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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

Objective

To review the literature and collect expert advice for proposing preventive and curative treatments of mouth and dental involvement in patients with systemic sclerosis (SSc; scleroderma).

Methods

The literature pertaining to mouth and/or dental involvement related to SSc was reviewed, and recommendations were developed according to the suggestions of a French multidisciplinary working group of experts and validated by a lecture committee.

Results

Dentists face 3 main issues in caring for SSc patients: oral mucosa involvement, manducatory apparatus and mouth involvement responsible for limitations in mouth opening, and treatment-related adverse events. An increased risk of tongue carcinoma has been noted. In patients with severe limitation in mouth opening (<30 mm), recommended treatments are a specific mouth-opening rehabilitation program, flexible sectional dentures, and splint therapy. Indications for dental implants depend on the severity of SSc, comorbidities, and/or ongoing bisphosphonate treatment. Prevention of mouth infections and caries implies patient education and teaching about mouth and dental hygiene, periodontal maintenance, and treatment of sicca syndrome. Cessation of tobacco use is mandatory. Patient-tailored rehabilitation may improve limitations in mouth opening. Systematic dental panoramic radiography allows for the early detection of dental caries.

Conclusion

Prevention of oral and dental complications is a major issue in patients with SSc. Dental treatment should be tailored to limitations in mouth opening, disease severity, and ongoing treatments.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

Systemic sclerosis (SSc; scleroderma) is a connective tissue disease characterized by an autoimmune reaction with specific autoantibodies, excessive collagen deposition, and vascular hyperreactivity and obliterative microvascular phenomena (1–4). The American College of Rheumatology classification, developed to distinguish SSc from other connective tissue diseases, has provided a common definition of the disease (5). Patients with SSc are classified according to the extent of skin involvement: limited SSc, with no detectable skin involvement (6); limited cutaneous SSc (lcSSc) (6), with skin involvement essentially limited to the hands and face; and diffuse cutaneous SSc (dcSSc), with proximal skin involvement (7). The disease prevalence varies between 50 million inhabitants in Japan, 100 and 150 million inhabitants in Europe (8), and more than 200 million inhabitants in the US and Oceania (9). SSc mainly affects women, with a female to male ratio of 4 to 8 (9) and a peak frequency between ages 45 and 64 years (9, 10). In patients with lcSSc, visceral involvement is rare and the prognosis is good, with the exception of the 10–15% of patients in whom pulmonary arterial hypertension, gastrointestinal involvement, and/or interstitial lung disease (ILD) eventually develop (11). Patients with dcSSc experience visceral involvement, which is responsible for reduced life expectancy (11). In addition to diminishing life expectancy, SSc is responsible for skin, tendon, joint, and vessel damage, which leads to disability, handicap, and worsening of quality of life (12–14).

The mouth and face are frequently involved in SSc (15). Therefore, patients often experience aesthetic concerns with skin sclerosis and telangiectasia, diminished mouth opening, altered dentition, difficulties during dental surgery and/or dry mouth. Mouth-related disability can be assessed by the Mouth Handicap in Systemic Sclerosis (MHISS) scale (16). Interestingly, factor analysis of this scale extracted 3 factors representing handicap induced by reduced mouth opening, sicca syndrome, and aesthetic concerns (16). These data are directly associated with the 3 main problems dentists face in caring for patients with SSc: 1) oral mucosa involvement and ulcerations associated with dry mouth; 2) manducatory apparatus involvement responsible for dysphagia, retraction of lips, perioral streaks, and limitation in mouth opening; and 3) treatment-related adverse events (17).

However, to our knowledge, no specific recommendations are available for the care of mouth and dental involvement in patients with SSc. Therefore, we reviewed the literature and involved expert advice to develop recommendations for treatment and prevention of mouth and dental issues in SSc.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

The methodology used to provide recommendations is summarized in Figure 1. A working group (see Appendix A for members of the working group) reviewed the literature on mouth and dental involvement in SSc by searching for articles published from 1984 to 2010 in Medline via PubMed without any restriction on language. We used the following medical subject heading keywords tested two by two: systemic sclerosis, scleroderma, microstomia, oral pathology, xerostomia, sicca syndrome, dental caries, dental treatment, dental prosthesis, and periodontal disease. In total, 52 articles with abstracts were selected, including 48 in English, 2 in French, 1 in Italian, and 1 in Hungarian. Guidelines were obtained from the Agence Française de Sécurité Sanitaire des Produits de Santé on the use of antibiotics in 2001 (18) and on dental care in patients treated with bisphosphonates in 2008 (19), together with the Protocole National de Diagnostic et de Soins of the French Haute Autorité de Santé (20).

