A 52-year-old male with chronic migraines takes amitriptyline (Elavil®). He presents with a chipped front tooth (#9). An Ellis class I fracture is noted on tooth #9. What is a direct side effect of amitriptyline?

Correct answer: A. Xerostomia

• A. CORRECT. Amitriptyline is a tricyclic antidepressant (TCA) with strong anticholinergic properties. Anticholinergic effects directly reduce salivary flow, causing xerostomia (dry mouth). This is one of the most common and significant oral side effects of TCAs and has important dental implications including increased caries risk.
• B. INCORRECT. Candidiasis is an indirect consequence of xerostomia (reduced saliva = less antimicrobial defense), not a direct side effect of amitriptyline. Candida infections may develop secondary to dry mouth but are not a direct pharmacological effect of the drug.
• C. INCORRECT. Gingival hyperplasia is associated with calcium channel blockers (e.g., amlodipine, nifedipine), phenytoin (anticonvulsant), and cyclosporine (immunosuppressant). Amitriptyline does not cause gingival overgrowth.
• D. INCORRECT. Burning mouth syndrome can be associated with medication effects, nutritional deficiencies, or psychogenic factors, but it is not a direct, established side effect of amitriptyline. Xerostomia, however, can cause oral discomfort that may feel like burning.