Labial salivary gland biopsy in Sjögren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases

Suppression of tumor necrosis factor alpha-induced matrix metalloproteinase 9 production by the introduction of a super-repressor form of inhibitor of nuclear factor kappaBalpha complementary DNA into immortalized human salivary gland acinar cells. Prevention of the destruction of the acinar structure in Sjögren's syndrome salivary glands

OBJECTIVE

We have previously shown that specific enhancement in acinar cells of proteolytic activity induced by tumor necrosis factor alpha (TNFalpha) may be responsible for the destruction of the acinar structure in the salivary glands of patients with Sjögren's syndrome. Because matrix metalloproteinase 9 (MMP-9) is regulated by nuclear factor kappaB (NF-kappaB), we investigated the effect of a super-repressor form of inhibitor of nuclear factor kappaBalpha (srIkappaBalpha) on the suppression of TNFalpha-induced MMP-9 production in acinar cells.

METHODS

Two srIkappaBalpha complementary DNA (cDNA)-transfected acinar cell clones (ACMT-6 and ACMT-7) and 1 empty vector-transfected cell clone (ACpRc-1) were established. After treatment of cell clones with TNFalpha, the expression of MMP-9 was examined. In addition, the effect of TNFalpha on cell growth and the morphogenetic behavior of cell clones cultured on type IV collagen-coated dishes were examined.

RESULTS

TNFalpha induced the production of MMP-9 in the ACpRc-1 cell clone, but greatly suppressed MMP-9 production in ACMT-6 and ACMT-7 clones. No apparent cytotoxic effect of TNFalpha treatment was observed in these cell clones. When ACpRc-1 cells were seeded on type IV collagen-coated dishes in the presence of both TNFalpha and plasmin, type IV collagen interaction with the cells was lost and the cells entered apoptosis. However, even when ACMT-6 and ACMT-7 cells were cultured under the same culture conditions as those for ACpRc-1, these cell clones attached to the substrate and grew consistently without showing apoptosis. Conclusion. These observations indicate that suppression of TNFalpha-induced MMP-9 production by the introduction of srIkappaBalpha cDNA corrected the aberrant in vitro morphogenesis of acinar cells grown on type IV collagen.

Salivary gland changes in chronic fatigue syndrome: a case-controlled preliminary histologic study

OBJECTIVE

The purpose of this preliminary study is to compare labial salivary gland changes of 11 patients with chronic fatigue syndrome with control subjects.

STUDY DESIGN

Changes in labial salivary glands were graded from 0 to 3+ for acinar dilatation, ductal dilatation, periductal fibrosis, plasmacytic infiltrate, lymphocytic infiltrate, mast cell infiltrate, and lymphocytic aggregates or foci.

RESULTS

Four of the 11 subjects had 2+ to 3+ changes in at least 4 of the 7 parameters examined. Only the presence of mast cells was statistically significant between the 2 groups. Two of these 4 patients had 1 lymphocytic focus per 4 mm(2) of tissue.

CONCLUSIONS

The salivary gland changes in patients with chronic fatigue syndrome show varying degrees of ductal and acinar dilatation, periductal fibrosis, lymphoplasmacytic infiltrates, and occasional lymphocytic foci, all suggestive of primary gland damage. The one parameter that showed statistical significance was the presence of mast cells (Fisher exact test, 0.0125).

Periodontal manifestations of collagen vascular disorders

Chronic degeneration of connective tissue components can be produced by a variety of autoimmune mechanisms. The designations connective tissue disease and collagen-vascular disease are commonly used to describe such conditions when a patient exhibits chronic, immune-mediated deterioration of connective tissue structures in a systemic distribution. Recognized conditions that fit this definition include rheumatoid arthritis, lupus erythematosus, progressive systemic sclerosis, CREST syndrome, and mixed connective tissue disease. Several characteristic oral manifestations of these conditions are recognized. Xerostomia associated with any of these conditions in addition to dryness of the eyes is the definition of secondary Sjögren's syndrome. Fibrosis of facial skin and the resulting limited jaw opening are diagnostic features of progressive systemic sclerosis. Several periodontal manifestations are associated with these connective tissue disorders. Dramatic periodontal ligament space widening that is associated with some cases of progressive systemic sclerosis has been appreciated for more than five decades. However, it has been more recently reported that the majority of progressive systemic sclerosis patients exhibit at least subtle generalized periodontal ligament widening when intraoral radiographs are carefully evaluated. This finding is, however, of limited periodontal significance because the teeth are typically not mobile. Comparisons of periodontitis indices such as pocket depth between healthy subjects and patients with progressive systemic sclerosis do not reveal significant differences (21). In addition, recent evidence suggests a tendency for more severe or progressive manifestations of periodontitis as a consequence of xerostomia that may result from these diseases.

Th1 predominance and perforin expression in minor salivary glands from patients with primary Sjögren's syndrome

Objectives of this study were to examine the cytokine and perforin mRNA expression in minor salivary glands from patients with primary Sjögren's syndrome (pSS), searching for possible correlation with clinical parameters and to identify the dominant cytokine pattern in the different groups. Oral mucosa biopsy samples from 42 pSS patients were studied. Total RNA was analysed by normalized RT-PCR using oligo-dT as the RT primer and IL-2, IFN-gamma, IL-12, IL-18, IL-4, IL-10, TGF-beta, TNF-alpha and perforin-specific primers for amplification. Results were analysed taking into account: (1) biopsy grade I to IV (Chisholm's classification); (2) diagnosis of either definite pSS (n=30) or probable pSS (n=12), following the European classification criteria (ECC), and (3) length of disease evolution from the beginning of symptoms to the time of biopsy, using an arbitrary cut-off point of 12 months. This studied showed that Th1-related cytokines (IL-2, IFN-gamma, IL-12, IL-18, TNF-alpha) and perforin were present in most samples. IL-4 (Th2) was totally absent but other Th2 and regulatory cytokines (IL-10, TGF-beta) were detected in the majority of samples. No significant differences were found between definite and probable pSS nor between grades II, III, IV and fibrous tissue biopsies. A statistically significant increase of IL-2 (P=0.012) and IFN-gamma (P=0.019) was observed in samples from patients with longer disease evolution, whereas the two Th1-inducer cytokines IL-12 and IL-18 were equally and highly expressed in all samples. In conclusion, a predominant Th1 pattern of cytokines was observed in all pSS samples, irrespective of biopsy classification. In addition, a significant increase of Th1 cytokine expression frequency was associated with longer disease evolution.

