Systemic Sclerosis (Scleroderma) and Orthodontics UK

What is systemic sclerosis and how does it affect the mouth?

Systemic sclerosis is a rare autoimmune connective tissue disease in which the immune system triggers excessive collagen deposition, causing progressive fibrosis of the skin and, in the diffuse form, internal organs including the lungs, oesophagus, heart, and kidneys. It predominantly affects women aged 30 to 50 and is distinct from localised scleroderma, which is confined to the skin. When the perioral tissues are affected, collagen accumulation causes the skin and mucosa around the mouth to thicken and lose elasticity, gradually reducing the size of the mouth opening — a feature known as microstomia. Restriction of the temporomandibular joint capsule and masticatory muscles can accompany this, further limiting jaw movement. For orthodontic purposes, microstomia is the central complicating feature: it directly limits how much physical access a clinician has to place, adjust, and remove appliances, and it tends to worsen gradually rather than staying static.

Microstomia: the defining access challenge for orthodontics

Microstomia develops gradually as perioral skin and connective tissue fibrose and tighten, reducing both the vertical and horizontal dimensions of the mouth opening. In more advanced cases, patients may struggle to open their mouth wide enough for a standard intraoral examination, let alone for bracket bonding, wire adjustment, or impression-taking. This has direct implications for orthodontic appliance choice: bulky brackets, wide archwire spans, and appliances that require significant retraction and access — such as certain expansion devices — become progressively harder to place and maintain as the condition advances. Clear aligners, which are inserted and removed by the patient outside of clinical appointments and require less in-appointment access once fitted, are often better tolerated than fixed appliances in patients with moderate microstomia, though severe restriction can make even aligner insertion and removal difficult without practice and, in some cases, adapted techniques.

Why timing matters more than technique

Because microstomia is progressive, the single most influential decision in orthodontic planning for a patient with systemic sclerosis is when to treat — not simply which appliance to use. Treating earlier in the disease course, while mouth opening is still relatively unrestricted, gives significantly more scope for appliance choice and reduces the risk that treatment becomes physically difficult to deliver partway through. Patients diagnosed with systemic sclerosis who are considering orthodontic treatment, or who already have a malocclusion, should raise this with their rheumatology and dental teams promptly rather than waiting, since mouth opening measured in millimetres today may not be the same in one or two years. For patients already in the more established or diffuse phase of disease, a realistic conversation about what is achievable — potentially prioritising function and hygiene access over full alignment — is more useful than pursuing a treatment plan that assumes stable access throughout.

Radiographic and periodontal findings relevant to orthodontic assessment

A relatively specific radiographic sign in scleroderma is symmetric widening of the periodontal ligament (PDL) space around some or all teeth, thought to result from fibrotic changes to the PDL itself. This finding, while not universal, is often described as pathognomonic when present and may prompt or support a scleroderma diagnosis if identified incidentally on a dental radiograph. For orthodontic planning, PDL widening does not necessarily prevent tooth movement, but bone and periodontal changes should be assessed on a case-by-case basis before applying orthodontic forces. Mandibular bone resorption, particularly at the angle, ramus, and condyle, has also been documented in systemic sclerosis and should be considered when interpreting a panoramic radiograph. Trigeminal neuropathy — altered or reduced sensation in the distribution of the trigeminal nerve — occurs in some patients and can affect how reliably a patient reports discomfort from an ill-fitting appliance or wire, making regular clinical review more important than relying on patient-reported pain alone.

Practical adaptations during orthodontic treatment

Several practical adjustments help make orthodontic care more comfortable and effective for patients with systemic sclerosis. Raynaud's phenomenon — cold-triggered vasospasm affecting the fingers, and sometimes the face — is present in the large majority of systemic sclerosis patients; local anaesthetic and any instruments used intraorally are best warmed where possible, and the treatment room kept warm, to reduce triggering symptoms. Sicca features (dry mouth from reduced salivary flow, sometimes overlapping with secondary Sjögren's syndrome) increase caries and periodontal disease risk during orthodontic treatment, when plaque control is already harder around fixed appliances — saliva substitutes, fluoride use, and more frequent hygiene review may be appropriate. Immunosuppressive or antifibrotic medications used to manage systemic sclerosis can affect wound healing and infection risk; the treating dentist should have an up-to-date medication list and liaise with rheumatology before any surgical adjunct to orthodontic treatment, such as extractions or exposure of an unerupted tooth.

Retention: a particular challenge with progressive microstomia

Retention after active orthodontic treatment carries specific challenges in systemic sclerosis. A fixed retainer bonded to the back of the incisors requires reasonable access for placement and for any repair if a bond fails, which can become progressively harder to achieve as microstomia advances after treatment has finished. Removable retainers avoid this ongoing access problem but rely on the patient being able to insert and remove them — a step that itself can become difficult with a significantly restricted mouth opening and reduced manual dexterity if hand involvement is also present, which is common in systemic sclerosis. Discussing retention strategy before finishing active treatment, rather than defaulting to a fixed retainer as a matter of routine, allows the retention plan to be matched to how the patient's mouth opening is likely to change over the following years.

Coordination with the rheumatology and oral medicine team

Systemic sclerosis is managed in the UK through rheumatology, often alongside oral medicine input where perioral or intraoral involvement is significant. Before starting orthodontic treatment, it is helpful for the orthodontist to have a summary from the patient's rheumatologist covering disease subtype (limited versus diffuse), current medications, and any planned interventions that might affect dental care, such as immunosuppression changes. Oral medicine specialists can advise on managing microstomia itself — including facial and oral stretching exercises used by some services to help maintain mouth opening — which, while not curative, may support easier orthodontic access if undertaken consistently. Patients transferring dental or orthodontic care, or moving between services, should ensure records of mouth-opening measurements and any PDL or bone findings are passed on, since these form an important baseline for judging whether the condition is progressing.

Useful related pages

This guide is for general information only. It is not a diagnosis, treatment plan, or substitute for advice from a registered dentist or orthodontist.