Gastroenterology

Background

The main function of the gastrointestinal (GI) tract is to break food down in to a suitable energy source to allow normal physiological function of cells. Needless to say, the process is complex and involves many different organs. Consequently, there are many conditions that affect the GI tract, some of which are acute and self-limiting and respond well to OTC medication and others that are serious and require referral.

General overview of the anatomy of the GI tract

It is vital that pharmacists have a sound understanding of GI tract anatomy. Many conditions will present with similar symptoms and from similar locations, for example abdominal pain, and the pharmacist will need a basic knowledge of GI tract anatomy – and in particular of where each organ of the GI tract is located – to facilitate a correct differential diagnosis.

History taking and physical exam

A thorough patient history is essential as physical examination of the GI tract in a community pharmacy is limited to inspection of the mouth. This should allow confirmation of the diagnoses for conditions such as mouth ulcers and oral thrush. A description of how to examine the oral cavity appears in the following section.

Conditions affecting the oral cavity

Background

The process of digestion starts in the oral cavity. The tongue and cheeks position large pieces of food so that the teeth can tear and crush food into smaller particles. Saliva moistens, lubricates and begins the process of digesting carbohydrates (by secreting amylase enzymes) prior to swallowing.

The oral cavity can easily be observed in the pharmacy provided the mouth can be viewed with a good light source, preferably a pen torch (Fig 6.1). The patient will usually present with some form of oral lesion and/or pain in a particular part of the mouth. The pharmacist should examine this area carefully, but the rest of the oral cavity should also be inspected. Checks for periodontal disease (bleeding gums) and other sites of mouth soreness should be performed.

Fig. 6.1 The oral cavity.

The floor of the mouth and underside of the tongue can be viewed by asking the patient to curl the tongue toward the roof of the mouth; the buccal mucosa is best observed when the patient half opens the mouth.

Mouth ulcers

Background

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 a few days to a few months. The majority of patients (80%) who present in a community pharmacy will have minor aphthous ulcers (MAU). It is the community pharmacists’ role to exclude more serious pathology, for example, systemic causes and carcinoma.

Prevalence and epidemiology

The prevalence and epidemiology of MAU is poorly understood. They occur in all ages but it has been reported that they are more common in patients aged between 20 and 40, and up to 66% of young adults give a history consistent with MAU. Lifetime prevalence is estimated to affect one in five of the general population.

Aetiology

The cause of MAU is unknown. A number of theories have been put forward to explain why people get MAU, including a genetic link, stress, trauma, food sensitivities, nutritional deficiencies (iron, zinc and vitamin B₁₂) and infection, but none have so far been proven.

Arriving at a differential diagnosis

There are three main clinical presentations of ulcers: minor, major or herpetiform. Although it is most likely the patient will be suffering from MAU (Table 6.1) it is essential that these and other causes are recognised and referred to the GP for further evaluation.

Table 6.1

Causes of ulcers and their relative incidence in community pharmacy

Incidence	Cause
Most likely	Minor aphthous ulcers (MAU)
Likely	Major aphthous ulcers, Trauma
Unlikely	Herpetiform ulcers, herpes simplex, oral thrush medicine-induced
Very unlikely	Oral carcinoma, erythema multiforme (Steven’s Johnson syndrome), Behçet’s syndrome

A number of ulcer-specific questions should always be asked of the patient (Table 6.2) and an inspection of the oral cavity should also be performed to help aid the diagnosis.

Table 6.2

Specific questions to ask the patient: Mouth ulcers

Question	Relevance
Number of ulcers	MAU occur singly or in small crops. A single large ulcerated area is more indicative of pathology outside the remit of the community pharmacist Patients with numerous ulcers are more likely to be suffering from major or herpetiform ulcers rather than MAU
Location of ulcers	Ulcers on the side of the cheeks, tongue and inside of the lips are likely to be MAU Ulcers located toward the back of the mouth are more consistent with major or herpetiform ulcers
Size and shape	Irregular-shaped ulcers tend to be caused by trauma. If trauma is not the cause then referral is necessary to exclude sinister pathology If ulcers are large or very small they are unlikely to be caused by MAU
Painless ulcers	Any patient presenting with a painless ulcer in the oral cavity must be referred. This can indicate sinister pathology such as leukoplakia or carcinoma
Age	MAU in young children (<10 years old) is not common and other causes such as primary infection with herpes simplex should be considered If ulcers appear for the first time after adolescence then the diagnostic probability is increased for them to be caused by things other than MAU

Clinical features of minor aphthous ulcers

The ulcers of MAU are roundish, grey-white in colour and painful. They are small – usually less than 1 cm in diameter – and shallow with a raised red rim. Pain is the key presenting symptom and can make eating and drinking difficult, although pain subsides after three or four days. They rarely occur on the gingival mucosa and occur singly or in small crops of up to five ulcers. It normally takes 7 to 14 days for the ulcers to heal but recurrence typically occurs after an interval of 1 to 4 months (Fig. 6.2).

