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

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 substiutes, 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.