Management of oral complications of disease-modifying drugs in rheumatoid arthritis

Stomatitis is a troublesome adverse effect of disease-modifying anti-rheumatic drug (DMARD) therapy in rheumatoid arthritis (RA) patients. Thisreview presents data to examine the incidence, clinical features andconsequences of DMARD-related stomatitis, and suggests an algorithm for itsclinical management. The specific objectives of the two studies presentedhere were to determine the incidence of DMARD-related stomatitis and itseffect on DMARD continuation, and secondly to identify the clinical andlaboratory risk factors. We investigated two cohorts of patients: (i) aretrospective survey of data collected from drug monitoring clinics run forpatients on DMARDs from 1987 to 1994 involving 1539 patients and 2394 drugexposures; (ii) a prospective study of 25 consecutive RA patientspresenting with DMARD-related stomatitis compared to 29 RA controls with nohistory of DMARD stomatitis. The retrospective survey showed that 2% ofDMARD patients stopped therapy because of stomatitis, but 55% of these wereable to resume the same therapy. In the case control study. 24% of patientsdiscontinued temporarily and 8% permanently. Cases of DMARD-relatedstomatitis differed from controls in that they had a higher incidence ofprevious mouth ulcers (40% vs 14%), they smoked less (8% vs 31%) andSchirmer's test was more often abnormal (44% vs 21%). There were nodifferences in RA severity, disease activity or oral hygiene. Haematinicdeficiencies were equally common in cases and controls: 30% for iron, 8%for vitamin B12 and 24% for folic acid. Herpes simplex virus was involvedin a minority (8%) of cases. In conclusion, the occurrence of stomatitis inRA patients on DMARD should not lead to cessation of drug therapy, but to acareful evaluation so that patients may be maintained on effectivetreatment.