Oral Complications of Sjögren's Syndrome

doi:10.1016/j.coms.2013.09.004

Oral and Maxillofacial Surgery Clinics of North America

Volume 26, Issue 1, February 2014, Pages 55-62

https://doi.org/10.1016/j.coms.2013.09.004 Get rights and content

Section snippets

Key points

•
A consensus exists that patients with Sjögren’s syndrome are more prone to dental caries, with decay often occurring in areas that are not usually caries-prone.
•
Although it is presumed that decreased salivary flow may lead to increases in periodontal disease, there is no increase in incidence and severity in patients with Sjögren’s syndrome.
•
Both intraoral and extraoral Candida infections are often found in patients with Sjögren’s syndrome.
•
Oral lesions may be found in patients with Sjögren’s

Saliva function

The three paired major salivary glands (parotid, submandibular, and sublingual) are responsible for 90% of oral secretions,¹ with the average adult producing 0.4 mL of saliva per minute, or 1.5 L per day.² Hyposalivation is a hallmark of SS, and diminished saliva is detrimental to function, but also to quality of life. Saliva plays an important role in facilitating speech, providing lubrication, buffering, remineralizing enamel, assisting in taste, formation of food bolus, initiating digestion,

Changes in oral microflora

Decreased salivary flow rates, such as those seen in SS, result in a modified oral microbial plaque composition.⁵ Although it has been found that total bacterial counts⁶ and salivary counts of periodontopathogenic microorganisms Fusobacterium nucleatum and Prevotella intermedia/nigriscens were similar in patients with SS and control subjects,⁷ increased number and frequency of cariogenic microorganisms Lactobacillus spp, and Streptococcus mutans in supragingival plaque, and Candida albicans

Caries

Dental caries development is a complex interplay between dietary factors, time, substrate, and bacteria. Characteristics of saliva are also important, including flow, composition, buffer and sugar clearance capacity, fluoride concentration, and more.¹¹ Xerostomia results in a decrease in secretory IgA, an antibody responsible for mucosal immunity, thereby weakening the defense system against dental caries.² Individuals with SS have a much lower pH and buffer capacity, with Mathews and coworkers¹

Fungal Infection

Persons with SS have an increased occurrence of fungal infections, with C albicans more frequent than the general population.39, 40 An inverse relationship between salivary flow rates (specifically a low stimulated flow)⁴⁰ and the level of Candida infection has been described by Tapper-Jones and colleagues.⁴¹ This is secondary to decreased buffering capacity and salivary output, and the immunocompromised status of patients with SS.¹ Intraorally, Candida infection may present as erythematous

Burning Mouth

Often accompanied by the most common oral manifestation of xerostomia in SS is the sensation of oral burning, or glossodynia.⁴⁶ Oral burning in SS is most likely attributed to secondary fungal infection as a result of the decreased salivary flow from SS (described previously),⁴⁴ and/or use of medications that impair salivary function. It is conceivable that SS-associated neuropathies (described next) may also manifest as glossodynia and oral burning. Differential diagnoses of oral burning

Dysphagia/Dysguesia

Chewing, speaking, and swallowing are difficult as a result of intraoral dryness.1, 11, 22 Swallowing food may require extra water intake to overcome swallowing difficulties.¹¹ Other subjective symptoms of oral dryness common to the SS patient population include sensitivity to flavorful foods, altered or diminished taste, oral pain, and coughing episodes or choking.3, 22

Swollen Salivary Glands

Swollen salivary glands have been commonly reported in the SS patient population. The American European Consensus Criteria for

Summary

Most well-documented oral complications associated with SS (ie, infectious, such as dental caries and candidiasis; oral lesions; functional difficulties) are direct manifestations of decreased saliva in the oral cavity. In addition, there are several other conditions associated with this patient population (eg, swollen salivary glands, neuropathic pain, GERD). Consequently, management of these patients entails treatment of symptoms and prevention and treatment of infectious processes (discussed