Primary Sjögren's syndrome (pSS): subjective symptoms and salivary findings

We studied the relationship between dry mouth, general health and objective findings in 16 patients having primary Sjögren's syndrome (pSS) according to the 1993 European classification criteria as well as in healthy controls. Serum autoantibody to SSA/SSB (AB) was correlated to unstimulated whole saliva flow (UWS) and labial salivary gland focus score (FS). All patients had dry mouth symptoms and UWS < or = 0.10 ml/min, but patients with UWS < 0.05 ml/min and AB had more complaints of oral and ocular dryness. These patients also tended to have more exocrine and non-exocrine manifestations, and oral dryness had a greater impact on their self-reported general health than in patients with UWS > or = 0.05 ml/min. Accordingly, we consider rating of oral dryness by visual analogue scales or categorised questionnaires to be valuable for the evaluation of oral involvement in pSS.

Lymphoma development in Sjögren's syndrome: novel p53 mutations

OBJECTIVE

Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltrations of the exocrine glands. Disease progression may lead to uncontrolled clonal proliferation of B lymphocytes and development of lymphoma. This study was undertaken to examine the possible involvement of the cell cycle checkpoint genes p53 and p21 in the pathophysiology of the syndrome.

METHODS

Protein expression of p53 and p21 was studied, by immunohistochemistry and Western blot analysis, in minor salivary gland (MSG) biopsy specimens from 7 patients with SS and 5 control subjects. In addition, sequence analysis of the p53 gene was performed on DNA samples obtained from MSG biopsy samples of the same 7 patients with SS and from 4 patients with SS and in situ non-Hodgkin's lymphoma (NHL).

RESULTS

The study revealed increased protein expression of p53 and p21 in MSG biopsy specimens from patients as compared with controls, while sequence analysis showed that the p53 gene was of the wild type. Furthermore, sequence analysis of the p53 gene from patients with SS and in situ NHL revealed 2 novel mutations in exon 5 of the p53 gene. These mutations are single-base substitutions and appear to be functional since exon 5 is included in the coding region of the p53 gene.

CONCLUSION

This is the first report on wild-type p53 gene activation in SS. Our findings indicate a probable role for the DNA damage response genes in the pathogenesis of this syndrome. The novel mutations of the p53 gene implicate dysregulation of this tumor suppressor gene as a possible mechanism for lymphoma development in SS.

Cytokine expression in human labial minor salivary gland epithelial cells in health and disease

Microdissection of biopsy material from labial minor salivary glands followed by RT-PCR demonstrates extensive production of cytokines IL-2, 1L-6, IL-10, TNF-alpha, TGF-beta, and IFN-gamma in both normal glands and in glands affected by Sjögren's syndrome. Continuation of these studies should expand our knowledge of normal salivary gland function and the pathogenesis of Sjögren's syndrome.

Morphological features of the minor salivary glands

The minor salivary glands are important components of the oral cavity, present in most parts of the mouth, and their secretions directly bathe the tissues. Individual glands are usually in the submucosa between muscle fibres, and consist of groups of secretory endpieces made up of mucous acinar cells and serous or seromucous demilune cells. The ductal systems comprise intercalated ducts, intralobular ducts usually lacking basal striations, and excretory ducts opening directly through the mucosa Minor glands secrete highly glycosylated mucins, containing blood group determinants, and probably active in tissue lubrication and bacterial aggregation. They also secrete several antimicrobial proteins and immunoglobulins, and the lingual serous (von Ebner's) glands secrete digestive enzymes and proteins with possible taste perception functions. Minor gland morphology and function can conveniently be studied in the rat. There are substantial differences between major and minor salivary glands, as well as among the minor glands, in the nature and composition of their mucous and serous secretory products. The role of minor salivary glands in the function and defence of the oral cavity may be better understood as a result of new physiological and molecular methods applicable to samples of limited size and availability.

Primary Sjögren's syndrome: salivary gland function and clinical oral findings

OBJECTIVE

To evaluate salivary gland function, saliva composition and oral findings in patients with primary Sjögren's syndrome (pSS) subdivided into patients with and without focus score > or = 1 (FS) and/or antibodies to SSA/SSB (AB) as well as in healthy controls.

SUBJECTS AND METHODS

Unstimulated (UWS) and chewing stimulated (SWS) whole saliva, and stimulated parotid saliva (SPS) were collected in 16 patients fulfilling the European classification criteria for pSS subdivided into those with FS and/or AB (n = 8) and those without FS and AB (n = 8), and in age-matched (n = 14) and young healthy controls (n = 13). UWS and SWS were analysed for Na+ and K+. SPS was analysed for Na+, K+, statherin, and proline-rich proteins (PRPs). Sicca symptoms, DMFT/DMFS, plaque (PI) and gingival (GI) scores, periodontal pocket depth (PPD), and mucosal status were recorded.

RESULTS

The young healthy controls had lower UWS as compared to the aged controls (P = 0.03). However, the aged controls had higher DMFT/DMFS (P < 0.001) and PI, GI and PPD (P < 0.01). Patients with FS and/or AB generally had lower saliva secretory rates than patients without FS and/or AB (P = 0.01 for UWS and SPS) and age-matched healthy controls (P = 0.001). There was no significant difference in the content of Na+ and K+, statherin and PRPs between groups. Patients with FS and/or AB had the highest frequency of oral mucosal changes and higher DMFT/DMFS than patients without FS and/or AB and healthy controls (P < 0.01). However, PI, GI, and PPD did not differ significantly.

CONCLUSION

Patients with FS and/or AB had lower salivary secretory rates, higher DMFT/DMFS, and more oral mucosal changes than patients without FS and/or AB. Additionally, data suggest that salivary gland function in healthy individuals do not decrease with age.

HIV-associated parotid lymphoepithelial cysts

BACKGROUND

An outstanding feature of the diffuse infiltrative lymphocytosis syndrome, or DILS, a subset of HIV-1 disease, is asymptomatic bilateral parotid swelling. Recognition of the entity is important because people with this disease will seek routine dental care.

CASE DESCRIPTION

The authors present a classic case of DILS. The patient exhibited bilateral parotid swellings caused by lymphoepithelial cysts, cervical lymphadenopathy, a CD8 circulating lymphocytosis and a CD8 lymphocytic infiltration into the labial salivary glands. A right superficial parotidectomy had been performed several years previously. However, no intervention was advised for the remaining left parotid because of its benign course.

