2.1 Drug-Induced Stomatitis

Stomatitis (inflammation of the mucosal lining of the mouth) from

medications can be caused by both local effects and systemically mediated

responses. 1

Drug-induced stomatitis is an inflammation of the oral mucosa, due to

local or systemic factors, which may involve the buccal and labial mucosa, palate,

tongue, floor of the mouth, and the gingivae. Pain from mucosal lesions can be

severe and can interfere with eating. Some cases of drug induced stomatitis have

no clinical presentation other than erythema, whereas other cases can be

catergorized as allergic stomatitis, lichenoid drug eruptions, lupus erythematous

like eruption, pemphigus like drug reactions, and erythema multiforme. 1,2

Ulceration of the oral mucosa is a common side effect of a wide variety of

antineoplastic agents, including Methotrexate, 5-fuorouracil, doxorubicin,

daunorubicin, bleomycin, and melphalen through inhibition of epithelial cell

mitosis. Allergic reactions can occur either locally from contact with the

medication of from systemic administrations, including antibiotics (tetracycline,

penicilin, sulfonamides, nitrofurantoin, isoniazid, para amino salicylic acid,

streptomycin, ketoconazol, griseovulsin), oral hypoglycemics, antihypertensive,

and heavy metals (especially gold compounds). Secondary oral effects may be

seen with drug induced vitamin deficiencies, including the B complex vitamins,

iron, vit.C, and vit.A. Thiamine deficiency (often result of chronic alcoholism)

may lead to painful mucosa and small vesicles on the buccal mucosa. 1

Fig. Characteristics oral drug reactions 4

There are some oral lesion reaction due to drug’s adverse effect, such as

aphtous stomatitis, antibiotic-induces stomatitis, and stomatitis medicamentosa

(stomatitis venetana).

Fig. Mechanisms of oral drug reactions 4

2.1.1 Aphthous Stomatitis

Aphthous ulcers are the most common oral mucosal lesions in the general

population. These often are recurrent and periodic lesions that cause clinically

significant morbidity. Many suggestions have been proposed but the etiology of

recurrent aphthous stomatitis (RAS) is unknown. Several precipitating factors for

aphthous ulcers appear to operate in subjects with genetic predisposition. An

autoimmune or hypersensitivity mechanism is widely considered possible.

Sometimes aphthous ulcers can be the sign of systemic diseases, so it is essential

to establish a correct diagnosis to determine suitable therapy. Before initiating

medications for aphthous lesions, clinicians should determine whether well-

recognized causes are contributing to the disease and these factors should be

corrected. 2

2.1.2 Antibiotic-Induces Stomatitis

Systemic long-term administration of broad spectrum antibiotics, such as

tetracycline, may cause a form of stomatitis. Clinically, it is a characterized by a

non-specific diffuse erythema of the oral mucosa. The tongue is extremely red and

painful, with desquamation of the filiform papillae. Hairy tongue and candidiasis

may also occur as a result of changes in the oral microbial flora. 3

Fig. Antibiotic-induced stomatitis, diffuse erythema, and desquamation of the

filiform papillae of the tongue 3

2.1.3 Stomatitis Medicamentosa (Stomatitis Venetana)

Systemic administration of medications may induce hypersensitive

reactions in the oral mucosa characterized as stomatitis medicamentosa, or

pharmaceutical stomatitis. 3

A plethora of drugs may cause stomatitis medicamentosa, including

antipyretics, nonsteroid anti-inflammatory drugs, sulfonamide, antiniotics, and

barbiturates. Clinically, the condition is characterized by diffuse erythema of the

oral mucosa, purpuric patches, vesicle or bullae, painful erosions, ulcers, etc. Any

area of the mouth may be involved. The lesions appear during or shortly after

administration of a drug and may recur. 3

Fig. Stomatitis medicamentosa, erosions on the dorsum of the tongue 3

Drug-induced oral disorders present a variable clinical picture and are

produced by numerous medications. These reactions may result from both

systemic and topical medications. Stomatitis medicamentosa may result from

immunologically mediated or toxic mechanisms. Contact stomatitis reactions

results delayed type hypersensitivity or primary irritaiton reactions. 4

Reference:

1. Wood, Nelson Dr. 2012. Stomatitis. Accessed at: November 15, 2012.

Available from: www.woodfamilydental.com.

2. Femiano, Felice MD, PhD et al. 2007. Guidline for Diagnosis and

Management of Aphtous Stomatitis. Pediatric Infectious Disease Journal

26 (8), pp. 728-732.

3. Laskaris, George. 1998. Color Atlas of Oral Diseases 3rd ed. Athens:

Litsas Medical Publication. pp. 82-83.

4. Tack, Alan D & Roy R. Rogers III. 2002. Oral Drug Reactions.

Dermatologic Therapy 15. pp. 236-250.