Microsoft word - soremouth.doc

DIFFERENTIAL DIAGNOSIS OF
ACUTE AND CHRONIC
SYMPTOMATIC ORAL ULCERATIONS
Acute and chronic ulcerations represent the most common symptomatic mucosal pathoses encountered by oral health care practitioners. Every clinician should have an organized approach to these problems which will be encountered frequently. The first step in all cases should be to divide and conquer. The ulcerations can be classified as acute or chronic, and this will cut in half the number of diseases in the differential diagnosis. Acute lesions arise rapidly (1 or 2 days), normally heal in 10-14 days and may recur at varying intervals. In some cases, the lesions may take longer than a month to heal, but this is not typical. Recurrences are highly variable. Some may never recur, while others may recur before the first crop has healed. On the other hand, chronic erosions tend to slowly evolve and become more problematic over an extended period of time. Instead of crops of lesions interspersed with periods of remission, the chronic erosions tend to persist with variable levels of intensity. Patients rarely present to their health care professional when these lesions first arise; the vast majority of chronic ulcerations have been present for months when the patients present for diagnosis and treatment. Normally, the distinction between acute and chronic ulcerations is made easily; but like everything else, there are gray areas. Prior to the development of a differential diagnosis, the patient’s medical history should be evaluated thoroughly. The presence of any extraoral lesions must be documented. A listing
of all utilized prescription and “over-the-counter” medications is mandatory. The following is a
list of common symptomatic oral ulcerations:
ACUTE
ACUTE ORAL ULCERATIONS
1. Recurrent Aphthous Ulcerations
Recurrent aphthous ulcerations (RAUs) are the most common oral ulcerations encountered by the health professional. Approximately 20 percent of the general population has a positive history for these ulcerations. Prevalence as high as 55 percent has been reported in populations under stress (professional school students). Numerous studies have indicated an immunologic cause. Although the humoral system is involved, the cell mediated immune response has received the most attention and is thought to be responsible for the initiation of the ulceration. Early RAUs do show similarity to a delayed hypersensitivity reaction. Investigators theorize RAUs are the result of bacterial toxins, foods, and other substances acting as allergens or haptens which initiate an immune response. A variety of allergens most likely is responsible. In addition, mucosal thickness and immunodysregulation appears involved in many patients. Elimination of one allergenic source often resolves RAU in some patients but not in others. Since discovery of the causative agent is most difficult, therapy has been directed toward decreasing the immune reaction. The prototypical and most common form is the minor aphthous ulceration (MiRAU).
These arise almost exclusively on nonkeratinized movable mucosa and exhibit yellow fibrinopurulent membranes surrounded by erythematous halos. The ulcerations vary from 2-10 mm (majority approximately 5 mm) and usually heal without scarring within 10-14 days. The recurrence rate is highly variable. The lesions may number from one to a hundred at a time. Several systemic medical problems can result in lesions clinically identical to RAU and must be ruled out in all cases which are severe or nonresponsive to therapy. A number of systemic disorders such as blood dyscrasia (esp. leukopenia), nutritional deficiencies (low zinc, iron, B12 or folate), Behçet's syndrome, Crohn's disease, celiac sprue and AIDS are associated with an
increased prevalence of aphthous-like ulcerations. In addition, every one of the other acute
ulcerative conditions may resemble RAU and must be ruled out prior to therapy. Topical
steroids appear to be the most consistently efficacious; chemical cautery is contraindicated.
Most over-the-counter medications produce more problems than they solve. If clinical
contraindications to steroids exist (children, pregnancy, nursing, hypertension, diabetes,
granulomatous infectious disease, G.I. ulcerations, blood dyscrasia, previous malignancy, etc.),
permission for corticosteroid utilization must be obtained from the attending physician or utilize
antimicrobials such as tetracycline or chlorhexidine. In all severe cases and those resistant to
normal therapy, a systematic evaluation for the underlying trigger or any related systemic
disorders should be performed.
