Oral Conditions and Their Treatment
1 Name several common infectious lesions of the oral cavity and summarize the treatments for each.
2 Describe immune reactions resulting in canker sores and lichen planus and discuss the treatments for each.
3 Name several oral conditions that result from inflammation and the measures used to treat them.
4 Discuss treatment options for xerostomia and name several other possible drug-induced oral side effects.
5 Discuss the pharmacologic agents most commonly used to treat oral lesions.
The dental health care worker is the first professional that patients visit when they notice a lesion in the oral cavity. Patients often ask the dental care provider, “What is this? How do I get rid of it? How long will it take to go away? Why do I have it? Is it cancer?” Patients who have even visited several physicians may appear at the office with commonly seen oral lesions. The first step is the diagnosis. Obtaining an in-depth history of the problem (by listening and asking open-ended questions) and examining the lesion can often result in a diagnosis or potential diagnoses. Depending on the diagnosis, the lesion may require only reassurance, palliative treatment, specific treatment, or even surgical intervention.
This chapter discusses a few of the more common oral lesions and medications used for the treatment of these conditions. Before discussing individual oral lesions, commonly used treatments for several types of lesions are discussed.
INFECTIOUS LESIONS
Acute Necrotizing Ulcerative Gingivitis
Acute necrotizing ulcerative gingivitis (ANUG), which is also called Vincent’s infection and trench mouth, has both bacteriologic (spirochetes) and environmental (stress, debilitation) factors (see Color Plate 4). ANUG is a spreading ulcer associated with a distinctive odor; the ulcerated area begins at the interdental papillae.
Good oral hygiene is the cornerstone of treatment, but other modalities have been recommended. Mouthwashes, such as hydrogen peroxide, or saline rinses assist by their flushing action. If pain or an elevated temperature accompanies ANUG, then aspirin or acetaminophen can be recommended. If eating is difficult, food supplements (Meritene, Sustacal, or Sustagen) may be used instead of meals. Vitamin supplementation is useful only if the patient has a vitamin deficiency. The food supplements mentioned contain the required vitamins and minerals. Antibiotics should be considered only if the patient is immunosuppressed or there is evidence of systemic involvement (see Table 7-1). Antibiotics useful for the immunosuppressed patient with ANUG include penicillin VK and metronidazole. Topical chlorhexidine gluconate, active against gram-positive and gram-negative organisms and Candida organisms, is used as a rinse for ANUG. The majority of ANUG cases respond dramatically to local treatment (oral prophylaxis with scaling).
Herpes Infections
Primary herpetic gingivostomatitis (see Color Plates 5, 6, and 7), or primary herpes, is the manifestation of the initial herpes infection. Occurring principally in infants and children, it is caused by the herpes simplex virus (HSV). Because it is often associated with or follows other infections, it is also known as a fever blister or cold sore. The painful lesions may appear throughout the oral mucosa. Beginning as an erythematous area, numerous ulcers with a circumscribed area of erythema appear. The ulcers can coalesce to form larger irregular ulcers with gray centers. Other signs of herpes include the formation of vesicles that become scabbed. Systemic symptoms that are more severe in infants can develop and in some cases, can be life threatening.
Without treatment, herpes is self-limiting in the patient with normal immunity. Approximately 80% to 90% of the adult population has been exposed to HSV. HSV-1 is involved in most oral lesions, and transmission is usually not sexual. HSV-2 is usually responsible for genital herpes and is transmitted sexually. Both HSV-1 and HSV-2 can spread to other parts of the body, for example, the eyes, genitals, and fingers (herpetic whitlow). When the lesions are in the vesicle stage, they are contagious and the virus can survive for several hours on surfaces (one should think about possibilities in the dental office).
After the primary episode, the patient may experience recurrent outbreaks (cold sores or fever blisters) that occur at irregular and variable intervals. Events that may precipitate a herpetic outbreak include sunlight (ultraviolet light), hormonal changes such as menstruation, lip pulling, a rubber dam, biting an anesthetized lip, emotional stress, or other infections (e.g., a viral respiratory infection). One should repeatedly apply petroleum jelly to the lips and be careful when manipulating the lips to minimize the trauma from a dental appointment. The effectiveness of the antiviral drugs varies depending on whether the outbreak is a primary episode or recurrence and whether the patient is immunocompromised or nonimmunocompromised.
