Salivary gland function in Sjögren's syndrome: a review

Diagnostic utility of Acoustic Radiation Force Impulse (ARFI) imaging in primary Sjoegren`s syndrome

OBJECTIVES

The purpose of the study was to assess the diagnostic utility of acoustic radiation force impulse (ARFI) imaging in primary Sjögren's syndrome (pSS).

METHODS

One hundred fifty-seven patients with sicca symptoms and/or salivary gland swelling were included. Sicca symptoms, Schirmer test, unstimulated whole saliva (UWS), SS-A/B antibodies, and histology were assessed according to American-European Consensus group (AECG) criteria. All patients underwent high-resolution ultrasound and ARFI imaging of the parotid (PG) and submandibular glands (SMG).

RESULTS

Seventy patients were classified as having pSS. The remaining 87 patients suffered from idiopathic sicca (n = 24), rheumatoid arthritis (n = 12), sarcoidosis (n = 9), cutaneous/systemic lupus erythematosus (n = 7), scleroderma (n = 2), dermatomyositis (n = 1), HBV/HCV (n = 2), and panarteritis nodosa (n = 1), and disorders in 29 patients were classified as not otherwise specified. ARFI values of the PG were significantly higher in the pSS versus non-pSS groups (2.86 ± 0.07 m/s vs. 2.15 ± 0.11 m/s, p < 0.0001). ARFI imaging demonstrated diagnostic sensitivity and specificity of 81 % and 67 %, respectively.

CONCLUSIONS

In addition to histology, ARFI imaging was the most important diagnostic tool for identifying early pSS.

KEY POINTS

• Early stages in Sjögren's syndrome become apparent with major salivary gland enlargements. • Schirmer and unstimulated whole saliva tests demonstrated insufficient sensitivity/specificity for early-stage diagnosis. • Acoustic radiation force impulse imaging is a reliable tool for diagnosing early disease stages.

[Diagnostic validity of dynamic salivary gland scintigraphy with ascorbic acid stimulation in patients with Sjögren's syndrome: comparation with unstimulated whole sialometry]

BACKGROUND/AIM

Beside many actual groups of classification criteria, uniform classification criteria for Sjögren's syndrome (SS) are still missing. The ophtalmic component of SS is well defined. Criteria for classifying its oral component remain controversial. The fifth item of the European Union and the United States of America (EU-US) revised diagnostic classification criteria in 2002, is an objective evidence of xerostomia, diagnosed by one of the tests: unstimulated whole sialometry (UWS), parotid sialography, and dynamic salivary gland scintigraphy (DSGS). The aim of this study was to evaluate senstitivity, specificity, positive and negative predictive value and accuracy of DSGS with ascorbic acid stimulation in detecting xerostomia in SS patients and to compare DSGS findings with UWS values.

METHODS

Tests DSGS and UWS were done in 20 patients with SS and in 10 of the control subjects. The findings of DSGS were graded from 1 to 4 scintigraphie (SCT) grade 1--normal finding; SCT grade 2--moderate function damage; SCT grade 3--serious function damage, SCT grade 4--very serious function damage. UWS measured 1.5 hour after the breakfast lasted 15 minutes. UWS bellow 2.5 ml/15min min. considered pathological.

RESULTS

All SS patients had pathological SCT findings. Comparing SCT grade between the patients and the control group, high statistical significance was found (p < 0.001). The estimated sensitivity of DSGS was 100%, specificity 80%, positive predictive value 91%, negative predictive value 100% and accuracy 93%. The calculated sensitivity of UWS was 75%. Salivary function damage detected by scintigraphy was in positive correlation with UWS findings.

CONCLUSION

DSGS is a diagnostic test with high sensitivity, specificity, accuracy and positive and negative predictive values in detecting salivary function damage in SS patients. DSGS and UWS are very sensitive diagnostic tests for objective evidence of xerostomia, and have to be ones of the earliest investigations which shoud be performed in subjects suspected of SS. Test DSGS is more sensitive, and seems to better reflect symptoms of dry mouth than UWS.