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Figure 1. Methodology used for the proposition of recommendations for the care of oral involvement in patients with systemic sclerosis (SSc). AFSSAPS = Agence Française de Sécurité Sanitaire des Produits de Santé; PNDS = Protocole National de Diagnostic et de Soins; HAS = Haute Autorité de Santé.

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The articles and guidelines were analyzed and a first set of recommendations was proposed for peer review by a working group. The revised recommendations were submitted to a multidisciplinary lecture committee (see Appendix A for members of the lecture committee) for review. The final document was modified according to the multiple critical appraisals of the 2 groups (Figure 1). The literature review was followed by critical appraisal by a multidisciplinary working group in order to classify data according to the levels of scientific rigor (levels 1, 2, 3, and 4) (21). When no scientific data were available, recommendations were based on the experience of the physicians of the review group and graded as “experts advocated routine.”

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

The following gives an overview of oral consequences and recommendations for treatment and prevention of mouth and dental issues in SSc. The levels of recommendations for the care of oral involvement in patients with SSc are detailed in Table 1.

Table 1. Levels of recommendations for the care of oral involvement in patients with systemic sclerosis*
Orofacial findingsManagementLevel of evidence
  • *

    Hierarchy of levels of scientific rigor (21): level 1 (high level), randomized controlled trials (RCTs) with high statistical power, meta-analyses of RCTs, decision analysis based on studies with high methodologic quality; level 2 (intermediate level), RCTs with low statistical power, nonrandomized comparative studies with high-quality methodology, cohort studies; level 3 (weak level), case–control studies; level 4 (weak level), comparative studies with important bias, retrospective studies, sample of cases, descriptive epidemiologic studies (cross-sectional, longitudinal). AVK = anti–vitamin K; LMO = limitation of mouth opening; BsP = bisphosphonate.

  • When no scientific data were available, recommendations were based on the experience of the physicians of the review group and graded as “experts advocated routine.”

Sicca syndromeTincture of pilocarpine, pilocarpine, anetholtrithione, salivary spray substituteExperts advocated routine
PeriodontitisHygiene education, scaling and root planning procedures, biannual maintenance sequences, antibiotherapyLevel 1
Plaque and/or AVK-induced gum hemorrhageHygiene education, scaling and root planning procedures, tranexamic acid mouth rinsesLevel 1
CariesConservative dentistry, dental prophylaxis with fluoride treatmentExperts advocated routine
Mandibular bone resorptionNo treatment, simple followupExperts advocated routine
Severe LMO (<30 mm)3 months of elongation exercisesLevel 2
Edentation(Fractionated in case of severe LMO) partial, complete removable dentures, dental implants (depends on comorbidities, BsP treatment, and/or hygiene)Experts advocated routine
Perioral “whistle” linesPulsed CO2 laserLevel 4

Mouth and dental consequences of SSc.

The following is an overview of the main aspects that dentists face in caring for patients with SSc: oral mucosa involvement, manducatory apparatus involvement, and treatment-related adverse events (17).

Oral mucosa involvement.

Sicca syndrome is detected in approximately 70% of patients with SSc (22, 23). This syndrome is secondary to salivary gland fibrosis. It may worsen in the presence of severe gastroesophageal reflux, which is frequently encountered in patients with SSc and is related to esophageal dysmotility and/or treatment-related adverse events. Less frequently, 7–14% of cases may present Sjögren's syndrome fulfilling the American-European Consensus Group criteria (24), mainly in lcSSc (22, 25, 26).

Atrophy of the oral mucosa may have a number of different causes: denutrition, vitamins B9 and B12 deficiencies, gastric atrophy that may occur with pernicious anemia, exocrine pancreatic insufficiency, or bowel involvement associated with bacterial overgrowth. Sometimes the tongue may become abraded, but usually moderately. Importantly, an increased prevalence of periodontitis has been reported in patients with SSc as compared to the general population (27). Inflammation of the gums and periodontitis may result from difficulties in ensuring oral hygiene mainly related to a limitation in mouth opening (17) and altered capillary vascularization (28), particularly in patients with dry mouth (29) (Figure 1).

