1. Clinical Pharmacy Lec:3
Mouth ulcer
Oral thrush
Head lice

2. Conditions affecting oral cavity
Mouth ulcers:
Aphthous ulcers more commonly known as mouth ulcers is a collective term used to describe various different clinical presentations of superficial painful oral lesions that occur in recurrent bouts at intervals between few day to a few months.
The majority of patients (80%) who present in a community pharmacy will have minor(MAU),

3. Prevalence an Epidemiology:
For MAU, the prevalence is poorly understood.
Occur in all ages but more common in (20-40).
Aetiology:
The cause of MAU is unknown.
A number of theories have been but forward to explain like: food sensitivity, stress, genetic, nutritional deficiencies( iron ,zinc, B12) and infection.

4. Arriving at differential diagnosis:
There are three main clinical presentation to ulcers: minor, major, herpetiform.

6. Clinical features of MAU
Roundish in shape.
Grey-white in colour.
Painful.
Small usually less than 1cm in diameter.
Occur singly or in small crops of
up to 5 ulcers.
Takes 7-14 days to heal.
Recurrence can occur after 1-4 months.

7. Conditions to eliminate
1.major aphthous ulcers:
Larger than 1 cm in diameter.
Numerous.
Occurring in crops of 10 or more.
Heal slowly may take months.
The ulcers often coalesce to form one large ulcer.

8. 2.Herpetiform ulcers: 3.Oral thrush:
Ulcers are pinpoint and occur in large crops of up to 100 at a time.
They usually heal within a month.
Occur in the posterior part of the mouth( an unusual location for MAU).
3.Oral thrush:
Usually presents as creamy- white soft elevated patches.

9. 4. Herpes simplex:
Ulcers tend to be small, discrete and many in number.
Signs of systemic infection like fever and pharyngitis.
5. Medicine-induced ulcers:
Ulcers seen at start of therapy or when increase the dose.
Mostly with Cytotoxic agents, NSAIDS, B-blockers.

14. Oral thrush Background:
Oropharyngeal candidiasis(oral thrush) is an opportunistic mucosal infection.
Unusual in healthy adult.
Aetiology:
Thrush (Candidiasis) is a fungal infection caused by Candida albicans which occurs commonly in the mouth (oral thrush).

15. Arriving at differential diagnosis
Oral thrush is not difficult to diagnose.
Careful history is taken.
Oral examination is performed.
Clinical features of oral thrush:
Oral thrush is a creamy white soft elevated patches that can wiped off revealing underlying erythematous mucosa.
Pain, soreness, altered taste, and burning tongue.
Lesions can be anywhere in tongue, palate, lips and cheeks .

18. Conditions to eliminate
1.minor aphthous ulcer
2. medicines induced
Inhaled corticosteroids and antibiotics.
3. denture wearers
Wearing dentures especially if they are not taken out at night, not kept clean, or do not fit well predispose people to thrush.

19. 4.underlying medical disorders
Diabetes
Xerostomia
Immunocompromised
Major aphthous ulcer
Herpetiform ulcer
5. Very unlikely causes include leukoplakia and squamous cell carcenoma

22. Evidence base for OTC medications

24. Head lice prevalence and epidemiology
Affecting all ages, although much more prevalent in children aged (4-11) years old especially girls.
Can occur at any time during the year.
Etiology
Can only be transmitted by head to head contact.

25. Clinical features of head lice
Live lice present.
Itching due to scalp allergic response to lice saliva and can take weeks to develop.

26. Arriving at differential diagnosis
Most parents will diagnose head lice themselves or be concerned that their child has head lice because of a recent local outbreak at school.
Parents also will buy products to prevent their child contracting head lice.

28. Conditions to eliminate
1. dandruff
Can cause scalp irritation and itching.
The scalp should be dry and flaky.
Skin debris may be present on clothes.

29. 2. seborrhoeic dermatitis
Will affect areas other than scalp mostly face.
If only scalp involvement is present , the child might complain severe and persistent dandruff.

30. Evidence based for OTC medication
Treatment options includes:
1. insecticides (malathion, permethrin) cure rate 70-80%
2. wet combing is alternative with cure rate 40-60%.
3.dimeticone is a recent introduction thought to work by coating lice internally and externally which leads to disruption in water excretion causing rupture lice gut by osmosis.

31. 4.Isopropyl myristate
A recent introduction to the Uk market.
Like dimeticone, it is pharmacologically inert but act by blocking the tracheal breathing system and coating the surface of the lice with a thin film of fluid.
More effective than permethrin.