Go Green, Go Online to take your course

© Desislava Dimitrova | Dreamstime.com

This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Earn

3 CE creditsThis course was

written for dentists, dental hygienists,

and assistants.

Published: September 2010Expiry: August 2013

Part I: Quelling Cold Sores and Aphthous UlcersWritten by Jacalyn Neceskas, PharmD, BCPS; Stacie Moore, PharmD; Susan Goodin, PharmD, FCCP, BCOP

Part I I: Relieving XerostomiaWritten by Fiona M. Collins, BDS, MBA, MA

A Peer-Reviewed Publication

2 www.ineedce.com

Educational ObjectivesThe overall goal of this article is to provide the reader with informa-tion 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.

AbstractRecurrent 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-the-counter and prescription products.

IntroductionRecurrent herpes labialis (cold sores) and recurrent aph-thous 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 RHLThe precise precipitating events and mechanisms for the oc-currence of RAU are as yet not fully explained. A wide range of factors have been implicated in RAU (Table 1), with non-smokers 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 sys-tem, with the presence of increased levels of circulating and inflammatory mediators including TNF-α, interleukin-2, natural killer cells, and antiendothelial cell autoantibodies.10

Table 1. Implicated factors and associations for RAUSensitivity to sodium lauryl sulfate StressIron, folate, zinc or vitamin B12 deficiency Local traumaMedication use Systemic diseasesImmune system involvement GeneticsHypersensitivity 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 transmit-ted 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 sen-sory 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 recogni-tion by the immune system, prompts the release of inflamma-tory mediators followed by a clinically evident RHL outbreak.

Table 2. Triggers and stressors for periodic reactivation of HSV-1

Anxiety/stressInfection (e.g., the common cold)Ultraviolet lightDental treatmentMenstruation

Ultra-violet (UV) light as a trigger has been well-studied in clinical trials. Rooney et al. investigated the effect of sun-screen (SPF-15) application compared to use of a placebo in a randomized, double-blind crossover study. No patients de-veloped active lesions while using SPF-15 sunscreen and only one had asymptomatic viral shedding, while during the pla-cebo 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 RHLRAU are classified as minor, major, and herpetiform recur-rent 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 sur-faces of the oral mucosa, including the tongue and palate. All 3 types can cause moderate to severe pain, and result in dif-ficulty 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 debilitat-ing pain, take up to several weeks or months to heal, and heal with scarring.

Part I: Quelling cold sores and aphthous ulcers

www.ineedce.com 3

Figure 1a. Major recurrent aphthous ulcers

Figure 1b. Minor recurrent aphthous ulcer

Figures1a,b:CourtesyofHIVdent

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 occur-rence 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 forma-tion 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 com-mon 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

Figure2a:CourtesyofDianeM.Daubert,RDH,MS

Figure 2b. Crusted recurrent herpes labialis lesion

Figure2b:CourtesyofWilliamL.Balanoff,DDS,MS,FICD

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 un-certainty about the frequency of recurrence. Treatment is most effective if initiated during the initial 48 hours of the recurrence.

General Considerations for PatientsIt 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 pre-vent 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 essen-tial to stress the importance of visiting (or returning to) the den-tist 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 fe-ver, 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 Over-the-counter productsThe mainstay of palliative care, aimed at relieving symptoms until RAU resolve, is over-the-counter (OTC) oral pastes

4 www.ineedce.com

and rinses. 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 bar-rier 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 double-blind, 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 in-gredients. 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 le-sions are widespread, a bioadherent barrier rinse (Rincinol®) can be considered and will coat all of the oral mucosa.

Prescription productsPrescription 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 effec-tive in reducing the duration of lesions when used 3-4 times dai-ly, 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 tri-amcinolone 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 con-taining 5% amlexanox (Aphthasol®) has been found in a place-bo-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 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 suppres-sion, which would require tapering off of their use.