With gastroesophageal reflux, mucogingival paresthesia may occur. Finally, the risk of tongue or pharyngeal carcinoma is increased (30).

Manducatory apparatus involvement.

Chewing and swallowing movements may be impaired as a consequence of mouth and tongue mucosa and temporomandibular joint capsule involvement. Sclerosis and atrophy of the lips and perioral tissues can lead to perioral streaks. Mouth-related disability can be assessed by the MHISS scale, which is reliable and has good construct validity. The 3 factors extracted from the scale represent handicap induced by reduced mouth opening, sicca syndrome, and aesthetic concerns that altogether contribute 63% of the total variance in handicap (16). With these data, mouth-related disability contributes to 35% of the variance in global disability as assessed by the Health Assessment Questionnaire (16).

With advanced sclerosis, the retraction of lips may become severe and the patient may be unable to close the lips, which leads to mouth breathing, sicca syndrome, and chewing impairment (23) (see Supplementary Figure 1, available in the online version of this article at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658). In addition, patients who are not able to close the lips cannot perform pulmonary function tests.

Mandibular bone resorption is more often encountered in patients with dcSSc responsible for marked facial sclerotic involvement and limitation in mouth opening (31–33). The mechanisms contributing to mandibular bone resorption are poorly understood. The condition might result from osteonecrotic lesions occurring as a consequence of microvascular involvement of bone vessels and/or of muscles inserted onto the maxilla and/or from vascular entrapment/compression by severe sclerotic skin and subcutaneous structures. Overall, gum and/or bone hypovascularization seems to be the most probable cause. In rare cases, mandibular resorption may cause neuropathy (34). Finally, wide periodontal ligament spaces, particularly in molar and premolar teeth, as well as dental root resorption, may also occur, although they are rarely reported (23, 28, 32, 35–37).

Inflammatory myopathy may occur during SSc (38) and may be responsible for impaired chewing and swallowing and increased risk of trouble swallowing and aspiration pneumonia (39). Therefore, these manifestations may cause severe functional impairment in addition to aesthetic impairment.

Treatment-related adverse events.

A number of drugs used as disease-modifying agents in SSc may be responsible for adverse events involving mouth and gum mucosa.

Calcium-channel blockers, largely prescribed to treat Raynaud's phenomenon and other vascular manifestations of SSc, are usually well tolerated, except for the occurrence of edema. However, calcium-channel blocker–induced gingival hyperplasia has been rarely reported in patients with SSc (23).

Corticosteroids are used with caution in patients with SSc because they have been associated with an increased risk of scleroderma renal crisis (40). When required, particularly in the presence of joint and/or inflammatory muscle involvement, corticosteroids should be prescribed at a low dosage (e.g., prednisone <15 mg/day) (20). Among the many adverse events that may occur in patients receiving corticosteroids, even if prescribed at a low dose, the risk of infection is increased (18). Therefore, patients with SSc receiving corticosteroids should be systematically investigated by dental panoramic radiography and eventually, a full-mouth series of intraoral radiography, to eradicate potential dental caries. Corticosteroids, especially in the case of prolonged treatment, are responsible for mouth infections, particularly oral candidiasis.

Cyclophosphamide is usually prescribed for patients with SSc who present severe and/or worsening ILD. This treatment, which is usually well tolerated, may be prescribed intravenously at 0.6 gm/m2/month for 6–12 months or orally at 1 mg/kg/day for 1 year. Again, among the many adverse events associated with cyclophosphamide therapy, the risk of infection is increased, particularly in patients with neutropenia (41). High-dose cyclophosphamide, which is under evaluation for autologous stem cell transplantation, may also cause stomatitis (41).

Methotrexate, usually prescribed for joint or inflammatory muscle involvement (20, 42) and/or skin involvement in patients with dcSSc (43), may result in mouth ulcers, although these ulcers usually occur only in the absence of folic acid treatment. These ulcers generally require local treatment, usually with antiseptic agents. Penicillin is not recommended for patients receiving methotrexate who have an infection because it may increase the hematologic toxicity of the drug. In addition, another antibiotic, trimethoprim/sulfamethoxazole, may add to the toxicity of methotrexate and result in stomatitis and/or hematologic toxicity and should be used with caution. Again, in this setting, folic acid therapy is mandatory.

