Juliette ROCHEFORT1, Yvon Roche1, Adrian Hij2, D. Farge2, Arnaud Rigolet3
- Unit of dentistry, Rothschild Hospital, Paris, France
- Unit of Internal Médicine and Vascular Pathology, St Louis Hospital, Paris, France
- Unit of Stomatology and Maxillofacial, St Louis Hospital, Paris, France
The Scleroderma Systemic(SSc) is a disease of connective tissue. Initiated by an endothelial injury, it’s characterized by an antoimmune reaction, which follows an antigenic stimulus whose exact origin is still unknown. It is manifested by manufacturing specific auto antibodies non-pathogenic, an excess deposition of collagen, vascular hyper-activity and an obliteration phenomenon and fibrosis micro-vascular .
This disease affects frequently the face and oral cavity, it has an organic and functional impact which it is important to evaluate, to treat and to prevent. Patients may present sclerosis skin with a reduction in mouth opening, an alteration of the production of saliva sometimes causing a deterioration of the teeth and a worsening of mucosal and joint pain.
What should i do in case of dry mouth ?
A dry mouth, or xerostomia, is felt by 70% of patients with Scleroderma Systemic. It is a dry syndrome, resulting of a fibrosis of salivary glands. It is highlighted thanks to “sugar test” which consists in measuring the time it takes a sugar to melt in the mouth. This drought can cause difficulties to feed and speak, and night hindrance and the appearance of perleche (inflammation of the lips commissure). The disease in salivary flow causes oral acidity increases the risk of developing caries lesions and oral mycosis.
Prevention depends on a good dental hygiene and daily mouthwash with an alkaline product (antacid: sodium bicarbonate at 14%).
In case of mycosis, these bath will be completed by an anti mycotic product (on medical prescription) if the infringement doesn’t require systemic therapy.
Moreover, therapeutic stimulation or saliva substitutes, such as artificial saliva in spray and moistening gel. Suck a shirt button helps to stimulate salivation (without being associated with the act of eating and to be exempt easily if accidentally swallowed), chew gum or eat sugarless candy, take time to chew, drink repeatedly in small quantities are solutions to be practiced, which improve significantly oral comfort .
What to do in case of limitation of mouth opening ?
Two patients out of three present or will present a limitation of mouth opening , due to sclerosis of the skin, lips and cheeks, and 93% suffer from a skin atrophy (2). Daily physiotherapy exercices realised by following the advice of a specialist can show the process of fibrosis (see fact sheet below). It’s very important tho start at the early stages of the disease. There are also techniques of plastic surgery with injected fat extracts, or stromal vascular fraction (SVF containing cells multipotent mesenchymal) whose beneficial effects are currently being studied.
What to do in case of pain of jaw, cheeks and ears?
These localized pains in cheeks, radiating to the ear, can be strong and interfere with feeding and elocution ; until 30% patients suffer from it (2).
In the rare case, the jaw joint (Temporo-mandibular joint, TMJ) is directly affected by the formation of intra-articular calcifications. Objectified by standards X Rays, they cause significant pain emphasizing the importance of early targeted rehabilitation. Morevover, some patients (10%) have erosions or bone resorptions, sometimes in the source of these facial pains (1-7). This process can only detected by clinical and radiological controls, it is necessary to realised you frequently to detect it as soon as possible (9).
Often, these pains caused by skin or muscular stiffness. The same exercises of physiotherapy as those described to maintain a good oral opening can help to reduce these pains. The method is described in a CD-Rom produced by the Rehabilitation Department of the Cochin Hospital in partnership with the Scleroderma Association of France (“ASF”) and Francophone Research Group on Scleroderma (“GFRS”).
Furthermore, the loss of posterior teeth worsens these pains causing an imbalance of the jaw and a muscle fatigue, it is therefore necessary to prevent their degradation or replace them when they are absent. Removable appliances or implants may be envisaged depending on the case.
What to do in case of damage of the Oral Mucosa ?
