Knowledge for Clinical Practice

WWW.DENTALLEARNING.NET

A PEER-REVIEWED PUBLICATION

DENTAL LEARNING

INSIDEEarn 2

CECredits

Written for dentists, hygienists

and assistants

Sjögren Syndrome: Oral Manifestations, Complications and ManagementFiona M. Collins, BDS, MBA, MA

DENTAL LEARNING

EDUCATIONAL OBJECTIVES

The overall goal of this article is to provide the reader with information on the management of the oral complications associated with Sjögren syndrome. After completing this article, the reader will be able to:

• Describe classic signs and symptoms of Sjögren syndrome, and its prevalence;

• List and describe changes in salivary flow and composition;

• Review the oral complications of Sjögren syndrome; and,

• Review options for the management of oral complications associated with Sjögren syndrome.

Sjögren syndrome is a chronic, inflammatory autoimmune disease with significant oral and systemic complications. Oral manifes-tations and complications of this disease include parched oral mucosa, discomfort, increased risk for caries and dental erosion, increased prevalence of candidal infections, and other conditions. A diagnosis of Sjögren syndrome may be suspected if dry mouth and dry eyes are both present, however a definitive diagnosis requires further investigation. Management of the oral complications of this syndrome requires palliative care/treatment of dry mouth and preventive care. Given the increased risk for oral diseases and non-Hodgkin’s lymphoma, frequent recalls and therapy are required.

ABSTRACT

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from ORAPHARMA. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2016 - 1/31/2020. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: October 2016. EXPIRATION DATE: September 2019. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combi-nation of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Joseph Riley, does not have a leadership or commercial interest in any products or services discussed in this educational activity. He can be reached at jriley@ims.co. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLA-TION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC, in writing. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to jriley@ims.co. Go Green, Go Online to www.dentallearning.net take your course.

Sjögren Syndrome: Oral Health Manifestations, Complications and Management

Integrated Media Solutions Inc./DentalLearning.net is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental profession-als in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. Integrated Media Solutions Inc./DentalLearning.net designates this activity for 2 continuing education credits.

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement.1/31/2016 - 2/1/2020 Provider ID: # 346890AGD Subject Code: 730

Dental Learning, LLC is a Dental Board of California CE Provider. The California Provider # is RP5062. All of the infor-mation contained on this certificate is truthful and accurate. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. This course meets the Dental Board of Califor-nia’s requirements for 2 units of continuing education. CA course code is 02-5062-16013

Sjögren syndrome (SS) is named after Sir Henrik Sjögren, who recognized its symptoms of dry mouth, dry eyes and arthritis in some of his female patients.1

SS affects around 4 million people in the US alone,2 with a 9:1 ratio of females to males.3 Genetic, viral, neural, environ-mental and hormonal factors have all been attributed to this disease, and women with SS have been found to be androgen deficient.4 However, no definitive etiology has been found.3,5,6 Up to 90% of individuals with SS have antibodies targeting the Ro 60 and La autoantigens.7

Primary SS is a chronic inflammatory autoimmune disease affecting the salivary, lacrimal and other exocrine glands.7

Secondary SS also includes rheumatoid arthritis, systemic lupus erythematosus or another connective tissue disease.7 Disease progression involves lymphocyte-mediated glandu-lar destruction, accompanied by autoantibody production,

ABOUT THE AUTHORFiona M. Collins, BDS, MBA, MA Dr. Fiona M. Collins has authored and presented CE courses to dental profes-sionals and students in the United States and internationally, and has been an active author, editor, writer, speaker and trainer for several years. Fiona is a member of the American Dental Association, the ADA

Standards Committee working groups, Chicago Dental Society, and the Organization for Safety, Asepsis and Prevention (OSAP). She is the ADA representative to AAMI and a Fellow of the Pierre Fauchard Academy. Dr. Collins earned her dental degree from Glasgow University and holds an MBA and MA from Boston University. AUTHOR DISCLOSURE: Dr. Collins has no financial relationship or interest with the commercial supporter of this course. She is the CE Editor for Dental Learning. Dr. Collins can be reached at fionacollins@comcast.net.

