Treatment of oral dryness related complaints (xerostomia) in Sjögren's syndrome

The Oral Microbial Ecosystem in Age-Related Xerostomia: A Critical Review

Xerostomia is a widespread condition among the elderly, impacting as many as 50% of individuals within this demographic. This review aims to analyze the association between age-related xerostomia and the oral microbial ecosystem. Xerostomia not only induces discomfort but also heightens the susceptibility to oral diseases, including dental caries and infections. The oral microbial ecosystem, characterized by a dynamic equilibrium of microorganisms, is integral to the maintenance of oral health. Dysbiosis, defined as a microbial imbalance, can further aggravate oral health complications in those suffering from xerostomia. This review investigates the composition, diversity, and functionality of the oral microbiota in elderly individuals experiencing xerostomia, emphasizing the mechanisms underlying dysbiosis and its ramifications for both oral and systemic health. A comprehensive understanding of these interactions is vital for the formulation of effective management and prevention strategies aimed at enhancing the quality of life for older adults.

The Mechanism of 540 nm Green Light in Promoting Salivary Secretion

Background: Although low-level laser therapy (LLLT) is a widely used noninvasive treatment because of photobiomodulation effects, its application for xerostomia remained uncertain. Tight junctions (TJs), mainly composed of claudins, occludin, and ZO family members, are crucial structures that determine material transport through paracellular pathway in salivary gland epithelial cells. This work aimed to investigate whether LLLT affected salivary secretion through epithelial TJs. Methods: Transepithelial electrical resistance (TER) measurement and paracellular permeability assay were applied to evaluate paracellular permeability in submandibular gland (SMG)-C6 cells after irradiation with 540 nm green light. Immunofluorescence and western blot were used to detect the expression of TJ proteins. Quantitative phosphoproteomics were performed to explore possible intracellular signals. Results: We found that irradiation with 540 nm green light significantly decreased TER values while increased paracellular transport in SMG-C6 cells. 540 nm green light-induced redistribution of claudin-1, -3, and -4, but not occludin or ZO-1. Moreover, above phenomena were abolished by preincubation with capsazepine, an antagonist of transient receptor potential vanilloid subtype 1. Notably, irradiation with 540 nm green light on the skin covering the whole submandibular gland regions promoted salivary secretion and attenuated lymphocytic infiltration in 21-week-old non-obese diabetic mice (n = 5 per group), a xerostomia animal model for Sjögren's syndrome. Through in-depth bioinformatics analysis and expression verification, ERK1/2 and EphA2 served as potential canonical and noncanonical signals underlying 540 nm green light. Conclusions: Our findings uncovered the novel therapeutic effects of 540 nm green light on xerostomia through regulation on the expression and distribution of TJs.

The Yin and Yang of Sodium Lauryl Sulfate Use for Oral and Periodontal Health: A Literature Review

Sodium lauryl sulfate (SLS) is an anionic surfactant, which has a wide range of usage in the health sector and in dental pharmaceutical products, especially in toothpastes. The objective of this review was to investigate the effects of SLS containing dentifrices on oral and periodontal health, possible side effects, and its benefits. A thorough literature search was done using databases of PubMed and Google Scholar and finally, 40 articles were included in the study. This narrative review revealed the sources of discrepancy and conflicting results regarding the impact of SLS on oral cavity as well as a lack of sufficient evidence in most topics. Hence, the evidence suggests improved drug bioavailability when used as a solubilizer, improved plaque control, and reduction in bad breath. On the other hand, SLS can serve as a risk indicator of prolonged oral wound healing time, recurrent aphthous stomatitis.

An Overview of the Dry Eye Disease in Sjögren's Syndrome Using Our Current Molecular Understanding

Sjögren's syndrome is a chronic and insidious auto-immune disease characterized by lymphocyte infiltration of exocrine glands. The patients typically present with ocular surface diseases related to dry eye and other systemic manifestations. However, due to the high prevalence of dry eye disease and the lack of objective and clinically reliable diagnostic tools, discriminating Sjögren's syndrome dry eye (SSDE) from non-Sjögren's syndrome dry eye (NSSDE) remains a challenge for clinicians. Diagnosing SS is important to improve the quality of life of patients through timely referral for systemic workups, as SS is associated with serious systemic complications such as lymphoma and other autoimmune diseases. The purpose of this article is to describe the current molecular understanding of Sjögren's syndrome and its implications for novel diagnostic modalities on the horizon. A literature review of the pre-clinical and clinical studies published between 2016 and 2022 was conducted. The SSDE pathophysiology and immunology pathways have become better understood in recent years. Novel diagnostic modalities, such as tear and saliva proteomics as well as exosomal biomarkers, provide hope on the horizon.

