Sjögren's Syndrome Oral Health Care From one third to one ...

[Pages:2]References: 1. Mahooney EJ, Spiegel JH. Sj?gren's disease. Otolaryngol Clin N Am. 2003;36:733-45. 2. Wall GC, Magarity ML, Jundt JW. Pharmacotherapy of xerostomia in primary Sj?gren's syndrome. Pharmacothereapy, 2002;22(5):621-29. 3. Fox PC, Atkinson JC, Macynski AA, Wolff A, Kung DS, Valdez IH, Jackson W, Delapenha RA, Shiroky J, Baum BJ. Pilocarpine treatment of salivary gland hypofunciton and dry mouth (xerostomia). Arch Int Med, 1991;151;1149-52. 4. Papas AS, Fernandez MM, Castano RA, Gallagher SC, Trivedi M, Shrotriya RC. Oral pilocarpine for symptomatic relief of dry mouth and dry eyes in patients with Sj?grens syndrome.. Adv Exp Med Biol. 1998;438: 973-8 5. Fife RS, Chase WF, Dore RK, Wiesenhutter CW, Lockhart PB, Tindall E, Suen JY. Cevimeline for the treatment of xerostomia n patinets with Sj?gren's syndrome. Arch Int Med, 2002;162:1293-1300. 6. Reich E, Petersson LG, Netuschil L, Brecx M. Mouthrinses and dental caries. Int Dent J.2002;52:337-45. 7. Peldyak J, Makinen KK. Xylitol for caries prevention. J Dent Hyg. 2002;76(4):276-85. 8. Al-Hashimi I. The management of Sj?gren's syndrome in dental practice. JADA, 2001;132:1409-17. 9. Najera MP, Al-Hashimi I, Plemons JM, Rivera-Hidalgo F, Rees TD, Haghighat N, Wright JM. Prevalence of periodontal disease in patients with Sj?gren's syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:453-7. 10. Jorkjend L, Johansson A, Johansson K, Bergenholtz A. Periodontitis, caries and salivary factors in Sj?gren's syndrome patients compared to sex- and age-matched controls. J Oral Rehab. 2003;30:369-78. 11. McCullough KB, Porter YS. Clinical and microbiological studies of periodontal disease in Sj?gren's syndrome patients. J Clin Periodontol. 2002;29:92-102. 12. Boutsi EA, Paikos S, Dafni UG, Moutsopoulos HM, Skopouli FN. Dental and periodontal status of Sj?gren's syndrome. J Clin Periodontol. 1999;27:231-35. 13. Radfar L, Shea Y, Steven FH, Sankar V, Leakan RA, Baum B, Pillemer SR. Fungal load and candidiasis in Sj?gren's syndrome. Oral Surg Oral Med Oral Pathol Oral Radiiol Endo 2003;96:283-7. 14. Rosen, DS. What is thrush, and how is it treated? Health News. 2002; 8(10):12.

Acknowledgements: Jeffrey Dee Fleigel, III UFCD 3DN

Carol M. Stewart MS, DDS, MS Co-Director, UF Center for Autoimmune Diseases Office : 352-273-6775 email: cstewart@dental.ufl.edu

Sj?gren's Syndrome Oral Health Care Information

University of Florida Center for Autoimmune Diseases

College of Medicine Division of Rheumatology and Clinical Immunology

Office: 352-273-5340 Fax: 352-392-8483 College of Dentistry

Division of Oral Diagnostic Sciences Oral Medicine Clinic: 352-273-6739

Fax: 352-392-2507

This informational pamphlet will provide you with the answers to some common questions such as:

? What is Sj?gren's Syndrome? ? What are some of the common

symptoms of Sj?gren's? ? How does Sj?gren's syndrome

affect the mouth? ? Are Sj?gren's patients at a greater

risk for tooth decay? ? What treatments are available for

oral dryness? ? Are Sj?gren's patients at a greater

risk for oral fungal "yeast" infections? ? Should Sj?gren's patients be evaluated for periodontal disease? ? Are dental implants a treatment option for Sj?gren's patients?