TREATMENT
The treatment of herpes may include an antiviral agent, depending on the patient and the episode. Many instances of herpes simplex are not affected by antiviral therapy. Adequate clinical trials determine whether an antiviral agent should be prescribed.
Symptomatic treatment of lesions includes swishing the mouth with topical diphenhydramine (DPH) (Benadryl) elixir or viscous lidocaine and spitting it out. Antiviral agents, such as acyclovir, valacyclovir, and penciclovir, are useful in certain herpes simplex infections (Table 13-1).
TABLE 13-1
DOSING OF FDA-APPROVED ANTIVIRAL AGENTS IN THE MANAGEMENT OF HERPES LABIALIS
| Drug | Indication | Dosing |
| Acyclovir topical cream (Zovirax) | Treatment of recurrent herpes labialis in adults and adolescents 12 years and older | Apply 5 times a day for 4 days |
| Acyclovir systemic ointment (Zovirax) | Treatment of herpes labialis in immunocompromised patients | Apply q3h 6 times a day for 7 days |
| Valacyclovir systemic (Valtrex) | Treatment of herpes labialis | 2 g orally every 12 hours for 1 day |
| Famciclovir (Famvir) | Treatment of herpes labialis in adults | 1500 mg PO single dose |
| Penciclovir topical (Denavir) | Recurrent herpes labialis in immunocompetent patients | Apply q2h while awake for 4 days |
| Docosanol 10% topical cream (Abreva) | Nonprescription treatment for herpes labialis | Apply 5 times daily |
Acyclovir: Acyclovir is available as tablets, capsules, oral suspension, ointment, cream, and parenteral forms. This discussion is limited to the oral and topical products; parenteral products are not discussed in-depth.
The approved indications for oral acyclovir include the treatment of primary and recurrent HSV in the immunocompromised patient. In the nonimmunocompromised patient, oral acyclovir is indicated for both treatment of the primary (first episode) outbreak and prophylaxis. Used prophylactically, it reduces the number and severity of recurrent outbreaks. Acyclovir should not be used prophylactically to prevent minor outbreaks because excessive use may lead to resistant strains of herpes.
Administration of oral acyclovir can be used before situations known to precipitate herpes lesions, such as a ski trip or wedding (stress), or a dental appointment that will produce trauma. The usual prophylactic dose of acyclovir is 400 mg twice a day (bid). It has yet to be shown that oral acyclovir produces a significant clinical effect in the treatment of recurrent lesions in the immunocompetent patient. It may shorten the time to healing or the pain by a small amount.
Topical acyclovir ointment does not affect the course of recurrent herpes in the immunocompetent patient. This may be a result of poor penetration or delay in applying the ointment. Cell damage may be irreversible by the time symptoms are noticed. Topical acyclovir cream was recently approved to treat herpes labialis in immunocompetent patients.
The incidence of resistance of the herpes organisms to acyclovir is increasing. If herpes lesions fail to respond to therapy, the virus should be tested for susceptibility to acyclovir. Resistant strains have been identified, especially in human immunodeficiency virus (HIV)-positive patients taking chronic acyclovir. This is the same principle that produces antibiotic resistance in the general population.
Penciclovir (Denavir), which is available only topically, has been shown to reduce by one-half day the duration and pain of lesions on the lips and face associated with both primary and recurrent herpes simplex. The advantages of penciclovir over acyclovir are that penciclovir can achieve a higher concentration within the cell and it remains in the cells longer. Table 13-1 summarizes the indications for the antiviral agents.
Famciclovir and Valacyclovir: Both famciclovir and valacyclovir are prodrugs that are converted to active antiviral agents. They are indicated in the treatment of acute localized varicella-zoster infections and recurrent genital herpes in immunocompetent adults. Valacyclovir is also indicated for the treatment of herpes labialis. Ganciclovir is indicated for serious cytomegalovirus retinitis in immunocompromised patients. It may be effective in some acyclovir-resistant organisms.
