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

Causes of Xerostomia

Xerostomia associated with SS has to be differentiated from dry mouth produced by the intake of xerogenic drugs and the sequelae of radiotherapy and, in some cases, chemotherapy.[3,4,5,6]Table I illustrates conditions or disorders that may be associated with xerostomia. It is also important to consider other medical conditions that may occur together with xerostomia.

Xerostomia caused by drugs/medications. Xerostomia is most commonly caused by the use of xerogenic medications.[7,8] More than 400 drugs, some in common use, can cause oral dryness and induce salivary gland hypofunction.[9] Xerogenic medications include anticholinergic drugs, anorectics, antihistamines, antidepressants, antipsychotics, antihypertensives, diuretics, and antiparkinsonian drugs.[10,11] At the dosages generally used, these drugs do not damage the structure of salivary glands, and when the drugs are discontinued the oral dryness disappears. A thorough medication history can sometimes differentiate pharmacologic xerostomia from xerostomia due to SS.

In addition, the decline in parotid gland secretions with SS is another distinguishing feature. Even when the resting parotid secretion rates are reduced, the parotid glands respond vigorously and within normal limits to gustatory stimulation (with 2% citrate) when the dry mouth is caused by xerogenic medications.

Also, the immunologic profile of patients with pharmacologic xerostomia fails to disclose the immune dysregulation that is characteristic of SS. Furthermore, microscopic examination of labial biopsy specimens discloses sound salivary gland tissues when medication is the cause of xerostomia.

Xerostomia caused by therapeutic irradiation. Xerostomia, mucositis, and impaired sense of taste are common sequelae in oral-cancer patients receiving external beam radiotherapy,[12] in patients treated with whole-body radiation, and in thyroid cancer patients treated with I131. The effects of radiation are dose-, time-, and gland-dependent, with the most pronounced xerostomia occurring when the salivary glands are directly irradiated. In most cases, the reduction in salivary gland function and the accompanying xerostomia are irreversible in radiotherapy.[6]

Differential diagnosis. Parotidgland tumors should be considered in the differential diagnosis when there is unilateral gland enlargement in the absence of other features of SS. SS is characterized by absence of gland pain, fluctuation in gland size, and chronic gland swelling without extension into the adjacent tissues. Enlargement of the lacrimal and salivary glands may occur in individuals with sarcoidosis, lymphoma, and lymphocytic leukemia. Although the sicca syndrome is usually not present in salivary and lacrimal gland malignancies, it may occur in sarcoidosis. Sarcoidosis is confirmed by the presence of noncaseating granulomas in the involved gland.[13] A variety of other disease processes may cause a sicca-like syndrome, including hyperproteinemias IV and V, hemochromatosis, and amyloidosis.[14] Central nervous system involvement in primary SS may mimic many neurologic disorders, particularly multiple sclerosis.[15]

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