Dental Management of Patients with Sjogren's Syndrome

Over the years, I have had to care for quite a number of patients with Sjogren's Syndrome which has some specific impacts on oral health...


What is Sjogren's Syndrome?

Sjogren's is an autoimmune exocrinopathy disease which is often multi-system. It most commonly affected middle-aged women. 

The immune system begins to attack exocrine glands - specifically there is infiltration of lachrymal, salivary and other exocrine glands by lymphocytes and plasma cells. This leads to acinar destruction. It primarily affects the parotid gland but others can also be affected.

There are 2 types:
  1. Primary Sjogrens or Sicca syndrome - dry eyes and dry mouth
  2. Secondary Sjogrens - in association with another autoimmune condition e.g. rheumatoid arthritis,  scleroderma, SLE and other connective tissue diseases

Symptoms

1. Oral features:
  • Xerostomia
  • Burning mouth
  • Lobulated tongue
  • Opportunistic infections
2. Ocular features
  • Keroconjunctivitis sicca - visual impairment
3. Cutaneous feature
  • Xeroderma
  • Vaginal dryness
  • Raynaud's phenomenon
4. Other features
  • Fatigue/joint stiffness
  • Respiratory dryness
  • GI symptoms e.g. dysphagia
  • Haematological symptoms e.g. anaemia, leucopenia 

Diagnosis

Diagnosis of Sjogren's often involves several tests and different institutes might use slightly different diagnostic criteria. But on the whole, a diagnosis is made by:
  1. Schrimer lest - to test lacrimal impairment
  2. Blood tests - to test for auto-antibodies (SS-Ro , SS- La) and rheumatoid factor
  3. Salivary flow tests
  4. Labial gland biopsy
  5. Siolography - this will only demonstrate an abnormal ultrasound appearance of salivary glands and will only inform a diagnosis

Management

There are several ways to manage Sjogrens and patients may respond differently depending on the severity of their symptoms and their individual response. Patients will often be managed by a specialist clinic such as oral medicine department. Examples of management include:

1. Management of dry mouth symptoms:
  • Frequent sips of water
  • Sucking on ice 
  • Sugar free chewing gum or lozenges
  • Salivary substitutes e.g. sprays, gels, pastilles
  • Humidifiers
2. Medication - pilocarpine

3. Management of other conditions 
  • Such as rheumatoid arthritis, SLE, with other systemic medications e.g. steroids and other immunosupressants 
  • Artificial tear and eye lubricants 

Impact on Dental Care

Access

Patients with other systemic conditions such as rheumatoid arthritis might have associated mobility issues and find getting to the dentist difficult, or have visual impairments which will create challenges. They may have lots of different medical and dental appointments to attend which can affect the ability to attend dental appointments. 

Clinical Features

Some patients will find sitting up difficult or be at increased risk of aspiration due to their dysphagia. As dental professionals we may need to support them with dry mouth care and management as per the suggestions above and this might also make it difficult for them to tolerate removable prostheses. Dentists must also be vigilent for signs of parotid enlargement and when to escalate this due to their increased risk of non-hogkins lymphoma. 

Side-effects of the Condition

Because of the reduced salivary flow, patients will have an increased risk of caries. Patients will need to be educated about this risk, and prevention messages delivered in terms of oral hygiene, diet advice and prescription of fluoride. Patients may also have disturbed taste so could prefer cariogenic foods. Patients will be susceptible to infections such as candida and angular chelitis, particularly if they are also on immunosupressive medications for autoimmune conditions. These medications could also have oral side effects or considerations such as steroid cover if they are on long term high doses of steroid medication. 



If you have any questions about this syndrome, let me know in the comments. 

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