Indian Journal of Dentistry

REVIEW ARTICLE
Year
: 2016  |  Volume : 7  |  Issue : 3  |  Page : 134--139

Review of orofacial considerations of systemic sclerosis or scleroderma with report of analysis of 3 cases


Arati Panchbhai1, Sangita Pawar2, Anuradha Barad2, Zamzam Kazi3,  
1 Department of Oral Medicine and Radiology, SP Dental College and Hospital, DMIMS University, Wardha, Maharashtra, India
2 Department of Oral Pathology, HSRSM, Hingoli, Maharashtra, India
3 Department of Oral Medicine and Radiology, SP Dental College, Wardha, Maharashtra, India

Correspondence Address:
Arati Panchbhai
Department of Oral Medicine and Radiology, SP Dental College and Hospital, DMIMS University, Sawangi (M), Wardha - 442 001, Maharashtra
India

Abstract

Scleroderma (skleros; hard, and derma; skin), is currently known as systemic sclerosis due to its progressive nature and widespread tissue involvement. It is a rare connective tissue disorder with a wide range of oral manifestations. Thickening of the skin is the hallmark of the disease. The patient education for self-care and multidisciplinary approach would be needed to manage the condition. The article presents the review of orofacial considerations in scleroderma with a report of analysis of orofacial manifestations 3 cases.



How to cite this article:
Panchbhai A, Pawar S, Barad A, Kazi Z. Review of orofacial considerations of systemic sclerosis or scleroderma with report of analysis of 3 cases.Indian J Dent 2016;7:134-139


How to cite this URL:
Panchbhai A, Pawar S, Barad A, Kazi Z. Review of orofacial considerations of systemic sclerosis or scleroderma with report of analysis of 3 cases. Indian J Dent [serial online] 2016 [cited 2019 Dec 11 ];7:134-139
Available from: http://www.ijdentistry.com/text.asp?2016/7/3/134/186702


Full Text

 Introduction



Progressive systemic sclerosis (PSS), conventionally called as scleroderma is a collagen disorder characterized by fibrosis that involves skin, mucosa, muscles, and internal organs such as the gastrointestinal tract, lungs, blood vessels, and kidneys. This rare disorder involves oral and paraoral structures that form the distinct domain of clinical manifestation of this disorder.[1],[2],[3],[4],[5] These mainly include mask-like facial appearance, microstomia, periodontal diseases, widened periodontal ligament (PDL) space, xerostomia, and osseous resorption.[3],[4],[5],[6],[7],[8] The present article reviews the orofacial considerations in scleroderma.

 Case Descriptions



3 patients, 26-year-old female (Case 1), 28-year-male (Case 2), and 46-year-old female (Case 3) reported to the dental hospital with a chief complaint of reduced mouth opening or narrowing of the mouth. The third case was the diagnosed case of scleroderma since 4 years with orofacial involvement.

On an average, all the patients mentioned the discomfort in food intake and brushing of the teeth, tightened feeling of the extremities, and the weakness. The summary of the analysis of clinical features in 3 cases is presented in [Table 1]. Case 1 and Case 2 had reduced mouth opening to 2 cm and 4 cm, respectively, with blanching; they were treated as the cases of submucous fibrosis. For the third case, although there was feeling of tightening, there was no obvious reduction of the mouth opening. For all the 3 patients, the physiotherapy in the form of mouth stretching exercises and tongue blade therapy was advised to improve their mouth opening. Case 1 also had a history of frequent oral ulcerations. She was given supplements as Vitamin B complex, folic acid, and lycopene. The second case also had generalized periodontal involvement with pockets, and mobility of teeth, scaling, and oral hygiene maintenance therapy were instituted for the patient.{Table 1}

All the patients were sent to the hospital for the thorough physical and dermatologic evaluation. The clinical, radiographic, and laboratory findings were consistent with a diagnosis of scleroderma.{Figure 1}

 Review of Literature



PSS is a connective tissue disorder that involves the skin, mucosa, blood vessels, and the viscera. To the best of our knowledge, it was first mentioned by Curzio of Naples in 1752 as scleroderma, the term is splitted as “sklero