THERAPY
Localized
-Lidex gel (Sore Mouth Solutions [SMS] 1-1). Easy to apply but slightly -Diprolene ointment (SMS 1-2). Thicker than gel but tasteless. Also available as gel but slightly bitter. Often prescribed generically due to difficulty to obtain 15gram tube. Another type which exhibits significantly more morbidity is the major aphthous
ulceration (MaRAU). This variant also has been called periadenitis mucosa necrotica
recurrens or Sutton’s Disease. These ulcerations are similar to MiRAU but are significantly
larger, deeper, take longer to heal and result in scarring. The lesions are seen predominantly on
movable mucosa, vary in size from one to several centimeters and often take up to six weeks to
heal. It is not uncommon for a new lesion to arise before the current ulcer has healed. Long
periods of remission are difficult to obtain. The usual topical steroids normally are ineffective.
More potent local steroids (Kenacort® tablets, Kenalog 40® Injection, dexamethasone syrup) or
systemic prednisone often are required for temporary control. All MaRAU patients should be
thoroughly evaluated to rule out a systemic basis for their ulcerations.
THERAPY
Accessible
Inaccessible Compounded ultrapotent dexamethasone solution (SMS 1-10) A relatively rare variant is the herpetiform aphthous ulceration (HeRAU). These
ulcerations appear similar to MiRAU but generally are smaller in size, more numerous and can be found on movable or bound mucosa. The typical size is 2 mm or less, and it is not uncommon for patients to exhibit more than 100 lesions at one time. The recurrences are spaced so closely that the patients are seldom free of these very painful lesions and often have the ulcerations continuously for several years. The lesions frequently cluster and superficially may resemble a primary herpetic infection; the lack of a painful and intensely erythematous gingiva combined with the recurrence history allows separation. Therapy with 2% tetracycline rinse has proved efficacious but, on occasion, is not effective or becomes ineffective with time. Topical corticosteroids is the treatment of choice. 2. Herpangina This is a specific viral infection which can be caused by any one of a number of strains of enterovirus. It normally is seen in young children but may occur in older patients. Once infected, permanent immunity to the infecting strain develops, but an individual can have the disease several times from different strains. By adulthood, most individuals exhibit immunity to several strains. Affected patients present with sore throat, low-grade fever, headache, sometimes vomiting and abdominal pain. The lesions closely resemble RAU and most commonly occur on the soft palate, pharyngeal wall and tonsillar pillars. They normally heal within a week. THERAPY
OTC ibuprofen and Sucrets® with dyclonine
3. Hand, Foot & Mouth Disease
This is another clinical presentation of enterovirus infection which can be caused by one of several strains. The majority of the cases arise in young children but can present in adulthood. It is characterized by an erythematous maculopapular rash of the skin which most frequently involves the hands, feet, legs, arms and buttocks. Anorexia, low-grade fever, coryza, sometimes lymphadenopathy, diarrhea, nausea and vomiting can occur. Oral lesions are invariably present and are the principal symptoms in over 90% of the patients. The lesions resemble RAU and occur primarily on the palate, tongue and buccal mucosa. The infection resolves within 10-14 days. Treat like herpangina. 4. Behçet's Syndrome This is a systemic abnormality which most likely is autoimmune and usually arises be- tween the ages of 10 and 45. It is 5-10 times more common in males. Oral, genital, skin and ocular lesions are seen. The oral lesions present as RAU, and the genital ulcers often are small and occur on the scrotum, root of penis, labia majora or perianally. Ocular lesions range from conjunctivitis to uveitis to hypopyon. The skin lesions usually present as pustules on the trunk, limbs or genitalia. A number of other systemic complications may occur also. Classic triad: oral ulcers, genital ulcers and ocular inflammation. If discovered, refer to an experienced dermatologist. Classically, herpes simplex is divided into type I in which the infections arise above the waist and type II which is seen below the waist. With the current changing sexual practices, a widespread translocation of the two types has occurred. Type I infection is extremely common, and 70-90% of the adult population has circulating antibodies against the virus. The following comments will be limited to infections of the perioral areas and oral cavity. When exposed to the virus, patients without circulating antibodies may luckily develop a subclinical infection. Those not so blessed (<10%) develop the primary herpes infection, and
the most common pattern is acute herpetic gingivostomatitis. Primary herpes normally
develops only once, but it must be remembered that types I and II are different viruses with each
capable of producing its own primary infection.
