Chemical Injuries of Oral Cavity

Introduction Oral cavity frequently manifests a serious reaction to the wide variety of drugs & chemicals Injury to the oral mucosa can result due to a large number of chemicals and drugs (irritants) that come in contact with oral tissues All these irritants evoke an inflammatory response This biological complex response can be irritative or allergic in nature

Most common involved sites: Oro-pharynx Tonsil Alveolar mucosa Tongue Masticatory mucosa of palate Gingival tissue

Classification CHEMICAL INJURIES Allergic reactions Non-Allergic reactions Systemic drugs Local drugs Systemic drugs Local drugs Stomatitis Medicamentosa Stomatitis Venenata Arsenic Aspirin Bismuth Sodium Perborate Gold Hydrogen Peroxide Dilantin Sodium Phenol Lead Silver Nitrate Mercury Trichloroacetic Acid Silver Volatile Oils Tetracycline Anti cancer Drugs

Stomatitis Medicamentosa Allergic inflammatory changes in the oral soft tissues associated with the use of drugs or medicaments, usually those taken systemically

Stomatitis Venenata/Contact Stomatitis An allergic condition of the oral mucosa resulting from contact with a substance to which the patient is sensitized, including cosmetics, dentifrices, mouthwashes, and dental materials, as well as drugs applied topically Symptoms: Inflammation and Edema of the mucosa Burning, Itching contact stomatitis on the gingiva due to nickel, palladium, and mercury.

Aspirin People use aspirin tablets mistakenly as a local obtundent, especially for the relief of toothache Efficacious if used systemically, Harmful to the oral mucosa if applied locally Usual they place the tablet against the offending tooth Within a few minutes, a burning sensation of the mucosa will be noted – “ASPIRIN BURN”

Aspirin burn Disorder caused due to local application of aspirin for the treatment of tooth pain Clinical features: Burning sensation of the mucosa Blanched or whitened in appearance of mucosal surface Separation and sloughing of the epithelium Frequent bleeding from the site The lesion heals with in a week.

Aspirin burn

Endodontic Materials Some commonly used endodontic materials are dangerous to the oral soft tissues These materials can cause soft tissue damage or deep spread of inflammation and necrosis if injected into hard tissues Formaldehyde, sodium hypochlorite, and hydrogen peroxide These caustic agents leak from the pulp chamber where they are usually placed This when spread into the periapical or gingival tissues leads to inflammation and necrosis

Sodium Perborate Used as a mouth-wash and in dentifrices specially for gingival diseases Adverse effects: Erythema of the oral mucosa Sloughing of the tissues Inflammation Edema Mucosal ulceration The lesions healed spontaneously with cessation of treatment

Hydrogen Peroxide Clear, colorless, odorless liquid which is an oxidizing agent Used in low concentration for various medicinal purposes oxidant, as bleaching agent, antiseptic/disinfectant used as oral antiseptic solutions

When more than 3% of hydrogen peroxide is kept in contact with keratinized oral tissue can cause mucosal irritation Manifestations: Mucosal necrosis Sloughing of the epithelium Symptomatic burning Stinging or Tingling sensation

Phenol Phenol is widely used in dentistry as a cavity sterilizing agent Also used as a cauterizing agent in various procedures It is extremely caustic Clinical manifestations: Painful burns of the oral mucosa and skin Bone loss Damage epithelium & Necrosis by denaturing proteins

silver nitrate Silver nitrate is used for the treatment of aphthous ulcers, as a cavity-sterilizing agent, caries preventive agent. Remains a popular treatment for aphthous ulcerations because the chemical cautery brings a rapid pain relief by destroying the nerve endings However its use should be discouraged, considering the painful burns of the oral mucous membrane

trichloro-acetic acid Trichloroacetic acid is used in dentistry as a cauterizing agent, particularly to cauterize gingival tissues when preparing a proximal or gingival cavity, when placing a band, or taking an impression Because of its extremely caustic nature, this acid may cause serious injury to the mucosa or skin if it is used carelessly

Non-allergic Reactions to Drugs and Chemicals used Systemically The systemic administration of various drugs and chemicals frequently evokes an oral reaction

