Continuing Education

Course Number: 125.1

Sjögren’s Syndrome:
Dental Considerations
Authored by Medha Singh, BDS, MS; Carole Palmer, EdD, RD; and
Athena S. Papas, DMD, PhD

Upon successful completion of this CE activity 1 CE credit hour may be awarded

A Peer-Reviewed CE Activity by

Approved PACE Program Provider

FAGD/MAGD Credit Approval
Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is does not imply acceptance
a service of the American Dental Association to assist dental professionals by a state or provincial board of
in indentifying quality providers of continuing dental education. ADA CERP dentistry or AGD endorsement.
does not approve or endorse individual courses or instructors, nor does it June 1, 2009 to May 31, 2011
imply acceptance of credit hours by boards of dentistry. Concerns or AGD Pace approval number: 309062
complaints about a CE provider may be directed to the provider or to
ADA CERP at ada.org/goto/cerp.

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and
courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to
contact their state dental boards for continuing education requirements.

Recommendations for Fluoride Varnish Use in Caries Management
Sjögren’s Syndrome:
Dental Considerations
LEARNING OBJECTIVES:
After reading this article, the individual will learn:
• The characteristics of Sjögren’s syndrome (SS) and
how to identify patients having SS.
• How to treat patients with xerostomia resulting from SS.
ABOUT THE AUTHORS
Dr. Singh is an assistant professor in
the Department of Public Health and
community Service, Tufts University
School of Dental Medicine, Boston,
Mass. She can be reached via e-mail at
medha.singh@tufts.edu.
Disclosure: Dr. Singh reports no conflicts of interest.
Dr. Palmer is a professor in the
Department of Public Health and
Community Service, Tufts University
School of Dental Medicine, Boston,
Mass. She can be reached via e-mail at
carole.palmer@tufts.edu.
Disclosure: Dr. Palmer reports no conflicts of interest.
Dr. Papas is professor in the Department
of Public Health and Community
Service, Tufts University School of
Dental Medicine, Boston, Mass. She
can be reached via e-mail at
athena.papas@tufts.edu.
Disclosure: Dr. Papas reports no conflicts of interest.
1
Continuing Education
INTRODUCTION
Sjögren’s syndrome (SS) is a chronic autoimmune rheumatic
disease. It is the second most common rheumatic disease in
the United States, after rheumatoid arthritis (RA), affecting
one to 4 million people. It typically begins in the fourth to sixth
decade of life.1 The majority (90%) of SS sufferers are
middle-aged white perimenopausal females. SS has also
been seen in men, children, and the aged. The prevalence
ratio of women to men is 9:1.1
The objective of this article is to discuss the
characteristics of SS, how dental clinicians can identify
patients having SS, and how to treat patients with
xerostomia resulting from this disease.
There are 2 types of SS, primary and secondary.2
Primary SS occurs independently of any other associated
disorders or systemic disease. Secondary SS occurs in
association with another connective tissue disease such as
systemic lupus erythematosus, RA, scleroderma, or
relapsing polychondritis.2 Secondary SS accounts for
approximately 60% of Sjögren’s patients.3
ETIOLOGY
Although the etiology of SS is unknown, multiple factors are
thought to be involved in its development:4
 Environment: infection by Epstein-Barr virus and
Helicobacter pylori bacterium is considered as a possible
factor for initiating SS.
 Sex hormones: the majority of SS sufferers are
females, suggesting that sex hormones may play a role
in the autoimmune response.
 Genetics: genetic factors are considered likely to play
a role, eg, in white people, HLA-DR3 gene is misread
as an antigen by lymphocytes; another example is the
presence of self-antigen ICA-69. When ICA-69 occurs
as a component of a specific cell or tissue, that cell or
tissue is mistakenly recognized as foreign by the
immune system and triggers an immune response.
 Increased antibodies: the presence of Sjögren’s-
 Continuing Education

Sjögren’s Syndrome: Dental Considerations

associated antibodies such as anti-Ro/SSA and anti-
La/SSB is associated with increased SS symptoms.
 Inflammatory reactivity: lymphocytes accumulate in the
salivary glands and produce several proinflammatory
cytokines, thus sustaining the disease. An accumulation
of lymphocytes, called a focus of inflammation, is
characteristic in exocrine glands of people with SS. This
focus is what is found when a lip biopsy of a minor
salivary gland is performed in the diagnosis of SS.
Figure 1.
SYMPTOMS Fissured tongue.

