Recommendation: Require medical referral

Recommendation: Require medical referral

Recommendation: Require medical referral

Above 14 days required physician evaluation.

Recommendation: Require medical referral

Indicative of secondary bacterial infection.

Recommendation: Require medical referral

These conditions may have predisposed patient for HSL

Recommendation: Pharmacological and non-pharmacological therapy

• • They are caused by HSV virus type-1; infecting for life;
  • are contagious and cannot be cured;
  • Lesion heal by 10-14 days
  • to relieve pain and irritation while the sores heal, prevent secondary infection, and prevent the spread of lesion

• • Keep lesions clean by gently washing with mild soap and water
  • wash hands frequently to prevent contaminating the lesions and to avoid spreading
  • Avoid precipitating or contributing factor
• Prevent transmission: avoid kissing, sharing utensils/ drinking vessels
• Avoid triggers: The virus gets reactive upon exposure to various triggers such as UV radiation, stress, fatigue, cold, or windburn. Other triggers include fever, injury, menstruation, dental work, infectious disease, and factors that suppress the immune system.

• Recommendation: OTC skin protectant to keep lesions moist + topical docosanol 10%; if needed, topical anesthetic (benzocaine, benzyl alcohol, dyclonine, and hexylresorcinol) and Triple-antibiotic ointment for secondary bacterial infection if needed.
• Medications
  • Docosanol 10%: apply 5 times daily no to exceed 10 days.
    • Indication:
      • The only FDA-approved product to reduce HSL duration and severity
      • Applied at the first sigh of an outbreak
    • A/E: minimal; bad taste
  • Topical oral anesthetics (benzocaine, benzyl alcohol, dyclonine, and hexylresorcinol)
    • Indication:
      • For pain and irritation
      • These products may numb the mouth or tongue, if these effects occur, do not eat or drink until they go away.
    • A/E
      • A/E minimal but include bad taste
      • Avoid in hypersensitive patients
      • Rare cases: methemoglobinemia
      • CI with prilocaine, nitrates, or sulfonamides
      • avoid in open lesions for systemic toxicity
    • Application: Applied with cotton-tipped swab or an applicator.
  • Systemic analgesics (Acetaminophen, NSAIDs)
    • Indication: For pain, discomfort, and irritation
    • A/E: Aspirin should never be retained in mouth before swallowing or placed in the area of oral lesion, as it can cause a chemical burn with associated tissue damage.

• Symptoms does not improved after 7 days of treatment or after 14 days of lesions' first appearance, refer to physician.

Recommendation: Require medical referral

Recommendation: Require medical referral

• Pregnant and breastfeeding women are often excluded from clinical trials due to ethical considerations. This means there's a lack of robust data on the safety and efficacy of many treatments in these populations. While many treatments for RAS are topical (e.g., mouthwashes, gels), there's still a potential for some absorption into the bloodstream.
• Some common ingredients in oral care products might have potential concerns in pregnancy or breastfeeding, even if they're generally safe for others.

Recommendation: Require medical referral

Above 14 days required physician evaluation.

Recommendation: Require medical referral

Indicative of secondary bacterial infection.

Recommendation: Require medical referral

These conditions are known to be associated with canker sores.

Recommendation: Pharmacological and non-pharmacological therapy

• These are non contagious and heals spontaneously in 10-14 days; goals are to relieve pain and irritation which will enable patients to normally drink, eat or perform routine oral hygiene.

• • Avoid spicy and acidic foods till lesion heal
  • avoid sharp-textured food that may cause trauma to the lesion
  • If desired, apply ice directly to the lesions in 10-minute increments but for no longer than 20 minutes in a given hour
  • Do not use heat. Heat will spread the infection if present
  • Relaxation and stress removal may reduce symptoms and frequency
  • Supplement with adequate nutrition
  • Patient with recurrent RAS should avoid using toothpaste using SLS, which may be irritating to oral mucosa.
  • Avoid local trauma (such as smoking, chemical irritation, biting the inside of the cheeks or lips, or injury caused by the tooth brushing or braces)
  • Gluten sensitive enteropathy and deficiencies of Iron and B vitamins are nutritional conditions associated with RAS

• Recommendation:
  • • Topical oral anesthetics
    • oral debriding/cleansing agents,
    • oral rinses & topical protectants
    • Systemic analgesics
  • These medication provide symptom relief but do not prevent its recurrence
  • Gels are preferred: easy to apply and more resistant to saliva wash
  • Do not swallow these produces

• Topical oral anesthetics (benzocaine, benzyl alcohol, dyclonine, and hexylresorcinol)
  • Indication
    • For pain and irritation
    • Applied with cotton-tipped swab or an applicator
    • These products may numb the mouth or tongue, if these effects occur, do not eat or drink until they go away.
  • A/E
    • A/E minimal but include bad taste
    • Avoid in hypersensitive patients
    • Rare cases: methemoglobinemia
    • CI with prilocaine, nitrates, or sulfonamides
    • avoid in open lesions for systemic toxicity
• Oral-debriding and wound-cleansing agents (hydrogen peroxide and carbamide peroxide)
  • Indication
    • Indicated during pain and irritation
    • Hydrogen peroxide 3% requires dilution before use
    • Avoid using above 7 days
    • Dosing: apply after meals up to 4 times a day
  • A/E
    • A/E: minimal but could induce soft-tissue irritation
    • Prolonged use causes: transient tooth sensitivity form decalcification of enamel
    • cellular changes,
    • and over-growth of undesirable organisms leading to ‘black hairy tongue”
• Topical oral protectants (glycyrrhiza, menthol)
  • Indication:
    • For pain and irritation
    • These product create a barrier by using a paste, adhering film or dissolvable patch to cover the lesion
    • Dosing: Apply as needed 9often 3-4 times a day)
    • Products available as patch or dissolving disc must be placed against the lesion for 10-20 seconds. Once the disc adheres to the lesion, the barrier is formed, and the disc will stay in place until dissolved
  • A/E
    • A/E: minimal but may include bad taste
    • Glycyrrhiza may increase BP. Monitor in hypertensives
    • Avoid concurrent use glycyrrhiza with warfarin (induce CYP450 2CP required for warfarin metabolism)
• Oral rinses (oral eycalyptol, menthol, menthyl salicylate, thymol, bee propolis)
  • Indication: For pain and irritation
  • A/E:
    • A/E: soft-tissue irritation and a bad taste in the mouth.
    • Eucalyptol may cause hypoglycemia
• Systemic analgesics (Acetaminophen, NSAIDs)
  • Indication
    • For pain, discomfort, and irritation
  • A/E: Aspirin should never be retained in mouth before swallowing or placed in the area of oral lesion, as it can cause a chemical burn with associated tissue damage.

• Symptoms does not improved after 7 days of treatment or after 14 days of lesions' first appearance, refer to physician.