Understanding the complexity of Sjogren's syndrome

July 1, 2003
Sjogren's (SHOW-grins) syndrome is a chronic disease with no known cure or treatment. It has many manifestations in the oral cavity

by Donna Herrera, RDH, BS, and Laura Thompson, RDH, BS

Sjogren's (SHOW-grins) syndrome is a chronic disease with no known cure or treatment. It has many manifestations in the oral cavity, and dental professionals may be among the first health-care workers to identify symptoms.

Sjogren's syndrome, an autoimmune disorder in which the body attacks its own moisture-producing glands, affects more than 1 million Americans. This disease typically affects white women, often near the menopausal age. The cause of Sjogren's syndrome is unknown. Theories have linked it to hormone levels due to menopause; however, viruses and genetics also have been studied.

Sjogren's syndrome is a condition that is important for all health professionals to research and understand. This syndrome and its symptoms are known to be misdiagnosed with diseases such as diabetes, lupus, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, and multiple sclerosis. It usually takes the health-care provider approximately six years to diagnose this disease from the time of onset. Specialists who treat Sjogren's syndrome are rheumatologists, ophthalmologists, dentists, and other specialists. Dental hygienists work within the oral cavity and are essential in determining whether an individual is experiencing these symptoms.

It is extremely important that the dental hygienist provide patients with detailed examinations. Providing a thorough medical health history and oral cancer examination — both extraoral and intraoral — would help identify whether the glands are functioning properly. If our patient is experiencing any of the above symptoms, we must be familiar with the treatments for these conditions. For example, a person experiencing dry mouth may be advised by dental professionals to use sugar-free products such as chewing gum, hard candy, or beverages. If the patient is suspected of this disease we need to refer them to the dentist as well as a medical professional

Damaging disease

Sjogren's syndrome is an autoimmune connective tissue disease that is caused when the immune system (white blood cells) turns against the body's own cells. It is characterized by lymphocytic infiltration of lacrimal and salivary glands, resulting in dry eyes and xerostomia. The immune system attacks the moisture-producing glands and causes dryness and other problems in the body. Sjogren's also can damage other glands in the body.

This disease can occur at any age but is more likely in people who are over the age 40. People of all ethnicity can be affected by this disease but it occurs more in white women, often near menopausal age. Scientists have not found the cause of Sjogren's syndrome. Sjogren's syndrome has been referred to as rheumatic disease because they both can be related to inflammation in joints, muscles, skin, or other body tissue. Sjogren's syndrome also can cause problems with the connective tissue.

Sjogren's syndrome is categorized as primary or secondary. Primary Sjogren's occurs by itself while secondary occurs along with another disease. Doctors can associate primary Sjogren's symptoms with tear and saliva glands. Patients with primary Sjogren's have certain antibodies that can help fight a particular disease. These antibodies are called SS-A, SS-B, and antinuclear (ANAs).

Secondary Sjogren's syndrome is categorized when an individual already has an autoimmune disease such as rheumatoid arthritis or lupus. Secondary Sjogren's causes more problems because there are two diseases occurring at the same time. Both primary and secondary Sjogren's can affect many parts of the body, which is also termed as extraglandular involvement. Extraglandular involvement is when problems go further than tear and salivary glands.

The main symptoms of Sjogren's syndrome are dry eyes, xerostomia (dry mouth), skin rashes, thyroid problems, joint and muscle pain, pneumonia, vaginal dryness, numbness, and tingling in the extremities and fatigue. Sjogren's can also affect the liver and pancreas, which then results in a greater chance in developing cancer in the lymph tissue. This risk of cancer makes continuous examinations a priority.

Involving specialists

Sjogren's syndrome is diagnosed first by the doctor. Various physicians and specialists are involved in diagnosing this condition. These physicians can include an allergist, dentist, dermatologist, gastroenterologist, gynecologist, neurologist, ophthalmologist, otolaryngologist, pulmonologist and urologist. These doctors do routine examinations such as detailed medical histories, physical exams, and lab work.

