4. Over-the-Counter Products for Oral Ulcerations

William M. Carpenter, DDS, MS, and Sol Silverman Jr., MA, DDS

Abstract: Over-the-counter products can be useful and effective in alleviating the pain from ulcerations of the oral mucosa. This article reviews over-the-counter medications that are available to treat ulcerative lesions. Among the categories included are covering agents, local anesthetics, and mouthrinses.

Ulcerations of the oral mucosa are a frequent occurrence as a result of many etiologic factors. An ulcer (loss of the surface epithelium) may be of a primary type (no previous lesion) or secondary to a previous lesion (vesicle or bulla).¹ The differential diagnosis would include those conditions shown in Table 1. This discussion will not involve recurrent herpes labialis (cold sores).

Since so many different pathologic conditions may be present in an ulcerative state and require different therapeutic/management approaches, the most important first step for treatment is an accurate diagnosis. This is often a very difficult task, and many diagnostic studies may be required.²

Once a working or definitive diagnosis is established, there are many effective and specific prescription medications or treatments that may be indicated. However, a number of ulcerative lesions require only a period of time until the epithelium can regenerate. See Table 1.^1-4

During this time, over-the-counter products may be useful and effective in alleviating the pain involved regardless of the etiologic agent. The advantages of an OTC product are the cost, availability and lack of side effects. The main side effect, if the instructions are properly followed, would be a hypersensitivity to one of the ingredients.

OTC Products^3-6

Localized Use (Direct Application)

Covering Agents

Several products are available that are covering agents (emollients). They act to ameliorate the pain by forming a protective covering.

The two main products in this category are:

• Orabase (Colgate Oral 1 harmaceutics) - an emollient paste composed of sodium carboxymethyl cellulose with pectin, gelatin, sugar gum, cellulose gum and tragacanth gum dispersed in a plasticized hydrocarbon gel composed of 5 percent polyethylene in mineral oil.
• Zilactin (Zila Pharmaceuticals) - a film-forming liquid composed of a hydroxypropyl cellulose and 10 percent benzyl alcohol.

These two products have been utilized for many years, and both are effective. However, some personal preferences exist, both with patients and practitioners. Both products have optionally available an anesthetic, benzocaine, to provide additional relief, if pain is severe.

Table 1 Traumatic events    Physical    Thermal    Chemical Vesicular disease    Microbiologic (usually viral) Immunologic    Recurrent aphthae    Bullous disease Hypersensitivity reactions Leukopenic ulcers secondary to:    Immunosuppression    Drug-induced-toxicities Microbiologic    Fungal    Bacterial Neoplastic    Benign    Malignant

Local Anesthetics

• Orabase - B - Benzocaine 20 percent.
• Zilactin - B - Benzocaine 10 percent.

In addition, another product is available.

• Orabase - B Gel - Benzocaine 15 percent w/w as the active ingredient in ethylcellulose with ethyl alcohol, 5 7 percent w/w propylene glycol, salicylic acid, tannic acid and sodium saccharin.

Other commercially available products containing benzocaine as the active ingredient are:

• Anbesol Liquid (maximum strength) - Benzocaine 20 percent, alcohol 60 percent and saccharin (maximum strength).
• Anbesol Liquid - Benzocaine 6.4 percent w/v, phenol 0.5 percent, potassium iodide, alcohol 70 percent v/v povidone iodine, camphor, glycerin and menthol.
• Anbesol Gel (Whitehall Labs) - Benzocaine 6.4 percent and 0.5 percent phenol, carbomer 934P.
• Senso-gard (Block Drug Co.) Benzocaine 20 percent, methylparaben, polycarbophil, polyethylene glycol, propylparaben and sorbitan mono-oleate.
• Tanac (Del Pharmaceuticals) - Benzocaine 10 percent and benzalkonium chloride 0.12 percent, polyethylene glycol 400, water, sodium saccharin, propylene glycol and tannic acid.
• Orajel Mouth-Aid (Del Pharmaceuticals) - Benzocaine 20 percent, benzalkonium chloride 0.02 percent, zinc chloride 0.1 percent, allantoin, carbomer, edentate disodium, peppermint oil, polysorbate 1.0, saccharin, sorbic acid, polyethylene and propylene glycol, propyl gallate, water, povidone, and stearyl alcohol.
• Kank-A (Blistex Inc.) - Benzocaine 20 cetylpyridium chloride 0.5 percent, mgm, 1 gm benzyl alcohol with benzoin tincture, castor oil, dimethyl isosorbide saccharin, ethylcellulose, tannic acid and propylene glycol.
• Medadyne (Dal-Med Pharmaceuticals ) - Benzocaine and methylbenzethonium chloride, methol camphor, benzyl alcohol, chlorothymol in base 61 percent.
• Hurricaine Liquid and Gel (Beutlich Pharmaceuticals) - Benzocaine 20 percent, polyethylene glycol flavoring.

One other product that has been in use for a long time, principally for sore throats but also for relief of pain in mouth sores, is a phenol product.

• Vicks Chloraseptic sore throat spray (Procter & Gamble) - Active; phenol 1.4 percent; inactive: D&C green No. 5, D&C yellow No. 10, D&C FD&C green No. 3, flavor, glycerin, purified water, saccharin sodium.