Using the modified Schirmer test for dry mouth assessment: A cross-sectional study

This study aimed to establish whether the modified Schirmer test could serve as a diagnostic tool for dry mouth, that is, whether it could reliably measure salivary film at selected locations within the oral cavity, and to identify levels of sensitivity/specificity and determine reference values. Therefore, a cross-sectional study (N = 120, mean age 63.5 [SD 13.9] years) was performed. The test was used at five locations (hard palate; buccal mucosa in molar region at 4 mm above occlusal plane; anterior tongue; lower lip; mouth floor), and results were recorded after 1, 2 and 3 min. A statistically significant discriminatory ability of the Schirmer test for the unstimulated salivary flow rates could be shown for the palate (at 3 min), buccal mucosa (at 1 min), mouth floor (at 1 min), and tongue (at 2 and 3 min) (areas under the curve 0.64-0.68), with individual sensitivity/specificity values depending on test location/time points. Thus, the modified Schirmer test has potential to become a simple and reproducible instrument for the detection of dry mouth based on low unstimulated salivary flow rates in dentistry and especially outreach care. Care must be taken concerning intraoral test location and measurement time.

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.

Comparative evaluation of three types of denture base materials with saliva substitute before and after thermocycling: An in vitro study

STATEMENT OF PROBLEM

Xerostomia refers to the decrease in the quality and quantity of saliva. In denture wearers, xerostomia affects the retention of the denture because of lack of wettability of the denture base. However, which denture base resin materials are best wetted by artificial salivary substitutes is unclear.

PURPOSE

The purpose of this in vitro study was to determine the wetting properties of 3 different commercially available denture base resin materials with artificial salivary substitute by using contact angle measurements and to compare these properties before and after thermocycling.

MATERIAL AND METHODS

A total 120 specimens were fabricated with 3 different denture base materials (n=40): heat-polymerized polymethylmethacrylate (DenTek), injection-molded nylon polyamide (Valplast), and microwave polymerized (VIPI WAVE). The advancing and receding contact angles were measured with a goniometer by using the WinDrop++ software program. The contact angle hysteresis was calculated from the advancing and receding contact angles values. The same specimens were subjected to thermocycling to measure the advancing and receding contact angles values. The comparative evaluation was carried out before and after thermocycling.

RESULTS

The mean ±standard deviation contact angles of the microwave-polymerized material were (62.40 ±1.21 degrees) advancing contact angle, (32.12 ±0.66 degrees) receding contact angle, and (30.28 ±1.40 degrees) contact angle of hysteresis. It was followed by the injection-molded nylon polyamide material, whose mean ±standard deviation contact angle values were (68.57 ±1.72 degrees) advancing contact angle, (43.02 ±1.39 degrees) receding contact angle, (26.27 ±2.05 degrees) contact angle hysteresis and high impact strength heat-polymerized polymethylmethacrylate material, whose mean ±standard deviation contact angle values were (69.81 ±0.16 degrees) advancing contact angle, (41.90 ±1.02 degrees) receding contact angle, and (27.91 ±0.97 degrees) contact angle hysteresis. The statistical analysis showed significant differences among contact angle values of the microwave-polymerized material as compared with the heat-polymerized polymethylmethacrylate and injection-molded nylon polyamide materials (P<.001).

CONCLUSIONS

The microwave-polymerized material showed better wettability with artificial saliva substitute than heat-polymerized polymethylmethacrylate and injection-molded nylon polyamide.

