Download Part I: Quelling Cold Sores and Aphthous Ulcers Part I I: Relieving

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This course was
written for dentists,
dental hygienists,
and assistants.
Part I: Quelling Cold Sores and
Aphthous Ulcers
Written by Jacalyn Neceskas, PharmD, BCPS; Stacie Moore, PharmD;
Susan Goodin, PharmD, FCCP, BCOP
Part II: Relieving Xerostomia
Written by Fiona M. Collins, BDS, MBA, MA
A Peer-Reviewed Publication
Published: August 2010
Expiry: July 2013
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Part I: Quelling cold sores and aphthous ulcers
Table 1. Implicated factors and associations for RAU
Educational Objectives
The overall goal of this article is to provide the reader with information on the etiology, pathophysiology, and treatment of
recurrent aphthous ulcers and recurrent herpes labialis. Upon
completion of this course, the reader will be able to:
1. List and describe the etiology and pathophysiology related
to recurrent aphthous ulcers and recurrent herpes labialis.
2. List and describe the general recommendations specific to
patients experiencing recurrent herpes labialis.
3. List and describe the treatment options available for recurrent aphthous ulcers and recurrent herpes labialis.
Abstract
Recurrent aphthous ulcers (RAU) and recurrent herpes labialis
(RHL) are two of the common oral/peri-oral lesions experienced
in the general population. Treatment options include over-thecounter and prescription products.
Introduction
Recurrent herpes labialis (cold sores) and recurrent aphthous
ulcers (canker sores) are common conditions that can be treated
to relieve discomfort and, with some treatments, aid healing.
Between 15% and 40% of people experience a cold sore in their
lifetime, and it has been estimated that up to 80% of adults carry
the herpes virus latently by age 30.1 Forty percent of carriers
in the United States are under age 20.2 In addition, the age at
which the virus is acquired and seropositivity vary by geography
and socioeconomic status, with a greater incidence in younger
patients in developing countries.3 Recurrent aphthous ulcers
(RAU) are distinct from recurrent herpes labialis (RHL) in
presentation and etiology. Although RAU are believed to be less
prevalent than RHL, affecting around 1% of the population according to NHANES III, other studies have found an incidence
of 5%-66%.4
Etiology and Pathophysiology of RAU and RHL
The precise precipitating events and mechanisms for the occurrence of RAU are as yet not fully explained. A wide range of factors
have been implicated in RAU (Table 1), with nonsmokers more
affected than smokers.5,6 Hypersensitivity to dairy and gluten, as
well as sensitivity to sodium lauryl sulfate, are considered etiological factors, and medications implicated in RAU include cardiovascular drugs, interferon, certain antibiotics, and anti-inflammatory
drugs.7,8,9 In addition, a higher incidence and severity of RAU
have been reported in patients with diseases that include Celiac
disease, ulcerative colitis, Behçet’s syndrome, and HIV infection.
No consistent association has been found with bacterial or viral
factors.10 Based on research there is involvement of the immune
system, with the presence of increased levels of circulating and
inflammatory mediators including TNF-α, interleukin-2, natural
killer cells, and antiendothelial cell autoantibodies.10
50
Sensitivity to sodium lauryl sulfate
Stress
Iron, folate, zinc or vitamin B12 deficiency Local trauma
Medication use
Systemic diseases
Immune system involvement
Genetics
Hypersensitivity to dairy and gluten-containing foods
RHL, in contrast, are caused by a prior primary infection with
herpes simplex virus type 1 (HSV-1). RHL are transmitted by direct contact with the secretions from herpetic lesions, resulting in a
primary infection that is often asymptomatic. Once acquired, the
infection lies dormant in the peripheral sensory neurons (trigeminal
ganglia) until periodic reactivation is induced by a particular trigger
or stressor (Table 2). Exposure to a trigger then precipitates viral
migration along sensory neurons to the epithelium where the virus
replicates and, upon recognition by the immune system, prompts
the release of inflammatory mediators followed by a clinically evident RHL outbreak.
Table 2. Triggers and stressors for periodic reactivation of HSV-1
Anxiety/stress
Infection (e.g., the common cold)
Ultraviolet light
Dental treatment
Menstruation
Ultra-violet (UV) light as a trigger has been well-studied in
clinical trials. Rooney et al. investigated the effect of sunscreen
(SPF-15) application compared to use of a placebo in a randomized, double-blind crossover study. No patients developed active
lesions while using SPF-15 sunscreen and only one had asymptomatic viral shedding, while during the placebo phase there were
27 reactivations of lesions, suggesting not only that UV light acts
as a trigger but also that sunscreen can play an important role in
preventing recurrences.11,5
Clinical Presentation of RAU and RHL
RAU are classified as minor, major, and herpetiform recurrent
aphthous ulcers. These differ in size (<1 mm to >10 mm in diameter), number and severity of the outbreak. RAU may first cause
a tingling sensation before the red raised area at the ulcer site appears prior to ulceration and the appearance of a flat or cratered,
grayish-yellow area surrounded by a ring of inflamed tissue. RAU
typically occur on nonkeratinized surfaces of the oral mucosa,
including the tongue and palate. All 3 types can cause moderate
to severe pain, and result in difficulty in eating, drinking, speaking, and swallowing. Minor and herpetiform RAU typically heal
within 7-10 days. The most severe are major RAU; these can cause
severe debilitating pain, take up to several weeks or months to
heal, and heal with scarring.
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December 2010
Figure 1a. Major recurrent aphthous ulcers
Figure 2b. Crusted recurrent herpes labialis lesion
Figure 2b: Courtesy of William L. Balanoff, DDS, MS, FICD
Figure 1b. Minor recurrent aphthous ulcer
RHL are self-limiting and typically heal without scarring;
nonetheless, they can significantly affect the patient’s quality of life
during outbreaks by resulting in pain, embarrassment, and temporary cosmetic disfigurement. They may also cause uncertainty
about the frequency of recurrence. Treatment is most effective if
initiated during the initial 48 hours of the recurrence.