Table 3. Treatment options for RAUOver-the-counterPain-relieving topical analgesic pastes Barrier creams and liquidMucosal barrier adhesive patch (Canker Cover)Bioadherent barrier rinse (Rincinol)Bioadherent barrier analgesic rinse (Kank-A)Prescription - topical Prescription - systemicViscous lidocaine rinse (2%) CorticosteroidsTetracycline rinse (5%) LevamisolCorticosteroid creams Thalidomide*Amlexanox (5%)Bioadherent barrier rinsePrescription - systemic*Mustneverbeusedinwomenwhoare/maybecomepregnant

Treatment and Care of RHLMajor goals of treatment of RHL include pain relief, reduc-tion of inflammation, improved (faster) healing, avoidance of secondary bacterial infections, and prevention of transmis-sion 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 treatmentsA 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 anti-septic 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 treat-ment 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 cessa-tion was 13.4 hours.19

www.ineedce.com 5

Natural productsA 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 investi-gated 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 ran-domized, double-blind clinical trial with 46 patients, where it was used every 2 hours during waking hours. The inves-tigators found that it reduced mean healing time by 1.5 days compared to placebo (based on patient diaries and telephone interviews) and was well-tolerated.28

Prescription productsFDA-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 replica-tion 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, double-blind, 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 identi-cal, randomized, double-blind, placebo-controlled multi-center 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 heal-ing by 1 day compared to use of acyclovir.33

Table 4. Clinical results of treatments for RHL

Treatment Clinical Results10% docosanol (Abreva)

Median pain cessation time reduced by 13.4 hours

Median reduction in healing time of 17.5 hoursTopical lysine (Lip Clear® Lysine+)

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

Reduced duration of painPenciclovir cream (Denavir®)

Median reduction in healing time of 0.7 - 1 day

Median pain cessation time reduced by 0.6 daysValacyclovir tablets Median reduction in healing time of 0.8 days

Median pain cessation time reduced by 0.5 - 0.7 daysFamciclovir tablets 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 ex-perienced 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

SummaryRecurrent 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 pre-scribing medicaments and drugs, the severity and frequency of the lesions, health status of the individual patient and clini-cal efficacy of the product should be considered.

6 www.ineedce.com

Part II: Relieving Xerostomia

Educational ObjectivesThe overall goal of this article is to provide the reader with infor-mation 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.

AbstractXerostomia (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 prescrip-tion and over-the-counter products, and recommendations should be tailored for the individual patient.

IntroductionXerostomia, 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, an-tihypertensives, 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 chemo-therapy can also result in xerostomia and changes to the consistency of saliva, head and neck radiation results in se-vere 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, breath-ing 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

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

Oral Signs and SymptomsIndividual 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

Figure 1. Dry appearance of oral mucosa

Figure 2. Angular cheilitis in patient with xerostomia

Figures1and2:CourtesyofSandraL.Boody,RDH,MEd

Detecting and Diagnosing Xerostomia in the Dental OfficePatients 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 whether the patient has the sensation of dryness in the mouth, dry lips, or difficulty speaking, chewing, or swal-lowing. Asking whether the patient has to sip water to chew

www.ineedce.com 7

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 xerosto-mia 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 objec-tive 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 fac-tor and is performed using either a specific questionnaire designed for the purpose or a visual analog scale (VAS).

Treatment Options for XerostomiaDental professionals are oral care experts and thus positioned to detect, diagnose and recommend primary treatment for xe-rostomia.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 dry-mouth patients containing lower levels of sodium lauryl sulfate (SLS), or without SLS, and with low foaming activity to reduce the possibility of irritation are avail-able (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, alco-hol, 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 chief symptom and complaint with xerosto-

mia – 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 ProductsPrescription products used to treat xerostomia include those that stimulate salivary production and those that relieve symp-toms. 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 lubri-cate 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 productsOver-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 wa-ter 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 ingredi-ent 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-the-counter spray and atomizer saliva substitutes have also been found to provide relief from xerostomia.7

8 www.ineedce.com

Figure 3. Mouthwashes, chewing gums and patch

These may contain glycerin, glycerol, mucin, or carboxy-methylcellulose 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 de-mineralization.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 unstimu-lated whole salivary flow.23

Figure 4a. Figure 4b. Patch placed in Patch during dissolution position with finger for xerostomia relief

Intraoral devices have recently also been investigated for the relief of xerostomia. One study found that a night guard fab-ricated 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

SummaryXerostomia 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 xe-rostomia. 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 sub-jective 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 in-clude 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 I1 Vestly JP,NorvalM.Mucocutaneous infectionswithherpes simplexvirus

andtheirmanagement.Clin Exp Dermatol.1992;17:221-37.2 Xu F, Schillinger JA, Sternberg MR, et al. Seroprevalence and coinfection

withherpessimplexvirustypeIandtype2intheUnitedStates,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 ChattopadhyahP,ChatterjeeS.RiskindicatorsforrecurrentaphthousulcersintheUS.Community Dent Oral Epidemiol.2007;35:152-9.