Fig. 6.2 Minor aphthous ulcer. Reproduced from R Cawson et al, 2002, Essentials of oral pathology and oral medicine, 7th edition, Churchill Livingstone, with permission.

Conditions to eliminate

Likely causes

Major aphthous ulcers: These are characterised by large (greater than 1 cm in diameter), numerous ulcers, occurring in crops of 10 or more. The ulcers often coalesce to form one large ulcer. The ulcers heal slowly and can persist for many weeks (Fig. 6.3).

Fig. 6.3 Major aphthous ulcer. Reproduced from R Cawson et al, 2002, Essentials of oral pathology and oral medicine, 7th edition, Churchill Livingstone, with permission.

Trauma: Trauma to the oral mucosa will result in damage and ulceration. Trauma may be mechanical (e.g. tongue biting) or thermal resulting in ulcers with an irregular border. Patients should be able to recall the traumatic event and have no history of similar ulceration or signs of systemic infection (Fig. 6.4).

Fig. 6.4 Ulcer caused by trauma. Reproduced from D Wray et al, 1999, Textbook of general and oral medicine, by Churchill Livingstone, with permission.

Unlikely causes

Herpetiform ulcers: Herpetiform ulcers are pinpoint and occur in large crops of up to 100 at a time. They usually heal within a month and often occur in the posterior part of the mouth, an unusual location for MAU (Fig. 6.5). Both herpetiform and major aphthous ulcers are approximately ten times less common than MAU.

Fig. 6.5 Herpetiform ulcer. Reproduced from R Cawson et al, 2002, Essentials of oral pathology and oral medicine, 7th edition, Churchill Livingstone, with permission.

Oral thrush

Oral thrush usually presents as creamy-white soft elevated patches. It is covered in more detail in the next section and the reader is referred to page 139 for differential diagnosis of thrush from other oral lesions.

Herpes simplex

Herpes simplex virus is a common cause of oral ulceration in children. Primary infection results in ulceration of any part of the oral mucosa, especially the gums, tongue and cheeks. The ulcers tend to be small and discrete and many in number. Prior to the eruption of ulcers the person might show signs of systemic infection such as fever and pharyngitis.

Medicine-induced ulcers

A number of case reports have been received of medication causing ulcers. These include cytotoxic agents, nicorandil, alendronate, non-steroidal anti-inflammatory drugs (NSAIDs) and beta-blockers. Ulcers are often seen at the start of therapy or when the dose is increased.

Very unlikely causes

Carcinoma: In 2009, over 6000 cases of oral cancer were confirmed. It is twice as common in men than women. Incidence rates increase sharply beyond 45 years of age. In men the highest incidence is seen in those aged 60–69, and in women it peaks in the over 80s. Smoking and excess alcohol consumption are two major risk factors.

The majority of cancers are noted on the side of the tongue, mouth and lower lip. Initial presentation ranges from painless spots, lumps or ulcers in the mouth or lip area that fail to resolve. Over time these become painful, change colour crust over or bleed. The painless nature of early symptoms leads people to seek help only when other symptoms become apparent. Symptoms therefore can be present for a number of weeks before the patient presents to a health care practitioner. Urgent referral is needed as survival rates increase dramatically if the disease is diagnosed in its early stages.

Erythema multiforme: Infection or drug therapy can cause erythema multiforme, although in about 50% of cases no cause can be found. Symptoms are sudden in onset causing widespread ulceration of the oral cavity. In addition the patient can have annular and symmetric erythematous skin lesions located toward the extremities. Conjunctivitis and eye pain is also common.

Behcet’s syndrome: Most patients will suffer from recurrent, painful major aphthous ulcers that are slow to heal. Lesions are also observed in the genital region and eye involvement (iridocyclitis) is common.

Figure 6.6 will aid the differentiation between serious and non-serious conditions that cause mouth ulcers.

Trigger points indicative of referral

Mouth ulcers

Symptoms/signs	Possible Danger/reason for referral
Children under 10	Minor ulcers rare
Ulcers greater than 1 cm in diameter Ulcers in crops of five to ten, or more Duration longer than 14 days	Suggests other causes of ulceration outside scope of community pharmacist
Painless ulcer Eye involvement	Possible sinister pathology

Fig. 6.6 Primer for differential diagnosis of mouth ulcers.
Duration
MAU normally resolve in 7 to 14 days. Ulcers that fail to heal within this time need referral to exclude other causes.
Painless ulcers
These can indicate sinister pathology, especially if the patient is over 50 years old. In addition, it is likely that the ulcer will have been present for some time before the patient presented to the pharmacy.
Numerous ulcers
Crops of 5 to 10 or more ulcers are rare in MAU. Referral is necessary to determine the cause.
Major ulcer or candidiasis
See Figure 6.9 for primer for differential diagnosis of oral thrush.

