Oral Manifestations of Commonly Prescribed Drugs

 

Am Fam Physician. 2020 Nov 15;102(9):613-621.

Author disclosure: No relevant financial affiliations.

Drugs are being prescribed with more frequency and in higher quantities. A serious adverse drug event from prescribed medications constitutes 2.4% to 16.2% of all hospital admissions. Many of the adverse drug events present intraorally or periorally in isolation or as a clinical symptom of a systemic effect. Clinical recognition and treatment of adverse drug events are important to increase patient adherence, manage drug therapy, or detect early signs of potentially serious outcomes. Oral manifestations of commonly prescribed medications include gingival enlargement, oral hyperpigmentation, oral hypersensitivity reaction, medication-related osteonecrosis, xerostomia, and other oral or perioral conditions. To prevent dose-dependent adverse drug reactions, physicians should prescribe medications judiciously using the lowest effective dose with minimal duration. Alternatively, for oral hypersensitivity reactions that are not dose dependent, quick recognition of clinical symptoms associated with time-dependent drug onset can allow for immediate discontinuation of the medication without discontinuation of other medications. Physicians can manage oral adverse drug events in the office through oral hygiene instructions for gingival enlargement, medication discontinuation for oral pigmentation, and prescription of higher fluoride toothpastes for xerostomia.

Drugs are being prescribed with more frequency and in higher quantities per patient, with an estimated prevalence of 59% of the U.S. population taking at least one prescription medication and 15% taking five or more prescription drugs.1 A serious adverse drug event from prescribed medications constitutes 2.4% to 16.2% of all hospital admissions with an estimated treatment cost of $1.6 to $5.6 billion.2 Increased usage of medications leads to increased adverse drug reactions, particularly in vulnerable elderly populations.3 All of the 10 most commonly filled prescription medications4 have adverse effects associated with the orofacial complex, including hypersensitivity type reactions, xerostomia, paresthesia, and dysgeusia5  (Table 135). Other adverse reactions, such as vomiting, can cause secondary oral symptoms of tooth erosion, oral mucosal erythema or edema, and subsequent increase in dental caries. Adverse effects can present as severe systemic disease, for example Stevens-Johnson syndrome. Close attention is warranted even in seemingly mild adverse effects, such as xerostomia, because these might decrease patient compliance with prescribed drug therapies or have negative effects on quality of life.6  A high suspicion for medication adverse effects as a source of oral complaints can thus lead to appropriate interventions, such as stopping the causative medication, finding appropriate substitutes, and identifying serious reactions in a timely manner. The main categories of oral or perioral manifestations attributable to prescribed medications are gingival enlargement, oral hyperpigmentation, oral hypersensitivity reaction, osteonecrosis, xerostomia, and other oral or perioral conditions such as angioedema and chemical burns (Table 2).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Minimizing intraoral plaque can reduce the incidence of medication-induced gingival enlargement.7,24,25,30,31

B

Systematic reviews of lower quality clinical trials and expert opinion

If oral hyperpigmentation does not resolve with discontinuation of the offending medication, surgical laser therapy is a treatment option.38

B

Based on a systematic review

Before starting antiresorptive therapy, patients should be counseled on maintaining good oral hygiene, routine dental visits, and tobacco cessation.52

C

Based on systematic review of clinical practice guidelines

Xerostomia is typically managed with conservative therapy and judicious use of medications; oral pilocarpine is effective in patients with persistent symptoms.6163

B

Based on a systematic review and two cohort studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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AARON GLICK, DDS, is a clinical assistant professor in the Department of General Practice and Dental Public Health at the University of Texas School of Dentistry at Houston....

VINU SISTA, DDS, is an assistant clinical professor in the Department of General Practice and Dental Public Health at the University of Texas School of Dentistry at Houston.

CLEVERICK JOHNSON, DDS, MS, is director of the Urgent Care Clinic and a professor in the Department of General Practice and Dental Public Health at the University of Texas School of Dentistry at Houston.

Address correspondence to Aaron Glick, DDS, University of Texas Dental Branch at Houston, 7500 Cambridge St., SOD 5411, Houston, TX 77054 (email: aaron.r.glick@uth.tmc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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