5 Oralpainanddiscomfort.In:AllenLV,BerardiRR,DeSimoneEL,etal,eds.Handbook of Nonprescription Drugs. 12th ed.Washington, D.C.: AmericanPharmacistsAssociation;2000:585-609.

6 NatahSS,KonttinanYT,EnattahNS,etal.Recurrentaphthousulcerstoday:areviewofthegrowingknowledge. Int J Oral Maxillofac Surg.2004;33:221-34.

7 BrokstadB,BarkvollP.Theeffectoftwotoothpastedetergentsonthefrequencyofrecurrentaphthousulcers.Acta Odontol Scand.1996;54(3):150-3.

8 AbdollahiA,RadfarM.Areviewofdrug-inducedoralreactions.J Contemp Dent Pract.2003;4:10-31.

9 TackAD,RogersRS.Oraldrugreactions.Dermatol Ther.2002;15:236-50.10 Jurge S, Cuffer R, Scully C, Porter SR. Mucosal disease series number

VI:Recurrentaphthousstomatitis.Oral Dis.2006;12:1-21.

www.ineedce.com 9

11 RooneyJF,BrysonY,MannixML,etal.Preventionofultraviolet-light-inducedherpeslabialisbysunscreen.Lancet.1991;338;1419-21.

12 Woo S, Challacombe SJ. Management of recurrent oral herpes simplexinfections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2007;103(Suppl1):e1-S12.e18.

13 MizrahiB,ShapiraL,DobAJ,HadHY.Citrusoilandmagnesiumsaltasantibacterialandanti-inflammatoryagents. J Periodontol.2006;77(6):963-8.

14 Mizrahi B,WolnermanY, Domb AJ. Adhesive tablet effective for treatingcankersoresinhumans.J Pharm Sci.2004;93(12):2927-35.

15 ShemerA,AmichaiB,TrauH,NathansohnN,MizrahiB,DombAJ.Efficacyof a mucoadhesive patch compared with an oral solution for treatment ofaphthousstomatitis.Drugs R D.2008;9(1)29-35.

16 Herlofson BB, Barkvoll P. Sodium lauryl sulfate and recurrent aphthousulcers.Apreliminarystudy.Acta Odontol Scand.1994;52(5):257-9.

17 KhandwalaA,WaninwegenRG,AlfanoMC.5%Amlexanoxoralpaste,anewtreatmentforrecurrentminoraphthousulcers.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 treatmentrecommended by health care professionals for treating recurrent herpeslabialis.J Am Dent Assoc.2004;135:48-54.

20 SacksSL,ThistedRA,JonesTM,etal.Clinicalefficacyoftopicaldocosanol10%creamforherpessimplexlabialis:amulticenter,randomizedplacebo-controlledtrial.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 AboutAbreva:Efficacyanduse.AbrevaWebsite.http://www.abreva.com.23 CarsonCF,AshtonL,DryL,etal.Melaleucaalternifolia (tea tree)oilgel

(6%)forthetreatmentofrecurrentherpeslabialis.J Antimicrob Chemother.2001;48:450-1.

24 GriffithRS,DeLongDC,NelsonJD.Relationofarginine-lysineantagonismtoherpessimplexgrowthintissueculture.Chemotherapy.1981;27:209-13.

25 TomblinFAJr,LucasKH.Lysineformanagementofherpeslabialis.Am J Health Syst Pharm.2001;58:300-4.

26 McCune MA, Perry HO, Muller SA, et al.Treatment of recurrent herpessimplexinfectionswithL-lysinemonohydrochloride.Cutis.1984;34:366-73.

