Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and periods of remission and exacerbation.
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Dental professionals play a crucial role in recognizing these lesions, preventing complications, and providing individualized treatment while considering immunosuppressive therapy, hematologic abnormalities, and increased infection risk. This review summarizes the oral manifestations of lupus, diagnostic considerations, and current evidence-based dental management strategies.
✅ Introduction
Systemic lupus erythematosus is an autoimmune connective tissue disorder affecting multiple organs, including the skin, kidneys, joints, nervous system, and oral cavity. Approximately 20–45% of patients develop oral lesions during the course of the disease, although prevalence varies depending on diagnostic criteria and disease severity.
Oral manifestations may result directly from autoimmune inflammation or secondarily from immunosuppressive medications. Since oral lesions may resemble other immune-mediated diseases, accurate diagnosis requires careful clinical examination and interdisciplinary collaboration.
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Oral Ulcers
Oral ulcers represent one of the most common manifestations of SLE and are included in the classification criteria established by rheumatology societies.
Clinical characteristics include:
▪️ Painless or mildly painful ulcers
▪️ Erythematous borders
▪️ White radiating striae
▪️ Central atrophy
▪️ Predilection for the hard palate, buccal mucosa, gingiva, and vermilion border
Lesions may occur during disease flares or remain asymptomatic for prolonged periods.
Discoid Lupus Lesions
Patients with discoid lupus erythematosus (DLE) frequently develop localized oral lesions characterized by:
▪️ Central erythema
▪️ Keratotic white plaques
▪️ Peripheral white striae
▪️ Telangiectasia
▪️ Atrophic areas
These lesions often resemble oral lichen planus, making biopsy and histopathological evaluation important when diagnosis is uncertain.
Xerostomia
Reduced salivary flow may result from:
▪️ Secondary Sjögren syndrome
▪️ Autoimmune salivary gland involvement
▪️ Medication side effects
Consequences include:
▪️ Increased dental caries
▪️ Oral candidiasis
▪️ Difficulty swallowing
▪️ Burning mouth sensation
▪️ Reduced quality of life
Periodontal Disease
Although lupus itself is not considered a direct cause of periodontitis, patients may demonstrate:
▪️ Increased gingival inflammation
▪️ Higher plaque accumulation
▪️ Delayed wound healing
▪️ Greater susceptibility to opportunistic infections
Poor plaque control combined with immunosuppressive therapy may exacerbate periodontal destruction.
Opportunistic Oral Infections
Immunosuppressive medications increase susceptibility to:
▪️ Oral candidiasis
▪️ Herpes simplex virus reactivation
▪️ Oral bacterial infections
Early recognition allows prompt treatment and reduces complications.
Temporomandibular Joint Involvement
Some patients experience:
▪️ Temporomandibular joint pain
▪️ Morning stiffness
▪️ Limited mouth opening
▪️ Myofascial discomfort
These symptoms may resemble other rheumatologic disorders.
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Diagnosis combines clinical findings with systemic evaluation.
The dental examination should include:
▪️ Complete oral soft tissue assessment
▪️ Salivary function evaluation
▪️ Periodontal examination
▪️ Photographic documentation
▪️ Biopsy of persistent suspicious lesions
▪️ Differential diagnosis from:
- Oral lichen planus
- Pemphigus vulgaris
- Mucous membrane pemphigoid
- Chronic traumatic ulcers
- Candidiasis
- Leukoplakia
Laboratory investigations performed by the medical team commonly include:
▪️ Antinuclear antibodies (ANA)
▪️ Anti-double stranded DNA antibodies
▪️ Anti-Smith antibodies
▪️ Complement levels
▪️ Complete blood count
▪️ Renal function tests
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Medical History Review
Prior to treatment, dentists should assess:
▪️ Disease activity
▪️ Current medications
▪️ Organ involvement
▪️ Recent laboratory findings
▪️ Bleeding disorders
▪️ History of infections
Communication with the patient's rheumatologist is recommended for complex cases.
Preventive Dentistry
Preventive care should emphasize:
▪️ Professional prophylaxis
▪️ Personalized oral hygiene instruction
▪️ Fluoride toothpaste
▪️ High-fluoride varnishes
▪️ Dietary counseling
▪️ Regular recall appointments
Management of Oral Ulcers
Treatment depends on lesion severity.
Common approaches include:
▪️ Topical corticosteroids
▪️ Protective oral rinses
▪️ Chlorhexidine mouthwash when indicated
▪️ Pain control
▪️ Elimination of local irritants
Persistent lesions require biopsy.
