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

Multidisciplinary Therapeutic Approach of a Patient With Sjogren's Syndrome: A Three-Year Follow-Up Study

Sjögren's syndrome is a chronic, inflammatory autoimmune disorder characterized by lymphocyte infiltration of the exocrine glands. Notably, the rehabilitation of partially edentulous patients with Sjögren's syndrome is limited by the scarce availability of studies that could inform therapeutic modalities and potential challenges during clinical procedures. This case report aimed to present the oral rehabilitation of a patient with Sjögren's syndrome who received fixed partial dentures (FPDs). A 28-year-old female patient sought treatment to restore her missing teeth. She was diagnosed with Sjögren's syndrome by a rheumatologist adhering to the revised version of the European criteria proposed by the American-European Consensus Group and was on a medication regimen including prednisolone, hydroxychloroquine, pantoprazole, pilocarpine, and tear substitutes to manage her condition. The final treatment plan consisted of extractions, management of gingivitis, post-and-core restorations, and a 2 mm vertical dimension increase with the placement of 15 porcelain-fused-to-metal (PFM) crowns and 4 short-span bridges. The patient underwent regular clinical and radiographic evaluations every 3 months since June 2020. Throughout this period, the fixed prostheses, teeth, and periodontal tissues demonstrated remarkable stability and exhibited no complications. This three-year case study provides evidence that meticulous planning and clinical execution can facilitate successful oral rehabilitation in young edentulous patients with Sjögren's syndrome. Tooth-supported fixed prostheses can effectively restore oral function and aesthetic appeal in these individuals, provided they undergo more frequent dental examinations than the general population and maintain a cooperative attitude throughout the treatment process.

A Study on Duration of Effect of Transcutaneous Electrical Nerve Stimulation Therapy on Whole Saliva Flow

BACKGROUND

Saliva is a complex fluid, whose important role is to maintain the well being of oral cavity. Salivary gland hypofunction or hyposalivation is the condition of having reduced saliva production which leads to the subjective complaint of oral dryness termed xerostomia.(7) Management of xerostomia includes palliative therapy using topical agents or systemic therapy. Electrostimulation to produce saliva was studied in the past and showed moderate promise but never became part of mainstream therapy. Hence, this study was undertaken to evaluate the effect of transcutaneous electrical nerve stimulation (TENS) on whole salivary flow rate in healthy adults and to evaluate how long this effect of TENS lasts on salivary flow.

MATERIALS AND METHODS

One hundred healthy adult subjects were divided into five age groups with each group containing 20 subjects equally divided into males and females in each group. Unstimulated saliva was collected using a graduated test tube fitted with funnel and quantity was measured. Transcutaneous electrical nerve stimulation unit was activated and stimulated saliva was collected. Saliva was again collected 30 minutes and 24 hours post stimulation.

RESULTS

The mean unstimulated whole saliva flow rate for all subjects (n = 100) was 2.60 ml/5 min. During stimulation, it increased to 3.60 ± 0.39 ml/5 min. There was 38.46% increase in salivary flow. Ninety six out of 100 responded positively to TENS therapy. Salivary flow remained increased 30 minutes and 24 hours post stimulation with the values being 3.23 ± 0.41 ml/5 min and 2.69 ± 0.39 ml/5 min respectively. Repeated measures One way analysis of variance (ANOVA) test showed that the difference between these values were statistically significant.

CONCLUSION

Transcutaneous electrical nerve stimulation therapy was effective for stimulation of whole saliva in normal, healthy subjects and its effect retained till 30 minutes and a little up to 24 hours. Transcutaneous electrical nerve stimulation may work best synergistically with other sialagogues and can be used for the management of xerostomia.

Sjögren's syndrome in older patients: aetiology, diagnosis and management

Sjögren's syndrome (SS) is a systemic autoimmune disease, characterized by chronic inflammation of exocrine glands that results in development of xerostomia and keratoconjunctivitis sicca. The disease activity of SS is not restricted to exocrine glands, and many other organs and organ systems can be involved. Diagnosis of SS in the elderly population can be challenging because xerostomia, dry eyes, symptoms of fatigue, weight loss and muscle pain are also common features of old age. Delay between clinical onset and diagnosis of SS in the elderly may be due to the shared features of SS and old age. The 2002 revised American-European Consensus Group (AECG) classification criteria for SS are the preferred tool used to confirm diagnosis of SS, but recently alternative criteria have been put forward by the American College of Rheumatology (ACR). The AECG criteria set combines subjective symptoms of dry eyes and dry mouth with objective signs of keratoconjunctivitis sicca, salivary gland dysfunction and histopathological (salivary gland biopsy) and serological (autoantibodies against SSA/Ro and SSB/La antigens) features. Treatment of SS in the elderly does not differ from that in younger patients. The aims of the treatment of SS are to control glandular and extraglandular manifestations, to prevent damage to organ systems and loss of function, and to decrease morbidity and mortality. Treatment of the elderly can be complicated by co-morbidities, an increased rate of adverse events related to therapeutic agents, and polypharmacy. Therefore, careful follow-up of the treatment is required.

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.

