Systemic lupus erythematosus (SLE) is a chronic autoimmune disease where the immune system attacks its own tissues. It is characterized by periods of disease exacerbation and remission. Common symptoms include arthritis, skin rashes, oral ulcers, and fatigue. SLE can damage multiple organs like the kidneys, heart, and lungs. The cause is unknown but genetics and environmental factors like sunlight exposure are believed to play a role. Diagnosis is based on clinical criteria and the presence of autoantibodies. Treatment involves managing symptoms, avoiding triggers, and suppressing the immune system. Dentists play an important role in monitoring for infections as SLE patients are more susceptible.

2. “Definition
"Systemic Lupus Erythematosus is ”
“ chronic inflammatory multisystem disease of unknown etiology.”
“an autoimmune disease where body’s immune system (antibodies in this
case referred to as autoantibodies) mistakenly attacks its own tissues”,
“causing multi-organ inflammation and diverse clinical manifestations with
domination of peripheral symmetric polyarthritis of small and large joints.”
“SLE is characterized with periods of exacerbation and remission”.
"Collagen Vascular Diseases"

3. ”

4. "Origins of the name: Systemic Lupus Erythematosus"
• -"“Lupus” is Latin for wolf, “Erythro” in Greek stands for red, and
Systemic is English word meaning that multiple organs are
involved."
• -"One theory explains that this disease has gotten its name
because it is similar to the attacks of a wolf on humans with its
severity, random spots of attack and repetitiveness."
-"Pathogenesis:"
• -"SLE results in tissue damage caused by attack of
autoantibodies and immune complexes."
• "It involves polyclonal and antigen-specific T and B lymphocyte
hyperactivity."
• -"T cell help in production of autoantibodies is critical for
development of full-blown disease."

5. "Proposed Etiology:"
• "-Definitive etiology is still unknown".
• "-We could only hypothesize what causes this disease is:
genetics, environmental factors (sun exposure to UV light),
estrogen (prepubertal and postmenopausal women have similar
incidence to men);"
• "-men with SLE have higher concentration of estrogenic
metabolites),"
• "-infection (viral: non-specific stimulant of immune response,
medications (Dilantin-anticonvulsant)),"
• "-oral contraceptive pills are associated with exacerbation (they
should be avoided in SLE patients)."
• "-25% of SLE patients have experienced false-positive tests for
syphilis due to circulating lupus anticoagulant in the blood."

6. "Diagnostic Criteria Description"
• "clinical"
• "1. Malar rash Classic “butterfly rash”; sparing of nasolabial folds, no scarring
2. Discoid rash; May cause scarring since invasion of basement membrane
3. Photosensitivity; Skin rush in reaction to sunlight
4. Oral/nasal ulcers; Usually painless
5. Arthritis; Symmetric, involving 2 or more small or large peripheral joints, non-erosive
6. Serositis; Pleuritis or Pericarditis
7. Neurologic disorder; Seizures or Psychosis"
• "Laboratory"
• "8. Renal disorder; Proteinuria
9. Hematologic disorder; Hemolytic anemia, Leukopenia, Lymphopenia,
Thrombocytopenia
10. Immunologic disorder; Anti-double stranded DNA Ab (50% of patients), anti-Sm Ab
(25-60% of patients), anti-phospholipid Ab.
11. Antinuclear antibody –(ANA); Most sensitive test (present in 90%of the patients))"

7. SignsandSymptoms
“2-Dermatologic”
"1-Musculoskeletal"
• "-The most common manifestations of SLE are Arthralgias and Nonerosive Arthritis occurs
in 95% of patients, it is symmetric and involves small joints of hands, wrists, and feet)."
• "-There is also avascularnecrosis (cause of pain, along with arthritis) and myositis."

8. "Abnormalities of the
skin, hair or mucous
membranes are second
most common
manifestation of SLE,
occurring in 85% of
patients."
"classic malar butterfly
rash, an erythematous
rash covering both
cheeks and the bridge of
the nose, with sparing of
the nasolabial folds."
"maculopapular rush
that can be located
anywhere on the body."
"nasal/genital ulcers,
panniculitis, alopecia,
urticaria and purpura."

