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?
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