Lupus – an autoimmune disease with profound consequences
Featured Products Promotional FeaturesPosted by: Dental Design 14th June 2024
Lupus (systemic lupus erythematosus, or SLE), is a chronic autoimmune condition that causes inflammation, and can damage any part of the body. The cause is currently unknown, although research has indicated that genetics, hormones and certain infections, including viruses, may be factors.[i] [ii] Symptoms may vary, but patients often experience joint pain, painful facial rashes, hair loss, oedema, pain when breathing deeply or lying down, headaches, depression, abdominal pain, sensitivity to the sun and a high incidence of oral health problems.[iii]
Inflammation in the body caused by SLE can have a devastating impact on a patient’s overall health, in severe cases affecting kidney function, damaging the brain and central nervous system and affecting cardiovascular health.[iv]
With such a long list of possible symptoms, as well as periods of remission between flare-ups, lupus can be difficult to diagnose. No single test can detect the condition, so a number of blood and kidney function tests are used. There is no cure, but a combination of treatments can be effective in managing many of the symptoms.[v]
SLE commonly affects adult women, more than men by 9 to 1. It is thought that currently up to 50,000 people in the UK have the condition. Lupus affects people of Afro-Caribbean, Asian and Hispanic heritage more than other populations;[vi] a study in the US found that African American women had almost twice the prevalence of SLE as white women.[vii]
Lupus and oral health
Lupus affects every bodily function, so it’s no surprise that the condition can significantly affect patients’ oral health, greatly impacting their oral health-related quality of life (OHRQoL).[viii]
Because of additional risks to oral health, careful dental care routines and frequent dental visits are vital to protect sufferers. However, visits to the dentist can be a challenge for many patients with SLE. The condition is associated with high risk of metal delayed-type hypersensitivity, including nickel, gold and mercury, often present in dental materials.[ix] Use of fluorescent light, such as surgical lighting, can also cause flare-ups due to an increased risk of photosensitivity.[x]
Oral lesions occur in more than 40% of people with SLE. In some cases, non-treatment of oral ulcers carries an increased risk for development of cancer.[xi] Development of oral shingles is also possible. Shingles (herpes zoster, or HZ) is reported as the most prevalent viral infection in patients with SLE.[xii]
Saliva dysfunction and oral microbial changes are a common symptom of lupus, leading to a high incidence of caries development in patients.[xiii] Studies have shown that about 79% of patients with SLE suffer from hyposalivation, and xerostomia is a common side effect of the condition. The decrease in salivary flow rate in SLE may be the result of secondary Sjogren’s syndrome, a condition affecting saliva production, which often accompanies immune system disorders.[xiv]
Xerostomia carries with it a number of risks to oral health. Saliva supports oral hygiene, providing lubrication to condition teeth and wash away food particles, keeping the oral cavity moist and clean. Salivary amylase helps to initiate the digestive process, and mucin and immunoglobulin in saliva protect the oral mucosa from microbial infection.
When saliva production is affected, gingivitis and periodontitis, dental caries, halitosis, fungal infections (candidiasis), and accelerating enamel erosion can occur.[xv]
Inflammation, periodontitis and lupus
Studies have also shown that SLE carries a significantly increased risk of periodontitis. The inflammatory condition is generally preventable through exercising good oral hygiene, however, once inflammation extends to the periodontium, the risk of bone loss, infection and tooth-loss increases.[xvi]
Studies clearly demonstrate an association with periodontal disease and the development of several autoimmune inflammatory conditions, including SLE. A causal link is difficult to prove, but there is a clear prevalence of poor oral hygiene and periodontal disease in patients presenting with symptoms of lupus .[xvii]
Managing a complex condition
Lupus is a complex condition to manage. Maintaining periodontal health with increased attention to daily oral hygiene is very important element of this. Frequent tooth-brushing is fundamental for maintaining oral health and reducing the formation of biofilms. However, research has shown that brushing alone may only remove 42% of plaque. Dental professionals are encouraged to educate patients on the added importance of interdental cleansers.[xviii]
FLEXI interdental brushes, used with PREVENT GEL from TANDEX are an ideal system for maintaining periodontal health. The FLEXI interdental brushes come in 11 different sizes, and the flexible brush can be shaped to reach all the gaps that a toothbrush can’t reach. The addition of PREVENT GEL supports patients who have impaired saliva production, containing chlorhexidine and fluoride to strengthen enamel and protect against bacteria.
Patients with autoimmune diseases like SLE have been shown to suffer disproportionately with poor oral health, and have been shown to have a greater risk of periodontitis. Educating patients with lupus on the importance of interdental cleaning helps them manage the additional risks to their oral health.
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Author Kimberley Lloyd- Rees on behalf of Tandex
Kimberley graduated from the University of Sheffield in 2010, where she now works as a clinical tutor in Dental Hygiene and Therapy as well as working in practice. She has spent her career working across a variety of specialist private and mixed dental practices, for the MOD and volunteering her time to a dental charity in Nepal.
[i] NHS. Lupus. Available at: https://www.nhs.uk/conditions/lupus/ Accessed March 2024.
