Clinical Pharmacy Lec:3 Mouth ulcer Oral thrush Head lice Conditions affecting oral cavity

1. Mouth ulcers: • Aphthous ulcers more commonly known as mouth ulcers is a collective term used to describe various different clinical presentations of superficial painful oral lesions that occur in recurrent bouts at intervals between few day to a few months. • The majority of patients (80%) who present in a community pharmacy will have minor(MAU),

Prevalence an Epidemiology: • For MAU, the prevalence is poorly understood. • Occur in all ages but more common in (20-40). Aetiology: • The cause of MAU is unknown. • A number of theories have been but forward to explain like: food sensitivity, stress, genetic, nutritional deficiencies( iron ,zinc, B12) and infection. Arriving at differential diagnosis: • There are three main clinical presentation to ulcers: minor, major, herpetiform.

Clinical features of MAU

• Roundish in shape. • Grey-white in colour. • Painful. • Small usually less than 1cm in diameter. • Occur singly or in small crops of up to 5 ulcers. • Takes 7-14 days to heal. • Recurrence can occur after 1-4 months. Conditions to eliminate

1.major aphthous ulcers: • Larger than 1 cm in diameter. • Numerous. • Occurring in crops of 10 or more. • Heal slowly may take months. • The ulcers often coalesce to form one large ulcer.

2.Herpetiform ulcers: • Ulcers are pinpoint and occur in large crops of up to 100 at a time. • They usually heal within a month. • Occur in the posterior part of the mouth( an unusual location for MAU). 3.Oral thrush: • Usually presents as creamy- white soft elevated patches.

4. Herpes simplex: • Ulcers tend to be small, discrete and many in number. • Signs of systemic infection like fever and pharyngitis. 5. Medicine-induced ulcers: • Ulcers seen at start of therapy or when increase the dose. • Mostly with Cytotoxic agents, NSAIDS, B-blockers.

Oral thrush Background: • Oropharyngeal candidiasis(oral thrush) is an opportunistic mucosal infection. • Unusual in healthy adult. Aetiology: • Thrush (Candidiasis) is a fungal infection caused by Candida albicans which occurs commonly in the mouth (oral thrush). Arriving at differential diagnosis • Oral thrush is not difficult to diagnose. • Careful history is taken. • Oral examination is performed. Clinical features of oral thrush: • Oral thrush is a creamy white soft elevated patches that can wiped off revealing underlying erythematous mucosa. • Pain, soreness, altered taste, and burning tongue. • Lesions can be anywhere in tongue, palate, lips and cheeks .

Conditions to eliminate

1.minor aphthous ulcer 2. medicines induced • Inhaled corticosteroids and antibiotics. 3. denture wearers • Wearing dentures especially if they are not taken out at night, not kept clean, or do not fit well predispose people to thrush. 4.underlying medical disorders • Diabetes • Xerostomia • Immunocompromised • Major aphthous ulcer • Herpetiform ulcer 5. Very unlikely causes include leukoplakia and squamous cell carcenoma

Evidence base for OTC medications

Head lice

prevalence and epidemiology • Affecting all ages, although much more prevalent in children aged (4-11) years old especially girls. • Can occur at any time during the year. Etiology • Can only be transmitted by head to head contact.

Clinical features of head lice

• Live lice present. • Itching due to scalp allergic response to lice saliva and can take weeks to develop.

Arriving at differential diagnosis

• Most parents will diagnose head lice themselves or be concerned that their child has head lice because of a recent local outbreak at school. • Parents also will buy products to prevent their child contracting head lice.

Conditions to eliminate

1. dandruff • Can cause scalp irritation and itching. • The scalp should be dry and flaky. • Skin debris may be present on clothes. 2. seborrhoeic dermatitis • Will affect areas other than scalp mostly face. • If only scalp involvement is present , the child might complain severe and persistent dandruff.

Evidence based for OTC medication

• Treatment options includes: 1. insecticides (malathion, permethrin) cure rate 70-80% 2. wet combing is alternative with cure rate 40- 60%. 3.dimeticone is a recent introduction thought to work by coating lice internally and externally which leads to disruption in water excretion causing rupture lice gut by osmosis.

4.Isopropyl myristate • A recent introduction to the Uk market. • Like dimeticone, it is pharmacologically inert but act by blocking the tracheal breathing system and coating the surface of the lice with a thin film of fluid. • More effective than permethrin.