Oral reactions to medications
As more new medications become available to treat a wide range of diseases, clinicians are seeing more adverse events in their patients’ mouths.
A literature review published in the January 2015 issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology focuses on common adverse drug events (ADEs) likely to be encountered by the dental health care provider. The report includes clinical presentations, pathogenesis and treatment planning of 12 types of drug-induced oral reactions: hyposalivation/xerostomia, lichenoid reaction/lichen planus, aphthous-like ulcers, bullous disorders, pigmentation, fibrovascular hyperplasia, keratosis/epithelial hyperplasia, dysesthesia, osteonecrosis of the jaws, infection, angioedema and malignancy. “Oral health care providers should be familiar with such events as they will encounter them in their practice,” authors said.
Among the most common oral mucosal reaction researchers reported is in the category of hyposalivation/xerostomia. Dry mouth is noted as an adverse effect for over 500 medications, with increasing prevalence of xerostomia noted as the number of medications used increases “(16.7% of patients reported xerostomia when using one medication daily vs. 36.9% when using greater than three medications daily).” Medications with even minimal anticholinergic properties may act in combination to exacerbate oral symptoms of dryness and the resulting discomfort.
Nonsteroidal anti-inflammatory drugs and antihypertensive agents have been historically associated with oral lichenoid reactions. In 1963, the term Grinspan syndrome was introduced to describe a previously undocumented clinical presentation characterized by the triad of oral lichen planus, diabetes mellitus and hypertension. It is now believed that this represents a lichenoid drug reaction, because “….drug therapy for hypertension in particular and likely diabetes mellitus is capable of provoking oral LHRs [lichenoid hypersensitivity reactions].”
The authors discuss potential effects of many drugs, including immunosuppressive drugs, chemotherapeutic agents, calcium channel blockers, antiresorptive medications and new biologic agents. They also explain how combined therapies may lead to higher incidences of some ADEs.
“The advent of targeted therapies in oncology has produced a number of novel complications in the oral cavity,” authors said among conclusions. “Oral health care providers should be aware of the manifestations of ADEs encountered in their practice.”
Read the original article.
Consulting Editor: Paul C. Edwards MSc, DDS, FRCD(C)
Professor, Dept. of Oral Pathology, Medicine, Radiology
Indiana University School of Dentistry
Associate Consulting Editor: Yi-Shing Lisa Cheng, DDS, MS, PhD
Associate Professor, Diagnostic Sciences,
TAMU-Baylor College of Dentistry
Oral lesions in older people
The population of older people in the world is increasing. As life span increases, people are more likely to experience general and oral health problems. Based on previously published studies, the most common oral problems in older people include tooth loss, dental caries, periodontitis, dry mouth and mucosal lesions including lichen planus and oral precancer/cancer.
Research studies on the associations between oral mucosal lesions, systemic diseases, intake of medications and salivary gland function are “relatively sparse.” Therefore, scientists at the University of Copenhagen, Denmark, conducted a study to determine prevalence of oral mucosal lesions in a sample of Danish people 65-95 years of age and to investigate the associations between those lesions and interacting factors, including age, gender, diseases/medical conditions, medications, tobacco and alcohol consumption, salivary flow rates and xerostomia. They hypothesized those specific diseases and medications, low labial and whole salivary flow rates and oral dryness, but neither age nor gender, is associated with the presence of oral mucosal lesions.
To study, scientists enrolled a total of 688 patients (389 women, 279 men), 65 or older who visited the dental clinic at the university. Subjects filled out a standardized questionnaire describing their systemic diseases/medical conditions, daily intake of prescribed and herbal medications and dietary supplements, smoking and alcohol habits. They also answered questions about xerostomia, measured salivary flow rates and conducted clinical examinations to diagnose oral mucosal lesions.
Results showed that oral mucosal lesions are prevalent in older people — 75% of all participants and 70% of non-medicated participants — had one or more oral mucosal lesion. The most common conditions were lingual varicosities (28.3%), denture stomatitis (12.7%); Candidiasis (11.8%); fissured tongue (9.1%); and frictional keratosis (8.4%).
Different types of lesions seemed to be associated with different factors. For example, oral mucosal lesions were generally associated with smoking and xerostomia. Sublingual varicosities were more common in participants with systemic diseases and medication intake, particularly with cardiovascular diseases and intake of cardiovascular medications, but not with age or gender.
In discussion, authors noted how in previous studies, fissured tongue and/or lingual varicosities were referred as normal age-related changes and therefore not registered in many studies. “However, in our study, there was no significant association between fissured tongue and age, which questions the exclusion of these so-called age-related conditions.”
Among conclusions, authors said their findings support the concept that tongue lesions, particularly fissured and atrophy of tongue papillae, are clinical indicators of medication-induced xerostomia and salivary gland hypofunction. Candida colonization and oral candiadiasis are further factors of concern in older people with comorbidities and who are taking multiple medicines.
“The presence of one or more of these indicators should make the clinician consider measurement of salivary gland function, implementation of preventive measures of caries and treatment of xerostomia and/or hyposalivation and oral infections/mucosal lesions,” authors advised.
The study was published in the April 6 online edition of Oral Diseases.
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Minor salivary gland cancers and radiation therapy
Although the majority of salivary gland tumors arise from major salivary glands, minor salivary glands still account for 9-23% of tumors. Most frequently located in the oral cavity, minor salivary gland tumors (mSGTs) can also be found in the oropharynx, nasopharynx, larynx and upper airway. Standard management for salivary gland tumors consists of surgical resection followed, in some cases, by radiation therapy (RT).