General Considerations for Patients
Figures 1a,b: Courtesy of HIVdent
RHL proceed through 8 stages of forming and healing:
Prodrome; erythema; papule formation; vesicle formation; ulceration/soft crust; hard crust; desquamation (dry flake); residual
swelling.12 During the prodromal phase, patients may experience
tingling, numbness, pain or itching associated with the initial
viral replication in the nerve endings.3,5,12 After the papules have
formed, these coalesce into fluid-filled vesicles that form a crust
and heal in 14-21 days during the first occurrence and within
7-10 days during recurrences.5 It is during the vesicle stage that
the patient experiences the highest viral load,3 and when the
vesicle bursts the patient is also at risk for bacterial superinfection, which would present with pus formation and may require
the use of topical antibiotics.5 Along with their classical signs and
symptoms, RHL can be definitively detected and identified using
DNA amplification tests or by swabbing the lesion and culturing
the virus.1 The most common location for RHL to occur is at the
junction of the oral mucosa and the lip at the vermilion border.
Figure 2a. Intraoral recurrent herpes labialis at vesicle stage
It is important to enquire about the occurrence of RAU and RHL
with all dental patients, particularly since both occur episodically
and may or may not be present at the time of the initial dental visit.
By doing so, patients can be proactively counseled on treatment
options and care of RAU and RHL, if required. This is especially
important for patients suffering from RHL, since treatment is best
initiated during the early (prodromal) phase to reduce the severity
of the recurrence.
Patients should be advised to keep the area adjacent to RHL
lesions clean by using a mild antibacterial soap and water and then
dabbing the area dry. Patients with RHL should also be advised
to wash their hands frequently to prevent the transmission of viral
secretions and infection, and to avoid triggers such as sunlight by
using sunscreen. Patients experiencing RAU should be advised to
avoid spicy and/or acidic foods and drinks, as these may exacerbate discomfort associated with RAU present at that time.
In recommending treatment for RAU and RHL, it is essential
to stress the importance of visiting (or returning to) the dentist or
physician if lesions do not heal within 14 days. Patients should also
be referred to their physician for further evaluation if the severity or
frequency of recurrences increases, or if they experience other signs
and symptoms of infection such as a fever, as these may indicate
an underlying systemic condition that needs to be investigated and
addressed. If hypersensitivity to a particular food ingredient or
chemical is suspected, patients can be advised to avoid these and
encouraged to discuss this with their physician. Immunocompromised patients should also be referred to their primary care physician or specialist.
Treatment and Care of RAU
Figure 2a: Courtesy of Diane M. Daubert, RDH, MS
December 2010
Over-the-counter products
The mainstay of palliative care, aimed at relieving symptoms until
RAU resolve, is over-the-counter (OTC) oral pastes and rinses.
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51
Wound-cleansing and debriding rinses are also available that can
be applied directly to the lesion or used as a rinse in accordance
with the recommendations of the clinician and product labeling.
Pain-relieving topical analgesic pastes typically contain 20%
benzocaine or 2% lidocaine, and barrier creams are also available
that help prevent irritation. A mucosal adhesive patch (Canker
Cover™) has been shown to help relieve pain, and forms a barrier over the lesion to help protect it from foods, drinks, and other
irritants. This patch contains citrus oil, which has demonstrated
antiseptic and anti-inflammatory properties.13 The combination
of citrus oil and magnesium chloride has been found in a doubleblind, placebo-controlled clinical trial to result in a shorter healing time of 1.5 days, versus 6 days for placebo (hydroxycellulose
base tablets containing no magnesium chloride or citrus oil) and
10 days for untreated patients. The mean time for the elimination of pain was also reduced (5 hours versus 48 hours and 134
hours, respectively).14 A separate study in subjects 18 years of
age and older compared the use of the same patch with use of
a bioadhesive oral solution (Kank-A®) containing benzocaine
and compound benzoin tincture as the active ingredients. It was
found that the mucoadhesive patch reduced healing time—mean
healing time was 36 hours versus 134.7 hours with the oral solution, there was greater pain reduction at 24 and 48 hours, and the
patch was well-tolerated.15 If lesions are widespread, a bioadherent barrier rinse (Rincinol®) can be considered and will coat all
of the oral mucosa.
Prescription products
Prescription products have also been utilized for the treatment of
RAU. Five percent tetracycline rinse has been found to reduce
healing time and duration of lesions, and to be well-tolerated
when used 4 times daily for 5 days or less.10 It should be noted
that this is contraindicated during tooth development due to the
risk of tetracycline staining. Corticosteroid rinses may be effective in reducing the duration of lesions when used 3-4 times daily,
especially where multiple larger ulcers are present and topical
application of pastes is impractical. Viscous lidocaine rinse (2%)
may be prescribed for pain relief, for rinsing and expectoration, or
direct application to the lesion. A bioadherent barrier rinse is also
available (Gelclair®). Corticosteroid creams of various potencies
have also been investigated for their ability to reduce inflammation and relieve pain, including medium-potency triamcinolone
acetonide paste (Kenalog in Orabase®), which has been shown
to reduce pain, inflammation, and ulceration when applied 2
or 3 times daily for 5 days.16 One topical cream containing 5%
amlexanox (Aphthasol®) has been found in a placebo-controlled,
double-blind clinical trial with 1335 subjects to increase the rate
of healing while reducing the duration of pain, when applied 4
times daily.17 It is indicated for use in patients 18 years of age
and older. A number of systemic treatments have been tested
for severe RAU, including the use of thalidomide, orally administered corticosteroids, and levamisol. Due to their toxicity and
contraindications, these are reserved for only the most severe
cases of RAU; thalidomide is teratogenic and must never be
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used in pregnant women or women who may become pregnant.18
With both topical and systemic higher potency corticosteroids,
consideration must be given to adrenal suppression, which would
require tapering off of their use.
Table 3. Treatment options for RAU
Over-the-counter
Pain-relieving topical analgesic pastes
Barrier creams and liquid
Mucosal barrier adhesive patch (Canker Cover)
Bioadherent barrier rinse (Rincinol)
Bioadherent barrier analgesic rinse (Kank-A)
Prescription - topical
Prescription - systemic
Viscous lidocaine rinse (2%)
Corticosteroids
Tetracycline rinse (5%)
Levamisol
Corticosteroid creams
Thalidomide*
Amlexanox (5%)
Bioadherent barrier rinse
Prescription - systemic
* Must never be used in women who are/may become pregnant
Treatment and Care of RHL
Major goals of treatment of RHL include pain relief, reduction of
inflammation, improved (faster) healing, avoidance of secondary
bacterial infections, and prevention of transmission of viruses to
others or self (e.g., autoinoculation to the eyes, which can result
in severe infections and blindness). To date no cure is available.
