The Prevalence of Dental Implants and Related Factors

in Patients with Sjgren Syndrome: Results from a

Cohort Study
THE JOURNAL OF RHEUMATOLOGY

Objective.To investigate prevalence and patient-reported outcomes of dental implants in patients

with Sjgren syndrome (SS).
Methods. A total of 205 female patients from an observational cohort study answered oral health
questionnaires about periodontal signs and symptoms, dentures, dental implants, comorbidities,
and therapies that may interfere with bone remodeling. Data were compared with the reports of 87
female healthy controls.
Results. The patients were older than the controls (58 12 and 54 14 yrs, respectively) and
differed substantially in the prevalence of self-reported gingivitis (60% and 35%), self-reported
periodontitis (19% and 8%), and in the numbers of remaining teeth (21 7 and 24 5). Patients
more frequently had removable prostheses (36% compared with 23%) and dental implants (16%
compared with 7%). The 32 patients with SS with dental implants had a mean number of 3.1 2.0
implants. Notably, for patients with implants, their oldest existing implant survived for a mean
period of 4.9 5.4 years. A total of 5 of 104 (4.8%) implants in the patients and none of the 14
implants in the controls had to be removed. A total of 75% of the patients were highly satisfied with
the implants and 97% would recommend them to other patients with SS.
Conclusion. A substantial portion of patients with SS have dental complications and require
subsequent implants. The majority were satisfied with the implants and would recommend them to
other patients. The high implant survival rate may encourage patients, rheumatologists, and
dentists to consider dental implants for the treatment of patients with SS.

DISCUSSION: []
In a recent systematic review, an implant survival rate of 92% in patients with SS was reported with
a mean observation period of 48 months. However, the number of patients with SS was only 1719.
Common implant therapy in patients with SS (21%), a high implant survival (97%, with a medium
followup of 46 mos), and a high patient satisfaction were also reported from a recent cohort study
on 50 patients with SS with dental implants and matched controls16. Data from studies reporting
on implant failure risks are heterogeneous, and the level of evidence regarding contraindications
for implant therapy remains low10,20,21,22,23,24. In the majority of cases in which an implant fails
to integrate, the cause is unknown19. The findings from our present study suggest that SS itself
does not impair the biology of osseointegration. A rather large number of dentists and
rheumatologists advised the patients not to have dental implants. The majority of them had
expressed concerns about initial osseointegration or a higher risk of implant failure. In addition, we
cannot rule out that other aspects such as the specific dental status of the included patients were
responsible for implant therapy not being recommended. However, our data and those reported by
Korfage, et al16 suggest that dental implants should be considered by dentists and
rheumatologists as a viable treatment option in patients with SS.
What rheumatologists should know about orofacial
manifestations of autoimmune rheumatic diseases
PERIODONTAL DESEASES AND RHEUMATOID ARTHRITIS
[] Furthermore, there is evidence of similarity in the pathogenesis of RA and PD. Microorganisms
such as Porphyromonas gingivalis may play a role in both conditions,16 being able to invade
isolated human chondrocytes in the knee joint, interfering with cell cycle and inducing these cells
apoptosis.20
Another important factor would be that P. gingivalis expresses the peptide arginine deiminase
(PAD), which converts arginine to citrulline by a citrullination process. This process, which is
common to some human proteins, is associated with the pathophysiology of RA. It has a low
immune tolerance to citrullinated proteins in synovial fluid, which triggers the development of
immunoglobulins against these proteins, present in joints and tendons.21,22 In addition, studies
have demonstrated the presence of antibodies in response to oral anaerobic bacteria in the
synovial tissue and serum. Others authors also found the presence of oral bacterial DNA in the
synovial fluid of RA patients.18 In fact, RA and PD have a vari- ety of markedly similar clinical and
pathophysiologic features (Table 2).23,24
Although periodontal disease has local clinical manifestations, its chronic inflammatory nature can
contribute to change and even worsen the course of RA and of other rheumatic diseases. A
recent systematic review by Kaur et al. (2013) demonstrated a good level of evidence to support
an association between RA and PD, taking into account tooth loss, the clinical attachment level,
and erythrocyte sedimentation rates. Moderate evidence was noted in C-reactive protein and
interleukin-1 values. A positive outcome of periodontal treatment was observed, with respect to the
clinical features of RA. However, more studies are needed to fully explore the biochemical
processes and the relationship between these chronic inflammatory diseases, despite the similarity
in the pathophysiologic characteristics of RA and PD. It is found that six months after the
completion of periodontal therapy, the improvement of oral health is strongly associated with an
improvement in endothelial function, with a decrease in local and systemic inflammatory
processes.25

