OTIC AND ORAL

CONDITIONS
Caroline Horner, PharmD, MBA
February 14, 2019
PMRP 3270: Nonprescription Pharmacotherapy, Natural Medicines, and Self-Care I
Objectives
• Differentiate patients who are not candidates for self-care
• Describe the symptoms related to each otic or oral condition
• Identify when nonpharmacological therapy can be utilized to
treat patients symptoms
• Plan appropriate regimens based on patient characteristics
OTIC CONDITIONS
• Excessive and impacted cerumen
• Water-clogged ears
Anatomy of the Ear
• Self-care is limited to outer ear
disorders
• Children and geriatric are more
prone
Exclusions to Self Care: Otic Conditions

Presence of
Bleeding or signs
Signs of infection ruptured tympanic
of trauma
membranes

Incapable of Hypersensitivity to
following proper recommended >12 years of age
instructions agents
Excessive/Impacted Cerumen
Pathophysiology Symptoms Risk factors

• Lubrication • Fullness or pressure • Narrow or

• Trap dust and in the ear misshapen ear
foreign materials • Gradual hearing canals
• Barrier to loss • Excessive hair
pathogens • Dull pain growth in ear canal
• Vertigo • Overactive
• Tinnitus cerumen glands
• Chronic cough • Hearing aids,
earplugs, sound
attenuators
Goal of Therapy

Soften and remove excessive/impacted cerumen using

proper and safe, effective agents to eliminate temporary
hearing loss and other symptoms.
Nonpharmacologic Therapy
• Use of wet, wrung-out washcloth draped over a finger
• Use daily to prevent impacted cerumen
• Avoid the use of cotton-tipped swabs or other foreign objects
• Murine Earigate System
• Rinse away ear wax build-up
• Isotonic, desalinated sea water
• Adult and child (age 6-12 years) formulations
• Directions: 1-2 applications 3 times per week
Ear Candling
• Hollowed tapered cone of cloth soaked
in beeswax and paraffin
• Burn with one end inserted into ear
canal
• Creates negative pressure to draw
cerumen from the ear
• Ineffective in removing cerumen
• 2007 FDA alert against importation and
sale of these devices
Carbamide Peroxide
• Carbamide peroxide 6.5% in anhydrous glycerin
• Only FDA-approved nonprescription cerumen-
softening agent
• Dose: 5-10 drops instilled into ear and allowed to
remain for 15 minutes
• Able to be used twice daily for up to 4 days
• Adverse events: pain, irritation, tenderness, redness,
discharge, dizziness
Aural Irrigation
• Use after cerumen-softening agent
• Use 8 oz. warm water or solution as directed by physician
• Steps for use:
1. Gently pull ear lobe back and down

2. Place open end of syringe in ear canal with tip pointed slightly upward

3. Squeeze bulb gently to introduce solution into ear canal

4. Allow solution to drain

Miscellaneous Agents
• Docusate sodium
• Glycerin
• Dilute hydrogen peroxide
• 1:1 solution of warm water and 3% hydrogen
peroxide
• Overuse can predispose to infection

• Olive oil (sweet oil)

• Mineral oil
*Lack efficacy compared to approved agent
CAM Therapies
• Olive oil
• Garlic oil
• Willow bark
• Chamomilla – helps with inflammation
Water-Clogged Ears
Pathophysiology Symptoms Risk factors

• Cerumen can • Wetness or • Hot, humid

swell and trap fullness climates
water in the ears • Gradual hearing • Sweating
• May occur due to loss • Swimming
the shape of the • Can progress to • Bathing
ear canal or itching, pain,
excessive • Improper use of
inflammation, aqueous
cerumen and infection solutions to
cleanse the ear
Goals of Therapy

To dry the ear the ear using a safe and effective agent
To prevent recurrences in those prone to retaining
moisture in the ears
Nonpharmacological Therapy
• Tilt the ear downward and gently
manipulate the auricle to help expel
excessive water from the ear
• Use a blow dryer on a low-heat setting
around the ear (not directly in it)
• Water absorbing ear plugs for those
age 17 and up
Isopropyl Alcohol
• Isopropyl alcohol 95% in anhydrous glycerin
• Alcohol acts as a drying agent
• Glycerin acts as solvent, emollient, and hygroscopic
agent

• Dose: apply 4-5 drops to ear canal

• Not for use in children <12 years old
• If symptoms have not resolved or have worsened
after 4 days of use or if signs of infection are present,
the patient should see their primary care physician
Acetic Acid and Isopropyl Alcohol
• 1:1 solution of 5% acetic acid and 95% isopropyl alcohol
• Alcohol acts as a drying agent
• Mixture has bactericidal and antifungal properties

• Counseling Points:
• Discard after use, do not keep
• Only white vinegar, not cider vinegar

