Sjögren's syndrome: the diagnostic potential of early oral manifestations preceding hyposalivation/xerostomia

Emerging biologic frontiers for Sjogren's syndrome: Unveiling novel approaches with emphasis on extra glandular pathology

Primary Sjögren's Syndrome (pSS) is a complex autoimmune disorder characterized by exocrine gland dysfunction, leading to dry eyes and mouth. Despite growing interest in biologic therapies for pSS, FDA approval has proven challenging due to trial complications. This review addresses the absence of a molecular-target-based approach to biologic therapy development and highlights novel research on drug targets and clinical trials. A literature search identified potential pSS treatment targets and recent advances in molecular understanding. Overlooking extraglandular symptoms like fatigue and depression is a notable gap in trials. Emerging biologic agents targeting cytokines, signal pathways, and immune responses have proven efficacy. These novel therapies could complement existing methods for symptom alleviation. Improved grading systems accounting for extraglandular symptoms are needed. The future of pSS treatment may involve gene, stem-cell, and tissue-engineering therapies. This narrative review offers insights into advancing pSS management through innovative biologic interventions.

Exploring Salivary Epithelial Dysfunction in Sjögren's Disease

Sjögren's Disease (SjD) is an autoimmune disease of the exocrine tissues. Etiological events result in the loss of epithelial homeostasis alongside extracellular matrix (ECM) destruction within the salivary and lacrimal glands, followed by immune cell infiltration. In this review, we have assessed the current understanding of epithelial-mesenchymal transition (EMT)-associated changes within the salivary epithelium potentially involved in salivary dysfunction and SjD pathogenesis. We performed a PubMed literature review pertaining to the determination of pathogenic events that lead to EMT-related epithelial dysfunction and signaling in SjD. Molecular patterns of epithelial dysfunction in SjD salivary glands share commonalities with EMT mediating wound healing. Pathological changes altering salivary gland integrity and function may precede direct immune involvement while perpetuating MMP9-mediated ECM destruction, inflammatory mediator expression, and eventual immune cell infiltration. Dysregulation of EMT-associated factors is present in the salivary epithelium of SjD and may be significant in initiating and perpetuating the disease. In this review, we further highlight the gap regarding mechanisms that drive epithelial dysfunction in salivary glands in the early or subclinical pre-lymphocytic infiltration stages of SjD.

Prediction of Sjögren's disease diagnosis using matched electronic dental-health record data

BACKGROUND

Sjögren's disease (SD) is an autoimmune disease that is difficult to diagnose early due to its wide spectrum of clinical symptoms and overlap with other autoimmune diseases. SD potentially presents through early oral manifestations prior to showing symptoms of clinically significant dry eyes or dry mouth. We examined the feasibility of utilizing a linked electronic dental record (EDR) and electronic health record (EHR) dataset to identify factors that could be used to improve early diagnosis prediction of SD in a matched case-control study population.

METHODS

EHR data, including demographics, medical diagnoses, medication history, serological test history, and clinical notes, were retrieved from the Indiana Network for Patient Care database and dental procedure data were retrieved from the Indiana University School of Dentistry EDR. We examined EHR and EDR history in the three years prior to SD diagnosis for SD cases and the corresponding period in matched non-SD controls. Two conditional logistic regression (CLR) models were built using Least Absolute Shrinkage and Selection Operator regression. One used only EHR data and the other used both EHR and EDR data. The ability of these models to predict SD diagnosis was assessed using a concordance index designed for CLR.

RESULTS

We identified a sample population of 129 cases and 371 controls with linked EDR-EHR data. EHR factors associated with an increased risk of SD diagnosis were the usage of lubricating throat drugs with an odds ratio (OR) of 14.97 (2.70-83.06), dry mouth (OR = 6.19, 2.14-17.89), pain in joints (OR = 2.54, 1.34-4.76), tear film insufficiency (OR = 27.04, 5.37-136.), and rheumatoid factor testing (OR = 6.97, 1.94-25.12). The addition of EDR data slightly improved model concordance compared to the EHR only model (0.834 versus 0.811). Surgical dental procedures (OR = 2.33, 1.14-4.78) were found to be associated with an increased risk of SD diagnosis while dental diagnostic procedures (OR = 0.45, 0.20-1.01) were associated with decreased risk.

CONCLUSION

Utilizing EDR data alongside EHR data has the potential to improve prediction models for SD. This could improve the early diagnosis of SD, which is beneficial to slowing or preventing complications of SD.

Beyond dry eye: The greater extent of Sjögren's systemic disease symptoms, the impact of COVID-19 and perceptions towards telemedicine identified through a patient co-designed study

BACKGROUND

Sjögren's ('SHOW-grins') is a chronic debilitating autoimmune disease characterised by dry eyes and dry mouth, secondary to reduced exocrine function of both the lacrimal and salivary glands. The persistent, severe and serious systemic complications of Sjögren's are poorly understood and often unappreciated, resulting in significant morbidity and treatment burden. This study aimed to explore the experiences of those living with Sjögren's, specifically access to healthcare and attitude towards telemedicine. Additionally, we sought to collect information regarding the impact of the pandemic on their quality of life (QoL).

METHODS

One hundred and ninety-four individuals attended an Irish Sjögren's Webinar. Attendees were invited to participate in two online surveys after the webinar. The first survey gathered information related to demographics, disease and experiences during the COVID-19 pandemic. A combination of bespoke items and validated questionnaires (EULAR Sjögren's Syndrome Patient Reported Index [ESSPRI], COVID-19 Impact on Quality of Life [COV19-QoL]) was used. The second survey consisted of a shortened Telehealth Usability Questionnaire. Both were prepared in collaboration with a patient advocate.

RESULTS

Survey 1: n = 76; response rate = 39.2%. Thirty-one respondents (41.4%) to survey 1 reported a delay of ≥5 years between the onset of symptoms and diagnosis. Dry mouth was the most common symptom experienced (76.8%, n = 63), followed by dry eye (74.4%, n = 61), fatigue (57.3%, n = 47) and joint pain (53.7%, n = 44), but a range of other symptoms were also reported. COV19-QoL results indicated that the pandemic had a detrimental effect on participants' overall QoL (4.0 ± 1.0) and physical health (4.0 ± 0.8) in particular. COV19-QoL and ESSPRI scores were moderately correlated (0.36, p = .002). Over 70% of respondents had a medical appointment cancelled, delayed or rescheduled (n = 60). Survey 2: n = 57; response rate = 29.4%. Those that had interacted with telemedicine reported largely positive experiences with the virtual model.

CONCLUSION

Clinicians should be aware of the range of symptoms experienced by patients with Sjögren's beyond those of sicca (dry eye and dry mouth) and fatigue. COVID-19 has negatively influenced the self-reported health and well-being of those with Sjögren's, particularly those with higher symptom scores. It is vital that optimised telemedicine models are implemented to ensure continuity in the provision of healthcare for those with chronic illness such as Sjögren's and in preparation for possible future pandemics.