XEROSTOMIA
[] xerostomia affects 1% of RA patients.26 About one third of RA patients have secondary SS.27 A
study including 604 RA patients showed a decrease in salivary flow in 43% of subjects.28 The risk
of developing hyposalivation increases with the severity of the disease. It is worth mentioning that
another study conducted in 483 hospitalized patients due to complications of arthritis found that
only 17.7% of xerostomia-positive patients were treated for xerostomia. In contrast, 84.8% of
patients treated for xerophthalmia were treated for this condition. It was also observed that the
therapeutic modalities administered for xerostomia were not effective and also were not in accor-
dance with current recommendations found in the medical literature.29

SYSTEMIC SCLEROSIS
[] The oral manifestations are scarcely studied and often neglected by clinicians, although
leading to major functional disability. Microstomia is the most common oral finding and develops
due to collagen deposition in perioral tissues, causing limitation of mouth opening, perioral groove
wrinkling, and soft palate, larynx and oral mucosa stiffness.46 Furthermore, hyposalivation and/or
dry mouth are secondary manifestations of the disease. TMD can also occur, with varying degrees
of subsequent resorption of mandibular branch, coronoid process, menton and condyle.5 It is
believed that these areas are reabsorbed due to the chronic collagen deposition. Tongue cancer
has a significantly increased frequency in patients with SSc that present a mouth opening <30 mm.
47 The resorption of some teeth has also been reported with some frequency in these

patients. There may be an abnormal increase in the frequency of decayed teeth and of an
atypical tooth eruption. Apparently there is also a predisposition for the occurrence of PD,
due to increased plaque buildup. This problem arises from the difficulty of cleaning the
mouth (caused by a smaller mouth opening) and in the use of the dental brush. This latter
complication is due to scle- rotic changes in fingers and hands. Furthermore, the use of
systemic corticosteroids for long periods influence in reducing the periodontal
inflammatory response, thus making this process a progressive and often insidious one.48

SJOGRENS SYNDROME
[] SS patients often display voice disorders and correlated symptoms that are associated with a
decrease in their quality of life. It is known that the lubrication of the vocal cords is carried out by
saliva.61 Thus, this biological fluid is important for a proper phonation.
[] Gustatory, mechanical and chemical sialogogues have been used to stimulate saliva
production. However, the effective- ness of these resources is low, because they provide only
temporary relief, requiring frequent applications.65 Many topical treatments such as sprays,
lozenges, mouthwashes, gels, oils or toothpastes have been evaluated, but there is no strong
evidence that any of these topical treatments is effective to references alleviate the patient with
dry mouth.66 Oxygenated tri-ester glycerol-based lubricants are more effective than water-based
electrolyte sprays. Chewing gum increases saliva production, but there is no evidence that these
products are better or worse than saliva substitutes. However, acidic secretagogues and those
containing sugar should be avoided,66 because these products lower oral pH, promote greater
tooth demineralization and irritate a mucous already very sensitive. One should opt for the use of
sugar-free chewing gum, but containing fluoride and bicarbonate in its composition. These
components increase salivary pH and assist in preventing tooth decay.67,68 Chemical sialagogues,
such as pilocarpine and cevimeline, are effective in relieving hyposalivation, but may cause
adverse effects.65 Electrical stimulation applied to the affer- ent pathways (through the oral mucosa
or skin) in areas of salivary glands, showed increased saliva production and relief of dry mouth in
patients with SS65 and in patients undergoing cervical-brain radiotherapy.69

