Topical Therapy for Lesions of The Oral Mucosa

Topical therapy has several advantages over the systemic administration of drugs. Side-effects, although not eliminated, are usually reduced and local application allows for maximum concentration of the drug at the site of the lesion. Agents tend to be more effective if they can be retained locally for as long as possible.

Covering agents

A number of gels and pastes are available to provide mechanical protection of ulcerative areas in the mouth. Agents such as carmellose gelatin gel may also be used as carriers for more active substances such as steroids or antifungal agents. A number of preparations of this kind are commercially available and others can be made up by a pharmacist. Unfortunately, patients often report difficulty applying these pastes, particularly at the back of the mouth.

Topical antiseptics

Chlorhexidine has antibacterial and some anticandidal activity and is currently the most effective antiplaque agent. Chlorhexidine can be used as a mouthwash, spray, or gel to control secondary infection in mucosal ulceration and as an adjunct, or short-term alternative, to toothbrushing and other oral hygiene measures. However, it frequently stains teeth brown and may cause discoloration of the tongue. Staining of the teeth is reversible but can be a problem with long-term use. Some patients do not like the taste of chlorhexidine and occasionally it causes idiosyncratic mucosal irritation. Parotid swelling has been reported in a few cases following use of chlorhexidine.

Topical analgesics

A topical analgesic preparation such as benzydamine (Difflam®) may provide temporary symptomatic relief for erosive and ulcerative oral lesions and enable the patient to eat and drink. Topical anaesthetic agents such as lidocaine gel (or rinse) can also be used for short-term symptomatic relief but should be prescribed with caution since secondary trauma could easily be painlessly effected during the period of anaesthesia. A further precaution to be taken includes the avoidance of preparations of sufficient strength to affect the laryngeal reflexes. Lidocaine rinses should not be used for long periods of time because of the possibility of systemic absorption and side-effects. In spite of these difficulties, it is, from time to time, justifiable to prescribe treatment of this kind. Local anaesthetics are also included in some throat lozenges and mouth ulcer pastilles (or paste) on sale to the public. Many contain sugar, however, and patients should be warned about their cariogenic potential.

Topical antibiotics

There are inherent disadvantages associated with the use of topical antibiotics because of the possibilities of selection for resistant strains and of inducing hypersensitivity reactions in the patient. The value of topical antibiotics outweighs such risks in some cases. Tetracycline (or chlortetracycline) is a useful topical antibiotic. As a 2 per cent solution, it is often effective in reducing secondary infection (and thus the discomfort) in cases of aphthous stomatitis, primary herpetic stomatitis, erosive lichen planus, and other severe ulcerative conditions. Interestingly, (chlor)tetracycline mouthwashes are particularly effective in reducing the discomfort of herpetiform aphthous stomatitis. Use of topical antibiotics cannot normally be accepted as long-term treatment for recurrent conditions and it is best regarded as treatment reserved for acute episodes. The mouthwash may be made by the patient dissolving the contents of a 250 mg tetracycline capsule in 10 ml of water to give a 2 per cent solution. It may be more effective to have the solution accurately made up by the pharmacist, including 10 per cent of glycerol as a demulcent.

 

If the treatment is not unduly prolonged, there is minimal trouble from overgrowth of resistant organisms in the mouth, although a candidal infection may occur and must be appropriately dealt with.

Many of patients have oral lesions that are persistent and severe. In such cases, the prolonged use of antibiotic-based mouthwashes is clinically justified, particularly in the chlortetracycline-triamcinolone combination that is used in such conditions as pemphigus and major erosive lichen planus.

 

Topical corticosteroids

One of the most important factors to be considered when using topical steroids is the degree of suppression of adrenal function that may occur when these drugs are administered. The degree of adrenal suppression varies not only from steroid to steroid and according to the method of use, but there is also considerable individual variation. For instance, a dose of systemic prednisolone that may apparently cause no side-effects in one patient may render another markedly Cushingoid. It is the author practice to use high-concentration, locally applied steroids to replace systemic medication wherever possible. Excessive use of topical steroid preparations can, however, result in a significant amount of systemic absorption. Application of more potent topical steroids also increases the likelihood of a superimposed oral candidiasis and some oral physicians advocate the concomitant use of a prophylactic, topical antifungal agent.

 

Source : Field A. 2003. Tyldesley's Oral Medicine. Vol 5th Ed. Oxford University Press. UK