oral medicine & Pathology

Drugs used in the treatment of oral mucosal diseases

Updated on: August 4, 2016

Analgesics

 

Acetyl-salicylic acid

 

Class

Non-steroidal antiinflammatory drug (NSAIDs).

Indications

Mild pain.

Main side effects

Gastric irritation and interference with haemostasis.

Contraindications

Peptic ulcer, bleeding, asthma, paediatric age group, advanced pregnancy,
renal diseases, allergy to acetylsalicylic acid.

Interactions

Corticosteroids and other NSAIDs (risk of peptic ulcer), allopurinol
(reduces the effects), and oral antidiabetic drugs (increases the effects).

Adult dose

300-600 mg up to 6 times daily/daily after meals.

 

Codeine

 

Class

Opiate.

Indications

 Moderate pain.

Main side effects

Nausea, headaches, drowsiness, constipation, and xerostomia.

Contraindications

Hepatic diseases and advanced pregnancy.

Interactions

Antihistamines, antidepressants, hypnotics and sedatives (increase sedative effects), monoamine oxidase inhibitors, alcohol, cocaine and cannabis (serious toxicity),
warfarin
(bleeding), analgesics (increases the effects), zidovudine (increases toxicity).

Adult dose

10-60 mg.
 

Diclofenac

 

Class

NSAID.

Indications

Moderate pain.

Main side effects

Gastric irritation, nausea.

Contraindications

Peptic ulcer, pregnancy, hypersensitivity to acetylsalicylic acid.

Interactions

Corticosteroids and other NSAIDs (risk of peptic ulcer),
lithium (increases
plasma levels), ciclosporin (increases renal toxicity).

Adult dose

25-75 mg, up to twice daily.

 

Antibacterial Agents

 

Amoxicillin

 

Class:

Penicillin.

Indications:

Oral bacterial infections.

Staphylococcus aureus is often resistant.

Main side effects

– Rare.

Diarrhoea, reactions due to hypersensitivity.

Contraindications

Hypersensitivity to penicillin, toxic dermatitis during mononucleosis, cytomegalovirus infection, lymphoid leukaemia, therapy with allopurinol.

Interactions

Probenecid (prolongs blood levels of amoxicillin), hypersensitivity induced by cephalosporin.

Adult dose

250-500 mg, 8-hourly.

 

Ampicillin

 

Class

Penicillin.

Indications

Oral bacterial infections.

Main side effects

– Rare.

Pain and inflammation of injected area. Nausea, vomiting, diarrhoea, hypersensitivity.

Contraindications

Hypersensitivity.

Interactions

Probenecid (prolongs and extends the blood l levels of ampicillin),
allopurinol (skin reactions to the ampicillin).

Adult dose

250-500 mg, 8-hourly.

 

Azithromycin

 

Class

 Macrolide.

Indications

Oral bacterial infections.

Main side effects

– Rare.

Diarrhoea, abdominal pain, nausea, vomiting.

Contraindications

Hypersensitivity to azithromycin and other macrolides, serious hepatic failure.

Interactions

Do not administer with antacids.

Adult dose

500 mg daily.

 

Cefadroxil

 

Class

Cephalosporin. Acts orally.

Indications

Oral bacterial infections.

Main side effects

– Rare.

Hypersensitivity.

Contraindications

Hypersensitivity.

Adult dose

1-2 g, 2 times/daily.

 

Cefazolin

 

Class

Cephalosporin.

Indications

Oral bacterial infections.

Main side effects

– Rare.

Localised pain after injection.

Hypersensitivity.

Contraindications

– Hypersensitivity.

Reduce dosage in case of renal failure.

Interactions

Probenecid (prolongs and extends the blood levels of amoxicillin), aminoglycosides and diuretics (increase renal toxicity).

Adult dose

1-2 g/daily intramuscular or intravenous, 4 times /daily.

 

Clarithromycin

 

Class

Macrolide.

Indications

Oral bacterial infections.

Main side effects

– Rare.

