ORAL MANIFESTATIONS OF DRUG REACTIONS and its treatment

BY-J.RAHUL RAGHAVENDERII YR B.D.SPRIYADARSHINI DENTAL COLLEGE

4/26/2014

•Oral mucosa is frequently involved in adverse reactions of drugs.

•Three mechanism have been proposed for drug allergies:(1)IgE mediated reactions(2)Cytotoxic reactions(3)Circulation of the antigen

ETIOLOGY AND PATHOGENESIS OF ORAL ADVERSE DRUG REACTIONS

1) Drug-related Disorders of the Salivary Glands

2) Drug-related Disorders of Taste

3) Drug-related Mucosal Disorders

4) Drug-related Mucosal Pigmentation

5) Drug-related Swellings

6) Drug-related Neuropathies

7) Drug-related Oral Malodor (Halitosis)

8) Drug related Oral Infections

9) Drug-related Oral Teratogenic effects

(1) DRUG-REALTED DISORDERS OF SALIVARY GLANDS

XEROSTOMIA

SALIVARY GLAND SWELLING

SALIVARY GLAND PAIN

HYPERSALIVATION

DISCOLORATION OF SALIVA

XEROSTOMIA

Xerostomia is the subjective feeling of oral dryness, which is often (but not always) associated with hypofunction of the salivary glands.

Fissured tongue with atrophy of the filiform papillae and a lobulated, erythematous appearance of the tongue

CAUSES

Antidepressants

Antipsychotics

Antihistamines

Antihypertensives

TREATMENT

Drug Substitution with Other Medications:

Anticholinergics :Tolterodine tartrate

Antiparkinson drugs : pramipexole, rapinirole

Pharmacologic Stimulant : EvoxacSalagen

SALIVARY GLAND SWELLING

Painless, usually bilateral, salivary gland enlargement

DRUGS RELATED :PhenylbutazoneOxyphenbutazoneChlorhexidinNaproxen therapy Clozapine, a novel antipsychotic agent

SALIVARY GLAND PAIN

DRUGS RELATED :

AntihypertensivesAnti-thyroid agentsChlorhexidineCytotoxicsGanglion-blocking agentsIodides Phenothiazines Sulphonamides

HYPERSALIVATION

DRUGS RELATED AnticholinesterasesAntipsychotic drug

Hypersalivation is excessive production of saliva.

TREATMENT : Hypersalivation is optimally treated by treating or avoiding the underlying cause.Mouthwash and tooth brushing may have drying effects.

DISCOLORATION OF SALIVA

Rifampacin(red-orange discoloration of saiva)

Doxorubicin

Clofazimine(pink to brownish-black saliva)

L-Dopa(brownish discoloration of saliva)

Rifabutin(brown or orange discoloration of saliva)

(2)DRUG-RELATED DISORDERS OF TASTE

HYPOGEUSIA ( loss of taste acuity ) : DRUGS: Antirheumatic drugs like penicillamine, antiproliferative drugs such as cisplatin, ACE inhibitors, and other drugs including azelastine, clarithromycin and zopiclone

AGEUSIA ( loss of taste sense ) DRUGS: Penicillamine, cisplatin, ACE inhibitor, etc.

TREATMENT:

Pilocarpine,(effects of acetycholine)Zinc supplementationZinc infusion in chemotherapy

DYSGEUSIA ( distortion of taste )

DRUGS:

Azelastine and emedastine, lithium carbonate and Tetracyclines,penicillamine

(3)DRUGS RELATED MUCOSAL DISORDERS

ORAL ULCERATION(a) Burning mouth

syndromeAspirinPotassium tabletsClonazepam

(b) Aphthous stomatitis

Labetolol

Alendronate

(c) Fixed drug eruptions Anesthetics, antibiotics, antiseptics, barbiturates

(d) Drug-related erythema multiforme Edematous papules Barbiturates, cephalosporins, NSAIDs, phenothiazines

(e) Oral mucositis Chemotherapy and radiotherapy•5-fluorouracil •Methotrexate •Doxorubicin •Cyclophosphamide

(f) Glossitis

•Glossitis is inflammation of the tongue that is characterized by swelling and intense pain.•Atrovastatin, Benzodiazepines, Captopril

(g)Vesiculo-bullous lesions Blisters Vesiculo-bullous lesions are reported for naproxen and penicillamine.

