Scleroderma is a chronic autoimmune disease characterized by the overproduction and excessive deposition of collagen, a fibrous protein, throughout the body’s tissues. This process leads to the hardening and tightening of the skin and connective tissues, often referred to as systemic sclerosis. While the disease affects various internal organs, its manifestations within the oral cavity are common and significantly impact a person’s quality of life and daily function. This article focuses on the effects of this systemic condition on the mouth and strategies for managing these complications.
Physical Manifestations of Oral Scleroderma
The fibrotic process frequently targets the tissues of the face and mouth, leading to structural changes that restrict movement and alter facial appearance. Tightening of the perioral skin often results in a “mask-like” facial expression and thin lips. Excessive collagen deposition causes the skin to lose elasticity and mobility, leading to deep wrinkles or furrows radiating outward from the mouth.
The most functionally limiting change is microstomia, the progressive reduction in the size of the oral opening. This limited opening is a direct consequence of the hardening of the facial and perioral tissues. Many patients with systemic sclerosis experience a maximal mouth opening of less than 40 millimeters, which is substantially restricted compared to a typical opening.
This physical restriction severely hinders basic functions, such as eating and speaking clearly. Simple actions like taking a bite of food become difficult because the mouth cannot open wide enough. The tightening also affects the ability to smile and can limit the range of motion of the jaw, occasionally involving the temporomandibular joint. The reduced opening creates significant obstacles for maintaining adequate oral hygiene and for dentists performing procedures.
The tongue can also be affected by fibrosis, becoming rigid and less mobile, which complicates speech and swallowing. In some cases, the pressure exerted by the tight mucocutaneous tissues contributes to the erosion and resorption of underlying bone structures, such as the angle of the mandible.
Associated Dental and Glandular Issues
Fibrotic changes often extend to the salivary glands, resulting in xerostomia (dry mouth). This reduced flow of saliva removes a natural protective mechanism from the oral cavity, sometimes compounded by medications used to manage the disease. Saliva plays a crucial role in neutralizing acids and washing away food debris and bacteria, so its reduction directly increases the risk of dental decay.
The lack of sufficient saliva heightens the susceptibility to other oral health problems, including fungal infections like oral candidiasis and generalized gum inflammation. Xerostomia also makes oral tissues prone to irritation and the development of painful sores, especially for those who wear dentures. Scleroderma can also affect the support structures of the teeth, leading to periodontal disease.
Periodontal issues, including gum recession and inflammation, are often observed. The tightening of the mucosal lining can mechanically pull the gums away from the teeth, contributing to recession. Radiographically, patients may exhibit a widening of the periodontal ligament space—the tissue that holds the tooth in the socket—due to increased collagen deposition in that area.
Idiopathic root resorption is another specific dental complication involving the progressive loss or damage of the tooth root structure. This condition can only be detected through dental X-rays. The combination of microstomia, reduced manual dexterity from hand involvement, and xerostomia makes routine oral hygiene a struggle, accelerating the progression of these complications.
Strategies for Maintaining Oral Health
Managing the oral health effects of scleroderma requires a specialized approach focused on counteracting physical and glandular limitations. For patients with microstomia, specialized hygiene techniques are necessary for effective plaque removal. Using an electric toothbrush, particularly one with a small head, significantly improves access and cleaning efficiency compared to a manual brush.
Flossing is challenging, so patients are advised to use flossing aids, such as floss holders or interproximal brushes, to navigate the limited space. A water flosser, which sprays water at a pressurized stream, is another effective tool for cleaning between teeth and along the gumline when opening is compromised. Due to the high risk of decay, prescription-strength fluoride toothpaste or calcium paste is recommended to strengthen tooth enamel.
To combat microstomia progression, physical therapy involving daily jaw stretching exercises is essential. These exercises, which may involve devices like the Therabite or simple tongue depressors, aim to maintain or improve the maximal mouth opening. Regular application of these stretching and oral augmentation exercises can lead to improvements in oral aperture, making eating and hygiene measures easier.
Managing xerostomia involves strategies to supplement or stimulate saliva production.
Xerostomia Management
- Over-the-counter saliva substitutes, available in gels or sprays, can provide temporary relief from dryness.
- Physicians or dentists may prescribe medications such as pilocarpine or cevimeline to actively stimulate the salivary glands to increase flow.
- Frequent sipping of water helps keep the mouth moist.
- Using sugar-free lozenges or gum can also stimulate saliva production.
The nature of the disease necessitates more frequent professional dental checkups, often every three months, to monitor for early signs of decay, periodontal disease, and bone changes.