Evidence base for over-the-counter medication

A wide range of products are used for the temporary relief and treatment of mouth ulcers. These products contain corticosteroids, local anaesthetics, antibacterials, astringents and antiseptics. Until, recently, corticosteroids were available OTC (triamcinolone acetonide 0.1% in Orabase and hydrocortisone sodium succinate pellets) but these have been discontinued by the manufacturers. This is unfortunate as a review in BMJ Clinical Evidence found corticosteroids did reduce the duration of pain with MAU (http://exodontia.info/files/BMJ_Clinical_Evidence_2007_Recurrent_Aphthous_Ulcers.pdf; accessed 22 November 2012).

Antibacterial agents (e.g. chlorhexidine)

A number of random controlled trials have investigated antibacterial mouthwashes containing chlorhexidine gluconate. Data from some, but not all studies, have found that they reduced the pain and severity of each episode of ulceration.

Products containing anaesthetic or analgesics

There is very little trial data to support the pain-relieving effect of anaesthetics or analgesics in MAU, apart from choline salicylate. However, these preparations are clinically effective in other painful oral conditions. It is therefore not unreasonable to expect some relief of symptoms to be shown when using these products to treat MAU.

Choline salicylate

Choline salicylate has been shown to exert an analgesic effect in a number of small studies. However, only one study by Reedy (1970) involving 27 patients evaluated choline salicylate in the treatment of oral aphthous ulceration. No significant differences were found between choline salicylate and placebo in ulcer resolution but choline salicylate was found to be significantly superior to placebo in relieving pain.

Protectants

Orabase is a paste of gelatin, pectin and carmellose sodium, which sticks when it comes in contact with wet mucosal surfaces. There is a paucity of data to support its efficacy. However, it has no known side effects, and can be used in any patient population.

Practical prescribing and product selection

Prescribing information relating to the medicines used for ulcers reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 6.3; useful tips relating to patients presenting with ulcers are given in Hints and Tips Box 6.1.

Hints and tips box 6.1: Ulcers

Application of Adcortyl

Apply after food, as food is likely to rub off the paste

Table 6.3

Practical prescribing: Summary of medicines for ulcers

^*Children should not be routinely given products as ulcers are rare in this age group.

Antibacterial agents (e.g. chlorhexidine)

Chlorhexidine (e.g. Corsodyl) mouthwash is indicated as an aid in the treatment and prevention of gingivitis and in the maintenance of oral hygiene, which includes the management of aphthous ulceration. Ten mL of the mouthwash should be rinsed around the mouth for about 1 minute twice a day. It can be used by all patient groups, including those who are pregnant and breastfeeding. Side effects associated with its use include reversible tongue and tooth discolouration, burning of the tongue and taste disturbance.

Choline salicylate (Bonjela Cool)

Adults and children over 16 years old should apply the gel, using a clean finger, over the ulcer when needed, but limit this to every 3 hours. It is a safe medicine and can be given to all patient groups. It is not known to interact with any medicines or cause any side effects.

Local anaesthetics (lidocaine e.g. Anbesol range, Iglu gel, Medijel) and benzocaine (e.g. Oralgel & Oralgel Extra Strength).

All local anaesthetics have a short duration of action; frequent dosing is therefore required to maintain the anaesthetic effect. They are thus best used on a when needed basis although the upper limit on the number of applications allowed does vary depending on the concentration of anaesthetic included in each product. They appear to be free from any drug interactions, have minimal side effects and can be given to most patients. A small percentage of patients might experience a hypersensitivity reaction with lidocaine or benzocaine; this appears to be more common with benzocaine.

Carmellose sodium (Orabase Protective Paste)

Orabase can be applied as frequently as requred. It is important that it is dabbed on, and not rubbed on, for it to stick correctly. Also, patients should be discouraged from putting too much on as the excess can peel off leaving the lesion exposed. There are no apparent interactions, and Orabase can be used in all patient groups.

Reference

Reedy, BL. A topical salicylate gel in the treatment of oral aphthous ulceration. Practitioner. 1970;204:846–850.

Background

Oropharyngeal candidiasis (oral thrush) is an opportunistic mucosal infection and is unusual in healthy adults. If oral thrush is suspected in this population community pharmacists should determine if any identifiable risk factors. A healthy adult with no risk factors generally requires referral to the GP.

Prevalence and epidemiology

The very young (neonates) and the very old are most likely to suffer from oral thrush. It has been reported that 5% of newborn infants and 10% of debilitated elderly patients suffer from oral thrush. Most other cases will be associated with underlying pathology such as diabetes, xerostomia (dry mouth), patients who are immunocompromised or be attributable to identifiable risk factors such as recent antibiotic therapy, inhaled corticosteroids, and ill-fitting dentures.

