Implant and Conventional Fixed Prosthodontic Rehabilitation of a Patient with Sjögren’s Syndrome
Understanding the complications of Sjögren's Syndrome on dental treatment:
Sjögren’s syndrome is the second most common autoimmune disease (after rheumatoid arthritis), predominantly affecting women (90%) with a mean age at diagnosis of 50 years. It can be classified as primary or secondary. Primary Sjögren’s syndrome affects the exocrine glands, particularly the lacrimal and the salivary glands, with focal inflammatory infiltrate, diminishing the gland function and resulting in ocular and oral dryness. Secondary Sjogren’s syndrome has additional rheumatic or connective tissue disease components such as rheumatoid arthritis, systemic lupus erythematosus, or progressive systemic sclerosis (scleroderma). At present, there remains no cure, and treatment is symptomatic with a multidisciplinary approach (1). Xerostomia causes a reduced buffering effect making the patient susceptible to caries, reduces lubrication causing difficulty with swallowing and speech, and can increase the potential for infection. Relief of some of the symptomatic complaints of xerostomia can be achieved with salivary substitutes and systemic parasympathomimetic agents such as pilocarpine (2). Intraorally, the tongue can have a beefy red appearance with loss of papillae or deep fissures. The mucosa can appear erythematous; lips may be dried with angular cheilitis and possible Candida infection (3). The risk of caries demands high patient compliance with oral hygiene, frequent maintenance visits, and fluoride application. Assessment of the patient’s caries susceptibility will guide treatment alternatives. Reduced saliva and altered composition have not been found to increase the risk of periodontal disease in Sjogren’s syndrome when compared to patients with other autoimmune diseases or patients with subjective xerostomia (4). However, when matched to healthy subjects, Sjogren’s patients were found to have a higher risk of adult periodontitis (5). Therefore, xerostomia itself may lead to a greater risk to periodontal health. Treatment of edentulous Sjogren’s patient can be complicated, with reduced denture retention affecting mastication, speech, and self-image (6). Lack of denture retention from xerostomia can lead to further irritation of compromised mucosa and candidiasis infection (7). Implant retained fixed prostheses successfully reduce these problems in the edentulous Sjogren’s patient (6, 7, 8).
This clinical report describes the planning considerations and treatment of a partially dentate Sjogren’s syndrome patient restored with conventional fixed and implant-retained prostheses.
Clinical Report: A 70-year older adult was seen at the Implant Clinic at the University of Iowa with a history of secondary Sjogren’s syndrome, diagnosed in 1984, associated with rheumatoid arthritis, progressive systemic sclerosis, and Raynauds disease. She did not exhibit sclerodactyly or esophageal dysfunction typical of CREST syndrome. Past medical history included a mastectomy in 1992, no allergies, or regular medication. An oral lubricant (Oral Balance, Laclede, Inc., Ranchero Dominguez, Ca.) was used in addition to regular sips of water to keep her mouth moist. She attended her own dentist every six months and reported restorations at each visit.
Her entrance complaint was “to have a few more teeth to chew with,” and her dentist was concerned that she would “be unable to wear dentures” due to xerostomia. She was concerned with the degree to which her teeth had been restored and their long-term prognosis.
Extraoral examination showed evidence of telangiectasia around the lips, taught peri-oral musculature (the result of systemic sclerosis), with reduced mouth opening (35mm inter-incisal distance. No lymphadenopathy, swelling, or tenderness was noted. Intraorally, there was marked hyposalivation; no saliva could be expressed from either parotid or submandibular ducts. Her tongue was smooth, glazed red, with minimal topography. She was missing maxillary right second premolar and molars, maxillary left premolars and molars, mandibular left first and third molar, and right second and third molar. Her remaining dentition had been heavily restored with composite, amalgam, and crowns with poor margins and secondary caries present. Maxillary right lateral incisor and canine, mandibular right central incisor, and first premolar were non-responsive to electric pulp test or dry ice. Periodontally, there was no mobility noted, and probing depths were less than 3mm (except mandibular left second molar, 6mm mesial probing depth, and grade I buccal furcation, grade I furcation was also found on a mandibular right first molar). Oral hygiene was fair; she brushed after every meal with pediatric toothpaste (Crest, Procter & Gamble, Cincinnati, OH) but did not use mouth rinses as this caused mucosal irritation. The vertical dimension of occlusion appeared adequate from an interocclusal distance at rest to maximum intercuspation and phonetic assessment of the closest speaking space. Maxillary right canine was in buccal cross-bite. Despite the extent of xerostomia, caries resistance, periodontal health, and patient motivation appeared favorable for tooth restoration.