PATIENT OR PUBLIC CONTRIBUTION

A group of people living with Sjögren's co-designed the structure and content of the webinar where the survey was shared. A public and patient involvement (PPI) contributor also collaborated in the selection of questionnaires used in the study, ensuring that the questions asked would best reflect the priorities of patients. They contributed to the writing of this manuscript as co-authors. Additionally, the research team and Sjögren's patients who contributed to this work have gone on to establish Sjögren's Research Ireland, a collaboration between patient advocates, researchers and PPI facilitators.

Phases and Natural History of Sjögren's Disease: A New Model for an Old Disease?

Sjögren's disease (SjD) is an archetypal and heterogenous autoimmune disorder that is characterized by exocrine glandular dysfunction. A proportion of patients develop severe extraglandular manifestations, such as cryoglobulinemia, and have an increased risk of lymphoma, both of which can adversely affect quality of life and occasionally mortality. As with most autoimmune disorders, the pathogenesis is poorly understood and difficult to predict, and, frustratingly, there is a lack of targeted therapies to cure this disease. We review the disease manifestations of SjD and propose a staged model for understanding the evolution of pathology. In longitudinal studies, most patients remain relatively stable in terms of their laboratory and clinical parameters. However, in the setting of various risk factors, a proportion of patients develop severe symptoms and/or lymphoma. We discuss potential underlying mechanisms for disease progression and the strengths and limitations of using a staged model to correlate the pathogenesis and spectrum of manifestations in SjD. Ultimately, understanding how and why some patients remain relatively stable, whereas others progress and develop florid systemic disease and a fraction develop lymphoma, is key to developing preventative and therapeutic treatments.

Systematic review with meta-analysis: Efficacy and safety of biological treatment on salivary gland function in primary Sjögren's syndrome

Objective: The study aimed to assess the efficacy and safety of clinical trials of biologics in improving the salivary gland (SG) function in primary Sjögren's syndrome (pSS), which has not been analyzed critically and systematically. Methods: PubMed, Web of Science, ClinicalTrials.gov, the EU Clinical Trials Register, and the Cochrane Library were searched for clinical trials that reported effects of biological treatment on the SG function and safety in pSS patients. Inclusion criteria were defined following participants, interventions, comparisons, outcome, and study design (PICOS) recommendations. The objective index (the change of unstimulated whole saliva (UWS) flow) and the serious adverse event (SAE) were assessed as main outcome measures. A meta-analysis of the efficacy and safety of the treatment was conducted. Quality assessment, sensitivity analysis, and publication bias were assessed. The effect size together with a 95% confidence interval was used to estimate the efficacy and safety of biological treatment and was plotted as a forest plot. Results: The literature search yielded 6,678 studies, nine of which fulfilled the inclusion criteria, with seven randomized controlled trials (RCTs) and two non-RCT clinical studies. Generally, biologics do not significantly increase UWS from the baseline of pSS patients compared to the control group at a matched time point (p = 0.55; standard mean difference, SMD = 0.05; 95% confidence interval, CI: -0.11 and 0.21). However, pSS patients with shorter disease duration (≤3 years; SMD = 0.46; 95% CI: 0.06 and 0.85) were prone to have a better response to biological treatment by showing higher increased UWS than patients with longer disease duration (> 3 years; SMD = -0.03; 95% CI: -0.21 and 0.15) (p = 0.03). For the meta-analysis of the safety of biological treatment, the SAEs in the biologics group were significantly higher than those of the control group (p = 0.0021; log odds ratio, OR = 1.03; 95% CI: 0.37 and 1.69). Conclusion: Biological intervention during the early course of the disease may benefit pSS patients better than that during the late course. Significantly, more SAEs in the biologics group indicate that the safety of biologics needs to be addressed for future biological clinical trials and treatment.

Diagnostic utility of a second minor salivary gland biopsy in patients with suspected Sjögren's syndrome: A retrospective cohort study

OBJECTIVE

To determine whether repeated minor salivary gland biopsy (MSGB) has a clinical diagnostic utility in patients with suspicion of Sjögren's syndrome (SS).

METHODS

Clinical, biological, pathological data and physician's diagnosis after each MSGB from patients with suspected primary or secondary SS who had benefited from 2 MSGB at Brest University Hospital between January 1st, 1990 and January 14th, 2015, were retrospectively collected. We compared the characteristics of patients with and without first positive MSGB, concordance between the MSGB, and analyzed the modifications of diagnosis after the second MSGB.

RESULTS

Ninety-three patients were included, first MSGB was positive for 23 and negative for 70. Patients with first positive MSGB had more often renal involvement (P<0.05) and hypergammaglobulinemia (P=0.01), anti-SSA antibodies (P<0.05) and positive second biopsy with focus score ≥ 1 or Chisholm>2 (P<0.01). The mean time between the 2 MSGB was 5.7±4.3 years. The concordance between the results of the 2 biopsies was low (κ = 0.34). MSGB influenced diagnostic's change in 10 cases where the second MSGB was always guided by new specific clinical manifestations.

CONCLUSION

We observed a low concordance between 2 MSGB in patients with suspected pSS in our study. Despite this variability, performing a second MSGB changed the initial diagnosis in only a minority of the patients and was particularly useful when clinical manifestations had deeply evolved.

The Future of Targeted Treatment of Primary Sjögren's Syndrome: A Focus on Extra-Glandular Pathology

Primary Sjögren's syndrome (pSS) is a chronic, systemic autoimmune disease defined by exocrine gland hypofunction resulting in dry eyes and dry mouth. Despite increasing interest in biological therapies for pSS, achieving FDA-approval has been challenging due to numerous complications in the trials. The current literature lacks insight into a molecular-target-based approach to the development of biological therapies. This review focuses on novel research in newly defined drug targets and the latest clinical trials for pSS treatment. A literature search was conducted on ClinicalTrials.gov using the search term "Primary Sjögren's syndrome". Articles published in English between 2000 and 2021 were included. Our findings revealed potential targets for pSS treatment in clinical trials and the most recent advances in understanding the molecular mechanisms underlying the pathogenesis of pSS. A prominent gap in current trials is in overlooking the treatment of extraglandular symptoms such as fatigue, depression, and anxiety, which are present in most patients with pSS. Based on dryness and these symptom-directed therapies, emerging biological agents targeting inflammatory cytokines, signal pathways, and immune reaction have been studied and their efficacy and safety have been proven. Novel therapies may complement existing non-pharmacological methods of alleviating symptoms of pSS. Better grading systems that add extraglandular symptoms to gauge disease activity and severity should be created. The future of pSS therapies may lie in gene, stem-cell, and tissue-engineering therapies.