Palliative treatment involves treating the patient’s symptoms. In a primary episode of herpes, fever may be managed by the administration of acetaminophen or by sponging the affected area with tepid water. The discomfort associated with herpes may be relieved by swishing diphenhydramine. This product is available under many trade names, for example, Diphen Cough, Diphenhist, Genahist, and Siladryl. All of these products are alcohol-free liquids. Perhaps the most commonly available product is Benadryl. The strength of all the products is 12.5 mg of the active ingredient per 5 ml (1 teaspoonful). Other agents, such as viscous lidocaine (Xylocaine) or combinations of diphenhydramine with kaolin (Kaopectate), calcium carbonate (Maalox Quick Dissolve), or simethicone (Mylanta Gas), are recommended for use in the oral cavity. Because antihistamines, such as diphenhydramine, have a structure similar to local anesthetics, they have some local anesthetic action and can therefore reduce the pain.
Sodium carboxymethylcellulose paste (Orabase plain or with benzocaine) may reduce discomfort. Food supplements may be used if intake of food is impossible (because of oral discomfort). These remedies are the same as those used for patients receiving cancer chemotherapy agents. Corticosteroids are contraindicated because they suppress the cellular immunity that inhibits viral infections.
Candidiasis (Moniliasis)
Candidiasis, a fungal infection caused by Candida albicans, often affects the oral and vaginal mucosa. Candidiasis occurs when the organisms multiply and predominate. Because Candida is part of the normal oral flora, it is always present in small numbers. When other flora are suppressed, Candida can predominate.
When a patient presents with oral candidiasis, it is important that the dental health care worker search exhaustively for potential predisposing factors. Systemic antibiotic treatment, especially with broad-spectrum antibiotics such as tetracycline, can predispose a patient to candidiasis. A dental health care worker may be the first professional to diagnose HIV-positive patients or those with acquired immunodeficiency syndrome (AIDS) (see Color Plate 8).
Although candidiasis can appear in several different forms, the lesions are typical and can usually be diagnosed by clinical appearance. They may be confirmed by culture. Topical products available to treat oral candidiasis include nystatin products (aqueous suspension, vaginal tablets [used as lozenges], and lozenges [pastilles]) or clotrimazole troches (see Chapter 8).
With chronic candidiasis (see Color Plate 9), ketoconazole tablets taken orally once daily can be used. Systemic alternatives include either fluconazole or itraconazole. All are effective, but they should be continued for at least 2 weeks and/or at least 2 to 3 days past the time when the symptoms have disappeared.
Angular Cheilitis/Cheilosis
Angular cheilitis appears as simple redness, fissures, erosion, ulcers, and crusting located at the angles of the mouth, which may or may not be painful (see Color Plate 10). Most cases of cheilitis are associated with a mixed infection. Often, C. albicans infection is present, and not uncommonly both Candida and gram-positive bacteria, such as streptococci and/or staphylococci, also invade the lesion.
Predisposing factors may include moisture from drooling (moist areas are more likely to be infected with fungus). In the past, a decrease in vertical dimension was thought to contribute to angular cheilitis, but recent evidence has not shown this to be true.
Depending on the presentation of the patient’s lesion, therapy is addressed toward treating the secondary infection(s). If Candida organisms are present, treatment with an antifungal agent (see Chapter 8) is indicated. Examples of topical antifungal agents include nystatin, clotrimazole, or miconazole. If inflammation is present, some practitioners prescribe a combination of an antifungal agent mixed with a topical steroid (e.g., Mycolog [nystatin (Mycostatin) plus triamcinolone acetonide (Kenalog)]). One concern, which may or may not be clinically significant, about using steroids with a fungal infection is that steroids inhibit the inflammatory reaction associated with cellular immunity (this is the reaction that normally fights fungal infections).
If a bacterial overgrowth is suspected, the organisms responsible are usually similar to staphylococci and streptococci. To treat this bacterial infection, systemic penicillinase-resistant penicillins, such as dicloxacillin, are indicated (see Chapter 7). A relatively new agent, mupirocin (Bactroban), is a topical antibacterial useful in the treatment of staphylococcal and streptococcal infections. Using mupirocin (see Chapter 7) decreases the likelihood of adverse reactions, and mupirocin is as effective as systemic penicillinase-resistant penicillins. A topical antifungal agent and mupirocin can be used concomitantly if both are indicated.