Use of antibiotics may result in oral candidiasis, particularly in patients with dry mouth and/or patients receiving antibiotic therapy. Anticholinergic antidepressants, which may be prescribed for patients with SSc who frequently present psychiatric symptoms, may also cause or increase the severity of sicca syndrome (44).

Bisphosphonates, which are prescribed in association with prolonged corticosteroid treatment (with a T score less than −1.5) to prevent osteoporosis or to treat corticosteroid-induced osteoporosis, may result in jaw osteonecrosis (19, 45).

Anti–vitamin K anticoagulants are prescribed for patients with SSc and pulmonary arterial hypertension, as assessed by right heart catheterization, to prevent thrombosis of pulmonary arteries (46). The dose of anti– vitamin K is usually adapted to obtain an international normalized ratio (INR) between 1.5 and 2. Of note, these treatments may result in spontaneous or induced gingival bleeding, particularly in patients with insufficient control of dental plaque.

Recommendations for medical, surgical, and prosthetic treatments.

Dental care.

Severe microstomia, limitation in mouth opening, and submucosal fibrosis represent major limitations to dental care. In the absence of other specific conditions, patients can receive dental care after local anesthesia with 3% lidocaine. In this setting, adrenaline should be avoided because it can worsen the microangiopathy.

Endodontic treatments, prosthetic preparations, and dental surgery should be performed preferentially in the morning. If necessary, in patients with stress and/or anxiety, premedication may be proposed with, for instance, 1.5 mg/kg hydroxyzine 90 minutes before surgery, with the patient avoiding driving a car. An escort must be available to accompany the patient after treatment.

In the presence of marked gum involvement with hypoperfusion and fibrosis, mucogingival surgery is contraindicated because of its limited efficacy and the increased risk of postoperative complications.

Dentists can perform conventional dental care in patients with SSc, including the use of different types of materials such as resin and amalgam composite material and dental crowns. Finally, dental care should be performed quadrant by quadrant in the mouth to avoid long sittings.

Antibiotics.

In the presence of a mouth or dental infection, antibiotics should be prescribed. The combination of amoxicillin and metronidazole represents the first-line therapy, especially with generalized aggressive periodontitis (47). In case of allergy or for patients receiving methotrexate as a disease-modifying agent, macrolides can be proposed. However, in the latter case, 5% tranexamic acid solution rinses are required for patients receiving oral anticoagulants, and the INR must be checked in the morning of the day of oral surgery.

Prosthetic treatment.

Prosthetic treatment may be difficult to perform for patients with microstomia. Fractionated imprints may be proposed to improve the tolerance of the prosthesis with remodeled tissues. In patients with partial or total dentures, to control the pain that is often related to dry mouth, the dorsum of the prosthesis, which is in contact with the mucosa, can be covered with an antiseptic mouth gel (chlorhexidine). If an ulcer occurs, dental occlusion and the periphery of the prosthesis should be investigated. In this setting, application of a topical anesthetic (lidocaine 2%) on the ulcer or a topical application containing hyaluronic acid can be proposed sometime after a meal because of the risk of trouble swallowing to relieve the pain during the scarring period. In patients with oral candidiasis, antifungal therapy should be prescribed (amphotericin B 10% solution, 3–4 teaspoons/day for 15 days).

In patients with marked microstomia in whom conventional prosthetic rehabilitation is not feasible, mouth and facial rehabilitation, as well as soft dental prosthesis, may be proposed (48, 49). However, flexible dentures are difficult to adapt and maintain, with consequences in terms of moisture retention and loss of support. In patients without teeth and with severe microstomia, rehabilitation with fractionated prosthesis and limiting the size of the teeth of the upper prosthesis may be proposed. The flexibility of the prosthesis in the median and sagittal position facilitates its insertion (50–57). Imprints should be made with a hydrophobic material such as thiocol, which allows for maintaining a salivary film between mouth mucosa and the prosthesis. Muscle contractures are prevented by hard splint therapy.

Dental implant surgery.

Dental implant procedures in patients with SSc are not well documented (58), and the background is not sufficient to propose a standardized approach. However, if the parodontal status is good, dental implants may be useful in 2 main cases: in the anterior portion of the jaw in the canine teeth area, to allow for stabilizing the dentures and thereby improving comfort and decreasing the risk of posttraumatic ulcer (59, 60), and in the area of the maxilla corresponding to the incisors and canine teeth, to improve aesthetics.

