Medically Compromised Patient: Sjögren's Syndrome

Colleen LeBlanc, Justina Svang

Seattle Central College Dental Hygiene

DHY 251 Human Pathophysiology

Tanya Kendall, RDH

July 31, 2022

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Sjögren’s syndrome, also known as sicca syndrome or SS, is a chronic autoimmune
disease that was first identified in 1933 by a Swedish ophthalmologist named Henrik Sjögren.
This condition can affect females and males of all ages; however, the majority of cases are
women who are over the age of 40. Sjögren’s syndrome severely damages exocrine glands,
causing them to not be fully functional. The glands that are mostly affected are the salivary and
lacrimal glands. Because of the damage to these glands, chronic dryness of the mouth and eye
is a common manifestation. A person with Sjörgen’s syndrome can also experience joint pain,
swelling and stiffness, skin rashes or dry skin, vaginal dryness, persistent dry cough and
prolonged fatigue. Like other autoimmune conditions, researchers do not know what causes
Sjögren’s Syndrome, however, they believe that both genetic and environmental factors are
involved. Sjögren’s syndrome does not currently have a cure; however, there are treatments
that can help alleviate the symptoms that are associated with it.
Sjörgen’s syndrome can be classified as primary Sjörgen’s syndrome or secondary
Sjörgen’s syndrome; Primary Sjörgen’s syndrome is the disorder without any other underlying
autoimmune disorders associated. Secondary syndrome involves other established autoimmune
diseases. Patients with primary Sjörgen’s syndrome experience symptoms of dry eyes and dry
mouth until it reaches the joint tissue. Some common manifestations of primary SS include
arthritis, decreased blood supply to fingers and toes (Raynaud’s phenomenon), and small blood
vessel inflammation (leukocytoclastic vasculitis). Secondary Sjörgen’s syndrome occurs once
the joint tissues are affected in addition to the primary SS symptoms. The diseases associated
with secondary SS are rheumatoid arthritis (RA), systemic lupus erythematosus (SLE),
progressive systemic scleroderma, dermatomyositis and polymyositis. Rheumatoid arthritis is
the most common underlying autoimmune disease linked to secondary Sjörgen’s syndrome.
Sjögren’s syndrome has many signs and symptoms and they can differ from person to
person. The most well known symptoms of this condition is chronic dryness of mouth,
xerostomia, and dryness of the eyes, keratoconjunctivitis sicca. This is caused by a lack of flow
of saliva and tears due to the exocrine glands being damaged. A person with Sjögren’s
syndrome may also experience extraglandular manifestations. “Arthritis, Raynaud's
phenomenon and leukocytoclastic vasculitis… are the most common extraglandular
manifestations of primary Sjögren's syndrome” (Jethlia, 2008). Lymphoma occurs in “about 5%
of the patients, this complication of Sjogren's syndrome is particularly found in patients with high
levels of immunoglobulins, autoantibodies and cryoglobulins. This disease goes beyond “organ
specific autoimmune disorders to a range of systemic manifestations (including)
musculoskeletal, pulmonary, gastric, hematologic, dermatologic, renal, and nervous system
involvement” (Jethlia, 2008). All of these signs, symptoms and manifestations are difficult to
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manage but people with SS can still live a good life with the right self care and knowledgeable
healthcare professionals.
Sjögren's syndrome is not easy to diagnose due to the fact that the many signs and
symptoms differ from person to person. The many signs and symptoms of Sjögren's syndrome
can resemble other medical conditions and they can even resemble side effects of some
medication, such as dry mouth. A health care provider can prescribe numerous tests including
blood tests, eye tests, imaging and biopsies. If a blood test is ordered, the provider might check
for “levels of different types of blood cells, presence of antibodies common in Sjögren's
syndrome, evidence of inflammatory conditions, and indications of problems with the liver and
kidneys” (Mayo Clinic, 2020). For imaging, they could order a Sialogram, a “special X-ray that
can detect dye that's injected into the salivary glands in front of your ears. This procedure
shows how much saliva flows into your mouth”. A salivary scintigraphy can be ordered. “This
nuclear medicine test involves the injection into a vein of a radioactive isotope, which is tracked
over an hour to see how quickly it arrives in all your salivary glands”. The biopsy is used to
detect clusters of inflammatory cells which can indicate someone has this syndrome.
As the salivary glands are not fully functional, it causes some difficulties with daily
activities such as eating and talking. Patients with this syndrome will also have an increased
need for thirst due to dry mouth. Saliva is a key component for moistening the oral cavity for
ease of comfort, lubricating the mouth as people chew then swallow food and acting as an
antibacterial agent. Some extraoral indications for patients with Sjörgen’s Syndrome are
chapped lips that lead to cracks, especially at the corners of one’s mouth and a sore mouth.
Intraoral indications include loss of papillae, pale presence of mucosa with lack of saliva, and
thick viscous consistency of the saliva. “Decreased salivary flow results in increased incidence
of dental caries and difficulty in wearing dentures” (Jethlia, 2008). Saliva helps protect the
tongue and aids in the development of taste and with the lack of saliva due to SS, patients can
experience a strange taste in their mouth. To alleviate dry mouth, patients can chew sugarless
gum to boost saliva flow.
Sjögren’s syndrome greatly affects the patient when it comes to the clinical aspect of
their oral hygiene. Conditions like Sjögren’s syndrome highlight the importance of the education
that dental healthcare providers give to their patients. Patients may know that their mouth is dry
but they might not know about the complications that occur with dry mouth. They could even be
unaware that they have Sjögren’s syndrome. With the knowledge that dental professionals
