What your dentist wants to know about scleroderma. David M Leader, DMD, MPH Department of Diagnosis And Health Promotion

What your dentist wants to know about scleroderma. David M Leader, DMD, MPH Department of Diagnosis And Health Promotion

MDS: 4600 dentists, 80% of DMDs in MA Council on Access, Prevention and Interprofessional Relations National organization for people with scleroderma and their families and friends Oral Medicine Clinic Services include treatment of oral problems related to infectious and systemic disorders such as cancer, mouth lesions, dry mouth, AIDS/HIV, and taste disorders.

Survey of 350 scleroderma patients (Phyllis, D., Leader, D., and Tao,W., 2011) Scleroderma patients: Have difficulty finding a dentist who is prepared to treat them. (28%) Would not recommend their current dentist to other scleroderma patients. (63%)

A survey of dentists knowledge and attitudes with respect to the treatment of scleroderma patients David M Leader, DMD, MPH Department of Diagnosis and Health Promotion Tufts University School of Medicine Athena Papas, DMD, PhD Rubenstein Oral Medicine Clinic Tufts University School of Dental Medicine Matthew Finkelman, PHD Biostatistics Tufts University School of Dental Medicine Journal of Clinical Rheumatology, June 2014

Attitude If I were contacted by a patient who has scleroderma, I would 1 Treat the patient. 120 45% 1. I have 2 an ethical Refuse to responsibility treat the patient. to treat scleroderma 0 patients. 0% 93% Gather more information on 3 scleroderma or on the patient's 133 50% 2. I feel prepared to condition. treat scleroderma patients. 71% 3. I am 4 concerned Refer that the patient. in not knowing how 7to care for someone 3% who has scleroderma I may harm them. 51% 4. Treating someone with scleroderma might be time consuming. 5 I don't know what I would do. 5 2% 71% Total 265 100%

Knowledge Question 1 Scleroderma/systemic sclerosis is most like which of the following? 1 Shingles 3 1% 2 Sjögren s syndrome 121 46% 3 Ectodermal dysplasia 85 32% 4 Multiple sclerosis 20 8% 5 I don't know 33 13% Total 262 100%

Knowledge Question 2 Hallmarks of scleroderma/systemic sclerosis include: 1 Thickening of the skin 5 2% 2 Limited opening of the mouth 4 2% 3 Xerostomia 3 1% 4 All of the above 251 95% 5 None of the above 2 1% Total 265 100%

Scleroderma - Radiography Widening of the periodontal ligament in several teeth is pathognomonic for Scleroderma.

Knowledge Question 3 Dentists may be the first to suspect scleroderma/systemic sclerosis due to: 1 Enamel erosion 16 6% 2 A high, unexplained caries rate 72 27% 3 Unusual radiographic findings 49 19% 4 Increased pain sensation 21 8% 5 I don't know 104 40% Total 262 100%

Results Cross tabulation Knowledge score I feel prepared to treat scleroderma patients. 0 1 2 3 Total No Count 5 39 31 1 76 % 6.6% 51.3% 40.8% 1.3% 100.0% Yes Count 5 75 80 25 185 % 2.7% 40.5% 43.2% 13.5% 100.0% Total Count 10 114 111 26 261 % 3.8% 43.7% 42.5% 10.0% 100.0% Mann Whitney U test p = 0.04

Bottom line If you would like to learn more about scleroderma, how would you prefer to learn about it? 258 of 269 (95.9%) respondents chose at least one. 80% 70% 60% 50% 40% 30% 20% 10% 50% 74% 45% 66% 18% 0%

SURVEY OF AMERICAN DENTAL SCHOOLS ON THEIR CURRICULUM FOR TREATING PATIENTS WITH RHEUMATIC DISEASES, SPECIFICALLY SCLERODERMA Caitlin Nash, RD, LDN, MPH candidate Public Health and Professional Degrees Program Tufts University School of Medicine David M Leader, DMD, MPH Department of Diagnosis and Health Promotion Tufts University School of Medicine

Teaser Nearly every school teaches predoctoral students about the treatment of patients with rheumatic diseases. (most of those include scleroderma) About half of the schools offer continuing education about the treatment of patients with rheumatic diseases.