These highly symptomatic cases typically begin with high fever and lymphadenopathy which are followed in a few days by diffuse oral lesions. In all of the cases, the gingiva is painful and demonstrates enlargement and an intense erythema. Ulcerations of the midfacial free marginal gingiva are not uncommon. These ulcerations along with the pain help separate this form of gingivitis from those which are plaque-related. Multiple fragile vesicles develop and rapidly ulcerate; observation of an intact vesicle is rare. The lesions frequently cluster and coalesce. The ulcerations vary in size from a few millimeters to a centimeter and may resemble RAU closely, especially the herpetiform variety. The involvement of bound mucosa, especially the gingival changes, is the clue to the diagnosis. The lesions can extend past the wetline and involve the vermilion border of the lips. If the diagnosis is in question, a cytologic smear can be beneficial if performed within the first 3-5 days. Intraoral culture is not worthwhile. Therapeutic attempts most often are directed toward palliation. Benadryl solution or dyclonine can be utilized as a short-term anesthetic and can be complemented by a non-steroidal anti-inflammatory medication such as Motrin®. Tetracaine lollipops work great in this situation. If the patient is diagnosed prior to day three of the ulcerations, liquid acyclovir has been shown to be highly effective in reducing the severity of the infection. Without therapy, the ulcerations normally heal in 10-14 days. THERAPY
Acyclovir suspension (SMS 3-1), ibuprofen (SMS 3-8), tetracaine lollipops (SMS 3-6)
After the initial infection, the surviving virus is sheltered in the nerve ganglia which innervate the area. The virus is contained in that location by the cell mediated immune response.
Any reduction of containment can result in reactivation of the virus and a recurrent infection
known as secondary herpes. Old age, pregnancy, allergy, trauma, respiratory illnesses,
menstruation, and underlying systemic disease or malignancy have been associated with an
increased frequency of the recurrent infection. Involvement of the lips and perioral skin is
common and known as herpes labialis.
The clinically evident portion of the infection frequently is preceded by prodromal symptoms which include burning, stinging, soreness, paresthesia and/or redness of the affected
area. Shortly thereafter, vesicles appear. These vesicles are filled with clear fluid, subsequently
rupture and lead to formation of a brown crust. The vesicles are a few millimeters in diameter
but tend to cluster and coalesce. Significant edema and occasional secondary infections may
complicate the course. Most cases are unilateral, but bilateral examples are not rare. The fluid
within the vesicles is contagious and can cause spread of the lesions if allowed to contact other
open wounds. Patients with active lesions should be dismissed prior to dental therapy. In
addition, it must be remembered that the virus can survive up to five hours in a damp gauze; all
health care personnel must maintain barrier protection until all contaminated instruments and
disposable materials have been eliminated. The virus may infect any unprotected finger and
result in very painful recurrences to the affected digit (herpetic whitlow).
A number of therapeutic medications have been utilized, most of which work well in some patients but not in the majority. Idoxuridine, vidarabine, and lysine have demonstrated limited usefulness in certain patients. Systemic antiviral capsules (acyclovir, valacyclovir, famciclovir) have demonstrated clinical efficacy, but only valacyclovir has been studied extensively in clinical trials. Although individual patients exhibit varying results, acyclovir ointment has demonstrated no statistically significant clinical benefit for herpes labialis in the immunocompetent patient. In contrast, penciclovir cream has demonstrated a measurable reduction in the intensity and duration of the lesions. Although rare in immunocompetent patients, viral resistance to acyclovir has been reported in immunocompromised patients and should warn against over use. High-dose short-term systemic therapy with valacyclovir has been proven to the highly effective in aborting or minimizing attacks. THERAPY
During prodrome
After bubbles appear Denavir (SMS 4-5) Prior to dental care Secondary herpes also can occur within the oral cavity and is known as recurrent
herpetic stomatitis. Once you have crossed over the wetline and entered the oral cavity,
recurrent herpes is seen in the immunocompetent patient only on keratinized mucosa which is
bound to bone. This is really nice, because it is exactly opposite from MiRAU which occurs
almost exclusively on movable mucosa. The lesions begin as small pin point areas of erythema
which, with time, develop central yellow zones of fibrin. Intact vesicles are rare. The lesions
tend to cluster and coalesce. Most areas are localized and unilateral. The majority of the cases
are associated with mild symptoms and do not require therapy. The ulcerations tend to heal in 5-
7 days. These lesions are not unusual following dental procedures, even in patients who have not
had a history of primary herpes.
