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Table of Contents
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 80-83

Dental decay and salivary flow in patients taking systemic isotretinoin: A prospective study

1 Department of Dental, Ministry of Health, King Saud University, Riyadh, Saudi Arabia
2 Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Dermatology, King Saud University, Riyadh, Saudi Arabia

Date of Submission18-Nov-2020
Date of Acceptance02-Jun-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Fawziah Alfaifi
Department of Dermatology, King Saud University, P.O.Box - 7805, Riyadh - 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_122_20

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Background: Isotretinoin causes dryness of the mucous membranes. Medications altering the salivary flow are a risk factor for dental caries. Purpose: To prospectively assess caries and salivary flow in patients taking systemic isotretinoin. Methods: Twenty-four patients treated with 0.5 mg/kg of isotretinoin every day for 8 months were studied. The control group was the same patients before start taking oral Isotretinoin. Salivary flow, buffer capacity, bacterial tests, and caries status based on the decay, missing, and filled teeth (DMFT) index were assessed. Results: At baseline, there was slight to moderate calculus on the teeth. DMFT index, stimulated saliva flow, and bacterial tests for Streptococcus mutans increased during isotretinoin treatment (P < 0.05). There was no significant difference (P > 0.05) in buffering capacity or Lactobacillus. Conclusion: Systemic isotretinoin increased the DMFT index and bacteria rate and decreased salivary flow that might lead to dental caries.

Keywords: Dental decay, isotretinoin, salivary flow

How to cite this article:
Alkanhal NA, Aldaij MH, Alkanhal HA, Al-Haddab M, Alfaifi F. Dental decay and salivary flow in patients taking systemic isotretinoin: A prospective study. J Dermatol Dermatol Surg 2021;25:80-3

How to cite this URL:
Alkanhal NA, Aldaij MH, Alkanhal HA, Al-Haddab M, Alfaifi F. Dental decay and salivary flow in patients taking systemic isotretinoin: A prospective study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:80-3. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/80/341195

  Introduction Top

Acne is the most common skin condition.[1],[2] Isotretinoin has been used extensively to treat moderate-to-severe acne.[1],[2],[3] Mucocutaneous and ophthalmological adverse events are common.[4],[5] Isotretinoin suppresses sebum production, causing drying of the skin and mucosa.[6],[7]

Saliva is important for the maintenance of soft and hard oral tissue integrity and the prevention of dental caries.[8] The functions of saliva include lubrication of the soft tissue, antimicrobial activity, a buffering effect, and mechanical cleansing of oral debris and noxious agents.[8],[9]

Decrease salivary flow is a risk factor for dental caries.[10] Salivary flow can be affected by drugs, radiation therapy for head and neck cancer, and Sjögren syndrome.[11] Dental caries is a pathological process driven by cariogenic bacteria in the mouth and the host immune system, as well as local conditions in the oral environment.[12] The number of decayed, missing and filled teeth (DMFT) index is one of many methods used for assessing dental caries.[13]

The aim of this study was to prospectively assess dental caries and salivary flow in patients taking systemic isotretinoin.

  Methods Top

The patients were evaluated in this study from February 2017–Dec 2019. This study was conducted at the Dermatology Department of King Khaled University Hospital. This research was approved by the Institutional Review Board (E-17-2273). Based on power and sample size program software for a chosen power of 0.85 and an alpha coefficient of 0.05, 40 patients were recruited [Table 1]. A total of 24 patients met the inclusion criteria when seen in a regular appointment with their dermatologist and completed three dental visit examinations. Sixteen patients were excluded because they stopped taking the medication, skipped their appointments, or left Riyadh city.
Table 1: Inclusion and exclusion criteria

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The patients were treated with 0.5 mg/kg of isotretinoin (Roaccutane)® every day for 8 months as decided by their dermatologist. The patients who participate in this study acted as a control group before start taking Isotretinoin. Gender and age were recorded, and all patients were asked about their oral hygiene and drug intake to make sure that all patients used the same oral hygiene approach before and while taking systemic Isotretinoin.

  • At the 1st and 3rd visit: The teeth were assaessed by using a disposable oral kit examination (include a dental mirror, a probe and explorer), then we assessed salivary flow, pH, Streptococcus mutans (SM) and Lactobacillus (LB) by using a caries risk test (CRT®) kit (Intro Pack, Ivoclar Vivadent AG, Schaan, Liechtenstein) [Figure 1]
  • At the 2nd visit: Patients were asked about oral hygiene, dietary habits, if they had any changes in the oral cavity (such as dryness, stained teeth, calculus, and cavitation), if they had visited a dental clinic, and if they were still using the medication [Figure 1].
Figure 1: Study synopsis. Each patient enrolled in this study was subjected to three visits over 8 months. The same patients acted as a control group before receiving the medication systemic isotretinoin is (T0). The measurements were taken from the same patients at the end of treatment with systemic isotretinoin is (T1)

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Decay, missing, and filled teeth index procedure/oral examination:

We assessed the teeth by using the DMFT index for all teeth, excluding the third molars. One blinded examiner did all of the clinical evaluations. No radiological examination was undertaken.

