The Impact of Lupus on Oral and Dental Health – Kaleidoscope Fighting Lupus
From ulcers and dry-mouth, to tooth decay and gum disease, lupus can significantly affect your oral and dental health. Read more about the surprisingly complex relationship between lupus and a healthy smile!
The mouth can be a “window” into overall health. When an individual has a chronic illness such as SLE, keeping on top of oral health is just as important as keeping the rest of the body healthy. Without a proper diet, self-care and medical dental intervention, overall health may become vulnerable and weaken when under the attack of microscopic bacteria or other conditions. Individuals with lupus should pay strict attention to any new symptoms or changes in health including oral and dental health.
Up to 40% of individuals with SLE may develop various mouth ulcers including desquamative gingivitis (red, shedding and ulcerated gums), marginal gingivitis (ulcers where food typically collects in the mouth around the teeth) and erosive mucosa lesions (painful, white ulcers). Common signs and symptoms of compromised oral and dental health include:
- gums that are red, tender, bleeding and swollen, or pulling away from teeth;
- gum infections (periodontitis);
- evidence of cavities or tooth decay;
- painful teeth or pain when chewing;
- bad breath;
- swelling of the lips;
- inflammation of the tongue, and
- lesions and ulcers in the mouth and/or on the gums;
Mouth ulcers are particularly important to take seriously. There are many types, ranging from common canker sores (aphthous) and injury, but can also be side effects of medications or systemic diseases like SLE and rheumatoid arthritis. While mouth ulcers and lesions are more often systemic (as with SLE), they can also be a sign of cutaneous or discoid lupus. Research has shown that it is imperative to reach out to a healthcare practitioner as soon as these serious symptoms are noticed.
Mouth ulcers are one of the main symptoms of lupus in children and often go unnoticed. Most ulcers are painless and erupt on the hard pallet. Though rare, a child may develop discoid lupus and present with ulcers on the soft pallet, tongue and on the lining of the lips and cheeks (buccal mucosa). These ulcers indicate that treatment is needed right away to not only treat lupus, but to also preserve the health of teeth and mouth tissue as a child grows.
Some medications, including some of the drugs used to treat lupus, may cause mouth ulcers. These treatments include immunosuppressants, corticosteroids, and anti-rheumatics such as methotrexate.
Other medications that may cause mouth ulcers include:
- anticholinergic bronchodilators;
- anti-hypertensives and beta blockers
- antiretrovirals and interferons;
- blood thinners and hypoglycemic agents;
- non-steroidal anti-inflammatory drugs (NSAIDs);
- potassium-channel blockers and protease inhibitors.
Note: It is important that if an individual has mouth ulcers that they reach out to a healthcare practitioner immediately before stopping any treatment.
Other causes of mouth ulcers and changes in teeth include:
- stress and anxiety or feeling tired and fatigued;
- hormonal changes;
- poorly fitting dental appliances such as braces, dentures and mouth guards;
- biting the insides of the cheeks and lips;
- vitamin B12 and iron deficiencies; and
- other conditions such as oral lichen planus, leukoplakia, herpetic gingivostomatitis, irritable bowel disease, acid reflux and celiac disease.
Genetics, lack of dental care and dental hygiene affect teeth as well as having compromised oral health from ulcers and lesions. Individuals with lupus are also more susceptible to cavities and tooth decay. While scientists are not exactly sure why, they speculate the following:
- Irregular dental hygiene: While an individual may not be feeling well due to other lupus symptoms or having mouth discomfort, they may actually neglect a strict dental hygiene regime or visit the dentist regularly.
- Impaired salivary gland function: Sjögren’s syndrome may affect the amount of saliva that is produced (see more on Sjögren’s below).
- Disturbed oral microbial community: SLE may cause stress to the oral microbiome, making it less diverse. By studying dental plaque, one group of researchers have identified 87 phylotypes (a specific classification of organisms) that are found nearly two-fold in individuals with a healthy mouth versus individuals with tooth decay and cavities.
Improper diet can also cause plaque buildup, tooth decay and enamel erosion. Diets heavy in sugar, acidic foods and drinks (coffee and tea included) and dehydration from lack of water can also be detrimental to dental health.
Stress and anxiety can be equally as harmful to jaw function and healthy teeth. Individuals who are stressed often clench and grind their teeth (bruxism), especially when sleeping. This action not only pushes the jaw and teeth out of alignment, but can also cause premature wear-and-tear of the teeth, cracking enamel and allowing entry points for bacteria to grow. Temporomandibular disorders – commonly known as TMJ – can manifest as a result of overworked jaw muscles and the temporomandibular joints that are located on either side of the jaw. Symptoms of TMJ include pain, the inability to fully open or close the jaw, an uneven bite and ear pain. Most TMJ can be treated successfully with a mouthguard that is worn at night or during times of stress – surgery is the last resort if all other interventions fail.
