Mouth and throat preparations

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1 Mouth and throat preparations Nicolene van der Sandt, BPharm, MPharm candidate at Sefako Makgatho Health Sciences University Tumelo Ramoleta, BPharm, MPharm candidate at Sefako Makgatho Health Sciences University Correspondence to: Keywords: mouth and throat infections, mouth and throat preparations, dental care Abstract The increasing prevalence and severity of oral disease in South Africa and the resultant effect on quality of life remain of major concern. However, to aid in the relief thereof a variety of over-the-counter (OTC) locally acting mouth and throat preparations are available. The use of these preparations broadly include the symptomatic relief of painful, inflamed and irritated mouths and throats due to various causes, use in dental procedures and the treatment of fungal infections. Medpharm S Afr Pharm J 2016;83(8):19-26 Introduction In South Africa, the increasing prevalence and severity of oral maladies is a growing concern as it affects patients quality of life.1 Disorders of the mouth and throat can either be acute or chronic and may involve infection, inflammation, irritation, pain, ulceration, trauma or fungal infections, to name a few.1 To treat these disorders, several OTC locally acting mouth and throat preparations are available, from liquids to gargle solutions, oral gels, lozenges and sprays.2 The preparations usages range from routine mouthwashes for oral hygiene, to the treatment of coughs due to allergies or colds. For more severe indications, the majority of the preparations may be used for the symptomatic treatment of minor oral infections, sore, irritated or inflamed mouths and throats, for traumatic conditions and in dental procedures. Other common uses include the treatment of dental ulcers and sore gums, oral lesions and denture irritation. Lastly, mouth and throat preparations are available for the treatment of fungal mouth infections (including oral candidiasis) and fungal stomatitis associated with dentures.2 Mouth and throat disorders Common mouth and throat disorders which mouth and throat preparations are used for include2: Painful, inflamed or irritated mouths and throats Minor mouth and throat infections Routine mouthwash for oral hygiene Tonsillitis, laryngitis, certain mouth and gum infections Coughs due to allergy and colds Traumatic conditions and dental procedures Dental ulcers, oral lesions and painful gums Denture irritation Fungal infections and fungal stomatitis of the mouth associated with dentures Some of these disorders are discussed below. Pain and inflammation Dental pain may be associated with either pulpal or periapical periodontitis disease. Pulpal disease is associated with impulsive, resilient and poorly localised aching pain, aggravated by exposure to temperature. Periapical periondititis disease is characterised by well localised severe pain, which often lasts for several hours.3 Inflammation of the mouth is commonly referred to as stomatitis and may be localised and mild or widespread and severe and either on the inside or outside of the mouth. Stomatitis may manifest with swelling, redness of the oral mucosa and a single or multiple painful red ulcer/s. These symptoms often result in dehydration and malnutrition as patients struggle to eat or drink. The risk of the development of secondary infection exists, specially in immunosuppressed patients and some conditions are recurrent.4 Contributing factors to stomatitis include systemic disease, local infections, irritation (physical or chemical) or allergic reactions. Numerous causes are idiopathic. Xerostomia, which refers to a dry mouth, is a known cause and may predispose a patient to stomatitis as the lack of saliva exposes the oral mucosa to insults.4 Dental pain and inflammation can be treated with OTC preparations, in which case standard pain treatment is used.⁵ Painful and irritated throat A painful throat is caused by pain in the posterior pharynx, which may be experienced with or without swallowing. The pain may be severe and may lead to refusal of oral intake. Several factors may S Afr Pharm J 19