A number of controlled clinical trials have demonstrated the efficacy of oral and topical antiviral agents for the prevention and
treatment of RHL.12,19,20,21
Over-the-counter treatments
A number of OTC products are available for the relief of pain
associated with RHL, thereby offering palliative care. These
contain topical analgesics such as benzocaine and camphor, lidocaine, or pramoxine. In addition, some contain an antiseptic
ingredient such as benzalkonium chloride and some contain
sunscreen, skin softener (to soften the crust), and skin protectants. Most of these OTC products are safe for use in young
children—the indications and directions on the product labeling
should be followed. Nonprescription 10% docosanol cream (Abreva®) is FDA-approved for the treatment of RHL in patients
12 years of age or older,22 and works by inhibiting viral fusion to
the host cell. In a randomized, double-blind, placebo-controlled
study of 743 patients age 18 or over who experience more than 2
recurrences of RHL per year, the application of 10% docosanol
cream 5 times daily resulted in a reduced healing time and time
to cessation of pain, but did not reduce lesion formation. Patients
were included only if their lesions had not progressed beyond
the erythema phase. The median reduction in healing time was
17.5 hours and the median reduction in time to pain cessation
was 13.4 hours.19
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December 2010
Natural products
A number of natural products have efficacy claims for treating or
preventing RHL. These include tannic acid, tea tree oil, lemon
balm and rhubarb-sage topical cream. Tannic acid has been
found to be ineffective, and there is insufficient data to determine
the efficacy of tea tree oil;23 limited data is available to show efficacy for lemon balm and rhubarb-sage topical cream.
Lysine has also been used to treat RHL. After it was found
that arginine deficiency suppressed HSV growth in the laboratory, lysine—an analog of arginine—was investigated for the
treatment of RHL with the hypothesis that it would prevent the
utilization of arginine by HSV.24 Lysine can be given orally or
applied topically. Studies on orally administered lysine, which is
sold as a dietary supplement, have produced conflicting results.
One crossover study in 65 patients receiving either 500 mg lysine or placebo for 12 weeks found no reduction in the number
of recurrences of RHL with either treatment.25 A separate randomized study found no differences in recurrence rates whether
patients were taking 624 mg or 1248 mg of lysine daily, but did
find significant reductions in recurrences compared to use of
placebo.26 Topical lysine (e.g., Lip Clear® Lysine+) has been
shown to reduce healing time and to provide relief. An open label
trial with 30 patients found that 40% of patients reported a full
cure (complete disappearance and resolution of the eruption) by
day 3 and 86% by day 4.27
Finally, an over-the-counter homeopathic formulation of
zinc oxide with glycine (Novitra®) was studied in a randomized,
double-blind clinical trial with 46 patients, where it was used
every 2 hours during waking hours. The investigators found that
it reduced mean healing time by 1.5 days compared to placebo
(based on patient diaries and telephone interviews) and was welltolerated.28
Prescription products
FDA-approved prescription products for the treatment of RHL
include topical treatments and orally administered systemic
treatments. Topical agents include acyclovir cream (Zovirax®)
and penciclovir cream (Denavir®). Acyclovir is applied as a
cream and works by interfering with the replication of the herpes
simplex virus; it is recommended for use in patients age 12 years
and older and should be used for 4 days, 5 times a day, as soon as
the prodromal (initial) phase begins.29 In 2 randomized, doubleblind, placebo-controlled clinical trials with Zovirax®, reduced
length of time to healing and reduced duration of pain were
found, but acyclovir did not prevent the progression of lesions to
the vesicular phase.30
Penciclovir (1%) is available for use in people age 12 and older
and should be applied every 2 hours for 4 days (while awake) as
soon as symptoms occur. The efficacy of penciclovir was demonstrated in a randomized, double-blind, placebo-controlled trial
with 1573 patients 18 years of age and older who experienced at
least 3 RHL per year. The median time to healing was reduced
by 0.7 to 1 day, and the time to loss of pain was reduced by a
median of 0.6 days.31 Two other identical, randomized, doubleDecember 2010
blind, placebo-controlled multicenter studies with a total of 2537
patients demonstrated the efficacy of penciclovir in reducing
healing time when applied within 1 hour of the onset of symptoms. A difference was also found when the cream was used at
the papule stage; its use did not prevent lesions from progressing
to the vesicle stage.32 A separate small study also demonstrated
reduced time to healing by 1 day compared to use of acyclovir.33
Table 4. Clinical results of treatments for RHL
Treatment
10% docosanol
(Abreva)
Topical lysine
(Lip Clear® Lysine+)
Clinical Results
Median pain cessation time reduced by 13.4 hours
Median reduction in healing time of 17.5 hours
Lesion resolution in 86% of patients by day 4
Zinc oxide with
glycine (Novitra®)
Median reduction in healing time of 1.5 days
Acyclovir cream
(Zovirax®)
Reduced length of time to healing
Penciclovir cream
(Denavir®)
Valacyclovir tablets
Famciclovir tablets
Reduced duration of pain
Median reduction in healing time of 0.7 - 1 day
Median pain cessation time reduced by 0.6 days
Median reduction in healing time of 0.8 days
Median pain cessation time reduced by 0.5 - 0.7 days
Median reduction in healing time of 1.8 - 2.2 days
Systemic orally administered tablets containing acyclovir have
been found to reduce time to healing when given as 400 mg 5
times per day in a subset of patients, but not at doses of 200 mg,
5 times per day for 5 days.34,35 Valacyclovir is approved by the
FDA for the treatment of RHL, administered as a dose of 2000
mg given twice for 1 day, which has been shown to decrease the
median time to healing by 0.8 days and to decrease the median
number of days of pain by 0.5-0.7 days. There was no effect on
lesion progression.36 Oral famciclovir is also approved for the
treatment of RHL. Famciclovir as 1500 mg in a single dose or
750 mg given twice for 1 day have both been found to reduce the
median time to healing by 1.8-2.2 days, based on a double-blind,
randomized trial of 701 patients age 18 or older who experienced
at least 3 episodes of RHL annually. However, the single dose
of 1500 mg was found to offer greater reduction in the time to
resolution of pain or discomfort.37
Summary
Recurrent aphthous ulcers and recurrent herpes lesions occur
frequently in the general population. After a diagnosis has been
made, patients should be given general advice regarding care
of these and, in the case of RHL, avoiding transmission of the
herpes virus to others. When recommending or prescribing medicaments and drugs, the severity and frequency of the lesions,
health status of the individual patient and clinical efficacy of the
product should be considered.
