Systemic lupus erythematosus (SLE) is an autoimmune disease, predominately affecting females, that has widespread damaging effects on various body tissues. Its etiology is not fully understood but is thought to be influenced by genetic and environmental factors (Di Battista et al., 2018). SLE can present with various clinical signs and symptoms some of which affect the orofacial tissues. Furthermore, some of these orofacial features contribute to a diagnosis of SLE when considering diagnostic criteria (e.g. oral ulceration).

The aim of this review was to provide an overview of the orofacial manifestations of SLE and how SLE may influence dental treatment/management.

Methods

Searches were performed for English papers in Google Scholar and Pubmed/Medline databases over a 41 year period. A wide range of dental keywords were used in the search strategy to accompany searches for ‘systemic lupus’ OR ‘lupus'(e.g. ‘dental implants’, ‘salivary glands’). Studies with SLE patients reporting one or more orofacial manifestations or those involving dental/oral treatment were included. Bias risk assessment of included studies was carried out by two reviewers independently.

Results

• 30 articles satisfied the inclusion criteria and were included.
• The bias risk assessment deemed 16 articles to have a bias grade A, 12 with a bias grade B and 2 with a bias grade C.
• The review provides narrative summaries about the orofacial manifestations of SLE and how SLE may influence dental management. The review divides its findings into several clinical topics and provides a narrative summary for each of teh following:
  • Oromucosal lesions
  • Caries, periodontal disease & tooth loss
  • Salivary glands involvement and xerostomia
  • Temporomandibular joint involvement
  • Oral management and treatment-related adverse effects
  • Considerations for dental treatment
  • Prophylactic antibiotics/antifungals
  • Anticoagulants/antithrombotic agents
  • Screening for potential malignancies
  • Considerations for oral rehabilitation

Conclusions

The main limitation of this review consisted in the lack of prospective follow-up studies and the heterogeneity among studies populations. The need of prospective studies appears mandatory to clearly determine the etiology of the association between SLE and oral disease

Systemic lupus erythematosus is a multisystem autoimmune disease with a wide spectrum of clinical presentations, partly linked to treatment-related adverse effects, but also related to the disease itself. Orofacial involvement plays an important role in the disease course, both for the diagnosis and for treatment

The findings in this review article highlighted that a multidisciplinary approach is needed for dental and medical management of SLE patients

Comments

This well written review covers a wide range of issues related to the orofacial manifestations/dental management of patients with SLE and highlights the complex multidisciplinary approach required for the diagnosis and management of these patients in the context of orofacial features. As the authors of the review highlight, the aetiology of SLE is not fully understood and further evidence in the form of prospective studies is required to improve the quality of evidence surrounding this topic. It may have been beneficial if the review summarised more clearly exactly the types of studies included (e.g. retrospective/case controlled) to allow the reader to more easily assess the type of evidence presented.

Furthermore, many of the included studies within the review also looked at other forms of lupus (e.g. cutaneous lupus erythematosus, discoid lupus erythematosus) and it may have been clinically relevant to mention how the orofacial considerations compare between these types, especially given discoid lupus erythematosus can also  affect the mouth, (e.g. Ranginwala et al., 2012).

Since this review was published, the new ‘2019 European League Against Rheumatism/America College of Rheumatology classification criteria for systemic lupus erythematosus’ was published presenting a structed weighted criteria based on a scoring system with positive antinuclear antibody serology as an obligatory entry criterion (Aringer et al., 2019). This structed criteria may improve the infrastructure for future prospective studies.

Links

Primary paper

Benli M, Batool F, Stutz C, Petit C, Jung S, Huck O. Orofacial manifestations and dental management of systemic lupus erythematosus: A review [published online ahead of print, 2019 Dec 30]. Oral Dis. 2019;10.1111/odi.13271. doi:10.1111/odi.13271.

Other references

Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Annals of the Rheumatic Diseases 2019;78(9):1151-1159.doi: 10.1136/annrheumdis-2018-214819.

Di Battista M, Marcucci E, Elefante E, et al. One year in review 2018: systemic lupus erythematosus. Clin Exp Rheumatol. 2018;36(5):763-777.

Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM. Oral discoid lupus erythematosus: A study of twenty-one cases. J Oral Maxillofac Pathol. 2012;16(3):368-373. doi:10.4103/0973-029X.102487.

Picture Credits

By Doktorinternet – Own work, CC BY-SA 4.0, Link