Rabu, 27 Maret 2013

Oral manifestations of vitamin deficiencies

Oral manifestations of nutritional deficiencies include nonspecific signs and symptoms that involve the mucous membrane, the teeth and the periodontal tissues, salivary glands and peri-oral skin. Owing to the rapid rate of cell turn over in the mucous membrane(3-7 days), compared with the skin (up to 28 days) the oral cavity may exhibit early signs and symptoms of systemic disease or nutritional deficiencies. Thus dentist may be the first person to detect nutritional deficiencies of an individual and should be able to differentiate it from local causes.

Vitamins are organic components in food that are needed in very small amounts for growth and for maintaining good health.

There are mainly two types of vitamins.

·     Fat soluble- which can be stored with other lipids in fatty tissues or in the liver and can build up to toxic levels. Require bile for absorption
Ex. vitamin A (Beta Carotene), vitamin D, vitamin E, vitamin K (Menadione).

·   Water soluble - absorbed directly in the  blood stream, travel freely and  are not stored. Excreted  in the urine.
Ex. folate (folic acid), biotin, Vitamin B-1 (Thiamin), Vitamin B-2 (riboflavin), Vitamin B-3 (Niacinamide), vitamin B-5, vitamin B6 (Pyridoxine) vitamin B12 (Cobalamin), pantothenic acid, and vitamin C (ascorbic acid)

Vitamins are required in the diet in only tiny amounts, in contrast to the energy components of the diet such as sugars, starches, fats, and oils. Not all the vitamins affect the oral mucosa. Water soluble vitamins have oral mucosal involvement include vitamins B-2, B-3, B-6, B-12, folic acid and vitamin C whereas vitamins A, D, E fat soluble vitamins affect oral mucosa.

Vitamin A
Vitamin A (retinol) is part of the family of retinoids which is present in food and the body as esters combined with long-chain fatty acids.

Source- liver, milk , butter, cheese, egg yolks and fish oils. Retinol or carotene added margarineBeta-carotene -green vegetables, carrots and other yellow and red fruits.
Retinol is stored in the liver and is transported in plasma bound to an α-globulin, retinol-binding protein (RBP).

  • Vision- Retinaldehyde in its cis form is found in the opsin proteins in the rods (rhodopsin) and cones (iodopsin) of the retina. Light causes retinaldehyde to change to its trans isomer, and this leads to changes in membrane potentials that are transmitted to the brain.
  • Retinol and retinoic acid are involved in the control of cell proliferation and differentiation.
  • Retinyl phosphate is a cofactor in the synthesis of most glycoproteins containing mannose.
reference nutrient intake (RNI)- 700 μg
lower reference nutrient intake (LRNI)- 300 μg
keratosis of labial mucosa
Oral manifestations-
Inadequate cell differentiation-impaired healing & tissue regeneration; desquamation of oral mucosa; keratosis;  increased risk of candidiasis; gingival hypertrophy & inflammation; leukoplakia; decreased taste sensitivity; xerostomia; disturbed or arrested enamel development; irregular tubular dentine formation and increased caries risk.

 Other - Xerophthalmia, night blindness, keratomalacia, follicular hyperkeratosis.

·        Clinical diagnosis where nutritional deficiencies common
·        Blood vit.A level
·        Response to replacement therapy
·         retinol palmitate 30 mg orally for two days
·         treat associated malnutrition and super added infection
Adverse effects-
  • High intakes of vitamin A-Chronic ingestion of retinol can cause liver and bone damage, hair loss, double vision, vomiting, headaches and other abnormalities. Single doses of 300 mg in adults or 100 mg in children can be harmful.
  •  Retinol is teratogenic-The incidence of birth defects in infants is high with vitamin A

Vitamin D
active form 1,25-dihydroxycholecalciferol (1,25-(OH)2D3).
The primary source of vitamin D in humans is photoactivation (in the skin) of 7-dehydrocholesterol to cholecalciferol, which is then converted in the liver to 25-hydroxycholecalciferol (25-(OH)D3) and further converted by renal 1α-hydroxylase to the active metabolite.
Sources-Sunlight,reference nutrient intake (RNI)- No dietary intake required
lower reference nutrient intake (LRNI)- 10 μg (living indoors)
·   Maintain serum calcium level within normal range
enamel hypoplasia
oral manifestations-incomplete mineralisation of teeth & alveolar bone excess- Pulp calcification; enamel hypoplasia.
General- Causes hypocalcaemia, which leads to excess parathyroid hormone secretion, causing bone demineralization. Which leads to,
vitamin D dependent Rickets
·         Rickets
·         Osteomalacia