Regulation of MMP9 transcription by ETS1 in immortalized salivary gland epithelial cells of patients with salivary hypofunction and primary Sjögren's syndrome

Primary Sjögren’s syndrome (pSS) patients exhibit enhanced degradation of the salivary epithelium initially through MMP9 overexpression. We assessed the expression of MMP9 and an associated transcription factor, ETS1, in primary salivary gland epithelial cells (SGECs) and investigated potential regulatory mechanism(s) in immortalized SGECs. SGECs and iSGECs were derived from pSS and/or xerostomic “sicca” patients. siRNA knockdown of ETS1 in iSGECs was performed to determine MMP9 mRNA (qRT-PCR) and protein expression (ELISA). ETS1 binding to MMP9 promoter was assessed by luciferase activity and binding confirmed by mutagenesis and ChIP. Effects of ETS1 overexpression on progenitor and Epithelial-Mesenchymal transition (EMT) associated markers were determined by Western blot. Expression of ETS1 and its phosphorylated form in iSGECs was determined by immunofluorescence microscopy. ETS1 and MMP9 were overexpressed in SGECs of pSS and non-pSS sicca patients with salivary gland lymphocytic infiltration compared to non-pSS sicca patients without infiltration. ETS1 siRNA knockdown reduced both MMP9 mRNA and protein levels. ETS1 overexpression affected the expression of EMT and progenitor cell markers. Lastly, ETS1 bound the MMP9 promoter within the DNA region of −296 bp to −339 bp. ETS1 may impair salivary function through direct transcriptional control of the MMP9 promoter. ETS1 upregulation may also affect other factors involved in repair of the dysfunctional pSS salivary epithelium.

A Review on Xerostomia and Its Various Management Strategies: The Role of Advanced Polymeric Materials in the Treatment Approaches

The medical term xerostomia refers to the subjective sensation of oral dryness. The etiology seems to be multifactorial with the most frequently reported causes being the use of xerostomic medications, neck and head radiation, and systematic diseases (such as Sjögren’s syndrome). Xerostomia is associated with an increased incidence of dental caries, oral fungal infections, and difficulties in speaking and chewing/swallowing, which ultimately affect the oral health-related quality of life. The development of successful management schemes is regarded as a highly challenging project due to the complexity of saliva. This is why, in spite of the fact that there are therapeutic options aiming to improve salivary function, most management approaches are alleviation-oriented. In any case, polymers are an integral part of the various formulations used in every current treatment approach, especially in the saliva substitutes, due to their function as thickening and lubricating agents or, in the case of mucoadhesive polymers, their ability to prolong the treatment effect. In this context, the present review aims to scrutinize the literature and presents an overview of the role of various polymers (or copolymers) on either already commercially available formulations or novel drug delivery systems currently under research and development.

Parotid gland swelling in primary Sjögren's syndrome: activity and other sialadenosis causes

OBJECTIVE

To assess the prevalence of parotid gland swelling (PGS), and its association with features of Sjögren's syndrome (SS) and other causes of sialadenosis in a Latin-American cohort of primary SS.

METHODS

We included 668 patients from Argentina, Brazil, Mexico, and Paraguay. We retrospectively registered demographics, disease duration, oral/ocular symptoms, serology and scored the basal ESSDAI. We defined PGS as a recurrent or persistent increase of volume of any parotid glands during adulthood (self-reported and/or physical examination). We registered the presence of diabetes mellitus, dyslipidaemia, body mass index, and alcohol consumption. We used logistic regression analysis reporting OR and 95% CI.

RESULTS

PGS was present in 242 patients (36.2%): 78 previous to SS diagnosis, 86 concomitantly, 73 during follow-up, and five unknown. At the multivariate analysis, PGS was associated with RF (OR 2.47, 95% CI 1.1-6.5, p= 0.0001), basal articular ESSDAI domain (OR 1.63, 95% CI 1.01-2.6, p= 0.04), and alcohol consumption (OR 2.42, 95% CI 1.41-4-15). Patients with PGS during the follow-up had a higher prevalence of alcohol consumption (45.3%) compared with the remaining PGS cases (26.8%; OR 2.41 95% CI 1.2-4.7), or patients without parotid gland swelling (15.6%; OR 3.8 95% CI 1.7-8.2) in all the adjusted models.

CONCLUSION

PGS generally precedes or presents concomitantly with SS diagnosis, and is related to RF and articular activity. Alcohol consumption is an additional factor in PGS, especially during follow-up. The meaning of this last finding as well as its prognostic implications remains to be elucidated and deserves further evaluation in prospective studies.

Progenitor cell niche senescence reflects pathology of the parotid salivary gland in primary Sjögren's syndrome

Objective

Salivary gland (SG) progenitor cells (SGPCs) maintain SG homeostasis. We have previously shown that in primary Sjögren’s syndrome (pSS), SGPCs are likely to be senescent, and may underpin SG dysfunction. This study assessed the extent of senescence of cells in a SGPC niche in pSS patients’ SGs, and its correlation with functional and clinical parameters.

Methods

The expression of p16 and p21 as markers of senescence in both total SG epithelium and a SGPC niche (basal striated duct cells, BSD) was examined in SGs of pSS (n = 35), incomplete pSS (n = 13) (patients with some signs of pSS, but not fulfilling all classification criteria) and non-SS sicca control (n = 21) patients. This was correlated with functional and clinical parameters.

Results

pSS patient SGs contained significantly more p16⁺ cells both in the epithelium in general (P <0.01) and in the BSD layer (P <0.001), than non-SS SGs. Significant correlations were found in pSS patients between p16⁺ BSD cells and secretion of unstimulated whole saliva, stimulated whole saliva, stimulated parotid saliva, CD45⁺ infiltrate, ultrasound total score and ACR-EULAR classification score, but not with EULAR Sjögren’s syndrome disease activity index (ESSDAI) and EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) scores. Correlations with total epithelium p16⁺ cells were weaker. Incomplete pSS patients also had increased numbers of p16⁺ epithelial and BSD cells. Based on protein and mRNA expression, p21⁺ appears not to play a significant role in the SG in pSS.

Conclusion

These findings suggest SGPC senescence may be an early feature of primary Sjögren’s syndrome and may contribute to defective SG function in pSS but not to systemic disease activity.

Early diagnosis and treatment for Sjögren's syndrome: current challenges, redefined disease stages and future prospects

There are some challenges and unmet needs in the early diagnosis and management of Sjögren's syndrome (SjS) such as prominent glandular dysfunction at diagnosis and long diagnostic delay. Those challenges are partly attributed to the lack of a good knowledge of the early stages of SjS, which is a major obstacle to delivering appropriate care to SjS patients. Findings from both clinical and experimental studies suggest the plausibility of a redefined SjS course consisting of 4 stages, which includes initiation stage, preclinical stage, asymptomatic SjS stage and overt SjS stage. More studies focusing on the pathological processes and changes during the early stages of SjS are needed. To enable early diagnosis and treatment for SjS, more useful biomarkers of the early stages of SjS need to be identified, and individuals at high risk of SjS development need to be identified. Appropriate screening can be performed to facilitate the early diagnosis of SjS among those high-risk individuals.

Multicenter clinical trial on dental implants survival rate: a FDS76® study

BACKGROUND

Implantology, thanks to its predictability in oral rehabilitations, has become a widespread method for rehabilitating edentulous patients, offering excellent patient satisfaction. Improving the quality of oral health, especially if rehabilitation involves minimal short and long-term complications, leads to an improvement in the quality of life of our patients.

METHODS

This clinical study was conducted to evaluate the short and long-term complications (up to 18 months) of implant-prosthetic rehabilitations performed with a new dental implant (FDS76^®, Italy).

RESULTS

The results showed a limited number of complications or implant failures.

CONCLUSIONS

Knowing the latter could certainly help improve both surgical and dental materials performance.

