Case Reports in Medicine Figure 2: Liquorice All-Sorts with Red and Black Liquorice Twirls (by Allan Candy Toronto Ont.) and black Panda Liquorice Tubes (Elco Fine Foods, Richmond Hill, Ont.). These sweets are marketed freely to the public. Figure 3: Short lived staining of the tongue after sucking black Liquorice confection. This stain is water soluble and usually disappears after a few hours. 4.2. Liquorice Hypertension: A Case Report. A 55-year-old women presented with a brown/black tongue for routine dental check and maintenance. (See Figure 3). There was neither history of antibiotic use nor any current tobacco abuse. She had been diagnosed with hypertension two years previously. Despite multiple antihypertensive drugs, her blood pressure remained elevated. Preoperative dental of vital signs revealed blood pressure (BP) measures of Systolic 160 mm Hg/Diastolic 125 mm Hg. Although this was attributed to a possible “white-coat hypertension” phe- nomenon, she was referred to the hypertension clinic for fur- ther investigation and management of hypertension. Other than prescribed blood pressure-lowering drugs (diuretics, an ACE inhibitor and Beta-blocker), she was not taking any other medication or herbal products. She exercised regularly, denied excessive alcohol intake and consumed a “healthy” diet. On examination, casual sitting blood pressure was high, despite treatment. Routine laboratory investigations revealed hypokalemia. The diuretic was discontinued, K+ supple- + ments were given and she was advised to consume a K - rich diet. Two weeks after stopping the diuretic, plasma K+ 3 was still low and hypertension was uncontrolled. The patient was investigated for hyperaldosteronism. Plasma aldosterone and rennin levels were very low. In light of hypokalemia and reduced plasma aldosterone levels, a diagnosis of pseudo- hyperaldosteronism was made. A detailed dietary history revealed that since the patient stopped smoking 4 years ago, she started eating liquorice regularly every day. This helped her relieve her cravings for tobacco. She always enjoyed eating liquorice, but since quitting smoking she consumed at least one pack of 200–250 g or more of black liquorice daily. The patient was advised to stop eating liquorice and to continue her K+-rich diet and K+ supplementation. Three months later K+ blood level was normal. Eighteen months after presentation at the hypertension clinic and after stopping liquorice consumption, her blood biochemistry remained normal and her blood pressure was controlled to within normal limits. Much lower doses of drugs than originally used kept her BP stable and she was clinically well. 4.3. Oral and Dental Eﬀects. Drug-induced local oral reac- tions are common [25]. A wide variety of drugs may induce one or more oral reactions including allergic reactions, aphthous-like lesions, burning mouth syndrome, glossitis, ulcerations, erythema multiforme, vesiculo-bullous lesions, color changes, oral lichenoid reactions, black hairy tongue, oral mucositis, gingival hyperplasia, salivary gland changes, dental changes, oral motor disorders, oral malodours, oral infections including osteonecrosis of the jaws, angioedema, and cheilitis [25]. Liquorice not only has local oral eﬀects but also has systemic eﬀects, as the above case report shows. Glycyrrhyzin by itself does not stain teeth, but when combined with dark food dyes, tobacco and/or curries, liquorice is associated with stains. Frequently liquorice is mixed with dark caramel and food colorings which leave a surface brownish/black tongue stain (Figure 3). It contributes to increased tobacco staining, especially when included in aromatic pipe tobaccos; the dental stain is directly proportional to the amount and frequency of the pipe smoking. Not only is the palatal and lingual side of teeth prone to accumulating dark tobacco stain but also the mucosa undergoes speciﬁc changes. (Figure 4) Combined with chewing tobacco, liquorice additives enhance and prolong the ﬂavour of the chewing tobacco experience, and consequently damage from longer contact time onto the gingiva, seeming to derive more from tobacco contents rather than just liquorice. (Figures 5 and 6), Adjacent recession, cervical dentinal staining, and thickening with hyperkeratosis of mucosa are seen. 5. Discussion Liquorice eﬀects on the body are not widely acknowledged or understood by the public. This is because it is generally a pleasant experience and safe to eat liquorice ﬂavoured candies, and although it is rare for someone to gormandise on them to reach toxic levels, as the case report indicates, this does occur.