Sjogren's Awareness Month: During April, hygienists can help screen for signs of xerostomia
Elicia Lupoli, RDH, outlines a strategy for hygienists during Sjogren's Awareness Month, which includes checking for causes of xerostomia.
By Elicia Lupoli, RDH, BSDH
One of the most common words I heard in dental hygiene school was xerostomia. While xerostomia is often a sign of an adverse drug reaction and can be a subjective symptom, dental hygienists are very aware of the oral effects on patients with salivary hypofunction. For some patients, it may also be a potential sign to an underlying systemic disorder.
April 2017 is the 19th annual Sjogren's Awareness month. During April, the Sjogren's Syndrome Foundation has asked for all dental providers to promote awareness of this disease.
Sjogren's Syndrome (SS), pronounced as, “SHOW-grins,” is classified as a chronic autoimmune disease of inflammatory nature, dysfunction of the endocrine glands, and may also include extra-glandular involvement. The exocrine glands are a phenomenally imperative part of regulating the body, which secrete necessary enzymes and when compromised, normal processes of the body react or fail. The simplest example is not being able sweat to bring the bodies temperature down. Extraglandular involvement of the central nervous system (CNS), blood vessels, and respiratory tract can be another result of SS.(1) Interstitial lung disease has been recorded as the worst lung disease for these patients.(1)
SS is most common in women in their middle ages and generally does not discriminate against ethnicity.
This chronic condition gradually destroys the exocrine glands function, most commonly the salivary and lacrimal glands, eventually leading to hypo salivation and ocular dryness. SS patients display signs that are more drastic than ropey saliva and frequent thirst. It is important to understand there is a prominent difference in patients with dry mouth or patients with hyposalivation due to SS.
SS can be much more than dry mouth and eyes (sicca disease); patients also commonly experience fatigue and arthralgia. Twenty percent of patients with SS develop neuropathies.(2) These patients can demonstrate cognitive impairments, such as dementia and lack of concentration.(2)
B and T-cell lymphomas (non-Hodgkin’s lymphoma) and Hodgkin’s disease have also been found in SS patients.(3) According to the InterLymph Consortium, “Sjogren syndrome was associated with a 6.6-fold increased risk of NHL (non-Hodgkin’s lymphoma), and secondary Sjogren syndrome yielded a higher risk than the primary form.”(4)
There are two types of SS. Primary Sjogren’s syndrome (pSS, pSjS) occurs as an isolated disease; patients do not exhibit another autoimmune disorder. The other type is secondary Sjogren’s syndrome (sSS, sSjS), which is when a patient has an existing autoimmune disease, most commonly rheumatoid arthritis (RA).(3,5) An estimated 60% of SS patients have the disease secondary to RA, systemic lupus erythematous (SLE) or systemic sclerosis.”(5)
This article is a broad view of SS since the complications and symptoms often overlap.
While the cause is unknown, as with most autoimmune diseases, research suggests genetic, epigenetic, environmental, and infectious factors.(2-5) Due to the high percentage of peri-menopausal women afflicted, there has been suggestion that hormones play a role.(5)
Sjogren’s multi-organ manifestations lead to difficulties is diagnosis and treatment. Many times SS can be misdiagnosed as other connective tissue diseases—lupus and fibromyalgia, for example.(6)
According to the Sjogren's Syndrome Foundation, “Health-care providers sometimes treat each symptom individually and do not recognize that a systemic disease is present, because all disease symptoms are not always present at the same time and because Sjogren’s can involve several body systems. Currently, there is no single test to confirm a diagnosis.”
Diagnosis mainly relies upon each health-care practitioner being aware of their patients’ histories and the symptoms they present with. Xerostomia may be present due to medications, but not a true hypofunction of the salivary glands. In dentistry, we should be aware of the first signs related to hyposalvation:
- Watch patients for caries in locations that are easily cleansable
- Perform a head and neck screening on all patients and report any glandular inflammation
- Document patients that present with dry, fissured lips and tongue for no reason, and any opportunistic infections. “Chronic erythematous candidiasis can affect up to 70%–80% of patients with pSS.”(3)
If hyposalvation cannot be alleviated, the Sjogren's Syndrome Foundation recommends for the dental team to refer patients to their primary care physician or rheumatologist to further test for a systemic disease, such as SS.