Although rarely produced by a deficiency of vitamin B6 (pyridoxine) or B2 (riboflavin), cheilosis can result from deficiencies of these vitamins. Vitamin B supplements would be useful, but only if a vitamin deficiency exists.
Alveolar Osteitis
Alveolar osteitis, or “dry socket,” occurs in 2% to 3% of all tooth extractions, most commonly in the lower molar region, where the incidence is considerably higher than in other areas. Alveolar osteitis is thought to be caused by loss or necrosis of the blood clot that has formed in the extraction site, exposing the underlying bone. The exposed bone produces severe pain. Predisposing factors include oral contraceptive use and menstrual cycle phase. Smoking, especially after extraction, can increase the likelihood of dry socket. Inhaling on a cigarette produces a negative pressure in the oral cavity that may dislodge the clot.
Infection, swelling, elevated temperature, lymphadenopathy, and a foul odor may be present. Treatment consists of rinsing with saline water and debridement, placement of a pack, analgesics, and supportive therapy. Although there is some indication that local placement of antibiotics may reduce the incidence of dry socket, aseptic techniques, proper suturing techniques, and minimal trauma should be used as prophylactic measures. Most literature does not recommend the use of prophylactic antibiotics. If infection is present, antibiotics are indicated (treatment not prophylaxis). Antibiotics may be indicated in patients at high risk for infection.
IMMUNE REACTIONS
Recurrent aphthous stomatitis (RAS), which is sometimes referred to as a canker sore, is a common oral lesion occurring in about 20% of the population. It is seen after 20 years of age and has an unknown etiology, although an involvement of the immune system is suspected.
RAS presents clinically as a few small to many large ulcers. These ulcers can even coalesce into giant ulcers. Although three distinct types have been clinically identified—minor, major, and herpetiforme—the most common form of aphthous ulcers is the minor type (see Color Plates 11 and 12).
The etiology of aphthous stomatitis involves an immunologic component and may be associated with a focal immune dysfunction in which T lymphocytes play a significant role. There is a decreased ratio of T-helper (CD4+) cells to T-suppressor/cytotoxic (CD8+) cells. An increase in the CD8 cells is seen. The oral mucosa is destroyed by lymphocytes.
Many hypotheses have been considered concerning the etiology of RAS, including the following: an allergenic/hypersensitivity reaction (endogenous [autoimmune], exogenous [hyperimmune]), genetic, hematologic, hormones, infection, nutrition, and nonspecific events such as trauma and stress. Another hypothesis is that it is a hypersensitivity reaction to the sodium lauryl sulfate present in many over-the-counter (OTC) products, including most toothpastes (Table 13-2).
TABLE 13-2
TOOTHPASTES (DENTIFRICES) THAT DO NOT CONTAIN SODIUM LAURYL SULFATE*
| Dentifrice | American Dental Association Approved |
| Arm & Hammer Dental Care Baking Soda Tooth Powder | No |
| Platinum Whitening Toothpaste with Fluoride | No |
| Pycopay Tooth Powder | No |
| Sensodyne Gel, Cool Mint | No |
| Sensodyne-SC Toothpaste | Yes |
*Many products with almost identical names made by the same company do contain sodium lauryl sulfate. Mr. Toms contains sodium lauryl sulfate. The ingredients are listed on toothpaste tubes.
CORTICOSTEROIDS
Steroids have been the mainstay of therapy for RAS for many years. Topical steroids, such as fluocinonide or betamethasone, are used to reduce the inflammation associated with the lesions. Topical corticosteroids are available in different strengths and potencies (see Chapter 19). The amount of antiinflammatory action present depends on the strength of the steroid; however, the possibility for adverse reactions associated with the corticosteroids increases with increased strength of the steroid. Creams or gels are more easily applied than ointments (greasy base), but gels, because they contain alcohol, can cause burning. Examples of topical steroids are triamcinolone acetonide, clobetasol, and fluocinonide.
Another base, carboxymethylcellulose paste (Orabase), is a plasticized base that hardens into a plastic-like plaster. Steroids are incorporated into this paste, which is applied after drying the area. Patient opinions differ with respect to this base. Some like its plastic consistency and covering of the lesion, but others dislike the soft, shell-like inflexible lump of base. Orabase is available plain or mixed with either hydrocortisone or triamcinolone acetonide.
