this research is made by a dental student (me) under supervision of our oral medicine specialist dr. muhassad almudhafer and this research is collected from several articles hope u like it this my email if u would like to contact me - mnmmnz4503.mm@gmail.com

1. SYSTEMIC LUPUS
ERYTHREMATOSUS
Oral medicine case presentation
Mohammed n. Al-Ghazali
Supervisedby Dr . Muhassadalmudhaffar
2018
Corporate Edition
MicrosoftCorporation
2018

2. INTRODUCTION
Type of lupus that is an episodic, multisystem
autoimmune disease characterized by
widespread inflammation of the blood vessels
and can affect most body tissues and organs ,
most commonly involved include the heart, skin,
joints, kidney, and nervous system . young
women are most often affected ,with peak age of
onset between 15 and 40 years
Lupus is a chronic disease, but symptoms may
come and go after the initial diagnosis. Lupus is
unpredictable and dangerous . The cause is
unknown, but sun exposure can trigger lupus in
susceptible individuals. Certain medications
have side effects that mimic lupus (drug-induced
lupus), which usually resolve once the
medication is stopped.
ETIOLOGY
SLE represents the classic prototype of an
autoimmune disease involving immune
complexes. Both the natural and the .adaptive
parts of the immune system are participating,
with the latter involving both B and T
lymphocytes.133,134 Environmental factors are
of importance as sun exposure, drugs, chemical
substances, and hormones which all have been
reported to aggravate the disease. A genetic
predisposition is supported by an elevated risk
for siblings to develop LE and by an increased
disease concordance in monozygotic twins.
More than 80 different drugs have been
associated with the onset of systemic lupus
erythematosus (SLE), including hydralazine,
methyldopa, chlorpromazine, isoniazid,
quinidine, and procainamide.135
Epidemiology
SLE is up to 10 times more common in women
than men, and typically has a predilection for
women in their child-bearing years . Reliable
data about the prevalence of SLE are difficult to
come by. Variable methods for data collection
and inconsistency regarding case definition
contribute to this problem, but it is clear that the
statistics vary with ethnicity. The overall
prevalence is estimated to be about 1 per 1000.
A study from Birmingham, UK, found the
prevalence to be 27.7/100,000 in the general
population, but nearly 9 times higher in Afro-
Caribbean females . Data from a national health
survey in the USA found the self-reported
prevalence of SLE (defined as having been
given a diagnosis of SLE by a physician) to be
241/100,000. Recognizing that this may well be
an over-estimate, combining self-reporting with
evidence of a current prescription for anti-
malarials, corticosteroids, or other
immunosuppressive medications reduced this
figure to 53.6/100,000
CLINICAL FINDINGS
The oral lesions comprises white striae with a
radiating orientation, and these may sharply
terminate toward the center of the lesions, which
has a more erythematous appearance.
However, several clinical manifestations of oral
LE exist. The most affected sites are the gingiva,
buccal mucosa, tongue, and palate. Lesions in
the palatal mucosa can be dominated by
erythematous lesions, and white structures may
not be observed (Figure 1). Oral mucosa lesions
compatible with LE may be the first sign of the
disease. Approximately 20% of the patients with
LE have been reported to display oral
lesions,137 although the figures vary from 9 to
45%.138
Oral findings occur in up to 40 % of patients with
SLE, and their presence can be important in
helping to initially establish the diagnosis.
Aphthous-like ulcerations or granulomatous
swellings may also be seen. Sjögren syndrome
is common in patients with SLE and can develop
at any point during the course of the disease
.Hematologic abnormalities are frequently