'' (hard) and ''derma '' (skin).[9],[10] Since hidebound skin is the clinical hallmark of the disease, it is also called “hidebound disease.”[1] Although mainly thought of autoimmune origin, the other etiological factors such as genetic, environmental, nervous, and vascular are postulated to be the causes of the disease.[1],[8],[11]{Figure 2}

Classification

The disease can occur in three forms:

Circumscribed or localized scleroderma, it is manifested in two forms as morphea and linear scleroderma. Morphea is characterized by localized thickening of the skin. It starts as violaceous or purplish-brown oval skin patches, that enlarge, become indurated, and eventually lose hair and the ability to sweat. Linear scleroderma is a form of the localized disease and develops as a thin band of sclerosis that may run through the entire length of an extremity, involving underlying muscle, bones, and joints.[1],[5],[6] The lesion of linear localized scleroderma of the head and face is called en coup de sabre, and these lesions may result in hemiatrophy of the face [5]Generalized or progressive scleroderma (diffuse form-PSS), characterized by tautness of the skin with distinctive involvement of the lungs, heart, kidneys, and gastrointestinal tract, and osteolytic changes in the skeleton, Raynaud's phenomenon, acrosclerosis, and oral and perioral tissues involvement.[5],[12],[13],[14]Acrosclerosis, a combination of scleroderma of the extremities and Raynaud's disease [14],[15]A variant of this disease is known as the “crest syndrome,” which is an abbreviation for calcinosis cutis, Raynaud's phenomenon, esophageal dysmotility with dysphagia, sclerodactyly, and telangiectases.[15]{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}

Clinical features

PSS is a disease of low incidence, with 4–253 cases per million or an average of 4–19 new cases per million. The blacks or African-Asians are involved more than whites or Caucasians.[1],[2],[8],[13],[16] The disorder primarily affects the females in the age group of 30–50 years.[16],[17] Although disease manifests variably, the tightening of skin and Raynaud's phenomenon would be the early manifestation. The cutaneous involvement usually begins as the pitting edema followed by thickening and tightening of the skin to include the distal portions of the extremities most commonly. Depending of the involvement, it may lead progressively to pulmonary disease, renal disease, esophageal dysmotility, dysphagia, polyarthralgia with the stiffness of joints, myopathy, myocardiopathy. Subcutaneous calcifications, telangiectasia, and hyperpigmentation may be the features of the disease. The extent of involvement leads to corresponding discomfort, disability, and cosmetic problems.[1],[2],[8],[12],[13],[14],[15],[16],[17]

Oral manifestations

The head and neck region is involved in approximately 70% cases of PSS.[6],[11],[18],[19] The characteristic orofacial features are the mask-like appearance or the mouse-facies due to the pinched nose, atrophy of the ala of the nose, thin and rigid lips, and loss of skin fold on the face.[1],[6],[10],[20] Other features are inability to open the mouth wide, reduced interincisal opening, tongue rigidity, xerostomia, pigmentations, mouth ulcers, telangiectasia, periodontal disease, pulpal calcifications, pseudo ankylosis and trigeminal neuropathy,[21] and the secondary manifestations such as mobility of teeth, dental caries, candidiasis, subluxation, and altered mandibular guidance. The esophageal dysmotility may cause acidity induced by gastroesophageal reflux that lead to dental erosion and dental caries.[6] The radiographic features include PDL widening in approximately two-third cases with a predilection for the posterior region of the jaws as compared to the anterior region.[10],[20] The pressure resorption of the jaw bone is prominently seen at angle, condyle, coronoid process, gonial angle, posterior border of ascending ramus, and at the muscle insertion sites.[6],[15],[19],[22] The exact etiology of the osteolysis is unknown, but there are three proposed theories: (1) Tightening of the facial skin may exert excessive pressure on the mandible and induce the bone loss; (2) the vasculopathy associated with this disease may diminish the blood supply to the mandible resulting in bone ischemia and necrosis; and (3) atrophy of the muscles of mastication may lead to bone necrosis.[8],[15] Calcinosis of the soft tissues around the jaws may be evident.[23]

Diagnosis

The clinical sign of stiffened skin texture and a skin biopsy may confirm the diagnosis.[7] The biopsy reveals the features of atrophy of skin or mucosa, thickening and hyalinization of collagen fibers, and sclerosis of the blood vessel walls. Several serological tests are also useful for confirmation of the diagnosis.[3] Antinuclear antibodies may be seen in approximately 90% of scleroderma patients and are characteristically antinucleolar or anticentromere antibodies or anti-ribonucleic acid polymerase III antibodies.[3],[8]