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IL-33 is a relatively new member of the IL-1 cytokine family, which plays a unique role in autoimmune diseases, particularly some oral diseases dominated by immune factors. The IL-33/ST2 axis is the main pathway by which IL-33 signals affect downstream cells to produce an inflammatory response or tissue repair. As a newly discovered pro-inflammatory cytokine, IL-33 can participate in the pathogenesis of autoimmune oral diseases such as Sjogren's syndrome and Behcet's disease. Moreover, the IL-33/ST2 axis also recruits and activates mast cells in periodontitis, producing inflammatory chemokines and mediating gingival inflammation and alveolar bone destruction. Interestingly, the high expression of IL-33 in the alveolar bone, which exhibits anti-osteoclast effects under appropriate mechanical loading, also confirms its dual role of destruction and repair in an immune-mediated periodontal environment. This study reviewed the biological effects of IL-33 in autoimmune oral diseases, periodontitis and periodontal bone metabolism, and elaborated its potential role and impact as a disease enhancer or a repair factor.
Salivary gland regeneration and repair in Sjögren’s syndrome
2023, Translational Autoimmunity: Volume 6: Advances in Autoimmune Rheumatic Diseases
Sjögren’s syndrome (SS) is a chronic autoimmune disease involving the exocrine glands with occasional extraglandular manifestations. SS has remained a dilemma to cure over the years. The available therapies do not act directly on the underlying pathogenesis and are short-lived. With innovative regenerative medicine, and its applications toward degenerated salivary gland, promising permanent therapy may be administered to patients. Regeneration of the atrophied acinar cells through stem cell transplantation, tissue engineering, and gene therapy has demonstrated potential toward unraveling the underlying cause of xerostomia in SS. Isolated stem cells have shown prospective results in regenerative therapy. Biocompatible scaffolds have found their purpose toward reproducing salivary organoids using tissue engineering. Applications of genetic therapy toward prevention of SS and renewal of degenerated salivary tissue have also been recently experimented. Thus, this chapter focuses on recent exploratory techniques of regeneration or replacement of damaged salivary gland to restore its functional capacity.
Autoimmune diseases
2022, Clinical Immunology
There are over 80 defined autoimmune diseases, characterized by the activation of the immune system and tissue damage in the absence of an external threat to the organism, which affect 5 percent-7 percent of the population. Diseases considered to be autoimmune in origin can be characterized by activation of the adaptive immune response with B and T lymphocytes responding to self-antigens in the absence of any detectable tumor invasion or microbial assault; or as those that display the activation of the innate immune system and an excess of inflammatory mediators, but no evidence of an antigen-specific immune response, the former constituting the vast majority of such disease entities. Here we will discuss the immune cells and immune responses involved in autoimmune reaction, initiation and facilitation of autoimmunity and then will elaborate on human multisystem autoimmune diseases and some more common system-specific autoimmune diseases.
Dysphagia and Swallowing Disorders
2021, Medical Clinics of North America
Citation Excerpt :
Dry mouth may contribute to oropharyngeal dysphagia and inability to make a proper bolus from lack of saliva. This symptom might point to an underlying medication issue (Table 1) or a systemic problem like Sjogren disease.34 Leakage or spillage of food or liquids from mouth may indicate a problem in the oral phase of swallowing, perhaps a cranial nerve injury.33
Protocolised odontological assessment of patients with primary Sjögren's syndrome
2021, Reumatologia Clinica
El objetivo de este estudio es describir los hallazgos de una evaluación odontológica protocolizada en pacientes con síndrome de Sjögren primario (SSp) atendidos en las consultas de reumatología de la Comunidad de Madrid.
Estudio descriptivo multicéntrico en el que se incluyeron pacientes con SSp clasificados según criterios del consenso Europeo-Americano de 2002. Se recogieron datos demográficos, clínicos y serológicos. Se realizó una exploración oral, se recogió el flujo salival y el índice de caries CAOD. Los pacientes rellenaron la escala visual analógica para xerostomía, el cuestionario Oral Health Impact Profile-14 y un cuestionario de salud oral.
Se reclutaron 61 pacientes. El 98% fueron mujeres y la edad media fue de 57 años. El 52,5% presentaban signos orales patológicos (flujo salival no estimulado/sialografía/gammagrafía de glándulas salivales) y el 90,2% antiRo/antiLa+. El 92% de los pacientes referían xerostomía y un 61% hiposialia. Treinta y cinco pacientes presentaron lesiones de la mucosa oral. El índice CAOD fue de 16,97 ± 7,93 y la escala visual analógica para la xerostomía fue de 46,69 ± 14,43. Los resultados del Oral Health Impact Profile-14 fueron de 23,13 ± 14,16. Los pacientes con signos orales patológicos obtuvieron una puntuación en el Oral Health Impact Profile-14 significativamente mayor (p = 0,03), al igual que los pacientes con afectación del sistema nervioso periférico (p = 0,001).
La prevalencia de xerostomía en esta cohorte de pacientes con SSp fue muy elevada y el 61% de los enfermos presentaron hiposialia. Más de la mitad de los pacientes sufrieron lesiones orales. La salud oral presentó un impacto negativo en la calidad de vida de los pacientes con SSp, siendo mayor en aquellos pacientes con signos orales objetivos patológicos y en los que presentaban afectación del sistema nervioso periférico.
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.
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.
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)
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.
Cross-Country Validation of the Association Between Oral Health and General Health in Community-Dwelling Older Adults
2019, Journal of the American Medical Directors Association
Oral health is known to be associated with general health, but longitudinal relationships between oral health and general health indicators have not yet been fully explored in international research.
The sample consisted of 3 longitudinal databases: a sample from Belgium from the Protocol 3 project (n = 8359), a combined sample from 6 European countries (n = 2501) from the IBenC study (Belgium, Finland, Iceland, Germany, Italy, and the Netherlands), and a sample from New Zealand (n = 15,012). All clients were 65 years or older and received long-term home care services.
Bayesian models were used to analyze the associations between 3 oral health indicators (chewing difficulty, nonintact teeth, and dry mouth) and 4 aspects of general health (activities of daily living functioning, cognition, depression, and health instability). In addition, the models explored the associations between current oral health and general health status and future oral health and general health status.
Clients who had poorer oral health had a higher risk of suffering from poor general health. Especially chewing difficulty was associated with all general health indicators in all data sets (odds ratios > 1). Dry mouth and nonintact teeth showed significant associations with almost all general health indicators. Additionally, having poor oral health (respectively general health) was predictive of poor general health (respectively oral health) at future assessments (significant cross-lagged parameters).
The results point out the need of the inclusion of oral health assessment and advice from dentists or oral health practitioners into the multidisciplinary conversation. In addition, identifying older people with oral health problems is essential in order to provide treatment and monitoring. Raising awareness for oral health is important, and policy makers should foster oral health promotion and care for older adults in order to keep them in good health.