The hallmark symptoms of SS are xerophthalmia (dry eyes)

and xerostomia (dry mouth).5 SS sufferers often report that
their eyes feel extremely dry, gritty, or sandy; they may
experience a reduction in tearing.6 They may report that the

Figure 2.
eyes burn and/or itch, appear red, and are more sensitive
to sunlight than usual. If not treated early enough ulcers of Enamel
the cornea can occur, which may lead to blindness. demineralization.
Xerostomia affects the oral cavity, causing difficulty
swallowing, speaking, chewing, and wearing dentures;
changes in taste; burning or soreness of oral mucosa; fissured

Figure 3.
tongue (Figure 1); and increased susceptibility to oral

Class V caries seen

candidiasis. Xerostomia also results in enamel
commonly in Sjögren’s
demineralization (Figure 2) and an increase in the incidence
of dental caries (Figures 3 and 4) as well as increased Syndrome (SS).
accumulation of bacterial plaque and associated gingival
inflammation and periodontal disease.
SS affects the major salivary glands (parotid,
submandibular, and sublingual), causing them to appear
enlarged, swollen, and tender on palpation. SS also affects

Figure 4.
the blood vessels, the nervous system, muscles, skin, heart,
Class VI caries seen
and other organs such as the kidneys. As a result, sufferers
may develop muscle weakness, confusion and memory commonly in SS.
problems, dry skin, and feelings of numbness and tingling in
the extremities.7 They may also report having joint or muscle diagnostic tests, including one objective measure (ie, by
pain, low grade fever, increased fatigue, and vasculitis.8 histopathologic examination [lip biopsy] or antibody
Lymphomas develop in 6% of SS patients.9 screening [blood test]).10

 Salivary function tests: determine the actual severity of

DIAGNOSIS
xerostomia.11 Unstimulated saliva is produced by the
Most recent criteria state that one may be diagnosed as salivary glands at rest. If the unstimulated salivary flow
having SS if one is positive for 4 of the following 6 is less than 0.1 mL/min it is positive for SS.

2

Sjögren’s Syndrome: Dental Considerations
 Schirmer’s test: this test is performed for the diagnosis
of dry eyes. It assesses tear formation. The test in-
volves placing a filter paper in the lower conjunctival
sac. If less than 5 mm of paper is wetted in 5 minutes
then the Schimer’s test is positive for SS.
 Lip biopsy: involves performing biopsy of minor salivary
glands in the lower lip. Lip biopsy report is considered
positive for SS when there is presence of a focal score
of one or more.12
 Serologic and laboratory findings: blood test is
performed to detect for SSA (anti-Ro) antibodies; SSB
(anti-La) antibodies; antinuclear antigen; rheumatoid
factor. Presence of these antibodies in the blood is
positive for SS.
 Patient reports of symptoms of dry mouth: a positive
response to all of the following questions is considered
diagnostic for salivary hypofunction:13 Do you sip
liquids to aid in swallowing food? Does your mouth feel
dry when eating food? Do you have difficulty swallowing
food? Does the amount of saliva in your mouth seem to
be too little? Do your nose or throat feel dry? Do you
have a dry cough, hoarseness of voice? Decreased
sense of taste?
 Patient reports of symptoms of dry eyes: a positive
response to all of the following questions is considered
diagnostic for dry eyes:13 Do your eyes feel dry, “gritty”
or “sandy,” or burn? Do you use tear substitutes more
than 3 times a day?
 In addition, clinical signs such as dry fissured tongue,
swollen salivary glands, and enlarged lymph nodes in
the neck may assist in the diagnosis of SS.
MANAGEMENT
There is no known approach to prevent or cure SS; therefore
treatment is tailored to managing the symptoms. Early
diagnosis and aggressive symptom-based treatment will help
alleviate much of the discomfort, retard the progression of the
disorder, and promote comfort and productivity.14
Patients with SS are at high risk for dental caries, as
3
Continuing Education
Figures 5 and 6.
Intraoral appearance
of SS. SS causes
decalcification of
enamel and increases
the risk for dental
caries. (Images
courtesy of Dr. Athena
Papas.)
xerostomia increases the vulnerability of tooth enamel.
Thus, extra effort must be made to protect teeth from
demineralization and dental caries (Figures 5 and 6). SS
sufferers should have a comprehensive dental exam and
bite-wing radiographs annually to detect any new carious
lesions. In addition, they should receive frequent dental
checkups due to increased risk for other oral disease. These
patients are also at high risk for periodontal disease and
should receive periodontal prophylaxis every 3 months
followed by an application of fluoride varnish.15
The dentist or dental hygienist should reinforce the
importance of regular brushing and flossing. An electric
toothbrush is recommended to effectively remove plaque
and prevent gingivitis.16 Patients need aggressive fluoride
therapy in the form of professionally applied concentrated
sodium fluoride varnishes and daily use of prescription
strength fluoride toothpaste (PreviDent 5000 Dry Mouth
[Colgate-Palmolive Company]). Calcium also has a
remineralizing effect on dental enamel. A calcium-containing
remineralizing oral rinse such as Caphsol (Eusa Pharma) is
recommended. Antibacterial rinses such as 0.12% chlor-
hexidine gluconate (Actavis MidAtlantic) are indicated in an
effort to reduce gingivitis.17
Xerostomia also causes the oral mucosa to become dry
and sore. Oral lubricants such as vitamin E or Oral Balance
(GlaxoSmithKline) are effective in soothing these irritated
tissues. Patients are advised to break the vitamin E capsule in
the mouth and swish and spit. Xerostomia also causes the lips

