Relationship Between Disease Characteristics and Oral Radiologic Findings in Systemic Sclerosis: Results From a Canadian Oral Health Study

Influence of systemic sclerosis on periodontal health: A case-control study

AIM

Patients with systemic sclerosis (SSc) present various clinical and radiological oral manifestations. However, precise evaluation of the oral features associated with diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc (lcSSc) is limited. The objective of this study was to evaluate the periodontal ligament (PDL) surface in SSc patients in comparison with controls. Assessment of oral-health-related quality of life (OHRQoL) and the levels of different biomarkers in the gingival crevicular fluid (GCF) was performed.

MATERIALS AND METHODS

SSc patients and matched controls underwent standardized oral examination and cone-beam computed tomography (CBCT). Levels of interleukin-6 (IL-6), chemokine (C-X-C motif) ligand 4 (CXCL-4) and matrix metalloproteinase-9 (MMP-9) in the GCF were determined by enzyme-linked immunosorbent assay. PDL surface was measured on CBCT axial views. OHRQoL was quantified using the Mouth Handicap in SSc Scale (MHISS).

RESULTS

Thirty-nine SSc patients and 39 controls were included. SSc patients exhibited increased PDL surface, higher number of missing teeth as well as elevated IL-6, MMP-9 and CXCL-4 levels. Reduced mouth opening was observed in dcSSc but not in lcSSc patients. MHISS score was higher in dcSSc than in lcSSc patients. Although worse periodontal parameters were found in both subgroups compared with controls, dcSSc patients presented lower gingival inflammation.

CONCLUSIONS

SSc is associated with PDL space widening, impaired oral health and OHRQoL.

Periodontal disease and its association to endothelial dysfunction and clinical changes in limited systemic sclerosis: A case-control study

OBJECTIVES

Periodontal disease occurs frequently in patients with limited cutaneous systemic sclerosis (lcSSc) while data about underlying pathways contributing to periodontal changes are scarce. The aim of this study was to evaluate periodontal disease and to investigate its association with endothelial dysfunction and clinical changes in patients with lcSSc.

METHODS

In 38 lcSSc patients and 38 controls, periodontal status was evaluated by disease-specific questionnaire, dental examination including bleeding on probing (BOP), pocket depth, and plaque index, and dental panoramic radiograph. Periodontopathogen bacteria were collected subgingivally using paper points and interleukin-1 (IL-1) gene polymorphisms were evaluated using buccal swabs. Endothelial dysfunction was measured by flow-mediated dilatation, pulse-wave velocity and biochemical analysis, including arginine metabolites and endothelial microparticles. Additionally, lcSSc-specific clinical changes and parameters were recorded.

RESULTS

Periodontitis was present in 31 patients with lcSSc (81.6%) and in 27 controls (71.1%) (p = .280). LcSSc patients had a lower teeth number (p = .039) and Eikenella corrodens was to a higher degree detectable in patients with lcSSc (p = .041) while the remaining periodontal parameters revealed no differences between both cohorts. Significant correlations between parameters of arterial stiffness, EUSTAR index, number of teeth and BOP were observed (all p < .05). Detection of Prevotella intermedia was associated with selected IL-1 gene polymorphisms (p = .032) and Porphyromonas gingivalis was associated with severe periodontitis (p = .041).

CONCLUSION

Periodontal disease may occur frequently in patients with lcSSc and may be associated with arterial stiffness and with SSc activity.

Open-Full-Jaw: An open-access dataset and pipeline for finite element models of human jaw

BACKGROUND

State-of-the-art finite element studies on human jaws are mostly limited to the geometry of a single patient. In general, developing accurate patient-specific computational models of the human jaw acquired from cone-beam computed tomography (CBCT) scans is labor-intensive and non-trivial, which involves time-consuming human-in-the-loop procedures, such as segmentation, geometry reconstruction, and re-meshing tasks. Therefore, with the current practice, researchers need to spend considerable time and effort to produce finite element models (FEMs) to get to the point where they can use the models to answer clinically-interesting questions. Besides, any manual task involved in the process makes it difficult for the researchers to reproduce identical models generated in the literature. Hence, a quantitative comparison is not attainable due to the lack of surface/volumetric meshes and FEMs.