Medication-Induced Xerostomia and Hyposalivation in the Elderly: Culprits, Complications, and Management

Medication-induced xerostomia and hyposalivation will increasingly become oral health issues for older and geriatric patients because of the likely high prevalence of medication intake and polypharmacy, with a complex negative impact on other symptoms such as dysphagia, caries incidence, malnutrition, and quality of life. All healthcare professionals are encouraged to investigate dry mouth symptoms among their patients, since diagnosis can easily be performed within daily clinical practice. This practical article also provides a review of available treatment options, which include medication changes towards products with fewer xerogenic side effects or dose reductions, if possible, as well as multidisciplinary, preventive care-oriented approaches that consider all influencing factors and treatment of the oral symptoms. In addition, several topical agents and saliva substitutes are discussed that may provide symptomatic relief but need to be carefully adapted to each patient's situation in terms of usability and practicability and in the knowledge that therapeutic success varies with each individual. Innovative methods such as intraoral electrostimulation or topical application of anticholinesterase on the oral mucosa are also discussed. The most commonly prescribed pharmaceutical treatment options for dry mouth are pilocarpine (a parasympathomimetic agent with potent muscarinic, cholinergic salivation-stimulating properties) and cevimeline (a quinuclidine analogue with therapeutic and side effects similar to those of pilocarpine). These pharmaceutic treatment options are described in the context of older patients, where the highly prevalent cholinergic side effects, which include nausea, emesis, bronchoconstriction, among others, need to be thoroughly supervised by the healthcare professionals involved. Providing these therapeutic options to patients with medication-induced dry mouth will help improve their oral health and therefore maintain a better quality of life, general health, and well-being.

Wettability of 3 different artificial saliva substitutes on heat-polymerized acrylic resin

STATEMENT OF PROBLEM

The prosthodontic problems faced by a patient with xerostomia are of great concern. To aid in retention, artificial saliva substitutes should exhibit good wettability on the denture base.

PURPOSE

The purpose of this in vitro study was to evaluate the wettability of 3 different artificial saliva substitutes on heat-polymerized acrylic resin and to compare these properties with natural saliva and distilled water.

MATERIAL AND METHODS

A total of 150 heat-polymerized acrylic resin specimens were prepared with 25×15×2 mm dimensions. The specimens were divided into 5 groups (n=30): human saliva, distilled water, Aqwet, Mouth Kote, and Stoppers 4. The advancing and receding contact angle values were measured by using a goniometer, and the contact angle hysteresis and equilibrium angle were calculated. One-way ANOVA and the Bonferroni multiple comparisons test were performed to determine the difference between contact angle values among the groups (α=.05).

RESULTS

The means of the 5 groups differed significantly (P<.05). The comparison between human saliva and Aqwet showed no significant difference for advancing contact angle, receding contact angle, contact angle hysteresis, or equilibrium contact angle, while comparison between the remaining groups indicated statistically significant (P<.05) results. All 3 saliva substitutes used in this study (Aqwet, Mouth Kote, and Stoppers 4) had significantly better wetting properties than distilled water.

CONCLUSIONS

Human saliva had the lowest advancing, receding, and equilibrium contact angle values and the highest angle of hysteresis on heat-polymerized acrylic resin. Aqwet had better wetting ability than the other artificial salivary substitutes tested and was comparable to the human saliva on heat-polymerized acrylic resin. All saliva substitutes have better wetting properties than distilled water.

Acidification induces OGR1/Ca2+/calpain signaling in gingival fibroblasts

Gingivitis, the mildest form of periodontitis, is generally considered a consequence of prolonged exposure of the gingiva to periodontal pathogens. On the other hand, several epidemiologic reports have suggested that other etiologic factors such as oral acidification may also increase the susceptibility of the periodontium to destruction. However, the pathologic mechanism underlying the effects of oral acidification on the gingiva is still largely unknown. In this study, we analyzed molecular pathways mediating the influence of the acidic environment on human gingival fibroblasts (HGFs). Acidic extracellular pH caused biphasic increase of intracellular Ca²⁺ level ([Ca²⁺]_i) through activation of ovarian cancer G protein-coupled receptor 1, phospholipase C, and Ca²⁺ release from the endoplasmic reticulum, but not through voltage-gated Ca²⁺ channels or extracellular Ca²⁺ influx via transient receptor potential cation channel subfamily V member 1. The acidic environment was also transiently cytotoxic for HGFs; however, the activation of pro-apoptotic proteins poly (ADP-ribose) polymerase-1 and BAX was not observed. Furthermore, we found that intracellular matrix metalloproteinase 1 was consistently upregulated in HGFs grown in regular medium, but significantly reduced in the acidic medium, which depended on [Ca²⁺]_i increase, lysosomal pH homeostasis, and Ca²⁺-dependent protease calpain. Considering that HGFs, essential for oral wound healing, in the in vitro culture system are placed in wound repair-like conditions, our findings provide important insights into molecular mechanisms underlying HGF functional impairment and chronic damage to the gingiva caused by the acidic intraoral environment.