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Part II: Relieving Xerostomia
Educational Objectives
Oral Signs and Symptoms
The overall goal of this article is to provide the reader with information on xerostomia and treatments for the relief of dry mouth.
Upon completion of this course the reader will be able to:
1. List the etiological factors for xerostomia.
2. List and describe the signs and symptoms of xerostomia.
3. List and describe the treatment options available for the
relief of dry mouth.
Individual patients may experience the signs and symptoms of
xerostomia to varying degrees depending on the residual level
of function of the salivary glands. Symptoms associated with
xerostomia include a sticky and/or dry feeling in the mouth, a
sensation of pain and burning mouth, alterations in taste, stringy
or ropey saliva, difficulty speaking, and a reduced ability to chew
and swallow a bolus of food due to a (relative) lack of saliva. Signs
of xerostomia include an increased level of carious lesions, the
appearance of dryness of the oral mucosa intraorally, increased
levels of plaque, bad breath, and oral irritations including
angular cheilitis, dry and cracked lips. In addition, xerostomia
patients are at increased risk for candidal and other oral infections. The chief complaints of patients with xerostomia are the
feeling of dryness in the mouth and difficulties experienced with
swallowing and speaking.7
Abstract
Xerostomia (dry mouth) affects a significant number of adults
and its prevalence increases with age, primarily as the result
of the increased use of medications and an increased risk and
incidence of diseases/conditions associated with xerostomia.
The symptoms of xerostomia can be debilitating and result in
a reduced quality of life. Treatment options for the relief of dry
mouth include prescription and over-the-counter products, and
recommendations should be tailored for the individual patient.
Figure 1. Dry appearance of oral mucosa
Introduction
Xerostomia, or dry mouth, is a common affliction in the general
population. An extensive and increasing number of medications are associated with xerostomia, including antidepressants
and psychotropics, antihistamines, antihypertensives, and
cardiovascular drugs. Estimates on the number of medications
with xerostomia as a side effect range from more than 500 to
more than 1500.1,2,3 Diseases associated with xerostomia include
Sjögren’s syndrome, diabetes, AIDS, and Parkinson’s disease.4
While chemotherapy can also result in xerostomia and changes
to the consistency of saliva, head and neck radiation results in
severe xerostomia and, as with nerve damage, can completely
destroy functioning of the salivary glands. Tobacco and alcohol
use also result in a dry mouth. In addition, breathing through
the mouth (and snoring) result in dry mouth – this, however,
is of a temporary nature and resolves once nose breathing resumes. There is an increased prevalence of xerostomia with
age, and it has been estimated that around 25% of adults in the
over-65 age group experience xerostomia and at least 10% of all
adults are affected.5 While older patients experience dry mouth
more frequently, this is related to medication use or other conditions rather than aging itself.6
Figure 2. Angular cheilitis in patient with xerostomia
Figures 1 and 2: Courtesy of Sandra L. Boody, RDH, MEd
Table 1. Factors in xerostomia
Medication use
Nerve damage
Auto-immune diseases
Tobacco use
Parkinson’s disease
Alcohol use
Head and neck radiation therapy
Mouth breathing
Chemotherapy
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Detecting and Diagnosing Xerostomia in the
Dental Office
Patients should be screened for xerostomia. The medical and
dental history forms used in the dental office should include
questions on medication use, diseases, and medical conditions,
and should be reviewed for any present that may result in xerostomia. The medical and dental history forms should also include
specific questions on symptoms related to dry mouth, including
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December 2010
whether the patient has the sensation of dryness in the mouth,
dry lips, or difficulty speaking, chewing, or swallowing. Asking
whether the patient has to sip water to chew and swallow helps
elucidate problems. Detecting xerostomia is best accomplished
in the dental office. The oral mucosa may be observed to be dry
and parched in appearance, there may be dry or cracked areas
on the lips or at the corners of the lips, and an increased caries
experience may also indicate xerostomia.
Clinical assessment should include placing the mirror against
the buccal mucosa to see if it sticks to the mucosa (indicative of
inadequate salivary flow). If it is suspected that a patient may
have xerostomia, unstimulated and stimulated salivary flow tests
will help objectively determine if xerostomia is present and to
what degree. In both cases the patient salivates for five minutes
and expectorates his or her saliva into a cup or other vessel. A
recent protocol for collecting unstimulated saliva recommends
that the patient refrain from eating, drinking anything (except
water), smoking, chewing gum, and consuming caffeine for one
hour before the test is conducted, and that the patient sit still
while saliva is collected. For stimulated saliva, the standardized
protocol recommends that the patient chew gum in time with
a metronome prior to collection of saliva.8 It should be noted
that while an objective salivary flow test could indicate that a
patient has mild, moderate, or severe xerostomia, the patient
may subjectively experience this differently (better or worse).
When assessing xerostomia prior to and after initiation of dry
mouth–relief treatment, subjective assessment by the patient is a
key factor and is performed using either a specific questionnaire
designed for the purpose or a visual analog scale (VAS).
Treatment Options for Xerostomia
Dental professionals are oral care experts and thus positioned to
detect, diagnose and recommend primary treatment for xerostomia.9 Patients should be counseled on the importance of home
care – extra thorough brushing and flossing to remove plaque is
necessary to help prevent caries and periodontal disease and to
reduce halitosis. Patients with xerostomia are at increased risk
for caries; professional fluoride therapy is indicated as is home
use of fluoride toothpaste. Toothpastes formulated for drymouth patients containing lower levels of sodium lauryl sulfate
(SLS), or without SLS, and with low foaming activity to reduce
the possibility of irritation are available (Biotene Dry Mouth
Toothpaste; Biotene PBF Fluoride Toothpaste). As appropriate, patients can be advised to use prescription level paste/gel or
over-the-counter alcohol-free adjunctive fluoride rinses. Patients
should also be advised to avoid consumption of sugar-containing
foods, drinks, and snacks and other fermentable carbohydrates
in order to reduce caries risk, as well as to avoid tobacco, caffeine,
alcohol, and alcohol-containing rinses due to their drying effect.
