US Pharm. 2013;38(3):8-11.
The typical community pharmacist answers questions from
hundreds of patients with conditions causing pain every year. These
include headache, muscle and joint pain, stomach pain, and a host of
other issues. Some of these patients experience pain in the eyes, ears,
mouth, teeth, and throat. It is critical to know which of these may be
self-treated and which should be referred for a more thorough
examination by a physician or dentist.
Eye pain is never amenable to self-treatment.1
Every nonprescription eye care product, whether for dry eye, allergic
conjunctivitis, or red eye, carries a label warning against use in the
presence of ophthalmic pain.1 The reason for this strict
prohibition against self-treatment becomes clear when considering the
potential causes of eye pain. Some are infectious, such as an ophthalmic
or sinus infection, a stye, inflammation/infection of the upper and/or
lower eyelids, viral conjunctivitis, or other viral infections (e.g.,
influenza).2 The patient may have eye burns, which can result
from working with an arc welder without protective eyewear. Eye pain
may also be caused by migraine, glaucoma, use of contact lenses, or a
recent ophthalmic surgical procedure. A look at this list reveals that
appropriate treatment consists of an immediate appointment with a
physician, as many of the potential causes are progressive conditions
and could lead to irreversible destruction of the visual field (e.g.,
As in the case of eye pain, pharmacists should always
refer patients with ear pain to a physician. The only safe and effective
non-prescription otic products are for impacted earwax and
water-clogged ears.1 These conditions are not common causes
of overt otic pain, and all products sold for them carry a warning
against use if ear pain is present.1 Ear pain may be due to
an acute or chronic infection of the ear, or may be referred pain from
an infection of the throat, sinus, or a tooth.3 Arthritis of
the jaw or temporo-mandibular joint syndrome (TMJ) can be causal. The
patient may have an ear injury caused by high altitudes, a ruptured or
perforated tympanic membrane, or an object stuck in the ear canal.
Oral pain differs from ophthalmic and otic pain in that
judicious questioning by the pharmacist can allow recognition of several
self-treatable conditions. The pharmacist should ask about the source
of the pain. Intraoral pain can arise from the tongue, gingiva, hard or
soft palate, or inner lip area. The duration of the pain is also
critical to explore.
Canker Sores: Canker sores, or recurrent aphthous stomatitis (RAS), are extremely painful oral lesions of uncertain etiology.1,4
Their usual location is the tongue or inside surfaces of the cheeks or
lips. RAS can be recognized by the following characteristics: roundish
and about a half inch in diameter with a shallow crater, a regular
border surrounded by a red halo, and a whitish-yellow interior.
Oral Injury: The
mouth is susceptible to many types of minor injuries. They include
burns from eating hot food; accidental bites of the cheek or lip; an
abrasion from hard food, a toothpick, or a toothbrush; lip lesions from
braces; and gum lesions from poorly fitted dentures.5 In
virtually all of these cases, the patient can clearly pinpoint the cause
of the injury and the approximate date that it occurred.
Sore Mouth: A
number of lozenges, sprays, and strips for sore throat also include the
vague indication “for sore mouth.” If a patient complains of sore mouth
in the absence of canker sores, burns, or injuries of any type, it may
be caused by a number of morbid conditions that are best referred to a
physician, including burning mouth syndrome (BMS).6
BMS is most often seen in middle-aged women, producing a painful
scalding sensation in the tongue, lips, palate, or entire intraoral
mucosa. Pain may be constant or intermittent. Potential etiologies
include perimenopausal and postmenopausal hormonal changes, damage to
nerves, xerostomia (due to various causes, e.g., Sjögren’s syndrome),
diabetes, gastric reflux, oral candidiasis, poorly fitted dentures, or
an allergic reaction to dental materials. These problems require a
physician to diagnose them and suggest a possible course of therapy.
Oral Ulcers of Unknown Cause: Patients
may ask the pharmacist for assistance with one or more painful
intraoral ulcers. In some cases, the patient has no history of canker
sores and cannot recall any specific injury that caused the lesion(s).
The patient should be asked if he or she uses dip or chewing tobacco.