Saliva flow rate procedure

Patients chewed an enclosed paraffin pellet for 5 min, and their saliva specimens were collected in a suitable container, then the volume was measured by using a disposable syringe. After that, the rate of saliva in millimeter per minute was obtained by dividing the stimulated saliva by 5 min.[14]

Buffering capacity

Buffer capacity was determined by using the pH test field, and the entire yellow test was wetted with the patient's saliva collected from the container by a pipette. After 5 min of reaction time, the color of the test field was compared with the color samples.

A blue color indicated a value of 3, which is a high buffer capacity; a green color indicated 2, which is a medium buffer capacity; and yellow indicated 1, which is a low buffer capacity of the saliva.[15]

Bacterial test

The agar was removed from the test vial and a NaHCO3 tablet was placed at the bottom of the vial. The protective foils were carefully removed from the two agar surfaces. Both agar surfaces were wetted with the saliva using a pipette without scratching the agar surface. The test vial was placed upright in an incubator at 37°C for 48 h. After removing the vial from the incubator, the density of the SM and LB colonies were compared with the corresponding evaluation pictures in the enclosed model chart. The counts of SM and LB in the saliva were as follows: SM/LB value 1: Bacterial counts <105 CFU/ml saliva (colony-forming units/milliliter), which indicated a low caries risk; SM/LB value 2: Bacterial counts: >105 CFU/ml saliva, which indicated a high caries risk.[15]

All parameters were evaluated at two different time points:

  • T0: Represents measurements that were taken before treatment with systemic isotretinoin
  • T1: Represents measurements that were taken at the end of treatment with systemic isotretinoin.


The statistical analyses were performed by using the Statistical Package for the Social Sciences (SPSS) software, version 21 (IBM SPSS Statistics, Chicago, IL, USA). Data were analyzed with the paired samples t-test. Statistically significant was considered when the P < 0.05.

  Results Top

The distribution of the study sample according to gender is 14 (58.3%) of the participants were female, while 10 (41.7%) were male [Figure 2]. The flow chart of the study is given in [Figure 3]. DMFT index was higher at T0 than at T1 [P < 0.05, [Table 2]]. Stimulated saliva flow was higher in all patients at T0 than at T1 [P < 0.05, [Table 3]].
Figure 2: Sample distribution according to gender

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Figure 3: The follow chart of the study

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Table 2: Paired samples test (Decay, Missing and Filled Teeth)

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Table 3: Paired samples test (stimulated salivary flow)

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Buffering capacity was similar between T0 and T1 [Table 4]. There was an increase in the counts of SM bacteria [P < 0.05, [Table 5]] but not of LB bacteria [P > 0.05, [Table 5]].
Table 4: Paired samples test (buffering capacity)

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Table 5: Paired samples test (caries risk test: Bacterial test Streptococcus mutans and lactobacillus)

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  Discussion Top

Most of the patients at the end of this study had increased rates of caries, especially on the buccal surface, palatal surface, or both and had slight to moderate calculus on the teeth consistent with increase the number of bacteria and decrease of saliva flow. Starting from the 3rd month on isotretinoin, the patients had a stain on their teeth and dryness of their mouths and lips. Moreover, there was an increase in the DMFT index during the treatment in all patients between T0 and T1. On the other hand, Lupi-Pégurier et al. reported the final DMFT scores did not differ significantly between the control and treated groups, but the difference in the DMFTfinal–DMFTbase line was compared between the two groups, and it was higher in the treated cohort.[16]

Stimulated salivary flow measurement is essential for testing salivary gland function.[17],[18] Hyposalivation is considered when the salivary flow rate is <0.7 ml/min.[18] In the current study, the salivary flow rates decreased. In addition, 7 patients after 8 months under this medication had lower than the described hyposalivation threshold. Lupi-Pégurier et al.'s study used a salivary flow baseline– salivary flow end of treatment that was compared between the control and treated groups, and it was significantly higher in the treated cohort.[16]