Salivary electrophoresis in the diagnosis of Sjögren's syndrome

OBJECTIVE

The purpose of this study was to investigate the potential use of salivary electrophoresis for the diagnosis of Sjögren's syndrome.

METHODS

Salivary protein profiles of 43 patients and 39 healthy control subjects were compared on three different gel electrophoresis systems: sodium dodecylsulfate-polyacrylamide gel electrophoresis, anionic polyacrylamide gel electrophoresis, and immobilized pH gradient gel electrophoresis (isoelectric point, 3.5-5.0).

RESULTS

Most of the patients with Sjögren's syndrome exhibited an electrophoretic profile that was different from that of the healthy control subjects. Among the three gel electrophoresis systems examined, the immobilized pH gradient system appeared to be the most reliable for Sjögren's syndrome. Tests of accuracy revealed that the immobilized pH gradient system exhibits high specificity (97%), sensitivity (95%), positive predictive value (97%), and negative predictive value (95%) in the diagnosis of Sjögren's syndrome.

CONCLUSIONS

Our results suggest that salivary electrophoresis is a potentially useful test for the diagnosis of Sjögren's syndrome.

Pancreatic exocrine involvement in primary Sjögren's syndrome

Exocrine pancreatic involvement of primary Sjögren's syndrome (SS) was studied. Pancreatic enzyme levels (total amylase, pancreatic isoamylase and immunoreactive trypsin) along with anti-ductuli antibodies (Ab) were studied in 77 patients with primary SS. In 10 patients with normal and 10 with abnormal enzyme levels pancreatic CT scans were also obtained. All enzyme levels were significantly increased in comparison to the control group. Immunoreactive trypsin was found to be the most frequently increased enzyme (35.3% of pSS patients). Anti-ductuli Ab were not found in any patient. Pancreatic CT scans were normal in all subjects with enzymatic increase, whereas 2 abnormal scans were demonstrated in patients without enzyme changes. Our study suggests that exocrine pancreatic involvement is frequent when measured by enzyme levels. Nevertheless, we were unable to demonstrate any morphological lesion by CT scan.

Healing of experimental wounds in sialadenectomized rat

The present study evaluates the healing of an experimental standardized full thickness excisional wound in the palate of a sialadenectomized rat model. Experimental rats underwent sialadenectomy of the submandibular and sublingual glands and ligation of the parotid ducts. A full thickness circular wound, 3 mm in diameter, was produced in the palate. Wound diameter was measured clinically and the area of inflammation and area of new connective tissue formation were determined histologically at 3, 7, 14, 21 and 28 days post-surgery. Wound diameter was similar in both the experimental and the control groups. The area of inflammation, however, was larger (p less than 0.05) in experimental rats at days 3, 7 and 14. New connective tissue formation was less (p less than 0.05) in sialadenectomized rats at days 14 and 21. The present results indicate that palatal wound healing is altered and delayed in sialadenectomized rats.

The periodontal status of patients with Sjögren's syndrome

Sjögren's syndrome (SS) is a chronic inflammatory disease characterized by xerostomia. Although a common observation in SS is increased susceptibility to caries, the level of periodontal disease has not been described in these individuals. The purpose of this study was to determine the periodontal status of 14 SS female subjects who had a mean age of 52.9 +/- 11.6 years. Plaque, gingival, and calculus indices as well as probing depth (PD) and attachment level (AL) were determined on 7 index teeth in each subject. Result indicated that individuals with Sjögren's Syndrome did not exhibit significant periodontal disease.