Dental Implants in Patients with Sjgrens Syndrome

ABSTRACT

Background: Limited evidence is available for applying dental implants in Sjgrens

syndrome (SS) patients.
Purpose: This study aims to retrospectively assess clinical outcome of implant therapy in
a cohort of well-classified patients with SS.
Materials and Methods: All SS patients attending the University Medical Center
Groningen for follow-up (n = 406) were asked whether they had implants. In SS patients
with implants peri-implant health and implant survival was recorded and compared with
data from matched healthy controls. Patients symptoms, health-related quality of life,
oral functioning, and satisfaction were assessed using validated questionnaires.
Results: Of the responding SS patients (n = 335), 21% was provided with implants. Of
these 69 SS patients, 50 SS patients were willing to join our study. In SS patients, peri-
implant health was reasonably good with minor marginal bone loss and a peri-implantitis
prevalence of 14%, comparable with healthy controls. Implant survival was 97% (median
follow-up 46 months) [IQR 26;73], and overall patients satisfaction was high. Oral
functioning correlated negatively with dryness, patients satisfaction, and chewing ability
in SS patients.
Conclusions: Implant therapy is common in our cohort of SS patients. In spite of
shortcomings of our retrospective analysis, implants in SS patients seem to perform
comparable with implants in healthy patients.

DISCUSSION

[] Overall implant survival in this cohort was 97% with a median follow-up of 46
months, which is comparable with the implant survival in our matched healthy controls
and the previously reported implant survival in healthy patients.811 All four lost implants
were lost within 3 months after insertion, comparable with the timing of implant loss in
healthy patients.811 In two other studies on implant survival in SS patients reported in
literature, implant survival in SS patients was 84% and 100%, respectively.16,19

[] Based on the present analysis, we conclude that dental implants seem to be a

favorable treatment option in the prosthetic treatment of patients with SS. Although in our
study there seem to be more signs of peri-implant mucositis in SS subjects than in healthy
controls, this difference does not seem clinically relevant, as peri-implant scores both
were at the healthy end of the peri-implant health spectrum. Furthermore, implant
survival is high, prevalence of peri-implantitis is comparable with healthy patients with a
median follow-up of 3.8 years, no excessive bone loss was seen and patients were
satisfied with their implant-retained prosthetic devices. However, as this paper reports on
the intermediate results of dental implants in Sjgrens patients, there is some caution
with regard to the potentially increased risk on peri-implantitis in the long term. We
cannot exclude that the reported more frequent presence of peri-implant mucositis in
Sjgrens patients will be associated with an increased prevalence of peri-implantitis later
on. When taking the favorable results of this study, including the potential hazard of peri-
implantitis on the long round into account, we feel that dentists, implantologists,
rheumatologist, and other healthcare workers should encourage SS patients with dental
problems to discuss the possibilities to treat dental problems with implant-retained
prosthetics.
Oral microbiota associated with hyposalivation of
different origins
ABSTRACT
We analysed and compared the oral microbial flora in four groups with hyposalivation caused by
radiation therapy (RT), primary Sjgrens syndrome (pSS), medication or unknown factors
(Unknown), or neuroleptic treatment (Neuro). A control group with normal salivary secretion was
also included. The subjects included were 548years old and had 254 teeth. We analysed their
microflora in rinsing samples using a cultivation technique. A marked increase
in Lactobacillus spp. and Candida albicans was characteristic of the RT group. In the pSS group,
85% of subjects had high numbers of mutans streptococci despite good oral hygiene, frequent
dental visits and fluoride use. The Unknown group had an oral flora similar to that of the controls.
In the Neuro group, with a stimulated secretion rate similar to that of the Unknown group, the
numbers of aciduric and acidogenic microorganisms were close to those in the pSS group. The
results indicate that changes in the oral microflora associated with hyposalivation are related to the
reason for the hyposalivation rather than to the magnitude of the decrease in the salivary secretion
rate.