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

, State University of New York at Buffalo

In This Article


Table I - Conditions Associated With Xerostomia

Disease/Condition Examples
Drugs/medications Anorectics, anticholinergics, antidepressants, antipsychotics, sedatives and hypnotics, antihistamines, opiates, antiparkinsonian drugs, antihypertensive agents
Irradiation Systemic diseases Therapeutic radiation to the head and neck, whole-body, I131
Rheumatoid conditions: collagen-vascular, connective tissue diseases (eg, SS );
Dysfunction of the immune system (eg, AIDS);
Hormonal disorders (eg, diabetes mellitus);
Neurologic disorders (eg, Parkinson's disease);
Psychogenic disorders Depression
Aging Contributory factor; probably does not induce xerostomia per se
Decreased mastication Animal and limited human data have shown that intake limited to liquid or soft foods leads to salivary gland atrophy and subsequent decrease in salivary flow. More studies are needed to determine its contribution to xerostomia.

Adapted with permission from Int Dent J (1992;42:291-304), Copyright © 1992, FDI Dental Press Ltd.[4]

Table II - Normal Salivary Flow Rates: Means and Ranges

  Mean Range
Type of Secretion (mL/min) (mL/min)
Resting whole saliva 0.3-0.4 0.08-1.83
Stimulated (masticatory) whole saliva 1-2 0.2-5.7

Adapted with permission from J Intern Med (1996; 239:467-474), Copyright © 1996, Blackwell Science Ltd.

Table III -Microscopic Findings in Extraglandular Manifestations of Primary SS

Organs Microscopic Findings
Gastrointestinal Esophagitis, atrophic gastritis, pancreatitis, cholangitis, chronic hepatitis, peritonitis
Respiratory Rhinitis, laryngo-tracheitis, bronchitis, bronchiolitis, alveolitis, interstitial pneumonitis, pleuritis
Cardiovascular Raynaud's phenomenon, small vessel vasculitis, medium-sized vessel vasculitis, pericarditis
Endocrine Thyroiditis
Skin Vasculitis
Genitourinary Vaginitis, interstitial nephritis, glomerulonephritis
Nervous Encephalitis, polyneuritis, mononeuritis multiplex
Hematopoietic Anemia, lymphocytopenia, neutrocytopenia, thrombocytopenia, MALToma,† and lymphoma
Muscles and joints Synovitis with or without exudation, myositis

† MALT = Mucosa-associated lymphoid tissue.

Adapted with permission from J Intern Med (1996;239:467-474), Copyright © 1996, Blackwell Science Ltd.[45]

Table IV - Copenhagen, San Diego, and European Community Criteria for the Diagnosis of Sjögren's Syndrome

San Diego
Primary SS
European Community
Primary SS
Dry eyes (xerophthalmia) * Abnormal Schirmer's test of tear production
* Abnormal tear BUT*
* Positive rose bengal staining†
* Abnormal Schirmer's test
* Positive rose bengal staining†
* Ocular symptoms (dry eye, "sand in the eye"), Abnormal Schirmer's test, or rose bengal staining >=4 spots
Dry mouth (xerostomia) * Decreased unstimulated whole saliva flow rate, or abnormal salivary scintigraphy, or
* abnormal labial biopsy
* Decreased parotid flow rate
* Abnormal lip biopsy
* Oral symptoms (feeling of dry mouth, difficulty swallowing dry food, feeling of dryness while eating or breathing)
* Abnormal lip biopsy
* Decreased unstimulated whole saliva flow rate, or
* abnormal sialography, or
* abnormal scintigraphy
Autoantibodies No * Elevated rheumatoid factor (>=1:320) or elevated ANA (>=1:320) or+ Anti SS-A or + Anti SS-B * Elevated rheumatoid factor or elevated ANA or + Anti SS-A and/or SS-B
tissue disease
    Secondary SS
* Rheumatoid arthritis
* Systemic lupus erythematosus
* Polymyositis
* Biliary cirrhosis
* The quality of tear production and, more specifically, the stabilty of the lacrimal secretions is tested by a test called break-up time (BUT).
† The rose bengal staining is used to detect abnormalities on the eye's surface.
ANA = antinuclear antibody.

Table V - Ancillary Tests for the Diagnosis of SS

Test Description
Schirmer I
(Fox et al, 1986)[46]
Tear production is assessed with a paper strip, which is placed on the unanesthetized ocular conjunctiva. A distance of less than 9mm of wetting in 5 minutes is considered abnormal.
Rose bengal or fluorescein dye
(Fox et al, 1986[46];
Prausse et al, 1989[47])
Dye is used to assess the effects of ocular dryness. Staining of the bulbar conjunctiva is considered abnormal and uncovers areas of epithelial erosions in the cornea and conjunctiva.
Sialometry: the measurement of salivary flow rate expressed in mL/min
(Sreebny, 1988[3])
Salivary output is assessed by collecting resting whole saliva (3 cycles of 2 minutes; the patient is instructed not to swallow her/his saliva and is asked to expectorate into a preweighed tube at the end of each cycle); stimulated whole saliva (patient is instructed to chew on wax or paraffin for 3 cycles of 2 minutes each and then asked to expectorate into a preweighed tube); stimulated (2% citrate) parotid saliva (a Lashley cup [Figs. 9 and 10] is used and every 30 seconds 2% citrate is applied to the tongue. Parotid saliva is collected for 6 minutes into a preweighed tube). Salivary flow rates are determined gravimetrically.
Lip biopsy
(Fox, 1985[48];
Daniels, 1984[49])
The labial mucosa is anesthetized and an incision is made (Fig. 11). Six to 8 minor salivary glands are exposed and removed for microscopic examination (Fig. 12).
Salivary gland scintigraphy
(Del Balso, 1995[50]
99m per technetate followed by sequential with a gamma camera. Activity is recorded over a given period of time, and this information is used to generate quantitative time-activity curves, as well as images of the salivary glands.

Adapted with permission from International Dental Journal (1992; 42:4(suppl 2):S291-S304), Copyright © 1992, World Dental Press, Ltd.

Table VI - Selected Commercially Available Artificial Salivas

Product Manufacturer Preservative
Xerolube Scherer Paraben
Saliva Substitute Roxane Paraben
Mouth Cote Parnell  
Salivart Westport None
Opti-moist Colgate  


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