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LUPUS
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10.1111/ODI.13271
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Abstract
Accepted Article
Background: Systemic lupus erythematosus (SLE) is an autoimmune multisystem disease with
numerous clinical manifestations. There is no consensus about the ideal oral management for this
group of patients to date. This review aimed to describe the broad spectrum of orofacial and
clinical manifestations and their therapeutic approaches.
Methods: Studies concerning orofacial manifestations of SLE and dental treatment modalities
were selected by a literature search (1978-2019) using Google Scholar, PubMed/MEDLINE
electronic databases.
Results: The initial search strategy provided a total of 129 articles, and of these, 30 were included
for qualitative synthesis. The reviewed studies revealed that SLE patients are more at risk of
compromised oral and dental health exhibiting increased risk of periodontal diseases and temporo-
mandibular joint disorders. The use of systemic drugs especially immunosuppressive and
anticoagulants in SLE patients may also influence their oral management.
Conclusion: Results emphasize the need to carry out, at an early stage of the disease, an
appropriate oral management of these patients to improve oral health related quality of life and to
prevent the need of more invasive therapeutics. A multidisciplinary approach is needed for dental
and medical management of such patients.
Eligibility criteria
The inclusion criteria included English-language papers, studies involving patients who
had suffered from SLE, studies reporting one or more orofacial manifestation, studies assessing
performed oral/dental treatment by validated methods. Review articles, editorial letters, opinions,
brief communications, conferences, duplicates, studies with inadequate information or
incompatible methodology, studies not dealing with SLE patients, studies involving SLE patients
with concurrent systemic and/or syndromic diseases were excluded.
Data collection
The following parameters obtained from the articles were assessed according to the study
design: groups, sample size (number of SLE patients), patient’s characteristics, time from SLE
diagnosis, drug treatment, oral involvement, oral rehabilitation method, main results and main
conclusions. The data collected were presented as tables.
Conflict of interest
Authors have no conflicts of interest related to this study.
Author contributions
All authors contributed to the development of the drafts, revision and refinement of the
manuscript. All authors reviewed the final version of the manuscript.
of these criteria (at least one of the immunological and at least one clinical) or histologically diagnosed lupus nephritis is necessary for classification as
SLE.
Acute cutaneous lupus (including malar rash) ANA above laboratory reference range
Chronic cutaneous lupus (including classical discoid Anti-dsDNA above laboratory reference range (except
rash) ELISA)
Oral ulcers (palate, buccal, tongue or nasal) Anti-Sm
Nonscarring alopecia Antiphospholipid antibody (lupus anticoagulant, false-
Synovitis (≥2 joints), tenderness (≥2 joints), morning positive RPR, medium or high titer anticardiolipin, anti-
stiffness (≥ 30 min) (characterized by swelling or β2 glycoprotein I)
effusion) Low complement (C3, C4, or CH50)
Serositis (typical pleurisy or pericardial pain,>1 day) Direct Coombs test (in the absence of hemolytic
Renal (urine protein/creatinine or 24h urine protein, anemia)
>0.5 g)
Neurologic (e.g., seizures, psychosis)
Hemolytic anemia
Leukopenia (< 4000/mm3) or lymphopenia (<
1000/mm3)
Thrombocytopenia (<100000/mm3)
Table 2: Risk of bias assessment