2 cause pain and irritation of the throat, tonsillopharyngitis being the major cause. 6 Dental caries Commonly known as tooth decay or tooth cavity, dental caries are caused by the breakdown of teeth due to the presence of bacteria.⁷ The tooth enamel and the layer underneath (termed dentin) are dissolved by acids producing bacteria. Common symptoms experienced include pain during eating, tissue inflammation surrounding the tooth, and infection or loss of the affected tooth.⁸ Contributing factors involve poor oral hygiene, receding gums and socioeconomic factors such as poverty. It is recommended that individuals brush their teeth regularly (twice daily) and floss between their teeth (once daily). Additionally, low amounts of sugar and fluoride should be consumed. These preventative measures aid not only in preventing dental caries, but reduce the extent and severity thereof. 7,9 Candidiasis Candidiasis is an oral fungal infection affecting the mucous membranes of the mouth. Candidiasis is caused by an organism of the candida species, most commonly Candida albicans. There are different types of candidiasis and treatment is tailored accordingly i.e. pseudo-membranous, erythematous and hyperplastic. 10,11 Mouth and throat preparations The following mouth and throat preparations are available in South Africa: Andolex, Andolex-C, Cepacol, Daktarin, Dequadin, Dermadine oral antiseptic, Dynexan, Endocol, Golden throat lollies, Medi-Keel A, Orochlor, Podine mouthwash and gargle, Septadine oral antiseptic, Strepsils and Strepsils intensive, Throflam, Throflam-CO and Vari miconazole. 2 Table I provides the trade names of all of the mouth and throat preparations available, with the indication, available dosage form and dosage instructions for each one of the preparations. Table II lists the contraindications, adverse effects and/ or special precautions for the preparations listed in Table I. Table I: Mouth and throat preparations Sore throat Sore and irritated throat Minor mouth irritation Minor sore throat infections Indication MEDI-KEEL A : Lozenge, throat gargle and throat spray Dosage instructions Lozenge: Suck one lozenge slowly every 2 3 hours as required Throat gargle: Gargle ml every 3 4 hours as required Throat spray: Repeat every 2 hours if required Use at full strength 5 sprays Children 6 12 years: 3 sprays ANDOLEX : Solution, spray and lozenge Solution: Gargle with 15 ml undiluted, every hours If stinging occurs the solution may be diluted Symptomatic relief of painful mouth and throat inflammatory conditions, traumatic conditions and dental operations Spray: 5 10 sprays on affected area and swallow gently Repeat every hours as required ANDOLEX-C : Oral rinse, spray, lozenge and oral gel Lozenge: Suck one lozenge slowly in mouth every 1 2 hours as required Max. 12 lozenges/day Relief of minor infections and painful mouth and throat inflammatory conditions, dental plaque Relief of minor infections and painful mouth and throat conditions Painful inflammatory mouth conditions including mouth and dental ulcers, sore gums Oral rinse: Gargle with 15 ml undiluted for 30 seconds, every hours Children 6 12 years: 5 15 ml every 3 hours Spray: 5 10 sprays on affected area and swallow gently Repeat every hours as required Lozenge: Suck one lozenge slowly in mouth every 1 2 hours as required Max. 12 lozenges/day Oral gel: Gently massage 1 cm into affected area every 2 3 hours Max. 12 times/day CEPACOL : Lozenge and gargle Painful/irritated throat, minor mouth infections, oral hygiene Lozenge: Suck on one lozenge as required Gargle: Gargle with full strength or diluted with equal volume of water as required S Afr Pharm J 20

3 DAKTARIN : Oral gel Fungal infections of mouth Fungal stomatitis associated with dentures Fungal stomatitis (dentures) Oral candidiasis Apply evenly after meals to affected area 3 4 times/day depending on severity of the infection Continue for 2 days after infection clears Retain in mouth for max. time possible for best results Apply to lesion in evening and leave overnight Remove dental prosthetics at night and brush with gel DEQUADIN : Mouth paint Infectious ulceration of mouth, gums, buccal membrane and throat Denture irritation Apply directly to affected areas 2 3 times/day DERMADINE ORAL ANTISEPTIC : Liquid Painful infected/inflamed mouth and throat Routine mouthwash Mouthwash: Dilute 1:2 parts water Infection: Gargle with full strength for 30 seconds hourly Children < 3 years: Dilute 1:3 parts water and paint mouth DYNEXAN : Ointment Mucous membrane, lips and gums anaesthetic, cold sores, mouth ulcers, denture irritation Apply small amount to affected area 3 times daily/ every 5 7 hours ENDCOL : Lozenge Sore, infected or irritated throat Suck one lozenge every 3 hours as required Max. 8 lozenges/day Children < 12 years: Half a lozenge every 3 hours GOLDEN THROAT LOLLIES Tonsillitis, laryngitis, certain mouth and gum infections Suck one lolly every 3 hours Dissolve slowly in mouth for max. effect OROCHLOR : Solution and spray solution Sore throat, pain and discomfort, minor mouth irritation Solution: Gargle ml undiluted or diluted in a small amount of water every 3 4 hours as required Do not swallow Spray solution: 4 8 sprays every 4 hours, max. 32 sprays/day Children 6 12 years: 2 4 sprays every 4 hours, Max.16 sprays/day PODINE MOUTHWASH AND GARGLE : Mouthwash Mucosal or gingival surface antiseptic Adjunct in oral surgery and dental practice Minor throat infections Symptomatic relief Mouth and throat infections Dilute 1:2 parts water, rinse and spit out Gargle with full strength for 30 seconds Repeat hourly or as directed Children < 3 years: Dilute 1:3 parts water, paint mouth with cotton bud SEPTADINE ORAL ANTISEPTIC : Liquid Minor throat infections Gargle with full strength for 30 seconds Repeat hourly as directed STREPSILS : Lozenge Minor mouth and throat infections Coughs due to allergy and colds Dry, irritated painful throat Sore throat Suck one lozenge in mouth every 2 3 hours Suck one lozenge in mouth every 2 3 hours Max. 8 lozenges/day S Afr Pharm J 22

