Oral and dental
Problems with the mouth, oral cavity and teeth can have a very negative impact on quality of life for people with scleroderma, leading to difficulties with speech and eating.
Mouth ulcers, receding gums, loose teeth ... these are just some of the dental and oral issues Scleroderma and Raynaud's can cause. How are you coping with the effects of Scleroderma and Raynaud's on your dental and oral health? Have you been able to manage these? Stephen Porter is Institute Director and Professor of Oral Medicine in UCL Eastman Dental Institute. He recently discussed these issues during his Facebook Live Q&A on dental & oral involvement in Scleroderma & Raynaud's.
Thankfully, many people find treatments to control and manage oral and dental scleroderma symptoms effectively. We encourage everyone who is experiencing problems with oral health to seek advice from their doctors, dentists and other relevant health professionals.
Reduced mouth opening (microstomia)
Reduced mouth opening in systemic sclerosis is caused by tightness in the skin of the face around the mouth.
Many people don't notice this particular problem as it emerges slowly over many years and they adapt to cope over time. If the mouth opening becomes very small it can have an impact on eating, dental hygiene and speech. It never progresses to a point where patients are unable to feed or speak.
No drug treatments can prevent or treat microstomia. It's thought that exposure to cold may be an important driver of skin tightening of the face, so try to keep warm with a thermal blanket and cover the face during cold spells – you could use a scarf or neck gaiter/tube.
Mouth stretching exercises are probably the best treatment for microstomia. For best effects it is recommended that you perform these exercises once or twice a day (perhaps at the same time as you brush your teeth to make it easy to remember). Please see here for our mouth exercises.
Before exercising, it is always wise to warm up the area you plan to exercise. You can warm up the facial muscles by massaging the skin around your mouth with your fingers or using a warm flannel/compress over your mouth for 30 seconds before starting.
You may notice some aching of the muscles around your mouth for a few days after starting the routine. The exercises themselves shouldn't be painful, so listen to your body, lessening the pressure should you experience any significant discomfort.
Try performing the exercises in front of a mirror, but don't do them if you have sores around your mouth until you have sought medical advice.
A permanently dry mouth can cause difficulty in speech and swallowing and is very uncomfortable. In systemic sclerosis, a dry mouth is usually the consequence of loss of saliva due to some destruction of the salivary glands. A dry mouth can also be caused by Sjögren's syndrome, which often overlaps with scleroderma.
However many medicines may make the mouth dry as a side effect and if you have a very dry mouth it may be helpful for your doctor to review your medications with this in mind.
Treatments for a dry mouth include:
- Salivary substitutes - these include sprays and gels, which can be sprayed or rubbed into the mouth when required. A number of salivary substitutes are available
- Sipping water or diluted sugar-free drinks can help to keep the mouth moist
- Chewing sugar-free chewing gum can help to stimulate production of saliva
- Specific salivary stimulant medications such as pilocarpine can cause some stimulation of salivary flow
Denture problems in scleroderma
Scleroderma can give rise to a number of denture problems.
People with microstomia can have difficulties in inserting and removing their dentures. In addition the microstomia can make it difficult for impressions to be taken when dentures are being made.
A dry mouth can mean the denture will cause rubbing and gum ulcers in the mouth lining (oral mucosa). This can be minimised by applying salivary substitutes to the fitting surface of the denture, and having the denture regularly checked and modified.
Denture-associated candida infection can occur if the denture isn't cleaned regularly or it's kept in at night. To minimise this, make sure you take them out while you sleep and clean dentures often using soap and water and a denture brush. It is best to clean dentures after each meal or at least once daily. Toothpastes should not be used to clean dentures as they are too abrasive.
Poorly fitting dentures and dry mouth may cause the development of red patches or ulcers at the corners of the mouth (angular stomatitis). Antifungal cream like miconazole can be applied to the fitting surface of the denture. It's also important to get the dentures regularly checked by your dentist.
'Osseo-integrated implants' are a means of ensuring the retention of dentures. These are titanium screws that are placed within the jaw bones, the bone eventually uniting with the titanium of the implant. It is then possible to construct either dentures that clip onto the implant, or bridges that firmly attach to implants. There are no major medical reasons to rule out considering implants if you have scleroderma.
