Oral Adverse Drug Reactions Encountered by

DentistsCharles Sharkey M.S., M.B.A. Pharm D.

Pharmacy Site Manager/Pharmacy Residency Coordinator

Increased knowledge and understanding of medication related adverse events encountered in dental practice

Recognition of the occurrence of these adverse effects upon oral cavity

Improved management of these adverse events

Lecture Objectives

Identify the culprit medication if possible Establish a timeline for use Local or systemic reaction Medication history Medication Allergies A first time event or repeat event

General Considerations

Inflammation of the oral cavity Stomatitis venenata refers to an irritant or

allergic reaction from topical medications Stomatitis medicamentosa refers to a

reaction occurring from systemically administered medications.

Hypersensitivity reactions

Stomatitis

Localized reactions ranging from mild erythema to vesiculation and necrosis.

Irritant reaction Fixed drug reaction Allergic contact stomatitis Antibiotics, Nicotine, Aspirin

Stomatitis Venenata

Nicotine Induced Stomatitis

Aspirin Induced Stomatitis

Ranges from nonspecific generalized erythema to ulceration in the oral cavity.

Patient complaints of pain, tingling, burning in the oral cavity.

Antibiotics

Stomatitis Medicamentosa

Local irritation Chemotherapy adverse effects Opportunistic infections Fixed drug reactions Lichen planus-like reactions

Ulceration of the Oral Cavity

Local irritation Topical application of Aspirin (caustic effect) Topical application of pancreatic

supplements (enzymatic effect) Oral ulceration with Captopril and

Nonsteroidal anti-inflammatory drugs (NSAID’s)

Ulceration of Oral Cavity

Chemotherapy associated mucositis Widespread sloughing and erythema Extremely painful which may require opioid

analgesics. Methotrexate, 5-fluorouracil, doxorubicin,

melphalan, mercaptopurine, bleomycin.

Ulceration of Oral Cavity

Candidiasis Oral Cavity (Thrush)

Candidiasis Oral Cavity (Thrush)

Chemotherapy Induced Mucositis

A number of drugs can alter the ecosystem of the oral cavity or depress immune system increasing patient susceptibility to oral infections.

Overgrowth of organisms that are part of the oral flora including bacterial, fungal, and viral superinfections.

Destruction of the natural mucosal barrier Reduced Salivary secretion

Oral Cavity Infections

Gram negative bacilli such as Pseudomonas, Klebsiella, E.coli, Enterobacter, Proteus

Yeast infections with Candida albicans Opportunistic infections with Herpes

Simplex, varicella zoster, and cytomegalovirus

Immunocompromised Ecological imbalance due to antibiotics i.e.

Thrush, bacterial infections.

Oral Cavity Infections

Papulosquamous disorder involving skin and mucous membranes (Chronic disease)

Immune mediated pathogenesis Reticuliar pattern with white lacy line

patterns in the oral mucosa List of drugs causing LP like reactions include NSAID’s, ACE inhibitors, Phenytoin,

Allopurinol, antibiotics to name but a few.

Lichen planus (LP)

Drug reactions mimicking disorders associated with blistering including pemphigus vulgaris, pemphigoid linear immunoglobulin A bullous disease (LABD), erythema multiforme (EM), and toxic epidermal necrolysis (TEN).

Bullous disease

Allergic angioedema occurs as acute and often transient oral and facial swelling.

Non allergic, and allergic reactions to food with histamine release.

Drug induced with histamine release. Aspirin, Penicillin's, ACE inhibitors.

Swelling/Angioedema

Swelling/Angioedema

Swelling/Angioedema

Painless or associated with tenderness. Local causes i.e. duct obstruction Drug related. Sulfonamides, NSAID’s, phenothiazine's.

Salivary Gland Enlargement

Patients complain of dry, cotton mouth due to reduced or absent saliva flow

Not a disease but a side effect Difficulty in speech, chewing, altered taste. Drug induced affecting parasympathetic

system. Anticholinergic effects Atropine, Amitriptyline, antiparkinsonian

medications, amphetamines, antipsychotics.

Xerostomia

Xerostomia Drug Induced

Xerostomia Drug Induced

Begins within several months of drug therapy

Swelling which is firm, and painless. Cyclosporine induced.

Gingival enlargement

Firm, painless overgrowth of fibrous tissue. Phenytoin is the classic drug

Gingival hyperplasia

Amlodipine induced gingival hyperplasia

Gingival hyperplasia

Drug Induced Gingival Hyperplasia

Calcium Channel Blocker Induced Gingival Hyperplasia

Facial or oral paresthesia. Chemotherapeutic agents such as the vinca

alkaloids. Drug induced with monoamine oxidase

inhibitors, tricyclic antidepressants, isoniazid, and propranolol.

Sensory Loss

Dysgeusia is a distortion of sense of taste Abnormal taste sensation Approximately 250 drugs can affect taste Major ones include chemotherapy, asthma

treatment with albuterol, and zinc deficiency

Taste Alterations

Drug induced inflamed taste buds

Taste Alterations

Direct or indirect effect on oral mucosa. Cytotoxic effects on rapidly dividing cells of

the oral mucosa. Antimetabolites, Antibiotics, plant alkaloids,

Alkylating agents. Most reactions resolve within three weeks

after removing offending drug. Preventive measures.

Chemotherapeutic Agents

Changing the oral mucosa flora. Penicillin's, Cephalosporin's, Sulfonamides,

Tetracycline's. This can lead to overgrowth of other organisms

i.e. Thrush Tetracycline's can stain teeth anywhere from

bright yellow shade to dark brown Exposure to light over time initiates chemical

reaction

Antibiotics

Presenting with brown teeth in the front due to light exposure

Yellow teeth in the back Tetracycline homologues (similar drugs) have

been implicated with discoloration Minocycline binds to teeth and thru oxidation

discolors teeth Can stain teeth even after fully developed

More about Tetracycline

Ciprofloxacin administered intravenously in infant can stain teeth a green color

Staining tends to be mild in nature

Antibiotics

Tetracycline Induced Staining of Teeth

Tetracycline Induced Staining of Teeth

Doxycline Teeth Staining

Minocycline Induced Teeth Staining

Stimulates release, and blocks reuptake of neurotransmitters

Feelings of pleasure and euphoria Meth Mouth Distinctive pattern of decay buccal smooth

surface of teeth and interproximal surface of anterior teeth

Methamphetamine Abuse

Meth Mouth

Meth Mouth

Remove the offending drug Avoid using the offending drug in certain age

groups Change the drug if possible Artificial Saliva Zinc supplementation Nystatin Oral Solution

How do we treat these conditions

Local anesthetics Antibiotics Dental repair Topical fluorides Avoid sugar containing beverages Patient education

How do we treat the conditions

Good Oral Health is the Goal

Good Care Means Knowing A Medication History

Questions?