In the immunocompromised patient, recurrent herpes can appear very atypical clinically (chronic or aggressive HSV infection). Many patients initially present with herpes labialis and subsequently develop an intraoral ulceration with an elevated brownish cap (necrotic epithelium). Instead of healing, the lesions spread laterally as superficial erosions which often exhibit a raised white border. The lesions may occur on any mucosal surface. Treatment is to resolve the cause for the immunocompromised status and treat with one of the effective systemic antiviral medications. This unusual pattern has been seen in everything from asthma patients using steroid inhalers to leukemia patients. If recurrent herpes is found on movable mucosa in a “healthy patient” or becomes chronic and spreads laterally, immunosuppressive causes should be investigated. This viral infection is produced by the varicella-zoster virus and is much like recurrent herpes in that it is a recurrence of a previously received infection: chickenpox. The virus resides in sensory nerve ganglia and upon reactivation causes vesicular eruptions of the affected skin or mucous membranes. The disease usually affects adults and presents with fever, malaise and pain along the course of the involved nerves. The vesicles follow the nerves and usually are unilateral and anatomic. Initially, intraoral lesions present as white, opaque vesicles that ultimately rupture and form ulcerations that may resemble RAU. Many attacks begin for no apparent reason but may be related to underlying trauma, tumor, malignancy or immunosuppression. Systemic antivirals (acyclovir, valacyclovir, famciclovir) are efficacious, with topical capsaicin utilized for residual neuritis. THERAPY
Chickenpox Acyclovir suspension (SMS 5-1)
Zoster
Erythema multiforme (EM) is an acute diffuse ulcerative condition of unknown cause which can involve the skin and any mucosal surface. In about half the cases, a triggering event can be found. A number of viral infections, the most common of which is herpes simplex, precedes the attack by one to three weeks. Other patients can trace the outbreak to an allergen exposure, often one of a large number of possible medications. Rare cases have been associated with underlying internal malignancies. The ulcerations may arise at any age but are most commonly seen in young adult males. The dermatologic manifestations characteristically present with erythematous macules, papules and/or vesicles which are distributed on the extremities, face and neck. The classic lesion is a macule which exhibits alternating rings of varying shades of erythema, the so-called “bull’s eye” or “target” lesion. Oral lesions are common and occasionally can be seen in the absence of other lesions. Out of all of the acute oral ulcerative conditions, primary herpes and EM produce the most severe symptoms. It is not unusual for patients with oral EM to bring a relative to speak for them. The oral lesions present predominantly on movable mucosa but are not limited to that location. The individual areas appear as a large zone of irregular epithelial necrosis. The
epithelium rapidly sloughs, leaving a large painful erosion. The lesions often are numerous and
diffuse. Involvement can extend past the wetline onto the vermilion border of the lips. On
occasion, the lesions can involve the skin and the mucosal surfaces of the eye, mouth and genital
areas and have been termed Stevens-Johnson Syndrome.
