Nutrition and Oral Medicine (Nutrition and Health)

Chapter 6 / Medications, Nutrition, Diet, and Oral Health 99reversible within a few months, even with continued therapy (38). Therapies such asHAART, protease inhibitors, clarithromycin, and lansoprazole (Prevacid) therapy forHeliobacter pylori infection, terbinafine, pentamidine, and isotretinoin (Accutane) maycause some degree of loss of taste or altered taste. Taste disturbances tend to be selflimitingand often reversible in 2–3 mo following discontinuation of the medication. Itmay be feasible to contact the patient’s physician to see whether there are substitutemedications that can be used that have less effect on either salivary flow or taste. Possibleapproaches to relief from dysgeusia include increased use of flavoring agents during foodpreparation, substituting alternative protein sources if the patient is unable to toleratemeat, and use of artificial saliva as needed. Optimal oral hygiene is essential. Use of a“swish and spit” with iced lemon water can temporarily decrease dysgeusia and increasepatient comfort and satisfaction with subsequent meals (39). Patients should be reassuredthat, in most cases, taste will return to baseline. If the patient has persistent taste disturbances,a referral to an oral medicine specialist would be appropriate.6.3. Stomatitis/GlossitisStomatitis (inflammation of the mucosal lining of the mouth) from medications canbe caused by both local effects and systemically mediated responses. Pain from mucosallesions can be severe and can interfere with eating. Some cases of drug-induced stomatitishave no clinical presentation other than erythema, whereas other cases can be categorizedas allergic stomatitis, lichenoid drug eruptions, lupus erythematouslikeeruptions, pemphiguslike drug reactions, and erythema multiforme (40). Ulceration ofthe oral mucosa is a common side effect of a wide variety of antineoplastic agents,including methotrexate, 5-fluorouracil, doxorubicin, daunorubicin, bleomycin, andmelphalen through inhibition of epithelial cell mitosis (41). Allergic reactions can occureither locally from contact with the medication or from systemic administrations ofthe drug. Lichenoid drug eruptions have been linked to a number of medications, includingantibiotics (tetracycline, penicillin, sulfonamides, nitrofurantoin, isoniazid, paraaminosalicylic acid, streptomycin, ketoconazole, griseofulvin), oral hypoglycemics(sulfonylureas), antihypertensives (-adrenergic blocking agents [methyldopa]); ACEinhibitors (captopril; reserpine), nonsteroidal anti-inflammatory agents (indomethacin,azulfidine, phenylbutazone, naproxen) (42), and heavy metals (especially gold compounds)(43). Secondary oral effects may be seen with drug-induced vitamin deficiencies(Table 2), including the B-complex vitamins, iron, vitamin C, and vitamin A.Thiaminedeficiency (often the result of chronic alcoholism) may lead to painful mucosaand small vesicles on the buccal mucosa and tongue. Riboflavin (vitamin B 2 ) and pyridoxine(vitamin B 6 ) deficiency has been associated with angular cheilitis, atrophic glossitis,burning mouth, and mucosal ulcerations. Isoniazid, which inhibits the metabolismof B 6 , can be associated with peripheral neuritis affecting the cranial nerves that supplythe oral cavity. Acute deficiencies in niacin, folic acid, or vitamin B 12 can cause the oralmucosa to become red, swollen, and tender to the touch. Pernicious anemia caused byvitamin B 12 deficiency and folic acid deficiency can cause painful glossitis and gingivitis,as well as atrophy of the papillae of the tongue, resulting in a “bald” tongue.Long-term use of methotrexate, cholestyramine (Questran), colchicines, sodiumaminosalicylate, ethanol, metformin (Glucophage), methyldopa, cimetidine (Tagamet),allopurinol (Zyloprim), and oral contraceptives have all been implicated in vitamin B 12