27 SinghBB,UdaniJ,VinjamurySP,etal.SafetyandeffectivenessofanL-lysine,zinc, and herbal-based product on the treatment of facial and circumoralherpes.Altern Med Rev.2005;10:123-7.

28 Godfrey HR, Godfrey NJ, Godfrey JC, et al. A randomized clinical trialonthetreatmentoforalherpeswithtopicalzincoxide/glycine. Alter Ther Health Med.2001;7:49-56.

29 Zoviraxcream5%(packageinsert).Glaxosmithkline.30 Spruance SL, Nett R, MarburyT, 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 SpruanceSL,ReaTL,ThomingC,etal.Pencyclovircreamforthetreatmentof recurrent herpes simplex labialis: a randomized, multicenter, double-blind,placebo-controlledtrial.J Am Med Assoc.1997;277:1374-9.

32 Raborn GW, Martel AY, Lasonde M, et al. Effective treatment for herpessimplexlabialiswithpenciclovircream:combinedresultsoftwotrials.J Am Dent Assoc.2001;133:303-9.

33 FemianoF,GambosF,ScullyC.Recurrentherpeslabialis:efficacyoftopicaltherapy with penciclovir compared with acyclovir (acyclovir). Oral Dis.2001;7:31-3.

34 Raborn GW, McGaw WT, Greace M, et al. Oral acyclovir and herpeslabialis: a randomized,double-blind,placebo-controlledstudy.J Am Dent Assoc.1987;115(1):38-42.

35 Spruance SL, Stewart JC, Rowe NH, et al.Treatment of recurrent herpessimplexlabialiswithoralacyclovir.J Infect Dis.1990;161:185-90.

36 Spruance SL, Jones TM, Blatter MM, et al. High-dose, short-duration,earlyvalacyclovirtherapyforepisodictreatmentofcoldsores:resultsoftworandomized, placebo-controlled, multicenter studies. Antimicrob Agents Chemother.2003;47:1072-80.

37 SpruanceSL,BodsworthN,ResnickH,etal.Single-dose,patient-initiatedfamciclovir: a randomized, double-blind, placebo-controlled trial forepisodictreatmentofherpeslabialis.J Am Acad Dematol.2006;55:47-53.

References Part II1 PorterSR,ScullyC,HegartyAM.Anupdateoftheetiologyandmanagement

of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2004;97:28-46.

2 SreebnyLM,SchwartzSS.Areferenceguidetodrugsanddrymouth—2ndedition.Gerodontology.1997;14:33-47.

3 http://www.drymouth.info/practitioner/overview.asp4 Mouly SJ, Orler JB, TilletY, Coudert AC, Oberli F, et al. Efficacy of a

new oral lubricant solution in the management of psychotropic drug-inducedxerostomia:arandomizedcontrolledtrial.J Clin Psychopharmacol. 2007;27(5):437-43.

5 Managingxerostomia.Vital6,32–34(1March2009)|doi:10.1038/vital944

6 AtkinsonJC,GrisiusM,MasseyW.Salivaryhypofunctionandxerostomia:diagnosisandtreatment.Dent Clin N Am.2005;49:309-26.

7 Vissink A, Panders AK, Gravenmade EJ, Vermey A. Treatment of oralsymptomsinSjögren’ssyndrome.Scand J Rheumatol Suppl.1986;61:270-3.

8 Navazesh M, Kumar SK. Measuring salivary flow: challenges andopportunities. J Am Dent Assoc.2008;139Suppl:35S-40S.

9 Frost PM. Difficulties in dental prescribing of saliva substitutes forxerostomia.Gerodontology.2002;19(2):123-4.

10 http://www.medicinenet.com/pilocarpine-oral/article.htm11 Papas AS, Clark RE, Martuscelli G, O’Loughlin KT, Johansen E, et al. A

prospective, randomized trial for the prevention of mucositis in patientsundergoing hematopoietic stem cell transplantation. Bone Marrow Transplant.2003;8:705-12.

12 Christersson CE, Lindh L, Arnebrant T. Film-forming properties andviscosities of saliva substitutes and human whole saliva. Eur J Oral Sci. 2000;108:418-425.