Because EM is self-limiting, some clinicians do not feel the necessity to treat the lesions. In those patients receiving therapy, systemic steroids normally are utilized. Patients with significant oral lesions should receive therapy. With appropriate therapy, the pain and duration of their suffering can be diminished dramatically. Although systemic steroids are occasionally required, those with only oral involvement often can be resolved with 0. 1 % dexamethasone syrup or Prelone® syrup. Patients with diffuse dermatologic and oral involvement, which are treated with systemic steroids, rarely exhibit failure of the oral lesions to resolve in a timely fashion. This problem can be circumvented through use of Prelone® in a “swish and swallow” pattern in the same dosages as that utilized with systemic prednisone. In patients with recurrent EM limited to mucosal surfaces, prophylactic acyclovir should be prescribed to rule out a viral trigger. THERAPY
Restricted to mouth Compounded ultrapotent dexamethasone solution (SMS 1-7)
Vermilion border
This entity is different from the other types of acute sore mouth because it most often is confused with a salivary gland neoplasm and generally not included in a discussion of acute ulcerations. The disorder may occur in serous or mucous glands of the oral, nasal or respiratory areas but usually occurs in minor salivary glands of the palate. The changes mimic a mucoepidermoid carcinoma both clinically and histologically, but the appropriate diagnosis can be made by those with previous experience with these changes. Following local ischemia of undetermined origin, coagulative necrosis develops within the affected gland. Intraorally, the most common site is the palate, and the presentation is so distinctive that the diagnosis often can be made secondary to the unique clinical pattern. The affected area begins as an enlarged, tender and erythematous zone which arises over a couple of days. Subsequently, the overlying mucosa breaks down with the formation of a well-circumscribed and deep ulceration. Bilateral lesions can occur. Pain often is mild considering the size of the defect, which may be large with healing taking as long as 10 weeks. Biopsy often is utilized to confirm the clinical impression. SORE MOUTH SOLUTIONS
RAU, ERYTHEMA MULTIFORME, LICHEN PLANUS, LOCALIZED PEMPHIGOID 1-1. Lidex Gel (0.05% Fluocinonide): Apply thin film to affected area three times a day. Augmented betamethasone dipropionate ointment 0.05% (Diprolene): Apply thin film to the affected area three times a day. Temovate Gel (0.05% Clobetasol Propionate): Apply thin film to the affected area 3 times a day. POTENT. Treatment should be limited to 14 days and amounts greater than 50 grams a week should not be used (unlikely). Clobetasol 0.05% and Clotrimazole 0.1% 10 grams compounded in an oral powder puffer. Use up to five times daily. This custom formulation is used for patients who are having problems with secondary candidiasis. Clobetasol 0.05% and Clotrimazole 0.1% compounded in 3% methocel gel. Dispense 30 gram tube and apply thin film to affected area 4-5 times daily. This custom formulation is used for patients who are having problems with secondary candidiasis. Dexamethasone Solution {0.5mg/5ml (0.01%)}: Rinse and hold for two minutes, then expectorate. Use 1-2 tsp. four times a day. Dexamethasone Solution {5mg/5ml (0.1%)}: Rinse and hold for two minutes, then expectorate. Use 1-2 tsp. four times a day. Very potent; must expectorate; use with caution. Must be compounded upon request. Prelone Syrup (Prednisolone 15mg/5ml): Rinse and hold for two minutes, then expectorate. Use 1-2 tsp. four times a day. In addition, Prelone utilized as “swish and swallow” is an excellent method for local coverage and systemic administration selected cases (erythema multiforme, pemphigus, etc). Kenacort Tablets (8mg Triamcinolone): Dissolve one tablet TID for 3 days; one tablet BID for 3 days and one tablet once a day for three days. 1-10. Kenalog 40 Injection (5cc vials, 40mg/ml Triamcinolone): Inject one cc around border of 1-11. Protopic (topical tacrolimus ointment, 0.1 or 0.03%): Apply thin film to the affected area 2-3 times daily. More potent than cyclosporine. The medication should be used only as a second line therapy in patients who have failed corticosteroid use. 1-12. Tetracycline (500mg QID) and Niacinamide (500mg QID): Use for resistant pemphigoid. Improvement usually seen in 2-6 weeks. After six months, attempt to taper if disease is well controlled. Patients on niacinamide can experience flushing which normally resolves if reduced to 1.5 gms/day. 1-13. Dapsone: Use for resistant cases of pemphigoid. Doses ranging from 25-200 mg/day are used. Referral to experienced dermatologist often wise due to significant side effects. 