A Note regarding Sjögren’s Syndrome…
Approximately 15% of Individuals with more severe SLE may also develop an overlap of Sjögren’s syndrome. One of the more common symptoms of Sjögren’s is dry mouth.
Saliva helps to keep the mouth clean by washing away food particles and neutralizing the acids that are produced by bacteria. Saliva also helps to breakdown food and starts the digestion process. When the mouth is dry, an individual is more susceptible to disease as well as poor oral and dental health. Plaque can build on teeth and decay may set in. Gums may become inflamed, resulting in gingivitis. The inability to chew and digest food properly can cause gastrointestinal issues. The power of saliva can easily be underestimated.
Sjögren’s mouth symptoms are typically treated with drugs that increase saliva production including pilocarpine (Salagen) and cevimeline (Evoxac). Other treatments for managing dry mouth include artificial saliva sprays and rinses, drinking water, avoiding caffeine and chewing sugarless gum or sucking on sugarless candy.
Individuals with SLE are at a significantly greater risk of developing gum disease (periodontitis). One reason for this may be that individuals with SLE can be vulnerable to Aggregatibacter actinomycetemcomitans (Aa), a pathogen often found when more aggressive periodontal disease is present and the individual is experiencing high disease activity or a lupus flare. This pathogen has also been linked to an increased risk of periodontal disease in individuals with RA.
Those who test positive for anti-dsDNA antibodies have also been shown to have higher concentrations of antibodies against Porphyromonas gingivalis, Treponema denticola, Streptococcus gordonii and Capnocytophaga ochracca.
Several members of a healthcare team including a dental care provider or dermatologist can diagnose and treat oral health issues.
A healthcare or dental practitioner can often diagnose mouth and dental conditions through a visual and/or dental exam. If the condition is more invasive and/or it is suspected that an individual has lupus, further diagnostic testing may be necessary. Diagnosing lupus may include:
- a complete medical and family health history;
- a physical exam;
- lab tests including blood, urine and kidney assessments and antibody tests
- skin biopsies; and
Common treatments for mouth ulcers, sore gums and sore teeth include:
- antibiotics and/or antifungal medications if infection is present;
- corticosteroids such as prednisone and prednisolone;
- antimalarials such as hydroxychloroquine (Plaquenil);
- topical steroid creams;
- oral hydrocortisone;
- corticosteroid lozenges;
- topical anesthetics such as benzocaine;
- biologics such as belimumab (Benlysta);
- antimicrobial mouthwash;
- pain-killing mouthwashes, sprays or gels;
- warm salt-water rinses;
- special toothpastes and rinses for sensitive teeth and gums;
- red-light therapy.
When an individual needs to see a dental practitioner, the practitioner will also take a complete medical and oral health history. The practitioner will then exam the mouth and will take X-rays and gum measurements as necessary.
Treatments for oral and dental conditions such as gingivitis and periodontitis include:
- Scaling: This is a deep cleaning to remove all traces of tartar and bacteria from the surfaces of the teeth and beneath the gumline.
- Root planning: Root planning includes removing the products bacteria produces as a result of inflammation. This treatment also smooths root surfaces and discourages plaque buildup in order to promote healing.
- Antibiotics: Oral and topical antibiotics may be prescribed to treat and prevent gum infection after scaling and root planning.
Surgical periodontitis treatments include:
- Flap surgery: A flap is made in the gum so the root can be exposed for cleaning.
- Soft tissue grafts: Skin may be grafted where there has been gum tissue loss.
- Bone grafting: If bone is destroyed, a bone graft may be necessary to help hold teeth in place.
- Guided tissue regeneration: This process helps bone grow back where it has been destroyed by bacteria. Fabric is placed between the bone and teeth so unwanted tissue does not grow but new bone does.
- Tissue-stimulating proteins: A protein gel is applied at the root of a tooth stimulating healthy enamel, bone and tissue growth.
Dental restoration may be needed to address problems with teeth such as cavities, tooth decay, misaligned, receding gums or other problems. These restorations include fillings, bridges, crowns, dentures and implants. If teeth are severely out of alignment due to crowding or gaps and teeth need to be moved, spacers or braces may be necessary as well as possibly oral surgery.
Scientists have found that individuals with lupus who have more gum disease-causing bacteria also experience higher disease activity. These scientists stress the importance of good oral and dental hygiene as ways an individuals can take control of their health and work towards symptom relief.
