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

Clinical Features

The majority of SS patients--80% to 90%--are women. SS can occur at any age (documented cases of children with SS have been published),[22,23,24] but usually presents during the fifth decade of life.[25] The real incidence of this disease is unknown, but estimates of the number of US cases of SS range from 1 to 4 million.[26]

Ocular symptoms. A reduced aqueous component of the precorneal tear film causes a sensation of dryness.[27] About 80% of patients with SS complain of ocular grittiness, burning, or a foreign-body sensation. Other complaints include ocular itch, soreness, diminished visual acuity, and photophobia. Contact lenses, air conditioning, and dry climates are poorly tolerated by these patients.[18,28]

Oral symptoms. The main oral complaint of SS patients is xerostomia. It has been suggested that the symptom of dry mouth appears when the salivary flow rate decreases to about 50% of the original "normal" level.[29] The range of normal salivary flow rates for healthy individuals is remarkably wide (Table II) and differs according to the measurement technique used.

However, because numerous population studies have shown the mean resting flow rate for whole saliva to be 0.3 to 0.4mL/min, it seems reasonable (following Dawes' findings) to view with concern unstimulated whole saliva flow rates lower than 0.15mL/min. For stimulated whole secretions, the clinician should be suspicious of a rate lower than 0.5mL/min.[4]

People with xerostomia tend to consume great amounts of fluids.[2] They may also complain of mild-to-severe burning and tingling sensations in the mouth, particularly in the tongue.[30,31,32] Because saliva is critical to the adherence and the retention of dentures, such patients may complain about their inability to wear dentures.[31,32] Furthermore, patients with dry mouth complain of their difficulty chewing and swallowing foods, particularly dry foods.[30] Sense of taste and its acuity, particularly for sweet and bitter tastes, may be deteriorated in Sjögren's patients.[3] Finally, Sjögren's patients with severe feelings of oral dryness may complain of pain (sometimes accompanied by oral ulcers), which is not a feature of mild episodes of xerostomia.[3]

Oral signs. The intraoral signs can be characterized by an increased incidence of carious lesions in a short period of time.[31,32] Caries of the anterior teeth and root surfaces are seen (Fig. 2).[33] In patients who receive regular dental care, multiple, recently placed restorations indicate a history of high caries activity. In xerostomic patients, the dorsum of the tongue may appear fissured or lobulated, with atrophy of the filliform papillae. The tongue also may appear smooth and red and the lips may be involved (angular cheilitis), suggesting fungal infection (Fig. 3). The oral mucosa may appear red and atrophic, and it may easily ulcerate. Xerostomia is also associated with an increase in the number of yeast organisms in the mouth and with the onset of oral candidiasis (Fig. 4).[34] Salivary gland enlargement, a rare occurrence in SS, can last from a few weeks to several months (mild cases); the gland may remain chronically enlarged, fluctuating in size in severe cases (Fig. 5). Bilateral enlargement of the parotid or submandibular glands also may occur in severe cases. Despite the salivary flow impairment, retrograde acute bacterial sialoadenitis is rare and is best treated with antibiotics.

Figure 2. Rampant dental caries. Caries of smooth dental surfaces affecting the cervical regions of mandibular anterior incisors. Gingival recession and early root caries are clearly apparent in this patient with primary SS.
Figure 3. Erythematous candidiasis. Focal areas of erythema and lingual depapillation are characteristics of chronic candidiasis in patients with xerostomia. Fissured tongue is also observed.
Figure 4. Acute pseudomembranous candidiasis. This SS patient has recurrent episodes of acute pseudomembranous candidiasis due to her extreme salivary gland hypofunction.
Figure 5. Salivary gland enlargement. Facial asymmetry produced by enlargement of the right parotid gland in a patient with SS. The swelling is asymptomatic and fluctuates in size throughout the course of several months.

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