9. “3. Oral
 Painless, shallow oral ulcers, mostoften occur on the hard and soft
palate.
 There is also a mild involvement of mucosalulcers as symptomof this
disease.
 Oralulcers occur at onset in 11% of patients, while at any time is
present in 30% of patients.
 The lesions appear as maculae (red patches) that will later transform
into irregular erosions and ulcers which often heal with scarring.
 Purpuric lesion such as ecchymosis and petechial may occur.
 In 30% of the cases, pathology of major salivary glands may occur
leading to secondary Sjogren’ssyndromeand severeXerostomia”

10.  Patient complains:
"Candidiasis" "Xerostomia, burning mouth,
soreness. Almost 50% of
them have oral mucosal
lesions (eg, lip lesion) caused
by vasculitis and oral ulcers:"
"lip lesion presents a central
atrophic area with small
white dots of small radiating
white striae"
"interoral lesion presents a
central depressed red
atrophic area dissolving into
small white lines"
"TMJ disorder"

11. “4. Gastrointestinal
”
"Renal involvementoccursin
about50% of patients, with
only few % withirreversible
changes."
"Proteinuriaisthe most
commonclinical sign."
"Othersignsare:Pancreatitis,
LupusEnteropathy,Hepatitis
and Hepatomegaly"

12. “
“5. Systemic
”
“6. Cardio-Vascular
Pericarditis is the most common cardiac manifestation, occurs up to 30% of patients.
Raynaud’s phenomenon, Thrombosis, Vasculitis, Livedo reticularis, Hemolytic anemia
(most common vascular manifestation, in almost all patients), Leukopenia (50% of
patients), Lymphopenia, Thrombocytopenia.”
“7. Ophthalmic
Conjunctivitis,
Episcleritis,
Keratokonjuctivitis (occurs in 20% of patients)”
“8. Pulmonary
 Interstitial lung disease
 pulmonary hypertension
 Alveolar hemorrhage
 Pleuritis.”
Fever Malaise/Fatigue Lymphadenopathy
Weight loss

13. “9. Neurological
 Depression
 Personality disorder
 Cerebritis
 Transverse myelitis
 Seizures
 Head ache
 Peripheral neuropathy »
”

14. Histopathology of Oral Lesions
"•Microscopic features of lupus
mucosal lesions are quite similar
to those of lichen planus and
erythema multiforme."
"•A common microscopic feature
of these lesions is the band-like
subepithelial inflammation."
"•However, in patients with SLE
and erythema multiforme, the
inflammatory infiltrate extends
deeper into the underlying
connective tissue and shows a
perivascular pattern."
"•Deep submucosal vesicles may
also be apparent."
"•Lupus lesions will exhibit
periodic acid-Schiff staining in the
basement membrane zone."
"•Direct immunofluorescent
testing will show immunoglobulin
and complement deposition along
the basement membrane zone in a
granular pattern that is
characteristic of type III
hypersensitivity reactions."

15. Treatment
"•The goals of SLE
management are based on
prevention, reversal of
inflammation"
"•maintaining states of
remission and alleviation of
Avoidance of flare-ups of
lupus and skin lesions consists
of protection from ultraviolet
sunlight".
•"Other immunosuppressive
agents such as
cyclophosphamide,
methotrexate and
azathioprine are reserved for
severe organ disease such as
advanced lupus nephritis"

16. "Perioperative Management by the Dentist "
"Dentists must enforce preventive dental care and monitor patients with SLE closely for head
and neck infections because they are predisposed to severe infections."
"These infections are often silent and difficult to detect because of a paucity of pain and
swelling"
"Thorough clinical examination is required to avoid overlooking infections."
"Infections can progress rapidly in patients with SLE because of disease or therapy-related
immunosuppression"
"Patients suffering from chronic renal failure are often on dialysis. Dental surgery should be
planned one day after dialysis treatment to ensure elimination of administered medications and
their by-products."
"Patients on long-term corticosteroids may require supplemental dosing on the day of a
potentially stressful dentoalveolar surgery."
"A multidisciplinary approach to medical consultation and appropriate referrals ensures
comprehensive medical and dental management of patients with SLE."