Because of the low incidence of mSGTs, large-scale randomized clinical trials investigating the role of radiation therapy in treating minor salivary gland tumors are lacking. A multi-specialty team of scientists analyzed the data from the Surveillance, Epidemiology, and End Results (SEER) database to assess the effect of adjuvant RT on the survival of patients with non-metastatic mSGT and factors influencing its benefit. (SEER is a program initiated by the National Cancer Institute, and the SEER database covers cancer incidence, demographics, characteristics, treatment and survival information from some 19 states and for about 28% of the US population) — http://seer.cancer.gov/registries/list.html.
To evaluate, scientists identified 2,222 patients who were treated with and without adjuvant RT for mSGT of the head and neck for a period of 20 years—from 1988 to 2008. Scientists determined the time of diagnosis to the time of death. They analyzed co-variables including age; race; gender; year of diagnosis; cancer staging—T (tumor size), N (lymph node involvement); tumor location; grade and histology for influences on survival. While most patients (65%) had surgery alone, postoperative radiation therapy was administered in 33% of the cases.
Among results, adjuvant RT influenced better survival outcomes compared to surgery alone in a subset of patients.
Although initial analyses performed without accounting for other covariates showed adjuvant RT was associated with lower survival compared to the group who had surgery alone, when covariates were accounted for adjuvant RT correlated with a 24% survival advantage.
Adjuvant RT is associated with improved survival in patients with mSGT and adverse clinicopathologic factors such as advanced T/N category, adenoid cystic or adenosquamous histology, and high grade (poorly differentiated) histology, authors reported.
The study’s complete findings are published in the May 2015 issue of Oral Oncology. An online tool designed to help clinicians predict the survival impact of adjuvant radiation therapy in patients with minor salivary gland tumors (mSGTs) was generated by the scientists through their investigative research on the matter.
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Oral tongue cancer in women: incidence and survival
The rising incidence of oral tongue cancer (OTC) among women in the U.S. drew a team of researchers to conduct a study on factors influencing OTC incidence and survival. The scientists, from Emory University in Atlanta, Georgia, published their findings in the June 2015 issue of Oral Oncology.
While the overall frequency of oral cavity cancers has been declining, women have experienced an increased prevalence of malignant tumors of the anterior tongue over the past three decades. Regarding evidence on the subject, many of the population-based studies focused primarily on comparisons between men and women, the scientists found. Previously published studies often included OTC together with cancers originating in the base of the tongue and the tonsils, which have very different etiology and prognosis.
With these knowledge gaps in mind, the team conducted a study to explore trends in OTC rates among women and to examine demographic and ethnic background characteristics as determinants of survival.
To analyze, scientists first identified women diagnosed with OTC (of which more than 90% are squamous cell carcinoma) that were reported to the Surveillance, Epidemiology and End Results (SEER) program from 1973 to 2010 and then compared incidence and survival rates of squamous cell carcinoma among them.
The total study group consisted of 3,443 women age 30 year and over, after excluding patients with base of tongue and lingual tonsil cancers. Scientists categorized race into three groups—African American, White and Other. Other comprised American Indians/Alaska Natives and Asians/Pacific Islanders (AI/AN & A/PI). Hispanic ethnicity is not well documented in SEER, particularly in earlier years, so researchers did not separate Hispanics from non-Hispanics.
Cases were grouped according to place of residence— metropolitan, urban and rural; disease stage at diagnosis; age; marital status and type of surgical and radiation treatment received. (Data on chemotherapy are not available in SEER.)
Results showed the only statistically significant difference in trends for incidence rates was between white and African American women. While the African American women experienced a decrease in OTC incidence, with the decrease particularly pronounced prior to 2000, the incidence among white women began to increase significantly around 1990. The trend for AI/AN & A/PI women revealed no significant changes over time until about 2005 and then showed a decrease, although the downward trend was not statistically significant.
Further examination revealed that white women over the age of 50 experienced little change in disease occurrence between 1973 and 2010. By contrast, OTC incidence among white women under 50 years of age trended up significantly after 1988.
While incidence of OTC in African American women was declining and on average about one half of that of white and A/PI or AI/AN women, their prognosis was clearly worse. “This disparity in survival was attenuated, however, and was not statistically significant after controlling for age, marital status and, most importantly, treatment and stage.”
Although not statistically significant, authors said in discussion that they believe the racial difference in outcome is real and deserves further examination “… given the fact that management of these tumors is mostly standardized. A discrepancy in extent of surgical resection or access to expertise in these procedures will need to be further examined as a possible contributing factor.”
Among assertions, scientists called for future research to identify risk factors behind the increase of OTC noted specifically in younger white women after 1990 and health interventions promoting early detection in high risk populations and women with limited access to medical care.
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Mark your calendar for our 2016 annual meeting
Please join us for the American Academy of Oral and Maxillofacial Pathology Annual Meeting at the Westin Cincinnati, May 21-25, 2016.
Registrants are also invited to join the AAOMP for a rare opportunity to learn from some of the world's leading oral and maxillofacial pathologists on Friday, May 20, 2016, at the Westin Cincinnati.
Watch for more information!
Diagnose and treat soft tissue lesions with confidence
The ADA now offers an Oral Pathologist Kit to guide dentists through over 200 soft tissue conditions. The kit contains both a book and app. The ADA Practical Guide to Soft Tissue Oral Disease takes readers through screening, description and documentation, differential diagnosis, and guidelines for observation and referral. The Oral Pathologist App allows users to search conditions by name or by entering clinical observations.
Both book and app include photos and descriptions to aid diagnosis. Sample pages from the book and a table of contents can be found on this page. To order the app, book or kit, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 15423E before June 5 can save 15 percent on all ADA Catalog products.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on oral and maxillofacial pathology, the second in the series on this topic for 2015. Other Specialty Scan issues are devoted to endodontics, oral and maxillofacial radiology, orthodontics, pediatric dentistry, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.
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