Sipping water and sleeping with a humidifier have also been
shown to help relieve the symptoms of dry mouth. Palliative care
of oral irritations can be achieved using topical analgesic pastes
containing 20% benzocaine or 2% lidocaine, or using a barrier
cream or rinse. The main focus of this article is on the relief of the
December 2010
chief symptom and complaint with xerostomia – the sensation of
dryness and the discomfort this brings. A number of treatment
options are available for xerostomia relief, including prescription
and over-the-counter products.
Dry Mouth Relief
Prescription Products
Prescription products used to treat xerostomia include those
that stimulate salivary production and those that relieve symptoms. Orally administered systemic treatments that stimulate
the production of saliva include pilocarpine hydrochloride
(Salagen) and cevimeline hydrochloride (Evoxac). Side effects
can include dizziness, alterations in vision, stomach upset, and,
rarely, rapid or slowed heart rate and breathing trouble.10 Caphasol is a unit-dose prescription rinse containing calcium and
phosphate ions and has been clinically proven to lubricate dry
mouth and to reduce the occurrence and severity of mucositis
associated with head and neck radiation.11 A second prescription
rinse, Numoisyn Liquid, is indicated for relief of dry mouth, has
a similar viscosity to saliva, and produces a barrier bioadhesive
film on the dentition and oral mucosa.12 The linseed extract contained in Numoisyn has been found to relieve the symptoms of
dry mouth.13
Over-the-counter products
Over-the-counter products available for relief of dry mouth
include mouthwashes, liquids, sprays, gums, lozenges, and
a patch. Mouthwashes are formulated to help relieve dry
mouth, soothe the oral mucosa, help cleanse the oral cavity,
and combat halitosis. These typically contain a base of water
and either hydroxyethylcellulose (Biotene Dry Mouth and PBF
Mouthwashes) or carboxymethylcellulose (Oasis Moisturizing
Mouthwash). Natural-based mouthwashes containing plant
extracts and essential oils are also available. Over-the-counter
saliva substitute gels and liquids are also available. The primary
goals for these are rapid relief of dry mouth and soothing of the
oral mucosa. Oral Balance Gel (Biotene) contains protective enzymes as the active ingredient in a hydroxyethylcellulose base.
It has been found to be effective in relieving dry mouth, including in head-and-neck-radiation patients and patients who had
received whole-body irradiation and chemotherapy.14,15 Biotene
saliva substitute has also been shown to be effective in elderly
patients for relief of dry mouth.16 The use of Oral Balance Gel
and Dry Mouth Toothpaste has been clinically shown to provide
greater relief and palliative care in head-and-neck-radiation
patients than use of a carboxymethylcellulose gel and regular
toothpaste.17 A second saliva substitute containing the same
enzymes is available as a liquid in a small portable bottle (Oral
Balance Liquid), while another product (Numoisyn Liquid)
contains linseed extract. Another option is office-dispensed GC
Dry Mouth Gel which can be applied with a finger. Over-thecounter spray and atomizer saliva substitutes have also been
found to provide relief from xerostomia.7
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Figure 3. Mouthwashes, chewing gums and patch
Figure 4a.
Patch placed in
position with finger
Figure 4b.
Patch during dissolution
for xerostomia relief
Intraoral devices have recently also been investigated for the relief of xerostomia. One study found that a night guard fabricated
as an ethylene vinyl acetate sheet covering the palate and dental
arches, without any reservoir, provided relief from nocturnal
xerostomia (assessed using a visual analog scale);24 replacement
full dentures with reservoirs containing saliva substitute may
also provide relief.25
Summary
These may contain glycerin, glycerol, mucin, or carboxymethylcellulose in the base formulation (Salivart; Biotene and Oasis
Moisturizing Mouth Sprays; Mouth-Kote; Moi-Stir). Spray
saliva substitutes have been found to be effective and their application easy and acceptable to patients.18
Sugar-free lozenges and chewing gums are available that can
be used ad libitum to stimulate saliva if salivary gland function is
still present19,20 (Wrigley chewing gums). These may also contain xylitol (SalivaSure lozenges, Epic chewing gum, Biotene Dry
Mouth Gum), or casein phosphopeptide-amorphous calcium
phosphate (CPP-ACP) (Trident Extra chewing gum), which
has been shown to help reduce demineralization.21 One brand
of lozenge contains essential oils and zinc gluconate and claims
to impede biofilm and to kill bacteria associated with halitosis
(Salese with Xylitol).22 In addition to stimulating saliva, chewing gum may also help remove plaque and debris through the
process of mastication; for many patients chewing gum is a habit
they already enjoy and can modify simply by changing to the
recommended gum for dry mouth. Patients should be cautioned
against using chewing gums containing sugar, which would further increase their high risk for caries.
An innovative patch has been introduced for dry mouth relief
(OraMoist Dry Mouth Patch). Using a finger, this small mucoadhesive patch is applied to the side of the palate, or in denture/
appliance wearers to the cheek, and dissolves over the course of
2–4 hours to moisturize the mouth and stimulate saliva to provide
relief from xerostomia. A recent small study comparing this patch
with mouthwash found the patch to be more effective in relieving dry mouth, based on patient self-reporting. Twice as many
subjects reported relief using the patch, and its use resulted in a
1.5-fold increase in unstimulated whole salivary flow.23
56
Xerostomia is a debilitating condition that affects a significant
percentage of the population and results in reduced quality
of life. Treatment is aimed at relieving dry mouth through the
stimulation of saliva and use of oral moisturizing products,
and at helping to reduce the risk of conditions associated with
xerostomia. Once a patient has been diagnosed with xerostomia,
treatment planning and recommendations can be made for its
management. When making recommendations on products for
the relief of dry mouth, the patient’s preferences and subjective
assessment of relief attained should be explored – taste, vehicle,
ease-of-use and portability, and perceived relief are all factors in
patients’acceptance and use of these treatments.26 Dry mouth can
be relieved using a number of vehicles that include toothpastes,
mouthwashes, saliva substitutes, chewing gums, lozenges, or a
mucoadhesive patch, and combinations of these can be used for
effective relief of dry mouth.
References Part I
1
Vestly JP, Norval M. Mucocutaneous infections with herpes simplex virus and
their management. Clin Exp Dermatol. 1992;17:221-37.
2 Xu F, Schillinger JA, Sternberg MR, et al. Seroprevalence and coinfection with
herpes simplex virus type I and type 2 in the United States, 1998-1994. J Infect
Dis. 2002;185:1019-24.
3 Esmann J. The many challenges of facial herpes simplex infection. J
Antimicrob Chemother. 2001;47:17-27.