17. ORO DENTAL treatment & management
"Lupus related lesions require biopsy for definitive diagnosis"
"because they can mimic erythema multiform and lichens planus, so: "
• "Ask the patient about his health history"
• "Instruct the patient about severe head and neck infections"
"• document whether the patient can be
managewith
aspirin,
warfarin,
anticoagulanttherapy to treat
bleeding.
This is done because SLE is
superimposed with ant phospholipid
antibod"

18. "• Topical antifungal
therapy(clotrimazole)"
" NYstatinsuspension"
"Chlorhexidine rinse 0.12% is of major
importance until the lesion resolves and to
contain periodontal diseases."
"Topical steroid application for symptomatic
oral lesion for 2 weeks:"
• "• -0.05% fluocinonide gel/ clobetasol gel
+ hydrogen peroxide + butter milk
gargle….. on mucous membrane ulcers"
• "- apply this for 2-3 times a day for 9
weeks while applying minimal steroid"

19. "If 2 weeks pass and the lesion showed no progression for the better, go for
systemic therapy:"
"• antimalarials treats skin rashes, mouth ulcers, joint pain"
"• thalidomide, clofazimine, methotrexate"
"• corticosteroids decrease swelling, pain used in case of significant
organ involvement"

20. “
Scleroderma
”
Scleroderma/Systemic sclerosis
•Hallmark sign:
•skin becomes thick, less pliable
•Limits embrasureand opening
•sclerodactyly
•Effects on internal organs
•Raynaud’s syndrome
•Treated with many medications used for other rheumatic diseases

21. “Sclerodermaand oral health
”
Xerostomia (dry mouth,
Sjögren's syndrome).
Psychological effects
(depression, self image).
Oral effects of
medications.
Pain and difficulty opening.
Gastro-Esophageal
Reflux (GERD)

22. “SclerodermaIncreases Patients' Decay Rate Many
interrelatedWays
”
“Oral Effects of Medications:
 Xerostomia.
 Oral Lesions.
 Stomatitis.
 Candidiasis.
 Intraoral hemorrhage
 Dysgeusia – taste change.
 Gingival hyperplasia – swollen gums.
 Osteonecrosis (Bone death) of the Jaw”

23. “Multiple tooth resorptionsyndrome”

24. “Caries Management By Risk Assessment
Risk factors that apply to many scleroderma patients:
 Special health care needs
 3 or more carious lesions (cavities) in last 3 years
 Teeth missing due to caries last 3 years
 Severe dry mouth
 Medications that reduce salivary flow
 Visible plaque
 Exposed root surfaces
 Lack of a dental home”
“Treatment of Xerostomia
 Symptomatic.
 Caphosol.
 Calcium/phosphate preparations
o Paste or rinse
 Artificial saliva.
o Salivart
 Sugar free candies.
 Fluoride gel and rinse
 Medical
o Pilocarpine (Salagen)
o Cevimeline (Evoxac) )”

25. “Fluoride Varnish
”
“Gastroesophageal refluxdisease management:
 Work withMD andPatient
o Medication
 PPI,H2 antagonists, Antacids
o Diet
 lowacid,no caffeine,nothingfor2 hoursbefore bed
o Endoscopyto Rule outBarrett's esophagus andulcerations”

26. “Dental management tools and
techniques:
 Patience
 Shorten burs.
 Floss with a floss aid.
 Impressions with smaller or cut down trays.
 Mouth prop
 Rubber dam
 Patience of both parties
 Short appointments and/or breaks
 Adjust patient:
o Physical therapy.
o Commissurotomy.”

27. “Adaptive tooth brush”
“Physical therapy”
“Therabite and Orastretch
”

28.  REFERENCES:
o Burket, Greenberg M, Glick M. Burket's oral medicine. New York: BC Decker Inc;
2003.
o Albilia JB1, Lam DK, Clokie CM, Sándor GK. Systemic lupus erythematosus: a
review for dentists. J Can Dent Assoc. 2007. 73(9):823-8.
o Brennan M, Valerin M, Napeñas J, Lockhart P. Oral manifestations of patients
with lupus erythematosus. Dental Clinics of North America. 2005;49(1):127-141.