Lupus
Dental Concers For Lupus Patients
Patients with systemic lupus erythematosus (SLE) may have a variety of oral problems or concerns. Oral complications associated with SLE can be either directly related to this disorder or occur as a side effect of the medical therapy needed to control SLE. Close coordination between the lupus patient, their physician and the dentist is the single most important ingredient in both prevention and treatment of these complications. SLE is a chronic, progressive autoimmune disorder, which normally cycles through periods of flare-ups followed by quiescence. SLE can affect most major organs in the body The oral cavity is usually involved 50 percent or more of the time. As a general rule, the condition of the mouth will reflect the medical control of the lupus.
Unfortunately, no cookbook answers can be offered in an article such as this one because each lupus patient has a unique set of circumstances surrounding her/his disorder. Therefore, the following comments should be considered as quite general and may or may not apply to any given patient with SLE.
Approximately 50 percent of patients with SLE have some degree of kidney involvement. While routine dental treatment will not likely directly affect a patient’s renal condition, the prescription of certain antibiotics or analgesics by the dentist could become problematic if these medications are known to adversely affect renal function. Examples of these medications might include tetracycline, aspirin or nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen.
Cardio-respiratory disorders are also seen in some lupus patients. Of most significance is the so-called Liebman-Sacks endocarditis, which is found in approximately 50 percent of patients at the time of autopsy Unfortunately, this heart condition may not be detected by a physician. Therefore, current recommendations suggest that dental patients with SLE be given antibiotics prior to invasive dental visits, which are likely to result in bacteria entering the blood stream. This measure is intended to prevent an infection of the heart valves. In patients who have lupus-related lung problems, nitrous oxide (laughing gas) may be a problem because of its tendency to depress breathing.
Twenty-five percent of lupus patients have an antibody known as the “lupus anticoagulant.” When this antibody is found in the presence of a platelet deficiency, abnormal bleeding may occur. Certainly, periodontal surgery or the extraction of teeth might become a problem in these circumstances. One of the defining criteria for the diagnosis of SLE is arthritis. A number of medications are employed by physicians to control arthritis. NSAIDS might result in oral aphthous-like ulcers (canker sores). Plaquenil is also used in some circumstances to control arthritis and may result in a lichenoid reaction or rash on the inside of the mouth. Immunosuppressive medications such as cyclophosphamide or methotrexate may result in opportunistic bacterial infection which could compromise periodontaly involved teeth or dental implants.
Steroids such as prednisone might result in oral fungal infections such as candidiasis. For this reason, frequent dental visits and careful attention to oral hygiene practices are of paramount importance in patients with SLE. If arthritis of the hands is significant enough to compromise oral hygiene practices, the dentist may be able to suggest an electric toothbrush, which will suit a patient’s particular needs. Oral lesions of the lip and mucous membranes have been reported in about one-half of patients with SLE. The lesions are often non-specific in appearance and may look like red or white spots or lacy white lines. These lesions may be ulcerated and painful. Mouth lesions associated with SLE often resemble a common oral and skin condition called lichen planus. A simple biopsy is usually sufficient to establish the diagnosis. It is often difficult to determine whether the oral lesions are directly related to the lupus or are present because of a medication reaction.
Depending on the extent, severity and location of oral lesions, consideration should be given to obtaining a consultation from a dentist who specializes in oral medicine, oral pathology, oral surgery or periodontics. Oral therapy should address patient nutrition and hydration, oral discomfort, oral hygiene, and the management of secondary infection, as well as local control of the disease process. If the oral lesions are painful enough to limit normal dietary intake, nutritional supplementation and adequate hydration are of utmost importance. Commercially available weight-control beverages serve this purpose in a costeffective manner. Cold beverages or the use of ice chips may provide temporary relief of oral pain. Citrus fruits, carbonated beverages and other acid-containing or spicy foods will exacerbate oral discomfort, so they should be avoided. Mouth rinses containing alcohol should be avoided because of the oral discomfort, which may result from their use. One teaspoon of baking soda in eight ounces of water is an inexpensive and effective mouth rinse.
Artificial saliva substances are commercially available and can assist the SLE patient if their mouth feels dry. SLE patients must be encouraged to brush and floss their teeth after meals in a gentle, yet efficient, manner. This may be enhanced by placing a soft toothbrush under hot tap water to further soften the bristles. It can not be over-emphasized that close coordination between the lupus patient, her/his physician and dentist is the best way to ensure oral comfort and health. Every effort should be made to facilitate communication between the dentist and physician so as to protectand enhance the lupus patient’s oral and systemic health.
Reprinted with permission and thanks from Lupus Update, newsletter of the Maryland Lupus Foundation. Editorial Comment: The decision to use antibiotics as a prophylaxis for lupus patients prior to invasive dental procedures should be individualized and based on the demonstrated presence of cardiac abnormalities.