The decision to perform dental implant surgery is not straightforward, and the patient and dental physician should discuss the treatment in detail to take into account the disease severity, the presence of sicca syndrome, limitations in brushing teeth, ongoing treatments (particularly bisphosphonates), and/or the treatment of an oral cancer. Ideally, anterior implants are favored, particularly in the canine area of the jaw, to stabilize a removable metal prosthesis. In the rare cases of posterior implants, when possible, prosthesis on stilts is preferred over dental bar attachment. Prosthesis on stilts can increase the salivary flux because of the absence of mucosal contact and because of the ease in prosthesis removal with the help of lateral locks, which allows for easier maintenance (59). In patients with marked gingival fibrosis and severe microvascular impairment, dental implants may be contraindicated. Overall, the risk/benefit ratio must be evaluated, and all risks related to the surgery explained in detail. In addition, microbiologic samples should be taken before deciding on dental implant surgery.

General anesthesia.

Severe and/or end-stage visceral involvement, mainly lung involvement with pulmonary arterial hypertension and/or pulmonary fibrosis and myocardial involvement, may lead to caution in performing general anesthesia and surgery in patients with SSc (61–63). Therefore, anesthetists should be involved early, when surgery is planned, to better evaluate the risk related to general anesthesia and consider the risk/benefit balance for each patient (see Supplementary Figure 2, available in the online version of this article at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658). If pulmonary and cardiac investigations have not been performed for more than 6 months, pulmonary function tests and Doppler echocardiography should be repeated. The anesthetist also needs to evaluate the peripheral venous aspect, particularly in patients with dcSSc and severe skin sclerosis, which may cause major difficulties in performing peripheral venous catheterization as well as microstomia, which may represent a limitation in performing oral intubation. In such a case, tracheal fibroscopy will be helpful in order to prevent intubation-induced complications. In addition, severe gastroesophageal reflux and/or gastric palsy must be investigated because they may increase the risk of aspiration pneumonia after endotracheal extubation.

A number of measures can be proposed to improve the care of patients with SSc in the operating room. The room temperature should be increased and warming blankets can be proposed, particularly in the recovery room, to avoid a worsening of Raynaud's phenomenon and its complications. If an oxymeter is used, its electrode should be located on the forehead, not at the ear or the fingers, because of Raynaud's phenomenon. In case of severe limitation in mouth opening because of advanced tissue sclerosis and loss of skin elasticity, all manipulations of the jaw at the time of intubation, even minimal, may lead to commissural disruption. This risk may be increased if a mouth wedge is used. Commissural disruption will almost always require sutures and the application of topical scarring treatment.

Recommendations for preventing mouth and dental complications.

The following are recommendations for preventing the 3 issues dentists face in caring for patients with SSc.

Mouth mucosa involvement.

The prevention of mouth infections and caries implies patient education and teaching about mouth and dental hygiene, including brushing techniques, steerable interdental brushes, dental silk string, and mouthwash with antiseptic agents such as chlorhexidine or fluoride gels (14, 64). With sicca syndrome, mouth hydration with water and a number of sialagogue treatments (tincture of pilocarpine 40 drops/day; pilocarpine 5 mg, 3 caps/day; and anetholtrithione 3 caps/day) or salivary spray substitute can be proposed (65). Antiseptic mouthwash without alcohol (chlorhexidine 0.12%) can be used, but for a short time, i.e., not more than 5 or 6 days, so as not to perturb the mouth ecosystem. Mouthwash with bicarbonate may be used for a longer time (66). After patient education on brushing and flossing techniques and eventual hand exercises, 2 sequences of scaling and root planning should be performed to care for gum inflammation. Maintenance sequences should be performed at least twice a year, with adaptation depending on physical examination, severity of SSc, manual dexterity, and patient adherence (14, 64, 67, 68). In patients without plaque control or with marked hand disability due to SSc, an electric toothbrush may be proposed. Prevention of oral candidiasis implies a thorough cleaning of removable metal prostheses. In addition, all efforts must be made to help the patient stop smoking (65), because the use of tobacco can increase body temperature, thus leading to vasodilation and hyperkeratosis, as well as have negative effects on bones of the jaw and gum. Systematic examination of oral mucosa is warranted at the first visit, to rule out carcinoma (30).

