Raiyyan Tahsan

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ENT Case No 8. 𝘼𝙥𝙝𝙩𝙝𝙤𝙪𝙨 𝙪𝙡𝙘𝙚𝙧𝙨

কারো মুখে প্রায়ই ছোট ঘা এর মতো দেখা যায় 😫সাদা ছোট ঘা, বা লাল ফোস্কার মতো বের হয় যার নাম 𝘼𝙥𝙝𝙩𝙝𝙤𝙪𝙨 𝙪𝙡𝙘𝙚𝙧𝙨 *

(Buccul mucosa Common site Of Apthous Ulcer*)Non Keratinized mucosa* তে হয়!!জ্বরঠোসার মত ঠোঁটের উপরে,বাহিরে হয় না..

ছোট্ট থেকে বৃদ্ধ বয়স অবধি সমস্যাটি কম বেশি সকলকেই ভোগায়।এই সমস্যায় ভোগেননি এমন মানুষ কমই আছে!!

🔹লক্ষন গুলো হলো :–

• জ্বালা পোড়াও ব্যাথা

• খেতে গেলে জ্বালা বেশি হয়😮‍💨

• অল্প ফোলা ,ঘা

𝘼𝙥𝙝𝙩𝙝𝙤𝙪𝙨 Ulcer এর একেবারে সঠিক কোনো কারণ পাওয়া যায়নি।তবে কিছু কিছু Aggravating factor এর জন্য হতে পারে♦যেমন_________

▫️আঘাতের কারণে হতে পারে

▫️Stress,রাত জাগা

▫️মেয়েদের ক্ষেত্রে During menstuation **most common

▫️Immune suppressed দের ক্ষেত্রে

▫️Hormonal Imbalances

Treatment 🚨🚨

প্রথমত এইটা হলো self Limiting ,So নিজে নিজেই সেরে যায় ৭-১৪ দিন এর মধ্যে…..তবে অনেকে মুখে কোনো ঘা মানেই Microral জেল use করেন!!

– Aphthous Ulcer এর জন্য Micoral gel নয়🚫🚫🚫

So Mx should be..

✅Triamcinolone Oral paste(Best option)****

বাজারে 𝙏𝙧𝙞a𝙡𝙤𝙣 𝙤𝙧𝙖𝙡 𝙥𝙖𝙨𝙩𝙚 নামে পাওয়া যায়…

Oral Paste 1:-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Indications of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Cenolon Dental Paste USP, 0.1% is indicated for adjunctive treatment and for the temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma.

Pharmacology of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Like other topical corticosteroids, triamcinolone acetonide has anti-inflammatory, antipruritic, and vasoconstrictive properties. The mechanism of the anti-inflammatory activity of topical steroids, in general, is unclear. However, corticosteroids are thought to act by the induction of phospholipase A2 inhibitory proteins, collectively called lipocortins. It is postulated that these proteins control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of their common precursor, arachidonic acid. Arachidonic acid is released from membrane phospholipids by phospholipase A2.

Dosage & Administration of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Press a small dab (about 1/4 inch) to the lesion until a thin film develops. A larger quantity may be required for coverage of some lesions. For optimal results use only enough to coat the lesion with a thin film. Do not rub in. Attempting to spread this preparation may result in a granular, gritty sensation and cause it to crumble. After application, however, a smooth, slippery film develops. The preparation should be applied at bedtime to permit steroid contact with the lesion throughout the night. Depending on the severity of symptoms, it may be necessary to apply the preparation two or three times a day, preferably after meals. If significant repair or regeneration has not occurred in seven days, further investigation is advisable.

Contraindications of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Triamcinolone acetonide dental paste is contraindicated in those patients with a history of hypersensitivity to any of the components of the preparation; it is also contraindicated in the presence of fungal, viral, or bacterial infections of the mouth or throat.

Side Effects of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

The following local adverse reactions may occur with corticosteroid-containing dental pastes: burning, itching, irritation, dryness, blistering or peeling not present prior to therapy, perioral dermatitis, allergic contact dermatitis, maceration of the oral mucosa, secondary infection, and atrophy of the oral mucosa.

