Mandibular Function is Severely Impaired in Systemic Sclerosis Patients

Aims: To evaluate the presence of temporomandibular disorders (TMD) in systemic sclerosis (SSc) patients and its possible association with the severity of skin involvement. Methods: The presence of TMD was evaluated in 35 SSc women and 30 age- and sex-matched healthy controls by means of the anamnestic (Ai) and clinical (Di) Helkimo indices; the jaw mobility was further analyzed (MI). Skin involvement was scored by the Modified Rodnan Skin Score (MRSS). Results: Signs and symptoms of TMD were more frequent in SSc patients than in controls, the frequency distribution of the different clinical dysfunction indices differing significantly (P < .001) between patients (Di0 8.6%, DiI 48.6%, DiII 22.8%, and DiIII 20%) and controls (Di0 50%, DiI 33.3%, and DiII 16.7%). Cyclophosphamide for severe and rapidly progressive cutaneous fibrosis was prescribed in six out of seven patients with severe signs (DiIII), in contrast this treatment was indicated for only two out of 25 patients with mild to moderate signs (DiI and DiII, P < .001). Impaired jaw mobility was more frequent in SSc patients than controls (P < .001). It was severe in 77.1%(MIII) and mild in 22.9% (MII) of the cases, in contrast to controls (MI0 33.4%, MII 53.3%, and MIII 13.3%; P < .001). Approximately half of SSc patients with severe (MIII) but none of those with mild impairment were on cyclophosphamide treatment for severe cutaneous fibrosis (P = .02). Conclusion: Severe signs of TMD according to the anamnestic and clinical Helkimo indices were very frequent in SSc patients.

Helkimo indices and fibrosis;systemic sclerosis;temporomandibular disorders;temporomandibular joint

1. Mayes MD. Scleroderma epidemiology. Rheum Dis Clin North Am 2003;29:239–254.

2. Valentini G, Black C. Systemic sclerosis. Best Pract Res Clin Rheumatol 2002;16:807–816.

3. Tamby MC, Chanseaud Y, Guillevin L, Mouthon L. New insights into the pathogenesis of systemic sclerosis. Autoimmun Rev 2003;2:152–157.

4. LeRoy EC, Black C, Fleischmajer R, et al. Scleroderma (systemic sclerosis): Classification, subsets and pathogenesis. J Rheumatol 1988;15:202–205.

5. Poole 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;3:7–13.

6. Auluck A, Pai KM, Shetty C, Shenoi SD. Mandibular resorption in progressive systemic sclerosis: A report of three cases. Dentomaxillofac Radiol 2005;34:384–386.

7. Osial TA Jr, Avakian A, Sassouni V, Agarwal A, Medsger TA Jr, Rodnan GP. Resorption of the mandibular condyles and coronoid processes in progressive systemic sclerosis (scleroderma). Arthritis Rheum 1981;24:729–733.

8. Pizzo G, Scardina GA, Messina P. Effects of a nonsurgical ex ercise program on the decreased mouth opening in patients with systemic scleroderma. Clin Oral Investig 2003;7:175–178.

9. TerzIoglu A, Cigsar B, Aslan G. Surgical correction of microstomia in a patient with scleroderma. Ann Plastic Surg 2002;49:222–223.

10. Haers PE, Sailer HF. Mandibular resorption due to systemic sclerosis. Case report of surgical correction of a secondary open bite deformity. Int J Oral Maxillofac Surg 1995;24:261–267.

11. Subcommittee for Scleroderma Criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classifica-tion of systemic sclerosis (scleroderma). Arthritis Rheum 1980;23:581–590.

12. Furst DE, Clements PJ, Steen VD, et al. The modified Rodnan skin score is an accurate reflection of skin biopsy thickness in systemic sclerosis. J Rheumatol 1998;25:84–88.

13. Savioli C, Silva CA, Ching LH, Campos LM, Prado EF, Siqueira JT. Dental and facial characteristics of patients with juvenile idiopathic arthritis. Rev Hosp Clin Fac Med Sao Paulo 2004;59:93–98.

