Oral Manifestations Associated with Rheumatic Diseases

Oral ulcers are associated with several rheumatic disorders most notably Behcet’s disease and systemic lupus erythematosus (SLE). Oral ulcers may also be induced by various medications commonly used in rheumatology. • Biopsies of the ulcers are generally not helpful in determining etiology when Behcet’s disease is suspected, but may be useful in other settings. • Red/white, erosive, and lichenoid lesions are frequently encountered in SLE as well as in medication-associated lichenoid reactions. Anti-malarial medications, highly relevant to the treatment of SLE, can cause such reactions. Intraoral biopsy should be considered for white and red lesions when the diagnosis is not clear. SLE ulcers require the performance of direct immunofluorescence. • Conventional gingival hyperplasia is associated with medications such as cyclosporine. This is often exacerbated by poor oral hygiene. • A particular pebbly, hemorrhagic gingival hyperplasia known as “strawberry gingivitis” is characteristic of granulomatosis with polyangiitis. • Xerostomia and hyposalivation are common findings not only in patients with Sjögren’s syndrome but in the setting of polypharmacy. Diabetes mellitus, anxiety, and inadequate oral hydration exacerbate this problem. • Hyposalivation predisposes the oral cavity to candidiasis, periodontal disease, and dental caries because of the altered oral milieu. The lack of lubrication stemming from hyposalivation often results in mucosal trauma and difficulty chewing and swallowing. • Many patients present with burning sensations in the mouth secondary to hyposalivation, candidiasis, or inflammatory mucosal disease. These causes of oral burning should be distinguished from primary burning mouth syndrome, a form of dysesthesia most likely to occur in post-menopausal women. The burning mouth syndrome is often associated with mood disorders and fibromyalgia. • An inflammatory arthritis may affect the temporomandibular joint in rheumatoid arthritis, psoriatic arthritis, and juvenile idiopathic arthritis. Chronic nonbacterial osteomyelitis leads to jaw swelling and pain. Osteonecrosis of the jaw and osteomyelitis may result from use of anti-resorptive therapies. • Progressive orofacial fibrosis in patients with systemic sclerosis leads to narrowing of the opening of the mouth and upper airway, resulting in microstomia. • Jaw claudication may be the first sign of giant cell arteritis. • Periodontal disease appears to play an important role in the pathophysiology of rheumatoid arthritis.