Management of Xerostomia
Recommended strategies include:
▪️ Frequent hydration
▪️ Sugar-free chewing gum
▪️ Saliva substitutes
▪️ Fluoride therapy
▪️ Caries prevention protocols
Patients should avoid alcohol-containing mouthwashes.
Infection Control
Dentists should monitor patients receiving:
▪️ Corticosteroids
▪️ Azathioprine
▪️ Mycophenolate mofetil
▪️ Methotrexate
▪️ Cyclophosphamide
▪️ Biologic agents
Signs of candidiasis or viral infection should be treated promptly.
Surgical Considerations
Before invasive procedures, clinicians should evaluate:
▪️ Platelet count
▪️ White blood cell count
▪️ Coagulation status
▪️ Renal function
▪️ Risk of delayed healing
Elective procedures should preferably be performed during periods of disease remission.
✅ Drug Considerations
| Medication | Dental Considerations |
|---|---|
| Corticosteroids | May delay wound healing and increase the risk of opportunistic infections. Consider stress-dose corticosteroids for selected patients with adrenal suppression undergoing major oral surgery. |
| Hydroxychloroquine | Generally well tolerated. Rarely associated with oral mucosal pigmentation. Routine dental treatment usually requires no modification. |
| Azathioprine, Methotrexate, Mycophenolate Mofetil, Cyclophosphamide | Increase susceptibility to bacterial, viral, and fungal infections. Monitor for oral ulcers, delayed healing, and opportunistic infections. |
| NSAIDs | May increase bleeding tendency in susceptible patients. Consider this risk before invasive dental procedures. |
| Anticoagulants | Assess bleeding risk before oral surgery. Review coagulation status and consult the patient's physician when indicated. |
Dental practitioners should:
▪️ Perform comprehensive oral examinations at every recall visit.
▪️ Identify oral lesions suggestive of lupus early.
▪️ Implement individualized preventive programs.
▪️ Coordinate care with rheumatologists and primary physicians.
▪️ Monitor medication-related adverse effects.
▪️ Delay elective invasive procedures during active disease when feasible.
▪️ Provide intensive caries prevention for patients with xerostomia.
💬 Discussion
Recent evidence highlights the growing importance of oral health in the multidisciplinary management of lupus. Oral lesions may represent the first clinical manifestation of systemic disease and occasionally correlate with disease activity. Early recognition by dental professionals facilitates timely referral, improves patient outcomes, and reduces diagnostic delays.
Modern immunomodulatory therapies have significantly improved disease prognosis but also increase susceptibility to opportunistic infections and delayed healing. Consequently, individualized dental treatment planning should incorporate current medications, systemic involvement, hematologic status, and the patient's overall immune function. Preventive dentistry remains the cornerstone of long-term oral care for individuals with lupus.
✍️ Conclusion
Oral manifestations of lupus represent clinically significant findings that require early recognition and careful management by dental professionals. Evidence-based dental management should prioritize prevention, accurate diagnosis, control of oral inflammation, management of xerostomia, and close collaboration with rheumatologists. Comprehensive, individualized care can improve oral health, reduce complications, and enhance quality of life in patients living with lupus.
📚 References
✔ Albrecht, J., Berlin, J. A., Braverman, I. M., Callen, J. P., Costner, M. I., Furukawa, F., ... Werth, V. P. (2004). Dermatology position paper on the revision of the ACR criteria for systemic lupus erythematosus. Lupus, 13(11), 839–849. https://doi.org/10.1191/0961203304lu2024oa
✔ Fanouriakis, A., Kostopoulou, M., Alunno, A., Aringer, M., Bajema, I., Boletis, J. N., ... Boumpas, D. T. (2019). 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Annals of the Rheumatic Diseases, 78(6), 736–745. https://doi.org/10.1136/annrheumdis-2019-215089
✔ Petri, M., Orbai, A. M., Alarcón, G. S., Gordon, C., Merrill, J. T., Fortin, P. R., ... Ramsey-Goldman, R. (2012). Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis & Rheumatism, 64(8), 2677–2686. https://doi.org/10.1002/art.34473
✔ Schiødt, M. (1984). Oral manifestations of lupus erythematosus. International Journal of Oral Surgery, 13(2), 101–147. https://doi.org/10.1016/S0300-9785(84)80037-9
✔ Stojan, G., & Petri, M. (2018). Epidemiology of systemic lupus erythematosus: An update. Current Opinion in Rheumatology, 30(2), 144–150. https://doi.org/10.1097/BOR.0000000000000472
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