Immune checkpoint inhibitors impact in dentistry

Immune Checkpoint Inhibitors: The Silent Disruptor in Your Dental Chair

Immune checkpoint inhibitors (ICIs) are a big deal in cancer care. Drugs like nivolumab, pembrolizumab, and ipilimumab are turning once-hopeless cases into long-term survivorship stories. But they do have an side effects that your dentist may catch. If you’re a dentist—or a patient on ICIs—its important to understand what the oral side effects are and what to do to limit the damage.

What Are Immune Checkpoint Inhibitors?

They’re drugs that take the brakes off the immune system, helping it recognize and destroy cancer cells. Think of them as immune system “unleashers.”They target molecules like:

  • PD-1/PD-L1 (Programmed Death-1 / Ligand-1)
  • CTLA-4 (Cytotoxic T-Lymphocyte Antigen-4)

By doing this, they give T-cells the green light to attack not just tumors—but, unfortunately, sometimes your own healthy tissues, including those in your mouth.

Oral Side Effects from Immune Checkpoint Inhibitors:What are the dental concerns. 

Immune-related adverse events (irAEs) in the mouth can be unpredictable, painful, and hard to manage. Here’s what we’re seeing:

1. Oral Mucositis (a.k.a. Mouth Sores)

  • Painful ulcers that don’t follow trauma patterns.
  • Not dose-dependent like chemo-induced mucositis.
  • Can interfere with eating, talking, and oral hygiene.

2. Xerostomia (Dry Mouth)

  • Damage to salivary glands = Sahara Desert in your mouth.
  • Causes a huge increases in risk for caries and to a lesser extent fungal infections.

3. Lichenoid Reactions

  • White, lacy patches that mimic lichen planus.
  • May look like simple irritation—but often persist and recur.
Immune Checkpoint Inhibitors impact on oral health and dental care
Lesions from Kachlan Gen Dent 2025 seem pretty minor.

4. Autoimmune-like Conditions

5. Jaw Osteonecrosis (Rare but Nasty)

  • Seen in patients on combination therapies or with bisphosphonates.
  • Mimics medication-related osteonecrosis of the jaw (MRONJ).

Dental Implications: What changes should we make for Immune Checkpoint Inhibitor patients? 

Let’s get real: If your patient is on ICIs, your “routine” cleaning or extraction might not be so routine anymore. Here’s what needs to change:

⚠️ 1. Medical History Must Be Bulletproof

  • Ask what drug, how long, and which cancer.
  • Coordinate with oncology—don’t assume anything is safe.

🦷 2. Pre-Treatment Dental Clearance Is Crucial

  • Catch infections, fractures, or periodontal disease before they become complications during ICI therapy. Get aggressive with diagnosis especially if you can complete things before the medication starts.

🧪 3. Saliva Testing and Caries Management

  • Dry mouth = caries magnet.
  • Switch patients to high-fluoride toothpaste, saliva substitutes, or prescription rinses.

🧻 4. Biopsy Suspicious Lesions

  • Don’t guess. Lichenoid lesions or ulcers may mimic malignancy or rare immune reactions.

💊 5. Avoid Immunosuppressive Overlap

  • Be cautious with systemic corticosteroids. They can interfere with the anti-tumor effects of ICIs unless truly necessary.

Bottom Line: We’re In New Territory with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors are revolutionizing oncology, but they’re also throwing curveballs into dental care. These patients don’t behave like your typical chemo or radiation cases. You’ve got to stay alert, think systemically, and collaborate tightly with the rest of the care team.

Here’s a list of FDA-approved immune checkpoint inhibitors as of 2025, grouped by their target pathways:

🧬 PD-1 Inhibitors (Programmed Death-1)

These block PD-1 on T cells, preventing tumor cells from “hiding.”

  1. Nivolumab (Opdivo)

    • Bristol-Myers Squibb

    • Approved for: melanoma, NSCLC, RCC, head & neck cancer, Hodgkin lymphoma, others

  2. Pembrolizumab (Keytruda)

    • Merck

    • Approved for: melanoma, NSCLC, urothelial carcinoma, triple-negative breast cancer, many others

  3. Cemiplimab (Libtayo)

    • Regeneron / Sanofi

    • Approved for: cutaneous squamous cell carcinoma, NSCLC, cervical cancer

  4. Toripalimab (Loqtorzi)

    • Coherus / Junshi Biosciences

    • Approved for: nasopharyngeal carcinoma

🧬 PD-L1 Inhibitors (Programmed Death-Ligand 1)

These block the ligand, PD-L1, usually expressed on tumor cells.

  1. Atezolizumab (Tecentriq)

    • Genentech / Roche

    • Approved for: NSCLC, urothelial carcinoma, triple-negative breast cancer, HCC

  2. Durvalumab (Imfinzi)

    • AstraZeneca

    • Approved for: NSCLC, bladder cancer, biliary tract cancers

  3. Avelumab (Bavencio)

    • Merck KGaA / Pfizer

    • Approved for: Merkel cell carcinoma, urothelial carcinoma, RCC

🧬 CTLA-4 Inhibitors (Cytotoxic T-Lymphocyte–Associated Protein 4)

These release another brake on T-cell activation.

  1. Ipilimumab (Yervoy)

    • Bristol-Myers Squibb

    • Approved for: melanoma, RCC, NSCLC (often combined with nivolumab)

  2. Tremelimumab (Imjudo)

    • AstraZeneca

    • Approved for: HCC, NSCLC (in combination therapies)

🧬 Other / Emerging Immune Checkpoint Inhibitor Targets

(These are either newly approved or in trials. Some may be FDA-approved for niche indications.)

  • Relatlimab (targets LAG-3) – approved in combination with nivolumab (Opdualag)

  • Others in clinical trials (not FDA-approved yet): TIM-3, TIGIT, VISTA, B7-H3 inhibitors

✅ Total FDA-Approved ICI (Immune Checkpoint Inhibitors) Drugs (as of 2025): 9 core drugs

  • PD-1: 4

  • PD-L1: 3

  • CTLA-4: 2

  • 1 combo (nivolumab + relatlimab)