View all citing articles on Scopus

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Oral Complications of Sjögren's Syndrome

Section snippets

Key points

Saliva function

Changes in oral microflora

Caries

Fungal Infection

Burning Mouth

Dysphagia/Dysguesia

Swollen Salivary Glands

Summary

First page preview

Arch Med Res

Rheum Dis Clin North Am

J Am Dent Assoc

Oral Surg Oral Med Oral Pathol

J Am Dent Assoc

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral manifestations of Sjögren’s syndrome

J Dent Res

Xerostomia: a prevalent condition in the elderly

Ear Nose Throat J

Green tea polyphenols reduce autoimmune symptoms in a murine model for human Sjogren’s syndrome and protect human salivary acinar cells from TNF-alpha-induced cytotoxicity

Autoimmunity

Microbial ecology of dental plaque and its significance in health and disease

Adv Dent Res

Subjective and clinical oral symptoms in patients with primary Sjögren's syndrome

Clin Exp Rheumatol

Oral microbial flora in Sjögren’s syndrome

J Rhematol

Supra-gingival microbiota in Sjögren’s syndrome

Clin Oral Invest

Periodontal status and serum antibody responses to oral microorganisms in Sjögren’s syndrome

J Periodontol

Principles of microbial ecology and their application to xerostomia-associated opportunistic infections of the oral cavity

Adv Dent Res

Oral manifestations and their treatment in Sjögren's syndrome

Oral Dis

Salivary changes and dental caries as potential oral markers of autoimmune salivary gland dysfunction in primary Sjogren’s syndrome

BMC Clin Pathol

Effect of unstimulated saliva flow rate on experimental root caries

Caries Res

Physical and chemical aspects of saliva as indicators of risk for dental caries in humans

J Dent Educ

Bacterial diversity in human subgingival plaque

J Bacteriol

Whole saliva and the diagnosis of Sjögren’s syndrome: an evaluation of patients who complain of dry mouth and dry eyes. Part 1: screening tests

Gerodontology

The level of cariogenic micro-organisms in patients with Sjögren’s syndrome

Spec Care Dentist

The management of Sjögren’s syndrome

Nat Clin Pract Rheumatol

Current treatment modalities of oral problems of patients with Sjögren’s syndrome: caries prevention

Adv Dent Res

Dental caries and dental health behavior of patients with primary Sjögren syndrome

Acta Odontol Scand

Periodontal microbial ecology

Periodontol 2000

Periodontal conditions of individuals with Sjögren’s syndrome

J Periodontol

Is periodontal disease mediated by salivary BAFF in Sjögren’s syndrome?

Arthritis Rheum

Periodontal disease and Sjögren syndrome: a possible correlation?

Angiology

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

J Oral Pathol Med