3. present in patients with active SLE, and oral
hematomas may be observed in
thrombocytopenic patients
SLE diagnosis requires that four or more
of the diagnostic criteria displayed in
table 8 should be present at each time
poi
fig.1- Lupus lesion in the palatal mucosa in a
patient with Systemic lupus erythematosus.
fig.2- Typical “butterfl y”rash in a patient with systemic
lupus erythematosus. Photograph courtesy of Stephen
Sonis, D.M.D., D.M.Sc., Boston, MA
Risk Factors
The chances of developing lupusare higher in
people who:
 Are female.
 Are black.
 Are between the ages of 15 and 45.
 Have a family history of lupus.
 Take medicines that are associated
with drug-induced systemic lupus .
 Exposure to ultraviolet light, usually from
sunlight.
 Smoking. Smoking also may make getting
lupus more likely, and make it more
severe.
 Some medicines.
 Some infections. Some people who
have cytomegalovirus (CMV), parvovirus
(such as fifth disease), and hepatitis C
infections eventually get lupus.
The Epstein-Barr virus has been linked to
lupus in children.
 Chemical exposure. Suspected chemical
toxins include trichloroethylene in well
water and silica dust. Hair dyes and
straighteners, linked to lupus in the past,
are no longer thought to trigger lupus.
Diagnosis
Systemic lupus erythematosus (SLE) can be a
difficult condition to diagnose. This is because
the symptoms of SLE are sometimes very
similar to a number of other conditions, most of
which are far more common than SLE.

4. SLE may also be difficult to diagnose because
the symptoms can vary greatly from person to
person. They may also change over time. For
example, there may be periods where your
symptoms are not very noticeable, or times
when they flare up and become more severe.
Blood tests
If you suspect that the patient may have SLE
after examining the symptoms, then you will
need to refer him for a series of blood tests to
help confirm the diagnosis.
Some of the blood tests that may be carried out
are listed below.
Anti-nuclear antibody test
An anti-nuclear antibody test checks to see
whether there is a certain type of antibody cell in
the blood, known as the anti-nuclear antibody.
Approximately 95% of people with SLE have this
antibody.
However, it is possible to have the anti-nuclear
antibody without having SLE, so the anti-nuclear
antibody test is not a definitive way of testing for
the condition. we will need to use other tests to
confirm the diagnosis.
Anti-DNA antibody test
An anti-DNA test also checks for a certain type
of antibody in the blood. If the patient have the
anti-DNA antibody, it is highly likely you will have
SLE. However, the antibody can also be present
in people who do not have the condition.
The level of anti-DNA antibodies increases when
SLE is more active, so during a flare-up of
symptoms the reading from this test may be
greater than normal.
Complement level test
Complement is a chemical in the blood that
forms part of the immune system. we may test
the level of this chemical in the blood to check
how active your SLE is. The level of complement
in the blood decreases when SLE is more
active.
Other tests
Once the patient have been diagnosed with
SLE, we will normally need regular check-ups
and tests to monitor how the condition is
affecting the body.
If he have SLE it is possible that he may go on
to develop other conditions, such as anaemia or
kidney problems. Monitoring his condition will
allow us to check for these secondary conditions
and, if necessary, provide treatment for them as
soon as possible.
we may need to have a scan, such as an X-ray,
ultrasound scan or a computerised tomography
(CT) scan to check whether SLE is affecting his
internal organs.
Antibody
Antibodies and immunoglobins are proteins in
the blood. They are produced by the immune
system to fight against bacteria, viruses and
disease.
Blood
Blood supplies oxygen to the body and removes
carbon dioxide. It is pumped around the body by
the heart.
Heart
The heart is a muscular organ that pumps blood
around the body.
Kidney
Kidneys are a pair of bean-shaped organs
located at the back of the abdomen, which
remove waste and extra fluid from the blood and
pass them out of the body as urine.
TREATMENT
avoid the sun: Exposure to sunlight can
sometimes make SLE symptoms such as skin
rashes worse. Therefore, it is important to
make sure that the patient protect his skin
when he is out in the sun.
Non-steroidal anti-inflammatory drugs
(NSAIDs):
Drugs that reduce inflammation in the body ,if
the patient experience joint or muscle pain as
a result of SLE, you can prescribe a NSAID to
help ease the symptoms.