Sjögren's syndrome in systemic sclerosis. A clinical study of 26 patients

Features of Sjögren's syndrome were sought in 26 patients with systemic sclerosis and in age- and sex-matched control subjects. The assessments included a structured history to establish symptoms of dry eyes and dry mouth. Schirmer's I and II tear tests. Rose Bengal staining with slit lamp microscopy of the eyes, measurement of basal and stimulatory salivary secretion. We measured sweat secretion rates from the skin. Salivary scintigraphy and skin biopsies were performed on the patients. Only one patient showed the complete picture of Sjögren's syndrome with both clinical and investigational evidence of lacrimal and salivary gland involvement. A further patient had an abnormal Schirmer's II test and xerostomia with reduced salivary secretion and an abnormal scan, but no ocular symptoms and no keratoconjunctivitis sicca on ophthalmological examination. Two patients had reduced salivary flow and a dry mouth. A number of patients and control subjects showed various individual symptoms and signs of lacrimal and salivary disorders. These features alone are not sufficient for the diagnosis of Sjögren's syndrome. There is a clear need to adopt strict criteria for diagnosing the condition. The association of Sjögren's syndrome with systemic sclerosis seems doubtful and if it does occur it is very much less common than previously suggested.

Minor salivary gland swelling in patient with Sjögren's syndrome

A case of Sjögren's syndrome with an unusual minor salivary gland swelling is reported. The patient was a 63-year-old female with a chief complaint of palatal swelling and dry mouth. Clinical examination revealed diffuse swelling of the hard palate and bilateral parotid regions, and sialographic examination of the parotid gland showed evidence of sialoangiectasia. Histopathological findings of the palatal and parotid lesions revealed intense lymphoid cell infiltration replacing the salivary gland parenchyma, and scattered epimyoepithelial islands throughout the lesions. Although it is well known that major salivary gland swelling caused by marked lymphoid cell infiltration is one of the common features in patients with Sjögren's syndrome, a similar swelling in the region of the minor salivary glands is not usually apparent.

[Is the target of anti-cardiolipin antibodies the same in Gougerot-Sjögren syndrome and lupus erythematosus disseminatus?]

Forty-seven patients were diagnosed as having systemic lupus erythematosus (SLE) and 34 patients primary Sjögren's syndrome (SS); 30 controls were also studied. Anti cardiolipin (CL), anti double-stranded DNA (ds DNA) and anti single-stranded DNA (ss DNA) antibodies were determined by the enzyme-linked immunosorbent assay. Elevated anti-CL antibody levels were detected in 47.8 p. 100 (n = 46) of patients with SLE and in 85.3 p. 100 (n = 34) of patients with SS, but only once in controls. Elevated ss DNA were detected in 91.5 p. 100 (n = 47) of patients with SLE and in 18.3 p. 100 of patients with SS but never in controls. Elevated anti-ss DNA were detected in 93.3 p. 100 and 97.1 p. 100 respectively of patients with SLE and SS and in 3.3 p. 100 of controls. There was no correlation between anti-CL and thrombosis, circulating lupus anti coagulant or VDRL. The most striking association, however, was between anti-CL and anti ss-DNA antibodies in SLE. There was no correlation between anti-CL and anti ds-DNA antibodies in SLE patients. Anti CL antibodies were correlated both to ss-DNA and anti ds-DNA in SS patients. Absorption of positive anti-CL antibodies sera were done on DNA (ss-DNA and ds-DNA) affinity column chromatography: anti-CL antibodies were absorbed only by ss DNA in SLE and by both ss DNA and ds DNA in SS.

Sjögren's syndrome: clinical and laboratory features, immunopathogenesis, and management

Sjögren's syndrome may be accompanied by local oral problems such as dry mouth, rampant caries, candidosis, or sialadenitis, but it is a systemic autoimmune disorder with wide repercussions, including a small premalignant potential. This article reviews the clinical and immunopathogenic features, as well as the etiology, of Sjögren's syndrome and discusses the diagnosis and management of oral complications.

