“The patients had more decayed teeth, more periodontal disease (PD), less saliva production, and their mouth opening was smaller than controls,” says Murray Baron, MD, chief in the Division of Rheumatology at Jewish General Hospital in Montreal. “The rheumatologist needs to be aware that these problems exist and to then discuss them with our patients.”
Evolution of Dry Mouth
One interesting finding was the evolution of dry mouth in SSc patients. The presence of at least one Sjögren’s syndrome-related antibody (either RO 52/TRIM-21, SSA/Ro60 or SSB/LA) was associated with decreased saliva production. However, none of the disease severity scores were significantly associated with saliva production. Missing teeth were also associated with saliva production, but this finding was independent of disease severity. These results indicate that saliva production changes are not just related to fibrotic processes.
“I think the implication is that in scleroderma, which is a fibrosing process, the concern is not the global fibrosis of the glands that produces the losses in saliva,” says Dr. Baron. “This may be more of a manifestation of Sjögren’s syndrome.”
Diagnostic & Progression Implications
Dental complaints may be related to the severity of SSc and may be useful in diagnosing and following disease progression. The interincisal distance was inversely associated with disease severity. They used the mean global assessment of severity, higher skin scores, anti-topoisomerase I antibodies and diffuse disease to measure severity.
Patients had more jawbone erosions than controls, mostly in the condyles and coronoid processes. SSc severity was not associated with the number of mandible erosions, but there was an association between a smaller mouth opening and more erosions.
“We did find an inverse association between interdental distance and the number of erosions,” says Dr. Gornitsky. “Our finding lends support to the hypothesis that bone resorption of the mandible is secondary to increased pressure in the mouth related to collagen deposition in the adjacent oral facial tissues. However, we could not detect a relationship between facial skin score and number of erosions.”
Dr. Gornitsky notes that there are other concerns involving the jaw in these patients. Temporomandibular joint dysfunction can be a problem. Many show degenerative changes at the joint. Erosions can be so severe that it causes the jaw to fracture.
There was also a significant association between the number of teeth with a widened periodontal ligament and the physician’s global assessment of disease severity. The number of teeth with periodontal disease was not related to widening, leading Drs. Baron and Gornitsky to suggest that the widened periodontal ligament was more likely related to fibrosis than to PD itself.