Some users develop an intraoral tumor at the exact location where they
place their plug (“quid”) of tobacco. The pharmacist should also explore
the patient’s medical record for use of drugs that can induce oral
ulcers, such as aspirin, penicillin, sulfas, phenytoin, and
chemotherapy.5 Oral ulcers may be caused by autoimmune
disorders (e.g., systemic lupus erythematosus), blood dyscrasias,
infections, or compromised immune status. All of these situations are
potentially serious and must be referred without exception for physician
Safely Treating Oral Pain: There
are several product categories to explore when confronted with oral
pain due to canker sores or minor injury. Products for canker sores
include Orabase, Benzodent, Orajel For All Mouth Sores, and Kank-A, all
containing 20% benzocaine.1 They may be applied up to four
times daily. They also carry labeling for treating pain arising from
minor dental procedures, and irritation or pain from dentures or
orthodontic appliances. This particular group of products should not be
used by those under the age of 2 years. The patient should cease use and
see a physician or dentist in the following situations: if the symptoms
fail to improve in one week; if irritation, pain or redness persist or
worsen; and if inflammation, rash, or fever develops.
Teething: Teething pain is caused by the pressure of teeth erupting through the gingiva in babies, toddlers, and adults (third molars).1,7
Baby teething products typically contain benzocaine 5% to 20%, which is
safe and effective for this use, applied up to four times daily. If the
child also has fever, diarrhea, or nasal congestion, he or she should
be taken to a physician. Products with 7.5% benzocaine include Baby
Orajel Gel and Teething Swabs and Baby Anbesol. Baby Orajel Nighttime
contains 10% benzocaine.1
Topical use of benzocaine carries a risk of
methemoglobinemia (a rare blood disorder characterized by pale or
blue-colored lips and skin, shortness of breath, fatigue, confusion, and
tachycardia), especially in those under 2 years of age. For this
reason, the FDA recommends against use of benzo-caine in children under 2
years unless directed by a physician.8
Dental pain may be caused by dentinal hypersensitivity,
which may be self-treated under certain circumstances, or by toothache,
which is not self-treatable.
Dentinal Hypersensitivity: This
is a condition in which patients experience pain when the teeth are
exposed to certain triggers, such as cold, hot, or sweet drinks; air
blasted on the tooth during a dental procedure; or the pressures of
dental cleaning.1 A common cause is gingival recession
induced by abuse of tobacco products or by overzealous cleaning of the
teeth, especially with firm-bristle brushes. Toothpastes containing
potassium nitrate are safe and effective for hypersensitivity when used
twice daily in patients 12 years and older. However, patients should not
use the products longer than 4 weeks without making a dental
appointment to ensure that there is not a more serious condition causing
tooth pain. Products include Sensodyne, Crest Sensitivity, and Colgate
Toothache: Patients seeking assistance with a toothache (unrelated to teething) require referral.1,9
Possible causes for tooth pain include caries, a cracked tooth,
abscess, sinus infection, TMJ, or bruxism. A dentist can pinpoint the
underlying cause of pain. If the situation is resolved early, judicious
intervention may preserve the tooth. However, if caries proceeds without
correction, the situation may become irreversible, so that the tooth
will require a root canal or extraction. Although some Orajel and
Anbesol products claim efficacy for toothache, they only contain
benzocaine, some with added menthol. Benzocaine and menthol are not
proven to be safe or effective for this type of pain. Red Cross
Toothache contains eugenol, and eugenol can be dangerous to an exposed
nerve in a carious or cracked tooth. Thus, patients with toothaches
should be referred.
Throat pain is another condition that requires pharmacist
exploration to determine whether the patient should be referred or may
self-treat. Potential infectious causes of sore throat are laryngitis,
mononucleosis, mumps, influenza, streptococcus, tonsillitis,
epiglottitis, uvulitis, sexually transmitted diseases (e.g., gonorrhea,
chlamydia), or the common cold.1,10 Sore throat may be caused
by aplastic anemia, agranulocytosis, or acute leukemia. If the pain has
lasted more than 7 days, it is often due to low humidity, smoking, air
pollution, sustained yelling, postnasal drip, mouth breathing, acid
reflux, a throat injury, or chronic fatigue syndrome.
