The Biologic Therapy “Rituximab”: Its Uses in Oral Medicine and Adverse Oral Effects: A Narrative Review

Rituximab is an anti-CD20 monoclonal antibody that targets B lymphocytes, reducing antibody production. As a result, it is widely used to treat lymphomas, leukemia, and autoimmune diseases. This review aims to discuss the applications of rituximab in treating oral diseases and to highlight its potential adverse effects. It also summarizes guidelines from publications on managing patients receiving biologic therapies, including rituximab. A search of PubMed, Medline, Web of Science, Scopus, and Google Scholar was conducted using terms, such as rituximab, oral manifestations, adverse effects, periodontitis, gingivitis, autoimmune disease, and dental considerations. Case studies, case reports, and reviews with no publication date restrictions were included. The literature supports rituximab's effectiveness in managing oral lesions associated with autoimmune conditions, like pemphigus vulgaris, mucous membrane pemphigoid, paraneoplastic pemphigus, lupus erythematosus, and Behçet’s disease, using doses similar to lymphoma or rheumatoid arthritis protocols. However, its effectiveness for recurrent oral aphthous ulcers is not well established. Rituximab also shows promise in improving salivary gland function and reducing antibody titers in patients with Sjögren’s syndrome. Clinical reports have shown success in treating refractory cases of desquamative gingivitis, periodontitis, oral lichen planus, and vasculitis. Nevertheless, oral adverse effects have been reported, with medication-related osteonecrosis of the jaws (MRONJ) being the most severe side effect. Other side effects include oral lichenoid reactions observed in lymphoma cases treated with rituximab and infections caused by fungi, viruses, and bacteria. Animal studies indicate that rituximab can impair wound healing. There is a lack of standardized guidelines for the dental management of patients on rituximab therapy; available information is based on clinical experiences of physicians and surgeons. Dental professionals should be aware of the increased bleeding risk in these patients and eliminate all potential risk factors for MRONJ. For patient safety, individuals receiving rituximab should be under the supervision of a healthcare professional, such as a dentist or an oral medicine specialist experienced in managing biologic therapies, both before and after treatment. Keywords: Rituximab, Oral manifestations, Adverse effects, Dental considerations, Dental managemen