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A Concise Guide to Treating Painful Oral Lesions

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Drugs Used to Treat Osteoporosis and Bone Cancer Perio & Implant Centers The Team for of the Monterey Bay (831) 648-8800 Jochen P. Pechak, DDS, MSD in Silicon Valley (408) 738-3423 Which May Cause Osteonecrosis of the Jaws mobile: www.DrPechakapp.com he many bisphosphonates and monoclonal antibodies which are used to treat osteoporosis and bone cancer often web: GumsRus.com causeDrugsDrugs osteonecrosis Used Used of the to jaws.to Treat AsTreat dental clinicians,Osteoporosis Osteoporosis it is important that and andwe are Bone awareBone of this Cancers Cancers side effect before Ttreating our patients who are taking these drugs. The tables below summarize these drugs, the route these drugs are administered, andWhich Whichtheir likelihood May May of causing Cause Cause osteonecrosis Osteonecrosis Osteonecrosis of the jaws as reported byof of Dr. the theRobert Jaws JawsMarx at the University of Miami Division of Oral and Maxillofacial Surgery. PDL tm Osteoporosis Drugs Drugs Osteoporosis Used to Treat Drugs Osteoporosis PerioDontaLetter Jochen P. Pechak, DDS, MSD, Periodontics and Implant Dentistry Spring DrugDrug ClassificationClassification ActionAction DoseDose RouteRoute %% of of ReportedReported CasesCases of of OsteonecrosisOsteonecrosis AlendronateAlendronate BisphosphonateBisphosphonate OsteoclastOsteoclast 7070 mg/wk mg/wk OralOral 8282%% From Our Office A Concise Guide to Treating (Fosamax(Fosamax ToxicityToxicity to Yours... Generic)Generic) Painful Oral Lesions ResidronateResidronate BisphosphonateBisphosphonate OsteoclastOsteoclast 3535 mg/wk mg/wk OralOral 1%1% As dentists specializing in treat- (Actonel Toxicity (Actonel Toxicity ment of diseases of the oral cavity atients present frequently with Treating Cold Sores Atelvia)Atelvia) and associated structures, we are painful oral lesions. They are often also called upon to treat pain- IbandronateIbandronate BisphosphonateBisphosphonate OsteoclastOsteoclast 150150 mg/mos mg/mos OralOral 1%1% usually not serious, but patients And Canker Sores (Boniva) Toxicity IV ful oral lesions in the mouth. This P appreciate our attention to them, our (Boniva) Toxicity IV issue of The PerioDontaLetter con- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 55 mg/ mg/yryr IVIV 66%% reassurance they are not serious, and If the sore is on the lip, it is (Reclast) Toxicity tains guidelines on how to treat caused by a herpes virus infection (Reclast) Toxicity these common oral lesions. specific prescriptions for treatment. DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 6060 mg/6 mg/6 SubcutaneousSubcutaneous 1010%% There is usually no cure, but there are and is contagious. These are (Prolia) Antibody Impairment mos The back page of this issue con- (Prolia) Antibody Impairment mos tains a table summarizing the con- treatments that shorten their duration commonly called “cold sores” or Teriparatide (Forteo) and raloxifene (Evista) are also used to treat osteoporosis but work differently so TeriparatideTeriparatide (Forteo) (Forteo) and raloxifene and ralox (Evista)ifene (Evista) are also used are alsoto treat used osteoporosis to treat osteoporosisbut work differently, but work so they differently don’t cause so fusing array of bisphosphonates and reduce the pain. Some of these “fever blisters.” Patients should osteonecrosisthey don’t andcause no specialosteonecrosis precautions and are no necessary. special precautions are necessary. avoid touching them and then they don’t cause osteonecrosis and no special precautions are necessary. and monoclonal antibodies which are recurrent and others are self- are used to treat osteoporosis and induced such as toothbrush trauma touching their eyes since the herpes DrugsDrugsDrugs Used Used Used to Treatto to Treat Treat Bone BoneCancer Bone Cancer Cancer bone cancer. This table includes the and burns from hot foods. virus can spread to the eye and then route these drugs are administered, Always be mindful of looking for is much more difficult to treat. Drug Classification Action Dose Route % of Drug Classification Action Dose Route % of and their likelihood of causing oral cancer, and biopsy any Treatment: Over the counter Reported Reported drug-induced osteonecrosis of the suspicious lesion. Abreva crème applied five times a CasesCases of of jaws — a side effect which we clini- OsteonecrosisOsteonecrosis cians need to be aware of in treat- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 44 mg/mo mg/mo IVIV 67%67% ing our patients who are taking (Zometa) Toxicity these drugs. Figure 1. (Zometa) Toxicity Recurrent