·         Serum calcium and phosphate level-low
·         Plasma alkaline phosptasw level-high
·         1,25-dihydroxycholecalciferol levels( ≥20 ng/mL considered normal)
·         X ray wrist joint in rickets
·         Advice on balanced diet
·         Correction of predisposing factors
·         Daily administration of Vit.D3
Vitamin E
     Divided in to mainly two compounds.
·         Tocopherols-commonest is α-tocopherol
·         Tocotrienoles
Sources- Vegetables and seed oils, including soya bean, saffron, sunflower, cereals and nuts
reference nutrient intake (RNI)- 10 mg /day. But depend on amount of poly unsaturated fat intake.Function-
·         Act as a antioxidant
·         affect cell proliferation and growth
no oral manifestations apperant.
 ·       severe neurological deficits (gross ataxia)
 ·       aging effects on skin, hair, nails etc.
·  plasma α-tocopherol level corrected for the level of plasma lipids ( value as per milligram of plasma lipid or cholesterol)
·  vit E injection
·  vit E capsules
Vitamin K
Vitamin K is found as phylloquinone (vitamin K1) and menaquinone (vitamin K2)
Source- K1- green leafy vegetables, dairy products, rape seed and soya bean oils
               K2-Intestinal bacteria synthesizes in the terminal ileum and colon.
reference nutrient intake (RNI)- 1 μg/kg
·     A cofactor for the production of blood clotting factors.
for the post-translational carboxylation of specific protein-bound glutamate residues in γ-carboxyglutamate (Gla). Gla residues bind calcium ions to phospholipid templates, and this action on factors II, VII, IX and X, and on proteins C and S, is necessary for coagulation

·     for proteins necessary in the formation of bone.
Bone osteoblasts contain three vitamin K-dependent proteins, osteocalcin, matrix Gla protein and protein S, which have a role in bone matrix formation. Osteocalcin contains three Gla residues which bind tightly to the hydroxyapatite matrix depending on the degree of carboxylation; this leads to bone mineralization.

oral manifestations-Increased risk of bleeding & candidiasis
other-·   increase in the prothrombin time and haemorrhage
o        Cholestatic jaundice
o        vitamin K antagonists
o        Oral anticoagulants- ex: warfarin
o        Certain anti bacterial drugs
Thiamin (vitamin B1)
consists of pyrimidine and thiazole rings. The alcohol side-chain is esterified with one, two or three phosphates.
Source-cereals, grains, beans, nuts, pork and duck
reference nutrient intake (RNI)- 0.4 mg per 1000 kcal of energy requirement
lower reference nutrient intake (LRNI)- 0.23 mg per 1000 kcal

Thiamin diphosphate, often called thiamin pyrophosphate (TPP), is a cofactor in carbohydrate metabolism.
Thiamin deficiency-
no oral manifestations.·  beriberi(Dry beriberi, Wet beriberi)
· Wernicke-Korsakoff syndrome(dementia, ataxia, varying ophthalmoplegia and nystagmus)
  • in beriberi, where the only food consumed is polished rice
  • in chronic alcohol-dependent patients who are consuming virtually no food at all
  • rarely in starved patients
·         clinical diagnosis in endemic areas
·         response to treatment with thiamine
·         circulating thiamin concentration
·         transketolase activity in red cells using fresh heparinized blood.
·   In beri beri- Thiamine 50 mg i.m. is given for 3 days, followed by 25 mg of thiamine daily by mouth.
·  In Wernicke-Korsakoff syndrome- Urgent treatment with thiamine 250 mg i.m. or i.v. twice daily is given for 3 days combined with other B-complex vitamins

Riboflavin(Vitamin B2)
Riboflavin is a flavoprotein.
Sources- dairy products, fat and leafy vegetables
reference nutrient intake (RNI)- 1.3 mg
lower reference nutrient intake (LRNI)- 0.8 mg

·         cofactor for many oxidative reactions in the cell.
oral manifestations-angular cheilosis,atrophy of filliform papillae,enlarged fungiform papillae,shiny red lips,magenta tongue,sore tongue

magenta coloured tongue

atrophy of filliform papillae

general-seborrhoeic dermatitis, particularly involving the face (around the nose) and the scrotum or vulva.
·         In endemic areas mainly a clinical diagnosis
·         Riboflavin 5 mg daily  usually given as the vitamin B complex

Niacin (vitamin B-3)

