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Sjögren’s Syndrome

Diana Howsare

Kirkwood Community College

Dental Hygiene IV

Lisa Hebl

December 3, 2020
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Sjögren’s syndrome (SS) is a chronic, systemic autoimmune disease. SS has two forms

that are referred to as primary and secondary. Primary SS is associated with dysfunction of the

exocrine glands such as the salivary and lacrimal gland which results in the characteristic dry

eyes and dry mouth. While still maintaining the effects of primary SS, secondary SS is the result

of the patient having an additional autoimmune process such as rheumatoid arthritis. This disease

was discovered by Henrik Sjogren in 1933 (Vivino, 2017). Sjogren was the first to attribute the

common symptoms of dry eyes, dry mouth, and arthritis to all be connected and that the

underlying cause was a systemic disease. Not much is known about the cause of SS or where it

comes from. There are some connections between certain genes and theories of a viral etiology,

but nothing substantial has been proven. Updated classification criteria have allowed for more

cases to be reported, thus information is always being reassessed. It was originally thought that

the average patient was a caucasian women, but since then the known cases have diluted out any

one ethnicity in particular. However, since its discovery there has been a higher incidence in

women; the current ratio being a staggering women to men 9:1 (Dumusc et al., 2018). The

average age that one is diagnosed with SS is 50 years old, but there are also reported cases in

children. It often takes years to be diagnosed with SS after symptoms first appear. This could

contribute to the elevated age that SS is diagnosed.

Sjögren’s syndrome (SS) can have devastating effects on the body both directly and as a

result of consequences due to the effects; the primary effect is drying, generally of the eyes and

mouth. These effects are caused by dysfunction and destruction of the exocrine glands. Other

effects of SS include joint pain and arthritis, swollen salivary glands, skin rashes, vaginal

dryness, persistent cough, and prolonged fatigue. While these are often more direct effects on the
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body, because SS is an autoimmune disease, your immune system can also turn against your

liver, thyroid, kidneys, joints, lungs, skin and nerves (Mayo Foundation for Medical Education

and Research [MFMER], 2020). The effects of SS not only affect the body physically, but

mentally. The symptoms can often result in poor quality of life, increased financial burden, and

high rates of moderate to severe depression (Vivino, 2017). There are a variety of methods to

attempt to combat symptoms and progression of SS including artificial tears, saliva substitutes,

habit alterations, surgery, and medications. Medications are a common treatment option for

patients with SS. These medications can work to relieve dry eyes such as cyclosporin and

lifitegrast; relieve dry mouth such as pilocarpine and cevimeline; reduce inflammation such as

NSAID’s; or suppress the immune system such as methotrexate (MFMER, 2020). The

medications come with a variety of side effects of their own that can also affect the body and oral

cavity like causing gastrointestinal upset and suppressing the immune system which could lead

to infection. Management of the symptoms is important in maintaining quality of life and the

body because SS is chronic and can progress as more damage occurs.

One of the most common areas affected by Sjögren’s syndrome (SS) is the oral cavity.

The effects of SS on the oral can de detrimental to overall oral health. SS can cause dysfunction

of the salivary glads resulting in either decreased production or none at all. While dry mouth is

the symptom most commonly noted, the decreased saliva that causes this discomfort is the

source of many other effects. The patient may mention that they feel like they have less saliva

than they used to or that it is not enough. They may also mention having to drink more when

eating or that their mouth burns. Xerostomia can result in difficult chewing, swallowing, and

speaking. Visually the effects of xerostomia may appear as shiny, red tongue and mucosa, loss of
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papilla on the tongue, gum recession, and angular cheilitis (Rischmueller et al., 2016). Saliva

plays a very important role in the health of the oral cavity and protection against disease and

infection. The components of saliva buffer the pH of the mouth, lubricate the tissues, and aid in

protection and repair of oral mucosa (Wu, 2018). With limited or no saliva to maintain these

functions, the oral cavity is susceptible to halitosis, oral thrush, periodontal disease, and decay.

Decay, especially cervical dental caries, is a major concern for a SS patient. “Sjogren's syndrome

patients also have higher levels of dental caries, more tooth extractions, and higher dental

expenses over a lifetime compared to healthy controls” (Vivino, 2017). “In one study, for

example, patients with SS spent nearly three times more on out-of-pocket dental expenses and

had 1.7 more dental visits than subjects without SS” (Wu, 2018). Joint pain, arthritis, fatigue, and

mental health issues associated with SS can also increase the risk of these oral conditions. A

patient may not have the energy, motivation, or care to carry out home care like brushing and

flossing in an attempt to maintain oral health. Even if a patient has the motivation, symptoms

such as joint pain and arthritis can cause challenges or prevent them from being able to

accomplish tasks like holding a toothbrush and floss. Managing these symptoms is key to

maintaining oral health. While most treatment options involve a saliva substitute or medication

to stimulate saliva protection, many medications can cause xerostomia which is important to

keep in mind. Other medications the patient may be on like methotrexate can also effect the oral

cavity. Some side effects related to the oral cavity can be ulcerative stomatitis, gingivitis,

glossitis, and mucositis (Crossley et al., 2018). It is important to make sure saliva substitutes and

stimulators don’t negatively affect the oral cavity. Sugar-free candy or gum, xylitol products, and
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saliva substitutes with higher pH levels should be used over low pH and sugar containing

products.

While there can be some personal home care challenges associated with Sjögren’s

syndrome (SS) affects, there is generally not a need for a caretaker. SS patients are not

intellectually affected by the syndrome. There can be fatigue, joint pain, arthritis, and

musculoskeletal pain. These, if present in the patient, are generally not limiting enough to require

a caretaker. This will allow oral hygiene and home care instruction to be directly with the patient.