Other oral health problems in scleroderma
Oral ulcers can be a feature of autoimmune rheumatic diseases, and are a common side-effect of immunosuppressing drugs (such as mycophenolate mofetil (MMF), methotrexate, and cyclo-phosphamide) taken by people with scleroderma.
If you constantly get oral ulcers, you may need a change in immunosuppressive drug treatment. Maintaining good oral hygiene can help prevent mouth ulceration. The best treatment for mouth ulcers are those which contain a small amount of steroid such as Corlan ® pellets or Adcortyl in Orabase ®. These are available over the counter as well as on prescription.
Steroid inhalers (as used in asthma) can be sprayed onto active ulcers to promote healing. Preparations containing local anaesthetic such as Anbesol® and Rinstead pastilles® are useful for pain relief.
Salicylate gels such as Bonjela® and Teejel® can also help with pain but not with healing of mouth ulcers. Make sure to report any active ulceration that fails to heal within three weeks to your doctor or dentist.
Immunosuppressive drugs can also cause oral thrush (candida infection). This often presents with white spots on the tongue or mouth. It can be uncomfortable and requires treatment with anti-fungal medication.
Intermittent salivary gland enlargement (usually under the chin bone) can occur in scleroderma. Painful swelling of the salivary glands can be a sign of bacterial infection (sialadenitis) and sometimes requires use of antibiotics. Persistent swelling of salivary glands (more than one month) needs further investigation to identify a cause and should be reported to your doctor or dentist.
There are other problems that can arise with scleroderma but they are generally considered harmless. For example:
- The tongue may be less mobile because of shortening and thickening of the sublingual frenulum (the small band visible under the tongue which holds the tongue in position).
- Telangiectases (small dilated blood vessels) sometimes appear around the mouth, lips or gums but do not cause any problems in this area, and can be hidden with make-up or laser-treated at a specialist centre if you prefer.
- Enlargement of the gums can be a side-effect of nifedipine (and other calcium channel blocker) therapy. The enlargement is painless and usually subsides following a switch in vasodilator therapy.
The ideal tooth-brushing technique should remove the plaque but not cause any damage to the teeth or gums:
The roll technique is useful for people with healthy gums. The brush is placed with bristles on the gum tissue, the bristles are then pressed onto the gums making them blanch (whiten); maintaining the same pressure the bristles are moved across the gums onto the tooth surface. Behind the front teeth, the brush is held vertically and gently moved upwards and downwards.
The Bass technique is useful for patients with pre-existing gum disease. The bristles of the toothbrush are placed on the gum margins such that they point away from the crown of the tooth at an angle of 45°. The brush is vibrated backwards and forwards with a horizontal movement to gently dislodge the plaque. This can be a time-consuming method, is difficult to master and may cause mild trauma to the gums if not carried out appropriately with the correct brush.
Dental floss and dental tape needs to be threaded between the teeth and gently curled around the side of the tooth, slid down to the gums and gently brought back up to the top of the tooth. A suitable floss holder can make these easier to use for people with hand or joint problems.
For a Glossary of Terms click here.
Toothbrushes that might help:
- Angled brushes can help you access to areas of the mouth that are difficult to reach. These often have small heads and flexible handles and are therefore ideal for people with scleroderma.
- Altered filament length brushes - the middle row of filaments are shorter than the outer rows. These brushes clean above and below the tooth without causing over brushing. These are excellent for people with generally healthy mouths.
- Easy-Grip brushes - these are particularly useful for people who do not have the strength to grip closely or firmly. A toothbrush handle can be enlarged by fixing a ball of sponge rubber, nail brush or bicycle handle grip to the brush handle.
- Extended-handle brushes are particularly effective for people who cannot raise their arms. Two toothbrush handles can be glued or taped together or a tongue depressor can be taped to the brush handle.
- Electric toothbrushes - these are increasingly popular and are often more effective than ordinary brushes in removing plaque. They are ideal for people with scleroderma who have limited movement. Electric toothbrushes are often light and easy to hold.