Dry Mouth and Sjögren's Syndrome: An Overview PDF 2015

DRY MOUTH AND SJÖGREN’S SYNDROME: AN OVERVIEW ABGEENA KHAN, PENELOPE J SHIRLAW Prim Dent J. 2015;4(2): 70-74 Causes of dry mouth2,3 ABSTRACT...

DRY MOUTH AND SJÖGREN’S SYNDROME: AN OVERVIEW ABGEENA KHAN, PENELOPE J SHIRLAW Prim Dent J. 2015;4(2): 70-74 Causes of dry mouth2,3 ABSTRACT There are many causes of dry mouth (Table 1). Drug-induced xerostomia is Dry mouth is a common condition presenting to a GP or general dental the most common cause, and there are practitioner. The most common cause of a dry mouth is related to medication use, more than 1,800 medicines that have however patients with Sjögren’s syndrome, a multisystem autoimmune condition, dry mouth as a listed side effect.1,2 may present to their dentist rather than their GP complaining of dry mouth and dry The most common medicines include: eyes. This article explores the causes of dry mouth and how a patient can be Antidepressants (Tricyclic investigated to find the cause of their dry mouth. An overview of Sjögren’s antidepressants, monoamine oxidases syndrome, the relevant diagnostic criteria, presenting signs and symptoms, and selective serotonin reuptake investigations and management principles are outlined. inhibitors). Antihistamines. Antihypertensives (ACE inhibitors, e.g. Ramipril; Beta blockers, e.g. X erostomia (dry mouth) is extremely On average a person can produce Atenolol, Propranolol). common in the UK and affects 500ml of saliva over a 24 hour period. Diuretics (Bendroflumethiazide). about 13%1 of the population. Saliva production increases considerably Anti-reflux (Proton pump inhibitors Subjective xerostomia is the term used during eating producing on average e.g. Omeprazole). to describe the feeling of a dry mouth 2ml/min and reduces considerably Anti-cholinergics (Atropine). when there is plentiful saliva and the during the sleeping phase producing Benzodiazepines (Diazepam). salivary glands are functioning as on average 0.10ml/min. Analgesics (Opiates). normal. Objective xerostomia or hyposalivation are the terms used when there is decreased flow of saliva caused by failure of the salivary glands to function as normal. TA B L E 1 CAUSES OF DRY MOUTH Type Causes Subjective Xerostomia Mouth breathing Psychological KEYWORDS Objective Xerostomia Iatrogenic Dry Mouth, Subjective Xerostomia, (Salivary hypofunction) Drug-induced Objective Xerostomia, Salivary Irradiation Hypofunction, Drug Induced Smoking Xerostomia, Sjögren’s Syndrome, Salivary gland disease Challacombe Scale, Clinical Oral Sjögren’s syndrome/other connective tissue disease Dryness Scale Sarcoidosis HIV salivary gland disease Hepatitis C Neurological conditions AUTHORS Abgeena Khan BDS MJDFRCS(Eng) Dehydration PGCAP FHEA Diabetes and renal failure Specialty Doctor Oral Medicine, Guy’s and Physiological St Thomas’ NHS Foundation Trust Age Penelope J Shirlaw BDS FDSRCPS FHEA Others Consultant Oral Medicine, Guy’s and St Thomas’ NHS Foundation Trust Salivary gland developmental anomalies 70 P R I M A R Y D E N TA L J O U R N A L  Challacombe and Das on pages 77-79 1a 1b of this issue, is a useful clinical aid for all dentists in assessing patients presenting with a dry mouth. The purpose of this scale is to be able to identify visually whether patients’ have objective xerostomia, i.e. signs of reduced saliva production and to quantify the severity. If the scale for an individual appears to change over time then this will help select the most appropriate interventions (referral to a Figure 1a and 1b: Instruments used to examine the specialist) and therapy options. It works oral cavity will stick to the buccal mucosa and tongue as an additive score of one to 10; one being the least and 10 being the most severe. Each feature scores one, and symptoms will not necessarily progress in the order shown, however summated scores indicate the likely patient need for treatment of xerostomia. Score changes over time can be used to monitor symptom progression or regression.5 Salivary hypofunction causes changes to the soft and hard tissues of the oral cavity recognisable by a GDP as well as specialist. Examination reveals many common features: Figure 2: Absence of saliva pooling Instruments used to examine the oral in the floor of the mouth cavity will stick to the buccal mucosa Figure 3: Caries mainly affects the cervical and tongue (Figure 1). surfaces, cusp tips and incisal edges Saliva will be sparse or frothy and there maybe absence of saliva pooling in the floor of the mouth (Figure 2). Due to the changes in saliva composition and volume, the saliva has a reduced buffering capacity, resulting in a lower pH and so patients are more susceptible to dental caries. In addition, when there is a lack of saliva, there are more cariogenic bacteria present (Streptococcus mutans and Lactobacilli) which also contributes to a susceptibility to dental caries. Caries mainly affects the cervical Figure 4: The tongue maybe lobulated, Figure 5: Debris may be present surfaces, cusp tips and incisal highly fissured, depapillated or atrophic on the palate or under dentures edges (Figure 3). The tongue maybe lobulated, highly fissured, depapillated or atrophic Assessment of dry mouth (Figure 4). When a patient presents either to a Debris may be present on the palate general dental practitioner (GDP) or a or under dentures (Figure 