apthous Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% We hope you find this information Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% ulcers occur on (Aredia) Toxicity helpful. (Aredia) Toxicity moveable oral Bevacizumab Monoclonal VEGF 100-400 IV <1% As always, we welcome your Bevacizumab Monoclonal VEGF 100-400 IV <1% comments and questions. mucosa inside the (Avastin)(Avastin) AntibodyAntibody InhibitorInhibitor mg/mg/ 14 14 days days mouth and are not SunitinibSunitinib TyrosineTyrosine Kinase Kinase OsteoclastOsteoclast 55 mg/yr mg/yr IVIV <1%<1% contagious. (Sutent)(Sutent) InhibitorInhibitor ToxicityToxicity DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 120120 mg/mo mg/mo IVIV 15%15% (Xgeva)(Xgeva) AntibodyAntibody InhibitorInhibitor PDL tm 21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] 21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] Jochen P. Pechak, DDS, MS Jochen P. Pechak, DDS, MS 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] Diplomate, American Board of Periodontology Diplomate, American Board of Periodontology mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected] mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected] day will shorten their duration. Over Mouthwash” containing Benadryl, severe cases, a steroid gel called the counter Carmex lip balm applied Maalox, and viscous xylocaine will Clobetasol 0.05% (15gm tube) can be at the first tingle will help the pain. reduce pain dramatically. For larger prescribed and applied with a Q-tip Valtrex can be prescribed — two outbreaks, the steroid dexamethasone twice daily. Alternatively, dexa- grams in the morning and two grams can be added to the mixture. These methasone elixir 0.5mg/ml (12 oz. in the evening — taken at the first sign mixtures are compounded by a local bottle) can be used as a rinse, one of an outbreak. Zovirax or Denavir pharmacist. Alternatively, prescription tablespoon for two minutes four times ointments can also be prescribed, but dexamethasone elixir alone, 0.5mg/ per day. In severe cases, this rinse can are very expensive ($800-$900 per ml, can be used as a rinse – one be used in combination with Clobetasol tube) and often not covered by medical tablespoon for two minutes four times gel. For Desquamative Gingivitis, a day – or OTC Rincinol can be used insurance. A local compounding doxycycline 100 mg once a day for 30 Figure 4. Herpes virus infection Figure 5. Erosive Lichen Planus Figure 6. Oral Cancer occurs as a rinse to coat the lesions. pharmacist can make up a much less days has been found very useful. occurs on the lip and is occurs on the cheeks or tongue most commonly on the base of expensive generic version of Zovirax These conditions are a sometimes- contagious. Primary herpes and is characterized by white the tongue or in the throat. (5.5% acyclovir ointment). Treating Generalized painful annoyance, but are not serious infection occurs inside the mouth. striations. Early diagnosis is critical. Painful Ulcerations and recurrence is common. If not The most common sore inside the painful, no treatment is needed. mouth is an apthous ulcer, commonly More generalized, or occasionally Treating Yeast solve in the mouth five times a day a sexually transmitted virus which is Primary Herpes Infection will called a “canker sore.” These are not localized, blood-filled erosive lesions for 14 days. An alternative is Nystatin causing throat cancer in younger sometimes occur, most often in Infections viral, occur on movable tissue like the with the tissue sloughing (Nikolsky’s oral suspension (100,000 units/ people. Testing positive for HPV16 tongue or cheeks, and are not children, but occasionally in adults. ml-dispense 240 ml), take one means you are at greater risk of throat sign) sometimes form on the gums and Sores on the corners of the mouth contagious. The cause is unknown and cheeks. These are usually caused by This infection is characterized by very teaspoon and swish for two minutes, cancer and need to be monitored more are called Angular Cheilitis and cause they tend to recur. Desquamative Gingivitis (Benign painful ulcers throughout the then swallow, four times a day. For closely. These cancers occur most pain when opening and closing the Treatment for individual sores Mucous Membrane Pemphigoid). mouth, including the gums and throat. more severe yeast infections, Diflucan commonly on the base of the tongue mouth. These sores are usually caused includes application of over-the- Generalized or localized painful It is often accompanied by fever, 100 mg can be prescribed -- 15 or in the throat, so these areas need to by a yeast infection (Candida albicans) counter
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