• Dose: apply 4-5 drops to ear canal

• Not for use in children <12 years old
• Side effects: mild stinging or burning
Ear Drop Counseling
1. Warm ear drops to body temperature by holding container in palm of hand for
several minutes. Shake if indicated.
2. Tilt head to side with affected ear up
3. Position dropper tip near ear, but not inside of ear canal
4. Pull ear up and back
5. Place drops in ear
6. Gently press tragus over ear canal opening
7. Leave medication in ear as directed by package
Key Points – Otic Conditions
Limit self care to minor symptoms such as sense of fullness, pressure , or wetness in the ear

Refer children <12 years of age

Advise patients to contact their primary care provider if symptoms worsen or do not
improve by 4 days or if signs and symptoms of infection

Avoid use of cotton swabs, fingernails, or other devices to relieve itching or removing
cerumen from the ear

Only several products available on the market with proven efficacy

ORAL CONDITIONS
• Tooth Hypersensitivity
• Canker Sores (recurrent aphthous stomatitis)
• Cold Sores (herpes simples labialis)
• Dry Mouth (xerostoma)
Tooth Hypersensitivity
Pathophysiology Symptoms Triggers

• Damage to • Short, sharp • Heat

tooth leading to pain • Cold
exposed dentin • Caused by • Pressure
• Increased fluid triggers • Acidic foods
flow in dentin
• Sweet foods
tubule causes
nerve
stimulation and
pain
Goal of Therapy

To repair the damaged tooth surface using the

appropriate toothpaste
To stop abrasive tooth brushing practices
Exclusions to Self-Care
Mouth sores
Broken, loose, or associated with
Severe pain
knocked-out teeth poor-fitting
dentures

Presence of fever
Bleeding Trauma
or swelling
Non-Pharmacologic Therapy
• Identification and elimination of predisposing factors
• Avoid harsh tooth brushing technique
• Brush teeth less vigorously
• Use soft-bristled brush
• Avoid brushing teeth within 30-60 minutes after consuming acidic foods or
beverages
Potassium Nitrate 5%
• Mechanism: diffuses along dentin tubules to decrease the excitability of nerves
and alter the membrane potential
• Single application is not effective, use 2-4 weeks or as dentist recommends
• If hypersensitivity is not relieved within 14-21 days of using desensitizing
toothpaste, refer to dentist
Recurrent Aphthous Stomatitis
Precipitating
Pathophysiology Symptoms
Factors
• Unknown cause • Epithelial • Local trauma
• Possibly due to ulceration of • Immunologic
streptococci or movable mouth • Genetic
varicella zoster parts
• Food allergy
• Round or oval
• Hormonal
• Flat or crater-like changes
• Erythematous
halo of inflamed
tissue
Natural Process
• Some patients may experience pain in area
prior to lesion occurance
• Lesion may worsen with eating or drinking
and may inhibit these activities
• Most lesions persist for 5-14 days and heal
spontaneously
Goal of Therapy

To relieve pain and irritation to allow lesion to heal

To prevent complications, such as secondary bacterial
infection
Exclusions to Self-Care

Lesion associated
Lesion present Frequently
with underlying
≥14 days recurring lesions
pathology

Failure of prior
Symptoms of
appropriate self-
systemic illness
treatment
Non-Pharmacologic Therapy
• Address precipitating causes
• Tooth brushing technique
• Stress reduction
• Nutritional deficiency or food allergy, if identified

• Avoid spicy or acidic foods until the lesion heals

• Avoid sharp foods that may increase trauma
• Apply ice to the lesion for 10 minutes
• Do not use heat on lesion
Pharmacologic Options
• Oral debriding and wound cleansing agents
• Topical oral anesthetics
• Topical oral protectants
• Oral rinses
• Systemic analgesics
Debriding/Cleansing Agents
• Carbamide peroxide 10%
• Apply a few drops directly to the affected area and keep in
place for 1 minute then spit out

• Hydrogen peroxide 1.5%

• Swish ½ capful (10 mL) around the mouth for at least 1 minute
then spit out

• Use up to 4 times daily after meals and at bedtime for no

more than 7 days
• Do not swallow products
Topical Oral Anesthetics
• Benzocaine 10-20%
• Other ingredients: menthol, camphor, phenol,
dyclonine 0.05-0.1%
• Temporary pain relief
• Dose: apply to affected area up to 4 times per
day
• Most products for use in children >2 years old
Other Pharmacologic Options
• Topical Oral Protectants
• Creates barrier by coating or covering the lesion
• Apply as needed for pain relief, up to 4 times per day

• Oral rinses
• Mouthwashes like Listerine
• Saline rinses – 1-3 tsp of salt in 4-8 oz warm water

• Systemic analgesics
• Aspirin
• NSAIDs
• Acetaminophen
Topical CAM
Clove Oil
• Insufficient evidence
• Mild anesthetic, analgesic,
antibacterial
• Harmful in large doses
Lavender Oil
• Possibly effective
• Reduces pain, swelling, and redness
• Can cause GI side effects
• Rarely endocrine disturbances
Referral to Primary Care Provider
• Symptoms do not improve after 7 days of treatment
• Lesions do not heal within 14 days
• Symptoms worsen during self treatment
• Symptoms of systemic infection
• Fever
• Rash
• Swelling
Patient Counseling
• Cleansing or rinsing agents should be used prior to application of topical
anesthetics
• Reassess symptoms in 7 days of therapy
• Gels are preferred drug delivery application
• Easy to apply
• Not easily washed away
Herpes Simplex Labialis
Pathophysiology Symptoms Precipitating Factors

