consider discontinuing the offending agent or changing medication. Although cessation or substitution of the drug may lead to regression, surgical removal of the excess tissue (i.e., gingivectomy) may be necessary in certain individuals.
Consider periodontal surgery if gingival enlargement persists despite drug substitution and good plaque control (Aral et al., 2015; Cohen & Bhattacharyya, 2008).
DRUG-RELATED MUCOSAL DISORDERS
Disorders of the mucosal tissues can result from various drug-related effects, ranging from direct burns to Oral mucositis Oral mucositis is inflammation and ulceration of the mouth mucosa with pseudomembrane formation. Incidence and prevalence data for this condition are believed to be underreported and inconsistent because of the lack of consistency in diagnostic criteria for mucositis (Villa and Sonis, 2015; Blakaj, Bonomi, Gamez, & Blakaj, 2019). Two major etiological mechanisms are implicated in mucositis: direct toxicity associated with treatment and myelosuppression resulting from therapy. The pathogenic mechanism involves chemotherapy and radiotherapy causing reduction of cell renewal in the basal epithelial layers, with insufficient replacement of desquamated cells (Blakaj, Bonomi, Gamez, & Blakaj, 2019). Mucositis is considered an inevitable but transient side effect of antineoplastic therapies (Grenon, 2013) or radiation in head and neck oncology (de Barros da Cunha et al., 2015). It is characterized by squamous epithelial atrophy, vascular damage, and an inflammatory infiltrate concentrated at the basement region. Ulceration follows epithelial atrophy. Its severity can range from a minor erythema, edema, or allodynia to large and painful ulcers that affect eating, swallowing, and talking. Four grades (I, II, III, and IV) are used to score mucositis. Grades III and IV mucositis are painful and characterized by ulcerative lesions, which are covered by fibrinous-inflammatory (pseudomembranous) exudate (Blakaj, Bonomi, Gamez, & Blakaj, 2019). In its early stages, chemotherapy-induced mucositis can appear clinically as erythema 4 to 5 days after the start of treatment. Ulcers may develop 7 to 10 days after chemotherapy and often cause marked discomfort. The movable tissues of the buccal mucosa and the tongue’s lateral and ventral surfaces are the most common sites of chemotherapy-induced mucositis, whereas the hard palate and gingiva are less common. Often, these findings are resolved within 2 weeks of initial presentation (Villa & Sonis, 2015; Blakaj, Bonomi, Gamez, & Blakaj 2019). The frequency and severity of mucositis depend on several factors, including the type and dose of chemotherapeutic agents and patient-specific factors such as age, as well as nutritional, buccodental, and hematological status (Villa & Sonis, 2015; Blakaj, Bonomi, Gamez, & Blakaj 2019). Topical agent-induced oral ulceration Directly applying over-the-counter medications such as aspirin, hydrogen peroxide, potassium tablets, and phenol- containing medications to the mucosa may produce epithelial necrosis and ulceration (Butler, 2016; Durso, 2008; Kalmar, 2016; Rostami & Brooks, 2011; Fitzpatrick, Cohen, & Clark 2019). A superficial chemical injury of the oral mucosa can develop because of topical application of aspirin (Lewis & Jordan, 2012). Aspirin application can produce a whitish Fixed drug eruption Systemic medication-induced cutaneous disorders often display a characteristic clinical morphology such as urticaria, hypersensitivity syndrome, pseudolymphoma, photosensitivity, pigmentary changes, lichenoid dermatitis, vasculitis, Stevens-Johnson syndrome, or fixed drug
disturbances of the immune system and opportunistic infection.
Combination therapy with cytotoxic drugs can influence known side effects and increase the toxicity to the patient. The Consensus Development Panel of the National Institutes of Health (NIH) concluded that drug intervention cannot effectively prevent mucositis, an opinion that still holds (Chaveli-López & Bagán-Sebastián, 2016; NIH, 1989). Consequently, management of chemotherapy-related mucositis is still limited to reducing its severity. Good gingival status and good oral hygiene during chemotherapy can lower the incidence and severity of mucositis (Villa & Sonis, 2015; Blakaj, Bonomi, Gamez, & Blakaj, 2019). In addition, several interventions have been proposed to reduce mucosal exposure to chemotherapeutic drugs. For example, ice chips held in the mouth can constrict blood vessels and thereby reduce exposure of mucosal tissues to the chemotherapy agent. A Cochrane analysis that evaluated the effectiveness of prophylactic agents for oral mucositis in patients receiving treatment for cancer found that ice chips prevented mucositis at all levels: mild (relative risk [RR] 0.64), moderate (RR 0.38), and severe (RR 0.24; Riley, et al., 2017). It should be noted that patients receiving chemotherapy with oxaliplatin (part of a standard treatment for colorectal cancer) are likely to suffer cold sensitivity, which would make the use of ice chips inappropriate for those patients (Dana- Farber Cancer Institute, 2014). Other interventions that produced a significant difference compared with a placebo or no treatment were amifostine and hydrolytic enzymes. Even with these reported interventions, there still is not a treatment approach that is universally employed for mucositis. For relief of pain and discomfort caused by mucositis, the use of several anesthetics, analgesics, and mucosal coating agents (acting as cytoprotectants) has been suggested. Viscous lidocaine and benzydamine have been suggested as periodic rinses. Reports have been encouraging for the use of sucralfate suspensions for relief of pain and resolution of mucositis (Lalla et al., 2014). The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology has also made recommendations for care that would be especially helpful to individuals practicing in a tertiary cancer center or practitioners interested in providing ongoing care to patients with mucositis (Lalla et al., 2014). and corrugated appearance in the oral mucosa, with erosion and ulceration of more severely damaged areas. Aspirin’s low pH causes erythema and tissue necrosis and, with increasing time, coagulative necrosis. The most frequently involved site is the buccal sulcus or alveolar attached gingiva. For most patients, healing occurs once the chemical is removed (Jordan & Lewis, 2013, Fitzpatrick, Cohen, & Clark 2019). eruption (Butler, 2016; Durso, 2008; Jain & Gupta, 2015; Kalmar, 2016; Nair, 2015; Fitzpatrick, Cohen, & Clark 2019). Fixed drug eruption involves the development of one or more annular or oval erythematous patches with hyperpigmentation when the lesions resolve. Initially, limited
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