Sjögren’s Syndrome: Dental Considerations
to become dry. The regular use of topically applied oil-based
balms or vitamin E-containing balm may provide soothing relief
to dry cracked lips. The use of xylitol-containing salivary
stimulants such as Biotene gum (GlaxoSmithKline) or Trident
gum (Cadbury Adams USA) can help stimulate salivary flow in
patients having remaining functional salivary tissue. Xylitol
interferes with the growth of cariogenic bacteria; it is safe and
approved as a therapeutic sweetener by the US Food and
Drug Administration.17
Nonselective muscarinic receptor agonists such as
Pilocarpine or Civemiline may be prescribed for patients to
promote salivary function. These are parasympathomimetic
drugs and act therapeutically at the muscarinic
acetylcholine receptor M3 subtype. Sialagogues should
always be taken with food.18
For patients who are not able to afford prescription
medications or are unable to tolerate them, there are over-
the-counter products by Biotene gum for treatment of dry
mouth. Over-the-counter products have limited use and are
not as effective as prescription medication.
Oral candidiasis is frequently seen in Sjögren’s patients.
Treatment should be with topical antifungal rinses (Nystatin) or
lozenges (Clotrimazole). Systemic antifungal medication such
as Fluconazole is recommended for recurrent oral candidiasis
or when topical antifungal agents are ineffective.17
Sjögren’s sufferers should try to minimize any factors
that may exacerbate the symptoms of dry eyes and dry
mouth. The use of medications increases with age, with
more than 85% of persons aged 60 years and older taking
at least one prescription medication. Therefore, the
prevalence of medication-induced xerostomia is high in the
elderly population.19 The side effect of xerostomia has been
reported in approximately 80% of the most commonly
prescribed medications, which can compound the
discomfort of the xerostomia already resulting from SS. If
possible, alternative, nonxerostomic medications should be
used as substitutes.19
Patients should be counseled to avoid any products that
can contribute to oral dryness or irritation. Alcohol has a
drying effect and should be avoided in both beverages and
in oral products such as mouthwashes. Caffeine acts as a
mild diuretic which promotes fluid loss and may worsen dry
4
Continuing Education
mouth. If possible, patients should avoid or limit items which
contain significant amounts of caffeine such as coffee, tea,
and certain soft drinks. Tartar control toothpastes and tooth
whitening products should also be avoided as they can be
irritating to friable oral tissues. If patients tend to breathe
through their mouths, it is often helpful to encourage them
to try to increase nasal breathing and to be examined by an
otolaryngology specialist if there are impediments to normal
nasal breathing. The dry ambient air of most modern homes
contributes to a sensation of dryness. The use of a
humidifier, particularly at night, helps address this
concern.17
Patients are advised to minimize consumption of
carbohydrate-containing foods and beverages between
meals, especially sticky foods such as cookies, bread,
potato chips, gums, candies, acidic beverages, (such as
most carbonated and sports replenishment drinks) and
lemon products. Frequent sips of small amounts of sugar-
free fluids, especially water, can be helpful in diminishing
the effects of oral dryness. Many patients keep a bottle of
water handy to moisturize their tissues. However, excessive
sipping of water can actually reduce the oral mucus film
lining the mouth and worsen dry mouth symptoms.17
CONCLUSION
SS is an autoimmune condition which results in dryness in
many of the body’s tissues. The condition is rarely fatal, but
its symptoms can severely compromise health and quality
of life. The disease course of SS can vary with symptoms
ranging from very mild to fairly significant. Individuals with
secondary SS seem to have milder disease as compared to
those with primary SS. Early diagnosis and treatment are
extremely important in trying to prevent damage to major
organs. Ocular and oral care is particularly important to
prevent serious harm to eyes and teeth. Many effective
strategies are available to help patients manage their
symptoms (Table) as are helpful support groups such as
the Web site sjogrens.org. Routine follow-up care with the
physician and the dentist is essential.
With early intervention and good individualized care, people
with SS should be able to lead full and comfortable lives.
 Continuing Education