Manducatory apparatus involvement.

Microstomia is common during SSc. In patients with microstomia, mouth opening can be improved with rehabilitation (69). Pizzo and colleagues reported on the efficacy of elongation exercises and mouth opening exercises on improving the interincisor distance in patients with severe limitations in mouth opening (i.e., interincisor distance <30 mm); the mean ± SD improvement in mouth opening was 10.7 ± 2.06 mm, with no significant difference between patients with and without teeth (70). Among 10 patients evaluated at 18 weeks, all showed improved ability to chew, phonation, and mouth and dental hygiene. Patients without teeth are better able to completely insert their prostheses. Naylor and colleagues (49) reported on a randomized study of patients without teeth, finding a mean increase of 5.7 mm in mouth opening after 3 months of elongation exercises in patients who had a mean initial maximal mouth opening of 3.44 mm. These improvements were lost in part after discontinuation of physical therapy and respiratory rehabilitation (71). In a rehabilitation program dedicated to SSc, the rehabilitation department of Cochin Hospital has produced a CD-ROM displaying 36 movements, including 6 dedicated to increasing mouth opening (Mouthon and Poiraudeau: unpublished observations). The passive jaw motion therapeutic device “therabite” is effective in increasing the range of motion in patients with temporomandibular joint and muscle disorders who did not improve after manual manipulation of the mandible (72). However, to our knowledge, no data are available on SSc-associated microstomia, and future studies would be helpful to evaluate this promising therapy in patients with SSc.

To treat vertical wrinkling around the mouth, pulsed CO2 laser treatment has been proposed. In a preliminary study, Barete et al reported good aesthetic and functional results, with a significant improvement in mouth opening. However, the study involved few patients (n = 5) (73), and further studies are needed to confirm these results. This treatment may offer an alternative to other techniques available to fill in “whistle” lines, treatments that are insufficient and are contraindicated in connective tissue diseases (73). Telangiectasia may occur all over the mouth mucosa membranes, including those of palatine and jaw mucosa, and is usually not treated. However, in case of bleeding or aesthetic issues, laser treatment can be proposed, particularly with lip involvement. Finally, to our knowledge, no treatment exists for bone resorption, and patients are simply followed up.

Prevention of dental caries is important for patients with SSc and, in addition to eliminating foods containing sugar, patients should ensure the fluoridation of enamel with toothpaste or local fluoride preparations (sodium monofluorophosphate, sodium fluoride, every 3 months) (23, 74). In addition, the patient should be referred to a general practitioner for treatment of gastroesophageal reflux. Eventually, a 24-hour measure of gastric pH can be performed to detect and treat gastroesophageal reflux. Caries can be detected early by dental panoramic radiography and eventually, balanced long-cone radiography, to avoid the need for more invasive treatments in patients with severe SSc (see Supplementary Figure 2, available in the online version of this article at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658). These tests should be repeated every 5 years.

Drug-related adverse events.

The maintenance of a high level of mouth and dental hygiene allows for better control of drug-induced gum hyperplasia. However, for patients with severe disability and/or aesthetic impairment, a calcium-channel blocker may need to be replaced with another one; in rare cases, 2 different calcium-channel blockers belonging to the same class may both cause gum hyperplasia, thus requiring the use of another class of calcium-channel blocker (75). In some patients, gingival resection can be performed after treating periodontal involvement with scaling and root planning, mainly in patients with aesthetic and/or functional impairment (76).

Caution should be taken in patients receiving anticoagulant therapy if antifungal therapy is to be prescribed, and repeated measurement of INR is mandatory in this setting. Before starting bisphosphonates, a thorough oral examination should be performed, any unsalvageable teeth should be removed, all invasive dental procedures should be completed, and optimal periodontal health should be achieved (77) because of the increased risk of jaw osteonecrosis. Therefore, although the risk of jaw osteonecrosis is increased in the presence of severe microvascular impairment, we propose to apply recommendations from the American Association of Oral and Maxillofacial Surgeons (77). For individuals who have taken an oral bisphosphonate for less than 3 years and have no clinical risk factors, no alteration or delay in the planned surgery is necessary. For those patients who have taken an oral bisphosphonate for less than 3 years and have also taken corticosteroids concomitantly, and for those who have taken an oral bisphosphonate for more than 3 years with or without any concomitant prednisone or other steroid, oral bisphosphonate discontinuation should be considered for at least 3 months prior to oral surgery, if systemic conditions permit (77). In patients undergoing dental extractions, antibiotics should be prescribed the day before and continued until complete scarring, as assessed clinically and by radiography (18). Since no data are available concerning dental implants in patients with SSc treated with bisphosphonate, we do not recommend implant surgery in such cases.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

