Prevalence of Oral and Maxillofacial Disorders in Patients with Systemic Scleroderma-A Systematic Review

CREST syndrome diagnosed by oral lesions: A case report and review of the literature

BACKGROUND

Calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome is an acronym for the clinical features that are seen. Its etiology is unknown, affecting women three times more than men. CREST syndrome is often diagnosed by systemic symptoms. However, oral manifestations could be helpful in the early diagnosis of the disease. Less than 20 cases of CREST syndrome with oral symptoms were described.

OBJECTIVE

To report a case of a 26-year-old female, who was diagnosed with CREST syndrome based on findings of the oral mucosa.

CASE REPORT

Clinical examination revealed sclerodactyly and nail alterations. Oral findings were associated with hypochromic and paleness mucosa. The tongue was strongly rigid and reddish areas compatible with telangiectasias were found. The mouth opening was particularly compromised. Histological findings were suggestive of systemic sclerosis in the context of CREST syndrome. Considering the available diagnosis criteria, this case was diagnosed as CREST syndrome based on oral manifestations.

CONCLUSIONS

Oral manifestations of CREST syndrome could help in early clinical diagnosis, preventing a delay in the onset of an aggressive form of the disease. Accurate referrals of patients to specialists are needed for a multidisciplinary approach.

Orofacial Manifestation of Systemic Sclerosis: A Cross-Sectional Study and Future Prospects of Oral Capillaroscopy

BACKGROUND AND OBJECTIVES

oral alterations in Systemic Sclerosis (SSc) patients are widespread and include microstomia, periodontitis, telangiectasias, mandibular resorption, bone lesions, and xerostomia. This cross-sectional study aims to evaluate the differences between SSc patients (cases) and healthy subjects (controls) regarding oral manifestations, quality of life (QoL), and microcirculation alterations.

METHODS

plaque index (PCR), periodontal index (PSR), DMFT, salivary flow rate, and buccal opening were measured by expert clinicians. S-HAQ test, the Self-Rating Anxiety State (SAS), the Self-Rating Depression Scale (SDS), and the WHOQOL-BREF test were administered to patients to evaluate their QoL. Microvascular alterations were assessed by oral videocapillaroscopy, performed on gingival and labial mucosa. A statistical analysis was conducted to find significant differences between healthy people and SSc patients.

RESULTS

59 patients were enrolled in this study. Standard salivary flow is significantly more frequent in controls, while xerostomia, reduced flow, microstomia, lip retraction, and periodontitis are significantly more frequent in the cases. Gingival capillaroscopy showed differences concerning loop visibility, thickening of the gum, tortuosity of gingival loops, and reduced gingival density. Labial capillaroscopy demonstrates that visibility of the labial loops, the labial ectasias, and the tortuosity of the loops are significantly associated with the presence of scleroderma. Hand and facial deformities, hypomobility of the tongue, cheeks, lips, microstomia, and xerostomia significantly compromised the quality of life of SSc patients, which was significantly worse among them. Moreover, oral videocapillaroscopy could be a proper diagnostic method to detect oral microcirculation alterations. SSc patients often present ectasias, rarefaction of the reticulum, microhemorrhages, and megacapillaries, which negatively impact their oral health.

CONCLUSIONS

periodontitis, reduced salivary flow, and microstomia could be considered SSc oral manifestations. Joint deformities, facial appearance, and comorbidities significantly reduce the QoL of SSc patients compared to healthy subjects. Oral videocapillaroscopy could be an innovative and reliable technique to detect oral microcirculation anomalies.

Periodontal health status in systemic sclerosis patients: Systematic review and meta-analysis

OBJECTIVE

The present systematic review and meta-analysis aimed to evaluate the periodontal health of systemic sclerosis patients compared with non-systemic sclerosis controls.

