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Describe the role of the RDH in pharmacologic management of common oral conditions.
The dental hygienist may be the first to observe the oral lesion, so they must notify pt and dentist
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Identify the recommended therapies to resolve acute odontogenic pain.
- topical and injectable local anesthetic agents
- analgesics: oxycodone in combination with COX-inhibitor
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List the drugs of choice for mild odontogenic pain.
- over-the-counter COX-inhibitor preparations: aspirin
- ibuprofen
- maproxen
- acetaminophen
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Describe recommendations to relieve pain from OLP
- OLP (primary): topical corticosteroids
- OLP (secondary): for mod to severe OLP, or cases unresponsove to topical corticosteriods, systemic should be used, prednisone
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Describe the recommendations to relieve pain from RAS.
- primary: corticosteroids, covering agents, antiseptics, oxygenating agents, andti-inflammatory agents, cauterizing agents, and topical anesthetics
- secondary: entails use of systemic corticosteroids; prednisone
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Describe the recommendations to relieve pain from oral EM.
- Primary: topical anesthetic/antihistamine products; diphenhydramine (kid's benedryl), viscous lidocaine, mixed with a covering agent (kaopectate or maalox)
- secondary: Refer to physician
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Describe the recommendations to relieve pain from oral CP.
- primary: regularly applied tipical high-potency or ultrapotency corticosteroid ointment or gel
- secondary: a regimen of dapsone tablets
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Identify potential ADEs for each of the therapies for OLP, RAS, oral EM, and oral CP.
- OLP: insomnia, mood swings, nervousness, diarrhea, fluid retention, muscle weakness, and hypertension may occur
- RAS: problems related to consistent application of agents limit their effectiveness and might lead to oral candidiasis, thinning mucosa or atrophy
- oral EM: adequate hydration and nutrition is mandatory
- oral CP: head aches, hemolytic anemia, methemoglobineamia, bone marrow suppression, lover toxicity
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Describe oral health education topics and application instructions for RAS.
- The cause of it is unknown, but the primary goal in the management of it is to identify and eliminate or manage contributory factors which may include:
- local factors: trauma, tooth paste allergy
- nutritional deficiencies
- absorptive disorders
- food allergies
- other systemic conditions manifesting ulcerations
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Describe oral health education topics and application instructions for OLP
- Cause is unknown, but it is believed to be an autoimmune disease with a genetic predisposition
- It is the most common dermatologic disease with oral manifestations
- trauma, viral and bacterial infections, emotional stress, and drug therapy are all possible predisposing factors
- there is a possible association with OLP and oral squamous cell carcinoma
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Describe oral health education topics and application instructions for oral EM
- The disease can be minor, major, or potentially fatal (stevens-johnson syndrome) and toxic epidermal necrolysis
- Most cases are related to infections, especially HSV
- but most cases of SJS and TEN are related to pharmacologic agents
- It has been reported to develop after immunizations or radiotherapy
- If EM is related to a drug, pt should never take that drug, or any other drug with crossreaction potential
- the disease often recurs, so pts should be warned, and to seek medical attention right away if it does
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Describe oral health education topics and application instructions for oral CP
- The mean age of onset of this disease is 62 years, and appears to have a 2:1 predilection for women
- Oral mucosal lesions usually heal without scarring, but if they do scar, it is a result of submucosal fibrosis, which is a key feature of disease progression in other sites such as the conjunctiva of the eye, and the larynx
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Identify dermatologic conditions with oral lesions. Which is the most common?
Oral Lichen Planus
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Differentiate between the clinical appearance of herpes labialis and intraoral recurrent herpetic infection.
- herpes labialis: focal vesicular lesions affecting the lip vermilion or other perioral sites such as the skin or ala of the nose, the vesicles rapidly rupture and crust
- intraoral recurrent herpetic infection: small clusters of pinpoint ulcers, usually restricted to the keratinized mucosa
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Differentiate between treatments for primary versus recurrent herpetic infections.
- Primary herpetic infection: strategies are targeted to ensure adequate hydration and nutrition to provide palliation; topical anesthetic agent (diphenhydramine hydrochloride [children's benadryl]) or lidocaine viscous, and if necessary a systemic analgesic
- recurrent herpetic lesions: These lesions are self-limiting and often require no treatment; OTC topical agents are available to help, docosanol (Abreva) is the only OTC formulation specifically approved by the FDA for tx of RHL. Penciclovir (Denavir), acyclovir (Zovirax) creams are used
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How efficacious are preparations for treating recurrent HSV infection?
- They are most effective when initiated during the prodromal phase
- these lesions often don't require treatment
- the medications will not have a significant effect
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Describe oral health instructions related to the presence of RHL and warnings when topical anesthetic agents are recommended for recurrent herpetic lesions.
- All pts should avoid touching the lesion and practice good hygiene (wash hands) to reduce the risk of autoinoculation
- topical anesthetics are recommended for pts who manifest frequent recurrent episodes, or who otherwise desire antiviral therapy
- Also, for pts whom sunlight precipitates an outbreak, SPF 15 or higher lip balm is recommended
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List products for the tx of herpetic lesions, and describe instructions for their use.
