Systemic Lupus Erythematousand

Scleroderma (Crest Syndrome)

Arodis AriasMichelle Enriquez

Kimberly Goris

Systemic Lupus Erythematous

Systemic Lupus autoimmune disease. Causes immune system to make antibodies that

attack the body’s healthy cells and tissues. Inflames:

◦ Joints and muscle pain◦ Tendons◦ Skin◦ Other connective tissues and organs like the heart

Symptoms include:◦ Fatigue◦ Malaise◦ Hair loss◦ Oral sores◦ Butterfly rash

Lupus Symptom: Butterfly rash

Systemic Lupus Erythematous is unknown. Studies suggest it may be a combination of:◦ Genetic factors◦ Environmental factors, which may include:

sunlight, (UV rays)◦ Stress ◦ Viral ◦ Drug induced (methyldopa, procainamide,

isoniazid, chlorpromazine, TNF-blocking drugs).

Etiology

Systemic Lupus - most common

Cutaneous Lupus – “Discoid Lupus”

Drug Induced: occur in 5% of people with Lupus◦ Apresoline ◦ Quinidine◦ Isoniazid◦ Dilantin

Types of Lupus

Lupus Symptom: Hair Loss

Sex: female to male 10:1 Age: 20-45 Race: African American, Native America,

Asian and Hispanic.

Risk Factors

Treatment of Cutaneous SLE

No cure. Goal of treatment is to control symptoms.

Photo protection: avoid direct sun exposure.◦ Sunscreens containing dioxide or zinc oxide.

Triamcinolone acetonide 0.1% Clobetasol propionate 0.05%

Brand Name: Kenalog®, Oralone®, Pediaderm®

MOA : decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increase capillary permeability, suppress the immune system by reducing activity and volume of the lymphatic system.

Adverse effects: Frequency not defined.

Drug Interaction: Avoid concomitant use with Aldesleukin.

Contraindication: Hypersensitivity to triamcinolone or any component of the formulation; fungal, viral or bacterial infections of the mouth or throat.

Effects on Dental Treatment: ulcerative esophagitis, perioral dermatitis, atrophy of the oral mucosa, burning and irritation.

Topical Corticosteroids

Oral Corticosteroids Prednisone

Brand name: PredniSONE Intensol™

MOA : decrease inflammation. Inmunosuppresion, adrenal function suppresion at high doses.

Adverse effects: Temporary effects and likely dose related adverse effects like osteoporosis and adrenal suppression.

Drug Interaction:◦ Avoid ethanol◦ Prednisone interferes with calcium absorption. Limit caffeine◦ St. John’s wart may decrease prednisone levels.

Contraindications: Hypersensitivity to any component of the formulation; systemic fungal infections; administration of live attenuated vaccines with immunosuppressive doses of prednisone.

Effects on Dental treatment: No significant effects or complications reported.

Topical Calciuneurin Inhibitors

Tacrolimus (Protopic® 0.1%)Pimercrolimus

MOA: suppress cellular immunity. (Inhibits T-lymphocyte activation)

Adverse effects: CNS: headache; Dermatologic: skin burning; Respiratory: increased cough; Cardiovascular: peripheral edema; Gastrointesntinal: diarrhea; Ocular: conjuctivitis.

Drug Interaction: avoid use of Immunosuppresants and alcohol. Localized flushing (redness, warm sensation) may occur at applicationsite of topical following ethanol consumption.

Contraindications: hypersensitivity

Effects on Dental Treatment: No significant effects or complications reported.

Antimalarials

Hydroxychloroquine (Plaquenil®)Aminoquinolone

MOA: Interferes with digestive vacuole function within sensitive malarial parasite.

Adverse effects: Frequency not defined. Cardiovascular: cardiomyopathy; CNS: ataxia, dizziness, emotional changes; Dermatologic: alopecia; Gastrointestinal: abdominal cramping, anorexia, diarrhea, nausea.