In severe cases of RAS, a short course of systemic steroids (40 mg/day) may be indicated.
APHTHASOL
Aphthasol (Aphthasol) is a new drug used topically in treatment of aphthous ulcers. It is applied four times daily and can produce a decrease in the duration of both healing and pain by 0.7 days.
DIPHENHYDRAMINE
DPH alone is now preferred because of its local anesthetic action. Tetracycline suspension mixed with nystatin and DPH has been advocated.
IMMUNOSUPPRESSIVES
As a last resort, immunosuppressive agents, such as azathioprine (Imuran), methotrexate (Rheumatrex), and cyclosporine (Sandimmune), have been used to treat severe aphthous ulcers. Other immunomodulating agents, such as thalidomide and interferon, also have been used. Whether thalidomide is effective in the treatment of aphthous ulcers and suppression of recurrences is controversial. Some studies found a positive effect, whereas others found none. Thalidomide was previously approved for use in Europe for insomnia in pregnant women. It was later found that as little as one tablet, taken on a certain day of gestation, could produce phocomelia (missing arm and/or leg bones). It is currently used in certain South American countries to treat leprosy in men. Not unexpectedly, some thalidomide has been inappropriately transferred to women and teratogenic effects have been produced. The risk of teratogenic effects must be weighed against thalidomide’s potential beneficial effects. The United States has approved thalidomide for use only with very limited distribution.
Tetracycline has been used in the past, but current thinking is that adding tetracycline suspension to mixtures does not add to the therapeutic effect. Chlorhexidine (Peridex) has been used to manage this condition.
Lichen Planus
Lichen planus is a skin condition (see Color Plate 13) that often involves lesions on the oral mucous membranes. The oral lesions are present without the skin lesions in 65% of the cases. Lichen planus can present in three forms: striated, plaquelike, and erosive (contains the atrophic and bullous subtypes). The most characteristic type is hypertrophic lichen planus; this lesion has a white lacelike pattern that intersects to form a reticular pattern.
Symptoms of pain vary between no pain and extreme pain, depending on the presence of ulceration. The etiology of lichen planus is unknown, but current hypotheses include a viral infection, an autoimmune disease, and a hypersensitivity reaction to an unknown agent. The treatment for lichen planus depends on symptoms and includes oral and topical steroids, oral retinoids, and immunosuppressants.
MISCELLANEOUS ORAL CONDITIONS
With geographic tongue, the tongue may have lesions that typically appear to be a map of the world with the lesions appearing to be the continents. Usually, the lesions are ringed with erythema and their centers are white. There are changes in the patterns over time, and they may even disappear. The etiology of geographic tongue is unknown, but the condition may be related to hormonal changes, stress, infection, psoriasis, or autoimmune diseases. Often, the burning becomes severe when eating spicy foods or drinking alcohol. Treatment includes reassurance and avoidance of irritating food and alcohol.
Burning Mouth or Tongue Syndrome
Burning mouth or tongue syndrome has been called glossodynia and glossopyrosis (pyro, burn). With this syndrome, the oral cavity commonly appears normal, but the patient gives a history of experiencing a discomfort described as pain or a burning sensation that increases in severity through the day.
Glossodynia is a painful tongue and is divided into two types: with and without observable alterations on the tongue. It can be caused by many conditions, both local and systemic. Because the tongue is sensitive, small inflammation of fungiform papillae or small trauma from a tooth can be extremely painful. Other visible changes in the tongue are atrophy of the filiform papillae and generalized redness. Burning, stinging, or itching may occur.
The nature of the psychological component in this disease is unclear, but it is known that the presence of chronic disease can lead to depression and anxiety. Patients often are concerned that the cause of their problem may be related to malignancy. Scientific study must be done to determine its cause.
The etiology of burning tongue has not been elucidated, but numerous hypotheses have been proposed, including xerostomia, candidiasis, acid reflux, nutritional deficiency (B12, folate, or iron), immunologic reaction, hormonal changes, allergic reaction, inflammatory process, psychogenic reaction, or an idiopathic reaction. (The variety of hypotheses indicates that the cause of burning tongue has not yet been determined.)
