COLD SORES AND

MOUTH ULCERS
D R R A J A A H S A N A F TA B
C OM M UNI TY P HARM AC Y P RAC TI C E I
LEARNING OBJECTIVE

• Describe The Common Oral Diseases And Their Causes

• Compare The Major Characteristics Of Different Oral Diseases
And Infections
• Know What To Question Patients About In Order To Diagnose And
Refer / Treat Cold Sores And Mouth Ulcers
• Identify Warning Signs Of Pain Conditions -When To Refer
MOUTH ULCERS

• Also known as APHTHOUS ULCER

• The term “aphthous” is derived from a Greek word “aphthae” which means
ulceration

• These present clinically as multiple, small, round, or ovoid ulcers, with

circumscribed margins, covered by a yellowish or gray-white fibrinous exudate
and surrounded by an erythematous halo
APHTHOUS ULCER

• Collective term used to describe various different clinical presentations of

superficial painful oral lesions

• The majority of patients (80%) who present in a community pharmacy will

have minor aphthous ulcers (MAU)

• It is the community pharmacists’ role to exclude more serious pathology, for

example, systemic causes and carcinoma
PREVALENCE AND EPIDEMIOLOGY
• The estimated point prevalence of oral ulcers worldwide is 4%, with aphthous ulcers
being the most common, affecting as many as 25% of the population worldwide

• Occur in all ages but it has been reported that they are more common in patients
aged between 20 and 40, and up to 66% of young adults give a history consistent with
MAU

• Lifetime prevalence is estimated to affect one in five of the general population

• In a study among 11,697 randomly selected Malaysian subjects with an age range of
25-115 years and a mean age of 44.5 +/- 13.9 years who were examined for oral
mucosal lesions (ORAS). The prevalence of mouth ulcer was found to be 0.5% (64
subjects).
AETIOLOGY
• The cause is unknown
• A number of theories have been put forward.
• Stress
• Trauma (accidental bites of cheek or the tongue, burns from food,
lip abrasions from braces, denture lesions)
• Food sensitivities
• Nutritional deficiencies (Fe, Zn,Vit B12, folic acid)
• Infection
TYPES OF APHTHOUS ULCER
• There are three main clinical presentations of ulcers
• Minor Aphthous Ulcer
• Major Aphthous Ulcer
• Herpetiform ulcer
• Although it is most likely the patient will be suffering from MAU. it is essential that these and
other causes are recognized and referred to the GP for further evaluation
MINOR APHTHOUS ULCERS (MOST
LIKELY)
• Self-limiting
• Roundish, grey-white and painful
• Usually <1cm in diameter
• Shallow with a red raised rim
• Single or crops of up to 5 ulcers
• Up to 14 days
• Usually side of cheek, tongue or inside lip
• Pain is the key presenting symptom and can make eating and drinking difficult
• It normally takes 7 to 14 days for the ulcers to heal but recurrence typically occurs after an
interval of 1 to 4 month
MAJOR APHTHOUS ULCER (LIKELY)
• Greater than 1 cm in diameter
• Numerous ulcers, occurring in crops of 10 or more
• The ulcers often coalesce to form one large ulcer
• The ulcers heal slowly and can persist for many weeks
• Trauma induced ulcer
• Trauma to the oral mucosa will result in damage and ulceration
• Trauma may be mechanical (e.g. tongue biting)
or thermal resulting in ulcers with an irregular border
HERPETIFORM ULCERS (UNLIKELY
CAUSES)
• Pinpoint in appearance
• Large crops –up to 100 at a time
• Usually heal within a month
• distributed throughout the soft mucosa of the
Oral cavity
• Both herpetiform and Major aphthous ulcers are approximately ten times less common than
MAU
 UNLIKELY CAUSES
• Herpes simplex Virus induced ulcer
• Herpes simplex virus is a common cause of oral
ulceration in children
• Primary infection results in ulceration of any part of the oral
mucosa, especially the gums, tongue and cheeks.
• Infectious and easily transmissible. Ask for immediate family members
• The ulcers tend to be small and discrete and many in number.
• Prior to the eruption of ulcers the person might show signs of
systemic infection such as fever and pharyngitis.
UNLIKELY CAUSES

• Medicine-induced ulcers
• Cytotoxic agents,
• Non-steroidal anti-inflammatory drugs (NSAIDs) , Beta-blockers
• Ulcers are often seen at the start of therapy or when the dose is
increased
UNLIKELY CAUSES

• ORAL THRUSH (Oropharyngeal candidiasis)