13 Andersson G, Johansson G, Attstrom R, Edwardsson S, Glantz P-O, etal.Comparisonof theeffectof the linseedextractSalinum®andamethylcellulose preparation on the symptoms of dry mouth. Gerodontology. 1995;12:12-17.

14 ShahdadSA,TaylorC,BarclaySC,SteenIN,PreshawPM.Adouble-blind,crossover study of Biotène Oralbalance and BioXtra systems as salivarysubstitutesinpatientswithpost-radiotherapyxerostomia.Eur J Cancer Care (Engl).2005;14(4):319-26.

15 SugiuraY,SogaY,TanimotoI,KokeguchiS,NishideS,etal.Antimicrobialeffects of the saliva substitute, Oralbalance, against microorganisms fromoralmucosainthehematopoieticcell transplantationperiod.Support Care Cancer.2008;16(4):421-4.

16 Matear DW, Barbaro J. Effectiveness of saliva substitute products in thetreatmentofdrymouthintheelderly:apilotstudy.J R Soc Promot Health. 2005;125(1):35-41.

17 EpsteinJB,EmertonS,LeND,Stevenson-MooreP.Adouble-blindcrossovertrialofOralBalancegelandBiotene toothpasteversusplacebo inpatientswithxerostomiafollowingradiationtherapy.Oral Oncol.1999;35(2):132-7.

18 Silvestre FJ, Minguez MP, Suñe-Negre JM. Clinical evaluation of a newartificial saliva in spray form forpatientswithdrymouth.Med Oral Patol Oral Cir Bucal.2009Jan1;14(1):E8-E11.

19 ItthagarunA,WeiSH.Chewinggumandsalivainoralhealth. J Clin Dent. 1997;8(6):159-62.

20 Bots CP, Brand HS, Veerman EC, Korevaar JC, Valentijn-Benz M, et al.Chewing gum and a saliva substitute alleviate thirst and xerostomia inpatientsonhaemodialysis.Nephrol Dial Transplant.2005;20(3):578-84.

21 Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque andremineralization of enamel lesions by various forms of calcium in amouthrinseorsugar-freechewinggum. J Dent Res.2003;82(3):206-11.ref

22 Nuvorawebsite.http://www.nuvorainc.com/salese-learn-more.html23 Afriamian D. Treating Xerostoma Utilizing an Adhesive Oral Tablet As

ComparedWithBioteneRinses.Dataonfile.24 YamamotoK,NagashimaH,YamachikaS,HoshibaD,YamaguchiK,etal.

Theapplicationofanightguardforsleep-relatedxerostomia.Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2008;106(3):e11-4.

25 Hirvikangas M, Posti J, Mäkilä E. Treatment of xerostomia through useof dentures containing reservoirs of saliva substitute. Proc Finn Dent Soc. 1989;85(1):47-50.

26 MommF,Volegova-NeherNJ,Schulte-MöntingJ,GuttenbergerR.Differentsaliva substitutes for treatment of xerostomia following radiotherapy. Aprospectivecrossoverstudy.Strahlenther Onkol.2005Apr;181(4):231-6.

Author ProfilesDr. 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 divi-sion 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 Univer-sity and holds an MBA and MA from Boston University.

DisclaimerThe 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 FeedbackWe encourage your comments on this or any PennWell course. For your conve-nience, an online feedback form is available at www.ineedce.com.

10 www.ineedce.com

Online CompletionUse this page to review the questions and answers. Return towww.ineedce.comand sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. 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. 60%; 20%b. 70%; 30%c. 80%; 40%d. 90%; 50%

2. _________ is an implicated factor/associa-tion for RAU.a. Hypersensitivity/sensitivity to foods/chemicalsb. Medication usec. Geneticsd. all of the above

3. RHL is caused by a _________with herpes simplex virus type 1. a. primary infectionb. secondary infectionc. tertiary infectiond. none of the above

4. RHL is transmitted by _________.a. aerosolsb. direct contact with the secretions from herpetic

lesionsc. sneezing and coughingd. all of the above

5. _________ is a potential trigger/stressor for periodic reactivation of HSV-1.a. UV lightb. Anxiety/stressc. Dental treatmentd. all of the above