METHODS

We share an open-access repository composed of 17 patient-specific computational models of human jaws and the utilized pipeline for generating them for reproducibility of our work. The used pipeline minimizes the required time for processing and any potential biases in the model generation process caused by human intervention. It gets the segmented geometries with irregular and dense surface meshes and provides reduced, adaptive, watertight, and conformal surface/volumetric meshes, which can directly be used in finite element (FE) analysis.

RESULTS

We have quantified the variability of our 17 models and assessed the accuracy of the developed models from three different aspects; (1) the maximum deviations from the input meshes using the Hausdorff distance as an error measurement, (2) the quality of the developed volumetric meshes, and (3) the stability of the FE models under two different scenarios of tipping and biting.

CONCLUSIONS

The obtained results indicate that the developed computational models are precise, and they consist of quality meshes suitable for various FE scenarios. We believe the provided dataset of models including a high geometrical variation obtained from 17 different models will pave the way for population studies focusing on the biomechanical behavior of human jaws.

Investigation of the Expression of Inflammatory Markers in Oral Biofilm Samples in Patients with Systemic Scleroderma and the Association with Clinical Periodontal Parameters-A Preliminary Study

BACKGROUND

Systemic scleroderma (SSc) has multiple orofacial effects. The aim of this study was to analyze the expression of inflammatory mediators in biofilm samples. It was hypothesized that different expression levels and clinical associations might be drawn.

METHODS

A total of 39 biofilm samples from group 1 = SSc and group 2 = healthy control were examined for the expression levels of interleukin (IL)-2,-6, and -10; matrix metalloprotease (MMP)-9; and surface antigens CD90 and CD34 by quantitative real-time PCR and clinical parameters. Relative quantitative (RQ) gene expression was determined using the ∆∆CT method.

RESULTS

The mean bleeding on probing values (p = 0.006), clinical attachment loss (CAL) (p = 0.009), gingival recession (p = 0.020), limited mouth opening (p = 0.001) and cervical tooth defects (p = 0.011) were significantly higher in group 1. RQ expressions of IL-2 and CD34 were significantly lower, IL-6, MMP-9, and CD90 were significantly higher. There was a significant positive correlation of IL-6/MMP-9 and negative correlation of mouth opening/CAL and IL-6/CAL.

CONCLUSION

Different expression levels of IL-2, IL-6, MMP-9, CD34 and CD90 were detected in biofilm samples from patients with SSc compared to control. An immunological correlation to the clinical parameters of mouth opening and CAL was shown; thus, we conclude that SSc might have an impact on periodontal tissues.

Trigeminal neuralgia in systemic sclerosis

OBJECTIVES

Although trigeminal neuralgia (TN) has been associated with systemic sclerosis (SSc), there is a paucity of evidence and pathophysiological processes remain unknown. We undertook a nested case-control study to identify associations between TN and SSc in a large multi-centered cohort and identify possible pathophysiological links.

METHODS

Data were derived from a longitudinal cohort of 1652 SSc subjects. Cases with a physician-reported diagnosis of TN were identified at baseline visit (prevalent) and during follow-up (incident). Each case was matched on study visit to four SSc patients without TN. Sociodemographic, clinical and serological characteristics of cases and controls were compared.

RESULTS

At enrolment, 43/1652 (2.6%) subjects had a history of TN. During follow-up, an additional 36 subjects developed TN over 6193 person-years of observation (incidence rate 5.8 per 1000 person-years). Cases were identified and matched to 172 and 144 controls, respectively. Compared to controls, prevalent cases had more inflammatory myositis (24.4% versus 5.2%, p<0.001) and inflammatory arthritis (46.5% versus 30.2%, p = 0.043). Incident cases also had more inflammatory myositis (19.4% versus. 6.3%, p = 0.033) and inflammatory arthritis (50.0% versus. 16.2%, p<0.001) compared to controls. There was a trend towards more interstitial lung disease in prevalent (32.6% versus 23.8%, p = 0.241) and incident (55.6% versus 40.6%, p = 0.105) cases compared to controls.