The microscopic changes in the PDL consist of a widening as well as an appearance of hyalinization with diminution in the number of connective tissue cells than usually found.[24]

Orofacial considerations

The narrowing of the oral cavity, submucosal fibrosis, limited oral access, and tongue rigidity make the speaking, eating, and brushing difficult, also the limitation makes the endodontics, prosthetics, surgical, and restorative procedures complicated.[21],[25],[26],[27] Self-care education using long or extended handled brush or powered toothbrushes or flosses may be of use for daily care. Due to the debilitating nature of the disease, the patient may not be able to sit in a chair for long time, so that it brings limitation on working time of dental professionals. The mild analgesic taken 1 h before the sitting may add comfort to the patient.[17] The salivary hypofunction due to fibrosis or medications affect the oral health, speech, swallowing, and denture retention.[6],[11] Pilocarpine or oral lubricators like carboxymethylcellulose may be of use. Some of the patients may need daily fluoride therapy. The physiotherapy in the form of oral and facial stretching exercises may help to maintain the opening and the oral hygiene maintenance. Use of increasing number of tongue blades between the posterior teeth, Kabat's technique, and mechanical devices like TheraBite to stretch the facial tissues is an effective technique to increase mouth opening.[1],[6],[8],[11],[28] The oral opening may improve up to 5 mm by stretching exercises. In case of advanced cases, a bilateral commissurotomy may be necessary.[11],[27] In case of gingival and periodontal involvement, maintenance therapy should be adapted in place of surgery as progressive vascular fibrosis and deficient wound healing makes any surgical procedure difficult and harmful in such patients. The mucosal erosions and ulcerations need frequent attention. The antibiotics may need to be prescribed. The 5% tranexamic acid solution rinses are required for patients receiving oral anticoagulants, and the international normalized ratio must be checked on the morning of the day of oral surgery, the adrenaline should be avoided as it may exacerbate the existing micro-angiotherapy. Patients with Raynaud's phenomenon also need the warming aids in the room.[1],[11] Patients with extensive resorption of the angle of the mandible are at a risk of developing pathological fractures from minor trauma, including dental extractions.[1],[4],[5],[8]

The treating physicians should be consulted before orofacial management considerations. The early treatment interventions are crucial to avoid the systemic complications out of oral infections. The treatment modalities of the disease can be complex as is the nature of the disease, also the drug therapy of the condition include the calcium channel blockers and immunosuppressive agents which is the another matter of concern.