4 STREPSILS INTENSIVE : Lozenge Pain relief for painful throats Suck one lozenge in mouth every 3 6 hours Max. 5 lozenges/day Limit use to 3 days THROFLAM : Solution and spray Relief of minor infections and painful inflammatory conditions of the mouth and throat Solution: Gargle with 15ml undiluted for 30 seconds, every hours as required Rinse for oral lesions: Use 15 ml undiluted, hold solution in mouth and swirl around for 30 seconds, every hours as required Generally used undiluted, but may be diluted with water should stinging occur Children (6 to 12 years): Use 5ml to 15 ml as a gargle, every 3 hours. If unable to gargle use as an oral rinse Spray: 5 to 10 sprays directly unto the painful or inflamed area, every hours as required THROFLAM-CO : Solution and spray Relief of minor infections and painful inflammatory conditions of the mouth and throat Chlorhexidine can be used for the reduction of dental plaque Same as THROFLAM VARI MICONAZOLE : Oral gel Fungal infection of the mouth Fungal stomatitis associated with dentures Fungus stomatitis associated with dentures Oral candidiasis Apply evenly after meals to affected area 3 4 times/day depending on severity of the infection Continue for 2 days after infection clears Retain in mouth for max. time possible for best results Apply to lesion in evening and leave overnight Remove dentures at night and brush with gel Adapted from MIMS July Max. = Maximum Table II: Contraindications, adverse effects and special precautions of OTC mouth and throat preparations Mouth and throat preparations Contraindications Adverse effects Special precautions MEDI-KEEL A Lozenge: Same as Endcol, children < 6 years not recommended Throat spray: Children < 6 years unless directed by doctor All dosage forms: Pregnancy, lactation Solution and spray: Children < 12 years Lozenge: Children < 6 years - Lozenge: Same as Endcol Throat spray: Sensitivity to phenol, local irritation ANDOLEX Tissue numbness, stinging sensation, lightheadedness, nausea and vomiting, taste disturbances Lozenges: Dryness, thirst, tingling warm sensation in mouth. Laxative effect with excessive consumption ANDOLEX-C Same as Andolex plus reversible discolouration of teeth and tongue with prolonged use Safety in pregnancy and lactation not established Lozenge: Benzocaine sensitivity, epilepsy, impaired cardiac conduction, respiratory failure, hepatic damage, myesthenia gravis Throat gargle: Severe trauma, septic localised mucosa Throat spray: Consult doctor if symptoms persist Do not exceed 7 days uninterrupted treatment except under medical supervision If sore throat is complicated by a bacterial infection consider appropriate antibiotic treatment Same as Andolex plus should not be chewed and should not be used in children < 6 years Safety in pregnancy and lactation not established Oral gel: Do not eat/drink for 15 minutes after application S Afr Pharm J 24

5 Lozenge: Children < 3 years and diabetic patients CEPACOL Nausea and vomiting, CNS depression, depolarising muscle relaxant properties DAKTARIN - Children < 6 months whose swallow reflex is not fully developed, impaired hepatic function, concomitant use with drugs undergoing CYP3A4 metabolism Dysgeusia, GI disturbances, taste abnormalities, hypersensitivity reactions, choking, tongue discolouration, hepatitis, skin disorders Safety in pregnancy not established Avoid eye contact, ensure gel does not obstruct throat in infants and younger children, do not apply at back of throat, divide dosages into small quantities, observe for possible choking, monitor plasma levels of other drugs or make dose adjustments Drug interactions: Drugs undergoing CYP2CP and CYP3A4 metabolism may have prolonged activity/enhanced effects. May lead to hypoglycaemia in combination use with certain hypoglycaemics. DEQUADIN - - Avoid prolonged use PODINE MOUTHWASH AND GARGLE Non-toxic nodular colloid goitre Pregnancy, lactation Local irritation and sensitivity, possible goitre, hypo/ hyperthyroidism, metallic taste with prolonged use, increases salivation, burning, pain and coryza DERMADINE ORAL ANTI-SEPTIC Nontoxic nodular colloid goitre Sensitivity to Povidoneiodine Iodine allergy Pregnancy, lactation Sensitisation - DYNEXAN - Allergic reactions Epilepsy, myasthenia gravis, impaired cardiac conduction, shock, impaired liver function, prolonged use or use over extended areas Drug interaction: Sulphonamide activity may be antagonised Low plasma cholinesterase concentrations, concomitant use of anti-cholinesterase therapy and sulphonamides, Myasthenia gravis ENDCOL Nausea and vomiting, CNS effects, convulsions, hypotension, respiratory effects/failure, visual and auditory disturbances, tremors, systemic toxicity, cardiac toxicity, methaemoglobinaemia GOLDEN THROAT LOLLIES Epilepsy, CV disease, respiratory failure, hepatic impairment - - Infants OROCHLOR Same as Endcol Local skin sensitivity, tooth discolouration with prolonged use, taste disturbances, burning sensation of tongue, impaired swallowing, increased risk of aspiration, CNS and CV effects with systemic toxicity No eating 60 minutes post usage Epilepsy, CV disease, shock Myesthenia gravis, hepatic impairment SEPTADINE ORAL ANTI-SEPTIC Same as Dermadine oral antispetic Same as Dermadine oral antispetic STREPSILS Numbing lozenge: Impaired swallowing, increased risk of aspiration Orange with vit. C: Hyperoxaluria Eucalyptus menthol: Hypersensitivity reaction due to menthol Numbing lozenge: Same as Orchlor plus pregnancy, lactation Not recommended for children < 12 years S Afr Pharm J 25