CONCLUSION

This study provides novel evidence for a clinical association linking TN, inflammatory myositis, inflammatory arthritis and possibly interstitial lung disease. In addition to ischemia, we propose that TN in SSc could also be a consequence of inflammatory and possibly fibrotic processes.

Soft-Tissue Grafting Solutions

Many soft-tissue grafting solutions are available for reconstruction and restoration of volume and esthetics of keratinized attached mucosa at compromised periodontal and peri-implant interfaces. Presence of healthy soft tissues is crucial for functional and esthetic implant success as well as longevity of natural dentition. The options available each provide unique characteristics with different indications. This article is intended to provide an efficient and comprehensive overview of this topic, covering the essentials of periodontal anatomy and physiology, indications for soft-tissue grafting, and keys in recipient and donor-site preparation, and exploring the available procedural arsenal in soft-tissue grafting.

Volumetric Cone Beam Computed Tomography for the Assessment of Oral Manifestations in Systemic Sclerosis: Data from an EUSTAR Cohort

Background: Oral health issues are commonly reported in systemic sclerosis (SSc), comprising a broad spectrum of manifestations, e.g., reduced mouth opening, periodontal disease, increased periodontal ligament (PDL) space width, and mandibular resorption. We aimed to assess oral radiographic abnormalities, particularly PDL space widening and erosions, and to identify potential relations with disease measures. Methods: cross-sectional study in 43 SSc and matching controls receiving systematic oral assessments (full mouth dental/periodontal) and imaging (radiographs and cone beam computed tomography (CBCT)). Associations between disease variables and radiologic findings were investigated by univariate and multivariate analysis (SPSS-v.20, p < 0.05). Results: CBCT demonstrated generalized PDL space widening in up to half SSc, with at least one tooth involved, essentially in the posterior region (p < 0.05). Significant correlations between number of teeth with PDL space widening and disease severity, skin score, disease subset, topoisomerase I specificity, age, and disease duration were reported (p < 0.05). Additionally, mandibular erosions were described in one out of four patients, commonly condylar erosions. Conclusions: Tridimensional CBCT approach confirmed widening of PDL and mandibular erosions as common dental findings in scleroderma. Furthermore, widened PDL spaces correlated with several disease characteristics including severity, skin extent, and antibody profile.

[Oral health in patients with systemic sclerosis]

The aim of this study was to conduct literature review about oral manifestations of scleroderma. Systemic sclerosis is a multisystem autoimmune disorder characterized by widespread fibrosis, vascular alterations and inflammation. Systemic sclerosis mainly affects people in age from 30 to 50 years, but the onset of disease can occur in any age. The disturbance of microcirculation with the activation and proliferation of endothelium and smooth muscle cells plays an important role in pathogenesis of sclerodrma. These changes lead to sclerosis and fibrosis of various part in human body. Orofacial manifestations of scleroderma include: reduced mouth opening, widening of periodontal ligament, teleangiectasia, bone lesions. Systemic scleroderma is often accompanied by Sjogren's syndrome. Oral manifestations of Sjogren's syndrome are recurrent parotitis, angular cheilitis, xerostomia and multiple caries. Sjogren's syndrome leads to negative impact on patients health and mental status. Orofacial manifestations of systemic sclerosis are still poorly known, that is why more researches should be made to improve dental treatment of patients with systemic sclerosis.