Aetiology

It is reported that Candida albicans is found in the oral cavity of 30–60% of healthy people in developed countries (Gonsalves et al 2007). Prevalence in denture wearers is even higher. It is transmitted directly between infected people or via objects that can hold the organism. Changes to the normal environment in the oral cavity will allow C. albicans to proliferate.

Arriving at a differential diagnosis

Oral thrush is not difficult to diagnose provided a careful history is taken and an oral examination performed. It is the role of the pharmacist to eliminate underlying pathology and exclude risk factors. A number of other conditions need to be considered (Table 6.4) and specific questions asked of the patient (Table 6.5). After questioning the pharmacist should inspect the oral cavity to confirm the diagnosis.

Table 6.4

Causes of oral lesions and their relative incidence in community pharmacy

Incidence	Cause
Most likely	Thrush
Likely	Minor aphthous ulcers, medicine induced, ill-fitting dentures
Unlikely	Lichen planus, underlying medical disorders, e.g. diabetes, xerostomia (dry mouth) and immunosuppression, major & herpetiform ulcers, herpes simplex
Very Unlikely	Leukoplakia, squamous cell carcinoma

Table 6.5

Specific questions to ask the patient: Oral thrush

Question	Relevance
Size and shape of lesion	Typically, patients with oral thrush present with ‘patches’. They tend to be irregularly shaped and vary in size from small to large
Associated pain	Thrush usually causes some degree of discomfort or pain. Painless patches, especially in people aged over 50, should be referred to exclude sinister pathology such as leukoplakia
Location of lesions	Oral thrush often affects the tongue and cheeks, although if precipitated by inhaled steroids the lesions appear on the pharynx

Clinical features of oral thrush

The classical presentation of oral thrush is of creamy-white soft elevated patches that can be wiped off revealing underlying erythematous mucosa (Fig. 6.7). Pain, soreness, altered taste and a burning tongue can be present. Lesions can occur anywhere in the oral cavity but usually affect the tongue, palate, lips and cheeks. Patients sometimes complain of malaise and loss of appetite. In neonates, spontaneous resolution usually occurs but can take a few weeks.

Fig. 6.7 Oral candidiasis. Reproduced from CD Forbes and WF Jackson, 2004, Illustrated pocket guide to clinical medicine, 2nd edition, Mosby, with permission.

Conditions to eliminate

Likely causes

Minor aphthous ulcers: Mouth ulcers are covered in more detail on page 134 and the reader is referred to this section for differential diagnosis of these from oral thrush.

Medicine-induced thrush: Inhaled corticosteroids and antibiotics are often associated with causing thrush. In addition, medicines that cause dryness of the mouth can also predispose people to thrush. Always take a drug history to determine if medicines could be a cause of the symptoms.

Denture wearers: Wearing dentures, especially if they are not taken out at night, not kept clean, or do not fit well can predispose people to thrush.

Unlikely causes

Lichen planus: Lichen planus is a dermatological condition with lesions similar in appearance to plaque psoriasis. In about 50% of people the oral mucous membranes are affected. The cheeks, gums or tongue develop white, slightly raised painless lesions that look a little like a spider’s web. Other symptoms can include soreness of the mouth and a burning sensation. Occasionally, lichen planus of the mouth occurs without any skin rash.

Underlying medical disorders: As stated previously, oral thrush is unusual in the adult population. Patients are at greater risk of developing thrush if they suffer from medical conditions such as diabetes, xerostomia (dry mouth) or are immunocompromised.

Other forms of ulceration (e.g. major and herpetiform ulcers, herpes simplex): These are covered in more detail on page 135 and the reader is referred to this section for differential diagnosis of these from oral thrush.

Very unlikely causes

Leukoplakia: Leukoplakia is a predominantly white lesion of the oral mucosa that cannot be characterised as any other definable lesion and is therefore a diagnosis based on exclusion (Fig. 6.8). It is often associated with smoking and is a precancerous lesion, although epidemiological data suggests that annual transformation rate to squamous cell carcinoma is approximately 1%. Patients present with a symptomless white patch that develops over a period of weeks on the tongue or cheek. The lesion cannot be wiped off, unlike oral thrush. Most cases are seen in people over the age of 40; it is more common in men. Suspected cases require referral.

Fig. 6.8 Leukoplakia. Reproduced from CD Forbes and WF Jackson, 2004, Illustrated pocket guide to clinical medicine, 2nd edition, Mosby, with permission.

Squamous cell carcinoma: Squamous cell carcinoma is covered in more detail on page 137 and the reader is referred to this section for differential diagnosis of these from oral thrush.

Figure 6.9 will aid the differentiation of thrush from other oral lesions.

Fig. 6.9 Primer for differential diagnosis of oral thrush.
Duration
Any lesion lasting more than 3 weeks must be referred to exclude sinister pathology.
MAU
See Figure 6.6 for primer for differential diagnosis of mouth ulcers.
Antibiotics
Broad-spectrum antibiotics, e.g. amoxicillin and macrolides, can precipitate oral thrush by altering normal flora of the oral cavity.
Inhaled corticosteroids
High-dose inhaled corticosteroids can cause oral thrush. Patients should be encouraged to use a spacer and wash their mouth out after inhaler use to minimise this problem.

