|Dental Management of Patients with Autoimmune Disease|
|Monday, 20 February 2012 09:46|
Diseases that are categorized as autoimmune in nature can cause mucocutaneous lesions characterized by oral ulceration, keratoses, desquamation, and bullae. Rheumatoid arthritis can also cause destructive lesions of the temporomandibular joint while Sjogren's disease is associated with xerostomia. The patient with scleroderma may experience progressive restriction of jaw opening as a component of this connective tissue disease. The following information relates to the dental management of some of the more common autoimmune diseases.
Systemic Lupus Erythematosus rarely causes intra-oral lesions. But when they do occur they may present as painful irregularly shaped erythematous or red-white erosions. Medical management is primarily pharmacologic and the drugs typically used (i.e. systemic prenisone, azathioprine) will result in a resolution of the lesions. However, in the absence of significant systemic disease, some patients may prefer to manage oral lesions with topical medication. The medications that can be used in these cases include fluocinonide (Lidex), clobetasol (Temovate), and halobetasol (Ultravate) delivered at 0.05% in gel form three times a day or a mouthrinse (elixir) containing 0.5 mg/5mL (1 teaspoon) dexamethasone (Decadron) used as a swish with expectoration four times a day.
Prolonged use of topical oral corticosteroid can lead to oral candidiasis so if therapy exceeds several days it is advisable to provide a topical antifungal medication to reduce this potential complication. Another potential dental management consideration in the Lupus patient is potential TMJ abnormality and orofacial pain. These conditions should be managed conservatively with palliative treatment. (Aliko A, Ciancaglini R, Alushi A, Tafaj A, Ruci D. Temporomandibular joint involvement in rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis. Int J Oral Maxillofac Surg. 2011 Jul;40(7):704-9).
Sjögren's Disease / Rheumatoid Arthritis / Scleroderma
Oral dryness associated with Sjögren's disease can exacerbate dental caries and periodontal disease. In addition, the oral mucosa of the patient with the disease can become quite sensitive to spicy foods and alcohol. Patients with the disease are also at increased risk for oral fungal infection (candidiasis) and halitosis. Conditions such as insomnia, irritability, and depression are not uncommon. Speech and eating may be significantly affected.
Sjögren's syndrome is a rare condition that is most commonly observed in women. Salivary glandular dysfunction is profound. The condition is often found in conjunction with rheumatoid arthritis which, as previously noted, can cause severe temporomandibular joint disease involving significant condylar erosion coupled with opening limitation and joint pain, scleroderma (with associated jaw opening limitation), and systemic lupus which is described above. Primary Sjögren's syndrome can develop in childhood and may be seen as early as 10 years of age. (De Oliveira MA, De Rezende NP, Maia CM, Gallottini M.Primary Sjögren syndrome in a 2-year-old patient: role of the dentist in diagnosis and dental management with a 6-year follow-up. Int J Paediatr Dent. 2011 Nov;21(6):471-5.)
Symptoms of oral dryness may include mouth burning pain or dysesthesia and throat dryness; tongue, denture ridge soreness; taste dysfunction; speech problems; sore throat; and difficulty swallowing. (Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138 Suppl:15S-20S)(Kaplan I, Zuk-Paz L, Wolff A. Association between salivary flow rates, oral symptoms and oral mucosal status. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106:235-241)
Dental management in the patient with Sjögren's syndrome should include hygiene instruction, dietary consultation, prescription of saliva substitutes or oral moisturizing gels and saliva stimulants, caries control with fluoride and dental restoration, periodic recall and medication management. Some of the commercial saliva substitutes that are available over-the-counter (OTC) are: Moi-Stir, Optimoist, Orex, Sage Moist Plus, Salivart, Xero-Lube. Gels include Laclede (OraBalance) and Sage mouth moisturizer.
Patients should be encouraged to keep a water bottle with them and sip frequently during the day, to restrict use of drying drinks (e.g. drinks with caffeine), to avoid mouth rinses or drinks containing alcohol, and to use lip coating gels. Some benefit may also be accrued from use of a humidifier in the home and bedroom during sleep. Extreme dryness occurring during sleep can be modified by the use of a time-release oral adhering disc such as XyliMelts (OraHealth). This particular product has an additional potential benefit in that it contains xylitol, a carbohydrate with established anti-caries activity. (Burgess J, Lee P. XyliMelts time-release adhering discs for night time oral dryness. Int J of Dent Hygiene (XyliMelts time-release adhering discs for night-time oral dryness).
When there is partial function of the salivary glands, patients with Sjögren's may benefit from systemic therapy using prescribed products such as EVOXAC® (cevimeline HCl) or Salagen (pilocarpine HCL). (Treatment for Dry Mouth) Candidiasis can be managed with one of the topical antifungal agents listed below:
(The clinician's guide to treatment of common oral conditions. Forth Edition Edited by Simon W Rosenberg, Robert N Arm. 1997, AAOM)
Although dentists have a limited role in the management of patients with autoimmune disease, their contribution is important as it contributes to elimination of dental and oral disease and can significantly improve the patient's quality of life.