Clinicians should encourage patients to try a variety of products to identify which provide the greatest symptomatic relief. Supplemental fluoride therapy is also recommended as a caries-preventive agent in this patient population. Various caries risk assessment models identify drug-induced xerostomia as a major risk factor.20,21 Topical fluoride recom- mendations from the American Dental Association can be used to determine the most age-appropriate and risk-appropriate fluoride interventions, includ- ing dosage and frequency of application.22 Several commercial fluoride prod- ucts are available over the counter or by prescription that are specially-formulated for patients with xerostomia. To date, nonfluoride rem- ineralization therapies lack sufficient evidence to substantiate their benefits,23 thus, clinicians should use their judgment to determine whether the addition of these products may be appropriate to reduce caries risk. Good oral hygiene is essential for patients with chronic xerostomia. Practi- tioners should recommend a variety of oral aids to assist with mechanical disrup- tion of biofilm. These include oral irrigators, air flossers and power brushes. Sonic toothbrushing has been shown to stimulate salivary flow.24 Patients with chronic dry mouth benefit greatly from the daily use of antiseptic mouthrinses and ther- apeutic dentifrices to reduce biofilm and resultant bacterial infections.18 tion, dentifrices containing sodium bicarbonate may help raise oral pH levels. APHTHOUS ULCERS AND GINGIVAL HYPERPLASIA Several drug classes have been shown to cause aphthous ulcers.25 In addi- LICHENOID DRUG REACTION Lichenoid reaction is a delayed hypersensitivity reaction to a drug. Clinically, this condition is often confused with lichen planus, an autoimmune disease. Patients may or may not be symptomatic. There is a lack of consensus about diagnostic criteria because, with some cases, the condition may not resolve after the drug has been discontinued.6,27 Clinicians should assess a “new” presentation of lichen planus and correlate onset with the timing of the introduction of a medication since the last dental visit. Although many other drugs have also been implicated, common medications associated with lichenoid drug reaction include nons- teroidal anti-inflammatory drugs and antihypertensive agents. MUCOSITIS Radiation therapy and chemotherapy used for cancer treatment are associ- ated with causing oral mucositis, which can occur directly as a burn from radiation and from exposure to the toxic drugs used during chemotherapy that are secreted into the oral cavity via saliva. Drugs used for chemotherapy cause systemic immunosuppression, which reduces salivary immunoglobulins and increases risk for oral infections. Mucositis causes significant pain and alters the patient’s ability to eat, swallow and speak. Several systematic reviews have examined which agents are most effi- cacious for the treatment of mucositis.28–30 Although While it is difficult for patients to perform adequate oral hygiene with hyperplastic tissues, effective self-care may reduce the extent and severity of the lesion. Susceptible individuals carry a genetic risk for this drug manifestation.26 TASTE ALTERATION More than 250 drugs have been associated with altering taste (dysgeusia) and smell (dysosmia). Older adults frequently complain that food tastes bland or they cannot taste certain foods, resulting in behaviors such as adding salt, over-seasoning foods or simply not eating regularly. Several mechanisms of drug-induced taste alteration have been proposed, including secretion of the drug into saliva and gingival crevicular fluid, diminished turnover of taste buds, concentration of electrolytes in saliva, and altered neuronal and/or neurotransmitter function.3 Saliva is necessary to carry tas- tants over the taste buds, thus, patients may have multiple contributing fac- tors to explain distortion of taste. Clinicians should assess patients’ nutritional status — including eating habits, use of salt and food selection — to ensure proper intake of essential nutrients and adequate consumption. A referral to a registered dietician may be warranted. Patients complaining of an undesirable “aftertaste” may adopt a variety of behaviors to mask the taste. Clinicians should assess use of candy, gum, mints and excessive mouthwash, all of which may occur in this population. Patients should be assessed for oral signs of these behaviors and counseled accordingly. 32 Decisions IN DENTISTRY • December 2017 it may not be possible to switch the offending drug to another from a different medication class, if frequent ulceration affects the patient’s oral health-related quality of life, the prescribing physician should be contacted to determine feasibility of an alternate therapy. Topical over-the-counter and prescription anesthetics may help improve comfort. Gingival hyperplasia may be observed in patients taking anticonvulsants, calcium channel blockers and immunosuppressants used to prevent organ transplant rejection.3 the timing of the intervention and types of chemotherapy drugs used. There is insufficient and weak-quality evidence to support the use of chlorhexidine gluconate or povodine iodine for reducing either chemotherapy- or radiation therapy-induced mucositis.28–30 Current evi- dence supports the benefit of sucking on ice chips (i.e., cryotherapy).28–30 Emerging evidence suggests that use of a low-level laser may be beneficial in preventing mucositis, but more research is needed to support this intervention.31,32 “Magic mouthwash” describes a mixture of a topical anesthetic (e.g., over-the-counter liquid diphenhydramine or prescription lidocaine) with a coating agent. Patients rinse prior to eating and at bedtime. The coating allows the topical anesthetic agent to remain in contact with the tissues so the patient can take in nutrition, often in the form of a fortified liquid supplement. It is essential to help patients control pain and maintain nutri- tion during cancer treatment. Rinsing and swallowing the mouthwash at bedtime may also help patients sleep due to the sedative side effect of diphenhydramine. CONCLUSION Adverse oral drug effects negatively influence oral comfort, function and quality of life. Clinicians should assess their patients’ medication use to deter- mine risks for oral complications. Utilizing recommended interventions for oral adverse effects associated with medications can prevent oral infections, reduce discomfort, facilitate chewing and swallowing, and promote optimal oral health. Interprofessional collaboration with physicians and registered dieticians may be warranted to ensure appropriate strategies are in place for effectively managing medications. D DISCOVER MORE ONLINE:Examples of drugs that oppose the parasym- pathetic nervous system — as well as drug classes associated with aphthous ulcers and medications associated with lichenoid drug reactions — can be found at DecisonsInDentistry.com. DecisionsInDentistry.com Efficacy varies depending upon