6. _________ can play an important role in preventing recurrences of RHLa. Bitter aloeb. Sunscreenc. Lip salved. all of the above

7. Recurrent aphthous ulcers _________.a. result in the appearance of a flat or cratered,

grayish-yellow area surrounded by a ring of inflamed tissue

b. occur on nonkeratinized surfaces of the oral mucosac. can cause moderate to severe paind. all of the above

8. It is during the vesicle stage of RHL that the patient experiences _________.a. the highest viral loadb. bacterial superinfectionc. viral superinfectiond. 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 infectionb. avoid triggers such as sunlightc. 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. 7b. 10c. 14d. 21

11. _________ are the mainstay of palliative care for RAU.a. Prescription oral pastes and rinsesb. Over-the-counter (OTC) oral pastes and rinsesc. Corticosteroidsd. none of the above

12. A mucosal adhesive patch containing citrus oil and magnesium chloride _________.a. has been shown to help relieve painb. forms a barrier over the lesion to help protect itc. has been shown to reduce healing timed. all of the above

13. Pain-relieving topical analgesic pastes used for RAU typically contain _________.a. 10% benzocaine or 1% lidocaineb. 15% benzocaine or 2% lidocainec. 20% benzocaine or 2% lidocained. none of the above

14. 5% amlexanox has been found to _________ , when applied 4 times daily.a. increase the rate of healing of RAUb. reduce the duration of painc. provide only palliative reliefd. a and b

15. 10% docosanol cream _________.a. has been found to reduce healing time b. has been found to reduce the time to cessation

of painc. is a nonprescription creamd. all of the above

16. Topical lysine has been shown to reduce healing time and to provide relief for ____. a. RAUb. RHLc. RAU and RHLd. none of the above

17. _________ is an FDA-approved prescription product for the treatment of RHL.a. Acyclovir cream b. Penciclovir cream c. Fanclover creamd. a and b

18. _________ are factors in the occurrence of xerostomia.a. Medication, alcohol and tobacco useb. Chemotherapy and head and neck radiation

therapyc. Auto-immune diseasesd. all of the above

19. _________ is a symptom of xerostomia. a. A sticky and/or dry feeling in the mouth b. Stringy or ropey salivac. Difficulty speaking, chewing or swallowingd. All of the above

20. _________ can be a sign of xerostomia. a. The appearance of dryness of the oral mucosa and

oral irritationsb. An increased level of carious lesionsc. An increased level of plaque and bad breathd. 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. an unstimulated salivary flow testb. a visual analog scalec. a stimulated salivary flow testd. a and c

22. The results of the ________of xerostomia are important to proper treatment of the patient.a. objective assessmentb. subjective assessmentc. objective and subjective assessmentsd. none of the above

23. If a mouth mirror sticks when placed against the buccal mucosa _________.a. this suggests enzymatic activityb. this is indicative of inadequate salivary flowc. this is indicative of adequate salivary flowd. a and c

24. Toothpastes specifically formulated for dry-mouth patients contain _________.a. lower levels of SLS or no SLSb. lower levels of zincc. higher levels of antibacterial agentsd. 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 alcoholc. alcohol-containing rinsesd. all of the above

26. Xerostomia associated with mouth-breathing is _________. a. sometimes permanentb. always permanentc. always debilitatingd. none of the above

27. _________ has been shown to help relieve the symptoms of dry mouth.a. Sipping waterb. Chewing gumc. Sleeping with a humidifierd. all of the above

28. Mouthwashes for the treatment of xerostomia are formulated to effectively _________.a. help relieve dry mouth b. soothe the oral mucosa c. help cleanse the oral cavity, and combat halitosis d. all of the above

29. A small mucoadhesive patch used to treat xerostomia has been found to _________. a. effectively relieve dry mouthb. dissolve over 2-4 hours to moisturize the mouthc. increase whole salivary flowd. all of the above

30. Dry mouth can be relieved using _______. a. toothpastes, mouthwashes and saliva substitutesb. chewing gums and lozengesc. a mucoadhesive patchd. combinations of the above

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

Ifnottakingonline,mailcompletedanswersheetto

Academy of Dental Therapeutics and Stomatology,A Division of PennWell Corp.