Exist in two chemical forms, nicotinic acid and nicotinamide.
Sources- plants, meat (particularly offal) and fish.
Synthesize in body using tryptophan. Eggs and cheese contain tryptophan
reference nutrient intake (RNI)- 6.6 mg per 1000 kcal
lower reference nutrient intake (LRNI)- 4.4 mg per 1000 kcal
· act as hydrogen acceptors in many oxidative reactions, and in their reduced forms (NADH and NADPH) act as hydrogen donors in reductive reactions.
oral manifestations-Angular cheilosis; mucositis; stomatitis; oral pain; ulceration; ulcerative gingivitis; denuded tongue; glossitis; glossodynia; tip of tongue is red & swollen; dorsum is dry & smooth.


atrophic glossitis in pellagra
 general-Pellagra,dermatitis, diarrhoea and dementiaDiagnosis-
·  In endemic areas mainly a clinical diagnosis
·   Nicotinamide (approximately 300 mg daily by mouth) with a maintenance dose of 50 mg daily is given with dramatic improvement in the skin and diarrhoea.mostly vitamin B complex is given, as other deficiencies are often present.
·   increase in the protein content of the diet.
Vitamin B6
exists as pyridoxine, pyridoxal and pyridoxamine.
Sources- plant and animal foodstuffs.
reference nutrient intake (RNI)- 15 μg per g of dietary protein
lower reference nutrient intake (LRNI)- 11 μg per g of dietary protein

·  Pyridoxal phosphate is a cofactor in the metabolism of many amino acids.
oral manifestations-Angular cheilosis,sore or burning mouth,glossitis,glossodynia.
Some drugs (e.g. isoniazid, hydralazine and penicillamine) interact with pyridoxal phosphate, producing B6 deficiency.

Vitamin B complex or Vitamin B6
Vitamin B12
Cobalamins consist of a planar group with a central cobalt atom (corrin ring) and a
right-angles . Vitamin B12 was first crystallized as cyanocobalamin, but the main natural cobalamins have deoxyadenosyl-, methyl- and hydroxocobalamin groups attached to the cobalt atom.
Sources- meat, fish, eggs and milk.Not dystroyed by cooking.

reference nutrient intake (RNI)-  1.5 μg
lower reference nutrient intake (LRNI)- 1.0 μg

·  Co factor in DNA synthesis-methylation of homocysteine to methionine with the demethylation of methyl THF polyglutamate to THF. THF is a substrate for folate polyglutamate synthesis.
Absorption and transport-
Vitamin B12 is liberated from protein complexes in food by gastric enzymes and then binds to a vitamin B12-binding protein ('R' binder) related to plasma transcobalamin I (TCI), derived from saliva. Vitamin B12 bound to 'R' binder is released by pancreatic enzymes and becomes bound to intrinsic factor.
Intrinstic factor carries it to specific receptors on the surface of the mucosa of the ileum. Vitamin B12 enters the ileal cells and intrinsic factor remains in the lumen. Vitamin B12 is transported from the enterocytes to the bone marrow and other tissues by the glycoprotein transcobalamin II (TCII).
aphthous ulceration
oral manifestations-Angular cheilosis, mucositis, stomatitis, sore or burning mouth, haemorrhage gingiva, halitosis, epithelial dysplasia of oral mucosa, oral parethesia, detachment of periodontal fibres, loss or distortion of taste,  ulceration, ulcerative gingivitis, denuded tongue,glossitis, glossodynia, tongue is "beefy"red,  smooth & glossy, delayed wound healing, xerostomia, bone loss, apthous ulcers.

general-     Megaloblastic anemia and Pancytopenia
            Sub acute combined degeneration of spinal cord

o      Low dietary intake
o      Vegans
o Impaired absorption-stomach(Pernicious anaemia, Gastrectomy,)Small bowel(Ileal disease or resection, Bacterial overgrowth)

o       Congenital transcobalamin II deficiency
o       Nitrous oxide (inactivates B12)
o       Abnormal utilization
·        FBC,Blood picture(Macrocytic anemia)
Bone marrow shows the typical features of megaloblastic erythropoiesis
·        Serum vitamin B12 is  below 160 ng/L
·        Serum folate level is normal or high, and the red cell folate is normal or reduced
·        Vitamin B12 absorption tests- Schilling test
·      Hydroxocobalamin 1000 μg can be given intramuscularly to a total of 5-6 mg over the course of 3 weeks; 1000 μg is then necessary every 3 months.