CLINICAL IMPLICATIONS

Since patients with DILS can develop lymphomas, periodic observation is mandatory. Any change in the growth pattern requires that a fine-needle aspiration biopsy be performed.

Analysis of V(H)-D-J(H) gene transcripts in B cells infiltrating the salivary glands and lymph node tissues of patients with Sjögren's syndrome

OBJECTIVE

In patients with Sjögren's syndrome (SS), B lymphocytes have been found to infiltrate salivary glands, resulting in sialadenitis and keratoconjunctivitis. The disease is frequently associated with benign and neoplastic lymphoproliferation. The present study was undertaken to investigate whether clonal B cell expansion takes place in lymphocytic infiltrations of salivary glands under (auto- [?]) antigen stimulation, by analyzing in more detail the variable part (V(H)-D-J(H)) of the immunoglobulin heavy chain genes expressed in these B cells.

METHODS

Biopsies of the labial salivary glands and lymph nodes were performed on 2 female patients with SS. The Ig gene rearrangements in these tissues were amplified by reverse transcriptase-polymerase chain reaction using specific primers.

RESULTS

A total of 94 V(H)-D-J(H) transcripts were cloned and sequenced. Our data suggest a polyclonal origin of the B cell infiltrates. In 92 of the transcripts, V(H) genes were modified by somatic mutation. Further analysis showed counterselection for replacement mutations within the framework regions, suggesting that those B cells were stimulated and selected for functional expression of a surface Ig. In labial salivary glands from both patients, clonally related B cells became evident. Members of 1 particular clone were found in both the lip and lymph node material.

CONCLUSION

These data provide evidence, on the nucleotide sequence level, that an antigen-triggered clonal B cell expansion takes place in the salivary glands of patients with SS who do not have histologic evidence of developing lymphoma. It may be speculated that those B cell clones expand during disease progression, resulting in lymphomagenesis.

Ro/SS-A-reactive B lymphocytes in salivary glands and peripheral blood of patients with Sjögren's syndrome

The aim of this study was to investigate the production of anti-Ro/SS-A antibodies in labial salivary glands (LSG) and peripheral blood (PB) of Sjögren's syndrome (SS) patients. The ELISPOT method was performed to quantify the frequency of LSG lymphocytes and PB lymphocytes spontaneously secreting anti-Ro/SS-A antibodies. The total number of IgG-, IgA- and IgM-producing cells was also quantified. The bovine Ro 60-kD protein was used as target antigen. Six of six primary SS patients had LSG B cells producing anti-bovine Ro 60 kD of the IgG isotype, and two of two primary SS patients had in addition PB lymphocytes producing anti-bovine Ro 60 kD of the IgG isotype. The six patients who had IgG antibodies against the Ro/SS-A antigen in LSG all had focus scores of >/= 7 in biopsies of LSG. The results indicate that SS patients with a high degree of local inflammation in LSG have B cells producing anti-Ro/SS-A antibodies in both LSG and PB. Thus, the anti-Ro/SS-A antibodies may have pathogenic importance in the progression of the exocrinopathy of SS.

Ro/SS-A- and La/SS-B-reactive B lymphocytes in peripheral blood of patients with Sjögren's syndrome

The aim of this study was to investigate the production of anti-Ro/SS-A and anti-La/SS-B antibodies in peripheral blood (PB) of patients with Sjögren's syndrome (SS). The ELISPOT method was performed to quantify the frequency of PB lymphocytes spontaneously secreting anti-Ro/SS-A and/or anti-La/SS-B antibodies. The total number of IgG-, IgA- and IgM-producing cells was also quantified. The recombinant Ro 52-kD, Ro 60-kD and La 48-kD proteins were used as target antigens. Three of 18 SS patients had PB lymphocytes secreting IgG antibodies against the recombinant Ro 52-kD protein. The same three patients had high serum titres of anti-Ro 52-kD antibodies. In addition, these patients were classified as having severe disease, and all three had focus scores of >/= 8 in biopsies of the labial salivary glands (LSG). The correlation between the number of PB cells producing IgG antibodies against the recombinant Ro 52-kD protein and the focus score was significant (P < 0.01). The results indicate that only SS patients with severe disease and high degree of local inflammation in LSG have B cells producing anti-Ro/SS-A antibodies in PB. Thus, most of the spontaneous autoantibody production must take place in other body compartments, e.g. in exocrine glands and probably also in the lymphoid organs and/or other mucosal sites.

Submandibular and lacrimal gland immunoglobulin in the C3H.MRL-Faslpr autoimmune mouse model of Sjögren's syndrome

OBJECTIVE

To distinguish potential autoimmune and nonautoimmune mechanisms underlying the salivary gland inflammation seen in Sjögren's syndrome and normal aging.

STUDY DESIGN

Immunohistochemical studies were conducted on the lacrimal and salivary glands of 2- and 5-month-old C3H.MRL-Faslpr autoimmune strain mice and age-matched C3H/HeJ nonautoimmune controls.

METHODS

Glandular inflammatory foci, interstitial areas, and vasculature were stained for immunoglobulin G (IgG), immunoglobulin A (IgA), and complement to determine differences in their local immune parameter. Differences between the two strains were compared for immune changes attributable to autoimmune disease and between the two normal groups for normal aging changes.

RESULTS

Greater staining of IgG, IgA, and complement occurred in the inflammatory foci and interstitial areas of 5-month-old C3H.MRL-Faslpr lacrimal and submandibular glands compared with 5-month-old controls. Normal mice showed some increased immunoglobulin staining with aging, but little or no complement in any glands.

CONCLUSIONS

These differential findings suggest that the systemic autoimmune disease plays a more direct role in focal glandular inflammation in Sjögren's syndrome, whereas less severe immune mechanisms are involved in the inflammation of normal glands.

Using ultrasonography to diagnose Sjögren's syndrome

Ultrasonographic imaging of the parotid gland parenchyma represents a relatively new and extremely useful procedure that was applied in this study of patients with secondary Sjögren's syndrome, or SS. A nonhomogeneous parotid gland and hypoechoic areas were apparent in the sonograms of nine consecutive SS patients who were examined using this simple, noninvasive technique.