Diagnosis and management of xerostomia and hyposalivation

Xerostomia, the subjective complaint of dry mouth, and hyposalivation remain a significant burden for many individuals. Diagnosis of xerostomia and salivary gland hypofunction is dependent upon a careful and detailed history and thorough oral examination. There exist many options for treatment and symptom management: salivary stimulants, topical agents, saliva substitutes, and systemic sialogogues. The aim of this review is to investigate the current state of knowledge on management and treatment of patients affected by xerostomia and/or hyposalivation.

Effects of oral moisturising gel containing egg yolk antibodies against Candida albicans in older people

OBJECTIVE

The aim of this study was to evaluate the inhibitory effects of oral moisturising gel containing egg yolk antibody against Candida albicans (anti-CA IgY) in older people. Therefore, we measured the number of Candia CFU present on oral swabs at baseline and after using the gel.

METHODS

A randomised, double-blind, placebo-controlled trial was conducted among volunteers living in a nursing home in Japan. The participants were divided into two groups. The group 1 participants received oral care using an experimental oral moisturising gel with anti-CA IgY, and those in group 2 received oral care using a placebo oral moisturising gel without anti-CA IgY. The oral care was performed by care workers three times a day for 4 weeks. The participants' tongues were sampled using a swab method at baseline and after 2 and 4 weeks of using the oral gel, and the number of C. albicans, Candida tropicalis and Candida krusei colonies was counted.

RESULTS

The baseline oral condition of the participants in the two groups did not differ significantly. The experimental gel significantly reduced the number of C. albicans colonies from baseline to after 4 weeks of using the oral gel; however, no significant reductions were observed in the number of C. tropicalis or C. krusei colonies.

CONCLUSION

The use of oral moisturising gel containing anti-CA IgY for 1 month significantly reduces the number of C. albicans CFU present on swabs in older people.

Dental hygiene intervention to prevent nosocomial pneumonias

Nosocomial and ventilator associated pneumonias that plague critically ill, elderly and long-term care residents could be reduced with effective oral hygiene practices facilitated collaboratively between nurses and dental hygienists.

BACKGROUND

Nosocomial pneumonias, specifically aspiration pneumonias and ventilator-associated pneumonias in the elderly and infirm have become a major health care issue, The provision of oral care in hospital and hospital-like facilities presents challenges that can prevent patients from receiving optimal oral care One sequela can be aspiration pneumonia which ranks first in mortality and second in morbidity among all nosocomial infections. Since aspiration pneumonia is linked to the colonization of oral bacteria in dental plaque and biofilm, it is time to look for creative solutions to integrating the expertise of dental hygienists into health care teams in these institutional settings.

METHODS

A comprehensive review of the literature was conducted regarding the etiology and prevalence of health care related pneumonias. Evidence describing the challenges and barriers that the nurses, nursing staff, and dental hygienists face in the provision of oral care in hospitals and long-term care facilities is provided. Intercollaborative solutions to providing optimal oral care in hospitals and long-term care facilities are suggested.

CONCLUSION

Dental hygienists have the expertise and practice experience to provide oral care in hospitals, long-term care and residential facilities. They can contribute to solving oral care challenges through intercollaboration with other health care team members. Yet, there are long-standing systemic barriers that must be addressed in order to provide this optimal care. Dental hygienists becoming better assimilated within the total health care team in hospital and residential facilities can positively impact the suffering, morbidity and mortality associated with aspiration pneumonias.

Dry mouth and denture plaque microflora in complete denture and palatal obturator prosthesis wearers

OBJECTIVE AND BACKGROUND

The purpose of this study was to investigate the association of dry mouth with denture plaque microflora in patients with palatal obturator prostheses from the viewpoint of infection control.

