Oral Aphthous Ulcer - Guidelines for Prescribing Triamcinolone Dental PasteThey are shallow painful sores that have a shedding base with erythematous margins, may occur singly or in clusters and resolve spontaneously depending on their severity, in a week to 2 months usually with no scarring. They may recur 2 to 4 times a year or remain almost continuous. There is no convincing evidence of association between oral- to oral paste ulcers and premenstrual period, pregnancy or menopause. Removal of plaques may cause mild bleeding which helps confirm diagnosis of thrush. Refer oral- to oral paste Guideline for Oral Thrush.
They are shallow painful sores that have a shedding base with erythematous margins, may occur singly or in clusters and resolve spontaneously depending on their severity, in a week to 2 months usually with no scarring. They may recur 2 to 4 times a year or remain almost continuous. There is no convincing evidence of association between aphthous ulcers and premenstrual period, pregnancy or menopause.
Removal of plaques may cause mild bleeding which helps confirm diagnosis of thrush. Refer to Guideline for Oral Thrush. Herpes simplex infections may be HSV1 or HSV2 - multiple ulcerous or vesicular lesions initially transmitted by direct contact of saliva with another infected person.
These may be recurrent and are often activated by such risk factors as: Refer to Guideline for Cold Sores. Chicken pox varicella which involves presence of typical lesions on skin and mucous membranes, and spread to head, trunk and extremities. Usually occurs in children under 10 years old.
Shingles Herpes zoster - clinical diagnosis is based on vesicular eruption on one side only, often with prodromal pain which may involve sensory nerves and overlying skin of the head, trunk or limbs.
Shingles are more common in adults. Coxsackievirus hand, foot and mouth disease usually occurs in children, manifests as small 1 - 2 mm , tender lesions usually on the posterior pharynx including tonsils, soft palate, uvula and raised areas on hands and feet. No need to refer, but recommend fluids to prevent dehydration. Mononucleosis which usually involves close contact with other infected persons and includes generalized swollen lymph nodes, especially in the neck and groin.
Fever blisters may occur on lips. Syphilis - a painless sore in the mouth or on the lips occurring 10 days to 3 months after contact with infected person. Squamous cell carcinoma - if ulcers persist without healing.
Stomatitis caused by radiation therapy. Refer to attending physician for treatment. Non-pharmacological treatment of canker sores: Avoid hard, crusty, sharp, spicy, salty, and acidic foods and beverages that may irritate and increase pain of the ulcers.
Cautery can lead to more rapid improvement in pain, although it does not appear to speed overall healing. Lesions can be numbed with topical lidocaine prior to treatment and patients should rinse with water for several minutes after the procedure. Topical formulations containing local anaesthetics such as benzocaine or lidocaine which numb painful sores. Combination products which contain local anaesthetics in a vehicle that forms a protective coating over sore. Milk of magnesia and diphenhydramine allergy liquid mixed 1: Patient should be told to swish one teaspoonful in mouth for about one minute and then spit out.
Done every 4 to 6 hours, may help to relieve pain. It is considered to have medium range potency. There are no published randomized trials proving efficacy, but triamcinolone 0.
It may be necessary to reapply 2 or 3 times a day after meals depending on the severity of symptoms. Start at onset of symptoms and stop with resolution. Topically applied triamcinolone can be absorbed through the skin and mucous membranes; however the small amount of steroid absorbed when used as recommended makes any systemic effects unlikely. Pregnancy - Risk Factor C: Studies on animals show adverse effect and toxicity on fetus, but there are no adequate and well controlled studies done on pregnant women.
Triamcinolone should be avoided in early pregnancy and used topically only if the potential benefit outweighs the potential risk to the fetus. Topical triamcinolone has not been studied during breastfeeding. Since only extensive application of the most potent corticosteroids may cause systemic effects in the mother, it is unlikely that short-term application of topical corticosteroids would pose a risk to the breastfed infant by passage into breast milk.
Press a small dab of about 0. Use only enough to coat the area with a thin film. For comprehensive drug comparisons, see RxFiles charts www. This information should be routinely consulted before prescribing. Patient risk factors for developing an aphthous ulcer: Family history Female Age less than 40 Immunodeficiency Vitamin and mineral deficiencies weak link Precipitating factors for developing an aphthous ulcer: Mucosal injury Stress Food eg. For more information and photos, see: One or more shallow, painful sores with a white or cream coloured coating and reddish border Present on oral mucosa and at the base of the gums History of recurrent episodes Occasionally accompanied by fever, listlessness, swollen lymph nodes Three types of canker sores: Major aphthae refer if any of these points: Ensure proper fitting dentures.
Avoid use of toothpaste containing sodium lauryl sulphate SLS. Aviod use of mouthwashes. Avoid dehydration by drinking adequate fluids. Ibuprofen or acetaminophen may ease pain.
Topical pastes which form a protective layer over lesion. Directions for use of triamcinolone oral paste: Do not rub in, as this may cause the film to break and become granular or gritty. Use at bedtime and 2 or 3 times per day after meals Do not eat or drink 30 minutes after application Assess Benefit in 7 days: Prescribing and Billing Details.
If patient has had significant healing, but not full resolution, after 7 days, may extend treatment to 14 days. If one tube would not be sufficient for their treatment, a refill can be given to achieve 14 days of therapy. Each new aphthous ulcer is to be treated as a distinct episode and re-assessed. Only products with an official indication from Health Canada for oral aphthous ulcers are considered for these guidelines.
Only the active ingredients in the "products" section are approved for pharmacist prescribing. The association of menstrual cycle, pregnancy, and menopause with recurrent oral aphthous stomatitis: Aphthous Ulcers Canker Sores.
Compendium of Therapeutics for Minor Ailments. Canadian Pharmacists Association; Published March 19, Updated December 2, Minor D, Aphthous stomatitis. Available at Available at www. This site complies with the HONcode standard for trustworthy health information: Occur singly or in clusters of up to five lesions 2 to 10 millimetres in diameter Oval in shape Clearly defined outline with red and inflamed borders On lips, cheeks, floor of mouth, underside of tongue, and soft palate Painful.
Resolve spontaneously in 7 to 10 days Frequent recurrences possible. Occur in clusters of 2 or more lesions More than 10 millimeters in diameter May be irregular in shape More common in patients with compromised immune system.
Often in clusters of 5 - small sores 0.