Oxygenating Agents

Hydrogen peroxide is a major ingredient in several products as a mouthrinse or for direct application. The oxygenating effect helps to debride the ulcer and is a mild antibacterial agent.

• Peroxyl Mouthrinse (Colgate Oral Pharmaceuticals) - 1.5 percent hydrogen peroxide in an aqueous solution with ethyl alcohol 6 percent v/v sorbitol solution 70 percent, polysorbate 20 methyl salicylate, menthol, pluronic F108 and sodium saccharin.
• Peroxyl Oral Spot Treatment Gel (Colgate Oral Pharmaceuticals) - 1.5 percent hydrogen peroxide in a gel base.

Other oxygenating products are available that contain carbamide peroxide as the active ingredient.

• Cankaid Rinse (Dickinson Co.) - Carbamida peroxide 10 percent, in anhydrous glycerol, citric acid monohydrate, sodium citrate dehydrate, and edentate (disodium)
• Gly-Oxide (Smith-Kline Beecham) - Carbamide peroxide 10 percent, citric acid, glycerin, propylene glycol, sodium stannate and water.
• Periolav (Spectrumed, Inc.) Carbamide peroxide 10 percent in anhydrous glycerol.
• Orajel Perioseptic spot treatment (Del Pharmaceuticals) - Carbamide peroxide 15 percent in anhydrous glycerin, citric acid, edentate disodium, methylparaben, propylene glycol, water, sodium chloride, sodium saccharin.

Cauteries and Antiseptics

Other products are available that are chemical cauteries and mild antiseptics. Examples of this type of product are:

• Ora - 5 (Premier Dental Products Co.) - Copper sulfate, iodine, potassium, iodide and alcohol 1.5 percent.
• Oralief (H.T.C. Co.) - Zinc chloride, phenol, cetylpyridium chloride, alcohol, and glycerin.

Mouthrinses

There are several ulcerative conditions that are multifocal and/or diffuse and require a topical medication in a more easily applied form than direct application. These are available in liquid form and act as a covering agent. They can be swished and expectorated.

One combination is available as separate medications over the counter and can be mixed by the patient:

• Diphenhydramine hydrochloride (Benadryl) syrup (4 ounce). Mix equal parts Kaopectate liquid (12 ounce) or Maalox suspension (12 ounce). Sig: Rinse for one minute with 1 teaspoonful and expectorate. Repeat every two hours or at mealtimes.

If more of an anesthetic effect is desired, Hurricaine liquid may be added. (When topical anesthetics are used, patients should be cautioned concerning a reduced gag reflex and the need to avoid aspiration.)

• Biotene Mouthwash (Laclede Products) - Lysozyme (40 mg) lactoferrin (15mg) glucose oxidase 2,500 units, lactoperoxidase 2,500 units, calcium lactate, sodium benzoate, benzoic acid, propylene glycol, hydroxyethol cellulose, aloe vera, peppermint, water, xylitol hydrogenated starch.
• Orajel Perioseptic (Del Pharmaceuticals) - Hydrogen peroxide 1.5 percent, edentate disodium ethyl alcohol (4 percent v/v), methyl salicylate methylparaben, phosphoric acid, poloxamer 338, water, sodium saccharin and sorbitol.
• Amosan (Oral-B Labs Inc.) Sodium peroxyborate monohydrate buffered with sodium bitartrate.

Summary

These OTC medications have been employed successfully for many years in alleviating the pain associated with oral lesions and are major agents in the arsenal of the practitioner. The lack of prospective controlled studies makes outcome assessments difficult, and none of these has been shown conclusively to be other than palliative. Therefore preferences and benefits are variable in a population. Furthermore, it must be understood that an ulcer may be the manifestation of a serious disease that requires a more definitive treatment. Therefore, if lesions do not show any evidence of healing in a matter of a week, a definitive diagnosis must be ascertained and a more specific treatment rendered.

Authors

William M. Carpenter, DDS, MS, is in the Department of Pathology and Medicine, University of the Pacific School of Dentistry.

Sol Silverman Jr., MA, DDS, is in the Department of Stomatology at the University of California at San Francisco School of Dentistry.

References

1. Regezi JA and Sciubba J, Oral Pathology, Clinical Pathologic Correlarions, 2nd ed. WB Saunders Co, Philadelphia, 1993.
2. Eversole LR, Oral Pathology, Clinical Outline of Diagnosis and Treatment 3rd ed. Lea and Febinger, Philadelphia, London, 1992.
3. Physicians Desk Reference for Nonprescription Drugs. Medical Economics Co Inc, Montvale, NJ, 1997.
4. The Blue Book. American Academy of Oral Pharmacology, 24200 Chagrin Blvd, Cleveland, OH 44122, pp 15-8.
5. Dental Therapeutic Digest. Odontos Publishing Inc, 34696 Vine St, Eastlake, OH 44095, 1997.
6. Clinicians Guide to Treatment of Common Oral Conditions. American Academy of Oral Medicine, 159 W 53rd St, New York, NY 10019.

Copyright CDA Journal. Vol 26, No. 3. March 1998
Reprinted with permission