14. Savioli C, Silva CA, Siqueira JTT. Artrite reumatóide juvenil. In: Siqueira JTT, Teixeira MJ (eds). Dor Orofacial: Diagnóstico, Terapêutica e Qualidade de Vida. Curitiba: Editora Maio, 2001:477–487.

15. Fernandes EG, Savioli C, Siqueira JT, Silva CA. Oral health and the masticatory system in juvenile systemic lupus erythematosus. Lupus 2007;16:713–719.

16. Helkimo M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swed Dent J 1974;67: 101–121.

17. John MT, Zwijnenburg AJ. Interobserver variability in assessment of signs of TMD. Int J Prosthodont 2001;14: 265–270.

18. van der Weele LT, Dibbets JM. Helkimo's index: A scale or just a set of symptoms? J Oral Rehabil 1987;14: 229–237.

19. Marmary Y, Glaiss R, Pisanty S. Scleroderma: Oral mani-festations. Oral Surg Oral Med Oral Pathol 1981;52: 32–37.

20. Nagy G, Kovács J, Zeher M, Czirjáck L. Analysis of the oral manifestations of systemic sclerosis. Oral Surg Oral Med Oral Pathol 1994;77:141–146.

21. Moen K, Bertelsen LT, Hellem S, Jonsson R, Brun JG. Salivary gland and temporomandibular joint involvement in rheumatoid arthritis: Relation to disease activity. Oral Dis 2005;11:27–34.

22. Dervis E, Dervis E. The prevalence of temporomandibular disorders in patients with psoriasis with or without psoriatic arthritis. J Oral Rehabil 2005;32:786–793.

23. Cura C, Cotert HS, User A. Fabrication of a sectional impression tray and sectional complete denture for a patient with microstomia and trismus: A clinical report. J Prosthet Dent 2003;89:540–543.

24. Yenisey M, Külünk T, Kurt S, Ural C. A prosthodontic management alternative for scleroderma patients. J Oral Rehabil 2005;32:696–700.

25. Garino F, Capurso U, Garino GB. The role of mandibular repositioning splint in the orthodontic treatment of patients with TMJ dysfunction. Prog Orthod 2004;5: 44–53.

26. Suzuki Y, Abe M, Hosoi T, Kurtz KS. Sectional collapsed denture for a partially edentulous patient with microstomia: A clinical report. J Prosthet Dent 2000;84:256–259.

27. Naylor WP, Douglass CW, Mix E. The nonsurgical treatment of microstomia in scleroderma: A pilot study. Oral Surg Oral Med Oral Pathol 1984;57:508–511.

28. Sunderkötter C, Kuhn A, Hunzelmann N, Beissert S. Phototherapy: A promising treatment option for skin sclerosis in scleroderma? Rheumatology (Oxford) 2006; 45(suppl 3):iii52–iii54.

29. Babilas P, Landthaler M, Szeimies RM. Photodynamic therapy in dermatology. Eur J Dermatol 2006;16:340–348.

30. Kreuter A, Hyun J, Skrygan M, et al. Ultraviolet A1-induced downregulation of human beta-defensins and interleukin-6 and interleukin-8 correlates with clinical improvement in localized scleroderma. Br J Dermatol 2006;155:600–607.

31. Kreuter A, Hyun J, Stücker M, Sommer A, Altmeyer P, Gambichler T. A randomized controlled study of low-dose UVA1, medium-dose UVA1, and narrowband UVB phototherapy in the treatment of localized scleroderma. J Am Acad Dermatol 2006;54:440–447.

32. Brenner M, Herzinger T, Berking C, Plewig G, Degitz K. Phototherapy and photochemotherapy of sclerosing skin diseases. Photodermatol Photoimmunol Photomed 2005; 21:157–165.

33. Wetzig T, Sticherling M, Simon JC, Hegenbart U, Niederwieser D, Al-Ali HK. Medium dose long-wavelength ultraviolet A (UVA1) phototherapy for the treat-ment of acute and chronic graft-versushost disease of the skin. Bone Marrow Transplant 2005;35:515–519.