5. Commonly prescribed NSAIDs for SLE
include:
 ibuprofen
 naproxen
 diclofenac
 piroxicam
- with taken care of the side effect and
contraindication of the NSIAD .
Hydroxychloroquine:
is a type of medicine that is usually used to
treat malaria but it is also effective in treating
some of the symptoms of SLE, such as skin
rashes, joint and muscle pain and fatigue.
Many people with SLE take
hydroxychloroquine on a long-term basis as a
way of controlling their symptoms and helping
to prevent flare-ups.
Side effects :of hydroxychloroquine are rare
but may include:
 indigestion
 diarrhoea
 headaches
 skin rashes
Corticosteroids
type of medicine that helps to control the
inflammation associated with lupus and suppress
the immune system. They can be administered
orally, intramuscularly, topically, or IV (for high
doses over a short period of time).Higher doses
usually are reserved for patients with more
severe complications, such as nephritis or
myocarditis. Because of concern over the long-
term adverse reactions to corticosteroids, a goal
of T2T is to have patients on the lowest effective
dose of corticosteroids. Patients taking long-
term corticosteroids should be monitored
for osteoporosis and cataracts.
T2T GOALS FOR LUPUS
Using T2T for rheumatic conditions is more
complicated than using it for diabetes or
hypertension because the goal is a reduction in
disease activity or remission, rather than a
numeric target such as A1C or
BP.5 The T2T recommendations for lupus were
developed by a working group of specialists
proficient in research and treatment of lupus and
an international expert panel.3 The
recommendations are steppingstones that
providers can use, along with clinical judgment,
to apply T2T to lupus.3 Primary T2T goals
should be to achieve remission, prevent damage
accrual, and improve health-related quality of life
to reduce patient morbidity and
mortality.2,3 When remission is not feasible, the
target should be the lowest possible disease
activity.3 These targets have been the primary
endpoints of many studies of T2T for rheumatoid
arthritis, and can be measured by the various
disease activity/damage indices discussed
below.
Immunosuppressants
type of medicine that suppress the immune
system. They can help improve the symptoms
of SLE by limiting the damage that the
immune system causes when it attacks the
healthy parts of the body.
Commonly prescribed immunosuppressant
medicines include:
 azathioprine
 mycophenolate mofetil
 cyclophosphamide
Immunosuppressants are sometimes used in
conjunction with corticosteroids because
these medicines may ease symptoms more
effectively when used together. In addition,
use of immunosuppressant medication may
reduce the dose of corticosteroids that is
needed.
Immunosuppressant medication is usually
only prescribed if we have severe SLE. This
is because this type of medication is very
powerful and can cause side effects such as:
 loss of appetite, nausea, vomiting,
stomach pain, diarrhea, swollen gums,
bruising or bleeding more easily,

6. convulsions, dizziness, headache,
acne, extra hair growth ,weight gain
Rituximab
is a new type of medication that can treat
people with SLE who don't respond to the
medications listed above. Rituximab was
originally designed to treat certain types of
blood cancer, such as lymphoma. However, it
has since proved to be effective in treating a
number of autoimmune conditions, such as
SLE and rheumatoid arthritis.
Rituximab works by locking on to and killing
the B-cells, which produce antibodies that are
responsible for the symptoms of SLE. It is
administered directly into the vein over the
course of several hours. This is known as an
infusion.
Common side effects of rituximab include:
 flu-like symptoms, such as chills and a
high temperature while the medication
is being given
 dizziness
 nausea
 vomiting
now for the oral lesions we have(table9) below
to explain the topical therapy for these lesions
DENTAL MANAGEMENT:
The dental management of the lupus
patient should take into account the
complex pathologic manifestations of the
disease, including oral aspects and
complications of immunosuppressive
treatment.
Risk of Infection. a complete blood count
should be obtained prior to dental
treatment of slE patients.
Adrenal Suppression. It has proved to be
very difficult to estimate the risk of
adrenal suppression based on the dose,
duration of therapy, or time since the last
dose without formal testing, such as the
adrenocorticotropic hormone
suppression test. any patient treated with
supraphysiologic doses of corticosteroids
(7.5 mg of prednisone a day or higher)
for 2 weeks or longer is at risk of adrenal
suppression.72 The duration of adrenal
suppression is dependent on both the
dose and duration of the treatment, with
abnormal adrenal responses observed
ranging from about a week (20 mg of
prednisone for 5 days) to up to a year
after long-term high-dose steroid
administration
COMPLICATION OF SLE:
Cardiovascular disease:
people with SLE are seven to eight times
more likely to develop CVD than the general
population. The reason for this is that SLE can
cause inflammation of your heart and arteries,
making it more likely that you will develop
CVD.
Complication of blood