(h) Stevens-Johnson Syndrome (SJS)

• Milder form of toxic epidermal necrolysis• Ulcers and lesions start to appear in the

mucous membrane, starting in mouth and lips.• Extremely painful and reduce the ability of

the person to eat or drink• DRUGS:Sulfonamide Penicillins Quinolones Phenytoin NSAIDS Allopurinol

• TREATMENT:Antibiotic therapyRemoval of the offending agent

DRUG-RELATED WHITE LESIONS

•Lichenoid eruptions

beta blockers traditional

antimalarials thiazide

diuretics furosemide spironolactone Metformin penicillamine

•Elimination of precipitating factors and improving oral hygiene.

•Treatment usually involves topical corticosteroids such as Betamethasoneclobetasoldexamethasonetriamcinolone

TREATMENT

(4)DRUG RELATED MUCOSAL PIGMENTATION

(1) Drug-related superficial transient discoloration ( black hairy tongue )

• Discoloration of the dorsum of the tongue and other soft tissues and teeth may be of various colors, typically yellowish or brown.

• DRUGS RELATED : Iron salts, bismuth, chlorhexidine, or antibiotics

(2) Drug-related intrinsic pigmentation

Mucosal pigmentation : Amalgam

Gingival pigmentation : Gold or metal alloys

(3)Pink-red colouration

Hemolysis and exudation of hemoglobin to dental pulp.

overdoses with barbiturates and carbon monoxide

(5)DRUG RELATED SWELLINGS

•Drug-related gingival enlargement

PhenytoinCiclosporincalcium-channel-blockers ,nifedipineErythromycin

•Drug-related lip and mucosal swelling

•Penicillins, local anesthetic agents, cephalosporin derivatives, angiotensin-converting enzyme inhibitors(ACE), aspirin, and barbiturates.

•REASON: rise in levels of bradykinins and/or altered levels or function of C1 esterase inhibitor .

(6)DRUGS RELATED NEUROPATHIES

(1)Drug-related trigeminal neuropathies:

DRUGS : acetazolamide, labetalol, sulthiame, vincristine. TREATMENT: Anticonvulsant carbamazepine is the first line

treatment.

(2) Drug-related involuntary facial movements:

DRUGS : Butyrophenones, phenothiazines, tricyclic antidepressants

TREATMENT : Carbzmazepine, Botulinum Toxin.

(3) Drug-related orofacial pain and oral dysesthesia:

DRUGS : Benztropine ,Biperidin ,Griseofulvin TREATMENT : Antidepressants

(7)DRUG RELATED ORAL MALODOR (HALITOSIS)

Bad breath

DRUGS: Isosorbide dinitrateDimethyl sulphoxideDisulfiram

TREATMENT:Cleaning the tongueMouthwashes

(8)DRUG RELATED ORAL INFECTIONS

Alveolar osteitis (dry socket) ACE inhibitors

Facial edema (angioedema) Adrenomimetic bronchodialators Enalapril

Stomatodynia (pain in the mouth) Bentropine Penicillins

Cheilitis (inflammation and cracking of lips) Busulfan Atrovastatin

(9)DRUG RELATED ORAL TERATOGENIC EFFECTS

(1)Cleft lip(2)Cleft palate DRUGS : Anticonvulsant drugs Accutane Methotrexate

(3)Tooth discoloration DRUGS : Cadmium Minocycline Tetracycline

CONCLUSION

In most cases , the oral reaction will be resolved by symptomatic treatment.

Many clients take multiple medications ,therefore , dentists must be aware of the issues related to drug use including indications , interactions and adverse drug effects.

As a final note , rapid progress in pharmacotherapeutics requires clinicians to constantly update their knowledge of drugs used by their patients.