Arsenic Clinical manifestations: Arsenic in both organic and inorganic forms is sometimes used therapeutically May produce symptoms of either acute or chronic poisoning – Arsenic poisoning Clinical manifestations: Diffuse macular pigmentation Palmar and plantar hyperkeratosis Pre-malignant lesions called “Arsenical Keratosis” Basal cell carcinoma Cutaneous Squamous Cell Carcinoma Severe gingivitis Hyper salivation

Bismuth Oral Manifestations: Used for treating certain dermatologic disorders Oral Manifestations: Bismuth pigmentation of the oral mucosa, particularly of the gingiva and buccal mucosa pigmentation appears as a thin blue-black line in the marginal gingiva, which is sometimes confined to the gingival papilla - 'Bismuth Line‘ Pigmentation are seen in the buccal mucosa, the lips, the ventral surface of the tongue etc. Burning sensation of the mucosa Metallic taste

Mechanism : The pigments represent precipitated granules of bismuth sulfide produced by the action of hydrogen sulfide The hydrogen sulfide is formed through bacterial degradation of organic material or food debris and is most common in sites of food retention

Rx No specific treatment Can be bleached with hydrogen peroxide The line will gradually disappear over a long period of time if use of the bismuth compound is discontinued

gold Gold has been used in the past as a therapeutic drug Now a days only used in management of rheumatoid arthritis General manifestations: Dermatitis often preceded by pruritis Alopecia Loss of nails Slate-blue discoloration of sun-exposed skin (Chrysiasis)

Oral manifestations: Metallic taste Oral mucositis affecting the buccal mucosa, the lateral border of the tongue, palate, and pharynx

Dilantin/Phenytoin sodium Dilantin sodium - Anticonvulsant drug used for the control of epileptic seizures Manifestations: Gingival enlargement may begin as early as two weeks after intake Painless increase in the size of the gingiva Enlargement of one or two interdental papillae Surface of the gingiva shows an increased stippling and finally a cauliflower, warty, or pebbled surface

As enlargement increases, the gingival tissue becomes lobulated Enlarged gingiva may cover a portion or all of the crowns of many of the involved teeth Lingual and occlusal extension of the overgrowths may interfere with proper mastication and speech Enlargement may occur in localities apart from the gingiva, such as the palate in patients wearing a prosthetic appliance

Mechanism: Stimulate formation of epithelium & connective tissue and inactivates collagen (i.e.) increase production of collagen

Histopathology: Hyperplasia Acanthosis Long test tube like rete peg formation Increase fibroblasts & collagen fibres Chronic inflammatory cell infiltration

Rx Eliminate local irritants Alternative drug therapy Gingivectomy

LEAD (Pb) Lead poisoning (plumbism) -occupational hazard In adult Poisoning is through inhalation of lead vapor or dust. In infants Most cases result from ingestion by the child while chewing on wood painted with lead-containing paint

Clinical Features: Gastrointestinal disturbances Anemia Fatigue Nausea Vomiting Abdominal colic Constipation Anemia Fatigue Irritability, and Weakness Encephalopathy and renal dysfunction Dysfunction of the nervous system, kidneys, bone, and joints

Oral manifestation: Formation of a lead line - Burtonian's line It is gray or bluish black line of sulfide pigmentation occurs in the gingiva It is also found occasionally in other areas of the oral cavity Ulcerative Stomatitis Excessive salivation (Ptyalism) Metallic taste Salivary glands swelling Advanced periodontal disease and Tremor of the tongue

Mercury Mercury poisoning may be acute or chronic Systemic reactions in the acute form are so serious that the oral features need not be considered Chronic mercurialism occurs after prolonged contact with mercurial compounds including therapeutic use & as an occupational hazard

Elemental mercury – Harmless Mercury vapors – Hazardous Ingestion of mercury salts has adverse reactions The level of mercury released from amalgam restorations does appear sufficiently high to cause disease

Clinical features: Acute mercurialism: Abdominal pain Vomiting Diarhoea Thirst pharyngitis

Chronic Mercurialism Gastric disturbances Diarrhoea Insomnia Headache Mental depression Nephritis Fine tremors of the fingers and limbs

Oral manifestations: Ptyalism Metallic taste in the mouth due to excretion of mercury in the saliva Swollen salivary glands & tongue Hyperemia & Gingivitis Ulcerations of oral mucosa Alveolar bone destruction & loosening and exfoliation of the teeth.