Sjögren’s Syndrome: Dental Considerations

Table. Treatment Summary for Sjögren’s Symptoms

 Frequent dental checkups due to increased risk for oral disease
Annual comprehensive dental exam and bite-wing x-rays
Dental Office Care


 Periodontal prophylaxis every 3 months

 Fluoride varnish application

 Electric toothbrush to effectively remove plaque and prevent gingivitis

Daily use of prescription strength fluoride toothpaste PreviDent 5000
Home Oral Care


 Calcium-containing remineralizing oral rinse such as Caphsol

 Antibacterial rinses such as 0.12% chlorhexidine to help reduce gingivitis

 Oral lubricants such as vitamin E or Oral Balance can help soothe irritated tissues.
Topically applied oil-based balms or vitamin E-containing balm can relieve dry cracked lips
Xerostomia


 Xylitol-containing salivary stimulants such as Biotene gum or Trident gum can

help stimulate salivary flow

 Nonselective muscarinic receptor agonists such as Pilocarpine or Civemiline can

promote salivary function

 Over-the-counter products such as Biotene gum can help treat dry mouth

Oral Candidiasis  Antifungal rinses or lozenges and systemic antifungal medication

REFERENCES
1. Kassan SS, Moutsopoulos HM. Clinical manifestations
and early diagnosis of Sjögren syndrome. Arch Intern
Med. 2004;164:1275-1284.
2. Sawyer S. Primary Sjögren’s syndrome. Nurs Stand.
2004;18:33-36.
3. Dafni UG, Tzioufas AG, Staikos P, et al. Prevalence of
Sjögren’s syndrome in a closed rural community. Ann
Rheum Dis. 1997;56:521-525.
4. Wallace DJ. Sjögren’s syndrome. In: Wallace DJ, ed.
The New Sjögren’s Syndrome Handbook. 3rd ed.
Oxford, England: Oxford University Press; 2005:15-32.
5. Al-Hashimi I. Xerostomia secondary to Sjögren’s
syndrome in the elderly: recognition and management.
Drugs Aging. 2005;22:887-899.
6. Morozova RP, Zhaboiedov HD, Kirieiev VV, et al. The
normal tear fluid and decreased tearing in patients with
Sjögren’s disease and Sjögren’s syndrome. II. The lipid
content [in Ukrainian]. Ukr Biokhim Zh.1996;68:82-87.
7. Michowitz Y, Shiloach E, Horowitz M, et al. Transient lower
limbs paralysis—a rare presenting symptom of Sjögren’s
syndrome [in Hebrew]. Harefuah. 2005;144:241-242.
8. Lwin CT, Bishay M, Platts RG, et al. The assessment
of fatigue in primary Sjögren’s syndrome. Scand J
Rheumatol. 2003;32:33-37.
9. Kassan SS, Thomas TL, Moutsopoulos HM, et al.
Increased risk of lymphoma in sicca syndrome. Ann
Intern Med. 1978;89:888-892.
10. Longman LP, Higham SM, Bucknall R, et al. Signs and
symptoms in patients with salivary gland hypofunction.
Postgrad Med J. 1997;73:93-97.
11. Dawes C. How much saliva is enough for avoidance of
xerostomia? Caries Res. 2004;38:236-240.
12. Hocevar A, Ambrozic A, Rozman B, et al. Ultrasonographic
changes of major salivary glands in primary Sjögren’s
syndrome. Diagnostic value of a novel scoring system.
Rheumatology (Oxford). 2005;44:768-772.
13. Muscal E, Morales de Guzman M, Jung LK, et al.
Sjögren’s syndrome. emedicine.com/ped/topic2811.htm.
Accessed February 19, 2010.
14. Scagliusi P, Minenna G, D’Amore M, et al. New
therapeutic perspectives in Sjögren syndrome:
leflunomide [in Italian]. Recenti Prog Med. 2005;96:194.