MATERIALS AND METHODS

Online databases were searched for eligible studies on February 24, 2023. The primary outcomes of interest in systemic sclerosis patients and controls included the clinical attachment level, periodontal probing depth, recession depth, plaque index, bleeding on probing score, gingival index, number of teeth with periodontitis, prevalence of periodontitis and gingivitis, and extent and severity of periodontitis.

RESULTS

Fourteen studies met inclusion criteria and were incorporated in the qualitative and quantitative analysis. In comparison with the controls, systemic sclerosis patients had a higher prevalence of periodontitis (OR = 7.63 (1.74-33.50), p = 0.04, I2 = 69%), including more severe forms of periodontitis (OR = 6.68 (3.39-13.15), p = 0.85, I2 = 0%), as well as higher periodontal probing depth ((0.88 (0.45-1.31), p = 0.02, I2 = 99%)), clinical attachment level (1.22 (0.8-1.64), p = 0.003, I2 = 98%), and plaque presence (0.83 (0.13-1.53), p = 0.03, I2 = 96%). There was no statistically significant difference in gingival inflammation (1.14 (0.07-2.21), p = 0.04, I2 = 98%).

CONCLUSIONS

The systematic review and the meta-analysis showed that systemic sclerosis patients suffer from worse periodontal health than non-systemic sclerosis individuals.

[Autoimmunity and oral cavity, where are we in 2023?]

Autoimmune diseases (AIDs) remain an enigma to the current understanding of immune system functioning. Identifying their etiologies remains a major challenge, despite growing knowledge. The oral cavity has a very special place in regard to AIDs. The oral mucosa, the most exposed body's natural barrier to pathogens, plays a role in both education of the immune system and the organism's daily protection. On the one hand, systemic disturbance of the immune system can impact the oral sphere with early signs which are useful diagnostic tools. On the other hand, the current research efforts on interactions between microbiota and the immune system allow an update of the old hypothesis involving an initial infection to trigger autoimmunity. Dysbiosis of our microbiota, especially in the oral sphere, could lead to a breakdown in tolerance mechanisms. Immune tolerance has to maintain the integrity of the organism but also cohabitation with commensal microbiota. The relationship between periodontitis, a chronic infectious disease, and rheumatoid arthritis, one of the most common systemic autoimmune disorders, illustrates the possible relationship between chronic infections and the etiopathogenesis of autoimmunity. Indeed, its association with oral pathogens involved in periodontal damage raises questions about a possible infectious etiology of rheumatoid arthritis (RA) which would place the management of periodontitis not only as mandatory RA's support therapy but also as a prophylactic gesture to prevent autoimmunity.

Ultrasound abnormalities of the major salivary glands in Egyptian patients with systemic sclerosis

INTRODUCTION/OBJECTIVES

systemic sclerosis (SSc) is an autoimmune disorder with multiple organs destruction. This study aimed to identify the ultrasonographic changes of major salivary glands in Egyptian scleroderma patients and to detect their association to different disease manifestations.

METHODS

Forty-seven SSc patients and 43 apparent healthy volunteers were enrolled. Demographics, inflammatory markers, and autoimmune status were recorded. Ultrasound evaluation of salivary glands was performed. Salivary gland changes' associations were statistically examined with SSc susceptibility and disease manifestations.

RESULTS

Thirty-one SSc patients exhibited glandular pathology (p < 0.0001), compared to controls. Of these abnormalities, SSc patients showed a total parotid gray scale of 2, total submandibular gray scale of 2, total glandular gray scale of 4, and total glandular Doppler signal of 1 at p < 0.0001, compared to the control group. Patients with SSc and glandular pathology had a higher prevalence of arthritis (p = 0.029) and ESR (p = 0.002) than those with normal glandular ultrasound. Significant associations were reported between gray scale ultrasound (GSUS) of total parotid (odds ratio "OR" = 0.4), total submandibular (OR = 0.36), and total glandular (OR = 0.53) with susceptibility to SSc at p < 0.0001. Total glandular GSUS (p = 0.039) and total submandibular power Doppler (p = 0.044) correlated with the SSc duration. Total parotid GSUS (p = 0.008) and total glandular GSUS (p < 0.0001) correlated with Schirmer's test.