Diarrhoea, abdominal pain, nausea, headaches, skin rash.

Contraindications

Hypersensitivity, pregnancy, during breast-feeding and serious hepatic failure.

Interactions

It increases the blood haematological levels of carbamazepine and theophylline.

Adult dose

250 mg, 2 times /daily.

 

Clindamycin

 

Indications

Serious oral bacterial infections in case of allergy to penicillin.

Main side effects

Nausea, vomiting, diarrhoea, pseudomembranous colitis.

Contraindications

Hypersensitivity.

Interactions

It can enhance the blocking effect of neuromuscular drugs like pancuronium;
adverse reaction with erythromycin.

Adult dose

10-30 mg/kg/daily, 4 times/daily.

Metronidazole

 

Indications

Acute necrotising gingivitis, periodontal diseases.

– Effective against anaerobic microbes.

Main side effects

Nausea, diarrhoea, bad taste, peripheral neuropathies (especially in patients with liver disease).

Contraindications

Pregnancy.

Interactions

Warfarin (increases its effects), alcohol (disulfiram-type reactions).

Adult dose

200-400 mg, 8-hourly (take with meals).

 

Minocycline

 

Class

Tetracycline.

Indications

Mucous membrane pemphigoid.

Used for its anti-inflammatory activity.

Main side effects

It can cause vertigo, oral and skin pigmentation.

Contraindications

Pregnancy and children.

Interactions

Not known.

Adult dose

100-200 mg/daily.

 

Vancomycin

 

Class

Glycopeptide.

Indications

Oral bacterial infections in patients allergic to penicillin.

Main side effects

Nausea, fever, phlebitis, rashes, hearing loss, nephrotoxicity.

Contraindications

Renal or auditory impairment.

Interactions

None.

Adult dose

500 mg, 4 times/daily (orally or intravenously) or 1g, 2 times/daily intravenously.

 

Antifungal Agents

( For Oral Candidosis )

 

Amphotericin (topical)

 

Indications

Mild candidosis.

Main side effects

None.

Contraindications

None.

Interactions

None.

Adult dose

4-5 daily mouth washes (oral suspension 100 mg/mL).

 

Fluconazole

 

Indications

Useful against candidosis resistant to standard topical treatments,
especially in
subjects with immunosuppression.

Main side effects

Abdominal pain, nausea, diarrhoea, hepatic toxicity.

Contraindications

Pregnancy, children with renal disease. Less hepatotoxic than ketoconazole.

Interactions

Same as ketaconazole (below).

Adult dose

50-100 mg, daily; 2-3 daily mouth washes (suspension).

 

Itraconazole

 

Indications

Useful against candidosis resistant to standard treatments.

Main side effects

Nausea, vomiting, headaches, rash, oedema.

Contraindications

Pregnancy and breastfeeding.

Interactions

Absorption is reduced by antacids; it increases the effects of ciclosporin,
hypoglycaemic agents, diciumarol, digitalis and antihistamines.

Adult dose

Each tablet contains 200-400 mg, daily.

 

Ketoconazole

 

Indications

Useful against candidosis resistant to standard treatments.

Main side effects

Nausea, hepatic toxicity.

Contraindications

Pregnancy, patients with chronic hepatic disease.

Interactions

Cimetidine and ranitidine (absorption reduced), isoniazid and rifampicin
(effect reduced), antidiabetic drugs (increase the effects).

It increases the nephrotoxicity of ciclosporin.

Adult dose

200-400 mg, daily.

 

Nystatin

 

Indications

Candidosis in immunocompetent subjects.

Main side effects

Unpleasant taste, nausea, gastric conditions.

Contraindications

None.

Interactions

None.

Adult dose

4-6 daily mouth washes (oral suspension 100000 units per mL).

 

Miconazole (topical)

 

Indications

Candidosis in immunocompetent subjects.

In theory, better antifungal for the treatment of angular cheilitis.

Main side effects

Nausea.

Contraindications

None.