4 Chattopadhyah P, Chatterjee S. Risk indicators for recurrent aphthous ulcers
in the US. Community Dent Oral Epidemiol. 2007;35:152-9.
5 Oral pain and discomfort. In: Allen LV, Berardi RR, DeSimone EL, et al, eds.
Handbook of Nonprescription Drugs. 12th ed. Washington, D.C.: American
Pharmacists Association; 2000:585-609.
6 Natah SS, Konttinan YT, Enattah NS, et al. Recurrent aphthous ulcers today: a
review of the growing knowledge. Int J Oral Maxillofac Surg. 2004;33:221-34.
7 Brokstad B, Barkvoll P. The effect of two toothpaste detergents on the frequency
of recurrent aphthous ulcers. Acta Odontol Scand. 1996;54(3):150-3.
8 Abdollahi A, Radfar M. A review of drug-induced oral reactions. J Contemp
Dent Pract. 2003;4:10-31.
9 Tack AD, Rogers RS. Oral drug reactions. Dermatol Ther. 2002;15:236-50.
10 Jurge S, Cuffer R, Scully C, Porter SR. Mucosal disease series number
VI:Recurrent aphthous stomatitis. Oral Dis. 2006;12:1-21.
www.rdhmag.com
December 2010
11 Rooney JF, Bryson Y, Mannix ML, et al. Prevention of ultraviolet-light-induced
herpes labialis by sunscreen. Lancet. 1991;338;1419-21.
12 Woo S, Challacombe SJ. Management of recurrent oral herpes simplex
infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2007;103(Suppl 1):e1-S12.e18.
13 Mizrahi B, Shapira L, Dob AJ, Had HY. Citrus oil and magnesium salt as
antibacterial and anti-inflammatory agents. J Periodontol. 2006;77(6):963-8.
14 Mizrahi B, Wolnerman Y, Domb AJ. Adhesive tablet effective for treating
canker sores in humans. J Pharm Sci. 2004;93(12):2927-35.
15 Shemer A, Amichai B, Trau H, Nathansohn N, Mizrahi B, Domb AJ. Efficacy
of a mucoadhesive patch compared with an oral solution for treatment of
aphthous stomatitis. Drugs R D. 2008;9(1) 29-35.
16 Herlofson BB, Barkvoll P. Sodium lauryl sulfate and recurrent aphthous
ulcers. A preliminary study. Acta Odontol Scand. 1994;52(5):257-9.
17 Khandwala A, Waninwegen RG, Alfano MC. 5% Amlexanox oral paste, a
new treatment for recurrent minor aphthous ulcers. Oral Surg Oral Med Oral
Path. 1997;83(2):222-30.
18 Porter SR. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med.
1998;9(3):306-21.
19 Raborn GW, Chan KS, Grace M. Treatment modalities and treatment
recommended by health care professionals for treating recurrent herpes
labialis. J Am Dent Assoc. 2004;135:48-54.
20 Sacks SL, Thisted RA, Jones TM, et al. Clinical efficacy of topical docosanol
10% cream for herpes simplex labialis: a multicenter, randomized placebocontrolled trial. J Am Acad Dermatol. 2001;45:222-30.
21 Gaby AR. Natural remedies for herpes simplex. Altern Med Rev.
2006;11(2):93-101.
22 About Abreva: Efficacy and use. Abreva Web site. http://www.abreva.com.
23 Carson CF, Ashton L, Dry L, et al. Melaleuca alternifolia (tea tree) oil gel
(6%) for the treatment of recurrent herpes labialis. J Antimicrob Chemother.
2001;48:450-1.
24 Griffith RS, DeLong DC, Nelson JD. Relation of arginine-lysine antagonism
to herpes simplex growth in tissue culture. Chemotherapy. 1981;27:209-13.
25 Tomblin FA Jr, Lucas KH. Lysine for management of herpes labialis. Am J
Health Syst Pharm. 2001;58:300-4.
26 McCune MA, Perry HO, Muller SA, et al. Treatment of recurrent herpes
simplex infections with L-lysine monohydrochloride. Cutis. 1984;34:366-73.
27 Singh BB, Udani J, Vinjamury SP, et al. Safety and effectiveness of an L-lysine,
zinc, and herbal-based product on the treatment of facial and circumoral
herpes. Altern Med Rev. 2005;10:123-7.
28 Godfrey HR, Godfrey NJ, Godfrey JC, et al. A randomized clinical trial on
the treatment of oral herpes with topical zinc oxide/glycine. Alter Ther Health
Med. 2001;7:49-56.
29 Zovirax cream 5% (package insert). Glaxosmithkline.
30 Spruance SL, Nett R, Marbury T, et al. Acyclovir cream for treatment of herpes
simplex labialis: results of two randomized, double-blind, vehicle-controlled,
multicenter clinical trials. Antimicrob Agents Chemother. 2002;46(7):2238-43.
31 Spruance SL, Rea TL, Thoming C, et al. Pencyclovir cream for the treatment
of recurrent herpes simplex labialis: a randomized, multicenter, double-blind,
placebo-controlled trial. J Am Med Assoc. 1997;277:1374-9.
32 Raborn GW, Martel AY, Lasonde M, et al. Effective treatment for herpes
simplex labialis with penciclovir cream: combined results of two trials. J Am
Dent Assoc. 2001;133:303-9.
33 Femiano F, Gambos F, Scully C. Recurrent herpes labialis: efficacy of topical
therapy with penciclovir compared with acyclovir (acyclovir). Oral Dis.
2001;7:31-3.
34 Raborn GW, McGaw WT, Greace M, et al. Oral acyclovir and herpes labialis:
a randomized, double-blind, placebo-controlled study. J Am Dent Assoc.
1987;115(1):38-42.
35 Spruance SL, Stewart JC, Rowe NH, et al. Treatment of recurrent herpes
simplex labialis with oral acyclovir. J Infect Dis. 1990;161:185-90.
36 Spruance SL, Jones TM, Blatter MM, et al. High-dose, short-duration,
early valacyclovir therapy for episodic treatment of cold sores: results of two
randomized, placebo-controlled, multicenter studies. Antimicrob Agents
Chemother. 2003;47:1072-80.
37 Spruance SL, Bodsworth N, Resnick H, et al. Single-dose, patient-initiated
famciclovir: a randomized, double-blind, placebo-controlled trial for episodic
treatment of herpes labialis. J Am Acad Dematol. 2006;55:47-53.