Pregnancy & Lactation of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Pregnancy Category C. Triamcinolone acetonide has been shown to induce teratogenic effects in several species. It is not known whether oral application of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in breast milk. Caution should be exercised when corticosteroid- containing dental pastes are prescribed for a nursing woman.

Precautions & Warnings of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Cenolon dental paste may cause local adverse reactions. If irritation develops, Cenolon dental paste should be discontinued and appropriate therapy instituted. Allergic contact sensitization with corticosteroids is usually diagnosed by observing failure to heal rather than noting a clinical exacerbation as with most topical products not containing corticosteroids. Such an observation should be corroborated with appropriate diagnostic patch testing.

If concomitant mucosal infections are present or develop, an appropriate antifungal or antibacterial agent should be used. If a favorable response does not occur promptly, use of Cenolon dental paste should be discontinued until the infection has been adequately controlled. If significant regeneration or repair of oral tissues has not occurred in seven days, additional investigation into the etiology of the oral lesion is advised.

Systemic absorption of topical corticosteroids has produced reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, manifestations of Cushing’s syndrome, hyperglycemia, glucosuria, and other adverse effects known to occur with parenterally-administered steroid preparations; therefore, it may be advisable to periodically evaluate patients on prolonged therapy with corticosteroid-containing dental pastes for evidence of HPA axis suppression. If HPA axis suppression is noted, an attempt should be made to withdraw the drug or to reduce the frequency of application. Recovery of HPA axis function is generally prompt and complete upon discontinuation of therapy.

Use in Special Populations

Pediatric Use: The safety and efficacy of Cenolon dental paste in children is unknown. Pediatric patients may demonstrate greater susceptibility to topical corticosteroid-induced HPA axis suppression and Cushing’s Syndrome than mature patients because of a larger skin surface area to body weight ratio. Administration of corticosteroid-containing dental pastes to children should be limited to the least amount compatible with an effective therapeutic regimen. Chronic corticosteroid therapy may interfere with the growth and development of children.

Geriatric Use: Clinical studies of Cenolon dental paste did not include sufficient numbers of subjects age 65 and older to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

Therapeutic Class of Oral Paste :-Cenolon 0.1% 10gm tube (AS A Triamcinolone Acetonide AS A Corticosteroid, Glucocorticoids).

Corticosteroid, Glucocorticoids

OR

  • 𝘼𝙥𝙨𝙤𝙡 𝙤𝙧𝙖𝙡 𝙥𝙖𝙨𝙩𝙚 also Useful**
  • Oral Paste 2:-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).
  •  
  • Indications of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

Apsol is indicated for the treatment of aphthous ulcers.

  • Pharmacology of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

The mechanism of action by which Amlexanox accelerates healing of aphthous ulcers is unknown. In vitro studies have demonstrated Amlexanox to be a potent inhibitor of the formation and release of inflammatory mediators (histamine and leukotrienes) from mast cells, neutrophils and mononuclear cells. Given orally to animals, Amlexanox has demonstrated anti-allergic and anti-inflammatory activities and has been shown to suppress both immediate and delayed-type hypersensitivity reactions. The relevance of these activities of Amlexanox to its effects on aphthous ulcers has not been established. After a single oral application of 100 mg of paste (5 mg Amlexanox), maximal serum levels are observed at 2.4 hours. Most of the systemic absorption of Amlexanox is via the gastrointestinal tract and the amount absorbed directly through the active ulcer is not a significant portion of the applied dose. The half-life for elimination was 3.5 +/- 1.1 hours in healthy individuals.

  • Dosage & Administration of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

  • Apply the paste as soon as possible after noticing the symptoms of an aphthous ulcer. Continue to use the paste four times daily, preferably following oral hygiene after breakfast, lunch, dinner, and at bedtime.
  • Dry the ulcer(s) by gently patting it with a soft, clean cloth.
  • Wash hands before applying.
  • Moisten the tip of the index finger.
  • Squeeze a dab of paste approximately ¼ inch (0.5 cm) onto a fingertip.
  • Gently dab the paste onto the ulcer. Repeat the process if more than one ulcer are present.
  • Wash hands after application.
  • Wash eyes promptly if they should come in contact with the paste.
  • Use the paste until the ulcer heals. If significant healing or pain relief has not occurred in 10 days, consultation with the physician is required.
  • Contraindications of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

Amlexanox oral paste is contraindicated in patients with known hypersensitivity to Amlexanox or other ingredients in the formulation.

