Adverse drug reactions and oral side effects

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Adverse drug reactions and oral side effects

The safety profile of most medicines and vaccines becomes reasonably well established once on the market for a reasonable length of time. However, there is an ongoing need to be vigilant for the occurrence of less well known adverse effects and to respond accordingly, especially if the drug or vaccine involved is denoted by an inverted Black Triangle symbol (▼). These 'Black Triangle' drugs and vaccines are relatively new to the market, and therefore require closer supervision and surveillance to identify any safety issues regarding their use in the general population.

Suspected adverse reactions or side effects to a drug or vaccine should be reported via the Yellow Card system, providing as much information as possible on the circumstances surrounding the event. This allows for a more accurate picture to be developed on the safety profile of currently marketed medicines and vaccines, taking action where appropriate thereby protecting the public.

Side effects and their management

In clinical practice, the use of certain drugs in the treatment of medical conditions may often result in a range of predictable oral health side effects, many of which can be reported during a dental consultation. In certain cases, the side effects are relatively minor and can be simply managed, although there are cases where more urgent action or referral may be required. The sections below list predictable oral side effects commonly associated with certain drugs, with advice on management. The lists of drugs are not exhaustive. If a medicine-related side effect is suspected, the British National Formulary should be consulted.

When a patient presents with these symptoms, initial questions to ask include:

Do you have any existing medical problems?
How long have you experienced the symptom?
Have you recently started or stopped a medicine (including over the counter or herbal medicines)?
Have you recently changed the dose of a medicine?
Can you tell me what medicines you currently take?

Asking these questions will usually identify a potential drug-related cause (including any potential drug interactions) for the symptom(s) experienced by the patient, some of which can be safely managed whilst others may require a review of the patient's medicines by their doctor or pharmacist.

Where a patient may be experiencing a medication-related side effect that is not considered to be hazardous but is persistent and/or troublesome, they should be advised to continue taking the suspected medicine and to contact their doctor for further advice. This will allow an opportunity for the doctor to consider whether an alternative medicine (or even no medicine) would be more appropriate for the patient.

The patient’s progress should be monitored in follow-up appointment(s).

Drug-related oral health side effects

Drugs potentially implicated

penicillin
tetracyclines
oxygenation mouthwashes e.g. sodium perborate, hydrogen peroxide

Initial management

Reassure the patient of benign nature of the condition.
Advise that condition will resolve once treatment has stopped.

Subsequent care

If problem persists, advise patient to contact their GP.

Drugs potentially implicated

analgesics (opioid) e.g. morphine, oxycodone
antidepressants (tricyclic) e.g. amitriptyline, clomipramine
antidepressants (SSRI) e.g. citalopram, fluoxetine
antiemetics e.g. hyoscine hydrobromide
anticonvulsants e.g. carbamazepine, gabapentin
antihistamines (sedating) e.g. chlorphenamine, promethazine
antimanic drugs e.g. lithium carbonate, lithium citrate
antimigraine drugs e.g. pizotifen, clonidine
antimuscarinic drugs e.g. orphenadrine, procyclidine, trihexyphenidyl, ipratropium, tiotropium
Parkinson's disease drugs e.g. levodopa
antipsychotics e.g. clozapine, olanzapine, phenothiazines
antispasmodics e.g. baclofen, oxybutynin, solifenacin
beta-blockers e.g. atenolol, carvedilol
CNS stimulants e.g. atomoxetine, methylphenidate
diuretics e.g. furosemide
weight loss drugs e.g. liraglutide

Note: Drug-induced dry mouth is often caused by the anticholinergic properties of drugs. The above drug groups are not a comprehensive list of drugs that are associated with dry mouth, as many other drugs can cause these symptoms.

Initial management

Maintain good oral hygiene and use fluoride mouthwash.
Take frequent sips of cold water.
Suck ice-cubes.
Use sugar-free chewing gum to help stimulate saliva production.
Limit caffeine and alcohol intake, as these have a diuretic effect.
Where lips are dry and/or cracked, apply a lubricant e.g. aqueous cream or water-based saliva replacement gel.

Subsequent care

If dry mouth becomes troublesome or difficult to manage, artificial saliva products may be considered, for use as required.
Patients are more susceptible to candidal infection, therefore consider treatment with an appropriate antifungal agent where necessary.
If problem persists, advise patient to contact their GP.

Drugs potentially implicated

phenytoin
ciclosporin
amlodipine
diltiazem

Initial management

Reassure the patient of benign nature of the condition.
Discuss measures to improve oral hygiene.

Subsequent care

Advise the patient to discuss alternatives with their GP.

Drugs potentially implicated

phenothiazines
cytotoxic drugs
amiodarone
chloroquine
mepacrine
minocycline
zidovudine

Initial management

If the nature of the condition is confirmed as drug-related (i.e. non-malignant), reassure the patient of benign nature of the condition.
Advise patient to contact their GP.

Drugs potentially implicated

non-steroidal anti-inflammatory drugs
nicorandil
methotrexate
cytotoxic drugs
sulphonamides
sulfasalazine
anticonvulsants (such as phenobarbital, phenytoin, carbamazepine)
allopurinol
penicillin
gold
penicillamine

Initial management

Maintain good oral hygiene.
Symptomatic relief can be obtained through use of chlorhexidine mouthwash or topical corticosteroids.
If suspected adverse drug reaction or blood dyscrasias, refer patient to their GP immediately.

Subsequent care

If ulcer(s) have persisted beyond 7 days, or are severe or recurrent, advise patient to contact their GP.