References Part II
1
2
3
4
Porter SR, Scully C, Hegarty AM. An update of the etiology and management
of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:2846.
Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth—2nd
edition. Gerodontology. 1997;14:33-47.
http://www.drymouth.info/practitioner/overview.asp
Mouly SJ, Orler JB, Tillet Y, Coudert AC, Oberli F, et al. Efficacy of a
new oral lubricant solution in the management of psychotropic druginduced xerostomia: a randomized controlled trial. J Clin Psychopharmacol.
2007;27(5):437-43.
December 2010
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Managing xerostomia. Vital 6, 32–34 (1 March 2009) | doi:10.1038/vital944
Atkinson JC, Grisius M, Massey W. Salivary hypofunction and xerostomia:
diagnosis and treatment. Dent Clin N Am. 2005;49:309- 26.
Vissink A, Panders AK, Gravenmade EJ, Vermey A. Treatment of oral
symptoms in Sjögren’s syndrome. Scand J Rheumatol Suppl. 1986;61:270-3.
Navazesh M, Kumar SK. Measuring salivary flow: challenges and
opportunities. J Am Dent Assoc. 2008;139 Suppl:35S-40S.
Frost PM. Difficulties in dental prescribing of saliva substitutes for xerostomia.
Gerodontology. 2002;19(2):123-4.
http://www.medicinenet.com/pilocarpine-oral/article.htm
Papas AS, Clark RE, Martuscelli G, O’Loughlin KT, Johansen E, et al. A
prospective, randomized trial for the prevention of mucositis in patients
undergoing hematopoietic stem cell transplantation. Bone MarrowTransplant.
2003;8:705-12.
Christersson CE, Lindh L, Arnebrant T. Film-forming properties and
viscosities of saliva substitutes and human whole saliva. Eur J Oral Sci.
2000;108:418-425.
Andersson G, Johansson G, Attstrom R, Edwardsson S, Glantz P-O, et
al. Comparison of the effect of the linseed extract Salinum® and a methyl
cellulose preparation on the symptoms of dry mouth. Gerodontology.
1995;12:12-17.
Shahdad SA, Taylor C, Barclay SC, Steen IN, Preshaw PM. A double-blind,
crossover study of Biotène Oralbalance and BioXtra systems as salivary
substitutes in patients with post-radiotherapy xerostomia. Eur J Cancer Care
(Engl). 2005;14(4):319-26.
Sugiura Y, Soga Y, Tanimoto I, Kokeguchi S, Nishide S, et al. Antimicrobial
effects of the saliva substitute, Oralbalance, against microorganisms from oral
mucosa in the hematopoietic cell transplantation period. Support Care Cancer.
2008;16(4):421-4.
Matear DW, Barbaro J. Effectiveness of saliva substitute products in the
treatment of dry mouth in the elderly: a pilot study. J R Soc Promot Health.
2005;125(1):35-41.
Epstein JB, Emerton S, Le ND, Stevenson-Moore P. A double-blind crossover
trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with
xerostomia following radiation therapy. Oral Oncol. 1999;35(2):132-7.
Silvestre FJ, Minguez MP, Suñe-Negre JM. Clinical evaluation of a new
artificial saliva in spray form for patients with dry mouth. Med Oral Patol Oral
Cir Bucal. 2009 Jan 1;14(1):E8-E11.
Itthagarun A, Wei SH. Chewing gum and saliva in oral health. J Clin Dent.
1997;8(6):159-62.
Bots CP, Brand HS, Veerman EC, Korevaar JC, Valentijn-Benz M, et al.
Chewing gum and a saliva substitute alleviate thirst and xerostomia in patients
on haemodialysis. Nephrol Dial Transplant. 2005;20(3):578-84.
Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and
remineralization of enamel lesions by various forms of calcium in a mouthrinse
or sugar-free chewing gum. J Dent Res. 2003;82(3):206-11. ref
Nuvora website. http://www.nuvorainc.com/salese-learn-more.html
Afriamian D. Treating Xerostoma Utilizing an Adhesive Oral Tablet As
Compared With Biotene Rinses. Data on file.
Yamamoto K, Nagashima H, Yamachika S, Hoshiba D, Yamaguchi K, et al.
The application of a night guard for sleep-related xerostomia. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2008;106(3):e11-4.
Hirvikangas M, Posti J, Mäkilä E. Treatment of xerostomia through use of
dentures containing reservoirs of saliva substitute. Proc Finn Dent Soc.
1989;85(1):47-50.
Momm F, Volegova-Neher NJ, Schulte-Mönting J, Guttenberger R. Different
saliva substitutes for treatment of xerostomia following radiotherapy. A
prospective crossover study. Strahlenther Onkol. 2005 Apr;181(4):231-6.
Author Profiles
Dr. Jacalyn Neceskas is a pharmacist at the Cancer Institute of New Jersey, and
graduated with a PharmD.
Dr. Stacie Moore was a pharmacy resident at the Robert Wood Johnson University
Hospital in New Brunswick and holds a PharmD.
Dr. Susan Goodin graduated with a PharmD and is the director in the division of
pharmaceutical sciences at the Cancer Institute of New Jersey and associate professor of medicine at the Robert Wood Johnson Medical School in New Jersey.
Dr. Fiona M. Collins graduated with a dental degree from Glasgow University and
holds an MBA and MA from Boston University.
Disclaimer
The author(s) of this course has/have no commercial ties with the sponsors or the
providers of the unrestricted educational grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course. For your convenience, an
online feedback form is available at www.ineedce.com.
www.rdhmag.com
57
Online Completion
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Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade
report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by
returning to the site, sign in and return to your Archives Page.
Questions
1. It has been estimated that up to _________
of adults carry the herpes virus latently by
age 30 and that _________ of carriers in the
United States are under age 20.
a.
b.
c.
d.
60%; 20%
70%; 30%
80%; 40%
90%; 50%
2. _________ is an implicated factor/association
for RAU.
a.
b.
c.
d.
Hypersensitivity/sensitivity to foods/chemicals
Medication use
Genetics
all of the above
3. RHL is caused by a _________with herpes
simplex virus type 1.
a. primary infection
b. secondary infection
c. tertiary infection
d. none of the above
4. RHL is transmitted by _________.
a.
b.
c.
d.
aerosols
direct contact with the secretions from herpetic lesions
sneezing and coughing
all of the above
5. _________ is a potential trigger/stressor for
periodic reactivation of HSV-1.
a.
b.
c.
d.
