1. Chemical Injuries of Oral Cavity

2. 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

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

4. 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

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

6. 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.

7. 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”

8. 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.

9. Aspirin burn

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

20. 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

21. 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

22. 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

23. 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)

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

25. 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

26. 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

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

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

30. Rx
Eliminate local irritants
Alternative drug therapy
Gingivectomy

31. 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

32. 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

33. 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

35. 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

36. 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

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

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

39. 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.

40. 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

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

42. Pruritic maculopapular rash

43. 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)

44. 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

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

46. 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

47. 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

49. 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

50. 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

51. 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

53. 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

54. Rx Full crown Bleaching Bonded restorations Composite build up
Veneering

55. 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

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

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

58. Thank you