Multicenter clinical trial on dental implants survival rate: a FDS76® study

BACKGROUND

Implantology, thanks to its predictability in oral rehabilitations, has become a widespread method for rehabilitating edentulous patients, offering excellent patient satisfaction. Improving the quality of oral health, especially if rehabilitation involves minimal short and long-term complications, leads to an improvement in the quality of life of our patients.

METHODS

This clinical study was conducted to evaluate the short and long-term complications (up to 18 months) of implant-prosthetic rehabilitations performed with a new dental implant (FDS76^®, Italy).

RESULTS

The results showed a limited number of complications or implant failures.

CONCLUSIONS

Knowing the latter could certainly help improve both surgical and dental materials performance.

Salivary gland performance in autoimmune diseases: review and meta-analysis

Objectives: Autoimmune diseases include a spectrum of disorders in which immune response to the autoantigens leads to tissue damage or dysfunction. Xerostomia, salivary gland dysfunction and lack of saliva are some common symptoms associated with many autoimmune diseases.Methods: In this review study, the meta-analysis technique is used to objectively review the relationship between autoimmune diseases and salivary gland dysfunction. We have searched Medline and Embase and Google Scholar. By Revman 5.3, meta-analysis was performed to investigate the salivary flow rate in both stimulatory and non-stimulatory saliva. The sample size obtained from these studies was 130 people with autoimmune diseases and 100 healthy individuals.Results: The results showed a significant decrease in the level of non-stimulatory saliva in people with autoimmune diseases.Conclusions: A complete and comprehensive understanding of the clinical manifestation of systemic diseases is crucial in early diagnosis of diseases and identifying the mechanisms that develop the disease. Other than xerostomia, there is a significant reduction in salivary flow rate in patients with autoimmune diseases. As saliva plays a very important role in oral health and has significant functions, more attention is needed for monitoring and managing of hyposalivation in autoimmune patients.

Identification of differentially expressed genes in primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune disease that affects exocrine glands. To study the molecular mechanism and identify crucial genes/pathways in pSS pathogenesis, the microarray-based whole-genome gene expression profiles from salivary glands of patients with pSS and non-sicca controls were retrieved. After normalization and subsequent batch effect adjustment, significance analysis of microarrays method was applied to five available datasets, and 379 differentially expressed genes (DEGs) were identified. The 300 upregulated DEGs were enriched in Gene Ontology terms of immune and inflammatory responses, including antigen processing and presentation, interferon-mediated signaling pathway, and chemotaxis. Previously reported pSS-associated genes, including HLA-DRA, TAP2, PRDM1, and IFI16, were found to be significantly upregulated. The downregulated DEGs were enriched in pathways of salivary secretion, carbohydrate digestion and absorption, and starch and sucrose metabolism, implying dysfunction of salivary glands during pathogenesis. Next, a protein-protein interaction network was constructed, and B2M, an upregulated DEG, was shown to be a hub, suggesting its potential involvement in pSS development. In summary, we found the activation of pSS-associated genes in pathogenesis, and provide clues for salivary glands dysfunction. Experimental investigation on the identified DEGs in this study will deepen our understanding on pSS.

Protocolised odontological assessment of patients with primary Sjögren's syndrome

OBJECTIVE

The aim of this study is to describe the findings of a protocolised odontological evaluation of patients with primary Sjögren's syndrome (pSS) treated in rheumatology units in the Community of Madrid.

METHODS

Multicentric descriptive study in which pSS patients classified according to the American-European consensus of 2002 criteria were included. We collected the demographic, clinical and serological data of each patient. A complete oral examination was performed and salivary flow and the CAOD caries index were collected. The patients completed the visual analogue scale for xerostomia, the Oral Health Impact Profile-14 questionnaire and an oral health questionnaire.

RESULTS

Sixty-one patients were recruited. Ninety-eight percent were women and the mean age of the patients was 57 years. Pathological oral signs (unstimulated salivary flow/salivary glands sialography/scintigraphy) were present in 52.5% of the patients, anti-Ro/anti-La were positive in 90.2%. Ninety-two percent of the patients reported xerostomia and 61% of the patients suffered from hyposialia. Thirty-five patients presented oral mucosa lesions. CAOD index was 16.97±7.93 and visual analogue scale for xerostomia was 46.69±14.43. The results of the OHIP-14 questionnaire were 23.13±14.16. Patients with pathological oral signs obtained a significantly higher Oral Health Impact Profile-14 score (P=.03). We also found that patients with peripheral nervous system involvement obtained a significantly higher Oral Health Impact Profile-14 score (P=.001) CONCLUSIONS: The presence of xerostomia in this cohort of pSS patients was high and hyposialia was present in 61% of the patients. Oral lesions appeared in more than half of the subjects. Oral health had a negative impact on the quality of life of patients with pSS, being higher in those with pathological objective oral signs and in those with peripheral nervous system involvement.

Tooth loss in Sjögren's syndrome patients compared to age and gender matched controls

BACKGROUND

To analyze the prevalence and location of tooth loss in Sjögren's syndrome (SS) patients and compare them with an age- and gender-matched control group.

MATERIAL AND METHODS

Dental charts and x-rays of 108 (SS) patients were retrieved from an academic dental center and special care dentistry department. For each SS patient, an age- and gender-matched non-SS patient was randomly selected. Medication, number of extractions and date and location of extractions were assessed. Differences between SS and non-SS patients were analyzed using Mann-Whitney U tests, Chi-square tests and Fisher's exact tests.

RESULTS

Significantly more SS patients were edentulous compared to the non-SS group (14.8% versus 1.9%, p = 0.001). SS patients had a 61% higher risk to have experienced one or more extractions than control patients. In the SS group, there was a non-significant tendency for more maxillary teeth to have been extracted than mandibular teeth (42:34). In the control group, the number of extractions in the maxilla and mandible were comparable (21:20). When divided into sextants, the number of SS patients with one or more extractions was significantly higher than for non-SS patients for each sextant (p = 0.001 to p = 0.032). The largest difference in the proportion of patients with one or more extractions between the SS and non-SS patients occurred in the upper anterior sextant (3.4 times more frequent).

CONCLUSIONS

SS patients are more prone to experience dental extractions compared to patients without SS. It could be speculated that this is related to a decreased salivary secretion.

A randomized controlled study to evaluate an experimental moisturizing mouthwash formulation in participants experiencing dry mouth symptoms

OBJECTIVE

The aim of this study was to evaluate the efficacy and tolerability of an experimental moisturizing mouthwash versus water only in participants experiencing dry mouth symptoms, including those with Sjögren syndrome (n = 28).

STUDY DESIGN

Participants were randomized to the experimental mouthwash group (n = 53) or the water-only group (n = 47). For 8 days, the mouthwash group used 1 to 2 doses/day at home; both groups could sip water, as needed. Supervised treatment occurred on days 1, 3, and 8, and during this treatment, before and after administration, participants completed the Product Performance and Attributes Questionnaire parts 1 through 4.

RESULTS

Significant between-treatment differences on all Product Performance and Attributes Questionnaire questions were shown at most time points. On day 8, at 120 minutes, there was a significant difference on Product Performance and Attributes Questionnaire 3-Question 1 ("Relieves the discomfort of dry mouth"; the predefined primary efficacy variable) in favor of mouthwash versus water (0.63 [95% confidence interval 0.17-1.10]; P = .0084). Subgroup analysis found a significant difference that favored mouthwash in participants without Sjögren syndrome (0.67 [0.11,1.23]; P = .0203) but not with Sjögren syndrome (0.52 [-0.35,1.38; P = .2272). Eight, non-serious, oral treatment-related adverse events were reported by the mouthwash group.