P.O.Box116,Chesterland,OH44026orfaxto:(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.

�Paymentof$49.00isenclosed.(Checks and credit cards are accepted.)

Ifpayingbycreditcard,pleasecompletethefollowing: MC Visa AmEx Discover

Acct.Number:_______________________________

Exp.Date:_____________________

Charges on your statement will show up as PennWell

ANSWER SHEET

Part I: Quelling Cold Sores and Aphthous UlcersPart I I: Relieving Xerostomia

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone:Home() Office() Lic.RenewalDate:

Requirementsforsuccessfulcompletionofthecourseandtoobtaindentalcontinuingeducationcredits:1)Readtheentirecourse.2)Completeallinformationabove.3)Completeanswersheetsineitherpenorpencil.4)Markonlyoneanswerforeachquestion.5)Ascoreof70%onthistestwillearnyou3CEcredits.6)CompletetheCourseEvaluationbelow.7)MakecheckpayabletoPennWellCorp.For Questions Call 216.398.7822

Educational ObjectivesPart i.

1. Listanddescribetheetiologyandpathophysiologyrelatedtorecurrentaphthousulcersandrecurrentherpeslabialis.

2. Listanddescribethegeneralrecommendationsspecifictopatientsexperiencingrecurrentherpeslabialis.

3. Listanddescribethetreatmentoptionsavailableforrecurrentaphthousulcersandrecurrentherpeslabialis.

Part ii.

1. Listtheetiologicalfactorsforxerostomia.

2. Listanddescribethesignsandsymptomsofxerostomia.

3. Listanddescribethetreatmentoptionsavailableforthereliefofdrymouth.

Course EvaluationPleaseevaluatethiscoursebyrespondingtothefollowingstatements,usingascaleofExcellent=5toPoor=0.

1.Weretheindividualcourseobjectivesmet? Objective#1:YesNo Objective#3:YesNo

Objective#2:YesNo Objective#4:YesNo

2.Towhatextentwerethecourseobjectivesaccomplishedoverall? 5 4 3 2 1 0

3.Pleaserateyourpersonalmasteryofthecourseobjectives. 5 4 3 2 1 0

4.Howwouldyouratetheobjectivesandeducationalmethods? 5 4 3 2 1 0

5.Howdoyouratetheauthor’sgraspofthetopic? 5 4 3 2 1 0

6.Pleaseratetheinstructor’seffectiveness. 5 4 3 2 1 0

7.Wastheoveralladministrationofthecourseeffective? 5 4 3 2 1 0

8.Doyoufeelthatthereferenceswereadequate? Yes No

9.Wouldyouparticipateinasimilarprogramonadifferenttopic? Yes No

10.Ifanyofthecontinuingeducationquestionswereunclearorambiguous,pleaselistthem.

___________________________________________________________________

11.Wasthereanysubjectmatteryoufoundconfusing?Pleasedescribe.

___________________________________________________________________

___________________________________________________________________

12.Whatadditionalcontinuingdentaleducationtopicswouldyouliketosee?

___________________________________________________________________

___________________________________________________________________ AGD Code 016, 734, 739

AUTHOR DISCLAIMERThe author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

SPONSOR/PROVIDERThis 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 Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMERThe 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 to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National 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.

RECORD KEEPINGPennWell 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 POLICYAny 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

CANK910RDH

www.ineedce.com Customer Service 216.398.7822 11

The Time-Released Dry Mouth PatchThe Time-Released Dry Mouth PatchThe Time-Released Dry Mouth Patch

of your patients have dry mouth.

%

How does OraMoist Work?

• Apply the patch to the roof of the mouth (or cheek or gums).

• Time-released lipids moisten the mouth for up to 4 hours.

• Xylitol and lemon flavor stimulate saliva production and improve oral health.

• Use day or night.Call for your FREE Samples

1-800-448-1448

Available at:

in Oral Pain AisleFL, AZ, AR, CO, LA, NM, TX, UT

OraMoist–the non-prescription dry mouth

patch that provides hours ofmoisturizing relief.

The Time-Released Dry Mouth PatchThe Time-Released Dry Mouth Patch

www.oramoist.com

Now there’s help.