Interactions

None.

Adult dose

3-4 daily applications of 5 mL gel  (25 mg/mL).

 

Antiviral Agents

( Oral herpetic infections )

 

Acyclovir

 

Indications

Primary and recurrent herpes simplex virus infection (HSV), and varicella-zoster virus infection (VZV).

Main side effects

Headaches, gastric conditions, rash.

Contraindications

Pregnancy.

Interactions

It increases the renal toxicity of gentamicin, vancomycin, amphotericin
and
ciclosporin, zidovudine, interferon, alcohol and cocaine (neurological changes).

Adult dose

5 tablets daily (of 200-400 mg, one every 4 hours) until the primary HSV infection has cleared, for recurrent labial infections and intraoral and for varicella; 800 mg,
5 tablets
daily for the zoster.

Cream (5%): 4-6 daily applications for recurrent labial lesions.

250 mg/m2 IV every 8 hours for immunocompromised patients.

 

Foscarnet

 

Indications

Aciclovir-resistant HSV or VZV.

Main side effects

Nephrotoxicity, nausea, vomiting, anaemia, fatigue.

Contraindications

Renal disorders.

Interactions

Renal toxicity increases with amphotericin B, pentamidine and aminoglycosides;
pentamidine increases the risk of
hypocalcaemia.

Adult dose

40 mg/kg, daily intravenous every 8 hours.

 

Penciclovir

 

Indications

Primary and recurrent herpes simplex virus infection (HSV).

Main side effects

None.

Contraindications

None.

Interactions

None.

Adult dose

Cream 1%; 1 application every 2 hours/daily (during the day).

 

Valaciclovir

 

Indications

Varicella-zoster infections.

Main side effects

Nausea, headaches, vomiting.

Contraindications

Immunocompromised patients.

Interactions

Cimetidine and probenecid reduce haematological problems.

Adult dose

1g, 3 times daily.

 

Corticosteroids

 

1. Topical corticosteroids

The European Classification System has four levels numbered I to IV in descending order of potency to classify the clinical potency of corticosteroids:

– Very potent (class I).

– Potent (II).

– Moderately potent (III).

– Midly potent (IV).

Class I and II of topical steroids are usually preferred for the oral cavity, especially in the treatment of erosive bullous diseases.

– In the case of minor aphthae, a less potent cortisoid might be used.

– The greatest problem when using topical corticosteroids in the oral cavity
is
to make adherence to the mucosa possible for as long as it is necessary in order to carry out the treatment.

– For this, adhesive gels are used, which have a base of carboximethylcellulose (for instance, Orabase1) or hydroxyethylcellulose (to 4%) that are mixed in equal parts (50:50) with the topical steroid.

They are often used as an ointment because creams have a bitter taste and the gels can burn because they usually contain alcohol.

– In any case, it is possible to use salves that provide the paste with greater consistency but less adherence.

– In the case of gingival lesions, it is often useful to use a tray prepared in transparent soft resin or silicone that allows occlusive therapy.

– The most frequent side effect during a course of topical steroid treatment is candidosis, which is easily prevented with the help of antifungal treatments
in the form
of chlorhexidine mouthwash and miconazole gel.

 

Triamcinolone acetonide

 

Indications

Moderately potent (III).

Main side effects

Oral candidosis.

Contraindications

None.

Interactions

None.

Adult dose

3-6 daily applications.

 

Fluocinonide

 

Indications

Erosive-bullous diseases.

Used with adhesive gels of carboximethylcellulose (Orabase); potent (II).

Main side effects

Oral candidosis.

Contraindications

         zNone.

Interactions

None.

Adult dose

3-6 daily applications.

 

Clobetasol propionate

 

Indications

Erosive-bullous diseases.

– Used with adhesive gels of carboximethylcellulose (Orabase); very potent (class I).

Main side effects

– Oral candidosis.

– Very rarely adrenocortical suppression.

Contraindications

None.

Interactions

None.

Adult dose

2-3 daily applications.