• The classical presentation of oral thrush is of creamy-white soft
elevated patches that can be wiped off revealing underlying
erythematous mucosa.
• Pain, soreness, altered taste and a burning tongue can be present.
• Typically, patients with oral thrush present with ‘patches’. They tend to
be irregularly shaped and vary in size from small to large
• Lesions can occur anywhere in the oral cavity but usually affect the
tongue, palate, lips and cheeks.
• Patients sometimes complain of malaise and loss of appetite
VERY UNLIKELY CAUSES
• Erythema multiforme
• Symptoms are sudden in onset causing widespread ulceration
of the oral cavity
• Patient can have annular and symmetric erythematous skin lesions located toward the
extremities
• Conjunctivitis and eye pain is also common
• Behcet’s syndrome
• Rare disorder that causes blood vessel inflammation
throughout your body. They can include mouth sores,
eye inflammation, skin rashes and lesions, and genital sores
• Most patients will suffer from recurrent,
Painful major aphthous ulcers that are slow to heal
• Lesions are also observed in the genital region and eye involvement (iridocyclitis) is
common
VERY UNLIKELY CAUSES
• Carcinoma
• It is twice as common in men than women
• Incidence rates increase sharply beyond 45 years of age (Male 60-69, female
80years).
• Smoking and excess alcohol consumption are two major risk factors
• On the side of the tongue, mouth and lower lip
• Initial presentation ranges from painless spots, lumps or ulcers in the mouth or
lip area that fail to resolve.
• Over time these become painful, change color crust over or bleed.
• Urgent referral
DIFFERENTIAL DIAGNOSIS

• A number of ulcer-specific questions should always be asked of the patient and an inspection of
the oral cavity should also be performed to help aid the diagnosis
PRIMER FOR DIFFERENTIAL
DIAGNOSIS OF MOUTH ULCERS
1. Duration
• MAU normally resolve in 7 to 14 days. Refer if fail to heal
2. Painless ulcers
• These can indicate sinister pathology
3.Numerous ulcers
• Crops of 5 to 10 or more ulcers are rare in MAU
4. Major ulcer or candidiasis
TREATMENT OPTIONS

• Simple mouthwashes

• A warm saline mouthwash (half a teaspoon of salt in a glassful of

warm water or dilute compound sodium chloride mouthwash with
an equal amount of water) has a mechanical cleansing effect and
may relieve the pain of traumatic ulceration.

• Use until the discomfort and swelling ease

ANTISEPTIC MOUTHWASHES

• Used in the management of secondary bacterial infection.

• May accelerate the healing of recurrent aphthae.
• Chlorhexidine-mouthwash.
• Available as a mouthwash, gel and spray. It can stain teeth if used
regularly.
• Others: aminoacridine (mild antiseptic)
ANTIBACTERIAL AGENTS (E.G.
CHLORHEXIDINE)

• Chlorhexidine mouthwash is indicated as an aid in the treatment and

prevention of gingivitis and in the maintenance of oral hygiene

• Ten mL of the mouthwash should be rinsed around the mouth for about 1
minute twice a day.

• It can be used by all patient groups, including those who are pregnant and
breastfeeding
LOCAL ANALGESICS

• Local anaesthetic: lidocaine5% ointment, lozenges or spray

• Care must be taken not to produce pharyngeal anaesthesia prior to eating (risk of
choking).
• Anti-inflammatory preparations: benzydamine and flurbiprofen (NSAIDs).
• Benzydamine mouthwash or spray reducing the discomfort of post-irradiation
mucositis.
• full-strength mouthwash can cause some stinging and can be diluted with an equal
volume of water.
• Choline salicylate gel may provide relief for recurrent aphthae but excessive
application or confinement under a denture irritates the mucosa and can itself cause
ulceration.
CHOLINE SALICYLATE

• E.g. Bonjela®
• Relieves Pain, discomfort and soreness
• Massage 1cm of gel into the sore area –can be repeated every 3 hours
• Not in under 16
• Avoid in Pregnancy
BENZYDAMINE + CHLORHEXINE
GLUCONATE
• E.g. Difflam-C® Solution
• Adult: 15mL to be gargled for 30 seconds at 1.5-3 hourly intervals
LIDOCAINE+ CHLORHEXIDINE

• E.g. Oral Aid® Lotion

• Adult: rub sparingly and gently on affected area
TRIAMCINOLONE ACETONIDE

• E.g. Orrepaste®
• Dosage: apply once-tds
LIDOCAINE HCL + AMINOACRIDINE
HCL

• E.g. Medijel®
• Dosage: The gel should be applied directly to the affected area(s) with a clean finger or small
pad of cotton wool. If necessary application may be repeated after 20 minutes.
PATIENT ADVICE