 Conclusion



The management of scleroderma patients depends on the extent and severity of skin and organ involvement. Although the disease is not curable, the early diagnosis and personalized therapy as per the case helps to treat this disorder to some extent. The periodic dental evaluation is mandatory, maintenance of existing dentition is imperative as the microstomia and tongue rigidity can make the therapeutic interventions difficult. Self-care education and counseling to refrain from harmful habits such as tobacco, alcohol, betel nut, smoking, and caffeine may be of greater help in such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Hasan S, Khan R, Harron M, Khwaja K, Tarranum F, Husain A. Systemic sclerosis: Case report and literature review. Int J Contemp Dent 2011;2:46-53.
2Mayes MD, Lacey JV Jr, Beebe-Dimmer J, Gillespie BW, Cooper B, Laing TJ, et al. Prevalence, incidence, survival, and disease characteristics of systemic sclerosis in a large US population. Arthritis Rheum 2003;48:2246-55.
3Chung L, Lin J, Furst DE, Fiorentino D. Systemic and localized scleroderma. Clin Dermatol 2006;24:374-92.
4White SC, Pharoah MJ, editors. Oral Radiology: Principles and Interpretation. 6th ed. Saint Louis: Mosby; 2009. p. 467.
5Greenberg MS, Glick M. Burket's Oral Medicine Diagnosis and Treatment. 10th ed. India: BC Decker Inc., Elsevier; 2003. p. 478-502.
6Albilia JB, Lam DK, Blanas N, Clokie CM, Sándor GK. Small mouths. Big problems? A review of scleroderma and its oral health implications. J Can Dent Assoc 2007;73:831-6.
7Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St. Louis: Elseviers; 2009. p. 799.
8Doucet JC, Morrison AD. Bilateral mandibular condylysis from systemic sclerosis: Case report of surgical correction with bilateral total temporomandibular joint replacement. Craniomaxillofac Trauma Reconstr 2011;4:11-8.
9Singh PP, Kapoor S, Bither S. Oral manifestations in progressive systemic sclerosis: Case report. J Dent Oral Hyg 2011;3:89-94.
10Mehra A, Kumar S. Periodontal manifestations in systemic sclerosis: A review. Dent Today 2008;27:50, 52, 54.
11Alantar A, Cabane J, Hachulla E, Princ G, Ginisty D, Hassin M, et al. Recommendations for the care of oral involvement in patients with systemic sclerosis. Arthritis Care Res (Hoboken) 2011;63:1126-33.
12Scholand MB, Carr E, Frech T, Hatton N, Markewitz B, Sawitzke A. Interstitial lung disease in systemic sclerosis: Diagnosis and management. Rheumatology 2012;S1:008.
13Atzeni F, Bardoni A, Cutolo M, Hunzelmann N, Krieg T, Martini G, et al. Localized and systemic forms of scleroderma in adults and children. Clin Exp Rheumatol 2006;24:S36-45.
14Joachim G, Acorn S. Life with a rare chronic disease: The scleroderma experience. J Adv Nurs 2003;42:598-606.
15Jagadish R, Mehta DS, Jagadish P. Oral and periodontal manifestations associated with systemic sclerosis: A case series and review. J Indian Soc Periodontol 2012;16:271-4.
16Thompson AE, Pope JE. Increased prevalence of scleroderma in south western Ontario: A cluster analysis. J Rheumatol 2002;29:1867-73.
17Nikpour M, Stevens WM, Herrick AL, Proudman SM. Epidemiology of systemic sclerosis. Best Pract Res Clin Rheumatol 2010;24:857-69.
18Tolle SL. Scleroderma: Considerations for dental hygienists. Int J Dent Hyg 2008;6:77-83.
19Leung WK, Chu CH, Mok MY, Yeung KW, Ng SK. Periodontal status of adults with systemic sclerosis: Case-control study. J Periodontol 2011;82:1140-5.
20Auluck A. Widening of periodontal ligament space and mandibular resorption in patients with systemic sclerosis. Dentomaxillofac Radiol 2007;36:441-2.
21Fischoff DK, Sirois D. Painful trigeminal neuropathy caused by severe mandibular resorption and nerve compression in a patient with systemic sclerosis: Case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:456-9.
22Anbiaee N, Tafakhori Z. Early diagnosis of progressive systemic sclerosis (scleroderma) from a panoramic view: Report of three cases. Dentomaxillofac Radiol 2011;40:457-62.
23Alpöz E, Cankaya H, Güneri P. Facial subcutaneous calcinosis and mandibular resorption in systemic sclerosis: A case report. Dentomaxillofac Radiol 2007;36:172-4.
24Rajendran R. Immunological diseases. In: Rajendran R, Sivapathsundaram B, editors. Shafer's Textbook of Oral Pathology. 6th ed. India: Elsevier Pvt Ltd.; 2009. p. 789-90.
25Poole JL, Brewer C, Rossie K, Good CC, Conte C, Steen V. Factors related to oral hygiene in persons with scleroderma. Int J Dent Hyg 2005;3:13-7.
26Pizzo G, Scardina GA, Messina P. Effects of a nonsurgical exercise program on the decreased mouth opening in patients with systemic scleroderma. Clin Oral Investig 2003;7:175-8.
27Mouthon L, Rannou F, Bérezné A, Pagnoux C, Arène JP, Foïs E, et al. Development and validation of a scale for mouth handicap in systemic sclerosis: The mouth handicap in systemic sclerosis scale. Ann Rheum Dis 2007;66:1651-5.
28Maddali-Bongi S, Landi G, Galluccio F, Del Rosso A, Miniati I, Conforti ML, et al. The rehabilitation of facial involvement in systemic sclerosis: Efficacy of the combination of connective tissue massage, Kabat's technique and kinesitherapy: A randomized controlled trial. Rheumatol Int 2011;31:895-901.