Trigger points indicative of referral

Oral thrush

Symptoms/signs	Possible danger/reason for referral
Diabetics	May indicate poor diabetic control
Duration greater than 3 weeks	Unlikely to be thrush and needs further investigation by a doctor
Immunocompromised patients	Likely to have severe and extensive involvement. Outside community pharmacist’s remit
Painless lesions	Sinister pathology

Evidence base for over-the-counter medication

Only Daktarin oral gel (miconazole) is available OTC to treat oral thrush. It has proven efficacy and appears to have clinical cure rates between 80 and 90%. In comparative trials, Daktarin appears to have superior cure rates than the POM Nystatin.

Practical prescribing and product selection

Prescribing information relating to Daktarin Oral gel reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 6.6; useful tips relating to the application of Daktarin are given in Hints and Tips Box 6.2.

Hints and tips box 6.2: Daktarin

Application of Daktarin	Patients should be advised to hold the gel in the mouth for as long as possible to increase contact time between the medicine and the infection
Duration of treatment	Treatment should be continued for up to 2 days after the symptoms have cleared to prevent relapse and reinfection
Patient acceptability	Gel is flavoured orange to make retention in the mouth more acceptable to patients

Table 6.6

Practical prescribing: Summary of medicines for oral thrush

The dose of gel varies dependent on the age of patient. For adults and children over 6 years, the gel should be applied four times a day and those under six the dose is twice a day. The gel should be applied directly to the area with a clean finger. In May 2008 Jansen-Cilag, the manufacturers of Daktarin, chose to vary the Summary of Product Characteristics (SPC) to recommend that it is not used in infants under 4 months and only with care below the age of 6 months. This change appears to originate from a published report (De Vries et al 2006) documenting a 17-day-old baby who choked when exposed to miconazole oral gel.

It can occasionally cause nausea and vomiting. The manufacturers state that it can interact with a number of medicines, namely mizolastine, cisapride, triazolam, midazolam, quinidine, pimozide, HMG-CoA reductase inhibitors and anticoagulants. However, there is a lack of published data to determine how clinically significant these interactions are except with warfarin. Co-administration of warfarin with miconazole increases warfarin levels markedly and the patient’s (internationalised normalised ratio) INR should be monitored closely. The manufacturers advise that Daktarin should be avoided in pregnancy but published data does not support an association between miconazole and congenital defects. It appears to be safe to use whilst breastfeeding.

References

de Vries, TW, Wewerinke, ME, de Langen, JJ. Near asphyxiation of a neonate due to miconazole oral gel. Ned Tidschr Geenskd. 2004;148:1598–1600.

Gonsalves, WC, Chi, A, Neville, BW. Common oral lesions: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75:501–507.

Background

Gingivitis simply means inflammation of the gums and is usually caused by an excess build-up of plaque on the teeth. The condition is entirely preventable if regular tooth brushing is undertaken.

Prevalence and epidemiology

It is estimated 50% of the UK population are affected by gum disease and that more than 85% of people over 40 will experience gingival disease. Men more than women tend to suffer from severe gingivitis.

Aetiology

Following tooth brushing, the teeth soon become coated in a mixture of saliva and gingival fluid, known as pellicle. Oral bacteria and food particles adhere to this coating and begin to proliferate forming plaque; subsequent brushing of the teeth removes this plaque build up. However, if plaque is allowed to build up for 3 or 4 days, bacteria begin to undergo internal calcification producing calcium phosphate better known as tartar (or calculus). This adheres tightly to the surface of the tooth and retains bacteria in situ. The bacteria release enzymes and toxins that invade the gingival mucosa, causing inflammation of the gingiva (gingivitis). If the plaque is not removed the inflammation travels downwards, involving the periodontal ligament and associated tooth structures (periodontitis). A pocket forms between the tooth and gum and, over a period of years, the root of the tooth and bone are eroded until such time that the tooth becomes loose and lost. This is the main cause of tooth loss in people over 40 years of age.

A number of risk factors are associated with gingivitis and periodontitis; these include diabetes mellitus, cigarette smoking, poor nutritional status and poor oral hygiene.

Arriving at a differential diagnosis

Gingivitis often goes unnoticed because symptoms can be very mild and painless. This often explains why a routine check-up at the dentist reveals more severe gum disease than patients thought they had. A dental history needs to be taken from the patient, in particular details of their tooth brushing routine and technique, as well as the frequency of visits to their dentist. The mouth should be inspected for tell-tale signs of gingival inflammation. A number of gingivitis-specific questions should always be asked of the patient to aid in diagnosis (Table 6.7).

