Clinical Scenario

A 65‐year‐old male presents to your dental clinic for an emergency appointment. He complains of a left‐sided, painful facial swelling. His symptoms commenced 3 days ago and have increased significantly over the last 12 hours.

Structured Learning

1. What is the most likely cause of the bilateral facial erythema (Figure 12.1.1)?
   • The presence of a bilateral butterfly rash is present in 45–65% patients with SLE (an autoimmune disease that can affect the skin, joints, kidneys, brain and other organs, with oral involvement)
     

     

     

   • Typically, the butterfly rash appears in a malar distribution across the nose and cheeks
   • Other oral manifestations of SLE include oral ulceration, raised keratotic plaques, non‐specific erythema, purpura, petechiae and cheilitis

2. In addition to SLE, what other conditions should be included in the differential diagnosis of facial erythema?
   • Rosacea: a chronic inflammatory acneiform disease, pathogenesis uncertain, not associated with systemic illness
   • Erysipelas: painful and well‐circumscribed skin infection with systemic symptoms, including fever, chills and malaise
   • Cellulitis: skin infection, less well demarcated than erysipelas with little or no oedema that does not usually have systemic symptoms
   • Polymorphous light eruption: common form of primary photosensitivity, mainly affecting young women in spring/summer months
   • Drug‐induced photosensitivity: photosensitising medications cause unexpected dermatitis on sun‐exposed skin (e.g. fluoroquinolones)
   • Other: diseases such as sarcoidosis, pellagra (related to lack of vitamin B3), dermatomyositis appear less frequently
3. What factors could be contributing to the advanced tooth surface loss?
   • Attrition
     • Loss of posterior occlusal support causing increased loading on the remaining dentition
     • Bruxism more common in chronic pain conditions such as SLE‐associated arthritis
   • Erosion
     • Diet: high consumption of acidic fizzy drinks
     • Gastro‐oesophageal reflux disease likely (related to obesity – patient is taking omeprazole)
     • Xerostomia secondary to prednisone (less effective protection from saliva)
   • Abrasion
     • Unlikely cause in this patient as he brushes his teeth infrequently
4. You determine that the infected retained root #23 is the cause of this patient’s acute facial swelling. What factors increase his risk of oral infection?
   • Poor oral hygiene
   • SLE
     • Genetic factors predisposing to SLE include genes related to lymphocyte signalling, the innate immune response (type I interferon and nuclear factor kappa B signalling), apoptotic cell death and defective clearance of immune complexes
     • SLE is known to be associated with primary immunological abnormalities, such as lymphopenia and low production of interleukin‐2 (IL‐2)
   • Immunosuppression related to medication
     • Prednisone (systemic steroid)
     • Immunosuppressants (methotrexate; pimecrolimus which if used in high doses and frequently may be absorbed)
5. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Escort advisable due to reduced mobility and personality disorder
     • Informed consent may be affected by the underlying personality disorder; behaviour can further be affected by the side‐effect of systemic steroids
   • Medical
     • Poor compliance with medical care, including medication
     • Access and position in the dental chair will be affected by the patient’s lupus arthritis, peripheral arterial disease and obesity (see Chapter 16.4)
     • There is a risk of a hypertensive crisis due to arterial hypertension (see Chapter 8.1)
     • Risk of an adrenal crisis due to corticosteroid medication
     • Drug adverse effects and interactions
   • Dental
     • Acute presentation of dental infection
     • Poor oral hygiene
     • Poor motivation/infrequent dental attender
     • Highly cariogenic diet
     • Advanced tooth surface loss
     • Limited financial resources
6. The abscess relating #23 needs to be drained urgently. The patient has taken 30–40 mg/day of prednisone over the last 8 years. Can you proceed?
   • The procedure is considered low risk, because it is relatively simple (will last less than 1 hour), will be performed with local anaesthesia, and there are no other factors that would predict significant bleeding (except arterial hypertension)
   • Hence corticosteroid supplementation is not routinely given as drainage of a dental abscess is not considered as surgically stressful as a dental extraction
7. During the dental procedure, the patient complains that his head hurts, he feels nauseated and he is confused. What should you do?
   • Stop the procedure
   • Measure the patient’s blood pressure to distinguish between an adrenal crisis (generally accompanied by abrupt hypotension) and a hypertensive crisis (the patient has hypertension)
   • Take appropriate action
8. The patient stabilises and you are able to proceed with draining the buccal abscess. Due to the extent of infection and the fact the patient is immunosuppressed, you prescribe an antibiotic postoperatively. What drug interactions should you take into account?
   • Beta‐lactams (e.g. ampicillin and amoxicillin) reduce the excretion of methotrexate, enhancing its toxicity (see Chapter 12.2)
   • The rate of skin rashes caused by ampicillin and amoxicillin increases when combined with allopurinol
   • Moxifloxacin (a quinolone) is contraindicated for patients who take hydroxychloroquine
   • The risk of tendonitis and Achilles tendon rupture secondary to the administration of quinolones (e.g. levofloxacin and ciprofloxacin) can increase if combined with corticosteroids
9. What analgesic would you recommend?
   • For patients who take corticosteroids, non‐steroidal anti‐inflammatory drugs increase the probability of gastrointestinal haemorrhages
   • The risk of haematological and gastrointestinal toxicity of methotrexate is increased with non‐steroidal anti‐inflammatory drugs (see Chapter 12.2)
   • Non‐steroidal anti‐inflammatory drugs attenuate the effect of some antihypertensives such as angiotensin‐converting enzyme inhibitors (see Chapter 8.1
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