METHODS

Thirty palatal obturator prosthesis wearers were compared with 30 healthy maxillary complete denture wearers. Dry mouth was examined using a moisture-checking device and was diagnosed by the measured moisture levels. Denture plaque was collected by rubbing the mucosal surface of the denture with a swab; collected microorganisms were cultured and identified using culture-dependent methods. The number of colonising microorganisms and prevalence of microorganisms were examined according to the type of prostheses and presence of dry mouth using nonparametric tests and frequency analysis (α = 0.05).

RESULTS

The prevalence of Candida spp. and Staphylococcus spp. in palatal obturator prostheses was significantly higher than that in complete dentures. In palatal obturator prostheses, the total number of colonising microorganisms showed no significant differences between the groups with and without dry mouth on each side of the prostheses. However, the prevalence of Candida spp. and Staphylococcus spp. in the group with dry mouth was significantly higher than that in the group without dry mouth. The number of microorganisms and moisture levels of palatal obturator prosthesis wearers showed a significantly negative correlation with Candida spp. and Staphylococcus spp., but a positive correlation with Neisseria spp.

CONCLUSION

It was concluded that palatal obturator prosthesis wearers with a dry mouth have greater colonisation by Candida spp. and Staphylococcus spp. than do complete denture wearers.

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.

The protein kinase A pathway contributes to Hg2+-induced alterations in phosphorylation and subcellular distribution of occludin associated with increased tight junction permeability of salivary epithelial cell monolayers

Hg(2+) is commonly used as an inhibitor of many aquaporins during measurements of transcellular water transport. To investigate whether it could also act on the paracellular water transport pathway, we asked whether addition of Hg(2+) affected transport of radiolabeled probes through tight junctions of a salivary epithelial cell monolayer. Inclusion of 1 mM Hg(2+) decreased transepithelial electrical resistance by 8-fold and augmented mannitol and raffinose flux by 13-fold, which translated into an estimated 44% increase in pore radius at the tight junction. These Hg(2+)-induced effects could be partially blocked by the protein kinase A (PKA) inhibitor N-[2-((p-bromocinnamyl) amino) ethyl]-5-isoquinolinesulfonamide, 2HCl (H89), suggesting that both-PKA dependent and PKA-independent mechanisms contribute to tight junction regulation. Western blot analyses showed a 2-fold decrease in tight junction-associated occludin after Hg(2+) treatment and the presence of a novel hyperphosphorylated form of occludin in the cytoplasmic fraction. These findings were corroborated by confocal imaging. The results from this study reveal a novel contribution of the PKA pathway in Hg(2+)-induced regulation of tight junction permeability in the salivary epithelial barrier. Therapeutically, this could be explored for pharmacological intervention in the treatment of dry mouth, Sjögren's syndrome, and possibly other disorders of fluid transport.

Pulmonary defense and the human cathelicidin hCAP-18/LL-37

Antimicrobial peptides form an important component of the innate immune system. The cathelicidin family, a key member of the antimicrobial peptide defenses, has been highly conserved throughout evolution. Though widespread in mammals, there is currently only one identified human example, hCAP-18/LL-37. The cathelicidins have been found to have multiple functions, in addition to their known antimicrobial and lipopolysaccharide-neutralizing effects. As a result, they profoundly affect both innate and adaptive immunity. Currently, antimicrobial peptides are being evaluated as therapeutic drugs in disease states as diverse as oral mucositis, cystic fibrosis, and septic shock. One such peptide, the cathelicidin hCAP-18/LL-37, is reviewed in detail in the context of its role in lung physiology and defense.

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.

Rituximab treatment in patients with primary Sjögren's syndrome: An open-label phase II study

OBJECTIVE

To investigate the safety and efficacy of B cell depletion treatment of patients with active primary Sjögren's syndrome of short duration (early primary SS) and patients with primary SS and mucosa-associated lymphoid tissue (MALT)-type lymphoma (MALT/primary SS).

METHODS

Fifteen patients with primary SS were included in this phase II trial. Inclusion criteria for the early primary SS group were B cell hyperactivity (IgG >15 gm/liter), presence of autoantibodies (IgM rheumatoid factor, anti-SSA/SSB), and short disease duration (<4 years). Inclusion criteria for the MALT/primary SS group were primary SS and an associated MALT-type lymphoma (Ann Arbor stage IE) localized in the parotid gland. Patients were treated with 4 infusions of rituximab (375 mg/m2) given weekly after pretreatment with prednisone (25 mg) and clemastine. Patients were evaluated, using immunologic, salivary/lacrimal function, and subjective parameters, at baseline and at 5 and 12 weeks after the first infusion.