Ways that individuals with lupus can maintain and improve oral and dental health include:
- brushing teeth after each meal or at least twice a day using a soft toothbrush and replace it at least every three months and immediately after viruses and infections;
- flossing at least once a day, if not after every meal;
- avoiding gimmicky tools and products that make questionable claims or are overly “hyped” on social media;
- using dental rinses to kill bacteria, strengthen enamel, provide fluoride and/or keep the mouth moist;
- eating a balanced diet that is also low in sugar and acids as both can erode tooth enamel and cause decay;
- avoiding soft drinks, coffee, tea and alcohol or drink them in moderation only;
- avoiding foods that are too hard and drinks that are too hot;
- avoiding or quitting smoking;
- drinking plenty of water;
- keeping lips protected with petroleum jelly and lip balms with UV protection;
- avoiding sunlight especially if prone to developing lip ulcers/lesions from photosensitivity; and
- scheduling routine dental exams and cleanings. Discuss the need for more frequent visits with a dental care provider. Some individuals with lupus need to go more frequently.
Biting the insides of the cheeks and lips can result from tension and stress and can also cause or exacerbate mouth sores. Stress can also cause an individual to clench the jaw and grind teeth. Taking mental health into consideration and seeking the help of a therapist may be a good way to learn how to relieve stress and decrease anxiety, in turn eliminating these habits and improving oral health.
Poor oral health can take a toll on mental health. A 2018 study shows that individuals with SLE who were asked to complete an oral health impact profile (OHIP) had an overall lower health-related quality of life (HRQoL). Oral disorders such as those listed earlier in this article, along with the need for bridges and dentures for some individuals, can negatively impact self-esteem and interpersonal relationships. The European League Against Rheumatism (EULAR) suggests that individuals should be asked to complete assessments such as the OHIP at every healthcare visit in order for practitioners to treat individuals holistically and improve HRQoL.
Poor oral health may also cause other health problems. In 2000, the United States surgeon general along with the National Institute of Dental and Craniofacial Research published a landmark report on oral health in America. The surgeon general and researchers surmised that in the case of heart disease and stroke, for example, bacteria and viruses that originate in the mouth may infect blood vessel walls which can cause vascular inflammation and ultimately a buildup of fatty plaque and atherosclerosis. These conditions can lead to heart disease and stroke.
Diabetes is another condition that may be linked to poor oral health. Periodontal infections may interfere with glycemic control as cytokines are released with periodontitis. The cytokines can interfere with insulin production which can change metabolic processes and functions in the body.
Other health conditions that may be linked to poor oral health include:
- pneumonia; and
- pregnancy and birth complications including premature birth and low birth-weight.
As you can tell from the length of this blog, there are a multitude of issues and possible complications regarding the mouth and teeth for those living with lupus. It can be all too easy to neglect oral health and take it for granted. Our teeth and mouth do us a great service and work hard to keep us healthy and alive. Pay them back by taking great care to preserve their health. Developing good oral hygiene habits and staying on top of the mouth symptoms of lupus can be one way to take control of overall health and well-being … and give each of us more reasons to smile!
Al-Mutairi, K., Al-Zahrani, S., Bahlas, S., Kayal, R., & Zawawi, K. (2015). Periodontal findings in systemic lupus erythematosus patients and healthy controls. Saudi Medical Journal, 36(4), 463-468. doi: 10.15537/smj.2015/4/10746. Retrieved June 12, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404481/
Bagavant, H., Dunkleberger, M., Wolska, N., Sroka, M., Rasmussen, A., Adrianto, I. Montgomery, C., Sivils, K., Guthridge, J., James, J., Merrill, J., & Deshmukh, U. (2019). Antibodies to periodontogenic bacteria are associated with higher disease activity in lupus patients. Clinical and Experimental Rheumatology, 37(1), 106-111. Retrieved June 12, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309750/
Chiewchengchol, D., Murphy, R., Edwards, S., & Beresford, M. (2015). Mucocutaneous manifestations in juvenile-onset systemic lupus erythematosus: A review of literature. Pediatric Rheumatology, 13(1), 1-9. Retrieved June 12, 2020 from https://ped-rheum.biomedcentral.com/articles/10.1186/1546-0096-13-1