Growth of miniature pig parotid cells on biomaterials in vitro

Both Sjögren's syndrome and therapeutic irradiation for head and neck cancer lead to irreversible damage of the parenchyma of the salivary glands. This report describes an attempt to grow miniature pig (minipig) parotid gland cells on artificial films and tubular scaffolds with the ultimate intention of developing bio-engineered replacement tissue. Minipig parotid cells were isolated and cultured. The growth and structural and physiological features of the cells which were cultured on films and porous tubular scaffolds made from poly(ethylene glycol)-terephthalate (PEGT)/poly(butylene terephthalate) (PBT) were examined. By 9 days, the parotid cells on the films and the tubular scaffolds formed continuous monolayers. The secretory granules and nuclei of the cultured acinar cells remained polarised. Desmosomes, gap junctions and tight-like junctions were still present between the apical regions of adjacent cells. Amylase activity decreased during the culture period but was still evident in the medium after 10 days of culture. In conclusion, minipig parotid cells are well-maintained in vitro on both a flat surface and a three-dimensional (3D) scaffold. The addition of a Matrigel coating to the surface of synthetic materials aids cell growth and maintenance of a morphology that more closely resembles normal epithelium.

Oral manifestations of patients with lupus erythematosus

Lupus erythematosus manifests as cutaneous variants, such as discoid lupus erythematosus or systemic lupus erythematosus. Systemic lupus erythematosus is a multisystem autoimmune disease characterized by general autoantibody production and a wide range of mucocutaneous, renal, neuropsychiatric, cardiovascular, infectious, and hematologic manifestations. This article discusses the prevalence of and considerations for oral mucosal lesions in lupus erythematosus and the impact of the various disease manifestations of systemic lupus erythematosus on dental management.

The role of oral microbial colonization in ventilator-associated pneumonia

The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.

Xerostomia: clinical aspects and treatment

Xerostomia or dry mouth is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which make the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjogren's syndrome. Xerostomia is associated with difficulties in chewing, swallowing, tasting or speaking. This results in poor diet, malnutrition and decreased social interaction. Xerostomia can cause oral discomfort, especially for denture wearers. Patients are at increased risk of developing dental caries. A thorough intraoral and extra-oral clinical examination is important for diagnosis. Treatment may include the use of salivary substitutes (Biotene), salivary stimulants such as pilocarpine, ongoing dental care, caries prevention, a review of the current prescription drug regimen and possible elimination of drugs having anticholinergic effects. Because of the ageing population, and the concomitant increase in medicated individuals, dentists can expect to be presented with xerostomia in an increasing number of patients in the coming years and therefore should be familiar with its diagnosis and treatment. Therefore, the purpose of this review is to outline for clinicians the common aetiologies, clinical identification, and routine therapeutic modalities available for individuals with xerostomia.

Treatment of primary Sjögren's syndrome with low-dose human interferon alfa administered by the oromucosal route: combined phase III results

OBJECTIVE

This study tested the safety and efficacy of human interferon (IFN) alfa for treatment of salivary hypofunction and dry mouth symptoms in primary Sjögren's syndrome patients.

METHODS

Combined results are reported from 2 phase III clinical trials in which a total of 497 subjects with primary Sjögren's syndrome received 150 international units of human IFN alfa or matching placebo 3 times per day for 24 weeks by the oromucosal route.

RESULTS

Subjects given IFN alfa had a significantly (P = 0.01) greater mean increase in unstimulated whole saliva (UWS) flow, compared with subjects given placebo. In IFN alfa patients, increases in UWS correlated positively and significantly with improvements noted in 7 of 8 symptoms associated with oral and ocular dryness. The coprimary endpoints of stimulated whole saliva flow and oral dryness were not significantly improved in the IFN alfa group relative to placebo. No significant differences were found between the groups with respect to overall adverse event incidence or severity.

CONCLUSION

IFN alfa given at low dosage by the oromucosal route can significantly increase UWS flow in patients with primary Sjögren's syndrome, without causing significant adverse events.

Analysis of in situ proliferative activity in oral gingival epithelium in patients with xerostomia

BACKGROUND

Sjögren's syndrome is an autoimmune disease characterized by xerostomia and keratoconjunctivitis sicca. The relationship between xero-stomia and proliferative activity in human gingival epithelium is not known. Proliferating cell nuclear antigen (PCNA) is a nuclear protein associated with the cell cycle. Nuclear PCNA immunoreactivity is found in the proliferative compartment of normal tissues. The aims of this study were to evaluate PCNA expression in oral gingival epithelium of healthy and inflamed gingiva obtained from patients with Sjögren's syndrome, and to compare the results to age- and gender-matched subjects with normal salivary function.

METHODS

Eighteen Sjögren's syndrome patients and 28 controls (14 with chronic periodontitis and 14 with no clinical evidence of periodontal disease) were included in the study. Biopsies were obtained from both inflamed and healthy gingiva. The expression of PCNA was evaluated in formalin-fixed, paraffin-embedded gingival samples using an immunoperoxidase technique and PC10 monoclonal antibody to PCNA.

RESULTS

PCNA expression was observed both in the basal and suprabasal layers, and was found to be more prominent in the suprabasal layers. Proliferative index (PI) in inflamed gingiva was significantly lower in the Sjögren's syndrome group. However, no significant difference was observed between the study and control groups with respect to PI in healthy gingiva. In both groups, PI was found to be increased due to inflammation.

CONCLUSIONS

Our data indicate that proliferative activity is observed in the suprabasal layers and, less frequently, in the basal layer. Inflammation caused increased proliferative activity. However, this positive effect of inflammation on epithelial cell proliferation decreased significantly with a lack of saliva. Therefore, it appears that saliva-derived biological mediators may also contribute to increased proliferative activity observed during inflammation.

The need to introduce gene therapy to the dental curriculum

Recombinant DNA technology is finding its way into many aspects of clinical medicine. No application currently is more dramatic than gene therapy. Proofs of principle have already been established for gene therapy targeted to oral tissues, and more are likely to be demonstrated in the near future. The dental curriculum must begin to include the biological basis of DNA-based therapies and other related biomedical science progress.