  • Side Effects of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

Adverse reactions reported by 1-2% of patients were transient pain, stinging and/or burning at the site of application. Infrequent (<1%) adverse reactions in the clinical studies were contact mucositis, nausea, and diarrhea.

  • Pregnancy & Lactation of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

US FDA pregnancy category B. Teratology studies were performed with animals at doses up to two hundred and six hundred times, respectively, the projected human daily dose. No adverse fetal effects were observed. There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Amlexanox was found in the milk of lactating rats; therefore, caution should be exercised when administering Amlexanox oral paste to a nursing woman.

  • Precautions & Warnings of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

Wash hands immediately after applying Apsol oral paste directly to ulcers with the finger tips. In the event that a rash or contact mucositis occurs, discontinue use.

  • Use in Special Populations of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

Pediatric Use: Safety and effectiveness of Apsol oral paste in pediatric patients have not been established.

  • Overdose Effects of Oral Paste :-Apsol 5% 5gm tube AS A Amlexanox AS A  Corticosteroid, Glucocorticoids).

 

 

Ingestion of a full tube of 5 grams of paste would result in systemic exposure well below the maximum nontoxic dose of Apsol in animals. Gastrointestinal upset such as diarrhea and vomiting could result from an overdose.

  •  

কিছু ক্ষেত্রে Mouth wash ও use করা হয় ~(Local anestetic Mouth wash )

Oral fresh /Oralon*****

Mouth Wash 3.Oralon 0.2% 100ml Bottle (AS A Chlorhexidine Gluconate AS A Other antibacterial preparation).

Indications

Oralon Mouthwash is an antimicrobial solution which inhibits the formation of dental plaque. It is indicated as an aid in the treatment and prevention of gingivitis and in the maintenance of oral hygiene, particularly in situations where tooth brushing cannot be adequately employed (e.g. following oral surgery, in mentally or physically handicapped patients). It may also be used in a post-peridontal surgery or treatment regimen to promote gingival healing.

Pharmacology

Chlorhexidine is a very potent cationic chemoprophylactic agent that has a broad-spectrum of activity against gm+ve and gm-ve bacteria. It is both bacteriostatic and bactericidal depending on its concentration. The bactericidal effect, which is achieved at high concentrations, is due to the binding of the cationic to negatively charged bacterial cell walls and extramicrobial complexes. Bacteriostatic effect is achieved at low concentrations which causes an alteration of bacterial cell osmotic equilibrium and leakage of potassium and phosphorus.

Dosage & Administration

Adults: Thoroughly rinse the mouth for about one minute with 10 ml twice daily. In the dental surgery the patient should be instructed to rinse the mouth for one minute prior to treatment. Chlorhexidine Gluconate is incompatible with anionic agents which are usually present in conventional dentifrices. These should therefore be used before Chlorhexidine Gluconate (rinsing the mouth between applications) or at a different time of day.

For the treatment of gingivitis a course of about one month is advisable although some variation in response is to be expected. In the case of aphthous ulceration and oral candidal infections treatment should be continued for 48 hours after clinical resolution. For the treatment of dental stomatitis the dentures should be cleansed and soaked in Chlorhexidine Gluconate mouthwash for fifteen minutes twice daily.

Children and the Elderly: The normal adult dose is appropriate for elderly patients and children of 12 years and over unless otherwise recommended by the dentist or the physician. Children under 12 years of age should not use the product unless recommended by a healthcare professional. 

Route of administration: External (oral) use.

Interaction

Oralon is incompatible with anionic agents.

Contraindications

Chlorhexidine Gluconate is contraindicated for patients who have previously shown a hypersensitivity reaction to Chlorhexidine or to any of the excipients in the formulation. However, such reactions are extremely rare.

Side Effects

Discoloration: A superficial discoloration of the dorsum of the tongue may occur. This disappears after treatment is discontinued. Discoloration of the teeth and silicate or composite restorations may also occur. This stain is not permanent and can largely be prevented by reducing the consumption of tea, coffee and red wine and brushing with a conventional toothpaste daily.