- primary herpetic infection:
- diphenhydramine hydrochloride (benadryl) or lidocaine viscous: be careful of self-induced injury or interference with swallowing
- aceta minophen, and in rare instances acetaminophen/codeine: avoid aspirin in children
- RHL:
- docosanol (Abreva) cream: applied at first prodromal sign, reapplied 5 x's a day until lesion is healed
- penciclovir (denavir): apply every 2 hrs until lesion is healed
- acyclovir (zovirax): cream applied 5 x's a day until lesion is healed
- valacyclovir (valtrex) oral antiviral: 1-day therapy, take 2 tablets taken twice daily (2 tabs bid for 1 day)
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List products for candida infection and describe pt instruction for their use
- Nystatin: rinse; swished for 5 minutes a day and spit or swallowed, used 5 times a day. pastille is allowed to slowly dissolve in the mouth and is used 4-5 times a day, do not chew or swallow.
- Clotrimazole troche: dissolved slowly in the mouth, 5 times a day for 14 days
- Ketoconazole cream: applied to affected area once a day for 2-4 weeks
- Systemic oral antifungal agents are available for pts who are unresponsive to topical therapy: detoconazole, fluconazole, itraconazole
- fluconoazole is drug of choice
- itraconazole is reserved for treatment if it resists fluconazole
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Describe clinical signs of xerostomia.
- noticeable lack of wetness to the mucosal tissues and teeth
- saliva that is thick and ropey
- absence of saliva pooling in the floor of the mouth
- red, dry, and atrophic mucosa
- atrophic and fissured tongue
- incisal and smooth surfaces caries especially at cervical margins
- candidiasis
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Describe agents used to manage xerostomia.
- tx strategies may be targeted or palliative and supportive, or both
- consult w/physician to change, reduce, or discontinue meds that predispose xerostomia
- pts advised to: stay hydrated throughout day, use dentifrice w/fluoride 2x day, rinse with a fluoride rinse,remove and clean prostheses at night, avoid food/substances that irritate the mucosa, reduce sugar intake, chew xylitol gum or sugarless gum, don't use alcohol rinse
- Salivary substitutes are available: OralBalance, Optimoist, Salivart; buty they are poor imitators, Numoisyn is better
- Lip balm w/vitamin E helps chapped lips
- sialagogue (tablet): for pts w/residual salivary function
- pilocarpine (salagen): tx of it associated w/head and neck radiotherapy and sjogren syndrome, or cevimeline (evoxac)
- chlorhexidine gluconate rinse, and supplemental topical fluoride
- additional application of fluoride varnish
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Identify situations in which sialagogues are recommended. in what disease conditions should these drugs be used with caution?
- for pts with residual salivary function: such as head and neck radiotherapy and Sjogren syndrome
- Used with caution in pts with: significant cardiovascular disease, asthma, COPD, biliary tract disease, and kidney disease
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Describe management of pericoronitis
- Step 1: drainage established by a curet or periodontal probe under the operculum
- next, irrigation: with saline or antiseptic rinse; may be followed by inserting a wick of iodoform gauze; pt is to rinse w/ warm salt water for 2 mins every waking hour
- extract tooth: if opposing tooth is traumatizing operculum, opposing tooth extracted or underto odontoplasty; but make sure the infection is managed
- antimicrobial regimen prescribed: if pts manifests systemic signs of infection, and also following debridement to remove exudate (penicillin is initial drug of choice) if pen VK doesn't work, give them metronidazole (it is beta-lactamase resistant)
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Write out instructions for an alkaline saline mouth rinse recommended as tx for pts with pericoronitis.
rinsing with warm salt water for 2 minutes every waking hour
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Describe management of dry socket.
- Chlorhexidine rinse: immediately before extraction, and for 1 week (twice daily) after
- atraumatic surgical technique with attetntion to irrigate site w/saline, ensure removal of any bone or tooth fragments, and verify formation of clot
- post op instructions icluding: avoid smoking, sucking through a straw, drinking carbonation, and vigorous rinsing
- nutritious diet and use of gentle toothbrush
- 7.5 mg of hydrocodone and 200mg ibu for pain
- anything placed in socket will delay healing
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Describe oral health information in management of stomatitis
- Topical application of medicaments such as aspirin, is ill advised
- adverse mucosal effects of tobacco
- oral lesions may be associated with accidental exposure to gasoline and other chemicals
- can be caused by ill-fitting or poorly maintained removable dental prostheses
- meticulous oral hygiene cannot be overemphasized as effective preventive and therapeutic management of stomatitis
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Describe management of NUG.
- reinforcement of plaque control combined with debridement
- ultrasonic instrumentation or hand scaling with cpious irrigation to perform a simple debridement, not a fine scale
- pts should gently brush, and rinse w/3% hydrogen peroxide diluted solution or w/chlorhexidine
- pts should rest, avoid smoking and drinking alchohol
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Describe management of burning mouth syndrome.
- Clonazepam
- bezodiazepine such as chlordiazepoxide (Librium) as an alternative for clozazepam
- for pts unresponsive to the previous primary therapies; tricyclic antidepressant such as desipramine may be used
- for pts who are refractory to above therapies, anticonvulsant gabapentin may be used
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