Some common eye and mouth tests are Schirmer tests, staining with vital dyes, slit lamp examination, mouth examination, and salivary gland biopsy of the lip. If any of these tests become positive then additional routine blood tests, immunological tests, chest X-rays, and urinalysis are conducted to determine if other parts of the body are affected.

Sjogren's syndrome is different for every individual because different body parts are affected in every person. For example, artificial tears, salivary stimulants, and mouth lubricants can relieve dryness of the mouth or eyes. If there is extraglandular involvement the physician specialist will treat these problems. There are many medications and remedies that can be prescribed to help alleviate these problems.

A number of autoimmune conditions predispose patients to the development of lymphoma. Patients with Sjogren's syndrome develop lymphoma 44 times more than that of the population. Lymphoma is when Sjogren's syndrome develops into cancer in the minor and major salivary glands. Salivary glands become enlarged and become swollen and painful. Symptoms that occur are unexplained fever, night sweats, constant fatigue, unexplained weight loss, itchy skin, and reddened patches on the skin. These symptoms could also be a result of another infection or illness. If these symptoms occur, it is important that you consult your physician.

The dental team plays a very important role in patients with Sjogren's syndrome. It reviews every patient's medical history and performs oral cancer examinations thoroughly. Dental professionals are qualified to give information pertaining to conditions that might occur and instruct patients on how to maintain proper oral health instruction.

Signs to watch

There are many signs to watch for when suspecting Sjogren's syndrome. The dental team must look for decay, fillings that are loose, and swelling of the parotid gland. Immunological mechanisms have been suspected to have an important impact on periodontal disease. The immune dysfunction associated with Sjogren's may affect the body's defense against the microorganisms related to periodontal disease. Studies have shown patients with both Sjogren's and periodontal disease present a higher total number of microorganisms.

Although there is no cure for Sjogren's syndrome there are ways to treat it. A very important symptom to treat is xerostomia. Good oral hygiene is the key to the treatment of this disease along with using special toothpastes to decrease bacterial infection, special non-alcohol mouth rinse and topical fluoride.

The discomfort of the dry mouth causes many patients to drink large amounts of high sugar beverages. Patients should be advised to use sugar-free hard candy and gum to help relieve discomfort. A home remedy rinse that the patient can make also has shown to be useful. Mixing essence of lemon and citric acid in glycerin has provided relief for many hours. It is important to observe for changes in the parotid gland and periodontal tissues and to treat any significant finding quickly.

Research on Sjogren's syndrome is ongoing, as scientists learn more about how the genes are involved and which environmental factors trigger this disease. Gene therapy studies involve molecules that are inserted into the salivary glands that will help control inflammation and prevent destruction. Other studies are being performed that might help immune and hormonal systems work in people who suffer from these conditions. Many drugs are being studied that will help in salivary stimulation for eyes and mouth.

Many support groups help individuals cope with the problems associated with Sjogren's syndrome. This is the first step that should be taken for patients as well as their caregivers. Understanding Sjogren's syndrome can help reduce stress and can make individuals involved a little more comfortable in helping to treat this condition.

People who are diagnosed with Sjogren's syndrome experience an array of the following symptoms:

• Dry mouth
• Dry eyes
• Difficulty with chewing, swallowing, or talking
• A sore or cracked tongue
• Dry or burning throat
• Change in the sense of taste or smell
• Dental cavities
• Fatigue
• Low-grade fever
• Enlarged parotid glands (located behind the jaw in front of the ears)
• Joint pain
• Oral yeast infections
• Nosebleeds
• Bruising
• Skin rashes or dry skin
• Vaginal dryness
• Shortness of breath


• National Institute of Arthritis and Musculoskeletal and Skin Disease

• Mayo Clinic

• The Sjogren's Syndrome Foundation

Donna Herrera, RDH, BS, and Laura Thompson, RDH, BS, are recent graduates of the University of New Mexico, Division of Dental Hygiene, where they wrote the above article as part of their degree completion program.