RESULTS

Significant improvement of subjective symptoms and an increase in salivary gland function was observed in patients with residual salivary gland function. Immunologic analysis showed a rapid decrease of peripheral B cells and stable levels of IgG. Human anti-chimeric antibodies (HACAs) developed in 4 of 15 patients (27%), all with early primary SS. Three of these patients developed a serum sickness-like disorder. Of the 7 patients with MALT/primary SS, complete remission was achieved in 3, and disease was stable in 3 and progressive in 1.

CONCLUSION

Findings of this phase II study suggest that rituximab is effective in the treatment of primary SS. The high incidence of HACAs and associated side effects observed in this study needs further evaluation.

Xerostomia Secondary to Sj??gren???s Syndrome in the Elderly

Xerostomia is a common symptom in the elderly population. Studies have suggested that the underlying cause of approximately 40% of xerostomia in the elderly is Sjögren's syndrome. Although it is highly prevalent among middle-aged individuals, elderly patients account for up to 20% of Sjögren's syndrome cases. Sjögren's syndrome is a multisystem exocrinopathy characterised by dry mouth and dry eyes with wide-ranging extraglandular involvement. The exocrine manifestations of Sjögren's syndrome affect the mouth, eyes, nose, ears, skin, vagina and the entire respiratory and gastrointestinal systems. The nonexocrine involvement may include the joints, thyroid gland, liver, kidneys and the musculoskeletal, vascular and central nervous systems. Currently, the mechanism(s) of development and progression of Sjögren's syndrome is/are not clear. Inflammation and lymphocytic infiltration of the exocrine glands is a classical feature of Sjögren's syndrome. During the progression of the disease, the acinar cells of the exocrine glands are replaced by fibrosis, rendering the glands nonfunctional. Sjögren's syndrome remains one of the most underdiagnosed conditions, particularly in the elderly population, because the cardinal sicca symptoms, which are the hallmark of the disease, are frequently attributed to aging and/or medications, which consequently delays the diagnosis. This delay in diagnosis imposes significant physical, psychological and economic burdens on elderly patients. The diagnosis of Sjögren's syndrome requires evaluation of both the exocrine and nonexocrine components of the disease. Management of Sjögren's syndrome requires collaboration by the primary-care physician, rheumatologist, ophthalmologist and dentist. This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome with special emphasis on the oral component of the disease.

Detection and recognition thresholds to the 4 basic tastes in Mexican patients with primary Sjögren's syndrome

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic autoimmune disease characterized by inflammatory lymphocytic infiltration of the salivary glands, leading to dryness of the mouth (xerostomia). It has been postulated that xerostomia is the preceding stage for the development of alterations in taste acuity (dysgeusia) in this type of patients.

OBJECTIVES

To determine detection and recognition thresholds to the 4 basic tastes (sweet, salty, sour and bitter) in pSS patients and compare them to a control group. To determine if the long-term consumption of chile peppers and spicy Mexican diets had an effect on the taste perception and acuity of the pSS patients.

SETTING

This study was done in the Department of Food Science and Technology of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), a third-level hospital in Mexico City.

SUBJECTS

The patient group consisted of 21 Mexican females (mean +/- s.d., age: 53.1 +/- 9.8 y) diagnosed with pSS (time of duration of the disease, 8.6 +/- 6.6 y, median 7 y, range 1-25 y) who were recruited at the outpatient service of the Department of Immunology and Rheumatology of the INCMNSZ. The control group consisted of 20 healthy nonsmokers age-matched Mexican women (50.3 +/- 11.9 y) most of them personnel of the INCMNSZ, and some friends and nonblood relatives to the patients (sisters-in-law) who volunteered to participate in the study.

INTERVENTIONS

Detection and recognition thresholds were determined by the method of least noticeable differences on three occasions during three nonconsecutive days. Saliva production was determined by Saxon's test on two separate occasions.

