Dental Problems

Lupus Erythematosus

Lupus erythematosus is characterized by the presence of abnormal antibodies and immune complex. In this article, there is a brief discussion on the lupus erythematosus. Read on to know more.

Lupus erythematosus

Types:

There are two types of lupus erythematosus which are as follows:

  1. Discoid lupus erythematosus:

    It is confined to mucosa and skin.

  2. Systemic lupus erythematosus:

    It involves the multiorgan.

Etiology:

  • Genetic predisposition:

    A relative of patients have a higher incidences auto-antibodies, immune deficiency and connective tissue disease. This tendency is greatest among identical twins.

  • Immunological abnormality possibly mediated by the viral infection, immune complex chiefly consisting of antibody and nucleic acid account for majority of the tissue changes are seen.
  • Autoimmune disease:

    As these patients develop antibodies to man of their own cells.

  • Deposition of antigen:

    Antibody complexes.

  • Endocrine: (high incidence in females in pregnancy):

    Finding of increased estrogen level.

  • Biochemical increase in excretion of metabolic products, particularly tyrosine and phenylalanine, in certain SLE patient.

Discoid Lupus Erythematosus:

Clinical features:

  • Age and sex:

    It occurs in third and fourth decades, female predilection in the ratio of 5:1.

  • Site:

    The most common sites are oral mucosa, face, back chest and extremities.

  • Appearance:

    It is a circumscribed, slightly elevated, white patch which may be surrounded by red telangiectatic halo.

  • Cutaneous lesion:

    Cutaneous lesions are slightly elevated, purple or red macules which are often covered by yellow or gray adherent scales.

  • Carpet track extension:

    Forceful removal of scale results in ‘carpet track extension’, which has dipped into enlarged pilosebaceous canals.

  • Peripheral growth:

    The lesion increases in size by peripheral grow. Periphery of the lesion appears pink or red, white the center exhibits an atrophic scarred appearance.

  • Butterfly distribution:

    Butterfly distribution on macular region and across the bridge of the nose.

Oral manifestation:

  • Sites:

    The most areas are tongue, buccal mucosa, vermilion border of lip and palate.

  • Appearance:

    It begins as erythematous area, sometimes, slightly elevated, but more often depressed, usually with induration and typically with white spots.

  • Occasionally, superficial painful ulceration may occur with crusting or bleeding, but no actual scale formation.
  • Symptoms:

    There may be burning and tenderness which may be intermittent or disappear if the lesion becomes inactive.

  • Margins:

    The margins of the lesion are not sharply demarcated. Fine white striae radiated put from the margins.

  • Central healing:

    central healing may result in depression.

  • Lip:

    Erythematous, atrophic plaque surrounded by keratoic border may involve the entire lip.

Systemic Lupus Erythematosus:

Clinical Features:

  • Age and sex:

    It occurs in third (female) and 4th (male) decades and has female predilection (8:1).

  • Sites:

    It is characterized by repeated remissions and exacerbations with common sites being face, neck, upper arm, fingers and shoulder.

  • Symptoms:

    • It is manifested by symptoms of pain and fever in the joints and muscle.
    • It may present as burning sensation or itching as well as area of hyper-pigmentation.
    • Severely intensifies after exposure to sunlight.
  • Cutaneous lesions:

    The cutaneous lesion consists of erythematous patches on the face, which coalesce to form roughly symmetrical pattern over the cheeks and across the bridge of the nose, in a so called butterfly distribution.

  • Skin lesions:

    Skin lesions are bilateral and widespread with signs of acute inflammation. This finding helps to differentiate between skin lesions of SLE and DLE.

  • Organ involvement:

    • Involvement of various organs including kidneys and heart.
    • In kidney, fibrinoid thickening of glomerular capillaries producing the characteristic ‘wire loop’which may be sufficient to result in renal insufficiency.
    • Heart may suffer a typical endocarditis involving valves as well as fibrinoid degeneration of myocardium and epicardium.

Oral manifestation:

  • Site:

    The most common sites are buccal mucosa, palate and lip.

  • Symptoms:

    Complain of xerostomia, soreness of mouth or burning sensation.

  • Signs:

    Lesions similar to DLE, except that hyperemia, edema and extension of lesion is more pronounced. Greater tendency to petechiae and bleed, suspected ulcerations surrounded by red halo.

  • Lips:

    The lip lesions appear with central atrophic area with small white dots surrounded by keratinized border, which is composed of small radiating white striae. There is occasional ulceration of central area.

  • The intraoral lesion is composed of a central depressed red atrophic area surrounded by 2 -4 mm elevated keratotic zone, that dissolves into small white lines.

Laboratory findings:

  • LE cell inclusion phenomenon with surrounding pale nuclear mass apparently devoid of lymphocytes.
  • It is characterized by the presence of abnormal serum, immune complexes and antibodies.
  • Anemia, thrombocytopenia, leucopenia and anemia with sedimentation rate increased.
  • Serum gamma globulin increased and Coomb’s test is positive.

Dental consideration:

  • Thrombocytopenia may be sometimes severe. The result of a recent platelet count should be studied before undertaking oral surgery.
  • Bacterial endocarditis:

    Libman-Sacks vegetation under the mitral valve may occur in patients with SLE, it can lead to bacterial endocarditis. So patients with SLE should have antibiotic prophylaxis before dental treatment that is likely to cause bacteremia.

  • Exacerbation by drug therapy:

    Drugs which have been related to exacerbation include penicillin, sulfonamide and NSAIDs with photosensitizing potential.

  • Exacerbation by surgery:

    All elective surgeries including dental procedure to be avoided.

  • Susceptibility to shock and infection:

    Patients with SLE may be taking adrenal suppressive dose of corticosteroids or cytotoxic drugs and hence, they may be susceptible to infection and shock.

Histopathological features:

  • Hyperorthokeratinization, hyperpara -keratinization with keratotic plugging, atrophy of the rete pegs and liquefaction degeneration of basal layer.
  • Perivascular infiltration of lynphocytes and their collection about dermal appendages, basophilic degeneration of collagen and elastic fibers with edema, hyalinization and fibrinoid change.

Differential diagnosis:

  • Lichen planus:

    Homogenoud picture, no dark erythema and no telangiectasia. Mucosal changes are usually extensive and symmetrical.

  • Lichenoid reaction:

    History of drug is always there.

  • Ectopic geographic tongue:

    Systemic manifestation present in lupus erythematous, which is absent in ectopic geographic tongue.

  • Psoriasis:

    Auspitz’s’sign is positive.

  • Electro galvanic lesion:

    Dissimilar restoration are seen in oral cavity.

  • Leukoplakia and erythroplakia:

    Lesions tend to maintain same appearance and there are no skin changes.

  • Geograhic stomatitis:

    No skin changes, mucosal lesions change location rapidly.

  • Benign mucous membrane pemphigoid:

    No systemic complaint and serology test to be done.

Management:

  • It is treated by systemic corticosteroid therapy and should be managed by physician.
  • Anti-malarial drugs can be used in some cases.

The above article discusses about the

lupus erythematous

.

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