5). hospital clinic, a thorough history of oral The gingivae architecture maybe dryness and medical history is crucial changed with lack of stippling and for establishing the possible causes of the oral mucosa may have a more dry mouth. This should be followed by shiny, glassy appearance. examination and relevant investigations Patients who wear dentures may to reach a definitive diagnosis of present with denture-induced objective or subjective xerostomia. stomatitis from an increase in Candida species and Staphylococci Figure 6: Redness of the mucosa The Challacombe dry mouth scale,4,5 and this will appear as redness of the under the denture explained in depth in the article by mucosa under the denture (Figure 6). VOL. 5 NO. 1 FEBRUARY 2016 71  DRY MOUTH AND SJÖGREN’S SYNDROME: AN OVERVIEW All these effects can result in loss of function Stimulated parotid saliva flow rate surface and allows examination of the and patients can experience difficulties in The patient is sat in a relaxed and anterior eye). The Lissamine green dye speaking, chewing, swallowing dry foods upright position and a special suction stains any dessicated and dying cells and wearing dentures. cup is attached over the stensens duct on the ocular surface. opening. A stimulant, such as 2% citric Sjögren’s syndrome acid, is dropped onto the tongue and Tear break up time (TBUT) Sjögren’s syndrome is a chronic multi- saliva is collected into a universal pot To measure TBUT, fluorescein is placed system autoimmune rheumatic disease over 10 minutes. The saliva collected into the patients tear film and the patient characterised by mononuclear cell is measured in a graduated syringe. is asked not to blink while the tear film infiltration of the lacrimal and salivary is observed using a slit lamp. The TBUT glands causing progressive glandular Lacrimal flow rate (Schirmer test) is recorded as the number of seconds atrophy and hypofunction of these glands. A small strip of filter paper is placed that elapse between the last blink and This results in dry eyes (keratoconjunctivitis inside the lower eyelid of both eyes the appearance of the first dry spot in sicca) and dry mouth (xerostomia).6 and the patient is asked to close their the tear film. The aetiology of Sjögren’s syndrome is eyes for five minutes. The paper is then unknown, but may be triggered by an removed and the amount of moisture Blood tests environmental agent in a background of is measured. Less than 5mm wetting These include ENA, ANA antibodies genetic susceptibility. It is the second most of the paper is indicative of dry eyes. and rheumatoid factor levels. common autoimmune rheumatic disease and it is estimated that half a million people Ocular staining test Salivary gland ultrasound in the UK have Sjögren’s syndrome.7 It most (Lissamine green dye) An ultrasound of the major salivary commonly affects middle-aged women and A drop of Lissamine green dye is placed glands is useful for assessment of can have two peaks of age on onset. The in the eye and the patient is asked to the structure of the glands. first peak can occur during the childbearing blink twice to spread the stain over the period (usually mid 30s) and the second conjunctiva and cornea. The staining Labial gland biopsy peak during the post-menopausal period is scored using a slit lamp (an optical A labial gland biopsy is usually (usually mid 50s). instrument that provides a magnified performed under local anaesthetic. image of the tear film and the ocular A superficial incision is made on Assessment of patients when Sjögren’s syndrome is suspected TA B L E 2 Patients usually present to their GDP, GP or specialist with symptoms of dry COMMON SIGNS & SYMPTOMS OF SJÖGREN’S SYNDROME mouth and dry eyes but may also Type Symptom present with symptoms of arthralgia Glandular Dry mouth and throat and fatigue (Table 2). Dry eyes – feeling of grit/sand, burning, redness Tendency for candidal infection A thorough medical history should Parotid gland enlargement be obtained, as patients may have existing rheumatic conditions or other Extraglandular Excessive fatigue Myalgia and arthralgia autoimmune disorders. The clinical Peripheral neuropathy oral dryness score should be recorded. Polymyopathy Investigations are usually performed Lymphopenia in a specialist clinic, however it is useful Thrombocytopenia for general dental practitioners to be Hypocomplementaemia aware of these and what they entail. Hypergammaglobulinanaemia Cryoglobulinaemia Unstimulated whole Raynauds saliva flow rate Cutaneous vasculitis The patient is sat in a relaxed and CNS involvement – memory loss/confusion upright position and asked to spit Renal involvement gently into a universal pot for 10 Interstitial lung disease (pulmonary fibrosis) minutes. The saliva collected is Hepatobiliary chronic inflammation (primary biliary cirrhosis) measured in a graduated syringe. 72 P R I M A R Y D E N TA L J O U R N A L  TA B L E 3 AMERICAN-EUROPEAN CONSENSUS CRITERIA FOR SJÖGREN’S SYNDROME Objective In order to make a diagnosis of Sjögren’s syndrome, the following criteria must be met: Positive anti-Ro/anti-La antibodies. I. Ocular Symptoms (at least one) Positive labial gland biopsy ≥1 Symptoms of dry eyes for at least three months focus per 4mm2. A foreign body sensation in the eyes Reduced whole salivary flow Use of artificial tears three or more times per day