● Pain control medication. ● Superficial debridement to relieve soft tissue irritation. The most severe presentation of this condition is Stage 3 (exposed and necrotic bone extending beyond the region of alveolar bone, resulting in pathological fracture, extraoral fistula, oral-antral/oral-nasal communication, or osteolysis), in which patients should be treated with: ● Oral antibacterial mouth rinse. ● Antibiotic therapy and pain control. ● Debridement/surgical resection. (Ruggiero et al., 2014; Kilic & Doganay, 2018; Bansal, 2022) (Sanchez, Rogers, & Sheridan 2004; Wormser, Wormser, Strle, Myers, & Cunha, 2019). Tetracycline-related intrinsic staining is caused when the tetracycline molecule combines with calcium by chelation and is subsequently incorporated into the hydroxyapatite crystal of the tooth during mineralization (Kumar, Kumar, Singh, Hooda, & Dutta, 2012). As the tetracycline layer inside the tooth is oxidized by light, it forms visible discoloration and the appearance of the yellow, grey or brown permanent discoloration tends to be on the cervical one-third of the crowns. The degree of staining is related to the duration and timing of drug administration.
should receive systemic management, which may include pain medication and antibiotic therapy. Patients at Stage 1 (exposed and necrotic bone, asymptomatic, without evidence of infection) should be treated with: ● Patient education as well as medical history review. Patients at Stage 2 (symptomatic, exposed and necrotic bone associated with infection with or without purulence) should be treated with: ● Symptomatic treatment with oral antibiotics. ● Oral antibacterial mouth rinse. ● Oral antibacterial mouth rinse. ● Quarterly clinical follow-up. Tooth discoloration Numerous drugs can cause either extrinsic or intrinsic tooth discoloration (Teoh, Moses, & McCullough, 2019; Kuzenko, Mykhno, Sikora, Bida, & Bida, 2022). Extrinsic tooth discoloration, where the stain develops after tooth eruption, can result from chlorhexidine, linezolid, fluorides, and iron, as well as from habits such as tobacco and betel use. Certain antibiotics (ciprofloxacin, doxycycline, minocycline, and tetracycline) and some essential oils have also been implicated in intrinsic stains, where tooth discoloration occurs during tooth development, and are usually located within the tooth structure. Medications such as tetracycline may result in this type of generalized intrinsic discoloration and has a prevalence of 3%-4% in the general population
DAMAGE TO ORAL SOFT TISSUES
Color changes to the oral mucosa Mucosal pigmentation
examinations, and in some cases biopsy and laboratory investigations. The exact mechanism of intrinsic tissue discoloration varies by drug and is uncertain in many cases. Generally, discoloration resolves within weeks to months after removal of the drug, but sometimes the discoloration is permanent. The discoloration caused by antimalarial drugs such as chloroquine and mepacrine (quinolones) is ascribed to deposition of melanin or iron in mucosal tissues (Jallouli et al., 2013). The hyperpigmentation caused by tetracycline and minocycline has been attributed to the interaction of the drug with bone during its formation. Use of oral contraceptives may also cause pigmentation of the oral mucosa. It is postulated that estrogens produce high levels of cortisol-binding globulin, which decreases the level of plasma free cortisol. This decrease results in hypersecretion of adrenocorticotropic hormone and melanocyte-stimulating hormone, which in turn causes increased oral pigmentation (Sreeja et al., 2015). Gurvits & Tan, 2014; Hamad & Warren, 2018). Older case reports describe successful treatment of black hairy tongue with triamcinolone acetonide (Weinstein & Rosencrans, 1962). Educating patients regarding proper oral hygiene and encouraging routine tongue brushing are the best preventive and therapeutic measures. Treatment usually does not require pharmacological intervention; however, if fungal overgrowth is present and the condition is symptomatic, the clinician may prescribe a topical antifungal agent. Additionally, the clinician should counsel the patient that this is a benign process and prognosis is favorable. With black hairy tongue, the patient may see improvement with lifestyle modification, or spontaneous resolution (Gurvits & Tan, 2014; Hamad & Warren, 2018).
Many agents affect the coloration of the oral mucosa. Discoloration of the oral mucosa may have intrinsic or extrinsic causes (Sreeja et al., 2015; Rosebush, Briody, & Cordell 2019). Extrinsic discoloration is usually caused by habits (e.g., tobacco, betel nut use) or by consuming colored foods or beverages (e.g., red wine, coffee, tea). Some medications (e.g., chlorhexidine, iron salts, minocycline, bismuth subsalicylate, lansoprazole) may discolor the oral mucosa. Extrinsic staining is rarely serious. Intrinsic mucosal hyperpigmentation has many potential causes, ranging from non-serious conditions such as amalgam tattoo to serious conditions such as neoplasms (e.g., malignant melanoma, Kaposi sarcoma; Sreeja et al., 2015). Other causes of intrinsic hyperpigmentation include nevus, melanotic macule, Peutz-Jeghers syndrome, racial pigmentation, decorative or cultural tattoo practices, pregnancy, and Addison’s disease. Evaluation of a patient presenting with a pigmented lesion should include a full medical and dental history, extraoral and intraoral Black hairy tongue Black hairy tongue (lingua villosa nigra) consists of elongated filiform papillae of the tongue that become stained because of growth of chromogenic microorganisms (Gurvits & Tan, 2014; Hamad & Warren, 2018). Administration of oral antibiotics, poor dental hygiene, and excessive smoking have been associated with black hairy tongue. Specific medications that have been reported to cause this condition include antibiotics (e.g., penicillin, aureomycin, erythromycin, doxycycline, neomycin and linezolid), antipsychotics (e.g., olanzapine, chlorpromazine), and chemotherapeutics (e.g., erlotinib; Gurvits & Tan, 2014; Hamad & Warren, 2018). In most cases, empirical approaches adequately resolve black hairy tongue: brushing or scraping the tongue, improving oral hygiene, and eliminating potential associated factors (e.g., tobacco, strong mouthwashes, antibiotics;
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