Page 28 - GP Spring 2022

Sjögren’s Syndrome (SS) Table 3. Treatment and Prevention
Sjogren’s Syndrome (SS) is an immunologic disorder that may have Patient Education
a component that affects the salivary glands. Clinically, patients
present with a chronic, systemic autoimmune disorder of salivary Prevention
and lacrimal glands, and xerostomia. Keratoconjunctivitis sicca Symptomatic Treatment
and dry eyes are often present in these patients as well. 90% of Systemic and Topical Salivary Stimulants
Sjögren’s syndrome cases occur in women, with the average age of
onset occurring at 50 years old. Primary SS only involves the exo- Regenerative and Gene Therapies
crine glands in contrast to secondary SS, which is associated with
a definable autoimmune disease, usually rheumatoid arthritis. 80% Patient education should include detailed information about the po-
of primary and 30-40% of secondary SS cases involve unilateral or tential causes of dry mouth and the potential sequelae of impaired
bilateral salivary gland swelling. If unilateral or bilateral salivary salivary secretion, such as dental caries, candidiasis, and mucosal
gland swelling occurs, it may be permanent or intermittent.
complications. Therefore, patients should be encouraged to have
Biopsies may be necessary to confirm the diagnosis and rule out preventive oral healthcare such as frequent dental hygiene visits and
patient education provided by a dental hygienist or dentist. The
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B-cell lymphomas. Diagnosis and careful continuing follow-up of best diagnostic tool is an extensive review of the patient’s medical
SS is essential, in particular, history. Present risk factors should be considered. The use of caries
because the risk of develop- risk assessment (CAMBRA) is an important tool for patients with
ing non-Hodgkin lympho- xerostomia and they should be classified into high-risk categories.
ma in primary SS patients One of the most critical steps for managing xerostomia is establish-
is over 18 times that of the ing a diagnosis which typically involves a multidisciplinary team
general population. A labi- approach and determining an effective preventative therapy for
al gland biopsy can be per- dental and oral mucosa disease. In addition, it is recommended to
formed to confirm the diag- give the patient nutritional counseling so they are aware and avoid a
nosis of Sjögren’s syndrome high sugar diet, acidic foods, caffeine, sodas, and alcohol. Also im-
and to rule out the possibil- Figure 10. Sjogrens Syndrome portant is monitoring the patient’s condition every 4-6 months and
ity of a B-cell lymphoma. utilizing annual radiographs to evaluate for caries. Oral healthcare
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(Figure 10) professionals should also recommend drinking fluids with food, us-
Face Masks/COVID-19 ing oral moisturizers, artificial saliva, and a humidifier at night. Flu-
The efficacy of face masks during this pandemic has been well oride varnishes, dentifrices, rinses, and prescription-strength topical
documented. On March 11, 2020, the World Health Organization fluoride, either Rx or OTC, should also be prescribed or suggested.
(WHO) declared COVID-19 to be a global pandemic, as the glob- Patients wearing dentures should remove them at night and clean
al number was increasing daily. The cases worldwide continued them daily with solutions containing benzoic acid, 0.12% chlorhex-
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to increase because COVID-19 is airborne and easily spread by idine, or 1% sodium hypochlorite. (Table 3)
respiratory droplets to a susceptible host. As a result, face masks Treatment
are important components of personal protective equipment for Once a diagnosis of xerostomia is established, treatment is based
healthcare workers in hospitals and public civilians during this pan- upon the pathogenesis of the xerostomia and the prognosis of the
demic. However, wearing a mask for a prolonged period of time patient. Typically, it is recommended to avoid xerostomic medica-
can cause physical adverse effects such as headaches, difficulty tions, alcohol, and tobacco. Alcohol can dry out the mucosa through
breathing, rashes, and dry mucosa. A study was conducted with desiccation and tobacco dries the oral mucosa by mouth breathing
124 participants, 59 females and 65 males, and each was given a while smoking. The use of a sialagogue like pilocarpine (Salagen) is
questionnaire and wore an N-95 type mask for an average of six effective in patients with sufficiently remaining exocrine tissues. It
hours per day. Of these 124 participants, 63% experienced difficul- is suggested that patients who cannot tolerate systemic medications
ty breathing, 57% experienced dry mouth, 57% experienced nasal use OTC salivary substitutes or lubricants like Biotene (Laclede),
skin irritation, 83% developed sweating in the mask-covered area, drink lots of water, chew sugar-free gum, and suck on sugar-free
and 39% had frequent headaches. Since face masks cover both the candies or mints to help stimulate salivary flow. Patient preference
nose and mouth, it results in a reduction in the cooling impact of the and percentage of active salivary glands capable of producing the
facial temperature. In a recent study from ear, nose, throat (ENT) saliva will determine which treatment modalities are most effec-
professionals, they have noticed excess sweating around the mouth tive. It is important to consult with the patient’s physician regarding
region, which may contribute to xerostomia and nasal irritation. In medication-induced salivary gland dysfunction. 11
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addition to symptoms related to long-term mask use, data on Covid
infection-related oral manifestations show that oral signs of infec- Sialogogues, like pilocarpine (cevimeline hydrochloride), are use-
tion are evident in about 50% of cases. The most common signs ful, but this usefulness is limited by its other cholinergic effects like
are ageusia (loss of taste), xerostomia, mucosal lesions including bradycardia and lacrimation. The typical dosage of pilocarpine is 5
ulcerations, petechiae, and macules. The relationship between these mg orally three times per day and before bedtime. The total daily
lesions and COVID-19 is still poorly understood but is currently dose should not exceed 30 mg, and patients benefit most when the
being investigated. 13 drug is taken a half hour before meals. Dosage is dependent upon

Treatment and Prevention the severity of the patient’s xerostomia. Patients with a history of
bronchospasm, coronary obstructive pulmonary disease, congestive
Treatment should be designed to alleviate the discomfort of dry heart disease, and angle-closure glaucoma should not take pilocar-
mouth symptoms and it should be personalized based on patient pine. It is also important to remember that pilocarpine has adverse
needs. The treatment of xerostomia can be put into multiple cate- effects such as increased perspiration, bladder and bowel motility,
gories: 3 and feeling hot and flushed. 11

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