Table 6.7

Specific questions to ask the patient: Gingivitis

Question	Relevance
Tooth brushing technique	Overzealous tooth brushing can lead to bleeding gums and gum recession. Make sure the patient is not ‘over cleaning’ their teeth. An electric tooth brush might be helpful for people who apply too much force when brushing teeth
Bleeding gums	Gums that bleed without exposure to trauma and is unexplained or unprovoked need referral to exclude underlying pathology

Clinical features of gingivitis

Gingivitis is characterised by swelling and reddening of the gums, which bleed easily with slight trauma, for example when brushing teeth. Plaque might be visible; especially on teeth that are difficult to reach when tooth brushing. Halitosis might also be present.

Conditions to eliminate

Periodontitis

If gingivitis is left untreated it will progress into periodontitis. Symptoms are similar to gingivitis but the patient will experience spontaneous bleeding, taste disturbances, halitosis and difficulty while eating. Periodontal pockets might be visible and the patient might complain of loose teeth. Referral to a dentist is needed for evaluation and removal of tartar.

Medicine-induced gum bleeding

Medicines such as warfarin, heparin and NSAIDs might produce gum bleeding. It is also worth noting that a number of medicines can cause gum hypertrophy, notably phenytoin and ciclosporin. It has also been seen in patients taking nifedipine.

Spontaneous bleeding

A number of conditions can produce spontaneous gum bleeding, for example agranulocytosis and leukaemia. Other symptoms should be present, for example, progressive fatigue, weakness and signs of systemic illness such as fever. Immediate referral to the GP is needed.

Trigger points indicative of referral

Gingivitis

Symptoms/signs	Possible danger/reason for referral
Foul taste associated with gum bleeding Loose teeth	Suspect periodontitis
Spontaneous gum bleeding	Suspect periodontitis or more sinister pathology
Signs of systemic illness	Indicator of more serious underlying pathology

Evidence base for over-the-counter medication

Put simply, there is no substitute for good oral hygiene. Prevention of plaque build-up is the key to healthy gums and teeth. Twice daily brushing is recommended to maintain oral hygiene at adequate levels. Brushing teeth, with a fluoride toothpaste, to prevent tooth decay, should preferably take place after eating. Flossing is recommended, three times a week, to access areas that a toothbrush might miss. A Cochrane review (Robinson et al 2005) concluded that powered tooth brushes (with rotation oscillation action – where brush heads rotate in one direction and then the other) are more effective than manual brushing at plaque removal.

There is a plethora of oral hygiene products marketed to the public. These products should be reserved for established gingivitis or in those patients who have poor toothbrushing technique.

Mouthwashes contain chlorhexidine, hexetidine and hydrogen peroxide. Of these, chlorhexidine in concentrations of either 0.1 or 0.2% has been proven the most effective antibacterial in reducing plaque formation and gingivitis (Ernst et al 1998). In clinical trials it has been shown to be consistently more effective than placebo and comparator medicines, and there appears to be no difference in effect between concentrations. It has even been used as a positive control.

Practical prescribing and product selection

Prescribing information relating to the medicines used for gingivitis reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 6.8; useful tips relating to products for oral care are given in Hints and Tips Box 6.3.

Hints and tips box 6.3: Iodine mouthwash

Dental flossing

Correct technique is important otherwise gums can be traumatised. A piece of floss about eight inches long should be wrapped around the ends of the middle fingers of each hand leaving two to three inches between the first finger and thumb. The floss should be placed between two teeth and curved in to a ‘C’ shape around one tooth and slid up between the gum and tooth until resistance is felt then moved vertically up and down several times to remove plaque

Using fluoride

Fluoride does reduce dental caries. Drinking water in some parts of the UK contains measurable concentrations of fluoride. Therefore fluoride toothpastes or fluoride supplementation is not needed.
However, most people in Britain require fluoride supplementation which is normally through toothpaste. Most packs of toothpaste state how many parts per million of fluoride the toothpaste contains; 500 ppm is a low level, 1000-1500 ppm is a high level. A low-dose toothpaste should be used for children under 7 to avoid dental fluorosis which causes tooth discoloration
Oral fluoride supplements can also be given where fluoride in water is less than 0.7 parts per million. (see BNF for dosing)

Table 6.8

Practical prescribing: Summary of medicines for gingivitis

All mouthwashes, have minimal side effects and can be used by all patient groups. They are rinsed around the mouth between 30 seconds and 1 minute then spat out.

Chlorhexidine gluconate (e.g. Corsodyl 0.2%, Eludril 0.1%)

The standard dose for adults and children over 12 years old is 10 mL twice a day. Although it is free from side-effects, patients should be warned that prolonged use may stain the tongue and teeth brown. This can be reduced or removed by brushing teeth before use. If this fails to remove the staining then it can be removed by a dentist. Corsodyl is also available as a spray (0.2%) and gel (1%) and used twice a day.

Hexetidine (Oraldene)

Adults and children over 6 years of age should use a 15 mL dose two or three times a day.