Folic acid present in nature as polyglutamates.
Sources- green vegetables such as spinach and broccoli and in food of animal origin liver and kidney.    Cooking causes a loss of 60-90% of the folate.reference nutrient intake (RNI)-  200 μg
lower reference nutrient intake (LRNI)- 100 μg
·   act as coenzymes in the transfer of single carbon units in amino acid metabolism and DNA synthesis.
oral manifestations-Angular cheilosis; mucositis; stomatitis; sore or burning mouth; increased risk of candidiasis; inflamed gingiva; glossitis oral pain; ulceration; ulcerative gingivitis; denuded tongue; glossitis; glossodynia; tip or borders of tongue red & swollen; slick bald pale; apthous ulcers.
general-   Megaloblastic anemia and Pancytopenia
o Nutritional-poor intake(Starvation,alcohol intake,GI diseases )Antifolate drugs(  Anticonvulsants, Methotrexate, Pyrimethamine) Malabsorption

o Excess utilization- Physiological(Pregnancy, Lactation)Pathological(haemolysis, Malignant, Inflammatory diseases)
·         FBC and Blood picture-Macrocytic Anemia,Pancytopenia
·         Serum and red cell folate level
·         5 mg of folic acid daily
Vitamin C
Ascorbic acid is a simple sugar.
Sources- present in all fresh fruit and vegetables.
easily leached out of vegetables when they are placed in water and it is also oxidized to           dehydro-ascorbic acid during cooking or exposure to copper or alkalis.
reference nutrient intake (RNI)- 40 mg
lower reference nutrient intake (LRNI)- 10 mg
·        powerful reducing agent, main role is to control the redox potential within cells.
·       hydroxylation of proline to hydroxyproline, which is necessary for the formation of collagen
·        in high dosage (1-2 g daily) prevention of the common cold
·        preventive effect in atherosclerosis and cancer
inflamed bleeding gingivae
oral manifestations-Scurvy-red swollen gingivae; gingival friability; periodontal destruction ; sore burning mouth; soft tissue ulceration; increased risk of candidiasis; malformed teeth (inadequate dentine).

general-scurvy- Keratosis of hair follicles with 'corkscrew' hair, Perifollicular haemorrhages, Swollen, spongy gums with bleeding and superadded infection, loosening of teeth,
·         and hemorrhages, Anaemia, Failure of wound healing
·         Hypochromic anemia
·         Low Plasma ascorbic acid
·         Low leucocyte ascorbate
·         Initially  250 mg of ascorbic acid daily  and later 40 mg daily.
·         encourage to eat fresh fruit and vegetables.

Adverse Drug Reactions in the Oro facial Region

In this era an ever-expanding list of medications is linked to pathological reactions in the oral and perioral region. These adverse drug reactions have a broad spectrum of clinical manifestations that can mimic those of other disease states, including both local and systemic conditions. The clinical manifestations of oral reactions to the more commonly prescribed drugs have been discussed in this article.

Well known clinical patterns of adverse drug reactions of the oral cavity include xerostomia, swelling and gingival enlargement , nonspecific ulceration, vesiculobullous or ulcerative mucositis that mimics other immunological disorders , oro-facial pigmentation. A patient who complains of any of these signs and symptoms should be thoroughly questioned regarding medication. If an offending drug can be identified, its alteration or elimination, in consultation with the prescribing clinician, will often result in resolution of the clinical problem.

Drug induced xerostomia

Xerostomia, or dry mouth, is the most common adverse drug-related effect in the oral cavity. To date, xerostomia has been associated with more than 500 medications. The synergistic effects of medications have been recognized and are increasingly common in elderly patients taking multiple medications (polypharmacy). General drug classes that are strongly associated with xerostomia include antidepressants and antipsychotics, antihypertensives, antihistamines, and anticholinergics.

Root caries formed in a patient with drug induced xerostomia

Importantly, patients with xerostomia are also at increased risk for oral candidiasis, a superficial infection that may cause mucosal sensitivity or discomfort, as well as tooth decay that usually affects the cervical (gumline) and root surfaces. Several different mechanisms account for drug-related dry mouth, but an anticholinergic action underlies many: The M3-muscarinic receptors (M3R) mediate parasympathetic cholinergic neurotransmission to salivary (and lacrimal) glands, but other receptors may also be involved.


Early antidepressant medications such as tricyclic antidepressants (TCAs) unfortunately also blocked histaminic, cholinergic, and alpha1-adrenergic receptor sites, causing dry mouth. Newer antidepressants are essentially serotonin (5-hydroxytryptamine: 5HT) agonists, or block re-uptake of noradrenaline (norepinephrine) and/or serotonin. Members of the newer generation of antidepressants—including the selective serotonin re-uptake inhibitors (SSRIs) and multiple-receptor antidepressants (such as venlafaxine, mirtazapine, bupropion, trazodone, and nefazodone)—target one or more specific brain receptor sites without, in most cases, activating unwanted sites such as histamine and acetylcholine. The SSRI produce no significant changes in salivation, but dry mouth may still be seen (e.g., fluoxetine).


