Systemic Lupus Erythematosus and the Mouth
Dr John Hamburger, Senior Lecturer/Consultant in Oral Medicine, University of Birmingham, School of Dentistry
Systemic lupus erythematosus (SLE), as part of the name implies, may affect any part of the body. The mouth is no exception and indeed one of the diagnostic criteria for SLE is mouth ulceration, although not everybody with SLE will have mouth lesions.
As well as mouth ulcers, other oral manifestations of SLE include:
- Sjogren’s syndrome (dry mouth and dry eyes).
- Lupoid lesions (white patches that may be associated with ulcers).
- Drug-induced lesions (a side effect of medication).
These may occur in one in five patients with SLE. They are often small, round or oval ulcers that occur in crops, are painful and heal in about 2 weeks. The ulcers tend to recur, with repeated episodes occurring at 2-4 week intervals. In some patients these recurrent mouth ulcers may be associated with iron or vitamin B deficiency as well as anaemias. Certain medications such as non steroidal anti-inflammatory drugs (NSAIDs)eg ibuprofen; diclofenac, can also cause mouth ulcers in some people (see later).
There are many ways to treat these ulcers and it is always helpful to seek professional advice from your dentist. It is important to try to identify an underlying cause. If one can’t be found then the ulcers can be managed with various mouthwashes including, antiseptic mouthrinses and topical steroid preparations that help to reduce inflammation. If the mouth ulcers are severe, systemic medication such as prednisolone may be required.
Some patients develop reddened patches in their mouths with fine white lines that radiate from the centre of these patches and these are the so-called ‘oral lupoid lesions’. Sometimes they cause no symptoms whilst at other times they can become sore and ulcerate. They occur at various sites within the mouth, but the palate and lips are often involved. These lesions may resemble lichenoid lesions that are described later in this article. If they are not causing discomfort then no active treatment is required, but if sore they can be treated with various topical preparations. As for mouth ulcers, professional advice is important to ensure accurate diagnosis and appropriate management.
Sjogren’s syndrome is a connective tissue disease that shares some features with SLE, both clinically and in terms of laboratory findings. For example, similar antibodies may be found in both conditions [eg anti-Ro antibodies]. There is an acknowledged overlap between these 2 conditions which can make diagnosis difficult.
Sjogren’s syndrome was first described in 1933 by a Swedish ophthalmologist, Dr Henrik Sjogren. An association with SLE was reported around 50 years ago and approximately 50% patients with SLE may also have symptoms of Sjogren’s syndrome.
The main symptoms of Sjogren’s syndrome are dryness of the eyes and mouth, as well as other mucous membranes. Marked tiredness and lack of energy are also common features of this condition. Some patients will also have another connective tissue disease such as SLE or rheumatoid arthritis associated with the condition.
However, there are many other causes of dry mouth including mouth breathing, a large variety of prescription drugs, poorly controlled diabetes and dehydration as well as other inflammatory conditions.
Various tests are undertaken to help confirm a diagnosis of Sjogren’s syndrome. These include measuring the saliva flow rate, blood tests, a number of which you may already have had because of your SLE and special types of X ray investigations. Ultrasound scans of the salivary glands are increasingly used to help in the diagnosis of Sjogren’s syndrome – this is a very safe and non-invasive test that does not use X rays but interpretation of the scans requires very highly trained personnel. Biopsy of the small salivary glands just below the surface of the lower lip was once regarded as the gold standard. This is no longer routinely performed although in some patients it is still needed to confirm the diagnosis.
The treatment of dry mouth is at present largely symptomatic. Symptoms can be helped with frequent sips of water and there are a variety of preparations that can either stimulate saliva or replace it. Sugar free chewing gum can be helpful as the act of chewing as well as the presence of the gum in the mouth helps to stimulate saliva flow. Various sprays and gels are also available that act as saliva replacements. Often patients find the gels are more helpful than sprays as they provide relief of symptoms for a longer period of time. There is also a drug called pilocarpine that stimulates saliva flow but in some patients it causes some uncomfortable side effects that limit its use.
People with dry mouth are at increased risk of dental decay and gum disease and therefore keeping the mouth clean by regular tooth brushing and interdental cleaning with floss or interdental brushes is especially important. Topical fluoride mouthrinses are helpful in protecting the teeth from decay as is limiting sugar intake and acidic foods.
Keeping the eyes moist in Sjogren’s syndrome is also very important. Various types of eye drops are available and specialist advice is helpful in identifying the most appropriate tear replacement to use.
Drug-induced mouth problems
All tablets and medicines have side effects and occasionally these side effects can affect the mouth. However, it is important to remember that your medication has many more beneficial effects than side effects.
Mouth ulceration can be caused by non-steroidal anti-inflammatory drugs such as ibuprofen or diclofenac. Methotrexate can also cause mouth ulcers and sometimes this occurs as a result of the drug causing a reduction in the B group vitamin, folic acid. These ulcers are very similar to those ulcers described above.
A variety of prescription drugs can also produce ‘lichenoid reactions’. These appear as a lacy white network, interspersed with red areas of inflammation and sometimes, ulcers. They typically occur on the insides of the cheeks, underneath the tongue or the gums which can appear very reddened. Drugs that can cause these lesions include NSAIDs, hydroxychloroquine, gold and penicillamine as well as many tablets used to control blood pressure.
More recently it has become apparent that bisphosphonate drugs can, in a very small number of cases, cause a condition known as ‘osteochemonecrosis’ of the jaws. These drugs preserve the skeleton by inhibiting bone resorption. They are used to manage osteoporosis, they help to prevent osteoporosis in patients taking corticosteroids and are also prescribed to some patients with metabolic bone disorders. Additionally they help prevent the spread of certain tumours to the bones.
In a very small number of patients taking bisphosphonates, pieces of the jaw can die and protrude through the surface of the gum where they may become infected. The development of this condition depends on the type and dosage of the drug, how long it has been used for and other factors such as oral hygiene, gum disease and dental infection. Osteochemonecrosis usually affects the lower jaw with most cases following dental extraction. The majority of cases are associated with intravenous bisphosphonates rather than those taken by mouth. Following tooth extraction, approximately 1 in 10 patients on intravenous bisphosphonates may develop osteochemonecrosis compared to only 3 in 1000 patients taking oral bisphosphonates.
Osteochemonecrosis is very difficult to treat effectively so it is important to keep your mouth and teeth healthy and attend your dentist regularly so that tooth extractions or other surgical procedures can be avoided.
SLE and to a much lesser extent the medication used in its management can be associated with various mouth problems. Fortunately, good oral hygiene, a sensible diet and regular dental care can all help in minimising problems with the teeth and lining of the mouth.
We are very grateful to Dr. Hamburger for kindly supplying this article following his presentation at the LUPUS UK AGM and Conference in Stoke on Trent this year.