5

Sjögren’s Syndrome: Dental Considerations
15. Derk CT, Vivino FB. A primary care approach to
Sjögren’s syndrome. Helping patients cope with sicca
symptoms, extraglandular manifestations. Postgrad
Med. 2004;116:49-54.
16. Martuscelli G, Singh M, Papas AS, et al. Use of a
power toothbrush in a high-risk population. J Dent Res.
2004;83(special issue A):2435. iadr.confex.com/iadr/
2004Hawaii/techprogram/abstract_47442.htm.
Accessed March 31, 2010.
17. Brennan M, Fox P, eds, Singh M, Contributing author.
Clinician's Guide: Salivary Gland and Chemosensory
Disorders. 1st ed. Edmonds, WA: American Academy
of Oral Medicine; 2009.
6
Continuing Education
18. Papas AS, Sherrer YS, Charney M, et al. Successful
treatment of dry mouth and dry eye symptoms in
Sjögren’s syndrome patients with oral pilocarpine: a
randomized, placebo-controlled, dose-adjustment study.
J Clin Rheumatol. 2004;10:169-177.
19. Bowman J, Shirodaria S, Gallagher A, et al. Demographic
profile of subjects with medication-induced xerostomia at
three locations. J Dent Res. 2007;86(special issue
A):1106. iadr.confex.com/ iadr/2007orleans/ techprogram/
abstract_89855.htm. Accessed March 31, 2010.
 Continuing Education

Sjögren’s Syndrome: Dental Considerations

2. Patients having secondary SS could have any of the
following disorders EXCEPT:
POST EXAMINATION INFORMATION
To receive continuing education credit for participation in a. Rheumatoid arthritis.
this educational activity you must complete the program b. Lichen planus.
post examination and receive a score of 70% or better. c. Systemic lupus erythematosus.
d. Scleroderma.

3. Which would NOT be an indicator of low risk for caries?

Traditional Completion Option:
You may fax or mail your answers with payment to Dentistry
Today (see Traditional Completion Information on following a. Low streptococci and lactobacilli counts.
b. Xerostomia.
page). All information requested must be provided in order
c. History of fluoridated drinking water in childhood.
to process the program for credit. Be sure to complete your
d. Three meals a day, no snacks.

4. Which is NOT appropriate to manage adult patients with

“Payment,” “Personal Certification Information,” “Answers,”

high caries risk?

and “Evaluation” forms. Your exam will be graded within 72
hours of receipt. Upon successful completion of the post-
a. Topical fluoride treatment in the dental office.
exam (70% or higher), a letter of completion will be mailed
b. Remineralizing solutions/fluoride toothpastes.
to the address provided.
c. Chewing xylitol containing gum.
Online Completion Option: d. Dental examination and bitewing radiographs every
Use this page to review the questions and mark your 2 years.