• Avoid exposing the ulcer to foods which cause pain and aggravate the
symptoms
• Use a straw to drink
• Eat balanced diet
• Prevent damaging the inside of the mouth by using a softer toothbrush
• Consult dentist regularly
• Medication*
• If OTC nicotine gum or lozenges, consider use a different type, e.g. patches or
nasal spray
MEDICINE SUMMARY FOR ULCER
COLD SORES
D R R A J A A H S A N A F TA B
C OM M UNI TY P HARM AC Y P RAC TI C E I
COLD SORES

• A cold sore is an infection caused by the herpes simplex virus (HSV1)

• Groups of small blisters on the lip and around the mouth

• The skin around the blisters is often red, swollen, and sore

• The blisters may break open, leak a clear fluid, and then scab over after a few days

• Usually heal in several days to 2 weeks

PREVALENCE AND EPIDEMIOLOGY
• Herpes Simplex Virus (HSV 1).
– Sores around the mouth (Herpes Labialis)

• More than 50% of adults in the Western world show serologic evidence of
having been infected by HSV1

• When first contracted, the virus is known as the primary infection

• 20 to 40% of people have experienced cold sores at some time

AETIOLOGY
• HSV enters the body through a break in the skin around or inside
the mouth

• The virus then infects epidermal and dermal cells, causing skin
vesicles.

• It is usually spread when a person touches a cold sore or touches

infected fluid—such as from sharing eating utensils or razors, or
touching that person's saliva
SYMPTOMS OF COLD SORE

• A cold sore usually passes through several stages

• Tingling and itching: Many people feel an itching, burning or tingling

sensation around their lips for a day or so before a small, hard, painful spot
appears and blisters erupt.
• Blisters. Small fluid-filled blisters typically break out along the border where
the outside edge of the lips meets the skin of the face. Cold sores can also
occur around the nose or on the cheeks.
• Oozing and crusting. The small blisters may merge and then burst, leaving
shallow open sores that will ooze fluid and then crust over.
SYMPTOMS OF COLD SORE

• Prodromal symptoms –Itching, burning, pain or tingling before vesicle eruption

• Crust over usually within 24 hours
• Once crusted over no longer infective
• Usually resolve within 14 days
• REFER
• 14 days +
• Lesions within mouth
• Lesions spread rapidly over the face or are severe
• Immunocompromised/Immunosuppressive medicines
• Systemic symptoms e.g. fever and malaise
HINTS AND TIPS
TREATMENT
• Only the antivirals, aciclovir and penciclovir – which work by inhibiting the herpes virus
DNA polymerase – have demonstrated clinical effectiveness against the herpes virus
• Products containing ammonia, zinc and phenol appear to have no evidence of efficacy.
However, they might be useful in drying lesions and preventing secondary bacterial infections
• Local anaesthetics (e.g. lidocaine) and choline salicylate might also be useful for mildly
painful lesions.
• Aciclovir 5% Cream Zovirax®, Declovir®, Avorax®
• Apply 5 times daily at approx 4-hrly interval. For at least 4 days , if healing has not occurred
continue up to 10 days.
• Apply at first signs of cold sore
• SE –mild burning or stinging (goes away by itself), itching or mild drying and flaking of the skin,
hypersensitivity
TREATMENT
PREVENTION OF COLD SORES

• Avoid coming into contact with infected body fluids.

• Avoid sharing eating utensils, drinking cups, or other items that a
person with a cold sore may have used.
• After you have been infected with the virus, there is no sure way to
prevent more cold sores. But there are some things you can do to
reduce your number of outbreaks and prevent spreading the virus.
PREVENTION OF ATTACK

• Avoid the things that trigger your cold sores, such as stress and colds or the
flu.
• Always use lip balm and sunscreen on your face. Too much sunlight can cause
cold sores to flare.
• Avoid sharing towels, razors, silverware, toothbrushes, or other objects that a
person with a cold sore may have used.
• When you have a cold sore, make sure to wash your hands often, and try not
to touch your sore. This can help keep you from spreading the virus to your
eyes or genital area or to other people.
• Talk to your doctor if you get cold sores often.You may be able to take
prescription pills to prevent cold sore outbreaks
REFERENCES

• Rutter, P. (2013). Community pharmacy. Symptoms, diagnosis and treatment. 3rdedition.

Edinburgh: Churchill Livingstone.
• Blenkinsopp and P. Paxton; Symptoms in Pharmacy –a guide to the management of common
illness, Blackwell Publication, London, 1089.
• Berardi RR, McDermott JH, Newton GD, Oszko MA, Popovich NG, Rollins CJ et al. Handbook
of nonprescription drugs. 14thed. Washington: American Pharmacists Association; 2002.
• British Medical Association. British National Formulary. United Kingdom: Royal Pharmaceutical
Society of Great Britain; 2005.