CONCLUSIONS

The findings of a subjective questionnaire showed that an experimental moisturizing mouthwash provided greater relief than water only from dry mouth symptoms over 8 days.

Orofacial Manifestations and Temporomandibular Disorders of Sjögren Syndrome: An Observational Study

AIMS: Sjӧgren Syndrome is a disorder involving oral tissues, with xerostomia, dysgeusia, dysphagia, tooth decay, gingivitis, angular cheilitis and glossitis. Temporomandibular disorders are a generic term referred to clinical conditions involving the jaw muscles and temporomandibular joint. The aim of this study was to investigate the prevalence of oral manifestations and temporomandibular disorders (TMD) in Sjӧgren Syndrome (SS) patients compared with healthy people. METHODS: The study group included 72 SS patients (2 men, 70 women) diagnosed according to the American-European Consensus Group (AECG) Criteria. A randomly selected group of 72 patients, matched by sex and age, served as control group. The examination for TMD signs and symptoms was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) through a questionnaire and clinical examination. RESULTS: SS patients complained more frequently (95.8%) of oral symptoms (xerostomia, dysgeusia, dysphagia) than controls (22.2%) (χ²= 80.66 p< 0.001). TMD symptoms (muscle pain on chewing, difficulty in mouth opening, arthralgia, headaches, tinnitus) were complained by 91.7% of SS patients and by 84.7% of controls (χ²= 1,667 p= 0,196). At the clinical examination, 91,7% of SS had at least one oral sign respect to 75 % of controls. The salivary flow measurements showed high statistical significance between the two groups (Unpaired test, p< 0,0001). Myofascial pain (caused by muscular contracture) was significantly higher in the study group than in the control one (p≤ 0,05). Furthermore 18,05% of SS patients showed deflection versus 5,5% of controls (χ²=5,402 p=0,020). CONCLUSIONS: Sjӧgren's Syndrome seems to play a role in temporomandibular joint disorders.

A Mathematical Model Supports a Key Role for Ae4 (Slc4a9) in Salivary Gland Secretion

We develop a mathematical model of a salivary gland acinar cell with the objective of investigating the role of two [Formula: see text] exchangers from the solute carrier family 4 (Slc4), Ae2 (Slc4a2) and Ae4 (Slc4a9), in fluid secretion. Water transport in this type of cell is predominantly driven by [Formula: see text] movement. Here, a basolateral [Formula: see text] adenosine triphosphatase pump (NaK-ATPase) and a [Formula: see text]-[Formula: see text]-[Formula: see text] cotransporter (Nkcc1) are primarily responsible for concentrating the intracellular space with [Formula: see text] well above its equilibrium potential. Gustatory and olfactory stimuli induce the release of [Formula: see text] ions from the internal stores of acinar cells, which triggers saliva secretion. [Formula: see text]-dependent [Formula: see text] and [Formula: see text] channels promote ion secretion into the luminal space, thus creating an osmotic gradient that promotes water movement in the secretory direction. The current model for saliva secretion proposes that [Formula: see text] anion exchangers (Ae), coupled with a basolateral [Formula: see text] ([Formula: see text]) (Nhe1) antiporter, regulate intracellular pH and act as a secondary [Formula: see text] uptake mechanism (Nauntofte in Am J Physiol Gastrointest Liver Physiol 263(6):G823-G837, 1992; Melvin et al. in Annu Rev Physiol 67:445-469, 2005. https://doi.org/10.1146/annurev.physiol.67.041703.084745 ). Recent studies demonstrated that Ae4 deficient mice exhibit an approximate [Formula: see text] decrease in gland salivation (Peña-Münzenmayer et al. in J Biol Chem 290(17):10677-10688, 2015). Surprisingly, the same study revealed that absence of Ae2 does not impair salivation, as previously suggested. These results seem to indicate that the Ae4 may be responsible for the majority of the secondary [Formula: see text] uptake and thus a key mechanism for saliva secretion. Here, by using 'in-silico' Ae2 and Ae4 knockout simulations, we produced mathematical support for such controversial findings. Our results suggest that the exchanger's cotransport of monovalent cations is likely to be important in establishing the osmotic gradient necessary for optimal transepithelial fluid movement.

Validity and reliability of a Portuguese version of the Summated Xerostomia Inventory-5

OBJECTIVES

The aim of this study was to validate and determine the reliability of the Portuguese version of the Summated Xerostomia Inventory.

BACKGROUND

Many conditions such as head and neck radiation, autoimmune diseases or polypharmacy are characterised by hyposalivation which can affect oral and systemic quality of life. As such, this condition must be assessed, and the English version of the Xerostomia Inventory has been increasingly used to determine the severity of dry mouth perception.

MATERIALS AND METHODS

This was a descriptive cross-sectional study, which employed volunteers suffering from hyposalivation after local ethical committee clearance. Each patient signed an informed consent and responded to the Portuguese version of the questionnaire in the form of an interview. This was repeated again after 2 weeks. A standard single question provided a validity check. Data were analysed using Cronbach's α to test its reliability and total and interitem correlation, and intraclass correlation to determine its internal consistency and test-retest reliability. Significance was set at .05.

RESULTS

A sample of 103 volunteers was recruited. Cronbach's α was .84 and .87 for the first and second test administrations, respectively. The intraclass correlation coefficient value for the test-retest reliability was .93, and scores for the individual items ranged from .79 to .90. The correlation between the total score of the questionnaire and standard single dry mouth question was .66, indicating a very good correlation.

CONCLUSION

Demonstrating excellent psychometric properties, the Summated Xerostomia Inventory (Portuguese Version) is a valid tool for quantifying Xerostomia in a dry mouth-afflicted population.

Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity

CONTEXT

The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective.

OBJECTIVE

To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures.

METHODS

We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source.

RESULTS

157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL).

CONCLUSION

A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.

Effects of A Novel Disc Formulation on Dry Mouth Symptoms and Enamel Remineralization in Patients With Hyposalivation: An In Vivo Study

BACKGROUND

The goal of this study was to identify the in vivo effects in patients with hyposalivation of a novel slowly dissolving adhering test disc upon on enamel remineralization, oral biofilm, salivary production, pH and buffering, gingival health, and on self-evaluation of oral well-being.

METHODS

Five subjects with xerostomia wore custom made retainers carrying 5 demineralized enamel chips for periods of 1 week each. In 1 study arm, subjects used the test agent plus oral hygiene self-care; in the other they used oral hygiene self-care only, with a 1 week washout in between arms. The treatment sequence was randomized. Before and after each study arm Plaque Index (PI), Gingival Index (GI) and Sulcus Bleeding Index (mSBI) were recorded. Clinical plaque staining was quantified using digital image analysis. Saliva production, pH and buffering capacity were recorded. Subjects completed a self-evaluation questionnaire for oral comfort. Enamel samples underwent standardized Knoop microhardness testing to quantify mineralization status.