ACRODYNIA (Pink disease, Swift's disease) Chronic mercury exposure in infants & children (2-6 years) Clinical features: The skin of the hands, feet, nose, ears, and cheeks becomes red/pink and has a cold, clammy feeling- “Raw Beef Appearance” The children will frequently tear their hair out in patches

Pruritic maculopapular rash Severe sweating Irritability photophobia Lacrimation muscular weakness tachycardia Hypertension Insomnia gastrointestinal upset & Stomatitis

Pruritic maculopapular rash

Rx Oral manifestations: Profuse salivation and often much dribbling Sensitive & painful gingiva with ulcerations. Bruxism Loosening and Premature shedding of teeth (Many times, the child will extract loose teeth with his fingers) Rx Discontinuance of exposure to mercury Administration of BAL (British anti-lewisite; Dimercaprol)

silver (Argyria, Argyrosis) Occupational hazard or as the result of therapeutic use of silver compounds such as silver arsphenamine or silver nitrate Silver is disseminated throughout the body with substantial amounts accumulating as sub-epithelial deposits in the skin. These deposits result in a diffuse grayish-black pigmentation, occurring primarily in sun exposed areas

Sclerae and Nails are pigmented Slate-blue silver line along the gingival margins FIRST SIGN Diffuse Bluish Black discoloration of the oral mucosa

Amalgam Tattoo Accidental implantation of silver-containing compounds into the oral mucosal tissue usually results in a permanent gray black pigmentation, commonly referred to as “Amalgam Tattoo” They are named so as the most common source of embedded silver compounds is restorative amalgam The most common locations for amalgam tattoos are gingiva buccal mucosa and alveolar mucosa

Clinical feature: Histopathology: Amalgam tattoos appear as blue, black or gray macules, or rarely as slightly raised lesions Histopathology: Scattered fragments of the metal with in the connective tissue Fine black/brown granules Inflammatory reaction

tetracycline Discoloration of either deciduous or permanent teeth During prophylactic or therapeutic regimens instituted either to the pregnant female or postpartum in the infants Deposition in bone/teeth by formation of calcium tetracycline complex Discolouration depends on dosage duration form of tetracycline Age of the patient

Portion of the tooth stained depends on the stage of tooth development Critical period Deciduous teeth: 4 months in utero to 3 months postpartum for maxillary & mandibular incisors 5 months in utero to 9 months postpartum for maxillary & mandibular canines Permanent teeth: 3 – 5 months postpartum to 7 years of age for maxillary & mandibular incisors & canines

Clinical features: Yellowish or brownish – gray diffuse bands of discoloration seen with in the tooth structure Becomes more brown after exposure to light Tetracycline fluoresces under ultraviolet light, and accordingly, the teeth involved by its discoloration also fluoresce a bright yellow under ultraviolet light Minocycline staining is seen in skin, nails, sclera, thyroid, bones & teeth Teeth reveal varying patterns of discoloration

The crowns exhibiting blue-gray discoloration at the incisal three-fourths The exposed roots of erupted teeth revealing dark green discoloration Roots of developing teeth demonstrating a dark black color The discoloration of the dentition remains after discontinuance of the medication, Cutaneous staining fades away after discontinuation of medication

Rx Full crown Bleaching Bonded restorations Composite build up Veneering

Cancer chemotherapeutic agents The aim of cancer therapy is to primarily destroy the neoplastic cells A significant percentage of individuals however develop oral complications after this therapy The oral complications of the cancer therapy result due to the destruction of normal cells along with the neoplastic cells destruction

Clinical features: Alopecia Stomatitis, which may take a variety of forms Radiation sensitization Dermatitis

Oral manifestations: Mucositis and Ulceration Hemorrhage Xerostomia Loss of Taste (Dysgeusia) Osteoradionecrosis Trismus Demineralization Difficulty in Speech and Swallowing Herpes simplex infection Candidal infection

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