Main Oral Manifestations in Immune-Mediated and Inflammatory Rheumatic Diseases

Oral manifestations are frequent in patients with rheumatic diseases. The aim of this review is to offer readers practical advice concerning the onset, diagnosis and treatment of the main oral manifestations encountered in rheumatological and dental clinics. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, periodontal disease, and dysphagia may be the first expression of a number of rheumatic diseases. Some of these manifestations are aspecific and very frequent, such as oral aphthosis, which can be the first manifestation in patients with systemic lupus erythematosus; some are potentially dangerous, such as jaw claudication during the course of giant cell arteritis; and some are very rare but peculiar, such as strawberry-like gingivitis in patients with granulomatosis with polyangiitis. Other oral manifestations are due to adverse reactions to disease-modifying anti-rheumatic drugs. Oral alterations in rheumatic diseases are frequently overlooked in clinical practice, but their prompt recognition not only allows the local lesions to be appropriately treated, but also makes it possible to identify an underlying systemic disease.

Risk association between scleroderma disease characteristics, periodontitis, and tooth loss

Systemic sclerosis (SSc) is a multi-system disorder that can have significant adverse effects on the health of the mouth. The aim of this study was to investigate the associations between the disease characteristics of SSc, periodontal disease (PD), and tooth loss. Fifty-four patients affected by SSc and 55 non-diseased controls were matched for age and gender. SSc was characterized in subtypes and with the mean duration of disease and the Modified Rodnan Skin Score [mRSS]. Patients were surveyed and examined through the evaluation of the periodontal parameters and the number of teeth. A logistic regression analysis showed that patients with SSc presented a higher number of missing teeth (p = 0.001) and a significant median increased odds 2.95 (95% CI 1.26 to 6.84) of PD (defined as clinical attachment loss, CAL) compared to nondiseased controls (6.83, 95% CI 1.94 to 24.36). Moreover, the fewer values of PD was correlated with mRSS in the total SSc group and with the mean duration of disease in patients with limited SSc (p = 0.007), even after adjusting this correlation with the presence of the major organ involvement. This study showed that patients with SSc presented increased odds of PD and tooth loss compared to non-diseased controls. In SSc patients, the magnitude of PD was strongly associated with the mRSS and with the mean duration of the disease. The clinicians should be aware of the potential systemic health problems related to PD.

A case report of open craniofacial sutures, a novel feature of systemic sclerosis?

Scleroderma is an uncommon connective-tissue disease, its key feature being excessive collagen deposition resulting in fibrosis of the skin and internal organs. There are different types that can vary in severity from localized scleroderma to systemic sclerosis. Various clinical and radiographic findings can be attributed to the disease, which arise owing to the progressive nature of microvascular changes and collagen deposition. These include limited mouth opening, xerostomia, periodontal disease and cardiac and pulmonary disease. Whilst bone resorption has been reported, as far as we are aware, the literature has not described a case with failure of bony suture closure. Hence, we would like to describe what is probably a unique case of a patient with a 5-year history of systemic sclerosis, who was referred for management of increased mobility of her upper central incisors. Radiographic imaging (conventional and three-dimensional) confirmed increased bone resorption, partly owing to periodontal disease, but also owing to an open premaxillary suture. Similarly, other craniofacial sutures were diagnosed as being open, and, to our knowledge, this represents a yet undescribed finding in a patient suffering from scleroderma.

Review of common conditions associated with periodontal ligament widening

Purpose

The aim of this article is to review a group of lesions associated with periodontal ligament (PDL) widening.

Materials and Methods

An electronic search was performed using specialized databases such as Google Scholar, PubMed, PubMed Central, Science Direct, and Scopus to find relevant studies by using keywords such as “periodontium”, “periodontal ligament”, “periodontal ligament space”, “widened periodontal ligament”, and “periodontal ligament widening”.

Results

Out of nearly 200 articles, about 60 were broadly relevant to the topic. Ultimately, 47 articles closely related to the topic of interest were reviewed. When the relevant data were compiled, the following 10 entities were identified: occlusal/orthodontic trauma, periodontal disease/periodontitis, pulpo-periapical lesions, osteosarcoma, chondrosarcoma, non-Hodgkin lymphoma, progressive systemic sclerosis, radiation-induced bone defect, bisphosphonate-related osteonecrosis, and osteomyelitis.

Conclusion

Although PDL widening may be encountered by many dentists during their routine daily procedures, the clinician should consider some serious related conditions as well.

Acute Respiratory Events in Connective Tissue Disorders

Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.