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Sjögren’s Syndrome and Salivary Production

Authors: Katherine Salinas, Bryce Cheng, and Analia Veitz-Keenan, DDS, FAGD

Abstract

Sjögren’s Syndrome is an autoimmune condition characterized by dry eyes and mouth, significantly increasing the risk for
dental caries due to salivary hypofunction. Pilocarpine and cevimeline are pharmacologic agents used to manage xerostomia
in these patients.

Objective: To evaluate the comparative effectiveness of pilocarpine and cevimeline in increasing salivary flow and improv-
ing patient outcomes.

Methods: A focused literature search of PubMed identified three systematic reviews/meta-analyses that evaluated the ef-
fectiveness of salivary stimulants in patients with Sjögren’s Syndrome. Each review was appraised using tools to assess the
quality of evidence.

Results: All three studies showed that cevimeline and pilocarpine increased unstimulated salivary flow rate (USFR) and
symptom relief, with pilocarpine demonstrating greater improvement in objective salivary metrics. Risk of bias ranged from
moderate to high.

Conclusion: Pilocarpine appears more consistently effective than cevimeline in improving salivary function in patients with
Sjögren’s Syndrome, though its side effects may limit its use in medically complex individuals.
Background- purpose: Sjögren’s Syndrome is a chronic systemic autoimmune disease best known for causing dry eyes
and dry mouth. It develops when the immune system mistakenly targets the body’s moisture-producing glands. This condi-
tion often occurs alongside other autoimmune disorders, such as rheumatoid arthritis and lupus. While it can affect people
at any age, most individuals are diagnosed after the age of 40. 1

Dry mouth, a common symptom of Sjögren’s, has profound implications for oral health because saliva plays a crucial role
in maintaining the health of teeth and gums. It helps neutralize acids, wash away food particles, slow bacterial growth, and
deliver minerals like calcium and phosphate that aid tooth repair. Without adequate saliva, patients are more susceptible to
2,3
tooth loss, decay, gum disease, and oral infections. Increasing saliva production is a key focus in managing the condition.
4
Two commonly used medications to stimulate saliva are cevimeline and pilocarpine. Both are muscarinic receptor ago-
nists, activate receptors in salivary glands, and increase saliva production. 5

Unstimulated Salivary Flow Rate (USFR) is a key objective measure for evaluating salivary gland function and is common-
ly used for research. It is determined by collecting saliva over a defined period without external stimulation, such as chewing
or tasting. USFR provides insight into baseline saliva production, with normal rates around 0.3–0.4 mL/min. Values below
0.1 mL/min typically indicate hyposalivation and are associated with increased dental caries and oral discomfort risk. 6

This article aims to explore which of these two medications—cevimeline or pilocarpine—is more effective in increasing
saliva production and improving the quality of life for people with Sjögren’s Syndrome.

Methodology: An electronic database, PubMed, was used to search for the best available evidence for this topic. A focused
PubMed search was conducted using terms including “Sjögren’s Syndrome,” “pilocarpine,” “cevimeline,” “xerostomia,”
and “systematic review.” Inclusion criteria were: (1) systematic reviews/meta-analyses published in peer-reviewed journals;
(2) studies comparing pilocarpine and/or cevimeline; (3) outcomes involving USFR and/or symptom relief. A tool for ap-
praisal was used to assess the risk of bias and the methodology of the included reviews.

Results:
Three studies were selected based on their strong clinical relevance to the designated PICOTS ( Problem- Intervention-
Comparison- Outcome- Type of Question- Study design). Each study included randomized controlled trials (RCTs), pro-
viding high evidence for a therapy question. These articles allowed for a direct comparison between the salivary stimulants
pilocarpine and cevimeline, specifically evaluating their effectiveness in relieving dry mouth symptoms.

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