Pacific Coast Society of Orthodontists Bulletin Fall 2017 - 25

Let's Talk About That

women; 600mg for large men; 4-10mg/kg, up to
teen dose, for children every six hours prn with
food is a very good pain reliever. (Ibuprofen is
reported to be as good as narcotic analgesics,
e.g., Percocet, with fewer adverse effects.) However, the best acute dental pain reliever is both
ibuprofen and acetaminophen taken together
at the appropriate doses every eight hours as
needed.6 Acute pain relievers in orthodontics
should only be taken for one to three days. If pain
continues, look for signs of traumatic occlusion
or infection with an appropriate referral. Newer
recommendations limit acetaminophen to a
maximum of 3000mg per day for adults in order
to prevent liver toxicity. Ibuprofen is contraindicated in pregnancy, prior heart attack, excessive
bleeding, or if taking low-dose aspirin for stroke/
heart attack prevention. Do not recommend any
pain relievers during pregnancy (even acetaminophen has risks); defer any analgesic recommendations to the patient's OB.
PT: Soft tissue lesions are common during the
course of orthodontic treatment; aphthous
ulcers, herpes, and angular cheilitis come to
mind. Parents commonly ask, "Is there anything
you can prescribe to help?" What can we prescribe for these issues?
JZ: Aphthous ulcers and recurrent herpetic ulcers
occur frequently, in 15% to 20% of the normal
population. Orthodontists should know the difference by evaluating the location of the ulcers.
Aphthous ulcers occur on movable, soft oral tissue: the inner mucosa of lips, free gingiva, and
soft palate. Aphthous ulcers are not contagious.
Recurrent herpes have vesicals before ulcerations
and occur on non-movable oral tissue, attached
gingiva, and hard palate, and also around the
outer vermillion of the lip. Recurrent herpetic
ulcers are contagious. Therefore, always use
gloves for exams. To keep from spreading the
virus to other areas, patients should not touch
herpetic ulcers with fingers. Both types of ulcers
usually heal in 7 to 10 days with saltwater rinses.
If the ulcers do not heal, suspect a secondary

Fall 2017  PCSO Bulletin

infection that can be treated with chlorhexidine
0.12% 480ml; 15mL BID, swish and spit. For severe
aphthous ulcers, one may prescribe triamcinolone 0.1% in orabase 5gm; apply sparingly to
intraoral ulcer BID for one week. Triamcinolone
should not be applied to herpetic ulcers because
glucocorticoids worsen active viral infections.
Herpetic ulcers on the outer lip can be very
upsetting to patients. You can recommend OTC
docosanol cream 10% (Abreva) or prescribe acyclovir cream 5% 15gm to be applied sparingly
with a cotton swab to the affected lip ulcer five
times daily. Either of these medications is better
started early and has minimal effectiveness,
which may heal herpetic lip ulcers about one day
faster. If either type of ulcer reoccurs often, a
referral to a physician is appropriate in order to
evaluate for other systemic problems. If aphthous
ulcers reoccur often, the patient should be evaluated for possible systemic autoimmune disease,
such as lupus, Crohn's disease, etc. If herpetic
ulcers recur, the patient should be evaluated for
possible causes of decreased immunity that
might allow a dormant virus to become active.
In my opinion, angular cheilitis in the healthy
orthodontic population is usually secondarily
infected by staphylococcus from the outer skin.
OTC Neosporin ointment applied to the corners
of the mouth two to three times daily usually
heals this area in one to two weeks. Angular
cheiltis in infants, older patients, or patients
with decreased immunity is usually secondarily
infected by candida and can be treated with
clotrimazole 1% cream (OTC) applied two to three
times daily and covered with Vaseline or Neosporin ointment so the corners of the mouth
will not dry out and continue to crack. (Creams
dry out skin and cause further cracking. Ointments lubricate and hold moisture to prevent
further cracking.)
PT: Methods to increase the rate of tooth movement and decrease overall treatment time have
become a hot topic in orthodontics. Surgical procedures to produce a RAP (regional acceleratory

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2017