Effects on Dental Treatment: no significant effects or complications reported.

Immunosuppressants

AzaTHIOprine (Azasan®; Imuran®)Methotrexate (Rheumatrex®; Trexall®)Cyclophosphamide (Cytoxa)

MOA: antagonizes purine metabolism and may inhibit synthesis of DNA, RNA and proteins; may also interfere with cellular metabolism and inhibit mitosis.

Adverse effects: frequency not always defined; dependant upon dose, duration, indication, and concomitant therapy.

Drug interactions: avoid conccomitant use with BCG; Febuxostat; Mercaptopurine.

Contraindication: hypersensitivity to azathioprine or any component of the formulation.

Effects on Dental Treatment: No significant effects or complications reported.

B-cell Suppresor

RiTUXimab (Rituxan®)Belimumab (Benylsta®)

MOA: Its an IgG1-lamba monoclonal antibody that prevents survival of B lymphocytes. Reduces the activity of B-cell mediatoted immunity and the autoimmune response.

Adverse effects: Gastrointestinal: nausea; CNS: fever, insomnia, migrane, depression; Respiratory: bronchitis.

Effects on Dental Treatment: No significant effects or complications reported.

MOA: Management of pain and swelling.

Adverse effects: Cardiovascular: edema; CNS: dizziness; Dermatologic: rash; Endocrine: fluid retention.

Drug interaction: May increase levels of Anticoagulants; Antiplatelet Agent; Bisphosphonate derivatives; Collagenase.

Contraindication: associated with an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke.

Effects on Dental Treatment: Ibuprofen can interfere with the antiplatelet effect of low-dose aspirin (81mg/day), diminishing the effectiveness of aspirin as used for cardioprotection and stroke prevention.

NASAIDs

Scleroderma (Crest Syndrome)

A connective tissue disease that involves changes in the:◦ Skin◦ Blood vessels◦ Muscles◦ Internal organs

An autoimmune disorder when the autoimmune system attacks and destroys healthy body tissues

Reynaud’s phenomenon

Sclerodactyly

Telangiectasia

Treatment

Calcium channel blockers used for Reynaud’s phenomenon. Corticosteroids – Antiinflammatory NSAIDs ACE Inhibitors

Methotrexate Immune suppressing medicationAntineoplastic agaent

MOA: Ultrasoft acting IV barbiturate anesthetic.

Adverse effects: Frequency not defined.

Drug Interaction: None known.

Contraindication: Hypersensitivity to barbiturates (porphyria).

Effects on Dental Treatment: No significant effects or complications reported.

Medications

Cyclophosphamide Antineoplastic agent

MOA: Prevents cell division, and potent immunosuppressive.

Adverse effects: Dermatologic: alopecia; may cause sterility; nausea, vomiting, anemia, headache, nasal congestion.

Drug Interaction: Increased effect on Vitamin K antagonist.

Contraindication: severely depressed bone marrow function.

Effects on Dental Treatment: mucositis and stomatitis.

Medications continuation

Obtain thorough medical history which include all the medications and side effects.

Maintain patient on strict oral hygiene regimen and recalls.

Recommend powered toothbrush to patient due to lack of dexterity on their hands.

Advise patient to use WaterPick to clean interproximally since the patient may not be able to maneuver the dental floss.

Recommend patient to eat a healthy diet.

Dental Hygienist Role

1. What does Lupus affect?

2. What type of medications are used?

3. What is the most significant symptom of Scleroderma?

4. What does Raynaud’s phenomenon affect?

Questions

Resources You have full text access to this OnlineOpen articleArthritis &

RheumatismVolume 62, Issue 12, Article first published online: 30 NOV 2010

http://www.nlm.nih.gov/medlineplus/ency/article/000435.htm

http://www.medicinenet.com/systemic_lupus/page5.htm#what_is_the_treatment_for_systemic_lupus_erythematosus

http://emedicine.medscape.com/article/1064663-treatment