Optical simulations of a noninvasive technique for the diagnosis of diseased salivary glands in situ

A simulation experiment for three-dimensional (3D) imaging of exogenous fluorescinated antibodies that specifically bind to infiltrating lymphocytes in minor salivary glands was carried out. Small (approximately 1 mm3 volume) rhodamine targets, which mimic diseased minor salivary glands labeled with fluorescent antibodies to infiltrating lymphocytes in Sjøgren's syndrome, were embedded in a highly scattering tissue phantom consisting of a thick Delrin disk covered by index matched Delrin slabs of various thickness. In this way the variation of fluorescence profiles on the surface of tissue could be examined corresponding to the range of depths of the salivary glands in vivo. Surface images were obtained for different target depths and radial distances from laser excitation to target fluorophore. These images were analyzed and compared to calculations based on random walk theory in turbid media, using previously determined scattering and absorption coefficients of the Delrin. Excellent agreement between the surface profiles experimentally measured and those predicted by our random walk theory was obtained. Derivation of these theoretical expressions is a necessary step toward devising an inverse algorithm which may have the potential expressions to perform 3D reconstruction of the concentration distribution of fluorescent labels within tissue.

Very low-dose cyclosporin treatment of steroid-resistant interstitial pneumonitis associated with Sjögren's syndrome

Cyclosporin is known to be effective for both transplantation and a spectrum of immune-mediated diseases. Because this agent also causes severe adverse effects, especially nephrotoxicity, careful monitoring is required for the development of such reactions. Here we report the successful treatment with extremely low-dose cyclosporin (1 mg/kg/day) of a patient who had steroid-resistant interstitial pneumonitis and Sjögren's syndrome.

Standardized assessment of disease status in patients with primary Sjögren's syndrome: the foundation for creating criteria for disease activity and damage?

Primary Sjögren's syndrome (pSS) is increasingly acknowledged as a disease entity with consistent pathogenesis and clinical presentation. This has encouraged proposals for uniform nomenclature, as well as for classification of disease subsets and clinical disease manifestations. The purpose of this literature survey is to analyse present pathogenetic and clinical data on pSS from the viewpoint of their usability for developing criteria for activity and damage. It appears that the routinely used tests for evaluating clinical disease manifestations in pSS probably measure both activity and damage. Moreover, no immunopathogenic marker has been shown to adequately represent all aspects of disease activity in pSS. The survey demonstrates the need for longitudinal studies in which potential markers of disease activity and damage are validated.

Sjögren's syndrome: a model for dental care in the 21st century

The diagnosis and treatment of Sjögren's syndrome, which poses many severe complications, should be of critical interest to dentists, who are often the first practitioners to detect symptoms. Dentistry is an integral part of health care delivery for patients with this condition. Management of Sjögren's syndrome can be seen as a model for the expanded scope of dental care in the future.

Investigation of xerostomia in patients with rheumatoid arthritis

The authors investigated the prevalence of xerostomia in a group of 604 subjects participating in a rheumatoid arthritis, or RA, study to explore the relationship of reduced salivary flow symptoms and demographic, clinical and medical characteristics. Forty-three percent of these subjects exhibited one or more severe xerostomia symptoms. Separate analyses revealed that the subjects who had the most physical disease symptoms were at greater risk of having reduced salivary flow. The study's results suggest that patients with RA should be screened for xerostomia symptoms so appropriate clinical interventions can be initiated.

Prevalence of the diffuse infiltrative lymphocytosis syndrome among human immunodeficiency virus type 1-positive outpatients

OBJECTIVE

To ascertain the prevalence of the diffuse infiltrative lymphocytosis syndrome (DILS) in human immunodeficiency virus type 1 (HIV-1)-positive outpatients.

METHODS

The presence of sicca symptoms and visible salivary gland enlargement was determined by interview and physical examination, and the clinical stage was determined by chart review, in 523 HIV-positive patients. The diagnosis of DILS was established in those with parotid gland enlargement by minor salivary gland biopsy or radionuclide scintigraphy.

RESULTS

Definite DILS was found in 15 (3%) of the 523 patients, and possible DILS in 18 (3.4%). The prevalence of definite DILS was significantly higher in African Americans (4.5%). Self-reported facial swelling and xerophthalmia that was not explained by the effects of medication were found more frequently in those with DILS than in the non-DILS patients. Patients with DILS had higher CD8 counts (mean +/- SD 1,456 +/- 813/mm3) compared with those without DILS (934 +/- 624/mm3; P < 1 x 10(-6)), and were less advanced in their HIV clinical stage (Centers for Disease Control and Prevention stages A or B in 76% compared with 60% of the non-DILS group; P = 0.01).

CONCLUSION

DILS is an important problem in HIV-infected outpatients and tends to occur in patients whose clinical disease is at a less advanced stage. Patients with parotid gland enlargement accompanied by sicca symptoms should be screened for HIV infection.

Parotid gland swelling in HIV diffuse infiltrative CD8 lymphocytosis syndrome

HIV can affect salivary gland tissue. Parotid swellings have been observed in a subset of patients who are HIV-positive; the swellings are the result of a condition that has been termed diffuse infiltrative CD8 lymphocytosis syndrome. Initially the glandular enlargement results from a massive CD8 cell lymphoproliferation, but with time lymphoepithelial cysts become manifest. Two case reports are presented to illustrate this progression of diffuse infiltrative CD8 lymphocytosis.

Haplotype HLA-B8-DR3 Confers Susceptibility to Hepatitis C Virus-Related Mixed Cryoglobulinemia

Our aim was to investigate whether host genetic factors are involved in the onset of hepatitis C virus (HCV)-related mixed cryoglobulinemia (MC). We studied 25 consecutive patients presenting with a full-blown clinical picture of MC by physical examination, blood chemistry, assessment of cryoglobulins and their composition, nonorgan-specific autoantibodies, antibodies to HCV, serum HCV RNA, and HLA polymorphism. Biopsies of liver, bone marrow, and minor salivary glands were also performed in a number of patients. HLA results were compared with those of normal controls and patients with chronic HCV infection without MC and negative for autoimmune phenomena (pathological controls). Type II MC was found in 14 of 25 patients (56%), and type III MC was found in the remaining 11 (44%). All patients were positive for antibodies to HCV and/or serum HCV RNA. HLA-B8 was found in 40% (10 of 25) of patients compared with 10.1% (38 of 377) of normal controls (P = .00003, Pcorrected = .0005, relative risk [RR] 5.9) and 6.7% (2 of 30) of pathological controls (P = .007, Pcorrected = not significant). As for class II HLA molecules, only DR3 was significantly more frequent in MC patients (40%, 10 of 25) than in normal controls (15.1%, 57 of 377; P = .003, Pcorrected= .03, RR 3.7). Odds ratio (OR) for the risk of developing MC was calculated in patients positive for B8 and/or DR3, and the highest OR (8.2) was observed in individuals possessing both. The results suggest that the development of HCV-related MC is associated with HLA-B8 and DR3 markers.