CONCLUSIONS

Major salivary glands are affected in SSc. Hence, scanning these glands with ultrasound is an additive tool besides the current practice. Key Points • Major salivary gland changes, observed by ultrasonography, are new findings in Egyptian SSc patients. • Ultrasound changes of major salivary glands are associated with inflammatory markers and clinical manifestations of SSc. • Scleroderma ultrasonography scans of the main salivary glands could be added to the routine work.

Treatment of Scleroderma-Related Microstomia Using Hyaluronic Acid: An Interventional Study

Systemic sclerosis (SSc) or scleroderma is a rare, systemic, autoimmune connective tissue disease. It causes increased collagen synthesis, leading to multi-organ sclerosis, including the skin and joints. Patients' overall health and quality of life are harmed dramatically. Involvement of the face and, especially, the oral opening can limit patients' ability to speak and eat, oral hygiene, and cosmetic appearance. Profhilo® (NAHYCO®) is an over-the-counter product consisting of pure hyaluronic acid. It is used to improve skin quality by increasing collagen production and adipocyte vitality. This interventional study evaluated the results of perioral injections of hyaluronic acid in terms of improved skin quality, elasticity, and increased oral opening. Patients diagnosed with SSc received an injection of one syringe of Profhilo® (2 mL of hyaluronic acid) at each of two clinic visits at one-month intervals. The oral opening was measured between the upper and lower central incisors before and after treatment. Quality of life was assessed using the modified Rodnan Skin Score and Health Assessment Questionnaire-Disability Index. A total of 14 patients received the first treatment, and 11 received the second treatment. The mean oral opening increased from 31.6 mm (range 17-50 mm) prior to therapy to 35.8 mm (range 21-56) 2 months following the second injection. Statistical analysis showed that there was a significant increase in the oral opening as observed one week (36.2 mm, p = 0.011), one month (36.2 mm, p = 0.007), and three months (31.6 mm, p = 0.023) after the second injection, at the 5-month follow-up. Treatment of SSc patients' perioral area with Profhilo® can result in significant improvements in oral opening and quality of life.

Oral rehabilitation with dental implants in patients with systemic sclerosis: A systematic review

OBJECTIVE

To assess the influence of systemic sclerosis (SSc) on the survival rate of dental implants in SSc patients receiving implant-supported treatments.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement and the Cochrane Collaboration's guiding principles were followed during the study's execution. The data from three databases, PubMed, Google Scholar, and Scopus, available until January 2023, were used to compile the material for our research. Only English-language publications were submitted for this research and evaluated based on their titles, abstracts, and full texts. For performing a quality assessment, quality scores were calculated.

RESULTS

The total number of patients and implants studied were 37 and 153, respectively, all having had scleroderma. The patients' ages ranged from 28 to 77 years old, with a mean (SD) age of 58.16 (12.88). All the patients in the case reports and most in the case series study were female. The range of follow-up duration was from 1 to 10 years. In case report studies, the survival rate was 100%; in case series, it was 89.2%.

CONCLUSION

The SSc status had no discernible impact on the implant survival rate. Implant-based treatments in SSc patients should not worsen the overall morbidity and should not conflict with systemic treatments. Before starting implant therapy, a thorough risk assessment is essential, though.

Exploration of the underlying comorbidity mechanism in psoriasis and periodontitis: a bioinformatics analysis

BACKGROUND

Increasing evidence indicates that psoriasis (PSO) and periodontitis (PD) are likely to occur together, however, the underlying mechanism remains unclear.

MATERIALS AND METHODS

The expression profiles of PSO (lesion vs non-lesion, GSE30999, GSE14905) and PD (affected vs unaffected gingival tissue, GSE16134, GSE10334) were downloaded from the GEO database. First, we investigated the common differentially expressed genes (DEGs) of PSO and PD. Then, GO and KEGG enrichment analysis, protein interaction network (PPI) construction, and hub gene identification analysis were carried out. Finally, GO and KEGG enrichment analysis, miRNA interaction analysis, and transcription factors (TFs) interaction analysis for hub genes were performed.