• Caused by herpes • Small, red, fluid- • UV radiation

simplex virus filled vesicles 1-3 • Stress
• Transferred by mm in size • Fatigue
direct contact • Erythematous, • Cold
• Remission and inflamed border
• Windburn
reactivation • Crusted when
• Mensturation
mature
• Infection
• Immunosuppresion
Herpes Simplex Labialis
• Lesions appear on or around lips
• May experience burning, itching, tingling, or numbness prior to lesion
• Recurrent and may be painful
• May persist for 10-14 days, but is self-limiting
Goal of Therapy

To relieve pain and irritation to allow sores to heal

To prevent secondary infections
To prevent the spread of lesions
Exclusions to Self-Care

Increased Lesion
Compromised
frequency of present ≥14
immunity
outbreaks days

No previous
Symptoms of
diagnosis of a
infection
cold sore
Non-Pharmacologic Therapy
• Avoid precipitating causes
• Keep lesions clean by washing gently with mild soap
• Handwashing to prevent lesion contamination and autoinoculation
• Keep lesions moist to prevent drying and fissuring
• Avoid factors that delay healing
Docosanol 10% (Abreva)
• Reduce severity and duration of symptoms
• Mechanism: inhibits fusion between herpes virus
and the human cell plasma membrane to prevent
viral replication
• Begin use at first signs of outbreak
• Dose: apply 5 times daily up to 10 days until lesion
is healed
• Indicated for those age ≥12 years of age
Other Pharmacologic Options
• Topical Oral Protectants
• Prevent over drying of lesions

• Topical Aesthetics (benzocaine)

• Analgesics (systemic and topical)
• Topical antibiotic ointment
• Able to use up to 4 times per day if infection is suspected, also refer to primary care
CAM Options
Tea Tree Oil Lemon Balm Lysine

• Insufficient • Possibly • Possibly

evidence effective effective
• Topical use • May reduce • Reduce
• May cause healing time severity,
significant and healing time,
toxicity if recurrence if and
ingested applied early recurrence
Patient Counseling
• Cold sore lesions are contagious and appropriate measures should be taken to
prevent transmission
• Infections are self-limiting and pharmacologic therapy is to reduce symptoms
• Keep lesions moist and avoid itching or picking at wound
• Refer to primary care if symptoms have not resolved after 14 days or worsen
Xerostomia
Pathophysiology Symptoms Risk Factors

• Salivary flow is • Difficulty talking and • Sjogren’s syndrome

limited or completely swallowing • Diabetes
stopped • Stomatitis • Depression
• Burning tongue • Crohn’s disease
• Halitosis • Radiation therapy
• Candidiasis • Medications
• Hypersensitivity of • Alcohol
teeth • Tobacco
• Tooth decay • Caffeine
• Loss of appetite • Mouth breathing
Goal of Therapy

To relieve the discomfort of dry mouth

To reduce the risk of dental decay
To prevent and treat infections and periodontal disease
Exclusions to Self-Care

Tooth erosion or Reduced denture-

Fever or swelling
decay wearing time

Severe pain
triggered or
Trauma to teeth Bleeding gums
worsened by hot,
cold, or chewing
Non-Pharmacologic Therapy
• Avoid substances that reduce salivation
• Tobacco
• Caffeine
• Hot spicy foods
• Alcohol, including mouth rinses

• Limit intake of sugary or acidic food

• Increase water intake, as appropriate
• Maintain good oral hygine with soft tooth brush and
regular dental visits
• Adjust medications to coincide with meals
Artificial Saliva Products
• Vary based on:
• Viscosity
• Mineral content
• Flavoring

• Use after meals and before bed at minimum

• Mimic saliva chemically and physically
Patient Counseling
• Refer to dentist if symptoms do not improve or worsen
• Avoid tobacco and alcohol products to prevent reduced levels of saliva
• To limit tooth decay:
• Avoid sugary and acidic food
• Use soft toothbrush and fluoride toothpaste
• Regular dental visits

• Chewing gum can stimulate salivary flow

Key Points – Oral Conditions
• Address contributing or predisposing factors
• Most OTC products work to minimize symptoms
• Refer to primary care if symptoms do not resolve or worsen
• Canker sores and cold sores are self-limiting
Resources
• Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 18th
edition. 2015 American Pharmacists Association.
• Pray SW, Pray GE. Dentinal Hypersensitivity. US Pharm. 2011; 36(1):12-15.
• Weinburg MA, Maloney WJ. Treatment of common oral lesions. US Pharm. 2007;
32(3): 82-88.