3October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

Managing EditorBRIAN DONAHUE

Creative DirectorMICHAEL HUBERT

Art DirectorJOSEPH CAPUTO

Copyright 2016 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten permission from the publisher.

500 Craig Road, Floor One, Manalapan, NJ 07726

DENTAL LEARNING

connective tissue disorders and other clinical manifestations. SS results in severe salivary gland dysfunction and hyposaliva-tion, impacting quality of life more than all other etiologies for dry mouth except head and neck radiation therapy.8, 9

Patient Complaints Patients report a variety of complaints. In a survey of 400

patients with SS, 98% experienced dry mouth and 93% dry eye.2 (Figure 1) Patients may complain of a sticky and/or dry feeling in the mouth, a sensation of pain or burning mouth/tongue, alterations in taste, stringy/ropey saliva, difficulty speaking, and a reduced ability to chew and swallow food. Patients may also complain of nocturnal discomfort, difficulty and discomfort wearing dentures, or an inability to tolerate spicy foods.10-15 Mucosal dryness is the chief oral complaint.16 Muscles, blood vessels, lungs and kidneys can also be af-fected, and SS causes vasculitis and peripheral neuropathy.3,17 Approximately 50% of patients are estimated to develop non-glandular signs and symptoms, and patients have a high risk of non-Hodgkin’s lymphoma with approximately 5% of patients affected.3,17 Patients have between 10 and 50 times the risk of developing lymphoma compared to the general population.18,19

Changes in Salivary Flow and Composition Stimulated and unstimulated salivary flow rates of

<0.1 ml/minute and <0.7 ml/minute, respectively, signify dry mouth;20,21 a 50% reduction in overall salivary flow is considered hyposalivation.22 The parotid supplies >50% of stimulated salivary flow. Sixty-five percent of unstimulated salivary flow is provided by the submandibular glands, the parotids supply 20% and the remainder is produced by the sublingual and minor salivary glands.23 Stimulated salivary flow accounts for approximately 80% to 90% of total saliva produced in a 24-hour period.23 Salivary flow also has a diurnal pattern, and is significantly lower at night (~0.1 ml/minute in a patient with normal salivary flow).23 Reduced salivary flow means reduced clearance of bacteria, ferment-

able carbohydrates and acids, reduced buffering capacity and reduced availability of agents that inhibit demineralization and promote remineralization, lubricate and moisturize, pro-vide antimicrobial activity, and that aid digestion.23

The composition of saliva in SS is altered, leaving a thicker, stringy/ropey saliva. This results in difficulty eating, swallowing and speaking, and reduces oral lubrication and moisturization. Changes in cytokine expression and the levels of antimicrobial agents, enzymes and other agents are also found.7,24-27 In research on cytokine expression, patients with primary SS have been found to display lower levels of inter-leukin-1 beta (IL-1 ß),25 and elevated levels of IL-2 and sali-vary IL-6 compared to patients with secondary SS and those without SS.26 Increased levels of sodium have been observed,7

as well as for lactoferrin, lysozyme C, cystatin C and beta(2)-microglobulin,7 together with reduced levels of amylase and carbonic anhydrase.7 Other findings include reductions in the production of proteins, peroxidase activity, and secretory im-munoglobulin A.27 (Figure 2) These changes collectively alter the levels of functional agents in saliva, further impacting the perception of taste (carbonic anhydrase (gustin)), protection of soft and hard tissues, and digestion.

Oral Manifestations Patients present with dry and parched-looking soft tissues,

erythematous oral mucosa, dry or cracked lips and a parched appearance to the tongue.12 (Figure 3) Retained food and debris may be present due to reduced salivary clearance; more

Figure 1. Complaints by patients with Sjögren syndrome2

DENTAL LEARNING

4

dental plaque may also be evident, although patients with SS generally have good oral hygiene.7,28 Progressive salivary gland enlargement is a classic manifestation (Figure 4); in some patients, it precedes hyposalivation and changes to the appear-ance of the oral mucosa.12 Salivary gland enlargement may be unilateral or bilateral. (Figure 4) It is important to assess salivary gland enlargement. Severe oral dryness can result in a mouth mirror sticking to the cheek, and a digit (gloved) may adhere to soft tissue during palpation.12 Patients also may ex-perience halitosis, associated with methyl mercaptans produced by gram-negative bacteria.12