RESULTS

Eighteen DEGs were identified for further analysis, including 15 up-regulated genes and 3 down-regulated genes. 9 hub genes were then identified via Cytohubba, including IL1B, CXCL1, CXCL8, MMP12, CCL18, SELL, CXCL13, FCGR3B, and SELE. Their functions are mainly enriched in two aspects: neutrophil chemotaxis and migration, chemokine activation and interaction. The enriched signaling pathways includes three categories: host defense, inflammation-related signaling pathways, and disease-related pathways. 9 common miRNAs based on experimental evidence and 10 common TFs were further identified in both PSO and PD.

CONCLUSION

Our study revealed possible comorbidity mechanisms in PSO and PD from the perspective of bioinformatics tentatively. The data can present new insight for joint prevention and treatment of in PSO and PD, as well as provide data support for further prospective studies.

HIV-Associated Systemic Sclerosis: Literature Review and a Rare Case Report

Highly antiretroviral therapy (HAART) used in Human Immunodeficiency Virus (HIV) treatment may prolong the life span of people living with HIV/Acquired Immune Deficiency Syndrome (AIDS) but may also induce the onset of autoimmune disorders. However, HIV-associated systemic sclerosis (SSc) is an extremely rare occurrence, and only four case reports and two studies documenting this association have been reported to date. We report a rare case of HIV-associated SSc who was referred to us for pain management in her mandibular teeth. A 44-year-old female patient diagnosed with HIV-associated SSc reported a complaint of pain in the lower posterior teeth region. Physical examination revealed typical features of SSc. The pain in her mandibular teeth was due to food lodgement, and she was advised to use toothpaste with a powered toothbrush and mouth stretching exercises, followed by oral prophylaxis. The patient responded well to therapy. HIV-associated SSc is an extremely rare occurrence, with an obscure pathogenic mechanism of HIV-associated autoimmunity. Oral physicians play a crucial role in disease management and should be incorporated into the multidisciplinary team.

Dental implants in patients suffering from systemic sclerosis: a retrospective analysis of clinical outcomes in a case series with 24 patients

PURPOSE

Patients with systemic sclerosis (SSc) often suffer from premature tooth loss. This is a retrospective case series of patients with systemic sclerosis who were treated with dental implants.

METHODS

SSc patients treated with at least one dental implant between 5 August 1998 and 31 December 2018 were included in this long-term retrospective study. The primary study variables were the plaque index (PLI), sulcus bleeding index (SBI), peri-implant pocket depth (PPD) and interincisal distance (ID). The test for marginal homogeneity analysed whether the SBI and PLI values changed between examination and follow-up. A linear regression was performed for the PPD measurement. The rank correlation coefficient compared the SBI with the PLI and the PPD with the PLI. The survival rate data for the implants were analysed by the Kaplan-Meier procedure. P < .05 was considered significant.

RESULTS

Twenty-four patients [(age: mean 59.6 years (SD ± 13.08)] received a total of 72 implants. ID resulted in a mean value of 29.54 mm (SD ± 6.4 mm). The mean value of the PPD was between 2.4 mm and 2.8 mm. A comparison of the SBI with the PLI and the PPD with the PLI showed a significantly positive correlation between the SBI and the PLI and between the PPD and the PLI. The correlation between the PPD and the PLI (Spearman rho: 0.36, p < 0.001) was less pronounced than that between the SBI and the PLI (Spearman rho: 0.61, p < 0.001). Kaplan-Meier analysis showed a post-10-year implant survival rate of 87.6% (95%-KI: 75.5-94.0).

CONCLUSION

Implant-supported oral rehabilitation can be carried out and maintained successfully in SSc patients.