01 Dicembre 2020

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Sjögren’s syndrome. An updated practical guide for dental healthcare providers

Original article

Stefano Petti

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Objectives  This review is directed to dental healthcare providers (DHCP) such as dentists and dental hygienists and seeks to provide updated in­formation regarding the Sjögren’s syndrome (SS) that is more com­mon and undetected than expect­ed. Indeed, DHCP have a key role in early diagnosis and manage­ment of oral signs, symptoms, and complications.

Materials and methods  Scientific articles and reviews published on PubMed since 2018 were considered regarding SS early diagnosis, epidemiology and treatment of oral manifestations.

Results  SS is a chronic progressive auto­immune disease that affects the exocrine glands, primarily salivary and lacrimal glands, that leads to their progressive destruction. SS could be primary or secondary depending on coexisting autoim­mune diseases. SS has also sys­temic manifestations, with higher mortality and 40-fold higher non-Hodgkin lymphoma risk.

Typical oral SS feature is parotid and submandibular gland en­largement, while the characteris­tic symptom is xerostomia with reduced salivary flow rate (<0.1 mL/min) and decreased mucin production. Dry mouth leads to angular cheilitis and erythema­tous petechial-type lesions on the palate particularly in denture wearers, candidiasis and in­creased yeast colonization. Oral complications are cervical caries, gingivitis, periodontitis, dental ero­sion, ranula.

SS may originate from a local in­sult to an exocrine gland, followed by cellular necrosis, expression of SS antigens A and B (SS-A and SS-B), anti-SS-A and anti-SS-B autoantibody production, immune complexes formation, local in­flammation and lymphocytic infil­tration. Diagnosis is unclear with several existing criteria and lack of consensus, although the Ameri­can-European Consensus Group Classification criteria (AECG) are the most frequently used in high quality studies. This diagnostic uncertainty also produces unclear disease epidemiology. Incidence rate likely is 4-5x100,000 per year, prevalence could be 0.02- 0.7%, with almost one half of cas­es undetected. Male-to-female ratio is 1:9.

Conventionally, presumptive di­agnosis is performed through si­alography, which is invasive and exposes patients to high radia­tion. Other promising imaging techniques include scintigraphy with 99mTc-pertechnetate, mag­netic resonance, ultrasonogra­phy, and sialo-cone-beam com­puterized tomography. Unfortu­nately, SS is not curable.

Nevertheless, oral symptoms and xerostomia could be controlled through cholinergic agonists (pi­locarpine and cevimeline), active electrostimulation, sialogogues, acupuncture, salivary substi­tutes, toothpastes, mouthwashes and gels containing moistening agents, transcutaneous electrical nerve stimulation, intraductal irri­gation, while promising results from animal studies suggest that stem cells from human exfoliated deciduous teeth could in part re­store salivary gland structure.

Conclusions  Given that many SS cases are un­detected and that SS is a chronic disease, the role of DHCP is cru­cial in performing early diagnosis, alleviating oral symptoms, and treating oral complications.

Clinical implications  On the basis of nonspecific oral symptoms and anamnesis based on the AECG criteria, DHCP may suspect SS and suggest appropri­ate imaging techniques for the presumptive diagnosis. Although patients are referred to other spe­cialists, such as oral pathologists, immunologists, rheumatologists, DHCP must manage the oral SS manifestations using simple tools that yield only a few side and ad­verse effects.

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doi: https://doi.org/10.19256/d.cadmos.10.2020.07