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., untreated glaucoma).
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 diagnosis.
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 Sensitive.
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., Sucrets Classic).1
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 not sterile.
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 throat.
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 complications.
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. www.nidcr.nih.gov/OralHealth/Topics/Burning/BurningMouthSyndrome.htm. 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. www.fda.gov/forconsumers/consumerupdates/ucm306062.htm. Accessed 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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