Challenges treating oral mucosal diseases
good:
- easy access
- good blood supply
challenges:
- difficult for contact of drug to effected area for long enough to allow an effective therapeutic dose
- limited adhesion: salivary action, drug lacks adhesive properties, friction affects the mucosa
- lack of drug substantivity (prolonged contact bw material=drug and substrate= OM
- if severe oral disease eg. erosive LP/PV = systemic corticosteroids which have side effects
What does a Marketing Authorisation mean?
Why do topical corticosteroids not have a MA/ unlicensed
- been assessed for efficacy, safety and quality
- manufactured 2 appropriate standards
- appropriate information + labelling
because:
-OM have limited no. of prescriptions compared to other diseases= carrying out trials would not be economically justified.
Different categories of unlicensed medication
SPECIALS : made/manufactured specifically for an individual with raw materials/licensed medication
IMPORTED MEDICINES: have a MA outside the UK eg. oracort 0.1% in canada
OFF-LABEL USE: unlisenced use of lisenced medication eg. using betamethasone soluble tablets to produce a mouth rinse
Prescribing medications outside their MA, prescribers must:
1) have EVIDENCE & EXPERIENCE of using these medications in such a way that show efficacy safety
2) take responsibility for prescribing and overviewing patient and carry out follow ups, monitoring
3) make clear accurate leviable notes of the prescriptions and dose and reason for prescribing this unlicensed medication
When do we use topical corticosteroids
- mucocutaneous lesions (LP, LR, DLE, CBVHD)
- PV, MMP,
- ulcers eg. ROU
- OFG management
corticosteroids mechanism of action
- they are synthetic variants of naturally occurring glucocorticoid= hydrocortisone
- corticosteroid will bing to a glucocorticoid receptor present on all cells and SUPPRESS immune function and PROMOTE vasoconstriction
eg.
INFLAMMATORY CELLS;
decrease: inflammatory cells and cytokines and
encourage: inflammatory cell apoptosis
NORMAL STRUCTURES:
- vasoconstriction
- suppression of immune function
- reduce mucous secretion
- relax smooth muscles of airways=reducing asthma
When do we give systemic corticosteroids?
- severe/refractory disease eg. systemic involvement eg. pyrexia
- topical and adjunctive therapies have been unsuccessful
Optimal use of topical corticosteroids
- accurate diagnosis
- accurate drug selection
- correct formula and potency/dose
- potential adverse effects should be known
- patient acceptability (taste/texture)
- patient compatibility and frequency of appliance
- duration of use of medication
Important thing to know about corticosteroids
- NOT CURATIVE NOT ANALGESIC
- they are anti-inflammatory
- reduce symptoms
- rebound flare up if discontinued suddenly and course is not finished. this may need prolonged treatment
corticosteroid mouthwashes:
- easy to use
- practically difficult eg. at work?
- good for mobile tissue eg. tongue but hard to access areas eg. retromolar pad/soft palate= gag reflex
- all of mucosa including healthy tissue comes into contact
- instruct to SPIT OUT to prevent systemic involvement (topical corticosteroids are soluble and so readily absorbed by the GIT)
- ONLY ABOVE THE AGE OF 7 DUE TO IMPAIRED GAG REFLEX + COULD SWALLOW
corticosteroid Inhalers/spray
eg. betamethasone
- metered dose sprays
- practical and easy to bring with you
- directed to site of lesion so site-specific unlike mw
- difficult for people w/ impaired dexterity eg. cerebral palsy/RA
- probable absorption of corticosteroid
Types of topical corticosteroids with dosages
BETAMETHASONE
-soluble 500mcg tablets in 20ml of water QDS (4 times a day) for 5 days -> not to be swallowed
-betamethasone valerate (0.025/0.05/0.1%) BD (2 times a day) cream or ointment (BETNOVATE)
-Beclomethasone proprionate inhaler 50mcg/metered dose
50-100mcg BD (twice a day) i-ii puffs to affected area
CREAM VS OINTMENT
CREAM:
- oil+water
- flow easily and localisation is hard
- has preservatives which can cause adverse rxn in pt eg. OFG benzoates
OINTMENT
-oil+wax no water (or v little)
-localisation is difficult and flushed away by saliva
-usefull for buccal/labial sulcus+ gingiva
-pt may not like texture
NO PRESERVATIVES
Safety of topical corticosteroids and side effects and how to resolve these
- if used as intended (eg. no swallow) they’re safe w few adverse effects
- dermatological use= atrophy eg. rosacea/perioral dermatitis
- ORAL CANDIDOSIS esp with: diabetes, smoking, ill-fitting acrylic denture, pregnancy, high carb diet
- manage this side effect by using anti-fungals eg. miconazole/nystatin/fluconazole OR CHX mouthwash to prevent secondary bacterial infection
- preservative in creams (NOT OINTMENTS) can cause hypersensitivity and adverse rxns in ppl with OFG eg. benzoates so give an OINTMENT
- swallowing can cause systemic adverse effects
Systemic corticosteroids adverse effects
if stopped suddenly= Addison’s crisis due to adrenal insufficiency
some conditions are made worse:
- TB
- HYPERTENSION
- DIABETES
- OSTEOPEROSIS
- > prescribe with vit D and calcium and bisphosphonates
SIDE EFFECTS:
- endocrine conditions: addidons crisis and cushings disease (xs cortisol), diabetes gets worse
- HYPERTENSION
- OSTEOPEROSIS
- GI: peptic ulceration
- EYES: cataracts and glaucome
- depression
- delayed wound healing
topical analgesic examples
- difflam/benzydamine hydrochlorise
- lidocaine
- covering agents eg. orabase
DIFFLAM
- rinse/spray
- 0.15% benzydamine hydrochloride (difflam)= LA and analgesic and slighly anti-inflammatory
- its a non-steroidal anti-inflammatory agent
- not to be swallowed
- side effects: difficulty breathing, wheezing, pharyngeal rash
lidocaine
- 5% oral gel/ointment
- if too strong could suppress laryngeal reflex
Covering agents
- eg. orabase
- protective barrier against secondary infections
- protective barrier to further mechanical irritation in ROU patients
When do we use topical antibiotics
-hepetiform/severe ulcers
What conditions are closely associated to ulcer/ROU
- Haematinic deficiencies
- GIT- COELIAC and crohns disease
- Bechets disease
What is triorasol mouthwash
500mcg soluble tablets of bethamethasone 100mg dispersable doxycyline 1ml nystatin suspension dissolved in 10ml of water mouthwash for 2-3 mins and spit out don’t eat for 1 hr.
BETAMETHASONE=anti-inflammatory and decreases symptoms
DOXYCYLINE= antibacterial for herpetiform/severe ulcers
NYSTATIN= antifungal for candida superinfection/prophylaxis
disadvantages of triorasol mouthwash
- enamel staining
- tongue coating
- pt dislike taste and texture
Tacrolimus
0.03-0.1%
calcinurin inhibitor - inhibits IL2 activating t-cells
2nd line of action- thought to had malignant associations
-
ORAL ULCERS LECTURE 110
-
OROFACIAL FUNGAL INFECTIONS24
-
DRY MOUTH AND SALIVARY GLAND DISEASES31
-
ORAL PIGMENTATION23
-
VESICULOBULLOUS DISORDERS26
-
NUTRITIONAL GI DISEASE26
-
HIV CASED BASED DISCUSSION12
-
MUCOCUTANEOUS DISEASES23
-
FACIAL RASHES20
-
PHARMALOGICAL INTERVENTION32
-
OROFACIAL PAIN41
-
DOSAGES FOR OSCE9