1-14. Systemic Prelone Syrup (Prednisolone 15mg/5ml): Instruct patient to rinse entire daily amount first thing in the morning. Rinse and hold +/-2tsp at a time for AT LEAST two minutes then swallow. First four days: 5tsp. Days 5-8: 4 tsp. Days 9-11: 3 tsp. Days 12-13: 1.5tsp. Day 14: 1tsp. Patient should be instructed to call at the end of day three. If improving, continue on schedule. If not improving, continue at 5tsp for three more days then call again. If this fails, refer to MD and suggest systemic steroids at 1.5-2mg/kg/day until the lesions clear. Use of Prelone formulation will improve response. Mix 1mg Prograf capsule in 1000ml of purified water. Dispense 1000ml. Rinse 2 tsp (10ml) of solution for at least two minutes, then expectorate. Repeat four times daily. Store refrigerated. Shelf-life is one month. Compound 0.03% tacrolimus suspension. Rinse 1-2 tsp twice daily for five minutes. Once controlled, taper to once daily, then once every second day with subsequent attempt at temporary cessation. Mycostatin Oral Suspension (100,000 units of Nystatin per ml): Rinse and hold for two minutes. Use one tsp. four times a day. This is not my favorite due to high sucrose content and expense. Mycelex Troches (10mg Clotrimazole): Dissolve one troche five times a day for 14 days. Liver function tests required for course longer than 14 days. Excellent choice but expensive. Nizoral Tablets (200mg Ketoconazole): Take one tablet a day for 14 days. Liver function tests required for a course over 14 days. Generic ketoconazole now available and makes this a good choice. Diflucan (200mg Fluconazole): Take one tablet a day for 14 days. Clotrimazole 1% cream: This represents the first line therapy against angular cheilitis. This medication is OTC and surprisingly is effective in cases due to candida and bacteria. Mycolog II Ointment (100,000 units of Nystatin and l mg of Triamcinolone per gram): Apply thin film to the affected area four times a day. Works well for angular cheilitis in many patients. Will not be beneficial in cases of angular cheilitis due to strep or staph. Difficult to find, but generic equivalent can be obtained. Hydrocortisone 1% / Iodoquinol 1% Cream (Generic or Dermazene): Dispense 1 oz (28.4 gram) tube. Apply thin film to the affected area four times a day. This has anti-inflammatory, antibacterial and antifungal actions. Works well for angular cheilitis but tastes like death (helps stops chronic lip lickers). Also available in gel > Alcortin A gel: aloe polysaccharide 1%, hydrocortisone acetate 2%, iodoquinol 1% in 2 gram packets. Packets come individually or in box of 24. Peridex (0.12% Chlorhexidine Gluconate): For prevention, rinse capful (1/2 ounce) twice a day. Sold in 16 ounce containers. Avoid in pregnancy and nursing females. May cause staining of teeth, increased supragingival calculus and altered taste. Clorox: Dilute 1:5 with water and use as denture soak. Will discolor metallic frameworks. Zovirax Suspension {200mg/5ml (tsp) Acyclovir}: Rinse and swallow required amount five times a day for five days. For children too young to swallow capsules or in patients with primary herpetic gingivostomatitis. The dosage is 5mg/kg, not to exceed the adult dose. Weight (KG=2.2 lbs)
Required amount