7. . About half of SLE patients are anemic.
. Antiphospholipids: Their actions have
complex effects that include causing
narrowing and abnormalities of blood
vessels.
.Thrombocytopenia &Neutropenia
see fig.2
fig.2 - hematomas of the labial mucosa in a
patient with thrombocytopenia secondary to
a fl are of systemic lupus erythematosus
.These effects on blood vessels have also
been associated with confusion, headaches,
and seizures. Leg ulcers can also develop.
Lupus nephritis
Lupus nephritis is a potentially serious kidney
disease that is caused by prolonged
inflammation of kidneys as a result of SLE.
Lupus nephritis is a common complication of
SLE that is estimated to affect around half of
people with the condition.
Lupus nephritis tends to develop relatively
early on in the course of SLE, usually within
five years of receiving a diagnosis.
Symptoms of lupus nephritis include:
 swelling of your feet
 headaches
 dizziness
 blood in your urine
 a frequent need to urinate
In many cases, lupus nephritis does not cause
any noticeable symptoms. However, this does
not mean that the condition is not dangerous
as it can cause damage to kidney. Lupus
nephritis can also cause high blood pressure
(hypertension), which if not treated can put
the patient at risk of developing a serious
CVD in the long-term, such as a heart attack
or stroke.
Other autoimmune conditions
Approximately one in three people with SLE
also have another autoimmune condition,
such as thyroid disease, Sjogren's syndrome
or Hughes syndrome (antiphospholipid
syndrome).
The challenges of living
with lupus
Lupus is a difficult disease to live with. Though
current treatments can help alleviate certain
symptoms, there will still be days when the
condition can take such a toll, it can be hard to
simply get out of bed. "One day, I washed my
face and brushed the washcloth across my
eyelashes," 36-year-old Sharon Harris, president
and founder of Lupus Detroit - who was

8. diagnosed with lupus aged 23 - recently
told ABC News. "[It] stopped me dead in my
tracks. I was too exhausted to scream but it
knocked the life out of me so much so that I had
to sit on the edge of the tub to regroup. My
eyelashes hurt - I will never forget that." But it is
not just the physical symptoms that can
make day-to-day life difficult for people with
lupus; the disease can have a negative
impact on mental health, too. The UNVEIL
survey revealed that around 90% of people
with lupus experience anxiety asa result of
the condition and around 85% feel
depressed. Lupus can make a person feel tired
and week, causing them to withdraw from social
activities, which can make them feel isolated.
Another challenge with lupus is that the disease
is often "invisible," which can make it hard for
others to understand what people with lupus are
going through. "You may face many who doubt
the veracity of your illness, believing it is all in
your head. This can be extremely painful,
frustrating, causing anger and resentment,"
notes non-profit foundation Molly's Fund:
Fighting Lupus. Lupus can also change a
person's lifestyle dramatically. They may need to
give up work, for example, or they may need
assistance with general everyday tasks, such as
household chores, cooking or shopping.

9. References:
1- BURKET'S ORAL MEDICINE
Eleventh Edition by
Martin S. GreenberG, DDS,
FDS rCS
Michael Glick, DMD, FDS rCS
Jonathan a. Ship, DMD, FDS
rCS
2- Clinical Oral Medicine and
Pathology second edition by
Jean M. Bruch Nathaniel S.
Treister
3-
4- Lupus foundation of
America,Inc
5- American Autoimmune
Related Diseases
Association, Inc.
6- https://www.hse.ie/eng/health/
az/l/lupus/
7- The American College of
Rheumatology nomenclature and
case definitions for
neuropsychiatric lupus syndromes
8- Orphanet Journal of Rare
Diseases2006
9- Lupus Research
Institute, Living with lupus,
accessed 22 October 2015.
10- Lupus Foundation of
America, Lupus Awareness
Month, accessed 22 October
2015.
11- Danchenko N, Satia JA,
Anthony MS. Epidemiology
of systemic lupus
erythematosus: a comparison
of worldwide disease
burden. Lupus.
2006;15(5):308–318
12- Systemic lupus erythematosus: An
update on treat-to-target Roberts,
Amy Lynn PA-C; Rizzolo, Denise
PA-C, PhD Journal of the
American Academy of Physician
Assistants: September 2015
13- Petri MA,et al.(2005).Combined
oral contraceptives inwomen
withsystemic lupus erythematosus.
New England Journal ofMedicine,
353(24):2550-2558.
14- Crosbie D, et al. (2009).
15- WebMD Medical
Reference from
Healthwise / Systemic lupus
erythrematosus