Mouth and dental care are not specific to patients with SSc. However, a precise evaluation of the disease severity is necessary to determine whether dental care can easily be performed. A preventive approach is necessary to avoid mouth and dental complications in these patients. Therefore, SSc may involve the entire mouth and facial tissues, and a well-coordinated multidisciplinary approach is necessary.

The medical and paramedical team must work in concert to improve mouth hygiene and dry mouth and encourage rehabilitation in SSc patients. An excellent physician–patient relationship is mandatory for patient education. Mouth and dental care involve a number of health care professionals: kinesiotherapists, ergotherapists, physical therapists, nutrition specialists, nurses, physicians, dentists, and sometimes maxillofacial surgeons.

In conclusion, systematic evaluation of patients with SSc must be performed by the dentist in order to detect dental infections early and avoid invasive mouth and dental treatments that may be difficult to perform because of disease evolution and severity-related compromised oral access.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Mouthon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Alantar, Princ, Mouthon.

Acquisition of data. Alantar, Princ, Mouthon.

Analysis and interpretation of data. Alantar, Cabane, Hachulla, Princ, Ginisty, Hassin, Sorel, Maman, Pilat, Mouthon.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information
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APPENDIX A

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

MEMBERS OF THE WORKING GROUP AND LECTURE COMMITTEE

Members of the working group are as follows: Alp Alantar (Odontologie, Paris, Coordination), Jean Cabane (Médecine Interne, Paris), Eric Hachulla (Médecine Interne, Lille), Danielle Ginisty (Stomatologie, Paris), Michel Hassin (Stomatologie, Paris), Luc Mouthon (Médecine Interne, Paris), and Guy Princ (Chirurgie Maxillo-faciale, Paris).

Members of the lecture committee are as follows: Daniel Adoue (Médecine Interne, Toulouse), Marc Baranes (Odontologie, Nanterre), Jacques Christian Béatrix (Odontologie, Nemours), Nadia Benlagha (Odontologie, Montreuil), Jean Pierre Bernard (Stomatologie, Genève), Yves Commissionat (Stomatologie, Paris), Incigül Conrad (Radiologie, Courbevoie-Neuilly), Olivier Cottencin (Psychiatrie, Lille), Sarah Cousty (Odontologie, Toulouse), Arnaud Forgeot (Anesthésie-Réanimation, Paris), Jean Claude Fricain (Odontologie, Bordeaux), Jean Marc Galeazzi (Odontologie, Nanterre), Eric Gérard (Odontologie, Metz), Philippe Humbert (Dermatologie, Besançon), Brigitte Hättenberger (Stomatologie, Tours), Frédéric Larcher (Stomatologie, Sens), Michel Legens (Odontologie, Brest), Isabelle Marie (Médecine Interne, Rouen), Cédric Mauprivez (Odontologie, Paris), Jean-Louis Pasquali (Médecine Interne, Strasbourg), Yvon Roche (Odontologie, Paris), Christian Roux (Rhumatologie, Paris), and Jacky Samson (Stomatologie, Genève).

Supporting Information

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
  10. APPENDIX A
  11. Supporting Information

Additional Supporting Information may be found in the online version of this article.

FilenameFormatSizeDescription
ACR_20480_sm_supplfig1.TIF492KSupplementary Figure 1. Perioral sclerosis and lips retraction in a patient with diffuse systemic sclerosis.
ACR_20480_sm_supplfig2.TIF416KSupplementary Figure 2. Panoramic (A) and balanced long-cone (B) radiographic views of chronic periodontis in a 49-year-old woman with systemic sclerosis. Degree of peridental bone loss, distribution of localized or generalized bone loss, and vertical, horizontal, or both pattern of bone loss are essential to be evaluated for diagnosis and management of periodontal disease. Radiographs should be used only to supplement clinical examination: presence of plaque, gingival inflammation, bleeding, and/or recession.

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