Oral Pain: Assessing the Appropriateness of Self-Therapy

The importance of oral health is underestimated by many individuals until a problem arises. Oral pain and discomfort can negatively impact an individual’s daily routine.

Fortunately, pharmacists are in a pivotal position to guide patients in the proper selection of nonprescription products for the self-treatment of conditions that are often associated with oral pain or discomfort (Table 1^1,2). Pharmacists should always direct patients with oral conditions that are not amendable to self-treatment to seek care from their primary health care provider. Available nonprescription oral pain relief products include topical analgesics/anesthetics, toothpastes formulated for sensitive teeth, artificial saliva products for dry mouth, oral mucosal protectants, and products that treat and relieve cold sores (Online Table 2).

Table 2: Examples of Topical Nonprescription Oral Pain Products

Pediatric Teething Preparations

· Anbesol - Baby Oral Anesthetic Gel (benzocaine 7.5 %)

· Little Teethers Oral Pain Relief Gel (benzocaine 7.5%)

· Orajel - Baby Fast Teething Pain Relief (benzocaine 7.5%)

· Orajel - Baby Nighttime, Gel (benzocaine 10%)

Adult Preparations for Toothache and Canker Sore Relief

· Anbesol Liquid (benzocaine 10%)

· Blistex Kank-A Mouth Pain Liquid (benzocaine 20% W/V, compound benzoin tincture)

· Blistex Lip Medex (petrolatum 59%, camphor 1%, menthol 1%, phenol 0.5%)

· Canker Cover Oral Canker Sore Patches (menthol 2.5mg)

· Carmex

· Colgate Canker and Mouth Sore Pain Reliever (benzocaine 20%)

· Colgate

· Gly-Oxide Liquid (carbamide peroxide 10%)

· Herpecin L

· Gum Canker-X

· Orajel Mouth Sore Medicine (benzalkonium chloride 0.2%, benzocaine 20%, zinc chloride 0.1%)

· Orajel Ultra Fast Canker Sore Relief Plus, Film-Forming Gel (benzocaine 15%, menthol 2%)

· Orajel Instant Pain for Severe Toothache (benzocaine 20%)

· Orajel Maximum Strength Nighttime Formula P.M. Oral Pain Reliever Cream for Toothache (benzocaine 20%)

· Red Cross

· Orajel Protective Mouth Sore Discs (benzocaine 15mg)

· Quantum Canker Cover Patches (menthol 2.5mg)

· UlcerEase Anesthetic Mouth Rinse (purified water, glycerin, sodium bicarbonate, sodium borate, liquid phenol)

· Zilactin Tooth and Gum Instant Pain Reliever (benzocaine 20%)

Products Marketed for Cold Sore Treatment or Pain Relief Treatment

· Abreva Cold Sore/Fever Blister Treatment (docosanol 10%)

· Anbesol Cold Sore Therapy Ointment with Vitamin E & Aloe (allantoin 1%, Benzocaine 20%, camphor 3%, white petrolatum 64.9%)

· Aveeno Active Naturals Advanced Relief Cold Sore Treatment (white petrolatum 89.5%)

· Blistex Medicated Lip Ointment (allantoin W/W 1.0%, camphor W/W 0.5%, menthol W/W 0.6%, Phenol W/W 0.5%)

· Campho-phenique Medicated Cold Sore Treatment for Scab Relief (pramoxine HCl 1% W/W, white petrolatum 30% W/W)

· Carmex Lip Balm for Cold Sores (menthol 0.4%, camphor 1.7%, phenol 0.4%)

· Herpecin-L Lip Protectant & Sunscreen/Cold Sore Lip Balm (dimethicone 1%, menthyl anthranilate 5.0%, octyl methoxycinnamate 7.5%, octyl salicylate 5.0%, oxybenzone 6.0%)

· Neosporin LT Lip Treatment (allantoin 1.5%, pramoxine 1%)

· Orabase

· Orajel Overnight Cold Sore Patch (dyclonine hydrochloride 3mg)

· Quantum Lip Clear Lysine + Cold Sore Treatment Ointment (zinc oxide 1.2%)

· Releev 1 Day Cold Sore Treatment (benzalkonium chloride 0.13%)

· Zilactin Cold Sore Gel (benzyl alcohol 10%)

Products for Sensitive Teeth

· Aquafresh Sensitive

· Arm & Hammer Sensitive

· Biotene Toothpaste for Sensitive Teeth & Cavity Protection

· Colgate Maximum Strength Sensitive Plus Whitening Toothpaste

· Crest Sensitivity Extra Whitening Maximum Strength Toothpaste

· Orajel Tooth Desensitizer

· Sensodyne Toothpaste for Sensitive Teeth

Products for Dry Mouth

· Biotene Dry Mouth Toothpaste

· Biotene Oral Balance Dry Mouth Moisturizing Gel

· Biotene Dry Mouth Gum

· Mouth Kote

· Orajel Dry Mouth Relief Gel

· Oral Balance

· Oasis Moisturizing Mouthwash for Dry Mouth

· Quantum OraMoist Dry Mouth Discs

· Salivart Oral Moisturizer Spray

· SalivaSure Lozenges

· Stoppers 4 Dry Mouth Spray

Homepathetic Teething Products

· Boiron Camilia, Teething Relief (belladonna 5C HPUS, alkaloids, Chamomilla 9C HPUS, Ferrum phosphoricum 5C HPUS)