RESULTS

Plaque presence and clinical Plaque Indices decreased significantly with test agent use (p<0.05). Five-minute saliva production almost doubled 10 and 40 minutes after oral test disc insertion (significant, p<0.05). Salivary pH buffering improved in 4/5 subjects with disc use. All demineralized tooth samples re-hardened intraorally (p>0.05). The discs favorably impacted eating problems and dental sensitivity. Subjects were positive about disc flavor and mouth feel.

CONCLUSION

Using established in vivo techniques, the effects of a novel product in xerostomic patients were evaluated and quantified. The adhering disc facilitated eating, reduced dental sensitivity, improved saliva production and buffering capacity, reduced plaque, and alleviated xerostomia symptoms.

CLINICAL RELEVANCE

Xerostomia management is challenging. A novel dry mouth disc was effective in alleviating dry mouth symptoms.

A Potential of sFasL in Preventing Gland Injury in Sjogren's Syndrome

Fas and its ligand FasL, members of tumor necrosis factor receptor superfamily, have been implicated in the process of cell apoptosis. FasL consists of two forms, membrane FasL (mFasL) and soluble FasL (sFasL). sFasL can be produced by mFasL cleaved by matrix metalloproteinases (MMP) and also reveals a role for binding to Fas which is expressed on cell surface. Although Fas/FasL axis has been implicated in a variety of diseases, its role in Sjogren's syndrome still remains ill defined. In this study, we investigated the potential of sFasL in the pathogenesis of Sjogren's syndrome (SS). We found that the serum levels of sFasL in SS patients were significantly lower than healthy subjects. Moreover, serum levels of sFasL in patients with mild disease activity were higher than patients with severe disease activity. There is a positive correlation of the serum level of sFasL with uptake index of parotid gland in our expectation. In addition, liver injury involvement in SS patients showed decreased level of sFasL. Furthermore, we here also observed that the protective cytokine IL-10 expression was positively correlated with sFasL expression. Thus, our results here suggest a potential of sFasL in maintaining gland organ homeostasis.

Effect of Xerostomia on the Functional Capacity of Subjects with Rheumatoid Arthritis

OBJECTIVE

To evaluate the intensity of xerostomia and hyposalivation in subjects with rheumatoid arthritis (RA) as well as the effects of these conditions on functional incapacity and disease activity.

METHODS

The study sample comprised 236 individuals of both sexes who had RA. All the individuals were submitted to clinical evaluation and unstimulated sialometry. Functional capacity was determined by using the Health Assessment Questionnaire (HAQ), xerostomia was assessed using the Xerostomia Inventory, and disease activity was evaluated with the 28-joint Disease Activity Score (DAS28). The effect of Sjögren syndrome (SS) was analyzed, and the sample was divided into 2 groups: RA (191 subjects) and RA/SS (45 subjects).

RESULTS

The Xerostomia Inventory showed positive and significant correlation with fatigue (r = 0.243; p < 0.0001), number of painful joints (r = 0.218; p = 0.001), HAQ (r = 0.279; p < 0.0001), and DAS28 (r = 0.156; p < 0.0001). On regression analysis, both xerostomia (OR 3.89, 95% CI 1.84-8.23, p < 0.001) and DAS28 (for severe disease activity: OR 13.26, 95% CI 3.15-55.79, p < 0.001) showed influence on functional incapacity. Forty-five individuals (19.1%) presented with secondary SS, and having this diagnosis was not associated with disease activity or functional capacity.

CONCLUSION

Xerostomia demonstrated an adverse effect on quality of life of subjects with RA, being associated with a reduction in functional capacity. In this clinical setting, xerostomia can be monitored as a marker of worse clinical evolution.

Hepatitis Delta Virus Detected in Salivary Glands of Sjögren's Syndrome Patients and Recapitulates a Sjögren's Syndrome-Like Phenotype in Vivo

Background:

Low-level, chronic viral infections have been suspect in the development of select autoimmune diseases, including primary Sjögren's syndrome (pSS). Multiple studies have shown stimulation of antiviral response pathways in pSS tissues suggestive of a viral infection. Yet, with this data in hand, a causal link between a viral infection and development of pSS had not been identified. Therefore, a study was designed to further define the viral landscape within pSS-affected salivary gland tissue to identify potential viral-mediated triggers in the pathogenesis of this autoimmune disease.

Methods:

A viral microarray was utilized to measure viral transcripts present in salivary gland tissue from patients diagnosed with pSS compared to healthy controls. Murine models of salivary gland localized HDV antigen expression were developed to evaluate the capacity of a chronic HDV signature to trigger the development of a pSS-like phenotype.

Results:

Through this analysis, two distinct viral profiles were identified, including the increased presence of hepatitis delta virus (HDV) in 50% of pSS patients evaluated. Presence of HDV antigen and sequence were confirmed in minor salivary gland tissue. Patients with elevated HDV levels in salivary gland tissue were negative for detectible hepatitis B virus (HBV) surface antigen and antibodies to HBV or HDV. Expression of HDV antigens in vivo resulted in reduced stimulated saliva flow, increase in focal lymphocytic infiltrates, and development of autoantibodies.

Conclusion:

Identification of HDV in pSS patients and induction of a complete pSS-like phenotype in vivo provides further support of a viral-mediated etiopathology in the development of pSS.

Expression of Toll-like receptor -7 and -9 in B cell subsets from patients with primary Sjögren's syndrome

Introduction

Sjögren’s syndrome (SS) is a rheumatic autoimmune disease characterized by inflammation of exocrine glands. As autoantibodies are present in a majority of patients, B cells have been suggested to play an important role in onset and development of the disease. Toll-like receptors (TLRs) are pattern recognition receptors triggering innate immune responses. Since an increased expression of TLRs has been detected in other rheumatic diseases the purpose of this study was to explore TLRs in B cells of SS patients.

Methods

The expression of TLR-7 and -9 in B cell subsets of 25 patients with primary SS (pSS) and 25 healthy controls was analysed in peripheral blood using flow cytometry and real time quantitative PCR.

Results

We detected similar levels of CD19⁺ B cells in pSS patients and healthy controls. An increased number of naïve B cells, as well as fewer pre-switched memory B cells were found in pSS patients. No significant differences were observed in TLR-7 and -9 expression in B cells between pSS patients and healthy controls.

Conclusion

This study shows that pSS patients have an alteration in the B cell subpopulation composition compared to controls, with less pre-switched memory B cells and more naïve B cells. We did not detect any significant disparities in TLR-7 and -9 expression between the two groups.

The serological profiles of subgroup of primary Sjögren's syndrome correlation with the clinical features of parotid glands

OBJECTIVE

To investigate the difference of serological profile in pSS and their correlation with the clinical characteristics of parotid glands.

METHODS

This retrospective study includes 289 patients who fulfilled the 2002 American-European Consensus Group Criteria for pSS. The patients were categorized by the clinical features of parotid glands: Group 1 (massive group), Group 2 (infection group), Group 3 (swelling group) and Group 4 (others). The demographic data and serological profiles among these groups were compared. Statistical analyses of the results between groups were performed using the Student t test, Fisher's exact test, chi-square and analysis of variance.

