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 drugs 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.