Long-term drug treatment of schizophrenia with conventional phenothiazine antipsychotics such as fluphenazine is commonly associated with dry mouth. However, newly developed antipsychotic drugs with more potent and selective antagonistic activity against the dopamine D(2) receptor may not necessarily be associated with a lower incidence of dry mouth. Olanzapine is an atypical antipsychotic which appears to produce dry mouth.


The therapeutic effects of most of the older antihistamines were associated with sedating effects on the central nervous system (CNS) and antimuscarinic effects including dry mouth. Non-sedating antihistamines—most of which are histamine H1 receptor antagonists, such as acrivastine, astemizole, cetirizine, ebastine, fexofenadine, loratadine, mizolastine, and terfenadine, however—are not entirely free from ADRs, though there may be less dry mouth.


The ganglion blockers and particularly the beta-blockers (beta-adrenoceptor antagonists) may cause dry mouth, thought to be associated with activation of CNS and salivary gland alpha 2-adrenergic receptors. Such antihypertensive drugs, or sympatholytics (reserpine, methyldopa, and clonidine), are now little used because of such prominent adverse drug reactions such as dry mouth.  Newer centrally acting antihypertensives, with selective agonist effects on the imidazoline I1 brainstem-receptors in the rostral ventromedulla (RVLM), appear to modulate sympathetic activity and blood pressure without affecting salivary flow: Moxonidine and rilmenidine are examples of this new class.  ACE inhibitors, which block the ACE enzyme in the renin-angiotensin-aldosterone system, known to produce dry mouth.

Unfortunately, these associations are confounded by the fact that xerostomia is a subjective complaint, and some patients who report oral dryness may have apparently normal salivary gland function. Other patients whose mouths appear to be clinically dry may have no complaints. In addition, a certain amount of acinar atrophy and decreased glandular secretions are considered a normal part of the aging process. Also habits such as smoking, alcohol consumption, and even long-term use of caffeinated drinks may contribute to oral dryness or the perception of dryness. Underlying systemic diseases such as in non-insulin-dependent diabetes, saliva secretion is more affected by xerogenic drugs and autonomic nervous dysfunction than in non-diabetic controls Furthermore, the possibility of an underlying autoimmune etiology (eg, Sjögren syndrome) should also be considered in xerostomic patients. The cause for which the drug is being taken may also be important. For example, patients with anxiety or depressive conditions may complain of dry mouth even in the absence of drug therapy or evidence of reduced salivary flow. It is thus important to recognize that some patients complaining of a drug-related dry mouth have no evidence of a reduced salivary flow or a salivary disorder, and there may then be a psychogenic reason for the complaint.
Thus clinical tests to measure salivary flow (at rest and under stimulation) should be used cautiously in assessing a patient with suspected drug-induced xerostomia.


Drug related swellings


Drug-related gingival enlargement

Gingival enlargement is a well-described oral side-effect of drug therapy. The drugs most commonly implicated in causing this enlargement are phenytoin, ciclosporin and the calcium-channel-blockers, nifedipine, diltiazem, verapamil and amlodipine. Patients receiving therapy with both ciclosporin and calcium-channel-blockers (e.g., post-cardiac or -renal allograft recipients) may be sometimes, but not always, particularly liable to drug-induced gingival enlargement.

phenytoin induced gingival hyperplasia

In general, the gingival enlargement develops within a few months of the commencement of drug therapy, is usually generalized, is only partly associated with poor oral hygiene and local plaque accumulation, and responds variably to improved plaque control and/or withdrawal or reduction of drug therapy. Other drugs that have been occasionally reported to cause gingival enlargement include erythromycin, sodium valproate, phenobarbitone and vigabatrin.

Drug-related lip and mucosal swellings

Drug-induced mucosal swelling predominantly affects the lips and tongue although rare isolated swelling of the uvula [Quinke’s disease] can occur and is typically due to type I hypersensitivity reactions. Among the most common offending agents are ACE inhibitors, penicillin and penicillin derivatives, cephalosporins, barbiturates, aspirin, local anesthetic agents, and other NSAIDs. Affected mucosa typically appears edematous and erythematous within minutes or hours after exposure to the offending drug giving rise to angio-edema. Hypersensitivity to latex is an increasing problem in oral health care and may cause rapid-onset angio-edema in susceptible patients.