Correa, J., Branco, L., & Calderaro, D. (2017). Impact of systemic lupus erythematosus on oral health-related quality of life, Lupus. Doi: 10.1177/0961203317719147. Retrieved June 12, 2020 from https://journals.sagepub.com/doi/full/10.1177/0961203317719147?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Dry mouth. (n.d.). Mayo Clinic. Retrieved June 12, 2020 from https://www.mayoclinic.org/diseases-conditions/dry-mouth/symptoms-causes/syc-20356048
Gingivitis. (n.d.). Mayo Clinic. Retrieved June 12, 2020 from https://www.mayoclinic.org/diseases-conditions/gingivitis/diagnosis-treatment/drc-20354459
Howard, P. (2017, May 3). April’s topic of the month – Coping with oral and nasal ulcers. Lupus UK. Retrieved June 12, 2020 from https://www.lupusuk.org.uk/coping-with-oral-and-nasal-ulcers/
Jinbu, Y. & Demitsu, T. (2013). Oral ulcerations due to drug medications. Japanese Dental Science Review, 50(2), 4-46. doi: 10.1016/j.dsr.2013.12.001. Retrieved June 12, 2020 from https://reader.elsevier.com/reader/sd/pii/S1882761613000811?token=6ACCA8D17A9895D08A3A61355BCDD2586DA458BAE95D9A31667111A8BF378C50B5EE7BB28005BF97E12793CD4DDFCF59
Konig, M., Abusleme, L., Reinholdt, J., Palmer, R., Teles, R., Sampson, K., Rosen, A., Nigrovic, P., Sokolove, J., Giles, J., Moutsopoulos, N., & Andrade, F. (2016). Aggregatibacter actinomycetemcomitans-induced hypercitrullination links periodontal infection to autoimmunity in rheumatoid arthritis. Science Translational Medicine, 8(369). doi: 10.1126/scitranslmed.aaj1921. Retrieved June 12, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5384717/pdf/nihms-851268.pdf
National Institute of Dental and Craniofacial Research. (2000). Oral health in America: A report of the Surgeon General. Retrieved June 12, 2020 from https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
Oral health: The window to your overall health. (n.d.). Mayo Clinic. Retrieved June 12, 2020 from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475
Oral health and overall health: Why a healthy mouth is good for your body. (2019). Colgate Professional. Retrieved June 12, 2020 from https://www.colgateprofessional.com/education/patient-education/topics/systemic/why-a-healthy-mouth-is-good-for-your-body
Periodontitis. (n.d.). Mayo Clinic. Retrieved June 12, 2020 from https://www.mayoclinic.org/diseases-conditions/periodontitis/diagnosis-treatment/drc-20354479
Peterson, S., Snesrud, E., Liu, J., Ong, A. Kilian, M., Schork, N., & Bretz, W. (2013). The dental plaque microbiome in health and disease. PlosOne, 8(3). Retrieved June 12, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592792/pdf/pone.0058487.pdf
Rodriquez, J., Torres, G., Martinez, R. Mendoza, C., Solis, C., Coronel, S., Cortes, J., & Perez, R. (2016). Frequency of dental caries in active and inactive systemic lupus erythematosus patients: Salivary and bacterial factors. Lupus. doi: 10.1177/0961203316640909. Retrieved June 12, 2020 fromhttps://www.researchgate.net/profile/Juan_Loyola-Rodriguez/publication/299989048_Frequency_of_dental_caries_in_active_and_inactive_systemic_lupus_erythematous_patients_Salivary_and_bacterial_factors/links/5a09d812aca272d40f411a99/Frequency-of-dental-caries-in-active-and-inactive-systemic-lupus-erythematous-patients-Salivary-and-bacterial-factors.pdf
Rutter-Locher, Z., Smith, T., Giles, I., & Sofat, N. (2017). Association between systemic lupus erythematosus and periodontitis: A systematic review and meta-analysis. Frontiers in Immunology. doi: 10.3389/fimmu.2017.01295. Retrieved June 12, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5650969/
The health risks of gum disease. (2018). National Health Service. Retrieved June 12, 2020 from https://www.nhs.uk/live-well/healthy-body/health-risks-of-gum-disease/
The link between lupus and teeth. (2020). Colgate. Retrieved June 12, 2020 from https://www.colgate.com/en-us/oral-health/conditions/immune-disorders/the-link-between-lupus-and-teeth-0515
TMJ disorders. (n.d.). Mayo Clinic. Retrieved June 12, 2020 from https://www.mayoclinic.org/diseases-conditions/tmj/symptoms-causes/syc-20350941
Yang, L, Wang, J., Xiao, Y., Wang, X., Sun Q., Shang, J., & Zhao, Y. (2018). Saliva dysfunction and oral microbial changes among systemic lupus erythematosus patients with dental caries. BioMed Research International. doi: 10.1155/2018/8364042. Retrieved June 12, 2020 from http://downloads.hindawi.com/journals/bmri/2018/8364042.pdf
Author: Liz Heintz
Liz Heintz is a technical and creative writer who received her BA in Communications, Advocacy, and Relational Communications from Marylhurst University in Lake Oswego, Oregon. She most recently worked for several years in the healthcare industry. A native of San Francisco, California, Liz now calls the beautiful Pacific Northwest home.
All images unless otherwise noted are property of and were created by Kaleidoscope Fighting Lupus. To use one of these images, please contact us at [email protected] for written permission; image credit and link-back must be given to Kaleidoscope Fighting Lupus.
All resources provided by us are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views expressed here do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your healthcare practitioner with any specific questions or concerns.