gel in the mouth for as long as possible to increase contact time between the medicine and the infection

Treatment should be continue for up to 2 days after symptoms have cleared to prevent relapse and reinfection

Thank

you