Up to 20% of patients with weathering gums and underlying bony structures. It is periodontal diseases, this is due to the difficulty of brushing teeth in case of limitation of mouth opening, as well as tissue damage and microcirculation gums, and limiting antibacterial defenses (10-11). Plaque and tartar are then present in larger quantities and can cause gingival recessions, a reduction of bony height and tooth mobility (2). This highlights the importance of descaling at least twice a year
Maintaining a correct hydration and humidification of oral cavity by regular water intake prevent the majority of these symptoms. par des apports hydriques réguliers préviennent la majorité de ces symptômes. Skin atrophy is often accompanied by an involvement of internal mucous membrane of the cheeks and tongue, which seems depapillated.Tissues become smooth, dry and sometimes have cracks or painful ulcerations. In this case, anesthetic gels can be prescribed and limit these oral pains, by making, however, attention to wrong tracks. Regular periodontal care can limit the effects of this damage.
What to do in case of dental damage ?
Saliva has a protective role against caries, patients with Scleroderma Systemic have a higher risk of develop it. Prevention measures must then applied by bringing every day more fluorine, by the use of highly toothpast fluorinated or a fluorination gutter. To this must be added to follow-up visits at a dental-surgeon twice a year, accompanied by radiological check.
Dental disease may also be the consequence of joint and muscle dysfunction and be aggravated by nocturnal bruxism (unconscious dental movement either by grinding or by squeezing). This tooth grinding causes the wear and the erosion of the dental surfaces, as well as
lesions called cervical (the part of teeth close to the gum).Night gutters can limit the destruction of dental tissues. The dental surgeon will offer the best way to limit the local effects. One of the signs of Scleroderma Systemic can be expanding the ligament, present in 33% of cases (2). This ligament forming the junction between the tooth and the bone, its alteration is only visible on radiographs (panoramic or retro alveolar, the latter being more precise). This process involves the entire surface of the root and may be associated with a corresponding to resorption of the alveolar bone. It can lead to tooth mobility and loss (2-10-12). Biannual radiographic controls allow to identify and treat these changes as soon as the affected teeth.
Implants?
There is no formal contraindication in the implementation of dental implants for patients with Scleromderma Systemic., but it remains difficult to propose standardized approach, few cases have been published (1). The difficulty of access to the oral cavity, due to the limitation of the oral opening, makes of removable prostheses implanto-stabilized the best choice of oral rehabilitation. Other implantaires solutions can be also envisaged, according to the stage of the disease and the cutaneous and periodontal damage. These choices must be studied with a dental surgeon or a stomatologist, discussed with the medical team of the specialized department by weighing profits / risks for the patient, and have to be the object of multidisciplinary meetings.
Oral manifestations of Scleroderma Systemic are progressive and insidious. They owe before any being warned. Regular consultations should be performed twice a year. It is essential not to wait to have pain to consult a dental-surgeon, an accurate diagnosis and prevention are the most effective ways to fight against damages and dental oral seaquelae of Scleroderma Systemic.
Prevention
By patient :
o Oral hygiene :
- Brushing three times a day, 3 minutes, with a soft tooth brush ;
- Use of a highly fluorinated toothpaste ;
- Make mouthwashes after every meal ;
- Bi-annual descaling ;
- Daily use of fluoridated gutters to limit the risk of caries.
o Symptomatic treatment of dry mouth syndrome :
- Abundant drinks and regular, preferring water. Alkaline water (Vichy typ) can be recommended, without being systematic ;
- Suck a shirt button, better than a candy or a sugar-free chewing-gum ;
- Use several times a day salivary spray.
o Limitation of oral opening Limitation de l’ouverture buccale
- Take a mark (size of spoon, for example) and measure regularly this opening ;
- In case of bruxism, use a night gutter of discluding.
- Practise regular daily exercises of bucco facial physiotherapy. Sitting in front of a mirror:
*Pronounce the sound « A » mouth wide open by maintaining the maximum opening 5seconds. Repeat the action 10.
* Do the same with the sound « I ».
*Mouth wide open, make 10 times some steam on the mirror.
*Massage the inside of the mouth w ith a finger pulling the cheek outwardly (5minutes a day) (13) .
With the help of specialist :
o Dental infringement :
- Bi-annual descaling ;
- Clinic evaluation and radiological of all teeth ;
- Achievement of fluorinated gutters and nocturnal ;
- Regular care and eventual filling of edentulous (means to discuss) ;
- Achievement of splints to consolidate teeth which become fragile and mobile.
o Gum care if necessary.
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