What is Sj?gren's syndrome?

Sj?gren's syndrome is one of the most common autoimmune diseases affecting as many as 3,000,000 Americans. The disease is characterized by the body's immune system mistakenly attacking its own exocrine glands, which include saliva and tear glands. Although Sj?gren's occurs in all age groups and in both sexes, the average age of onset is in the late 40s and the disease is 90% female. Sj?gren's syndrome belongs to a family of autoimmune disorders including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, dermatomyositis, and vasculitis and ranks as the second most common rheumatic disease after rheumatoid arthritis1.

What are some of the common signs and symptoms of Sj?gren's Syndrome?

Symptoms vary from person to person but some of the most common symptoms of Sj?gren's are dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia)2. Symptoms may include but are not limited to a dry, gritty, or burning sensation in the eyes, difficulty talking,

chewing, or swallowing, a sore or cracked tongue, dry or burning throat, a change in the sense of taste or smell, increased dental decay, joint pain, digestive problems, dry nose, dry skin, and fatigue.

From one third to one half of patients may have diffuse, firm enlargement of the major salivary glands during the disease. It is usually bilateral, may be nonpainful or slightly tender, and may be intermittent or persistent in nature. Consult your physician as this may indicate a serious condition, such as a lymphoma.

How does Sj?gren's syndrome affect the mouth?

Sj?gren's affects saliva production in two ways: 1) generally decreasing the amount produced and 2) altering the proteins and components normally produced. Therefore, "dry mouth" and other oral problems may develop. Without saliva, people commonly experience oral discomfort, difficulty eating, tooth decay, and oral infections2. The lack of saliva can also cause a dry, cracking tongue, and may even disrupt speech patterns3. The oral symptoms of Sj?gren's syndrome can disrupt a person's quality of life.

Are Sj?gren's patients at greater risk for "tooth decay" or dental caries?

Yes. Because saliva functions to dilute harmful bacteria , buffer acids, and remineralize tooth enamel to help prevent cavities, patients are at an increased risk for tooth decay due to lowered saliva production. In order to prevent tooth decay one must maintain excellent oral hygiene monitored and by a dentist. Adequate oral care, use fluoride products, saliva stimulants, as well as proper diet will

aid in reducing susceptibility to dental decay.

Fluoride Products: Frequent use of

fluorides may control or even stop tooth decay and repair already developed small cavities6. Over-the-counter (OTC) fluoride products can be used such as ACT, alcoholfree rinse containing neutral sodium fluoride. It is important to follow the manufacturer's directions (or your dentist's instructions) when using OTC products. Daily use of a prescription fluoride product, such as Prevident gel, or Prevident 5000 Plus toothpaste may be recommended7. Prevident gel is as a fluoride treatment at bedtime following brushing and flossing. as a fluoride treatment. Prevident 5000 Plus is a fluoride treatment plus abrasive containing toothpaste, which may be used one per day, preferably bedtime, in place of brushing. Both products contain 1.1% neutral sodium fluoride. Toothpastes: A fluoride-containing toothpaste is generally recommended. Many OTC varieties are available. Toothpastes which contain abrasives, which are common in many whitening pastes, and "tartar" or plaque control products can sometimes be too harsh for routine use. Some patients have reported hypersensitivity reactions following use of these products. Mouthrinses: When choosing a mouthrinse it is important to avoid alcohol containing rinses which can sometimes irritate and dry the mouth. Biotene? mouthrinse is an over the counter antimicrobial alcohol-free mouthrinse that can also be used to reduce the amount of harmful bacteria in the mouth. Prescription mouthrinses containing 0.12% chlorhexidine gluconate, such as Peridex? or PerioGard?, are used to reduce harmful bacteria for short term management of gingivitis or aphthous ulcers. These should

only be used under the care of a dentist for prescribed periods. Saliva Substitutes: Saliva substitutes are also available for treatment. Saliva substitutes are not long lasting so they must be used frequently throughout the day. Some common ones are: Optimoist, Moi-Stir, Saliva Substitute, Salivart, and Mouthkote. Individuals with removable dentures affected by Sj?gren's also may benefit from the use of saliva substitutes7. Saliva Stimulation: Sugar-free candies and chewing gum can stimulate saliva production. Xylitol is a naturally occurring sweetener which does not contribute to dental decay8. When tested as a sucrose replacer, or even as a small dietary addition, systematic xylitol use leads to impressive reductions in the incidence of dental decay8.