RESULTS

There was a difference of serological profile in the different clinical characteristics of parotid glands of pSS. Serum Ig G value of Group 1 was the greatest, and complement C4 was lowest in the four groups. Serum Ig E value of Group 2 was the greatest and ESR of Group 3 was the greatest in the four groups.

CONCLUSION

This study has determined the differences of serological profile in the different clinical features of parotid glands of pSS patients, which may help advance our understanding of the disease and improve patient management.

Xerostomia in geriatric patients: a burgeoning global concern

Saliva plays a key role in maintaining oral homeostasis, function, and health. The prevalence of xerostomia and its consequences are rising due to the increasing aging population, the effects of some systemic diseases, medical management, and commonly-prescribed medications that reduce saliva production. When salivary function is diminished, patients are at a greater risk of developing caries, discomfort in wearing dentures, and opportunistic diseases, such as candidiasis. The psychosocial aspects of xerostomia can range from a mild effect on self-rated oral health to frustration, embarrassment, unhappiness, or substantial disruptions in quality of life. This article reviews the clinical features, diagnosis, and prevalence of dry mouth, as well as its treatment strategies.

Sialometry of upper labial minor glands: a clinical approach by the use of weighing method Schirmer's test strips paper

Objectives. To establish referential values ranges of hyposalivation and normosalivation for the salivary flow rate (SFR) of upper labial (LS) and palatal (PS) mucosa using Schirmer's test strips paper and as a second goal to determine the values ranges of the SFR of palatal (PS) and upper labial (LS) mucosa in subjects with and without xerostomia. Methods. A cross-sectional study was conducted among subjects distributed in three groups according to their unstimulated and stimulated whole saliva. Results. 144 subjects were enrolled in groups as follows: severe hyposalivation (n = 24), mild hyposalivation (n = 78), and normosalivation (n = 42). The mean and the 95% confidence interval for the LS flow rate (μL/cm²/min) were 3.2 (2.46 to 3.94), 5.86 (4.96 to 6.75), and 9.08 (7.63 to 10.53) (P < 0.001) for each group, respectively. The PS results were 1.01 (0.68 to 1.34), 1.72 (1.31 to 2.13), and 2.44 (1.66 to 3.22) (P = 0.014). Xerostomia complainers presented lower rates of LS (5.17 (4.06 to 6.23)) than non-complainers (7.33 (6.4 to 8.27)) (P = 0.003). Conclusions. The test was reliable to provide referential values ranges for LS flow rate measurement and was shown to be valid to distinguish normosalivation from severe and mild hyposalivation and also to predict xerostomia.

Validation of the Chinese version of the Summated Xerostomia Inventory (SXI)

OBJECTIVES

The aim of this study was to validate the Chinese version of the Summated Xerostomia Inventory (SXI).

METHODS

The English SXI was translated into Chinese, cross-cultural adaptation and pilot tested. The final Chinese version of SXI was tested in a consecutive sample of 212 patients with xerostomia. The reliability of the Chinese version of SXI was determined through internal consistency and test-retest methods. The construct validity of SXI was analysed by content validity, construct validity, and convergent validity.

RESULTS

Cronbach's alpha value for the SXI score was 0.798, and the test-retest intraclass correlation coefficient value for the SXI score was 0.837. Construct validity was proved by the presence of one-factor structure that accounted for 57.68 % of the variance and fitted well into the model. The correlation between the total score of the SXI and the global oral health question was 0.75, indicating very good correlation (P < 0.01).

CONCLUSION

This study provided preliminary evidence concerning validity and reliability of the Chinese version of the SXI. The results provide initial evidence that the SXI may be a useful tool for the mainland Chinese xerostomia patients for both clinical and epidemiologic researches.

Sjögren's syndrome: diagnosis and management

This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome. Sjögren's syndrome is a chronic inflammatory disorder of the exocrine glands with multiple nonexocrine features. It is found predominantly in middle-aged women but exists throughout the population. The diagnosis of Sjögren's syndrome can be challenging because the cardinal sicca symptoms may be subclinical or attributed to other causes, such as medications or aging. Differential diagnosis of Sjögren's syndrome can be confounded by the multiple exocrine manifestations in the mouth, eyes, ears, nose, skin, vagina, and respiratory and gastrointestinal tracts, as well as seemingly unrelated nonexocrine involvement in the thyroid, liver, kidneys and the musculoskeletal, vascular and nervous systems. This article concludes that early diagnosis of Sjögren's syndrome is crucial to prevent and/or minimize potentially life-threatening complications. Periodic follow-up of patients' status and collaboration between the primary-care physician and the rheumatologist, dentist, ophthalmologist and other specialists are indispensable.

The effects of lingual intervention in a patient with inclusion body myositis and Sjögren's syndrome: a longitudinal case study

OBJECTIVE

To report the 5-year course of a patient's swallowing disorder in the context of progressive neuromuscular disease and the effectiveness of a lingual strengthening treatment program.

DESIGN

This is a case report that describes a lingual treatment protocol that was repeated 3 times over a 5-year period with and without maintenance periods.

SETTING

The study was completed in 2 settings-an outpatient swallowing clinic at an acute care hospital and the patient's home.

PARTICIPANT

The subject was a 77-year-old woman who was diagnosed with inclusion body myositis and Sjögren's syndrome.

INTERVENTION

The patient participated in an intensive 8-week lingual strengthening protocol 3 times (at years 1, 4, and 5) and a subsequent maintenance program twice (at years 4 and 5).

MAIN OUTCOME MEASURES

Three outcome measures were collected during the study: (1) lingual manometric pressures at the anterior and posterior tongue, measured by using a lingual manometric device, (2) airway invasion measured by using an 8-point Penetration-Aspiration Scale, and (3) clearance of the bolus measured by using a 3-point residue scale.

RESULTS

Isometric lingual strengthening was effective in maintaining posterior tongue lingual pressure and Penetration-Aspiration Scale scores during the treatment periods. Residue scale scores did not significantly change during treatment.

CONCLUSIONS

We conclude that, in this patient, lingual strengthening slowed the progression of disease-related lingual strength loss and extended functional swallowing performance. Thus, this type of intervention may hold promise as an effective swallowing treatment option for patients with neurodegenerative inflammatory diseases such as inclusion body myositis and Sjögren's syndrome.

Effects of hydroxychloroquine on salivary flow rates and oral complaints of Sjögren patients: a prospective sample study

OBJECTIVE

The objective of this study was to evaluate whether hydroxychloroquine (HCQ) therapy effects subjective and/or objective complaints and salivary flow rates of patients with primary Sjögren's syndrome (PSS).

STUDY DESIGN

Thirty women recently diagnosed with PSS, scheduled for HCQ treatment (400 mg daily), participated and were clinically examined before initiation of 30 weeks of HCQ treatment. During baseline evaluation, both the objective and/or subjective oral findings were recorded. Unstimulated (uSFR) and stimulated salivary flow rates (sSFR) were determined. After initiation of HCQ treatment, study parameters were assessed at 6, 12, 18, 24, and 30 weeks. Each patient served as her own control; measurements of the baseline and control times were analyzed by ANOVA.

RESULTS

uSFR values increased significantly with HCQ treatment, but sSFR values, objective and/or subjective complaints did not change considerably.

