Recognizing and Managing the Oral Clues That Point to Sjögren's Syndrome

, State University of New York at Buffalo

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In This Article

Therapy for Sjögren's Syndrome

In SS, there are local and systemic considerations for therapy.

Local. Since salivary glands are highly responsive to stimulation of taste, masticatory muscles, and sensory nerves of the mucosa and periodontium, local stimulation can be attempted. The chewing of gum, mints, or inert substances like paraffin will stimulate salivation. Most commonly, the substances recommended are sugarless chewing gum, mints, and citric acid containing lozenges and rinses. However, the effects are short-lived. In some patients, substances such as citric acid may irritate the mucosa, particularly in those subjects with extreme oral dryness.

Patients must be cautioned to avoid sugar-containing secretagogues, as they increase the risk of caries. Xerostomia may be worsened by smoking and by consumption of alcohol and caffeine. Dryness and cracking of the lips are treated with regular applications of petroleum-based compounds. Patients are advised to use room humidifiers, especially at night. This will aid in relieving frequent symptoms of dryness of the throat and tongue.

The practitioner must be prepared to manage the complications of salivary hypofunction, which include increased numbers of caries, oral candidiasis, altered oral function, and oral pain.[42] A meticulous oral hygiene regimen, including regular tooth brushing with a fluoride-containing dentifrice, dental flossing, and use of supplemental fluoride, is essential in patients with decreased salivary function. Stannous fluoride and neutral sodium fluoride are the 2 most popular types of gel fluorides prescribed for daily use by patients with SS.[26] Dental appointments every 3 to 4 months are essential to assess patient compliance and control of caries resulting from insufficient salivary protection.

Systemic. Pilocarpine HCl is a parasympathomimetic drug that functions primarily as a muscarinic-cholinergic agonist with mild beta-adrenergic stimulatory properties. Pilocarpine increases salivary output and is effective in relieving oral dryness in patients with salivary gland hypofunction.[43] Fox and associates[44] reported on the effectiveness of 5mg of pilocarpine, 3 times a day, in a 6-month trial in patients with salivary hypofunction caused by radiation and also in patients with SS. Preliminary findings suggest that administration of pilocarpine during radiotherapy may reduce the severity of xerostomia.[12]

Side effects are well tolerated and no significant alterations are found in heart rate, blood pressure, or electrocardiographic parameters. However, pilocarpine will only be effective if there is a sufficient amount of remaining functional salivary tissue (insufficient amount of tissue may be left in the late stages of SS). Possible interactions with other medications or potential adverse cardiovascular and pulmonary effects may preclude its use in xerostomic subjects.[43] Thus, its use should be preceded by an extensive medical examination and close supervision by a physician. Pilocarpine (5-mg tablets) has received FDA approval for the treatment of xerostomia associated with radiotherapy. Multicenter clinical trials of pilocarpine use in SS patients are in progress.

Symptomatic. Many studies suggest that saliva substitutes are useful in the management of xerostomia. However, most patients are eventually dissatisfied with the lack of substantiveness of artificial salivas and prefer water. Table VI provides a list of selected salivary substitutes. Indeed, frequent sips of water or other fluids for the relief of oral dryness are often as effective as saliva substitutes.[33]

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