Oral manifestations of systemic autoimmune and inflammatory diseases: diagnosis and clinical management

Context: Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest stages, and early diagnosis, which may be spurred by a dental examination, is key for improved outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in collaboration with the medical team. This review aims to educate dental clinicians about the most relevant systemic autoimmune and inflammatory conditions with accompanying oral lesions, their implications for health, and management strategies supported by the biomedical literature and clinical experience. Ulcerative conditions including Behcet and Crohn diseases are discussed, along with rheumatic conditions including Sjögren syndrome, lupus erythematosus, and rheumatoid arthritis.

Evidence acquisition: Evidence was accumulated through PubMed searches using pertinent keywords for each subsection. References were reviewed and original publications examined to verify the accuracy of the information. We focused on evidence included in current reviews and randomized trials. Recommendations were supported by multiple studies and consensus expert opinion.

Evidence synthesis: Disease phenotypes described and clinical recommendations were synthesized from best-quality evidence available for each disease. Efforts were made to describe evidence selection within each disease section.

Conclusions: Dentists play an important role in the early detection and multidisciplinary medical management of complex autoimmune diseases. It is important to recognize prevalent medical and dental issues and special needs of patients with autoimmune conditions. The management of many inflammatory conditions is similar, and often begins with the use of topical steroids, analgesics, and antimicrobial treatments, in addition to careful attention to oral hygiene and appropriate fluoride usage. In this brief review, we aim to discuss the presentation/prevalence, diagnosis, and treatment of oral manifestations encountered in autoimmune, autoinflammatory and systemic chronic inflammatory diseases. Systemic autoimmune conditions are estimated to affect 5% to 8% of Americans.(1) Oral manifestations are encountered with high frequency, and are often the first clinical signs or symptoms of the general disease. Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. The dental practitioner may be asked to play a primary role in the diagnosis of such conditions and to participate with other health professionals working together to achieve effective clinical management. To aid in this process, we discuss in this article the current general knowledge of systemic autoimmune conditions that present with prevalent oral manifestations. The focus is on the diagnosis and management of the oral component of each disease. Importantly, whereas the etiology and pathogenesis and systemic clinical presentation may vary, presentation in the oral cavity is often similar and many conditions involve oral ulcerations. For this reason, we discuss the differential diagnosis and management of the most common oral ulcerations in a general section and subsequently address individual conditions that present with oral ulcerations. Similarly, treatment of various autoimmune/inflammatory oral conditions is often common and involves modulation or suppression of the immune response locally and/or systemically and will be therefore addressed in a common section as well as individually for each disease when unique treatment regimens are recommended. We present here our general treatment recommendations based on clinical experience and literature review; however, it is critical that good clinical judgment and specifics of an individual case should determine the appropriate dental/oral medicine intervention for a specific patient.