Drug induced Angioedema
Non-allergic oral swelling can also arise in response to angiotensin-converting enzyme (ACE) inhibitor therapy. This adverse effect occurs in patients, typically in the early weeks of therapy, although it may occur within a few hours of commencement of treatment, or after long-term therapy. The swelling usually affects the lips, although it can be localized to the tongue, and is occasionally fatal. African-Americans may be at particular risk. The tissue swelling associated with ACE inhibitor therapy may be due to a rise in levels of bradykinins and/or altered levels or function of C1 esterase inhibitor. Plasmacytosis due to ‘tartar control’ toothpastes gives rise to localized enlargements of the gingivae, tongue, and other oral mucosa.

Drug related salivary gland swelling

Some drugs have been related to salivary gland swelling. Painless, usually bilateral, salivary gland enlargement (resembling sialosis) may be an occasional side-effect of phenylbutazone, oxyphenbutazone or chlorhexidine. The bilateral sialadenitis observed in one adult following naproxen therapy was thought to be allergic in origin, since the affected patient also had a cutaneous rash. A similar mechanism has been proposed to underlie the salivary gland enlargement caused by intravenous radiological contrast media. Clozapine, a novel antipsychotic agent, may cause transient salivary gland swelling as well as sialorrhea.

Drug induced parotid swelling

Non specific ulceration and oral mucositis


Drug-related oral burns

Epithelial necrosis and ulceration may result from direct application of over-the-counter medications such as aspirin, hydrogen peroxide, potassium tablets, and phenol-containing compounds to the mucosa. Aspirin is often used by patients seeking relief from dental pain.

Aspirin burn

Sodium lauryl sulfate, present in some oral health care products, particularly dentifrices, may cause mucosal irritation or ulceration. The affected mucosa appears whitish and corrugated, with erosion and ulceration of the more severely damaged areas. The associated discomfort can be severe enough to require treatment with a major analgesic and/or a local anesthetic or even discontinuation of the chemotherapeutic agent.

Drug-related aphthous-like ulceration
A number of drugs are implicated in the development of nonspecific ulceration and oral mucositis, and the lesions are often associated with an equally nonspecific histologic appearance at biopsy.

Nicorandil  induced oral ulceration

These include barbiturates, beta-blockers, dapsone, NSAIDs, phenazone derivatives, thiazide derivatives, phenolphthalein, sulfonamides, and tetracyclines. Ulceration of the oral mucosa is a common adverse effect of a wide variety of antineoplastic agents, including methotrexate, 5-fluorouracil, doxorubicin, and melphalan

Fixed drug eruptions

Fixed drug eruptions (contact stomatitis or stomatitis venenata) comprise repeated ulceration
at the same site in response to a particular drug and may be caused by anesthetics, antibiotics, antiseptics, barbiturates, chewing gum, cosmetics, dental materials, dentifrices, mouthwashes, phenacetin, sulphonamides, or tetracyclines. The lesions may be localized to the mouth or can be associated with lesions at other mucocutaneous sites, and manifest as ulceration, bullae, erythematous patches, or superficial erosions.

Fixed drug eruption on the lip

Fixed drug eruption on skin

Initially, the lesions are solitary, but with repeated drug exposure, they may become multiple. these reactions normally resolve with hyperpigmentation and may recur at the same site with reexposure to the drug. Repeated exposure to the offending drug may cause new lesions to develop in addition to "lighting up" the older hyperpigmented lesions. A wide range of drugs may cause fixed drug eruption, particularly paracetamol, barbiturates, phenacetin, pyrazolone derivatives, sulphonamides, and tetracyclines, as may agents such as cinnamon.

Drug-related mucositis

Cytotoxic drugs are very commonly associated with mucositis and ulceration, which arises consistently with many chemotherapy regimens,particularly those involving methotrexate, 5-fluorouracil, doxorubicine, melphelan, mercaptopurine, or bleomycin . Such reactions can be so severe as to be treatment-limiting on occasion. Widespread sloughing and ulceration arise within days of commencement of therapy, the associated pain often requiring opioid therapy and/or alteration or cessation of chemotherapy. The ulceration may be a portal of entry for infection and hence a potential cause of septicemia. Drugs such as phenylbutazone that can cause agranulocytosis may also induce oral ulceration.

Immunosuppressive agents may also cause ulceration. Ulcers in iatrogenically immunocompromised individuals may have a herpesvirus etiology, or occasionally other infective causes. Opportunistic infection secondary to cytotoxic chemotherapy may cause oral ulceration. In particular, herpes simplex virus 1, varicella zoster, and cytomegalovirus give rise to oral ulceration, while, less commonly, ulceration may be due to Gram-negative bacterial infections (e.g., pseudomonas, klebsiella, Escherichia coli, enterobacter, or proteus) or to exogenous bacteria such as tuberculosis, or to fungi such as mucormycosis or even candidosis.

vesiculobullous or ulcerative mucositis that mimics other immunological disorders

Oral drug reactions that bear striking clinical, histopathologic, and even immunopathologic resemblance to idiopathic lichen planus, erythema multiforme (EM), pemphigoid, pemphigus, and lupus erythematosus (LE) are well recognized, and the list of reactions in each category is constantly expanding. Clinically, any oral site can be affected; however, the posterior buccal mucosa (cheeks), the lateral borders of the tongue, and the alveolar mucosa are most commonly involved. Lesions may be isolated, although bilaterally symmetric involvement is not uncommon.