UV light
Anxiety/stress
Dental treatment
all of the above
6. _________ can play an important role in
preventing recurrences of RHL
a.
b.
c.
d.
Bitter aloe
Sunscreen
Lip salve
all of the above
7. Recurrent aphthous ulcers _________.
a. result in the appearance of a flat or cratered, grayishyellow area surrounded by a ring of inflamed tissue
b. occur on nonkeratinized surfaces of the oral mucosa
c. can cause moderate to severe pain
d. all of the above
8. It is during the vesicle stage of RHL that the
patient experiences _________.
a.
b.
c.
d.
the highest viral load
bacterial superinfection
viral superinfection
the lowest viral load
9. Patients with RHL should be advised to
_________.
a. wash their hands frequently to prevent the transmission
of viral secretions and infection
b. avoid triggers such as sunlight
c. avoid spicy and/or acidic foods and drinks
d. a and b
10. It is essential to stress the importance of
visiting (or returning to) the dentist or physician if lesions do not heal within _________
days.
a. 7
b. 10
c. 14
d. 21
58
11. _________ are the mainstay of palliative care
for RAU.
a.
b.
c.
d.
Prescription oral pastes and rinses
Over-the-counter (OTC) oral pastes and rinses
Corticosteroids
none of the above
12. A mucosal adhesive patch containing citrus
oil and magnesium chloride _________.
a.
b.
c.
d.
has been shown to help relieve pain
forms a barrier over the lesion to help protect it
has been shown to reduce healing time
all of the above
13. Pain-relieving topical analgesic pastes used
for RAU typically contain _________.
a.
b.
c.
d.
10% benzocaine or 1% lidocaine
15% benzocaine or 2% lidocaine
20% benzocaine or 2% lidocaine
none of the above
14. 5% amlexanox has been found to _________
, when applied 4 times daily.
a.
b.
c.
d.
increase the rate of healing of RAU
reduce the duration of pain
provide only palliative relief
a and b
15. 10% docosanol cream _________.
a.
b.
c.
d.
has been found to reduce healing time
has been found to reduce the time to cessation of pain
is a nonprescription cream
all of the above
16. Topical lysine has been shown to reduce
healing time and to provide relief for ____.
a.
b.
c.
d.
RAU
RHL
RAU and RHL
none of the above
17. _________ is an FDA-approved prescription
product for the treatment of RHL.
a.
b.
c.
d.
Acyclovir cream
Penciclovir cream
Fanclover cream
a and b
18. _________ are factors in the occurrence of
xerostomia.
a.
b.
c.
d.
Medication, alcohol and tobacco use
Chemotherapy and head and neck radiation therapy
Auto-immune diseases
all of the above
19. _________ is a symptom of xerostomia.
a.
b.
c.
d.
A sticky and/or dry feeling in the mouth
Stringy or ropey saliva
Difficulty speaking, chewing or swallowing
All of the above
20. _________ can be a sign of xerostomia.
a. The appearance of dryness of the oral mucosa and oral
irritations
b. An increased level of carious lesions
c. An increased level of plaque and bad breath
d. all of the above
21. If it is suspected that a patient may have
xerostomia, _________will help objectively
determine if xerostomia is present and to
what degree.
a.
b.
c.
d.
an unstimulated salivary flow test
a visual analog scale
a stimulated salivary flow test
a and c
www.rdhmag.com
22. The results of the ________of xerostomia
are important to proper treatment of the
patient.
a.
b.
c.
d.
objective assessment
subjective assessment
objective and subjective assessments
none of the above
23. If a mouth mirror sticks when placed against
the buccal mucosa _________.
a.
b.
c.
d.
this suggests enzymatic activity
this is indicative of inadequate salivary flow
this is indicative of adequate salivary flow
a and c
24. Toothpastes specifically formulated for
dry-mouth patients contain _________.
a.
b.
c.
d.
lower levels of SLS or no SLS
lower levels of zinc
higher levels of antibacterial agents
all of the above
25. Patients with xerostomia should be advised
to avoid _________.
a. consumption of sugar-containing foods, drinks, and
snacks and other fermentable carbohydrates
b. tobacco, caffeine, and alcohol
c. alcohol-containing rinses
d. all of the above
26. Xerostomia associated with mouthbreathing
is _________.
a.
b.
c.
d.
sometimes permanent
always permanent
always debilitating
none of the above
27. _________ has been shown to help relieve
the symptoms of dry mouth.
a.
b.
c.
d.
Sipping water
Chewing gum
Sleeping with a humidifier
all of the above
28. Mouthwashes for the treatment of xerostomia are formulated to effectively _________.
a.
b.
c.
d.
help relieve dry mouth
soothe the oral mucosa
help cleanse the oral cavity, and combat halitosis
all of the above
29. A small mucoadhesive patch used to treat
xerostomia has been found to _________.
a.
b.
c.
d.
effectively relieve dry mouth
dissolve over 2-4 hours to moisturize the mouth
increase whole salivary flow
all of the above
30. Dry mouth can be relieved using _______.
a.
b.
c.
d.
toothpastes, mouthwashes and saliva substitutes
chewing gums and lozenges
a mucoadhesive patch
combinations of the above
December 2010
ANSWER SHEET
Part I: Quelling Cold Sores and Aphthous Ulcers
Part I I: Relieving Xerostomia
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Country:
Lic. Renewal Date:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
If not taking online, mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
Part I.
A Division of PennWell Corp.
1. Listanddescribetheetiologyandpathophysiologyrelatedtorecurrentaphthousulcersandrecurrentherpeslabialis.
2. Listanddescribethegeneralrecommendationsspecifictopatientsexperiencingrecurrentherpeslabialis.
3. Listanddescribethetreatmentoptionsavailableforrecurrentaphthousulcersandrecurrentherpeslabialis.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
For IMMEDIATE results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
Part II.
1. List the etiological factors for xerostomia.
2. List and describe the signs and symptoms of xerostomia.
Payment of $49.00 is enclosed.
(Checks and credit cards are accepted.)
3. List and describe the treatment options available for the relief of dry mouth.
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3. Please rate your personal mastery of the course objectives.
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4. How would you rate the objectives and educational methods? 5
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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
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the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
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EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
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Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
Customer Service 216.398.7822
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2010 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
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