Zovirax Capsules (200mg Acyclovir): Take one capsule five times a day for five days. Avoid in pregnancy and ages 0-12. Valtrex (1g Valacyclovir hydrochloride): Take one caplet twice daily for ten days. Therapy is most effective if initiated within 48 hours of initial signs and symptoms. Famvir (125mg Famciclovir): Take one tablet twice daily for five days. Dyclonine HCL, 0.5%: The brand name Dyclone has been discontinued by manufacturer due to low profits. This active ingredient can be obtained easily by compounder and custom formulated as desired. Rinse, spray or swab on affected areas PRN for pain. Supplied in 1 oz bottles. Also available in 1% strength for severe cases which fail to respond to 0.5%. Excellent topical anesthetic. Tetracaine 0.5% lollipops (compound medication): Swab in mouth for 8-10 minutes per hour. Don’t chew and be careful of hot/cold food or drink. Sucrets maximum strength oral anesthetic lozenges. These are over-the-counter and contain dyclonine. Benadryl solution (12.5mg/5ml diphenhydramine hydrochloride): Rinse and hold for two minutes. Use one tbsp. four times a day. Can be used as an inexpensive but mild topical anesthetic. Search for no alcohol variety. Motrin (400-600mg Ibuprofen): Take one tablet every four hours. 3-10. Tylenol (325mg acetaminophen): Take two caplets every 4-6 hours. SECONDARY HERPES 4-1. Zovirax Capsules (200mg Acyclovir): Take one capsule five times a day for five days, beginning in the prodrome or prior to known trigger. Avoid in pregnancy and ages 0-12. For maintenance in severe cases, take three capsules a day. Temporarily discontinue every six months to monitor activity of the virus. Therapy often breaks the back of the virus within a couple of years. Females must be sterile or practicing excellent contraception. Valtrex (1g Valacyclovir hydrochloride): take two caplets (total of 2 grams) twice daily for 1 day taken about 12 hours apart. Therapy should be initiated at the earliest symptom (tingling, itching, burning, etc.). For suppressive therapy, take 1 caplet daily. Valtrex (1g Valacyclovir hydrochloride) for prevention of recurrence associated with dental therapy: take two caplets (total of 2 grams) twice daily for 1 day taken about 12 hours apart, followed by one caplet twice daily for one additional day. Famvir (125mg Famciclovir): Take one tablet twice daily for five days. Denavir Cream (1% Penciclovir): Dispense 1.5mg tube. Beginning in the prodrome, apply thin film to the affected area every two hours during waking hours for a period of four days. Works best if initiated prior to appearance of vesicles. Zovirax Cream (5% Acyclovir): Beginning in the prodrome, apply thin film to the affected area six times a day for seven days. Superior absorption when compared to ointment formulation. Zovirax Ointment (5% Acyclovir): Beginning in the prodrome, apply thin film to the affected area six times a day for seven days. Does not penetrate skin well and is of limited usefulness, although some patients respond well. Abreva Cream (OTC; 10% topical docosanol): Few published studies. In the early stages of the recurrence, apply sufficient quantity to cover all lesions; rub in gently and completely; repeat five times a day until the lesions are healed. Viroxyn Swab (Sold through participating DDS/DMD & MD offices, 0.13% alkylbenzyldimethylammonium chlorides): Single-application treatment system with little available information. Break glass vial and saturate swab. Vigorously rub swab against lesion until are ingredients are dispensed. Do not use soap or other cleansers for 24 hours in the affected area. 4-10. Lysine Tablets (OTC): Beginning in the prodrome, take at least 2000mg per day for seven days; for maintenance, utilize 1000mg per day. This is effective in up to 40% of affected patients. 4-11. Peridex (0.12% Chlorhexidine gluconate): Rinse and hold one capful for two minutes then expectorate. Repeat twice daily. Good choice for mild recurrent herpetic stomatitis. Zovirax Suspension (200mg/5ml Acyclovir): Dispense required amount five times a day for five days. For children with varicella. The dosage is 20mg/kg, not to exceed the adult dose. Weight (KG = 2.2 lb)
Required amount
Famvir (500mg Famciclovir): Take one tablet three times a day for seven days. Appears to decrease time to resolution of pain when compared to acyclovir. In addition, prompt utilization appears to reduce the duration of postherpetic neuralgia. Valtrex (1g Valacyclovir hydrochloride): Take one caplet three times daily for seven days. Appears to decrease time to resolution of pain when compared to acyclovir. Due to lower cost, Valtrex appears to be a better choice than Famvir. Zovirax Capsules (800mg Acyclovir): Take one capsule five times a day for five days.

Source: http://www.opceseminars.com/sitebuildercontent/sitebuilderfiles/soremouth.pdf