Lipid composition and viscosity of parotid saliva in Sjögren syndrome in man

Extraction of the dialysed and lyophilized saliva of patients with this syndrome by chloroform-methanol yielded 15.9 +/- 2.4 mg of lipid/100 ml of secretion, a level 2-times higher than in normal individuals. The saliva of such patients also had 3-times more glycolipid and 20-times more phospholipid than normal, but differences in the content of neutral lipids were less apparent. The neutral lipids, however, had higher proportions of glycerides, and lower proportions of cholesterol and cholesteryl esters than normal. Viscosity measurements, made with a cone/plate viscometer at shear rates between 1.15 and 230 s-1, revealed similarities between the saliva of normal individuals and Sjögren's syndrome.

Salivary secretion and connective tissue disease in man

Parotid and submandibular gland secretions collected from patients with rheumatoid arthritis or systemic sclerosis have been analysed and the results compared with those obtained from a matched group of healthy individuals. Flow rates were measured and the saliva samples assayed for amylase, kallikrein, protein, and salivary IgA concentration. The results showed that only patients with rheumatoid arthritis had a reduced salivary flow, especially parotid flow, with a significantly increased concentration of salivary IgA in both parotid and submandibular saliva. Patients with systemic sclerosis did not show significantly altered salivary flow rates, but there was a marked depletion of salivary IgA content in both parotid and submandibular saliva. Neither disease states appeared to alter the kallikrein or amylase content of saliva. The possible clinical value of these findings is discussed.

The clinical picture of benign lympho-epithelial lesion

The histopathological diagnosis 'benign lympho-epithelial lesion' characterizes the major salivary gland disease in Sjögren's syndrome. It is not known if all cases with microscopically diagnosed benign lympho-epithelial lesion are variants of Sjögren's syndrome. The present clinical investigation showed that in 19 patients with the microscopical diagnosis of lympho-epithelial lesion, 84% fulfilled all criteria of Sjögren's syndrome. The rheumatoid factor and/or antinuclear factor was found in 84% and M-component was present in 16%. Sialography revealed sialectasis in all parotid glands. Salivary gland enlargement was found in 79%, and keratoconjunctivitis sicca in 89% of the patients. Systemic disease was found in 32%. The disease in the 2 patients with M-component took a malignant course, culminating in immunoblastic sarcoma and myelomatosis. The clinical diagnosis 'autoimmune sialadenitis' is proposed for the oral and salivary gland component is Sjögren's syndrome.

Effect of decreased salivation and pH on the adherence of Klebsiella species to human buccal epithelial cells

To assess the role of reduced salivary flow and intraoral pH on gram-negative bacterial colonization of the oropharynx, we studied in vitro Klebsiella adherence to normal human buccal epithelial cells at various pH values and to buccal cells from patients with pathological xerostomia (decreased saliva flow). Reduced pH significantly increased adherence of Klebsiella pneumoniae 84 to normal buccal epithelial cells (P less than 0.001). In contrast, two clinical isolates of K. oxytoca showed no significant pH-dependent change in adherence. A corollary of this was that patients with pathological xerostomia had significantly increased adherence of K. pneumoniae 84 to their buccal epithelial cells as compared with normal controls (P less than 0.01). These results suggest that reduced salivary flow and the concomitant reduction of intraoral pH may predispose patients to bacterial colonization with K. pneumoniae.

The effect of secretory immunoglobulin A on the in-vitro adherence of the yeast Candida albicans to human oral epithelial cells

Secretory immunoglobulin A (s-IgA) isolated from human breast milk inhibited the adherence of C. albicans to human oral epithelial cells. This inhibitory effect of s-IgA was maximal at 1 1/2 hours, it was concentration-dependent and was still detectable at subagglutinating antibody concentrations. The inhibitory action of s-IgA was due to its content of specific candidal antibody. Non-specifically bound s-IgA enhanced adherence of the yeast and presumably tends to impair the immune disposal of candida by specific antibody. The reduced adherence of candida pre-treated with 0.4 per cent formol saline at a concentration which kills the organism but leaves its surface antigens intact suggests that, although dead organisms may form an initial loose attachment to the epithelial surface, only viable organisms bind irreversibly. The specific-s-IgA appears to block surface sites on C. albicans involved in epithelial adherence but this action of s-IgA cannot be attributed solely to its agglutinating properties.