Hydrogen peroxide (e.g. Peroxyl)

Adults and children over 6 years of age should use 10 mL rinsed around the mouth up to four times a day.

References

Ernst, CP, Prockl, K, Willershausen, B. The effectiveness and side effects of 0.1% and 0.2% chlorhexidine mouthrinses: a clinical study. Quintessence Int. 1998;29:443–448.

Robinson, P, Deacon, SA, Deery, C, et al. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews. (Issue 2):2005. [Art. No.: CD002281. DOI: 10.1002/14651858.CD002281.pub2].

Background

Confusion surrounds the terminology associated with upper abdominal symptoms and the term dyspepsia is used by different authors to mean different things. It is therefore an umbrella term generally used by healthcare professionals to refer to a group of upper abdominal symptoms that arise from five main conditions:

• non-ulcer dyspepsia/functional dyspepsia (indigestion)

• gastro-oesophageal reflux disease (GORD, heartburn)

• gastritis

• duodenal ulcers

• gastric ulcers.

These five conditions represent 90% of dyspepsia cases presented to the GP.

In August 2004, The National Institute for Health and Clinical Excellence (NICE) issued clinical guidance on the management of dyspepsia in adults in primary care (see web sites at end of section). This guidance has specific information on pharmacist management of dyspepsia. This is still current (July 2012) and specific reference is made to this guidance.

Prevalence and epidemiology

The exact prevalence of dyspepsia is unknown. This is largely because of the number of people who self-medicate or do not report mild symptoms to their GP. However, it is clear that dyspepsia is extremely common. Between 25 and 40% of the general population in Western society are reported to suffer from dyspepsia and virtually everyone at some point in their lives will experience an episode. Estimates suggest that 10% of people suffer on a weekly basis and that 5% of all GP consultations are for dyspepsia. The prevalence of dyspepsia is modestly higher in women than men.

Aetiology

The aetiology of dyspepsia differs depending on its cause. Decreased muscle tone leads to lower oesophageal sphincter incompetence (often as a result of medicines or overeating) and is the principal cause of GORD. Increased acid production results in inflammation of the stomach (gastritis) and is usually attributable to Helicobacter pylori infection, or acute alcohol indigestion. The presence of H. pylori is central to duodenal and gastric ulceration – H. pylori is present in 95% of duodenal ulcers and 80% of gastric ulcers. The exact mechanism by which it causes ulceration is still unclear but the bacteria does produce toxins that stimulate the inflammatory cascade. Increasingly common are medicine induced ulcers, most notably NSAIDs and low-dose aspirin.

Finally, when no specific cause can be found for a patient’s symptoms the complaint is said to be non-ulcer dyspepsia. (Some authorities do not advocate the use of this term, preferring the term ‘functional dyspepsia’.)

Arriving at a differential diagnosis

Overwhelmingly, patients who present with dyspepsia are likely to be suffering from GORD, gastritis or non-ulcer dyspepsia (Table 6.9). Research has shown that even those patients who meet NICE guidelines for endoscopical investigation are found to have either gastritis/hiatus hernia (30%), oesophagitis (10–17%) or no abnormal findings (30%). It has also been reported that a medical practitioner with an average list size will only see one new case of oesophageal cancer and one new case of stomach cancer every four years. Despite these statistics, a thorough medical and drug history should be taken to enable the community pharmacist to rule out serious pathology. ALARM symptoms (see Trigger points for referral), which would warrant further investigation are surprisingly common and it is important that patients exhibiting these symptoms are referred. A number of dyspepsia specific questions should always be asked of the patient to aid in diagnosis (Table 6.10).

Table 6.9

Causes of upper GI symptoms and their relative incidence in community pharmacy

Incidence	Cause
Most likely	Non-ulcer dyspepsia
Unlikely	Medicine induced, peptic ulcers, irritable bowel syndrome
Very unlikely	Gastric and oesophageal cancers, atypical angina

Table 6.10

Specific questions to ask the patient: Dyspepsia

Question	Relevance
Age	The incidence of dyspepsia decreases with advancing age and therefore young adults are likely to suffer from dyspepsia with no specific pathologic condition, unlike patients over 50 years of age, in which a specific pathologic condition becomes more common
Location	Dyspepsia is experienced as pain above the umbilicus and centrally located (epigastric area). Pain below the umbilicus will not be due to dyspepsia Pain experienced behind the sternum (breastbone) is likely to be heartburn If the patient can point to a specific area of the abdomen then it is unlikely to be dyspepsia
Nature of pain	Pain associated with dyspepsia is described as aching or discomfort. Pain described as gnawing, sharp or stabbing is unlikely to be dyspepsia
Radiation	Pain that radiates to other areas of the body is indicative of more serious pathology and the patient must be referred. The pain might be cardiovascular in origin, especially if the pain is felt down the inside aspect of the left arm
Severity	Pain described as debilitating or severe must be referred to exclude more serious conditions
Associated symptoms	Persistent vomiting with or without blood is suggestive of ulceration or even cancer and must be referred Black and tarry stools indicate a bleed in the GI tract and must be referred
Aggravating or relieving factors	Pain shortly after eating (1 to 3 hours) and relieved by food or antacids are classic symptoms of ulcers Symptoms of dyspepsia are often brought on by certain types of food, for example caffeine containing products and spicy food
Social history	Bouts of excessive drinking are commonly implicated in dyspepsia. Likewise, eating food on the move or too quickly is often the cause of the symptoms. A person’s job is often a good clue to whether these are contributing to their symptoms