RESULTS

Although saliva production was severely reduced in pSS patients (1.35 +/- 0.55 ml/2 min, P<0.001) compared to controls (6.26 +/- 2.41 ml/2 min), all subjects recognized the 4 basic tastes when these were tested at suprathreshold concentrations. The detection thresholds for the sweet, sour and bitter tastes were higher in pSS patients, as well as the recognition thresholds for the salty, sour and bitter tastes. A relationship between time of evolution of the disease and saliva production with individual thresholds could not be established.

CONCLUSIONS

pSS patients exhibited different degrees of dysgeusia depending on the taste being studied, that is, they were mildly dysgeusic for the sweet and salty tastes and clearly dysgeusic for the sour and bitter tastes. Although both pSS patients and controls had consumed 'typical Mexican diets' their entire lives, our results showed that the consumption of chile peppers and spicy foods did not have any effect on the taste perception and acuity of the pSS patients.

Myelopathy in Sj??gren??s Syndrome

The incidence, aetiology and optimal treatment of CNS Sjögren's syndrome, including myelopathy associated with Sjögren's syndrome, are unknown at the present time. CNS Sjögren's syndrome is thought to be the result of an autoimmune vasculitis, but other mechanisms may be important. Spinal cord involvement in CNS Sjögren's syndrome may present as acute transverse myelitis, progressive myelitis, Brown-Séquard syndrome, neurogenic bladder or lower motor neurone disease. Optic nerve pathology frequently accompanies spinal cord involvement. Acute transverse myelitis has a high mortality and appears to be the most frequent form of spinal cord involvement in CNS Sjögren's syndrome, occurring in about 1% of all patients with Sjögren's syndrome. The patient's symptomatology and clinical course dictate current treatment of myelopathy. First-line treatment appears to be corticosteroid therapy. However, when the patient's condition fails to improve or deteriorates a nonsteroidal immunosuppressant agent should be considered. Agents used to treat myelopathy include cyclophosphamide, chlorambucil, azathioprine, ciclosporin (cyclosporin) and methotrexate in conjunction with corticosteroids. Most data exist as anecdotal reports. The agent of first choice, based on adverse effect profile and efficacy, appears to be cyclophosphamide given intravenously in pulse doses. Other nonsteroidal immunosuppressant agents should be considered, especially when lack of efficacy of, or intolerance to, cyclophosphamide exists in the patient's history. Glandular and other extraglandular symptoms may benefit concomitantly from the immunosuppressant treatment. In addition, when acute relief of symptomatology is needed, the patient may benefit from a trial of plasmapheresis or intravenous immunoglobulin. Infliximab (anti-tumour necrosis factor-alpha antibodies) has not been used as a treatment modality for myelopathy, but has shown some usefulness in the treatment of extraglandular symptoms, as well as peripheral nervous system manifestations of Sjögren's syndrome. This agent might be considered when all other treatment modalities have failed given the presumed importance of tumour necrosis factor in the pathogenesis of Sjögren's syndrome.

Implants in the medically compromised patient

Dental clinicians are confronted with an increasing number of medically compromised patients who require implant surgery for their oral rehabilitation. However, there are few guidelines on dental implant therapy in this patient category, so that numerous issues regarding pre- and post-operative management remain unclear to the dental clinician. Therefore, the aim of the present review is to offer a critical evaluation of the literature and to provide the clinician with scientifically based data for implant therapy in the medically compromised patient. This review presents the current knowledge regarding the influence of the most common systemic and local diseases on the outcome of dental implant therapy, e.g., abnormalities in bone metabolism, diabetes mellitus, xerostomia, and ectodermal dysplasias. Specific pathophysiologic aspects of the above-mentioned diseases as well as their potential implications for implant success are critically appraised. In line with these implications, guidelines for pre- and post-operative management that may assist in the successful implant-supported rehabilitation of this patient category are proposed.

Pharmacotherapy of xerostomia in primary Sjögren's syndrome

We reviewed the current literature concerning the treatment of dry mouth in patients with primary Sjögren's syndrome (SJS). Computerized MEDLINE search engines were used with the terms Sjögren, xerostomia, dry mouth, and treatment. References from key articles were searched, and all pertinent articles were procured and reviewed. Primary SJS is an uncommon but serious disorder. Dry mouth caused by SJS can lead to dental erosion, dysphagia, oral infections, and discomfort. Preventing these complications is of paramount importance. Pharmacotherapy is limited to topical saliva substitutes, which are considered first, followed by muscarinic stimulators such as pilocarpine or cevimeline, if required. Immunosuppressive therapy is being investigated. Patients should have regular oral and dental examinations to detect complications. Satisfaction with the efficacy and tolerability of treatment should be monitored frequently. The clinician may have to use a trial-and-error approach to determine a successful regimen.