Before using the mouthwash or, in the case of dentures, cleaning with a conventional denture cleanser. However, in certain cases a professional prophylaxis (scaling and polishing) may be required to remove this stain completely. Stained anterior toothcoloured restorations with poor margins or rough surfaces which are not adequately cleaned by professional prophylaxis may require replacement. Similarly where normal toothbrushing is not possible, for example with intermaxillary fixation, or with extensive orthodontic appliances, scaling and polishing may also be required once the underlying condition has been resolved. Taste: Transient disturbance of taste sensation and a burning sensation of the tongue may occur on initial use of the mouthwash. These effects usually diminish with continued use. Oral desquamation: In cases where oral desquamation occurs dilution of the mouthwash with an equal volume of tap water, freshly mixed, will often allow continued use of the mouthwash. Parotid gland swelling: Very occasionally, swelling of the parotid glands during the use of chlorhexidine mouthrinses has been reported. In all cases spontaneous resolution has occurred on discontinuing treatment.

Irritative skin reactions: Irritative skin reactions to chlorhexidine preparations can occasionally occur.

Generalised reactions: Allergic reactions, hypersensitivity & anaphylaxis to chlorhexidine have also been reported but are extremely rare.

Pregnancy & Lactation

There is no evidence of any adverse effects on the foetus arising from the use of Chlorhexidine Gluconate during pregnancy or on infants during lactation. Therefore no special precautions are recommended.

Precautions & Warnings

For oral (external) use only. Do not swallow. Keep out of the eyes and ears. If the mouthwash comes into contact with the eyes, wash out promptly and thoroughly with water. In case of soreness, swelling or irritation of the mouth, stop using the product and consult a healthcare professional.

Therapeutic Class

Other antibacterial preparation

NA komle then Antibiotic use korte hobe

কিছু 𝐅𝐮𝐧𝐠𝐚𝐥 𝐢𝐧𝐟𝐞𝐜𝐭𝐢𝐨𝐧 এ ফ্লুকোনাজল বেশ ভালো কাজ করে…এইটার Advantage হলো ,এটি 𝐎𝐫𝐚𝐥 & 𝐈𝐕 দুইভাবেই পাওয়া যায় & বাচ্চাদের সিরাপ ও…..Half life ও বেশি! & Drug Interaction ও কম!!

খুব Rarely Liver toxicity করে। তবে High Dose এ দিলে 𝐀𝐥𝐨𝐩𝐞𝐜𝐢𝐞 ,𝐃𝐫𝐲 𝐦𝐨𝐮𝐭𝐡,𝐌𝐞𝐭𝐚𝐥𝐥𝐢𝐜 𝐭𝐚𝐬𝐭𝐞 হতে পারে…

𝐂𝐫𝐲𝐩𝐭𝐨𝐜𝐨𝐜𝐜𝐚𝐥 𝐌𝐞𝐧𝐢𝐧𝐠𝐢𝐭𝐢𝐬 এ ফ্লুকোনাজল কে prefer করা হয় & Drug Of choice !!

IV route এ দিল Amphotericin B এর সমান Effective ***

𝐂𝐚𝐧𝐝𝐢𝐝𝐞𝐦𝐢𝐚 তে ICU পেশেন্ট দের With নরমাল WBC কাউন্ট..(ImmuneSuppressed না হলে Candidemia তে ইউস করা হয়..)

Molds & Dimorphic fungi এর বিরুদ্ধে Fluconazole তেমন Effactive না

প্রেগ্ন্যাসির তে Low Dose এ ও দেওয়া যাবে না Miscarriage & Still birth হতে পারে।

Fluconazole যেহেতু Liver কে তেমন damage করে না ,তাই liver Disease এ High risk Pt এর ক্ষেত্রে Prophylaxis এ প্রেফার করা হয় Also Allogeneic bone marrow transplants .. এখন Posoconazole ও দেয়া হয়..

ফ্লুকোনাজল prophylaxis in leukemic পেশেন্ট ;AIDS পেশেন্ট with low CD4+ T-cell counts, and in patients on surgical intensive care units is controversial….

