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

A Practical Approach Toward Diagnosis of Xerostomia

Efforts should be directed at ruling out primary or secondary SS in patients suffering from xerostomia. We offer a pragmatic approach to elucidate the genesis of dry mouth (Fig. 8):

  • Take a thorough clinical history to categorize patients with xerostomia.

  • Perform an oral examination and salivary gland function tests (Figs. 9,10) (sialometry for whole resting and stimulated whole saliva as well as 2% citrate stimulated parotid saliva).

  • Refer the patient to an ophthalmologist to rule out keratoconjunctivitis sicca.

  • Obtain an SS serologic profile (SS-A and SS-B antibodies, RF and ANA).

  • Biopsy the minor salivary gland of the lip (Figs. 11,12), if indicated.

Figure 8. Flow diagram illustrates the steps followed to determine etiologic factor(s) associated with dry mouth.
Figure 9. Lashley cup. The inner circular chamber is connected to a plastic tube for the collection of parotid saliva. The outer chamber is connected to a rubber bulb which is squeezed to create a negative pressure that maintains the cup in place without movement.
Figure 10. Lashley cup. The inner chamber is placed over the exit of Stensen's duct (on the buccal mucosa in the area of the first maxillary molar).
Figure 11. Lip biopsy. After local anesthesia, an incision is made to uncover the labial minor salivary glands.
Figure 12. Lip biopsy. 8 minor salivary gland acini were removed for microscopic examination.

A detailed clinical history provides the proper background to elucidate the genesis of xerostomia. A history of either radiotherapy, chemotherapy, or intake of xerogenic medications will suggest the etiologic factor of xerostomia. In the absence of these factors, an autoimmune disorder has to be considered. However, the clinician should keep in mind that a combination of factors can contribute to xerostomia. It is not rare to encounter patients who are taking antidepressants and/or antihypertensive medications that aggravate a genuine xerostomia of autoimmune origin.

The oral examination reveals the presence and extent of dental and oral soft-tissue conditions that contribute to deterioration of the patient's quality of life.

Use of sialometry in all patients complaining of xerostomia is justified for several reasons:

  • The procedure provides an objective analysis of salivary gland function.

  • The data obtained serve as a baseline from which to monitor the progress of xerostomia.

  • The genesis of xerostomia may be suggested by the magnitude of the salivary gland response to gustatory stimulation (ie, in pharmacologic xerostomia, the stimulated parotid flow rates are usually within normal limits, whereas in SS the parotid flow is severely impaired).

  • The relative low cost, simplicity, and noninvasive nature of sialometry makes it superior to scintigraphy.

  • Sialometry also provides vital information for the selection of patients who, once the proper diagnosis is established, may benefit from the intake of pilocarpine. (See Treatment for Xerostomia, next section.)

An SS serologic profile yields the data needed to substantiate the existence of an autoimmune process. Finally, a salivary gland lip biopsy clearly separates pharmacologic xerostomia (where sialoadenitis is absent) from xerostomia due to an autoimmune disorder (where sialoadenitis is present).

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