Oral lichenoid reactions

Initially described in association with antimalarial medications, lichen planus–like or lichenoid drug reactions have subsequently been reported in association with many other agents. Both papuloreticular and erosive manifestations may be observed; the latter is characterized by shallow irregular ulcerations or erosions with a peripheral border of fine keratotic striae that often appear to radiate from the center of the lesion. Although drug-induced lichenoid reactions tend to be erosive and unilateral compared with the typical bilateral presentation in idiopathic lichen planus. Currently, NSAIDs and ACE inhibitors appear to be among the most frequently cited offenders.  Interestingly, agents used in the treatment of lichen planus (eg, hydroxychloroquine, dapsone, levamisole) have themselves led to adverse lichenoid eruptions. Lichenoid reactions also may follow the use of HIV protease inhibitors antihypertensive agents, antimalarials, phenothiazines, sulphonamides, tetracyclines, thiazide diuretics, and many others. The exact pathogenic mechanism by which drugs may cause LP-like disease are not known. However, in LP, quite different immunological mechanisms are involved. Histopathological features not significant from idiopathic lichen planus. Thus  the most reliable means to diagnose lichenoid reactions is if the reaction remits with drug withdrawal and returns on rechallenge, but frequently this is not possible because of the need to ensure patient safety.

Oral lichenoid reaction

Dental restorative materials may also be associated with lichenoid lesions. Most patients with OLP have no evidence of any association with dental restorative materials. However, contact with or proximity to restorations involving amalgams or other materials causes some lichenoid reactions that is, lesions that clinically and histologically resemble LP closely, but have an identifiable etiology. These reactions are presumably due to allergic or toxic reactions to compounds released or generated, the Koebner phenomenon, or possibly due to plaque accumulated on the surfaces of the restorations. Some of these oral lesions may improve after substitution of the amalgam by other materials. Composite restorations have also been implicated in oral lichenoid reactions and so the wholesale replacement of amalgams as a possible treatment is not necessarily warranted.

Erythema multiforme (EM)  like reactions

As with idiopathic or virally induced cases (the latter often due to the herpes simplex virus), the disease has a rapid onset with a variable expression that can range from lesions limited to the oral mucosa to widespread mucocutaneous involvement. Drug-induced EM is frequently linked to agents such as sulfonamides, sulfonylureas, and barbiturates, among others. Oral lesions start as erythematous macules or patches that lead to short-lived vesicles or bullae, followed by ragged and shallow ulcerations that may become extensive. Hemorrhagic ulceration and crusting of the labial vermilion zone is common. Any intraoral site can be involved, but the attached gingival and palatal tissues are often relatively spared. Lesional discomfort can lead to decreased fluid intake and dehydration.

Drug induced Erythema multiforme on lips

A variety of lesions, including classic target or bull's eye lesions, can affect the skin.

Target lesions on skin

More severe forms of disease include EM major (Stevens-Johnson syndrome) and toxic epidermal necrolysis (TEN, Lyell syndrome). In addition to the oral and skin lesions, conjunctivitis of the ocular mucosa and urethritis of the genital mucosa are typical findings in patients with EM major. Over three-quarters of EM major cases and virtually all cases of TEN represent adverse drug reactions. In TEN, widespread mucocutaneous epidermolysis results in diffuse bullae formation and subsequent denudation that affects significant proportions of the skin and mucosal surfaces. Severe dehydration, electrolyte imbalances, and secondary infections are potentially life-threatening sequelae, and even with aggressive therapy the mortality rate is greater than 30%.


Pemphigoid like reactions

Pemphigoid like reactions can be limited to the oral mucosa, or they can affect other mucosal or cutaneous sites. Clinically, lesions appear as relatively sturdy vesicles or bullae that break down into shallow ulcerations. Generalized or multifocal involvement of the gingival tissues may be observed, with marked erythema and erosion of the superficial gingiva, a pattern that has been called desquamative gingivitis. Thiol-containing drugs and sulfonamide derivatives are among the most commonly involved medications, as are the therapeutic classes of NSAIDs, cardiovascular agents, antimicrobials, and antirheumatics .
celecoxib induced vesiculobullous lesion

Circulating autoantibodies to basement membrane components may or may not be detectable. The relatively young age of the patients at onset (the disease affects those younger than 70 y) may help distinguish this disease from idiopathic bullous pemphigoid or idiopathic cicatricial pemphigoid, because these latter conditions typically appear in persons aged 60-80 years. In addition, oral involvement may be more common in drug-induced bullous pemphigoid than in the idiopathic counterpart.