Radiographically there appeared good bone height in maxillary premolar positions for implant placement. An apical radiolucency was noted on mandibular right central incisor. Crown: root ratio of approximately 1:1 was found for maxillary right first premolar, the mandibular left second molar, and right first molar (figure 1.).
Several treatment options were discussed. The maxillary arch alternatives included continued maintenance and caries control; extra coronal restoration of anterior teeth with the extraction of right first premolar and posterior rehabilitation with removable partial denture or implant restorations; extraction of remaining maxillary teeth and complete denture; phased extractions and implant placement for an implant-retained maxillary prosthesis. Mandibular arch options included maintenance and caries control, restoration of salvageable teeth, phased extractions, and implant-retained prosthesis.
The patient preferred to maintain as many teeth as feasible and avoid a removable prosthesis.
She was concerned about the possibility of having her remaining maxillary teeth removed, implants not integrating, protracted treatment time, and compromising a final restoration. Therefore, the initial treatment plan involved assessing the viability of remaining teeth before a comprehensive rehabilitation, including maxillary implants to replace premolars.
Informed consent was obtained, diagnostic study casts were mounted on a semi-adjustable articulator (Teledyne Hanau, Buffalo, N.Y.), diagnostic wax-up completed to determine final tooth contours (correction of buccal cross-bite of maxillary right canine), and proposed implant positions (figure 2.). The patient was prescribed 1.1% neutral sodium fluoride gel (Prevident 5000 Plus, Colgate), and caries and original restorations were removed. Maxillary right first premolar, right lateral incisor, and mandibular incisors were planned for extraction as minimal sound tooth structure remained after caries control. Maxillary right canine, mandibular left second premolar, right canine, first and second premolar required root canal treatment. Matrices (Sta-Vac, Buffalo Mfg. Co., Syosset, NY) were fabricated from the diagnostic wax-up to guide tooth/foundation reduction and fabrication of provisionals. Foundations were placed, prepared for full veneer restorations, and provisionalised with acrylic resin (Biolon Crown and Bridge Resin, Dentsply/York Division, Dentsply International Inc., York, PA). The vertical dimension of occlusion was maintained throughout the disease control phase with acrylic resin (GC Resin, GC America Inc., Chicago, IL) indices.
Immediately following root canal treatment, custom cast dowel and cores (Type III gold) were fabricated and cemented with zinc phosphate cement (Fleck’s, Mizzy Inc., Cherry Hill, NJ) to mandibular left second premolar, right canine, first and second premolar (figure 3.). Crown lengthening (for ferrule effect and to finish preparation margins on sound tooth structure) and extraction of the non-restorable teeth was carried out by arch. Three months after periodontal surgery, teeth were remarginated, final impressions were made with polyvinyl siloxane (Extrude, Kerr Manufacturing Co., Glendora CA). Interocclusal records were made to allow cross mounting of master casts to casts of the provisional restorations at the determined vertical dimension of occlusion.
Four months after extraction of maxillary right first premolar, four endosseous implants were placed (directed from a surgical guide derived from diagnostic wax-up) in the right and left premolar positions (4.1 x 12mm Esthetic Plus ITI implants, Institut Straumann AG, Waldenburg, Switzerland. Figure 4.). Limited occlusal opening complicated surgical placement and required removal of mandibular provisionals to maximize space. Accuracy of castings of fixed partial dentures and crowns were verified intraorally, bisque bake and porcelain characterization was evaluated, glazed, and cemented with resin-modified glass ionomer cement (Vitremer, 3M Dental Products, St. Paul, MN). Canine-protected occlusion was developed to minimize lateral forces on the posterior occlusion. Protrusive guidance was evenly distributed across the incisors.
Implants were allowed to integrate for 3 months. Octabuments (Institut Straumann AG, Waldenburg, Switzerland) were torqued to 35N/cm, final impressions were made (Impregum, ESPE America, Norristown, PA) at the abutment level, and implants were provisionalised with acrylic resin. Splinted screw-retained crowns were cast, checked for passive fit, porcelain was applied, and occlusal screws tightened to place at 15N/cm (figure 5, 6, 7). Premolar occlusion was planned to produce an esthetic and functional rehabilitation.9Equal loading of anterior teeth, and posterior implants in centric occlusion were verified with Shimstock occlusion foil (Almore International, Inc., Portland, OR). Fluoride trays were fabricated, and the patient prescribed 1.1% neutral sodium fluoride (Karigel-N, Lorvic).