Haplotype HLA-B8-DR3 Confers Susceptibility to Hepatitis C Virus-Related Mixed Cryoglobulinemia

Our aim was to investigate whether host genetic factors are involved in the onset of hepatitis C virus (HCV)-related mixed cryoglobulinemia (MC). We studied 25 consecutive patients presenting with a full-blown clinical picture of MC by physical examination, blood chemistry, assessment of cryoglobulins and their composition, nonorgan-specific autoantibodies, antibodies to HCV, serum HCV RNA, and HLA polymorphism. Biopsies of liver, bone marrow, and minor salivary glands were also performed in a number of patients. HLA results were compared with those of normal controls and patients with chronic HCV infection without MC and negative for autoimmune phenomena (pathological controls). Type II MC was found in 14 of 25 patients (56%), and type III MC was found in the remaining 11 (44%). All patients were positive for antibodies to HCV and/or serum HCV RNA. HLA-B8 was found in 40% (10 of 25) of patients compared with 10.1% (38 of 377) of normal controls (P = .00003, Pcorrected = .0005, relative risk [RR] 5.9) and 6.7% (2 of 30) of pathological controls (P = .007, Pcorrected = not significant). As for class II HLA molecules, only DR3 was significantly more frequent in MC patients (40%, 10 of 25) than in normal controls (15.1%, 57 of 377; P = .003, Pcorrected= .03, RR 3.7). Odds ratio (OR) for the risk of developing MC was calculated in patients positive for B8 and/or DR3, and the highest OR (8.2) was observed in individuals possessing both. The results suggest that the development of HCV-related MC is associated with HLA-B8 and DR3 markers.

A comparison of intraoral Candida carriage in Sjögren's syndrome patients with healthy xerostomic controls

OBJECTIVE

Determination of the incidence of Candida carriage in patients with Sjögren's syndrome (SS) and xerostomic controls to assess the influence of immunologic disturbances in SS on carriage.

STUDY DESIGN

A total of 16 primary SS patients, 12 secondary SS patients, and 14 xerostomic controls were included in the study. Sampling was performed using an oral rinse method. Aliquots (100 microliters) were spread onto CHROMagar* and incubated for 48 hours. Species identification was confirmed by the germ tube test and API ID32C. Total colony-forming units per milliliter (CFU/ml) were counted and statistical analyses performed by the Kruskal-Wallis test.

RESULTS

Candida carriage in primary SS, secondary SS, and xerostomic patients was 81.25%, 66.7%, and 71.4%, respectively. There were no statistically significant differences in total CFU/ml. A wide range of species was isolated in each group.

CONCLUSION

The immunologic disturbances seen in SS do not significantly influence the intraoral Candida carriage in patients with a dry mouth.

Investigation of the clinical value of total saliva flow rates

The symptom of dry mouth was correlated with unstimulated (UWSFR) and stimulated (SWSFR) whole-saliva flow rate on chewing medical paraffin in 62 patients with dry-mouth complaints (30 with Sjögren's syndrome, 32 with sialosis) and 23 controls. The symptom of dry mouth was classified into grades 0,1,2,3,4 according to a Treatment Emergent Symptom Scale (TESS). UWSFR and SWSFR were determined after fasting in the morning. UWSFR was 0.070 +/- 0.089 ml/min in Sjögren's syndrome, 0.175 +/- 0.115 ml/min in sialosis, 0.330 +/- 0.188 ml/min in controls. SWSFR was 0.709 +/- 0.720 ml/min in Sjögren's syndrome, 1.561 +/- 0.867 ml/min in sialosis, 1.894 +/- 0.661 ml/min in controls. A highly significant correlation was found between TESS score and UWSFR and between TESS score and SWSFR. Only UWSFR was decreased in the patients with a TESS score of 1 or 2, while both UWSFR and SWSFR were significantly decreased in the patients with TESS scores of 3, 4. It is concluded that UWSFR is more sensitive in relation to dry-mouth complaints than SWSFR, and that a mild dry mouth is mainly related to decreased UWSFR.

Saliva: an additional diagnostic tool in Sjögren's syndrome

OBJECTIVE

To assess the available data and the place of salivary analysis in the diagnosis of Sjögren's syndrome (SS).

METHODS

A Medline search of English language articles published between 1985 and 1996 and a manual search of the reference lists of relevant articles formed the data sources. These were combined with our clinical and experimental experience in this field. Each method of salivary analysis was assessed according to study design, type of saliva used for the study, sensitivity/ specificity for the diagnosis of SS, and correlation to the histopathological findings.

RESULTS

Increased levels of salivary Na+, immunoglobulins (particularly IgA), anti-Ro and La antibodies, lactoferrin, lysozyme, beta 2 microglobulin, prostaglandin E2, thromboxane B2, interleukin-6, and hyaluronic acid have been detected in various studies. Results varied according to the different methods used for saliva collection.

CONCLUSION

Although many changes have been detected in various constituents of saliva in SS patients, no test has proved sensitive or specific enough for diagnosing SS.

Neuropeptides of the autonomic nervous system in Sjögren's syndrome

OBJECTIVE

To assess the activity level of the autonomic nervous system in Sjögren's syndrome (SS) and to correlate this with stress.

METHODS

Patients with SS (n = 12) and healthy controls (n = 10) were analysed for the content of vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY) in their stimulated saliva by radioimmunoassays and for stress by the use of a modified Jenkins Activity Survey (JAS).

RESULTS

The data are expressed as median (interquartile range). Salivary VIP output (pg/min) and NPY output (pg/min) were high in SS compared with healthy controls (30.0 (15.6, 36.6) versus 12.3 (9.2, 24.0), p = 0.045, 4.8 (0.6, 24.1) versus 0.7 (0.0, 2.4), p = 0.038, respectively). Patients experienced only a little, but not significantly, more stress than the healthy controls (stress index -2.8 (-7.7, 6.9) versus -5.2 (-12.9, 2.7), p > 0.05). Stress in general was associated with high salivary VIP concentrations (r = 0.41, p = 0.05).

