The options to help patients with oral and perioral pain problems such as neuropathies, burning mouth syndrome, neuromas and neuralgias. Vehicle-carrier agents and bases have been developed that can penetrate the mucosa and cutaneous tissues and transport the active medication to the treatment site. Dentists have been using topical agents with increasing frequency as part of the therapeutic protocol for orofacial painful neuropathy.

Several topical intraoral medications are used in the treatment of oral ulcerations and infections, including antifungals; nonsteroidal anti-inflammatory drugs (NSAIDs); and corticosteroids. Because of their rapid onset and low side-effect profile, topical medications offer a distinct advantage over systemic administration for orofacial disorders. Medicated lollipops, lozenges, and adhering powders are ideal for keeping an antibiotic or antifungal in contact with an infected area in the mouth.


Topical Anesthetics—Combinations of your Choice

Methemoglobinemia (MHb) is a potentially serious blood condition and an uncommon adverse reaction known to be associated with benzocaine. This condition reduces the ability of red blood cells to deliver oxygen throughout the body, which can lead to bluish discoloration of the skin, nausea and fatigue. It can progress to stupor, coma and death. Almost all reported cases of benzocaine-induced MHb were associated with high-concentration preparations (14 percent to 20 percent benzocaine). Compounding pharmacies can formulate low concentration or benzocaine-free topical anesthetics, including combinations of other topical anesthetics such as lidocaine and tetracaine or prilocaine.


Update on Burning Mouth Syndrome

Burning mouth syndrome (BMS), also referred to as glossopyrosis or glossodynia (when the burning occurs on the tongue only) is usually described as oral burning pain, sometimes with dysesthetic qualities similar to those present in other neuropathic pain conditions. The dorsal tongue, palate, lips and gingival tissues, individually or in combination, are the most common sites involved. Bilateral or unilateral oral burning pain has been found to be associated with jaw pain or uncontrollable tightness, taste changes, subjective dry mouth, geographic and fissured tongue, painful teeth, headache, neck and shoulder pain, difficulty speaking, nausea, gagging and swallowing difficulties. BMS has been reported to follow dental treatment, antibiotic usage and a severe upper respiratory infection. The lack of pathology to account for the pain can be frustrating. Pain is constant, progressively increases over the day, and usually decreases during eating. Patients, who are frequently distressed by their unremitting symptoms, may demonstrate psychological abnormalities including anxiety and depression.

Therapy for BMS involves the use of centrally acting medications for neuropathic pain, such as tricyclic antidepressants, benzodiazepines or gabapentin. Clonazepam is a benzodiazepine used either topically or in low doses orally, which appears to have excellent efficacy in the relief of the symptoms related to BMS. Topical medications, including clonidine, may be considered for application to local sites.

A combination of oral medications for the management of BMS (clonazepam, gabapentin, baclofen, and lamotrigine) significantly decreased pain in 38 or 45 patients. The most common adverse effect reported with the medication protocol was drowsiness followed by dizziness and perceived changes in mood. These results suggest that BMS may be treated with lower doses of a combination of medications rather than higher doses of a single medication, which may help to limit adverse effects such as drowsiness or dizziness.

Adv Otorhinolaryngol. 2006, 63:278–287 

The formulation for a mouthrinse containing clonazepam 1 mg per 5 ml has been reported. It is hypothesised that clonazepam acts locally to disrupt the mechanism(s) underlying stomatodynia. Topical formulations of gabapentin, ketamine, clonidine, and baclofen have been used to treat chronic neuropathic pain at various bodily sites.

Int J of Pharmaceutical Compounding July/Aug 2005, 9(4):310
Pain 2004 Mar;108(1-2):51-7       (click for abstract)
Pain Med. 2000 Mar;1(1):97-100