have, patients can be ready to take on Sjogren’s complications. For patient’s that have not
been officially diagnosed with Sjögren syndrome, “a thorough head and neck examination,
including an intraoral evaluation to identify the presence or absence of salivary pooling on the
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floor of the mouth, can help a dentist identify who might benefit from further diagnostic
evaluations” (ADA, 2021). If a patient has secondary Sjögren’s syndrome (in tandem with lupus
or rheumatoid), they most likely will have hyposalivation, aggressive dental caries, increased
risk in oral diseases, and dental hypersensitivity. One of the pillars of dental hygiene is patient
education. Educating patients about the many negative effects that Sjögren’s syndrome has on
their oral health can help with the damage that this autoimmune disease can cause. With the
right protocols and care, patients will hopefully be able to live more comfortably and healthy.
Dental hygienists should recommend antiseptic mouth rinses, over-the-counter saliva
substitutes, saliva stimulants, and lubricants. Mouthwashes should not contain any alcohol as it
can increase the rate of dryness in the mouth. Over-the-counter recommendations should
include an ingredient called xylitol. Xylitol suppresses the ability for bacteria to cause tooth
decay and reduces plaque counts; essentially improving dental health. It is also advised to
remind patients to hydrate themselves with water and continue to follow their drinking regimen
to lubricate their mouth. Dental hygienists should also recommend additional fluoride treatments
applied to patients’ teeth to decrease the risk of tooth decay.
When it comes to dental treatments, the patient’s mouth can feel extremely dry because
they are opened for a long duration. Clinicians can periodically rinse their mouth with water to
hydrate their oral cavity. Breaks should also be given as necessary, whenever patients need to
drink water. It is important to communicate with patients that it is acceptable to take breaks in
between. This will ensure safety and comfort throughout their treatment. Patients with
secondary Sjögren syndrome with the underlying condition, polymyositis, may have some
discomfort with blood pressure and chair position in the dental clinic. Polymyositis is an
inflammatory disease, affecting muscles of the body. The muscles become weak on both sides
of the body which causes discomfort when performing simple tasks like walking up the stairs,
getting up after being seated, and lifting. (Mayo Clinic, 2022) It is important to communicate
with patients about which arm is appropriate to take their blood pressure on, as the tightening of
the cuff can cause their muscles to feel weaker. Dental professionals may even decide to use
an automatic wrist cuff to take the patient’s blood pressure to avoid additional pressure on their
arms. Clinicians should also consider the height of the chair when patients are getting ready to
leave the operatory. The dental chair should not be high, as this can cause the patient to use
more of their muscles to kick their leg around to hop off the chair. This action can cause some
muscle discomfort and should not be performed by the patient. Clinicians should bring the chair
down to a level that is comfortable, so the patient can exit without struggling.
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In conclusion, Sjögren’s syndrome greatly impacts a person’s quality of life as soon as it
manifests. The majority of Sjögren’s syndrome patients are female over the age of 40. SS
severely damages the salivary and lacrimal glands. The most common signs and symptoms
include xerostomia, dry eyes, joint pain, swelling and stiffness, skin rashes or dry skin,
persistent dry cough and prolonged fatigue. Its etiology is idiopathic and there is no cure. The
key to managing a life with Sjögren’s syndrome are the treatments that can help alleviate the
symptoms that are associated with it. Sjögren’s syndrome occurs on its own (primary SS) or it
can come along with other autoimmune disorders such as rheumatoid arthritis (RA) or systemic
lupus erythematosus (SLE). SS greatly impacts a person’s oral health and the person should
have a trusted dental professional by their side to monitor their oral health. Their dental
hygienist should recommend saliva substitutes, saliva stimulants, and lubricants. Dental
appointments with Sjögren’s syndrome can be very uncomfortable and the patient’s oral
healthcare provider should take measures to make the dental appointment as comfortable as
possible. The oral healthcare provider should let the patient know that it is okay to take breaks
during the appointment so that the patient can drink water. The chair should be at the proper
level for the patient so that they do not strain getting in and out of the chair. As dental
hygienists, it is our responsibility to be aware of our patient’s individual needs so that they can
feel that they are having the high quality care that they deserve.
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References

ADA. (2021, October 19). Sjogren disease. American Dental Association. Retrieved from
https://www.ada.org/resources/research/science-and-research-institute/oral-health-
topics/sjogren-diseases

Feltsan, T., Stanko, P., & Mracna, J. (2012). Sjögren´s syndrome in present. Bratislavske
lekarske listy, 113(8), 514–516. https://doi.org/10.4149/bll_2012_116

Jethlia, A., Keluskar, V., & Shetti, A. (2008). Sjogren's syndrome. Journal of Indian Academy of
Oral Medicine and Radiology, 20(3), 85.
https://link.gale.com/apps/doc/A202034709/AONE?u=seat92874&sid=bookmark-
AONE&xid=002c912e

Mayo Foundation for Medical Education and Research. (2022, July 2). Polymyositis. Mayo
Clinic. Retrieved July 28, 2022, from
https://www.mayoclinic.org/diseases-conditions/polymyositis/symptoms-causes/syc-
20353208#:~:text=Polymyositis%20(pol%2De%2Dmy,lift%20objects%20or%20reach
%20overhead.

Mayo Clinic. (Ed.). (2020, July 22). Sjogren's syndrome. Mayo Clinic. Retrieved July 15, 2022,
https://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/symptoms-causes/
syc-20353216