CONCLUSIONS

These findings show that adequately processed saliva (containing aprotinin and EDTA as neuropeptidase inhibitors) contains measurable amounts of marker peptides of the autonomic nervous system. Secondly, VIP concentration but not output may be affected by stress, which may act by decreasing watery salivary flow. In patients with SS, VIP and NPY outputs are increased. This may indicate increased leakage into saliva or efforts to compensate for the diminished salivary flow, or both.

Association of a new allele of the TAP2 gene, TAP2*Bky2 (Val577), with susceptibility to Sjögren's syndrome

OBJECTIVE

To investigate the polymorphisms of TAP (transporters associated with antigen processing) genes among patients with primary Sjögren's syndrome (SS) in order to clarify the potential association of the polymorphisms with disease susceptibility.

METHODS

Polymorphisms of the TAP1 and TAP2 genes in 108 Japanese SS patients were determined by analyzing TAP genes using the polymerase chain reaction-single-stranded conformation polymorphism technique.

RESULTS

The allelic frequency of the TAP1 gene was not significantly different between SS patients and normal subjects. In addition to all known TAP2 alleles, a new allele (Bky2), which had a unique substitution at codon 577 (ATG-->GTG: Met-->Val), was identified in both groups. The allelic frequency of Bky2 was significantly higher in SS patients (12.0%) than in normal subjects (5.1%) (P < 0.05). Moreover, a significantly greater frequency of SS-A antibody was found among SS patients with Bky2 (18 of 23; 78%) than among those without Bky2 (33 of 85; 39%) (P = 0.001).

CONCLUSION

The mutation in TAP2 (Val577) may be involved in SS-A autoantibody production and could be a genetic factor that determines susceptibility to SS.

Association of Sjögren's syndrome with hereditary angioneurotic edema: report of a case

A case of hereditary angioneurotic edema (HANE) associated with Sjögren's syndrome is presented. One of the members of a pedigree of HANE due to deficiency of C1 inhibitor (C1INH) had a positive titer for anti-SS-A and anti-SS-B antibodies in the serum, complaining of symptom of dry eyes and dry mouth. A lip biopsy revealed lymphocytic infiltration of minor salivary glands. The patient had renal tubular acidosis (RTA). Thus the patient was diagnosed as suffering from Sjögren's syndrome with RTA.

Oral pilocarpine HCl stimulates labial (minor) salivary gland flow in patients with Sjögren's syndrome

Pilocarpine HCl has been shown to stimulate parotid and submandibular gland salivary flow. The purpose of this study was to determine whether this cholinergic-muscarinic drug also stimulates labial (minor) salivary gland (LSG) flow and to relate that with whole unstimulated salivary (WUS) flow rates. Subjects diagnosed with primary Sjögren's syndrome (SS-1; n = 9) or secondary Sjögren's syndrome (SS-2; n = 9) were enrolled in this study after meeting stringent enrollment criteria. An age-gender matched control group was also enrolled. The labial saliva was collected in a standardized manner on Periopaper for 5 min and the volume was analysed by the Periotron. Whole unstimulated salivary samples were collected for 5 min by the method of Mandel and Wotman (1976). Each subject was dosed with pilocarpine HCl (5 mg; tablets; p.o.). After 60 min the LSG flow as well as the WUS flow was determined again as previously. The results indicated a significant (> 180%) increase in both labial salivary gland flow as well as whole salivary flow in the SS-1 and SS-2 subjects (mean +/- s.e.m.): [SS-1: WUS = 0.1080 +/- 0.03 vs 0.2242 +/- 0.03 ml per 5 min; LSG = 93.1 +/- 22.2 vs 167.8 +/- 15.9 microliters/5 min; P < 0.001; SS-2: WUS = 0.1384 +/- 0.02 vs 0.2775 +/- 0.09 ml per 5 min; LSG = 97.7 +/- 20.2 vs 182.8 +/- 17.9 microliters per 5 min; P < 0.001]. These results indicate a significant increase in labial salivary gland flow as well as whole salivary flow as stimulated by pilocarpine HCl in Sjögren's syndrome patients.

Indicators of salivary gland inflammation in primary Sjogren's syndrome

The aim of this study was to establish additional indicators in saliva and plasma which are associated with salivary gland inflammation in patients with primary Sjögren's syndrome (SS). ELISA assays were used to determine the concentrations of sICAM-1, sVCAM-1, sIL-2R alpha, IgA, IgG, calprotectin and albumin in parotid saliva, whole saliva and plasma samples. Soluble ICAM-1 was present in whole and parotid saliva samples from primary SS patients. Soluble VCAM-1 and sIL-2R alpha could not be detected in salivary samples from either primary SS or control subjects. IgA, IgG, calprotectin and albumin concentrations were higher in both whole and parotid saliva in the patient group compared with the control group. The results showed increased levels of calprotectin in all saliva samples compared to plasma, suggesting that calprotectin may be locally produced. Increased plasma values of sICAM-1, sVCAM-1, sIL-2R alpha, IgA, IgG and calprotectin were detected in primary SS patients when compared to controls. The output/min of IgA, IgG, calprotectin and albumin was decreased in SS patients. Plasma levels of various proteins could offer information concerning glandular and extraglandular inflammatory processes. However, salivary levels of these proteins (particularly sICAM-1) tend to reflect more the local inflammatory activity, providing a convenient and non-invasive tool for diagnosis.

Salivary gland scintigraphy with 99mTc-pertechnetate in Sjögren's syndrome: relationship to clinicopathologic features of salivary and lacrimal glands

Salivary gland scintigraphy was performed on 52 patients who were suspected of having Sjögren's syndrome (SS), and the results were compared with clinicopathologic features of the salivary and lacrimal glands. The time-activity curves which were obtained from computer-assisted analysis of 99mTc-pertechnetate (99mTc) scintigraphy were classified into four types (normal, median, flat and sloped types). The stimulated parotid flow rate decreased and the incidence of SS-related sialographic and histopathologic findings increased significantly as the scintigraphic abnormality advanced. In addition, the lacrimal gland function decreased and the proportion of patients diagnosed as having keratoconjunctivitis sicca (KCS) increased significantly as the scintigraphic abnormality advanced. These results indicate that the results of scintigraphy are related not only to the clinicopathologic features of the salivary glands but also to the lacrimal gland function in SS.