The treatment of burning tongue syndrome depends on the particular etiology the practitioner believes in. Some clinicians treat the patient as they would if the patient had candidiasis. Others test for vitamin deficiencies. Palliative therapy involves using topical DPH to relieve the symptoms. Tricyclic antidepressants, such as amitriptyline, can be used on a trial basis, beginning with a dose of 10 mg at bedtime and slowly increasing the amount until an effective dose is achieved. Amitriptyline is used for two effects. It is thought that depression may play a role in this syndrome, and the amitriptyline may treat the depression. However, this is unlikely because the dose used is not an antidepressant dose and the onset of action is much quicker than the antidepressant effect of amitriptyline. The second mechanism of amitriptyline’s proposed effect is that amitriptyline is acting as an adjunct in the management of chronic pain. Amitriptyline has been shown to be effective in chronic pain. Additional studies are needed to determine whether any psychotropic agents might be effective in treating burning tongue.
INFLAMMATION
Pericoronitis is inflammation of the tissue around the crown of the tooth. This term, most commonly applied to partially erupted third molars, refers to an inflammatory response that is produced when food and bacteria become trapped between the operculum and the tooth. Periodontal pockets can become painful and swell. If the condition is observed early in its course, debridement with saline irrigation and the use of warm saline rinses will rectify the situation. With severe pericoronitis, debridement is still the primary treatment. If the affected tooth is to be extracted, extraction can prevent further episodes of pericoronitis. With erupting third molars, repeated episodes may occur. Analgesics can be used for the discomfort. Infection, usually managed by local treatment, may rapidly spread in debilitated patients and should be aggressively treated with antibiotics.
Postirradiation Caries
Changes in saliva after irradiation therapy and lack of proper plaque control can rapidly accelerate the rate of dental caries. Generalized cervical decay within the first year after radiation therapy can result. Meticulous oral hygiene, reinforced by the hygienist, short duration between subsequent recall appointments, artificial salivas, and self-application of sodium fluoride gel four times daily in a bite guard are recommended.
Root Sensitivity
Sensitivity of exposed root surfaces may be precipitated by heat, cold, and sweet or sour foods. Occlusal trauma may produce irritation to the exposed dentinal tubules; occlusal adjustment is the treatment. Roots exposed by periodontal surgery, extensive root planing, or accumulation of plaque and its byproducts are more difficult to manage. Applications of glycerin with burnishing, sodium fluoride, stannous fluoride, fluoride varnish, and adrenal steroids have been used in the dental office in an attempt to reduce root sensitivity.
Adequate clinical trials for these products are lacking. The patient may use home brushing with concentrated sodium chloride and 0.4% stannous fluoride. Sodium fluoride gel may also be self-applied in a bite guard. Desensitizing toothpastes have helped some patients, but controlled clinical trials with sufficient patient populations are lacking. Current research indicates that root sensitivity due to recession, bleaching, or abrasion may be successfully treated with amorphous calcium phosphate.
Actinic Lip Changes
Long-term exposure of the lip to the sun can cause irreversible tissue changes known as actinic cheilitis. These sun-related changes occur near the vermilion border of the lips and can progress to malignancy. Sunscreen preparations with higher (greater than 15) sun protective factors should be applied before sun exposure and reapplied as needed. If keratotic changes have occurred, treatment is topical 5-fluorouracil (5-FU), an antineoplastic agent that promotes sloughing of the skin (bad layers of cells are sloughed off). A topical steroid (see Chapter 19) may be used to relieve the irritation produced by 5-FU.
Stomatitis
Stomatitis is an inflammation of the mucus lining the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth. Stomatitis is caused by poor oral hygiene, by poorly fitted dentures, from mouth burns from hot food or drinks, or by conditions that affect the entire body such as medications, allergic reactions, radiation therapy, or infections. Treatment is based on its cause and usually includes good oral hygiene. If stomatitis is a result of mouth burns, then it should resolve on its own.
DRUG-INDUCED ORAL SIDE EFFECTS
Drug-induced oral side effects can be produced by a wide variety of drugs. Different kinds of lesions can be produced with the same drug, and the same kind of lesion can be produced by different agents. Some drugs that can cause changes in the oral cavity are listed in Box 13-1. Common oral side effects include xerostomia, drug-induced lichenoid-like reaction, and hypersensitivity reactions.