Clinical features of dyspepsia

Patients with dyspepsia present with a range of symptoms commonly involving:

• vague abdominal discomfort (aching) above the umbilicus associated with belching

• bloating

• flatulence

• a feeling of fullness

• nausea and/or vomiting

• heartburn.

Although, dyspeptic symptoms are a poor predictor of disease severity or underlying pathology, retrosternal heartburn is the classic symptom of GORD.

Conditions to eliminate

Unlikely causes

Peptic ulceration: Ruling out peptic ulceration is probably the main consideration for community pharmacists when assessing patients with symptoms of dyspepsia. Ulcers are classed as either gastric or duodenal. They occur most commonly in patients aged between 30 and 50, although patients over the age of 60 account for 80% of deaths even though they only account for 15% of cases. Typically the patient will have well localised mid-epigastric pain described as ‘constant’, ‘annoying’ or ‘gnawing/boring’. In gastric ulcers the pain comes on whenever the stomach is empty, usually 30 minutes after eating and is generally relieved by antacids or food and aggravated by alcohol and caffeine. Gastric ulcers are also more commonly associated with weight loss and GI bleeds than duodenal ulcers. Patients can experience weight loss of 5 to 10 kg and although this could indicate carcinoma, especially in people aged over 40, on investigation a benign gastric ulcer is found most of the time. NSAID use is associated with a three- to fourfold increase in gastric ulcers.

Duodenal ulcers tend to be more consistent in symptom presentation. Pain occurs 2 to 3 hours after eating and pain that wakes a person at night is highly suggestive of duodenal ulcer. If ulcers are suspected referral to the GP is necessary as peptic ulcers can only be conclusively diagnosed by endoscopy.

Medicine-induced dyspepsia: A number of medicines can cause gastric irritation leading to or provoking GI discomfort or they can decrease oesophageal sphincter tone resulting in reflux. Aspirin and NSAIDs are very often associated with dyspepsia and can affect up to 25% of patients. Table 6.11 lists other medicines commonly implicated in causing dyspepsia.

Table 6.11

Medicines that commonly cause dyspepsia

Antibiotics, e.g. macrolides and tetracyclines

Potassium supplements

ACE, angiotensin-converting enzyme; SSRI, selective serotonin reuptake inhibitor.

Irritable bowel syndrome: Patients younger than 45, who have uncomplicated dyspepsia and also lower abdominal pain and altered bowel habits are likely to have irritable bowel syndrome (IBS). For further details on IBS see page 168.

Very unlikely causes

Gastric carcinoma: Gastric carcinoma is the third most common GI malignancy after colorectal and pancreatic cancer. However, only 2% of patients who are referred by their GP for an endoscopy have malignancy. It is therefore a rare condition and community pharmacists are extremely unlikely to encounter a patient with carcinoma. One or more ALARM symptoms should be present plus symptoms such as nausea and vomiting.

Oesophageal carcinoma: In its early stages, oesophageal carcinoma might go unnoticed. Over time, however, as the oesophagus becomes constricted, patients will complain of difficulty in swallowing and experience a sensation of food sticking in the oesophagus. As the disease progresses weight loss becomes prominent despite the patient maintaining a good appetite.

Atypical angina: Not all cases of angina have classical textbook presentation of pain in the retrosternal area with radiation to the neck, back or left shoulder that is precipitated by temperature changes or exercise. Patients can complain of dyspepsia-like symptoms and feel generally unwell. These symptoms might be brought on by a heavy meal. In such cases antacids will fail to relieve symptoms and referral is needed.

Figure 6.10 will aid differentiation of the causes of dyspepsia.

Fig. 6.10 Primer for differential diagnosis of dyspepsia.
Alarm symptoms
These include, anaemia (signs can include tiredness and pale complexion), loss of weight, anorexia, dark stools, difficulty in swallowing, vomiting blood.

Trigger points indicative of referral

Dyspepsia

Symptoms/signs	Possible danger/reason for referral
ALARM signs and symptoms Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Melaena, dysphagia and haematemesis	Symptoms requiring further investigation
Pain described as severe, debilitating or that wakes the patient in the night Persistent vomiting	Suggests ulceration
Referred pain	Possible cardiovascular cause