Immunohistochemical characterization of the cellular infiltrates in Sjögren's syndrome, rheumatoid arthritis and osteoarthritis with special reference to calprotectin-producing cells

The aim of this study was to analyse the nature of infiltrating cells in minor salivary glands of patients with Sjögren's syndrome (SS). Furthermore, we wanted to characterize the tissue distribution of calprotectin-producing cells in inflamed salivary gland tissue of SS and in synovial tissue of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Cryostat sections of labial salivary gland tissue from patients with SS and synovial tissue from RA and OA patients were stained (ABC-immunoperoxidase technique) using monoclonal antibodies (MoAbs) to T cells (CD3), monocytes/macrophages (CD14, CD68), and calprotectin. Monocytes and macrophages were widely distributed in focal infiltrates of salivary gland tissue from SS patients. Calprotectin markers showed a distinct staining of infiltrating macrophages and around blood vessel walls. In synovial tissue samples, calprotectin was expressed in a high percentage of cells in the synovial lining, the subsynovium, and vessel walls. The percentages of cells stained for calprotectin were significantly higher in RA than in OA and SS tissues. Antibodies to the calprotectin complex stained cells with a similar distribution as antibodies against the separate polypeptide chains of calprotectin. The localization and differentiated expression of calprotectin in these chronic inflammatory conditions indicate a role in the inflammatory process and may be an additional marker of macrophages/granulocytes in SS, RA and OA.

Utility and safety of parotid gland biopsy in Sjögren's syndrome

Parotid gland biopsy was performed in 32 female patients affected by suspected Sjögren's syndrome. In all cases histologic findings were in agreement with this diagnosis and in two subjects led us to detect the malignant transformation into lymphoma. None of the patients developed relevant complications. Our study indicates that parotid gland biopsy in Sjögren's syndrome is a safe procedure and may be useful in performing diagnosis.

Orofacial radiological manifestations of systemic sclerosis

OBJECTIVE

To ascertain the orofacial radiological manifestations of systemic sclerosis.

METHODS

Twenty-one patients with known systemic sclerosis underwent panoramic, and where appropriate periapical, radiography parotid sialography and a labial gland biopsy.

RESULTS

The prevalence of periodontal ligament space widening was 33%, bone resorption 9.5% and abnormal parotid gland sialographic findings 43%. Root resorption affected 4 (33%) of the 12 dentate patients.

CONCLUSIONS

Orofacial radiological manifestations occur commonly in systemic sclerosis. Root resorption has not previously been reported.

Etiologies of the sicca syndrome: primary systemic amyloidosis and others

BACKGROUND

The sicca syndrome has been defined as the occurrence of xerostomia and xerophthalmia. Sjögren's syndrome is the most common cause of the sicca syndrome; however, these two syndromes are not synonymous and there are many potential etiologies of the sicca syndrome. A less known cause of sicca syndrome is amyloidosis that to date has only been reported in the nondermatology literature.

OBSERVATIONS

A 79-year-old man with known amyloidosis presented with persistent xerostomia. He had the classic cutaneous findings of periorbital and "pinch" purpura. A labial biopsy showed diffuse deposition of amorphous eosinophilic material surrounding salivary acini. Apple-green birefringence was noted with Congo red staining and the diagnosis was made of amyloidosis in the minor salivary glands causing xerostomia.

CONCLUSIONS

The sicca syndrome can be caused by systemic amyloidosis. Because this fact is not in the dermatologic literature, many dermatologists are not aware of this uncommon presentation. The knowledge of the many causes of the sicca syndrome and an understanding of the differences between this and Sjögren's syndromes are important for any dermatologist.

Neutral endopeptidase (EC 3.4.24.11) in labial salivary glands in healthy controls and in patients with Sjögren's syndrome

OBJECTIVE

Neuropeptides from nerve fibres can cause neurogenic inflammation. The potency of these peptides in vitro has led to the hypothesis that enzyme degradative systems are operative in vivo to limit their action. To consider this question neutral endopeptidase (NEP) in labial salivary glands in patients with Sjögren's syndrome was studied.

METHODS

Synthesis of NEP mRNA in situ in labial salivary glands was studied using the reverse transcriptase polymerase chain reaction (RT-PCR). Immunohistochemical staining was used to localise the NEP enzyme protein and its neuropeptide substrates and fluorophotometry to measure the corresponding enzyme activities in saliva.

RESULTS

NEP was found in nerve fibres and in perivascular, periductal, and periacinar axon terminal varicosities. Double labelling of PGP 9.5 and NEP confirmed this neuronal localisation of NEP. Although some fibroblast-like cells and occasional intravascular neutrophils were NEP positive, NEP mRNA was not found in labial salivary glands. Patients with Sjögren's syndrome and healthy controls did not have nerves containing NEP or neuropeptides (vasoactive intestinal peptide, substance P, or calcitonin gene related peptide (CGRP)) in lymphocyte foci. Salivary NEP activity was not decreased in patients compared with controls.

CONCLUSION

NEP in labial salivary glands is almost totally of neuronal origin and plays a part in proteolytic modulation of neuropeptides in salivary glands and saliva. These regulatory interactions seem to be altered in focal lymphocyte accumulations in Sjögren's syndrome.

Differentiation of dry mouth etiology

Dry mouth is a common complaint. While it is often considered to be synonymous with the diagnosis of salivary gland disease, this is not the case. There are many causes of the symptomatic complaint of oral dryness, both salivary and non-salivary. This paper will review the causes of "dry mouth" and the means of establishing the underlying diagnosis.

Current concepts of autoimmune exocrinopathy: immunologic mechanisms in the salivary pathology of Sjögren's syndrome

Sjögren's syndrome is a systemic autoimmune disorder characterized by symptoms of oral and ocular dryness and a chronic, progressive loss of salivary and lacrimal function. The exocrine involvement is the result of a focal, peri-ductal mononuclear cell infiltrate and the subsequent loss of secretory epithelial cells. The mechanisms of this autoimmune exocrinopathy are not understood fully. Many recent investigations have described alterations in a number of immune mediators within the salivary glands. These studies provide new insights into the immune regulation of normal salivary gland functions and the mechanisms of gland damage in Sjögren's syndrome.