The health-care providers most active in treating this disease are rheumatologists, ophthalmologists, and dentists. Traditionally, patients living with this disorder predominately receive palliative and supportive treatment.
In dentistry, SS patients should be managed with education on diet, oral hygiene, and three-month recalls. Salivary output should be measured and the risk for dental caries evaluated. Our jobs as oral health-care providers are to help SS patients the best we can by recommending products that will inhibit bacteria (xylitol or CHX), avoid further dryness (alcohol), reduce possibilities of burning/ulcers (SLS free), and help with caries prevention. While SS patients may not have been prone to decay in the past, we know that a decrease in, or a lack of, saliva may likely lead to future caries.
As registered dental hygienists we can play a vital role in these patients lives. Dry mouth is a common early symptom and mostly easy for us to identify. I urge everyone to think outside of the box.
When a patient presents with dry mouth and cannot find relief, even after purchasing and trying all the recommendations you and your dentist have suggested, please do not give up. Stay informed by educating yourself on evidenced-based products for patients. Ask other questions, “Are you dry anywhere other than your mouth? Tired? Have unexplained pain in your joints?” According to Dr. Ava Wu, the director of the Sjogren's Syndrome Clinic at University of California, San Francisco, “Dry eyes, dry mouth, and fatigue are the most common complaints.”
To help the Sjogren's Syndrome Foundation succeed with its advocacy during month of awareness about Sjogren’s during April, please participate on social media platforms by sharing the daily facts, stories, and personal Sjogren’s patient videos that will be launched by the foundation. Please use this hashtag: #ThisisSjogrensand/or recognize the foundation by including:
- Twitter (@SjogrensOrg)
- Facebook (@SjogrensSyndromeFoundation)
- LinkedIn (Sjogren’s Syndrome Foundation)
Elicia Lupoli, RDH, BSDH, is a Fones School of Dental Hygiene graduate who recently started to share her success with patients and passion for the industry through writing. She is the owner of a small LinkedIn group called "Dental Mentors" and advocates for mentorship throughout her endeavors. She attributes the start of her writing journey to Shirley Gutkowski, RDH, BSDH after meeting her at CareerFusion 2016. To contact her, send an email to firstname.lastname@example.org.
- Lenopoli S, Carsons SE (2014). Extraglandular manifestations of primary Sjogren's syndrome. Oral Maxillofac Surg Clin North Am, 26(1), 91-99. http://dx.doi.org/10.1016/j.coms.2013.09.008.
- Voigt A, Sukumaran S, Nguyen CQ. (2014). Beyond the glands: an in-depth perspective of neurological manifestations in Sjögren’s syndrome. Rheumatology (Sunnyvale), S4:010. doi: 10.4172/2161-1149.S4-010S4–010.
- Lopez-Pintor RM, Castro MF, Hernández G. (2015). Oral Involvement in patients with primary Sjögren's syndrome: multidisciplinary care by dentists and rheumatologists. Reumatol Clin, 11(6), 387-94. doi: 10.1016/j.reumae.2015.03.014.
- Ekstrom Smedby K, Vajdic CM, Falster M, Engels EA, Martinez-Maza O, Turner J, Cozen W. (2008). Autoimmune disorders and risk of non-Hodgkin lymphoma subtypes: a pooled analysis within the InterLymph Consortium. Blood, 111(8), 4029–4038. http://doi.org/10.1182/blood-2007-10-119974.
- García-Carrasco M, Mendoza-Pinto C, Jimenez-Hernandez C, Jimenez-Hernandez M, Nava-Zavala A., Riebeling C. (2012). Serologic features of primary Sjögren’s syndrome: clinical and prognostic correlation. Inter Jour of Clin Rheum, 7(6), 651–659. http://doi.org/10.2217/ijr.12.64.
- Sjogrens Syndrome Foundation. (2017). Provider/researcher. Retrieved from https://www.sjogrens.org/home/research-programs/healthcare-providers.