6 If hypersensitivity to aspirin or other NSAIDs exists, history of peptic ulcers, bronchospasm, rhinitis, pregnancy, lactation Children < 12 years STREPSILS INTENSIVE Taste disturbances, mouth paraesthesia, GI disturbances, mouth ulcers, oedema, urticaria, hypersensitivity reactions, jaundice, thrombocytopaenia, aplastic anaemia, agranulocytosis, prolongs bleeding time Move lozenge around in mouth and avoid irritation, reversible jaundice, thrombocytopaenia on withdrawal, minimum undesired effects by using minimum effective dose for a short duration, bronchospasm, precipitated in patients with asthma, history of bronchospasm, hepatic impairment, hypertension, bleeding disorders Drug interactions: Diuretic response to furosemide is reduced, anticoagulant activity interferes with antihypertensive effects THROFLAM : Solution and spray Hypersensitivity to any of the ingredients in the formulation Children< 6 years Safety in pregnancy and lactation not established Oral numbness, a burning or stinging sensation, dry mouth, thirst and GI disturbances, nausea, vomiting, tingling, warm feeling in mouth and altered sense of taste Prolonged use may result in reversible discolouration of teeth or tongue and silicate or composite restorations Do not use uninterrupted for longer that 7 days, except under medical supervision Allow at least 30 minutes between the use of toothpaste and Throflam Avoid contact with eyes Do not swallow Main consequence of indigestion is mucosal irritation, systemic toxicity is rare Adverse CNS effects have been known to occur following overdose with high dosages As there is no specific antidote for benzydamine, treatment should be symptomatic and supportive THROFLAM-CO : Solution and spray Same as THROFLAM Same as THROFLAM Same as THROFLAM Drug interaction: Toothpastes may contain anionic surfactants (e.g. sodium laurylsulphate), which are incompatible with chlorhexidine See Daktarin Adapted from MIMS July CV = cardiovascular, GI = gastrointestinal, CNS = central nervous system VARI MICONAZOLE Conclusion A variety of mouth and throat disorders exist in South Africa and the increasing severity and prevalence thereof are of major concern. Proper oral hygiene plays a vital role in overall health status. Patients have a variety of OTC mouth and throat preparations in a range of dosage forms to choose from based on personal preference. The majority of the preparations provide symptomatic relief of inflamed, painful or irritated mouths and throats. There are also OTC preparations available for the treatment of fungal infections and for use in dental procedures. References 1. Singh S Dental caries rates in South Africa: implications for oral health planning. South Afr J Epidemiol Infect Vol 26, No. 4 (Part II), pp MIMS July Roberts G, Scully C, Shotts R. ABC of oral health: Dental emergencies. BMJ. 2000;321(7260): Murchison DF Mouth sores and inflammation. Merck Manual Professional Version. 5. Van Wyk PJ, Van Wyk C Oral health in South Africa. International Dental Journal. Vol 54, pp Fried MP Sore throat. Merck Manual Professional Version. 7. Silk H Diseases of the mouth. Primary care: Clinics in office practice. Vol 41, No 1. pp Laudenbach JM, Simon Z Common dental and periodontal diseases: Evaluation and Management. The Medical Clinics of North America. Vol 98, No 6, pp Motloba PD Getting to the root of dentine hypersensitivity. International Dentistry South Africa Vol 8 No 3, p Crispian S Oral and maxillofacial medicine: the basis of diagnosis and treatment. 2nd Edition. Edinburgh: Churchill Livingstone. pp Samaranayake LP Essential microbiology for dentistry. 3rd Edition. Elsevier. pp and S Afr Pharm J 26

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