Prevalence and intraoral distribution of Candida albicans in Sjögren's syndrome

An imprint culture technique has been employed to study the prevalence and intraoral distribution of Candida albicans in 16 patients with Sjögren's syndrome and in 16 healthy controls matched for age, sex, and dental status. The prevalence and intraoral density of C. albicans was found to be significantly higher at almost all sites in the Sjögren's patients than in the controls. The distribution of candida was also altered, being significantly higher in the floor of the mouth and anterior labial sulcus in the Sjögren's group. There was an approximate inverse relationship between candida populations and rate of salivary flow. Mean candida densities were found to be significantly higher in those Sjögren's patients with detectable serum rheumatoid factor in the serum. However, patients with primary Sjögren's syndrome had significantly higher mean candida densities compared with patients with secondary Sjögren's syndrome.

Obstructive sialadenitis

The value of all the procedures which have been described for the investigation of disorders of the major salivary glands is discussed in so far as they aided the management of one bizarre case of obstructive submandibular sialadenitis. In particular an unusual indication for salivary gland scanning is also suggested.

Sialochemical examinations in non-tumorous parotid enlargements

Secretion rates and the composition of isolated parotid saliva samples were samples were examined in 51 patients suffering from chronic recurrent parotitis, sialosis, or Sjögren's syndrome, and in 17 healthy controls. Evaluation of the results indicated that sialochemical examination may provide a valuable help in the differential diagnosis of parotid diseases characterized by swelling of the gland. Chronic parotitis is characterized by a significantly decreased flow rate, extremely high sodium and protein concentration and lack of secretory response to stimulation. In Sjögren's syndrome the low flow rate was found to be associated with a decreased potassium secretion rate as well as decreased flow rate and decreased sodium concentration after stimulation. In sialosis, where flow rates display a considerable individual variation, a significant increase in potassium secretion rate could be revealed.

Oral swelling in Sjögren's syndrome

A case is reported of a 69-year-old female with Sjögren's syndrome who presented with a problem of interest to the oral surgeon. The clinical features and cryosurgical management of a rare cause of palatal swelling are described. The confusion that exists in the literature concerning the nomenclature of chronic inflammatory salivary gland lesions is discussed.

Improvement in lacrimal and salivary secretions after alkali therapy in Sjøgren's syndrome with renal tubular acidosis

A patient with Sjøgren's syndrome developed renal tubular acidosis which led to systemic acidosis and potassium depletion. Treatment with Shohl's solution and potassium supplements was followed by subjective improvement in tear flow, salivary flow, and by disappearance of bronchitic symptoms. Detailed objective assessments were then made during the next year, twice on treatment and twice without. These confirmed the subjective impression of improvement.

Sialochemistry in Sjögren's syndrome

The value of sialochemistry in the study of Sjögren's syndrome was explored by comparative examination of a spectrum of parotid components in twelve subjects with a positive diagnosis of the disease and twelve control subjects with normal gland function. The subjects with Sjögren's syndrome all exhibited a marked reduction in flow rate and phosphate concentration and a marked elevation in sodium and chloride concentration. The concentration of IgA was somewhat elevated (commensurate with reduced flow rate); the levels of IgG, IgM, and albumin were normal. The major functional abnormality in the parotid gland in Sjögren's syndrome appears to be luminal transport in the ductal region; leakage of serum components is minimal. Sialochemistry can be helpful in differentiating Sjögren's disease from other diseases of the salivary gland and in assessing degree of pathologic change.

HL-A in Sjögren's syndrome

HL-A phenotype frequencies were studied in 36 patients with Sjögren's syndrome and compared with those of 350 healthy individuals from the same geographical area. Patients suffering from Sjögren's syndrome had a significantly higher frequency of HL-A8 (P corrected less than 0.01). The relative risk of developing Sjögren's syndrome is 3.96 for HL-A8 positive individuals.