Proposta de um método prático de sialometria

Introdução: A xerostomia é uma queixa subjetiva que pode ou não estar relacionada à diminuição da salivação. Deve, porém, ser sempre investigada, pois está freqüentemente associada a doenças sistêmicas, incluindo a síndrome de Sjögren. Apesar de não haver padrão universal que caracterize a hipossalivação, consideramos a sialometria importante para avaliação do tratamento, através da realização de exames seriados em um mesmo paciente. Analisando as técnicas de sialometria já descritas, optamos por adaptar e padronizar o método de Bolwig e Rafaelsen (1972) por considerá-lo o mais prático e fidedigno e visando à partir de então a sua utilização em larga escala. Objetivo: Avaliar os resultados de método submúltiplo de sialometria. Material e método: Foram avaliados 10 sujeitos, 5 sem sintomatologia de xerostomia que formam considerados compatíveis e 5 com xerostomia. Foram submetidos ao método de sialometria com algodão pré e pós estimulados. Os resultados foram comprovados. Resultados: Todos os pacientes apresentaram melhora da saliva mensurável pelo método pós-estimulado. Conclusões: O método utilizado se mostrou de fácil realização e fidedigno.

The oral side of Sjögren syndrome. Diagnosis and treatment. A review

Sjögren syndrome (SS) is an inflammatory disease of the exocrine glands. Although not always present, signs and symptoms of dry eyes and xerostomia are characteristic features of SS. Oral dryness is one of the most important data of patients with SS. Several sets of criteria have been published; however, there is no definitive agreement concerning which is the most useful. In addition to its various clinical manifestations, lack of understanding of the causes of SS delays prompt diagnosis. Histologically, the salivary gland shows a characteristic lymphocytic infiltrate, which is implicated in the destruction of gland cells. Saliva performs an important role in maintaining and protecting oral health. Deficient quality and quantity of saliva have a detrimental consequence for dental and oral health. In some patients, appropriate information regarding dry mouth care is not offered because most professionals either neglect or ignore adequate attention to oral health. Therefore, lack of treatment is frequent. Medical and dental studies that focus on the oral aspects of diagnosis, consequences, and treatment of SS are commented on. Diagnostic methods used for the oral component are also reviewed. The role of the oral tests developed to diagnose SS is assessed, especially tests used by the majority of criteria. Impairment of salivary secretion increases the risk of developing oral diseases; the therapeutic modalities designed to ameliorate these damages by increasing salivary output or by substitution of saliva are reviewed. We discuss published prevention techniques to diminish dental, periodontal, and soft tissue infections.

The management of Sjögren's syndrome in dental practice

BACKGROUND

Sjögren's syndrome, or SS, is a multisystem inflammatory disorder of the exocrine glands with a wide range of extraglandular involvement. Symptoms of dry eyes and xerostomia, although not invariably present, are characteristic features of SS. An increased risk of oral and dental diseases is a prominent consequence of SS.

TYPES OF STUDIES REVIEWED

The author reviewed recent medical and dental studies that have advanced our understanding of the causes and treatment of SS. She particularly focused on studies addressing the diagnosis and treatment of the oral component of the disease.

RESULTS

Sjögren's syndrome is a widely underdiagnosed disease. A delay in the diagnosis of SS may have a significant physical, psychological and economic impact on the affected person. The pathogenesis of SS appears to involve a number of factors: immunological, genetic, hormonal and possibly infectious. Successful management of SS requires a multidisciplinary approach, and the dentist plays an essential role in the diagnosis and treatment of the disease. ORAL IMPLICATIONS: Impairment of salivary function in SS increases the risk of developing oral diseases. Effective management of oral health comprises enhancement of salivary output (cholinergic agonist drugs such as pilocarpine or cevimeline) and prevention and treatment of dental caries, oral candidiasis and allergic mucositis. Finally, periodic evaluation of various clinical and laboratory parameters is needed to monitor disease status.