Xerostomia, joint pain, and fatigue can all make home care a challenge and uncomfortable. A

couple components of home care that may need altered are the toothpaste and toothbrush used.

Given that the patient is more susceptible to dental cries and root exposure, a toothpaste with

fluoride will be essential. The fluoride will be able to help remineralize and strengthen tooth

structure that isn’t receiving any protection via the saliva. Toothpaste without sodium lauryl

sulfate (SLS) may also be more comfortable for the patient. The SLS is detergent and can cause

burning or irritation especially on dry tissues. For the patients toothbrush, extra-soft bristles are

ideal. These bristles will be more sensitive on the tissues aiding the patient in being able to brush

along the gemlike with less discomfort. While an electric toothbrush may be more effective in

plaque removal, this could be uncomfortable on the tissues. The small vibrations could also have

a negative effect on any arthritis and joint pain. For this reason, a manual toothbrush may be

preferred. It may also be beneficial to have a larger handle, foam handle, or universal cuff on the

toothbrush to aid in grasp depending on the severity of the arthritis and joint pain. This can also

be helpful when it comes to flossing. Interproximal cleaning is vital for a patient with SS because

of the dental caries risk and limited saliva. String floss may be more difficult to hold. This could
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warrant the use of a floss holder. A foam handle or universal cuff can even be added to the floss

holder if there is remaining difficulty. Gingival recession is a possible effect of SS, in this case

the use of alternative interproximal cleaning devices may be beneficial. Interdental brushes can

be used in-between teeth in areas of recession or where the interdental papilla may be missing.

Emphasizing home care to the patient and making sure to give thorough oral hygiene instruction

are going to be key to helping maintain oral health. With all of the effects SS causes for the oral

cavity, the clinician should make sure the patient understands what is going on in their mouth

and what they can do to help themselves. Because SS is slowly progressive, providers in settings

that patients are seen more regularly, like the dental office, should be able to recognize the

symptoms and help with early diagnosis (Catanzaro & Dinkel, 2014). While they should be

referred to a physician, managing their oral symptoms and preventing decay are components a

dental professional can accomplish. As with home care alterations, some clinician alterations can

be made to increase patient comfort throughout the appointment. Dental appointments require a

patient’s mouth to be open for extended periods of time. To help combat discomfort and

increased drying due to this a few steps can be taken. Applying water or saliva substitutes to the

oral mucosa can help keep them moist during treatment. To avoid cracking lips, apply a water-

based emollient first, then an oil-based material to lock in the moisture (Wu, 2018). To avoid

instruments, like the mirror, from sticking to tissues, they can be wetted before use. Dipping

them in water will not only avoid sticking on the patients tissues, but also provide more moisture

into the patients mouth. Other components of the dental appointment that may need to be altered

for a patient with SS are aerosol procedures. As a result of dry eyes and possibly weekend

immune response, anything flying into the eye could result in injury or infection. Sometimes
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these procedures are not necessary and able to be avoided, but safety glasses should be used

regardless. Pulmonary concerns associated with SS should all be considered for treatment

procedures. A chronic cough could be disruptive to the appointment and the patient may need to

be sat up throughout. The dry tissues may also extend to the airway which can result in recurrent

respiratory infections (Vivino, 2017). This could be a concern if a patient were to aspirate

something during the appointment. The US clinical practice guidelines for Sjögren’s was recently

developed by the Sjogren's Syndrome Foundation with guidance by organizations including the

American Dental Association which strongly recommended the application of topical fluoride to

all SS patients with xerostomia (Vivino, 2017).

Sjögren’s syndrome (SS) has many direct and indirect affects on the body and oral cavity.

While the cause is still unknown, the symptoms can have a huge affect on patients life and

health. Dental professionals are in a great position to be able recognize symptoms, manage oral

symptoms, and aid patients in maintaining oral health. Even with some unknown about SS, there

is a multitude of recommendations and information both for the patient and for clinicians to be

able to better treat patients with SS.

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References

Catanzaro, J., & Dinkel, S. (2014). Sjögren's syndrome: the hidden disease. Medsurg Nursing:

Official Journal of the Academy of Medical-Surgical Nurses, 23(4), 219–23. https://

link.gale.com/apps/doc/A382083691/AONE?u=kcccedar&sid=AONE&xid=a8cea977

Crossley, H. L., Meiller, T. F., & Wynn, R. L. (2018). Drug information for dentistry: Including

oral medicine for medically compromised patients & specific conditions (21th ed.).

Wolters Kluwer.

Dumusc, A., Rao, V., & Bowman, S. J. (2018). Sjögren's syndrome. Medicine (United Kingdom),

46(2), 126–130. https://doi.org/10.1016/j.mpmed.2017.11.002

Mayo Foundation for Medical Education and Research. (2020). Sjogren’s syndrome. Mayo

Clinic. https://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/symptoms-

causes/syc-20353216

Rischmueller, M., Tieu, J., & Lester, S. (2016). Primary sjögren's syndrome. Best Practice &

Research. Clinical Rheumatology, 30(1), 189–220. https://doi.org/10.1016/

j.berh.2016.04.003

Vivino, F. B. (2017). Sjogren's syndrome: clinical aspects. Clinical Immunology, 182, 48–54.

https://doi.org/10.1016/j.clim.2017.04.005

Wu, A. J. (2018). Maintaining the oral health of patients with sjögren’s syndrome. Dimensions of

Dental Hygiene, 16(4), 44-47. https://dimensionsofdentalhygiene.com/article/

maintaining-oral-health-patients-sjogrens/