Comment on: “Adverse Oral Mucosal Reaction to Sublingual Captopril: A Case Report With Exploratory Insights Into AI‐Assisted Clinical Reasoning”

1.

I read with great interest the recent case report by Garcia Júnior et al., Adverse Oral Mucosal Reaction to Sublingual Captopril: A Case Report With Exploratory Insights Into AI‐Assisted Clinical Reasoning, published in Special Care in Dentistry (Volume 46, Issue 4, July/ August 2026) describing a probable oral mucosal injury associated with repeated sublingual administration of captopril and highlighting the potential contribution of structured artificial intelligence assisted clinical reasoning in establishing the diagnosis. The report addresses an important and frequently overlooked topic and deserves recognition for drawing attention to an adverse event that may be underdiagnosed in routine clinical practice [1].

Beyond the originality of the case, the report raises broader questions regarding the continued use of sublingual captopril in emergency settings. Although this practice remains common in several countries, particularly in Latin America, contemporary evidence has consistently failed to demonstrate a clinically meaningful advantage of sublingual administration over conventional oral administration for hypertensive urgency [2]. Moreover, current evidence suggests lower tolerability with the sublingual route, reinforcing concerns regarding unnecessary local exposure of the oral mucosa [2, 3].

The present case is particularly valuable because it reminds clinicians that the route of drug administration may itself become the cause of disease. In oral medicine, attention is frequently directed toward pharmacological adverse effects related to the active compound, whereas injuries resulting from inappropriate administration techniques receive considerably less attention [4]. The biological plausibility of repeated chemical irritation of the thin, highly vascularized sublingual mucosa deserves greater recognition, especially when conventional oral tablets are repeatedly retained beneath the tongue despite not being specifically formulated for this route [5, 6].

The report also highlights an important educational opportunity. Greater detail regarding the patient's pharmacological history would further strengthen the causal interpretation. Elderly patients with multimorbidity commonly receive multiple medications capable of producing oral adverse effects, making a comprehensive medication review fundamental in establishing causality [7]. Likewise, clarification regarding whether the patient received a conventional oral captopril tablet administered off‐label beneath the tongue, rather than a formulation specifically designed for sublingual delivery, would enhance the mechanistic interpretation proposed by the authors [1]. Finally, additional discussion regarding the clinical rationale for maintaining repeated sublingual administration despite progressive worsening of the oral lesion would provide valuable insight into decision‐making in emergency care and might help readers recognize similar situations in their own practice [1].

An additional factor that warrants consideration is the increased biological vulnerability of older adults to medication‐induced oral mucosal injury. Age‐related reductions in salivary gland function, frequently exacerbated by multimorbidity (hypertension and diabetes) and the use of anticholinergic medications and diuretics, contribute to hyposalivation, one of the most prevalent oral conditions among older individuals [8]. Saliva plays a fundamental role in maintaining mucosal integrity by providing lubrication, mechanical cleansing, antimicrobial protection, buffering capacity, and growth factors involved in epithelial repair. Therefore, diminished salivary flow results in a dehydrated, thinner, and more friable oral mucosa that is considerably more susceptible to chemical irritation. Under these conditions, repeated sublingual administration of medications not specifically formulated for this route may prolong local drug exposure and increase the likelihood of epithelial injury and ulceration. Recognizing hyposalivation as a potential cofactor may further explain the greater susceptibility of elderly patients to route‐specific adverse drug reactions and reinforces the importance of individualized prescribing and careful oral examination in this population [9, 10, 11].

Another noteworthy aspect of this publication is its thoughtful incorporation of artificial intelligence into the diagnostic process. Rather than portraying AI as a diagnostic substitute, the authors appropriately demonstrate its role as a cognitive support tool whose performance depends fundamentally on the quality and organization of clinician‐generated information [1]. This balanced perspective represents an important contribution to the growing discussion surrounding the responsible integration of large language models into clinical decision‐making [1].

Ultimately, this case serves not only as a report of a rare adverse oral reaction but also as a timely reminder that long‐standing empirical practices should continue to be critically reassessed considering contemporary evidence.

I congratulate the authors for bringing attention to an issue that bridges oral medicine, pharmacovigilance, and clinical reasoning, and we hope this report stimulates further discussion regarding safer evidence‐based management of hypertensive episodes and greater awareness of route‐specific adverse drug reactions.

Author Contributions

Juliana Bertoldi Franco: Involved in writing, review and editing, writing, original draft and supervision.

Ethics Statement

The author declare that no ethical statement will be required for this manuscript.

Conflicts of Interest

The author declares no conflicts of interest.