Dental caries is associated with a high count of SM and LB. The SM plays a central role in the initiation of dental caries (fissures and smooth surfaces), while the LB are responsible for the progression of carious lesions and their main ecological site is carious dentin.[19] In our study, the rates of pathogenic bacteria (SM) were higher during isotretinoin treatment, representing more than 105 CFU/ml bacteria in the saliva comparing between the T0 and T1. The rates of pathogenic bacteria (LB) showed an insignificant but gradual increment. Lupi-Pégurier et al. reported the rates of SM and LB did not vary with time in either the control group or treated group.[16]

Regarding the buffering capacity, there was a gradual decrease in the mean of the high pH values observed during isotretinoin treatment, but it did not reach the significance level, similar to Lupi-Pégurier et al.'s finding.[16]

  Conclusion Top

Systemic isotretinoin increased the DMFT index and bacteria rate and decreased salivary flow rate. These changes may predispose patients to a greater risk of dental caries. We advise the dermatologist to consider counseling patients to visit the dental clinic regularly during their treatment with systemic isotretinoin. Furthermore, we advise the patients to follow oral hygiene instructions and use fluoride gel and xylitol gum to stimulate salivary flow. Limitations of this study include a small sample size, difficulty of follow-up, and failure to follow patients for more than 6 months after the last dose.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Quéreux G, Volteau C, N'Guyen JM, Dréno B. Prospective study of risk factors of relapse after treatment of acne with oral isotretinoin. Dermatology 2006;212:168-76.  Back to cited text no. 1
Zouboulis CC. The truth behind this undeniable efficacy–Recurrence rates and relapse risk factors of acne treatment with oral isotretinoin. Dermatology 2006;212:99-100.  Back to cited text no. 2
Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004;292:726-35.  Back to cited text no. 3
Charakida A, Mouser PE, Chu AC. Safety and side effects of the acne drug, oral isotretinoin. Expert Opin Drug Saf 2004;3:119-29.  Back to cited text no. 4
Hanson N, Leachman S. Safety issues in isotretinoin therapy. Semin Cutan Med Surg 2001;20:166-83.  Back to cited text no. 5
Reynolds NJ, Gough M, Clamp JR, Burton JL. Effect of oral isotretinoin therapy on saliva volume and composition. Br J Dermatol 1991;125:189-90.  Back to cited text no. 6
Oikarinen K, Salo T, Kylmäniemi M, Palatsi R, Karhunen T, Oikarinen A. Systemic oral isotretinoin therapy and flow rate, pH, and matrix metalloproteinase-9 activity of stimulated saliva. Acta Odontol Scand 1995;53:369-71.  Back to cited text no. 7
Stookey GK. The effect of saliva on dental caries. J Am Dent Assoc 2008;139 Suppl: 11S-17S.  Back to cited text no. 8
Lenander-Lumikari M, Loimaranta V. Saliva and dental caries. Adv Dent Res 2000;14:40-7.  Back to cited text no. 9
O'Sullivan EA, Curzon ME. Salivary factors affecting dental erosion in children. Caries Res 2000;34:82-7.  Back to cited text no. 10
Dawes C. Salivary flow patterns and the health of hard and soft oral tissues. J Am Dent Assoc 2008;139 Suppl: 18S-24S.  Back to cited text no. 11
Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat Rev Dis Primers 2017;3:17030.  Back to cited text no. 12
Hiremath SS. Indices. In: Hiremath SS. Textbook of Preventive and Community Dentistry. 2nd ed. India: Elsevier; 2011. p. 198-221.  Back to cited text no. 13
Joel A, Zurisadai N, Alejandra L, Hector M, Jany A, Alma N, et al. The importance of pH, salivary flow and different dental caries risk factors in pregnant women. J Dent Oral Hyg 2018;10:18-22.  Back to cited text no. 14
Baygin O, Tuzuner T, Ozel MB, Bostanoglu O. Comparison of combined application treatment with one-visit varnish treatments in an orthodontic population. Med Oral Patol Oral Cir Bucal 2013;18:e362-70.  Back to cited text no. 15
Lupi-Pégurier L, Muller-Bolla M, Fontas E, Ortonne JP. Reduced salivary flow induced by systemic isotretinoin may lead to dental decay. A prospective clinical study. Dermatology 2007;214:221-6.  Back to cited text no. 16
Erdemir U, Okan G, Gungor S, Tekin B, Yildiz SO, Yildiz E. The oral adverse effects of isotretinoin treatment in acne vulgaris patients: A prospective, case-control study. Niger J Clin Pract 2017;20:860-6.  Back to cited text no. 17
[PUBMED]  [Full text]  
Navazesh M, Kumar SK, University of Southern California School of Dentistry. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 2008;139 Suppl: 35S-40S.  Back to cited text no. 18
Karpiński T, Szkaradkiewicz A. Microbiology of dental caries. J Biol Earth Sci 2013;3:M21-4.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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