 

2. Systemic corticosteroids

 

Prednisone

 

Indications

– Severe erosive-bullous diseases (pemphigus mucous membrane pemphigoid,
erythema multiforme, and sometimes erosive lichen planus and major aphthae or herpetiform ones).

Main side effects

– Gastric irritation, mood swings, insomnia, water retention, hyperglycaemia, weight gain, arterial hypertension, osteoporosis, adrenocortical abolition
(Cushingoid aspect).

Contraindications

– Pregnancy, osteoporosis, decompensated diabetes, peptic ulcer, hepatic diseases, and psychosis.

Interactions

– Anticoagulants and oral antidiabetics (they reduce the effects), NSAIDs (increases the risk of peptic ulcer), furosemide (hypopotassaemia).

Adult dose

0.5-25 mg/kg orally, once/daily.

 

Other Immunomodulant Drugs

 

Azathioprine

 

Indications

– Severe erosive-bullous diseases (pemphigus or mucous membrane pemphigoid).

Together with corticosteroids in order to improve their
immunosuppressant effectiveness.

Main side effects

– Myelosuppression and hepatic toxicity.

– Chronic use might make the subject susceptible to malignant tumours.

Contraindications

Pregnancy.

Interaction

– Allopurinol (it increases azathioprine action), acetylsalicylic acid (bleeding),
othe
r immunosuppressants (increased risk of infections).

Adult dose

2-2.5 mg/kg orally.

 

Ciclosporin (topical)

 

Indications

– Severe erosive-bullous diseases (pemphigus, mucous membrane pemphigoid,
and erosive lichen planus).

– It can be used as a mouthwash or adhesive base similar to Orabase.

Main side effects

– Renal and hepatic toxicity, hypertension, and gingival hyperplasia.

All these side effects are rare when the drug is used topically.

Interactions

Allopurinol, analgesics and antifungals (increase toxicity of ciclosporin), antiepileptic drugs (reduction of effects)

Adult dose

1-10 mouth washes, daily (oral suspension 100 mg/mL); 1-2 daily applications
in
adhesive base similar to Orabase.

 

Dapsone

 

Indications

Mucous membrane pemphigoid.

Main side effects

– Anaemia, rash, neuropathy, headaches, renal and hepatic toxicity.

Contraindications

Deficit of glucose-6- phosphate dehydrogenase, pregnancy, and
cardiorespiratory diseases.

Interactions

– Trimethoprim and methotrexate increase the risk of haematological complications.

Adult dose

– 5 mg, daily for the first three days, then 10 mg, daily for the next three days, and then 15 mg, daily for the next three days; then 20 mg, daily.

 

Tacrolimus (topical)

 

Indications

lichen planus, pemphigoid.

Main side effects

Burning sensation.

Contraindications

None.

Interactions

None.

Adult dose

1-2 daily applications.

 

Other Drugs

 

Carbamazepine

 

Indications

Trigeminal neuralgia.

Main side effects

– Occasional vertigo, diplopia and haematological dyscrasia, usually with rash in the first three months of treatment.

Contraindications

– Deficit of glucose-6- phosphate dehydrogenase, pregnancy,
and
cardiorespiratory diseases.

Interactions

– Enhanced by cimetidine and isoniazide, it increases the effect of lithium; it interferes with oral contraceptives.

Adult dose

Usually start with 200 mg, daily.

Many patients need 200 mg every 8 hours; do not exceed 1800 mg, daily.

 

Pilocarpine

 

Indications

Xerostomia.

Main side effects

– Sweating, bradycardia, tachycardia, hypotension-hypertension, and biliary spasm.

Contraindications

– Hypertension, cardiovascular diseases, arrhythmia, psychosis,
urinary lithiasis and biliary diseases.

Interactions

Betablocker (risk of arrhythmia), anticholinergic (compromises its effects), cholinergic (increases its action).

Adult dose

– 1 teaspoon, 1-4 times daily (solution 5 mg/mL).

 

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