Capsule 3:-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Indications of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Flugal is indicated in-

  • Vaginal Candidiasis
  • Oropharyngeal Candidiasis
  • Esophageal Candidiasis
  • Tinea corporis/Tinea cruris/Tinea pedis/Other Tinea
  • Kerion
  • Pityriasis versicolor
  • Onychomycosis
  • Invasive candidal infections and cryptococcal infections (including meningitis)
  • Prevention of cryptococcal meningitis
  • Prevention of fungal infections in immunocompromised patients
  • Systemic Candidiasis and Cryptococcal infection
  • In Superficial Candidiasis
  • In Systemic Candidiasis & Cryptococcal infection

Other indications-

  • Fungal urinary tract infections
  • Disseminated candidiasis
  • Prophylaxis for fungal infection in neutropenic cancer patients.
  • Acute treatment of other systemic fungal infections such as coccidioidomycosis and histoplasmosis.

Pharmacology of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Fluconazole is a triazole antifungal agent. It is a potent inhibitor of fungal cytochrome P-450 dependent enzymes. Cytochrome P-450 enzyme system is essential component of fungal cell membrane which is responsible for the synthesis of ergosterol.

Dosage & Administration of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

Adults:

  • Vaginal Candidiasis: 150 mg as a single dose.
  • Oropharyngeal Candidiasis: 200 mg in 1st day followed by 100 mg daily for 14 days.
  • Oesophageal Candidiasis: 200 mg in 1st day followed by 100 mg daily for 14-30 days.
  • Tinea corporis/Tinea cruris/Tinea pedis/Other Tinea: 150 mg weekly for 4-6 weeks.
  • Kerion: 50 mg daily for 20 days.
  • Pityriasis versicolor: 400 mg as a single dose.
  • Onychomycosis: 150 mg weekly for 12 months.
  • Invasive candidal infections and cryptococcal infections (including meningitis): Orally or by IV infusion, 400 mg on first day then 200-400 mg daily.
  • Prevention of cryptococcal meningitis: Orally or by IV infusion 200 mg daily.
  • Prevention of fungal infections in immunocompromised patients: Orally or by IV infusion, 50-400 mg daily.


Child over 1 year-

  • In Superficial Candidiasis: 1-2 mg/kg daily.
  • In Systemic Candidiasis & Cryptococcal infection:3-6 mg/kg daily.

In serious life threatening infections upto 12 mg/kg daily has been given to children aged 5-13 years (Maximum 400 mg daily)

  • 1 year: 9 kg: 1/2 measuring spoonful
  • 1-2 years: 12 kg: 1 measuring spoonful
  • 2-3 years: 14 kg: 1½ measuring spoonful
  • 3-4 years: 16 kg: 2 measuring spoonful
  • 4-6 years: 20 kg: 2½ measuring spoonful


Use in Specific Population-

Elderly patient: The normal dose should be used if there is no evidence of renal impairment.

Renal Impairment: No adjustment in single dose therapy is required. In multiple dose therapy of patients with renal impairment, normal doses should be given on days 1 and 2 of treatment and there after the dosage intervals should be modified as follows:

  • Creatinine clearance (>41 ml/min): Dosage interval (hours) 24
  • Creatinine clearance (21-40 ml/min): Dosage interval (hours) 48
  • Creatinine clearance (10-20 ml/min): Dosage interval (hours) 72
  • Patients receiving regular dialysis: One dose after every dialysis session

Children: Renal clearance in children may be proportionately more rapid than in adults and doses up to 12 mg/kg is recommended.

Side Effects of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

 

Flugal is generally well tolerated. The commonest side-efects associated Flugal are symptoms associated with the gastrointestinal tract; these include nausea, abdominal discomfort, diarrhoea and fatulence. Other adverse events such as rash are rarely encountered (Incidence less than 1%). In rare cases, as with other azoles, anaphylaxis has been reported.

Pregnancy & Lactation of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

 

Fluconazole adverse fetal efects have been seen in animals only at dose levels associated with maternal toxicity. These levels are many times in excess of those recommended for therapeutic use. There has been little use during human pregnancy. Accordingly, fuconazole should not be used in pregnancy or in women of child bearing potential unless adequate contraception is employed.

Therapeutic Class of Capsule :-Flugal 150mg (AS A Fluconazole AS A Drugs for subcutaneous and mycoses).

 

Drugs for subcutaneous and mycoses

Raiyyan Tahsan Date:23-01-2025 Thursday Time:3-45-55 PM

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