5. Lip biopsy report for a patient suffering from

autoimmune-induced xerostomia is considered positive
answers. Return to dentalcetoday.com and sign in. If you

when the focal score is one or greater. Unstimulated

have not previously purchased the program, select it from
salivary flow below 0.1 mL/minute in a 15-minute
the “Online Courses” listing and complete the online
purchase process. Once purchased the program will be collection is an indication for dry mouth.
added to your User History page where a Take Exam link a. Both statements are true.
will be provided directly across from the program title. b. Both statements are false.
Select the Take Exam link, complete all the program c. The first statement is false, the second is true.
questions and Submit your answers. An immediate grade d. The first statement is true, the second is false.
report will be provided. Upon receiving a passing grade, 6. Which of the following is FALSE about fluorides?
complete the online evaluation form. Upon submitting the a. Forms fluorapatite.
form your Letter Of Completion will be provided b. Forms hydroxyapatite.
immediately for printing. c. Aids remineralization.
d. Interferes with plaque bacterial physiology.
General Program Information:
Online users may log in to dentalcetoday.com any time in 7. Which does NOT suppress the levels of Streptococcus
mutans in the mouth?
the future to access previously purchased programs and
a. Chlorhexidine.
view or print letters of completion and results.
b. Xylitol gum.
c. Sorbitol gum.
POST EXAMINATION QUESTIONS d. Topical fluorides.

1. Which of the following markers is present in the 8. Saliva is important in caries prevention because it
blood of a patient diagnosed with primary Sjögren’s restores the minerals that are lost from tooth structure.
syndrome (SS)? SS causes decalcification of enamel and increases the
risk for dental caries.
a. Rh factor.
a. Both statements are true.
b. ANA.
b. Both statements are false.
c. IgG.
c. The first statement is false, the second is true.
d. SSA.
d. The first statement is true, the second is false.

7
 Continuing Education

Sjögren’s Syndrome: Dental Considerations

PROGRAM COMPLETION INFORMATION PERSONAL CERTIFICATION INFORMATION:

If you wish to purchase and complete this activity
traditionally (mail or fax) rather than online, you must Last Name (PLEASE PRINT CLEARLY OR TYPE)
provide the information requested below. Please be sure to
select your answers carefully and complete the evaluation First Name
information. To receive credit you must answer at least 6 of
Profession / Credentials License Number
the 8 questions correctly.

Complete online at: dentalcetoday.com Street Address

TRADITIONAL COMPLETION INFORMATION: Suite or Apartment Number

Mail or fax this completed form with payment to:

City State Zip Code
Dentistry Today
Department of Continuing Education Daytime Telephone Number With Area Code
100 Passaic Avenue
Fairfield, NJ 07004 Fax Number With Area Code

Fax: 973-882-3622
E-mail Address

PAYMENT & CREDIT INFORMATION:

Examination Fee: $20.00 Credit Hours: 1.0 ANSWER FORM: COURSE #: 125.1
Note: There is a $10 surcharge to process a check drawn on
Please check the correct box for each question below.
any bank other than a US bank. Should you have additional
questions, please contact us at (973) 882-4700. 1.  a  b  c  d 5.  a  b c d

2.  a  b  c  d 6.  a  b
 I have enclosed a check or money order.
c d
 I am using a credit card.
3.  a  b  c  d 7.  a  b c d
My Credit Card information is provided below.
 American Express  Visa  MC  Discover 4.  a  b  c  d 8.  a  b c d

Please provide the following (please print clearly):

Exact Name on Credit Card PROGRAM EVAUATION FORM

Credit Card #
Signature
Approved PACE Program Provider
FAGD/MAGD Credit Approval
does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement.
June 1, 2009 to May 31, 2011
AGD Pace approval number: 309062
Please complete the following activity evaluation questions.
/ Rating Scale: Excellent = 5 and Poor = 0
Expiration Date
Course objectives were achieved.
Content was useful and benefited your
clinical practice.
Review questions were clear and relevant
to the editorial.
Dentistry Today, Inc, is an ADA CERP Recognized
Illustrations and photographs were
Provider. ADA CERP is a service of the American clear and relevant.
Dental Association to assist dental professionals in
indentifying quality providers of continuing dental
education. ADA CERP does not approve or endorse
Written presentation was informative
individual courses or instructors, nor does it imply and concise.
acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be
directed to the provider or to ADA CERP at
How much time did you spend reading
ada.org/goto/cerp. the activity & completing the test?