Prescription drugs: Saliva Stimulation

The two drugs currently approved for use in the United States are cevimeline hydrochloride (Evoxac?) and pilocarpine hydrochloride (Salagen?). Pilocarpine is a potent stimulator of exocrine secretion and has been indicated for this use for over 80 years3. Exocrine glands include the following: sweat, saliva, lacrimal, gastric, pancreatic, intestinal and mucus cells of the respiratory tract. There has been a lot of research done on the effectiveness of this drug in increasing saliva flow indicating that it is both safe and effective2, 3, 4. There are several contraindications for the use of pilocarpine; therefore it should only be taken after an examination by a physician or dentist. A 5mg dosage of Salagen? is recommended to be taken up to four times daily. Cevimeline is a newer drug indicated for the treatment of Sj?gren's. This drug works similarly to pilocarpine with different dosages and frequency. Evoxac? is taken up to three times a day and the dosages may vary depending on your physician/dentist recommendations5. Research has shown that cevimeline therapy is highly effective in improving the symptoms of dry mouth in patients with Sj?grens syndrome5.

Cevimeline, like pilocarpine hydrochloride, has some contraindications for its use. Therefore, professional consultation with a physician or dentist is necessary prior to taking either drug. Diet: Sj?gren's patients must remain well hydrated at all times to help alleviate the symptoms associated with the disease. This is especially true in patients taking prescription sialogogues like Salagen? and Evoxac?. Patients should drink plenty of water or sugarfree low acid content beverages and avoid spicy foods. Patients should avoid liquids high in sugar and acid, like soft drinks, due to the acceleration of tooth decay that can take place in the mouth. Alcohol and caffeine should be avoided because they can irritate the tissues of the mouth and promote dehydration.

Are Sj?gren's patients at a greater risk for oral yeast infections?

Yes. Oral yeast infections appear as red or white patches in the mouth or at corners of the mouth and may cause a burning sensation and altered taste. They are caused by Candida a yeast normally present in the mouth, but may appear at increased rates in people with Sj?gren's. An inverse relationship between salivary flow rates and the level of Candida infection has been described in research13. Because Sj?gren's patients have less saliva they may have increased rates of oral Candida. Research has shown plain, sugar-free yogurt can be consumed to prevent and even treat oral yeast infections14. Prescription anti-fungal mouth rinses, lozenges, creams, and systemic medication are also available through your dentist or physician if desired or necessary.

Should Sj?gren's patients be evaluated for periodontal disease?

Yes. Periodontal disease is the complex process of bone loss and gum attachment loss due to bacterial infection on the surface of the teeth. Older research did show a 2.2 times higher risk of having adult periodontitis than

healthy controls9. However, more recent research indicates patients with Sj?gren's syndrome are not at increased risk for periodontal disease when compared with healthy individuals of the same age and sex or individuals with other dry mouth disorders 10,11,12. Research is ongoing. However, your dentist should carry out periodontal assessment and monitoring.

Are dental implants a treatment option?

Yes, in selected cases. Conventional dentures can be intolerable for people with dry mouth. Conventional crown and bridge work may also be more susceptible to decay due to decreased saliva Therefore, implant-retained dentures or other implant supported dental prosthetics, or single-tooth implants may be a viable treatment option. Many factors must be considered in deciding who might benefit from this therapy. In individuals that meet routine criteria, implants generally succeed. However, extreme caution should be exercised in someone who is severely immune suppressed or has a history of bisphosphonate therapy. Bisphosphonate related osteonecrosis of the jaw occurring subsequent to surgical procedures in the mouth, is a growing concern.

In summary, with adequate management and care, adverse oral concerns related to Sj?gren's syndrome can be minimized and a better overall quality of life can be maintained.

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