Scleroderma and oral health Xerostomia (dry mouth, Sjögren's syndrome). Pain and difficulty opening. Oral effects of medications. Psychological effects (depression, self image). Gastro-Esophageal Reflux (GERD) Scleroderma & Dental Health 16

Scleroderma Increases Risk of Decay Diet Xerostomia Oral Hygiene GERD Host Resistance Professional care Self Cleaning Depression Scleroderma & Dental Health 17

CAMBRA Caries Management By Risk Assessment Risk factors that apply to many scleroderma patients: Special health care needs 3 or more carious lesions (cavities) in last 3 years Teeth missing due to caries last 3 years Severe dry mouth Medications that reduce salivary flow Visible plaque Exposed root surfaces Lack of a dental home

Oral effects of Medications Xerostomia. Oral Lesions. Stomatitis. Candidiasis. Intraoral hemorrhage Dysgeusia taste change. Gingival hyperplasia swollen gums. Osteonecrosis (Bone death) of the Jaw. Scleroderma & Dental Health 19

Treatment of Xerostomia Symptomatic. Caphosol. Calcium/phosphate paste Artificial saliva. Salivart Sugar free candies. Fluoride gel and rinse Medical Pilocarpine (Salagen) Cevimeline (Evoxac) Scleroderma & Dental Health 20

Caphosol 1 box contains 30 doses. 1 dose = 2 ampules mixed together. Available by Rx at pharmacies and at www.caphesol.com (free delivery).

Home Care Products MI Paste Fluoride Products Scleroderma & Dental Health 22

Why Can Muscarinic Agonists Be Used to Stimulate Saliva? o The severity of salivary dysfunction is disproportionate to the amount of lymphocyte infiltration o Most Sjögren s syndrome patients have remaining acinar cells in their salivary glands o Muscarinic receptors on these cells are still capable of responding to stimulation o In sufficient dosages, muscarinic agonists can increase secretion of exocrine glands

EVOXAC : Safety Considerations Contraindications: o uncontrolled asthma o hypersensitivity to the drug o acute iritis o narrow-angle (angle-closure) glaucoma

EVOXAC : Safety Considerations Cevimeline can potentially alter cardiac conduction, heart rate, and produce transient changes in hemodynamics. Close medical supervision: o history of cardiac disease o controlled asthma o chronic bronchitis o chronic obstructive pulmonary disease o beta adrenergic antagonists because of the possibility of conduction disturbances o history of nephrolithiasis or cholelithiasis

EVOXAC : Safety Considerations Special Populations Safety and effectiveness in pediatric patients have not been established Special care should be exercised when cevimeline is taken by geriatric patients, considering the greater frequency of decreased hepatic, renal, or cardiac function

EVOXAC : Safety Considerations Information for Patients If a patient sweats excessively while taking cevimeline, dehydration may develop Caution should be advised while driving at night or performing hazardous activities in reduced lighting

GERD Scleroderma & Dental Health 28

GERD Work with MD and Patient Medication PPI, H2 antagonists, Antacids Diet Low acid, no caffeine, nothing for 2 hours before bed Endoscopy to Rule out Barrett's esophagus and ulcerations. Scleroderma & Dental Health 29

Microstomia Adjust patient: Physical therapy. Commissurotomy. Adjust tools and technique: Patience. Shorten burs. Floss with a floss aid. Impressions with smaller or cut down trays. Scleroderma & Dental Health 30

Adaptive Toothbrushes Scleroderma & Dental Health 31

Power Toothbrushes Scleroderma & Dental Health 32

When flossing is a problem. Scleroderma & Dental Health 33

Fluoride Varnish Cavity Shield

Shorten Burs Scleroderma & Dental Health 35

Smaller or cut down trays Scleroderma & Dental Health 36

Physical Therapy Scleroderma & Dental Health 37

Therabite and Orastretch Require Rx, replacement parts, insurance.

Multiple tooth resorption syndrome Scleroderma & Dental Health 39

Diagnosis and treatment of resorption

Pathology

Wrap up Tell the dentist you have scleroderma and how it affects you. List of medications. Short appointments. Schedule for the best time of day for you. Physical therapy right before. Gloves and blanket. Scleroderma & Dental Health 42

Wrap up The dentist can help make your appointment more comfortable: Mouth prop. Rubber dam. Patience of both parties. Short appointments and/or breaks. Cut the air conditioning. Scleroderma & Dental Health 43

Wrap up See your dentist regularly (every 1-4 months). Prevents the need for long appointments. Helps maintain good self image and health. Scleroderma & Dental Health 44

Questions? David M Leader, DMD, MPH Tufts University School of Dental Medicine Department Diagnosis and Health Promotion Fourth Floor One Kneeland St Boston, Ma. 02111 David.Leader@Tufts.edu 45