[ii] CDC. Lupus basics. https://www.cdc.gov/lupus/basics/index.html Accessed March 2024.
[iii] National Institute of Arthritis and Musculoskeletal and Skin Diseases. Systemic Lupus Erythematosus (Lupus): Diagnosis, Treatment, and Steps to Take. Available at: https://www.niams.nih.gov/health-topics/lupus Accessed March 2024.
[iv] National Institute of Arthritis and Musculoskeletal and Skin Diseases. Systemic Lupus Erythematosus (Lupus). Available at: https://www.niams.nih.gov/health-topics/lupus. Accessed March 2024.
[v] National Institute of Arthritis and Musculoskeletal and Skin Diseases. Systemic Lupus Erythematosus (Lupus): Diagnosis, Treatment, and Steps to Take. Available at: https://www.niams.nih.gov/health-topics/lupus Accessed March 2024.
[vi] Lupus UK. What is Lupus? Available at: https://lupusuk.org.uk/medical/nurses-guide/what-is-lupus/#:~:text=Lupus%20commonly%20affects%20women%20in,about%201%20in%201000%20people. Accessed March 2024.
[vii] Feldman CH, Hiraki LT, Liu J, Fischer MA, Solomon DH, Alarcón GS, Winkelmayer WC, Costenbader KH. Epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among US adults with Medicaid coverage, 2000-2004. Arthritis Rheum. 2013 Mar;65(3):753-63. doi: 10.1002/art.37795. PMID: 23203603; PMCID: PMC3733212.
[viii] Lupus Foundation of America. People with Lupus Exhibit Increased Need for Dental Management. Available at: https://www.lupus.org/news/people-with-lupus-exhibit-increased-need-for-dental-management#:~:text=Tooth%20decay%20was%20present%20in,tooth%20loss%20than%20healthy%20population. January 2020. Accessed March 2024.
[ix] Bjørklund G, Dadar M, Aaseth J. Delayed-type hypersensitivity to metals in connective tissue diseases and fibromyalgia. Environ Res. 2018 Feb;161:573-579. doi: 10.1016/j.envres.2017.12.004. PMID: 29245125.
[x] Lupus Foundation of America. Lupus and the Mouth. Available at: https://www.lupus.org/resources/oral-health-issues-with-lupus. Accessed March 2024.
[xi] Qin L, Kao YW, Lin YL, Peng BY, Deng WP, Chen TM, Lin KC, Yuan KS, Wu ATH, Shia BC, Wu SY. Recurrent aphthous stomatitis may be a precursor or risk factor for specific cancers: A case-control frequency-matched study. Cancer Med. 2018 Aug;7(8):4104-4114. doi: 10.1002/cam4.1685. Epub 2018 Jul 15. PMID: 30009475; PMCID: PMC6089185.
[xii] Chen D, Li H, Xie J, Zhan Z, Liang L, Yang X. Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors. Exp Ther Med. 2017 Dec;14(6):6222-6228. doi: 10.3892/etm.2017.5297. Epub 2017 Oct 12. PMID: 29285180; PMCID: PMC5740583.
[xiii] Yang L, Wang J, Xiao Y, Wang X, Sun Q, Shang J, Zhao Y. Saliva Dysfunction and Oral Microbial Changes among Systemic Lupus Erythematosus Patients with Dental Caries. Biomed Res Int. 2018 Apr 2;2018:8364042. doi: 10.1155/2018/8364042. PMID: 29808167; PMCID: PMC5902118.
[xiv] Pasoto SG, Adriano de Oliveira Martins V, Bonfa E. Sjögren’s syndrome and systemic lupus erythematosus: links and risks. Open Access Rheumatol. 2019 Jan 29;11:33-45. doi: 10.2147/OARRR.S167783. PMID: 30774485; PMCID: PMC6357904.
[xv] National Library of Medicine. Xerostomia. Available at: https://www.ncbi.nlm.nih.gov/books/NBK545287/. March 2023. Accessed March 2024.
[xvi] Rutter-Locher Z, Smith TO, Giles I, Sofat N. Association between Systemic Lupus Erythematosus and Periodontitis: A Systematic Review and Meta-analysis. Front Immunol. 2017 Oct 17;8:1295. doi: 10.3389/fimmu.2017.01295. PMID: 29089946; PMCID: PMC5650969.
[xvii] Sojod B, Pidorodeski Nagano C, Garcia Lopez GM, Zalcberg A, Dridi SM, Anagnostou F. Systemic Lupus Erythematosus and Periodontal Disease: A Complex Clinical and Biological Interplay. J Clin Med. 2021 May 2;10(9):1957. doi: 10.3390/jcm10091957. PMID: 34063235; PMCID: PMC8125164.
[xviii] Kim YJ, Gil YM, Bae KH, Kim SJ, Ihm J, Cho HJ. The use of interdental cleaning devices and periodontal disease contingent on the number of remaining teeth in Korean adults. Sci Rep. 2022 Aug 16;12(1):13853. doi: 10.1038/s41598-022-17885-7. Erratum in: Sci Rep. 2022 Sep 7;12(1):15168. PMID: 35974036; PMCID: PMC9381548.
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