Pemphigus like reactions

Pemphigus like reactions can have features of either pemphigus vulgaris or pemphigus foliaceous, although pemphigus foliaceous is uncommon in the oral cavity.  Traditionally, drugs that are capable of inducing pemphigus are divided into two main groups according to their chemical structure. Drugs containing a sulfhydryl radical (thiol drugs or SH drugs) and non-thiol or other drugs, the latter often sharing an active amide group in their molecules. Thiol-containing drugs are the most common cause of pemphigus like reactions. Pemphigus vulgaris may occasionally be associated with drugs with active thiol groups in the molecule. Drugs implicated include penicillamine, phenol drugs, rifampicin, diclofenac, and, rarely, captopril, other ACE-inhibitors, and other drugs. In drug-induced pemphigus vulgaris, the relatively fragile vesicles are rarely observed at clinical examination, and most cases are characterized by irregular ulcerations with ragged borders that may coalesce to involve large areas of the mucosa. Patients may have circulating autoantibodies to the desmosomal components.

Drug-related Lupoid Reactions

Systemic lupus erythematosus (SLE) may be induced by a wide variety of different drugs. Indeed, over 70 agents have been implicated in causing drug-induced lupus. The most commonly implicated agents of drug-induced SLE are procainamide and hydralazine, although drugs less commonly associated include chlorpromazine, isoniazid, methyldopa, penicillamine, and quinine, as well as whole groups of drugs such as anticonvulsants, beta-blockers, sulphonamides, and others.

Drug induced lupoid reaction in oral mucosa

The possible pathogenesis of drug-related SLE may have an immunogenetic basis, and affected patients have some of the immunological features of classic SLE. Clinically, the oral lesions of drug-induced LE may simulate those of erosive lichen planus, with irregular areas of erythema or ulceration bordered by radiating keratotic striae. These lesions may affect the palate, buccal mucosa, and gingival or alveolar tissues. The rarity of lichen planus on the hard palate may be helpful in differentiating it from drug-induced LE.

Drug related mucosal pigmentation

Drug-related superficial transient discoloration

Superficial transient discoloration of the dorsum of the tongue and other soft tissues and teeth may be of various colors, typically yellowish or brown, and may be caused by some foods and beverages (such as coffee and tea), some habits (such as tobacco, betel, and crack cocaine use), and some drugs (such as iron salts, bismuth, chlorhexidine, or antibiotics), especially if these also induce xerostomia (such as psychotropic agents). When such discoloration noticeably affects the posterior dorsum of the tongue, and the filiform papillae are excessively long and stained dark brown or black, the term ‘black hairy tongue’ is used, but this is less common than other superficial discolorations.
Stomatitis has been reported after the use of proton pump inhibitors (PPIs) such as lansoprazole with amoxicillin , and discolored tongue or glossitis has been recorded after the use of lansoprazole plus antibiotics such as clarithromycin with or without amoxicillin  or lansoprazole alone.

Drug-related intrinsic pigmentation

Localized areas of pigmentation of the mucosa may be due to amalgam, while gingival pigmentation can arise secondary to the gold or metal alloys of crowns. Heavy metal salts were previously reported to cause pigmentation, particularly of the gingival margin. Blue, blue-grey, or brown mucosal pigmentation can be an adverse effect of antimalarials, phenothiazines, and phenytoin. Amiodarone may cause a grey orofacial and oral mucosal pigmentation.
Minocycline has increasingly been reported to cause widespread blue, blue-grey, or brown pigmentation of the gingivae and mucosae. While much of this pigmentation may reflect discoloration of the underlying bone and roots of teeth, there is also inherent pigmentation of the oral mucosa, including the tongue.

Drug induced pigmentation

Oral contraceptives may, albeit rarely, cause melanotic pigmentation, as can cyclophosphamide, busulphan, and ACTH. In HIV disease, drug-induced melanotic pigmentation may arise following therapy with clofazimine zidovudine and/or ketoconazole, the pigmentation being variably diffuse or macular-like Kaposi’s sarcoma of the mouth is a rare complication of immunosuppression, manifesting as a blue, red, or purple macule, papule, nodule, or area of ulceration, typically on the palate or gingivae, but able to affect other oral mucosal sites.