The most commonly listed oral side effect of drugs is xerostomia. Many drugs have been stated to produce xerostomia, but the effect is variable, depending on the patient and the dose of the drug. An extensive list of xerostomia-producing drugs is available in Appendix E.
Xerostomia
Xerostomia, or dryness of the mouth, may result from a drug (e.g., atropine), a disease (e.g., Sjögren’s syndrome [see Color Plate 14]), age, or radiation. Radiation therapy to the head and neck affects the salivary glands so that the consistency of saliva is altered and its volume is reduced substantially.
Many different groups of drugs produce xerostomia (Appendix E). For example, the anticholinergics and other drugs with anticholinergic side effects are likely to produce xerostomia. With xerostomia, the patient has a dry mouth. Saliva washes the teeth; xerostomia produces an increase in the incidence of caries, especially Class V lesions.
Treatment of xerostomia consists of the following:
• Caries prevention: The use of fluoride trays and gels and other topical agents to counteract the formation of caries should be recommended and demonstrated.
• Artificial saliva: Artificial saliva may be suggested for use in these patients. Table 13-3 lists selected drug groups and examples most likely to produce dry mouth.
TABLE 13-3
AGENTS THAT PRODUCE XEROSTOMIA (DRY MOUTH)
| Drug Group | Examples |
| Anticholinergics* | dicyclomine, hyoscyamine sulfate, trihexyphenidyl |
| Antihypertensives* | methyldopa, clonidine, prazosin |
| Antipsychotics* | haloperidol, thiothixene, phenothiazines, thioridazine |
| Tricyclic antidepressants* | amitriptyline, desipramine |
| Antihistamines | diphenhydramine, chlorpheniramine maleate, hydroxyzine |
| Adrenergic agents | phenylpropanolamine, pseudoephedrine |
| Diuretics | Dyazide, hydrochlorothiazide |
| Benzodiazepines | alprazolam, diazepam, triazolam |
• Home care: The use of fluoride rinses or trays containing fluoride to deliver fluoride should be recommended before extensive caries occur. Drinking water or chewing sugarless gum should be encouraged in place of gum and candies containing sugar.
• Change in medication or reduction in dose: With some drug groups, such as antidepressants, there are drugs that produce significant xerostomia and others that produce much less xerostomia. For example, the antidepressant amitriptyline produces a significant amount of xerostomia, whereas a different antidepressant, sertraline, produces much less. Any medication change must be coordinated with the patient’s physician and would depend on many factors.
• Pilocarpine: Cholinergic agents (P+), such as pilocarpine, can stimulate an increase in saliva in patients with functioning parotid glands. Chapter 4 discusses its dose and adverse effects.
• Cevimeline hydrochloride (Evoxac): Cholinergic agonist that binds to muscarinic receptors and increases the secretion of salivary glands. This drug is approved by the FDA for the treatment of dry mouth in persons with Sjögren’s syndrome. Adverse effects include excessive salivation, lacrimation, urination, and defecation.
Sialorrhea
Certain drugs may produce an increase in saliva termed sialosis, sialism, or sialorrhea. One example is the cholinergic agent pilocarpine.
Hypersensitivity-Type Reactions
Hypersensitivity reactions may be hyperimmune responses triggered by an antigenic component of the drug or its metabolite. Contact stomatitis is more localized when gum and candy are responsible and is more diffuse with toothpaste use. The buccal mucosa and the lateral borders of the tongue are often involved. Even cinnamon-flavored products have been implicated in hypersensitivity reactions. The potential for a hypersensitivity reaction is determined by the particular drug, the frequency of administration, the route of administration (antibiotics administered topically are more likely to produce hypersensitivity reactions than those given parenterally), and the patient’s immune system (immunoglobulin E [IgE]).
Oral Lesions That Resemble Autoimmune-Type Reactions
Many drugs are associated with eruptions that resemble lichen planus. Box 13-2 lists some drugs that have been associated with this type of reaction. The most common drug implicated is hydrochlorothiazide (HCTZ). Others include β-blockers and antimalarials.