Given the various and potentially serious possible
etiologies, the pharmacist should ensure that the cause of the sore
throat is related to the common cold, as this is the only etiology
innocuous enough to allow self-treatment. The facts can be determined by
asking patients about the presence of additional common cold symptoms,
such as nasal congestion and cough. If there are no other indications
that the patient has a cold, referral is the best course. Once the
pharmacist has determined that the sore throat is associated with other
symptoms of the common cold, self-treatment may be appropriate. However,
patients should be referred if the sore throat is severe, has persisted
for more than 2 days, or is accompanied or followed by difficulty in
breathing, headache, fever, rash, swelling, nausea, or vomiting.
Patients under the age of 2 years should also be referred. Safe and
effective ingredients in lozenges and/or sprays include menthol (e.g.,
Halls, N’ICE,), benzocaine (e.g., Cepacol Ultra), and dyclonine (e.g.,
Most people experience pain many times each year.
Sometimes these pains go away after a few days or less because they were
not due to a serious cause. An example is a tension headache, which can
be safely treated with Tylenol, Advil, or Aleve. In other cases, pain
is a warning that something dangerous is happening, such as an infection
or injury. If this is so, treating the pain without addressing its
cause is not a good move.
Treating Eye Pain
Pain in the eyes have many causes, from minor irritations
to conditions that can lead to blindness (e.g., untreated glaucoma). For
this reason, no nonprescription product is labeled for eye pain.
Further, all OTC eye drops carry a warning against their use if the
patient has eye pain. This pain is of such gravity that you would be
well advised to make an immediate appointment with your eye doctor if
dry eye, allergic conjunctivitis, or red eye is accompanied by pain.
Treating Ear Pain
Pain in the ear is similar to eye pain. You may have a
less serious condition, like swimmer’s ear (water-clogged ears), which
is self-treatable with ear drops containing alcohol (e.g., Swim-Ear).
However, the pain might arise from a more serious condition such as
otitis media, an infection of the middle ear, which should be treated
with an oral antibiotic, available only by prescription. You may also
require an antibiotic ear drop if the problem is outside the eardrum.
Never use old home remedies such as olive oil (sweet oil) to treat ear
infections. This oil is not effective and could be dangerous, as it is
Treating Oral Pain
Pain in the mouth, throat, and teeth is possibly
self-treatable. Canker sores on the tongue or inside the mouth can be
treated with topical anesthetics (e.g., Orajel), which contain
benzocaine. Teeth sensitive to hot or cold triggers, a condition known
as dentinal hypersensitivity, can be treated with special
toothpastes such as Sensodyne. A sore throat due to the common cold can
be treated with menthol lozenges (e.g., Halls Cough Drops) or benzocaine
sprays (e.g., Cepacol Ultra) that numb the linings of the mouth and
Pain from a toothache can be temporarily relieved with
products containing benzocaine (e.g., Anbesol). However, these products
only mask your pain and do not treat the underlying cause, such as a
cavity, so you must see a dentist as soon as possible to avoid
Read the Label of Nonprescription Products
When you have questions about pain, be sure to Consult Your Pharmacist.
Your pharmacist is specially trained to know which types of pain can be
safely self-treated and which types should be seen by a doctor or
dentist. Your pharmacist can also assist you in choosing a suitable
nonprescription product that is best for your situation. Some OTC pain
relievers should not be used if you are taking certain prescription
drugs, if you have specific medical conditions, or if your age is too
low or too high.
Remember, if you have questions, Consult Your Pharmacist.
1. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
2. Eye pain. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003032.htm. Accessed January 30, 2013.
3. Earache. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003046.htm. Accessed January 30, 2013.
4. Canker sore. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000998.htm. Accessed January 30, 2013.
5. Mouth sores. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003059.htm. Accessed January 30, 2013.
6. Burning mouth syndrome. National Institute of Dental
and Craniofacial Research.
Accessed January 30, 2013.
7. Teething. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/002045.htm. Accessed January 30, 2013.
8. Benzocaine and babies: not a good mix. FDA Consumer
Updates. May 31, 2012.
February 25, 2013.
9. Toothaches. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003067.htm. Accessed January 30, 2013.
10. Sore throat. WebMD. www.webmd.com/cold-and-flu/tc/sore-throat-topic-overview. Accessed January 30, 2013.
11. How to take BC Powder. Prestige Brands, Inc. www.bcpowder.com/products/how-to-take-bc-powder. Accessed February 11, 2013.
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