At one year post-rehabilitation, she remains caries-free with good oral hygiene and compliance. Other than a successful hip replacement, her general health remains stable.
Discussion: Sjogren’s syndrome is associated with a greater caries risk that makes restoration with implants advantageous (3). It has been shown that fixed implant restoration of edentulous Sjogren’s patients is successful and well-accepted (6, 7, 8). An alternative treatment for this patient would have been removing her remaining maxillary teeth in favor of an implant-supported maxillary prosthesis. However, failure rates of implants in the edentulous maxilla have been reported to be greater than in the mandible (10), and Isidor et al. reported higher failure of implant osseointegration (approximately 16%) in eight edentulous Sjogren’s patients (6). Isidor et al. cautioned against attributing this to Sjogren’s syndrome since the study population was small (6). In this patient, restoration of the anterior maxillary teeth, which are more easily maintained, with full veneer crowns was appropriate.
Assessment of patient motivation and oral hygiene is crucial before the comprehensive restoration of natural dentition (3). Treatment should be carried out as expeditiously as possible. For this patient, final tooth restoration was completed before implant restoration to avoid the risk of caries in the susceptible period of provisionalization. Fluoride application was maintained throughout treatment, and provisionals were removed and recemented every three weeks to ensure minimal washout of provisional cement (Durelon).
Careful treatment planning is required to minimize the risk of tooth/restoration failure and to optimize implant positioning. Individual units were placed where feasible (3). Maxillary and mandibular canine crowns and mandibular second premolar had rests, guide planes, and buccal undercut for removable partial denture clasps, should a necessary future prosthesis be indicated. Patient acceptance of final restorations was verified with provisional restorations, including hygienic pontic design for a posterior non-esthetic fixed partial denture (figure 8.) and supragingival margins detect good marginal fit and future maintenance (12). Screw retained implant restorations were planned for retrievability if failure of natural teeth and additional implants warranted a change in prosthesis design.
Limited mouth opening from progressive systemic sclerosis has been reported with Sjogren’s syndrome (13). This can complicate restoration of natural dentition, placement of implants, future maintenance, and oral hygiene measures. Regular reviews are required to monitor oral hygiene, fluoride compliance, assessment of oral health (40 times higher risk of lymphoid malignancy in Sjogren’s patients 1), and coordination with other specialties. Neutral sodium fluoride is recommended rather than acidulated fluoride gel to avoid tissue irritation and loss of porcelain glaze (3).
Written by Dr. Michael Heffernan
1. Periodontal manifestations of collagen vascular disorders; Gonzales T.S., Coleman G.C.; Periodontology 2000; 1999; 21; 94-105
2. Aging and saliva: A review of the literature; Vissink A., Spijkervet F.K.L., Amerongen A.V.N.
3. Sjogren’s syndrome: oral and dental considerations; Atkinson J.C., Fox P.C.; JADA 124; 74-85, 1993
4. Dental and periodontal status of Sjogren’s syndrome; Boutsi E.A., Paikos S., Dafni U.G., Moutsopoulos H.M., Skopouli F.N.; J Clin Periodontol 2000; 27: 231-235
5. Prevalence of periodontal disease in patients with Sjogren’s syndrome; Najera M.P., Al-Hashimi I., Plemons J.M., Rivera-Hidalgo F., Rees T.D., Haghighat N., Wright J.M.; Oral Surg. Oral Med. Oral Pathol. Oral Radio. Endod. 83 453-57, 1997
6. Outcome of treatment with implant-retained dental prostheses in patients with Sjogren syndrome; Isidor F., Brondum K., Hansen H.J., Jensen J., Sindet-Pedersen S.
7. Implant-supported fixed prosthesis treatment of a patient with Sjogren’s syndrome: A clinical report; Binon P.P., Fowler C.N.
8. Implant-supported prostheses in patients with Sjogren’s syndrome: A clinical report on three patients; Payne A.G., Lownie J.F., Van der Linden W.J.
9. A 6-year follow-up study of oral function in shortened dental arches. Part II: Craniomandibular dysfunction and oral comfort; Journal of Oral Rehabilitation 1994; 21: 353-366
10. A long-term follow-up of tissue-integrated implants in the treatment of the totally edentulous jaw; Adell R., Eriksson B., Lekholm U., Branemark P.I., Jemt T.; International Journal of Oral and Maxillofacial Implants 1990; 5; 347-359
11. Marginal Fit of Gold Inlay Castings; Christensen G.J. J Prosthet Dent 1966;16:297-305