What's New in Ocular and Oral Aspects of Sjögren's Syndrome and Do New Treatments Work?

Nurhan Sutcliffe; Alberto Recchioni; Shireen Hilmi; Saaeha Rauz; Anwar R. Tappuni


Rheumatology. 2021;60(3):1034-1041. 

In This Article

Management of Oral SS

Clinical evidence for the efficacy of interventions for management of the oral symptoms of SS are disappointingly scarce in the literature. The quality of evidence is highly variable and further complicated by the rarity of the condition, leading to small sample sizes. Topical saliva substitutes are the most commonly used products for the relief of dry mouth in SS, but there is no good-quality evidence demonstrating their efficacy in relieving symptoms of dryness or for increasing salivary gland flow.[55] Currently there is a large study being conducted investigating the effect of electrostimulation as a treatment for dry mouth. The intraoral device (Salipen, Saliwell, Harutzim, Israel) is being tested for its efficacy to produce a sustained salivary flow.

The efficacy of oral pilocarpine for improving the symptoms of dry mouth have been further confirmed in a recent systemic review and meta-analysis of interventions for the relief of oral dryness in SS.[55] While pilocarpine remains the treatment with the most supportive evidence for its efficacy in the literature, its side effects can limit its use. There has been a recent study looking into the use of topical, liquid pilocarpine that produced promising improvements in symptoms with fewer side effects than its systemic counterpart.[56] However, this study was not blinded or controlled and the sample size was modest.

There is little, if any, evidence to support the use of other systemic drugs for treating xerostomia, including cevimeline, DMARDs, infliximab, acupuncture and electrostimulation.[55] Some potential benefit in both salivary flow and xerostomia symptoms has been shown with IFN-α and rituximab, the latter especially in refractory cases with evidence of residual salivary production, but there were frequent adverse events from both of these agents, leading to withdrawal from treatment in some cases.[55,57]

A meta-analysis studying immunomodulatory drugs, including corticosteroids, DMARDs and biologics, found no significant benefit from any single agent.[57] However, the slowly progressive, insidious nature of SS often leads to late diagnosis and the patient often has the condition for many years before treatment is offered. The scarring and permanent loss of glandular function by this time often means that attempts to increase saliva production from the damaged glands are ineffective. An early diagnosis will allow therapies to be given to patients while they still have functioning glands.