CONCLUSION

A positive impact of 30 weeks of HCQ treatment only on uSFRs of SS patients was revealed.

Oral manifestations of Sjögren's syndrome

Sjögren's syndrome is a common autoimmune rheumatic disease. The most common symptoms of Sjögren's syndrome are extreme tiredness, along with dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Saliva plays an essential role in numerous functions of the mouth. Xerostomia can be caused by medications, chronic diseases like Sjögren's syndrome, and medical treatments, such as radiation therapy and bone marrow transplant. Xerostomia can eventually lead to difficulty in swallowing, severe and progressive tooth decay, or oral infections. Despite having excellent oral hygiene, individuals with Sjögren's syndrome have elevated levels of dental caries, along with the loss of many teeth, early in the disease. Sjögren's syndrome alters the protein profile and brings about a change in the composition of saliva. There is an increase in the levels of lactoferrin, beta(2)-microglobulin, sodium, lysozyme C, and cystatin C, and a decrease in salivary amylase and carbonic anhydrase. Up to 90% of individuals with Sjögren's syndrome have antibodies targeting the Ro 60 and La autoantigens. Natural aging, regardless of Sjögren's syndrome, is also another factor that brings about a significant change in the composition of saliva. The most prevailing cause of xerostomia in elderly persons is the use of anticholinergic medications. Currently, there is no cure for Sjögren's syndrome, and treatment is mainly palliative.

The efficacy of Xialine in patients with Sjögren's syndrome: a single-blind, cross-over study

Sjögren syndrome (SS) is a chronic inflammatory autoimmune disease of unknown cause whose main characteristic is severe dryness of the eyes and the mouth. The decreased functional capacity of the lacrimal and salivary glands which is the result of the inflammatory process and lymphocytic infiltration observed in SS is accountable for this complication. Twenty-nine patients with SS whose ages were ranging between 24-77, who were under treatment in Ege University Faculty of Medicine Department of Rheumatology, participated in the study, and their informed consents were obtained upon enrollment. Each patient recorded their subjective complaints on a separate questionnaire. The baseline and subsequent evaluation of the subjective findings on predetermined times (1 h after application of the material, at the end of the 1st, 7th, and 14th days) were also recorded on separate questionnaire sheets. Throughout the 14-day treatment period, no statistically significant differences were noted between the Xialine and placebo groups with regard to burning tongue, diminished taste, and waking up at night to sip water (p = 0.925, 0.527, and 0.066, respectively). However, patients' satisfaction with placebo decreased by 25.63% at the end of the test period, whereas it increased by 16.37% after Xialine administration. Overall, the patients preferred Xialine at the end of the study (p = 0.011). The main motive to administer saliva substitute is to improve lubrication and hydration of oral tissues. The results of this study indicated that Xialine is helpful in the management of xerostomia-related symptoms of SS patients. However, further investigations in larger scale group of patients are recommended to provide the effects of these agents on various complaints of xerostomia.

Bilateral parotid enlargement due to malnutrition under the influence of the media in an adolescent in Lithuania

The elimination of censorship for the media in post-communist countries in transition has contributed to increases in the prevalence of several medical problems. Children and adolescents are particularly vulnerable to the messages conveyed through the media, which influence their perceptions and behaviour. We describe a case of bilateral parotid enlargement due to malnutrition under the influence of self-prescribed diet in an adolescent. A 15-year-old girl reported to our institution under suspicion of Sjögren's syndrome for medical advice. Two months ago she developed persistent bilateral parotid enlargement and a dry mouth. Her medical history revealed a weight loss due to "self-prescribed" reduce diet. Social questioning clarified high use of the media and influence on the body concept and self image. On extra oral examination, a diffuse parotid enlargement was seen bilaterally. The examination of the mouth showed a low moisture level of the intraoral mucosa. The unstimulated whole salivary flow rate was 2 ml in 15 min. Laboratory findings evidenced anemia (107 g/l). The serum albumin concentration indicated a reduced level (28 g/l). Search for antinuclear antibodies, anti-SSA antibodies, anti-SSB, -Sm, -RNP and anti-double-stranded DNA antibodies was negative. Evaluation for antibodies against hepatitis C, cytomegalovirus and Epstein-Barr virus infection and HIV rendered negative results. A histopathologic examination of labial salivary gland biopsy revealed a picture of sialoadenosis. From the above investigations, a diagnosis of sialoadenosis due to malnutrition was made.

Salivary gland parameters and clinical data related to the underlying disorder in patients with persisting xerostomia

This study assessed salivary gland parameters and clinical data in patients referred to our clinic because of persisting xerostomia of unknown origin, in order to facilitate early diagnosis and recognition of the underlying disorder. Most patients were referred for diagnostic analysis of a possible Sjögren's syndrome (SS). A complete diagnostic work-up was available in all patients (n = 176), including data on salivary gland function, saliva composition, sialography, salivary gland swelling, pattern of complaints, general health, and medication. Patients were diagnosed with SS (n = 62), sialosis (n = 45), sodium retention syndrome (n = 30), or medication-induced xerostomia (n = 9). In 30 patients no disease related to salivary gland pathology was found. Unstimulated whole salivary flow was decreased in all patients, except in patients with sodium retention syndrome and in patients without salivary gland pathology. Submandibular/sublingual salivary flow was lowest in SS patients. SS and sialosis patients had increased salivary potassium concentrations, whereas only SS patients had increased sodium concentrations. About half of the sialosis patients mainly complained of persistent parotid gland swelling. Xerostomia-inducing medication was used by most patients. It was concluded that gland-specific sialometry and sialochemistry is useful in discriminating between the various disorders causing persisting xerostomia.

Progression of salivary gland dysfunction in patients with Sjogren's syndrome

BACKGROUND

Salivary gland dysfunction is one of the key manifestations of Sjögren's syndrome.

OBJECTIVES

(1) To assess prospectively loss of function of individual salivary glands in patients with primary and secondary Sjögren's syndrome in relation to disease duration and use of immunomodulatory drugs. (2) To study changes in sialochemical and laboratory values and subjective complaints over time.

METHODS

60 patients with Sjögren's syndrome were included in this study. Whole and gland-specific saliva (parotid and submandibular/sublingual (SM/SL)), samples were collected at baseline and after a mean of 3.6 (SD 2.3) years of follow-up. Disease duration was recorded for all patients.

RESULTS

Patients with Sjögren's syndrome with short disease duration had significantly higher stimulated flow rates at baseline than those with longer disease duration (p<0.05). When compared with healthy controls, the decrease in SM/SL flow rates at baseline was more prominent than that in parotid flow rates (p<0.05). Over time, there was a significant further decrease of stimulated flow rates, especially of the parotid gland, accompanied by increasing problems with swallowing dry food (p<0.05). The decrease was independent of the use of corticosteroids or disease-modifying antirheumatic drugs (DMARDs). Sialochemical variables remained stable.

CONCLUSIONS

Early Sjögren's syndrome is characterised by a decreased salivary gland function (parotis>SM/SL), which shows a further decrease over time, regardless of the use of DMARDs or steroids. Patients with Sjögren's syndrome with longer disease duration are characterised by severely reduced secretions of both the parotid and SM/SL glands. These observations are relevant for identifying patients who would most likely benefit from intervention treatment.