Stains
Staining of teeth may occur either as the teeth are formed or in a few cases in adult teeth. The tetracyclines are incorporated into forming teeth and thereby stain the teeth (see Color Plate 15). Today, this adverse reaction is well known and pregnant women or very small children are not given tetracycline. With adults, both intrinsic and extrinsic stains may occur. Minocycline is thought to produce a blue-gray coloration to the bone in adult teeth. Chlorhexidine rinse and liquid iron preparations can also cause extrinsic staining.
Gingival Enlargement
Gingival hyperplasia, now known as gingival enlargement (see Color Plates 16 and 17), has been renamed because hyperplasia is not the sole process that occurs in the gums. Gingival enlargement can occur in relation to several drug groups; the most common three are the following:
• Phenytoin (Dilantin): Chapter 16 discusses phenytoin and gingival enlargement. The rate of occurrence varies with the patient population, but almost half of the patients exhibit this reaction. Occurrence of gingival enlargement in patients taking phenytoin may be dose related. Oral hygiene practices affect its incidence and severity.
• Cyclosporine: Cyclosporine is the antirejection drug used for every patient who has had a kidney transplant and for patients receiving many other transplants. Cyclosporine is associated with gingival enlargement.
• Calcium channel blockers (CCB): CCBs are used for hypertension and congestive heart failure and have been associated with gingival enlargement.
• Others: Other implicated drugs include some anticonvulsants such as carbamazepine (Tegretol) and valproic acid (Depakene).
COMMON AGENTS USED TO TREAT ORAL LESIONS
For many oral lesions, especially those with a component of inflammation or immune response, corticosteroids are used. Depending on the severity of the lesions, the topical corticosteroids would be selected based on their potency. Weak, intermediate, and potent corticosteroids are used in turn until an agent is effective. The proper strength of steroid is the least potent that will ameliorate the lesion (see the steroid topical chart in Chapter 19). Hydrocortisone cream 1% is a low-potency topical steroid available OTC. The 2.5% hydrocortisone cream is available by prescription. Triamcinolone acetonide (TAC) is more potent than hydrocortisone and is in the middle range of potency of the steroids. It is available as 0.025%, 0.1%, and 0.5 %; the first two strengths are classified as moderate, and 0.5% is stronger. Fluocinonide (Lidex) is more potent than TAC and is available as a 0.05% cream or solution. Clobetasol (Temovate), 0.05% cream or solution, is in the most potent group. The latter would be used only if the other agents were ineffective.
If topical corticosteroid therapy is ineffective or if the condition is severe, then systemic corticosteroids may be indicated. When systemic steroids are used, prednisone is the most commonly used. There is little reason to use other agents because all corticosteroids have virtually the same effect. When dosing systemic steroids, the dose begins high (usually between 40 and 60 mg of prednisone per day) and is then tapered, depending on the progress of the lesions. In some cases, chronic systemic corticosteroids are required to control the oral lesion. When systemic steroids are used chronically, their adverse reactions must be managed (i.e., osteoporosis, fluid retention, diabetes, hypertension, and the manifestations of moon face, buffalo hump, and abdominal striae).
Palliative Treatment
Palliative treatment is treatment designed to make the patient more comfortable. Agents that reduce the pain of the oral cavity can be topical and systemic. Topical agents are applied by swishing the liquid around in the mouth. These agents include a local anesthetic agent (viscous lidocaine) (see Chapter 9) and an antihistamine with local anesthetic properties (DPH elixir) (see Chapter 18).
Many combination products have been prescribed, but their benefit over plain DPH elixir is controversial. Mixtures of diphenhydramine, lidocaine, and magnesium-aluminum hydroxide have been advocated. Systemic analgesics can often provide relief from a painful oral lesion. Topical and systemic agents may be used together for an additive effect. One concern with the use of topical local anesthetics is that reduction in the sensations from the throat could lead to choking. This can be minimized by avoiding eating directly after application. If isolated lesions are present, the anesthetic can be painted on the lesion using a cotton-tipped swab.
CLINICAL SKILLS ASSESSMENT
1. Name two ways to reduce alveolar osteitis.
2. Describe three causes of xerostomia and name several drugs that can produce this effect.
3. Explain the management of xerostomia, including preventive measures.
4. State the best way to prevent actinic lip changes.
Please visit http://evolve.elsevier.com/Haveles/pharmacology for review questions and additional practice and reference materials.