cutaneous lupus, DLE: Discoid lupus erythematosus, SS: Sjögren’s syndrome, RA: Rheumatoid arthritis, SSC: Systemic sclerosis, NSAIDs: Non-
Study Groups Findings Site of finding Patient Time from Drug treatment
description diagnosis
Burge et al SLE:n=53 Oral ulcer (36%) Hard palate NR SLE: 3 months-31 Chloroquine
(1989) CCL:n= 68 Cheilitis (6%) Vermillion years Prednisolon
Oral plaques (3%) border CCL: 6 months- Hydroxchloroquine
Soft palate 54 years Azathioprine
Lower lip
Erythemato-
ulcerative plaque
(46%)
White plaque types NR
(54%)
*Valid for SLE NR
Lourenço et group Buccal mucosa
al (2007) SLE: n=13 Lower lip NR
CLE: n=33 Upper lip
Xu et al
(2010) SS/SLE:n= 41 Oral ulcer: NR NR SS/SLE:113.8± Corticosteroid therapy
SLE:n= 214 14.6% (SS/SLE) 84.0 months
12.1% (SLE) SLE: 44.9±18.0
months
Aliko et al SLE:n=22 Red lesions (35.5%) Palate SLE:9.1%smoker SLE:6.6±7.0 Oral steroids
(2010) RA:n=88 White lesions (7.3%) Labial/buccal RA:14.8% years NSAIDs
SSC:n=14 Red-white mucosa smoker RA: 9.5±8.2 years Methylprednisolone
lesions(6.5%) Tongue SSC: SSC: 9.4±8.1 Methotrexate
Nodular Alveolar 7.1%smoker years
lesions(5.6%) mucosa/gingiva
Ulcerative lesions Sulci
(8.9%) Vermilion
Vesicullo-bullous border/lips
lesions(0.8%) Comissures
Pigmented Floor of the
lesions(3.2%) mouth
Other(4%)
SLE: n=188 Oral ulcer (28.1%) Buccal mucosa 27.2 % smokers <3->12 months Corticosteroid therapy
Khatibi et Erythema (white Lower lip 72.8 % non- Azathioprine
al (2012) speckles/striae) Upper lip smokers Hydroxychloroquine
(13.8%) Cyclophosphamide
Erythema (9.5%)
White plaque (2.6%)
Menzies et SLE: n=11 Oral ulcers (23%) Hard palate 45% smokers 1-26 years Oral prednisolone
al (2018) CCL: n=11 Erosions (23%) (38%) 14% ex-smokers Steroid inhaler
DLE: n= 20 Erythema (19%) Labial mucosa 29% nonsmokers Antibiotic
White plaque (19%) Buccal mucosa 12% unknown
Others (16%) Gingiva
Alveoler ridge
Study Groups Peridontal Saliva Dental TMJ Drug therapy Risky effect Results
involvement caries/Tooth involvement
loss
Grennan SLE:n=32 - Xerostomia:12.5% - - NR Concomitant Overlap
et al Gland abnormality: Sjögren’s syndromes can
(1977) 65% syndrome can be affect saliva
found in SLE capacity
patients
Jonsson SLE:n=37 - - - Severe NR TMJ is a frequent More clinical
et al C: n=37 dysfunction:1 involvement in attention should
(1983) 4% SLE and shows be paid in TMJ
TMD radiographic for SLE patients
signs:41% change
Skopoul SLE:n= 72 - Xerostomia: 17% - - NR Concomitant Perivascular
i et al Perivascular Sjögren’s lymphocytic
(1991) lymphocytic syndrome may infiltration of
infiltration:24% have effects in salivary gland
salivary gland in may be initial
SLE lesion of
Sjögren’s
syndrome in
SLE
Ben- SLE:n=22 - Flow:0.25±0.15 - - Prednisone Significantly high Alterations in
Aryeh et C: n= 27 ml/min NSAIDS levels of IgA and the salivary
al IgA:10.45 + 7.10 Cytotoxic drugs IgM were composition
(1993) mg/100 ml Antihypertensive detected in may show
IgM:0.36±0.39 drugs patients with SLE subclinical
mg/100 ml salivary gland
IgG:1.68±1.64 mg/100 involvement in
ml SLE
Correa SLE: n=75 Periodontitis:68 Flow:≤0.3 DMFTI: 13.65 - NR SLE has a Interdisciplinary
et al C:n= 78 % ml/min(12%) (6.48%) negative impact intervention
(2018) on the oral health with follow-up
related quality of is needed for
life of patients SLE care.
with SLE.
Table 5: Summary of the studies reporting dental implant treatment in SLE patients (C: case report)
Study Study Number Mean Number Mean Survival Time from Drug therapy
type of age of follow up rate diagnosis
patients (years) implants (months) (years)
Li et al CR 1 50 5 36 100 35? Corticosteroid
(2004) Paracetamol
Azathioprine Methotrexate
Chloroquine
Paracetamol
Ergun et CR 1 49 6 24 100 30 Hydroxychloroquine
al Steroids
(2010)
Drew et CR 1 28 15 18 100 NR Glucocorticoid
al Immunomodulators
(2018)
Accepted Article