Sjogren's syndrome: clinical spectrum and current diagnostic controversies

Although we have had a useful and internationally agreed-upon definition of Sjögren's syndrome (SS) for more than 30 years, we have not yet agreed upon criteria for diagnosing it. Understanding the clinical spectrum of SS and the various tests used to diagnose its components provides a basis for discussing controversies about diagnostic criteria. A review of the clinical features of SS and their diagnostic tests is followed by assessments of seven sets of diagnostic criteria and a proposal for future criteria. The various existing criteria use different combinations of clinical features and tests, which results in populations of different sizes and homogeneities being given the diagnosis of SS. Some criteria propose alternative tests in diagnosing components of SS, while others do not. Internationally accepted diagnostic criteria for SS that are as disease-specific as possible are needed for us to learn the epidemiology, pathogenesis, treatment, and prognosis of this clinically and scientifically important disease.

Lymphoma in Sjögren's syndrome. From histopathology to molecular pathology

A number of autoimmune diseases predispose to the development of neoplasia. A particularly well-recognized association is the development of lymphoma in Sjögren's syndrome. Although this risk has been estimated to be 44 times that of the general population, few reliable prognostic indexes exist for individual patients. Recent advances in molecular biology have improved our understanding of Sjögren's syndrome and permitted better characterization of the generalized lymphoproliferation associated with the condition. This article reviews the histopathology of the major and minor salivary gland lesions of Sjögren's syndrome and discusses advances in molecular biology that have permitted more accurate prediction of lymphoma development in this group of patients.

Salivary eicosanoid concentration in patients with Sjögren's syndrome

OBJECTIVE

To investigate eicosanoid concentrations in the saliva of patients with primary Sjögren's syndrome (SS).

METHODS

Whole mixed saliva of 36 subjects was assayed for eicosanoid concentrations using a radioimmunoassay. Patients with primary SS having positive lip biopsy served as the study group; their results were compared with data from patients with dry mouth and negative lip biopsy (dry mouth group), and with a group of normal healthy controls.

RESULTS

Concentrations of thromboxane B2 were significantly (p < 0.01) increased in 18 patients with primary SS compared with 10 patients with dry mouth and eight healthy normal controls (1.95 (SD 0.51) ng/ml saliva compared with 0.52 (0.1) ng/ml and 0.3 (0.1) ng/ml, respectively). Similarly, prostaglandin E2 concentrations were also significantly increased (p < 0.01) in 11 patients with primary SS compared with five patients with dry mouth and eight normal controls (3.75 (0.82) ng/ml saliva compared with 0.32 (0.1) ng/ml and 0.41 (0.1) ng/ml, respectively).

CONCLUSION

Salivary concentrations of eicosanoids are significantly increased in patients with primary SS, and this may prove helpful in the diagnosis of this disease.

Sjögren's in adult Still's disease?

The objective of the study was to search for clinical, ophthalmological and serological manifestations of Sjögren's syndrome in patients with adult onset Still's Disease (AOSD). Eight consecutive patients with AOSD were evaluated. In all cases a standardized questionnaire to disclose sicca symptoms as well as extraglandular manifestations commonly associated with Sjögren's syndrome(SS) was conducted. Ophthalmological and serological evaluation was undertaken in all patients. Oral involvement was investigated by minor salivary gland biopsy in 7 patients. One case presented symptomatic keratoconjunctivitis sicca and grade III Chisholm labial biopsy. A further 2 patients had grade IV (4 foci per 4 mm2) salivary gland biopsy, in the absence of xerostomia or xerophthalmia. The search for autoantibodies proved negative throughout. It was concluded that focal sialoadenitis was not uncommon in our patients with AOSD. Whether this finding corresponds to a true SS is not yet clearly determined.

Assessment of the European classification criteria for Sjögren's syndrome in a series of clinically defined cases: results of a prospective multicentre study. The European Study Group on Diagnostic Criteria for Sjögren's Syndrome

OBJECTIVE

To assess the recently proposed preliminary criteria for the classification of Sjögren's syndrome (SS) in a multicentre European study of a new series of clinically defined cases.

METHODS

The criteria included six items: I = ocular symptoms; II = oral symptoms; III = evidence of keratoconjunctivitis sicca; IV = focal sialoadenitis by minor salivary gland biopsy; V = instrumental evidence of salivary gland involvement; VI = presence of autoantibodies. Each centre was asked to provide five patients with primary SS, five with secondary SS, five with connective tissue diseases (CTD) but without SS, and five controls (patients with ocular or oral features that may simulate SS). The preliminary six item classification criteria set was applied to both the SS patients and the non-SS controls, and the performance of the criteria in terms of sensitivity and specificity was tested.

RESULTS

The criteria set was tested on a total of 278 cases (157 SS patients and 121 non-SS controls) collected from 16 centres in 10 countries. At least four of the six items in the criteria set (limiting item VI to the presence of Ro(SS-A) or La(SS-B) antibodies) were present in 79 of 81 patients initially classified as having primary SS (sensitivity 97.5%), but in only seven of 121 non-SS controls (specificity 94.2%). When the presence of item I or II plus any two of items III-V of the criteria set was considered as indicative of secondary SS, 97.3% (71 of 73) of the patients initially defined as having this disorder and 91.8% (45 of 49) of the control patients with CTD without SS were correctly classified.

CONCLUSION

This prospective study confirmed the high validity and reliability of the classification criteria for SS recently proposed by the European Community Study Group.

Sjoegren's syndrome: MR imaging of the parotid gland

To date, myoepithelial sialoadenitis (Sjoegren's syndrome) has been diagnosed with sialography and other techniques. First results of MR imaging offer new possibilities in the diagnostic imaging of this disease. Thirty-six patients with immunohistologically and serologically confirmed Sjoegren's syndrome and 25 patients suffering from other diseases, included as a control group, were examined by MR in transverse and coronal orientation. T-2-weighted sequences (TR/TE 1600/25/90) and T1-weighted sequences (TR/TE 500/25 ms) plain and after Gd-DTPA administration were obtained. In all patients the parotid gland showed characteristic internal patterns and abnormalities in gland size. There was a nonhomogeneous internal pattern with a characteristic speckled, honeycomb-like appearance visible especially on T2-weighted sequences. Enhancement with Gd-DTPA yielded no additional information. A staging system with four stages of Sjoegren's syndrome (no characteristic changes to a nodular and swollen gland) was developed. Magnetic resonance has become an important new tool in assessing parotid gland changes in patients suffering from Sjoegren's syndrome, and could well replace the more invasive and unpleasant diagnostic methods in the near future.