· Hyland’s Homeopathic Teething Tablets (Calcarea phosphorica [calcium phosphate] 3×, Chamomilla (chamomile) 3× HPUS, Coffea cruda (coffee) 3× HPUS, belladonna 3× HPUS 0.0003% alkaloids

Toothache and Teething Pain

Nonprescription oral anesthetics may contain 5% to 20% benzocaine or 0.5% phenol. No teething pain—relief products contain 0.5% phenol, but several products that contain phenol are available for treating other types of oral pain.¹ Most teething pain—relief products contain 7.5% benzocaine, but some nighttime formulas contain 10% benzocaine.

These topical analgesics are available in liquid and gel formulations. 1 Patients should be advised to only use products marketed for teething and tooth pain, especially for pediatric patients.¹ If benzocaine causes a hypersensitivity reaction such as redness or irritation of the gums after topical application, patients should be advised to discontinue use. If appropriate, pharmacists can advise patients to use oral analgesics to relieve discomfort.¹

Recurrent Aphthous Stomatitis (Canker Sores)

Several nonprescription products are available for the symptomatic relief of recurrent aphthous stomatitis. These products include oral debriding and wound cleansing agents, topical oral anesthetics, topical oral protectants, and oral rinses.¹

Cleansing and debriding agents contain carbamide peroxide (10% to 15%), hydrogen peroxide (3%), or sodium bicarbonate. 1 Patients should be advised that these products may be used 4 times daily after meals for no more than 7 days, and these products should not be swallowed.¹ Prolonged use of debriding and cleansing agents can lead to tissue irritation and decalcification of tooth enamel.¹

Patients may elect to use topical oral anesthetics for pain relief, and topical oral protectants to coat and protect lesions. Topical oral protectants temporarily relieve discomfort and may be applied as needed.¹

Oral antiseptic rinses may help to heal lesions. If there is evidence of infection, if lesions worsen or show no signs of improvement after 7 days of self-treatment, or if lesions do not heal within 14 days, patients should be advised to see their primary health care provider.¹

Products for Herpes Simplex Labialis

Docosanol 10% is the only FDAapproved nonprescription agent proved to reduce the duration and severity of a herpes simplex labialis (HSL) outbreak.¹ The FDA has advised that the use of topical skin protectants and external topical analgesic/ anesthetic products can provide symptomatic relief for individuals with HSL, but this use does not reduce the duration of an HSL outbreak. Myriad products can relieve pain associated with an HSL outbreak. Topical skin protectants such as allantoin and petrolatum may help to protect lesions from infection and relieve dryness.¹

Patients should be advised to seek care from their primary health care provider if lesions do not heal within 14 days, if signs of infection appear, or the condition worsens.1 During counseling, patients should be advised of potential triggers of outbreaks, such as stress, fever, menstruation, extreme cold, and windburn.^1,3

Xerostomia

Xerostomia (commonly known as dry mouth) can increase an individual’s risk for dental decay, infection, and periodontal disease.1 It is estimated that 29% to 57% of older adults experience some degree of xerostomia.¹ Because many medications and medical conditions can cause dry mouth, pharmacists can be instrumental in identifying patients who may be more susceptible to this condition (Table 3^1,4).

Artificial saliva substitutes and dry mouth—relief products are available as sprays, liquids, gels, mouthwashes, toothpastes, lozenges, and chewing gums. Products typically contain carboxymethylcellulose and glycerin, and some are available in mint or lemon flavor. Because xerostomia can increase the risk for dental caries, patients should be advised to practice good oral hygiene daily and maintain routine dental visits.

Endnote

During counseling, patients should be assessed for the appropriateness of selftherapy, informed about the proper use of oral pain products, and advised to seek medical care from their primary health care provider if oral pain does not improve or it recurs or worsens after the recommended duration of self-treatment.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References:

• Albanese N. Oral pain and discomfort. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Scully C, Shotts R. Mouth ulcers and other causes of orofacial soreness and pain. West J Med. 2001;174(6):421-424.
• Cold sore triggers. GlaxoSmithKline website. www.abreva.com/about-cold-sores/cold-sore-triggers. Accessed August 28, 2014.
• Dry mouth. National Institute of Dental and Craniofacial Research website. www.nidcr.nih.gov/OralHealth/Topics/DryMouth. Accessed August 28, 2014.