An increased caries risk and caries experience are ob-served, and early loss of teeth may occur,7 associated with hyposalivation, reduced buffering capacity, and the reduced availability of calcium, phosphate, fluoride, and antibacte-rial agents. Caries lesions are typically found at cervical and incisal sites, cusp tips, and recurrent caries at cervical margins.15 Dental erosion may be evident,29,30 with progres-sive loss of tooth structure and may be followed by dentinal hypersensitivity once open dentinal tubules are exposed. Ad-ditionally, an estimated 30% of patients experience GERD, compounding the risk for erosion.31 Sucking on acidic candies or lemons to relieve dry mouth increases the risk of erosion,32 and candies with sugar increase caries risk. Sour candies appear to contain greater concentrations of acid, and to be more detrimental than other candies.33 An asso-ciation may exist between SS and lichen planus (which has potential for malignant transformation), recurrent aphthous stomatitis, pemphigus vulgaris and mucous membrane pemphigoid.34

Periodontal Tissues Some studies have found no significant differences in the

periodontal status of patients with and without SS,28,35 while in others the converse has been observed.25,36-38 One study found a higher gingivitis index in patients with secondary SS (after ad-justing for plaque present), and a higher mean clinical attach-ment loss (CAL) and probing depth (PD).25 In patients with similar periodontal disease parameters, significantly greater CAL (p<0.01) and greater levels of gingival crevicular fluid (p<0.001) have been observed in patients with SS (mean 8.8 years) compared to those with dry mouth with a different etiol-

IL-1 betaAmylase Carbonic anhydrasePeroxidase activitySecretory immuno-globulin A

IL-2 and IL-6SodiumLactoferrin Lysozyme C Cystatin C Beta(2)-microglobulin

Figure 2. Salivary changes in primary SS Figure 3. Dry, fissured tongue in a patient with Sjögren syndrome.

©2016 American College of Rheumatology. Used with permission.

Figure 4. Salivary gland enlargement in a patient with Sjögren syndrome.

Image: Milorad Dmini MD/Wikimedia

5October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

ogy. Increased bleeding on probing has also been observed.36 Patients with SS (n=30) had better oral hygiene than

others, yet even when plaque scores improved there was no decrease in bleeding, periodontal pockets or gingival hy-pertrophy. This lack of improvement correlated with high salivary levels of B-cell activating factor (BAFF) (p<0.002). It was proposed that the effect of B cells in periodontal disease was influenced by salivary BAFF.38

Oral Infections - Candidiasis Patients with SS may experience candidiasis, presenting as

angular cheilitis, erythematous areas or white patches.12 The risk is greater for denture wearers, with candidiasis develop-ing on the palate. Yeast forms were present in samples from oral rinsing and supra-gingival plaque in 72% of primary SS patients, 41% of secondary SS patients and 0% of patients without SS in one study (p<0.0001); more than 85% of the yeasts were Candida.39 In another study, Candida was present in the saliva of patients with SS.37 One study found candidia-sis in 87% of patients with primary SS.40

Diagnosing Sjögren SyndromeSS may be suspected based on a history of dry eye and

dry mouth. Changes in taste, ocular/throat dryness and a sensation of ‘burning mouth’ may also suggest SS. Stimu-lated salivary flow (after chewing on paraffin or wax), and unstimulated salivary flow, can be objectively measured by having the patient salivate and expectorate into a cup for five minutes for each test.41 However, there are many etiolo-gies for hyposalivation, and the oral manifestations of SS are not unique.

A definitive diagnosis is made based on specific criteria and by a process of exclusion. The 2 main sets of standard criteria used are the European-American42 and the American College of Rheumatology Classification Criteria.43

European-American Criteria42

For a primary SS diagnosis:1. A lip biopsy must show focal lymphocytic sialoadeni-

tis (focus score ≥1 per 4 mm2) OR Anti-SSA (Ro), OR Anti-

SSB (La) antibodies (or both) must be present, AND, 2. 3 other of the total of 6 criteria must be present . (Table 2)

American College of Rheumatology Classification Criteria43

Two of three of the following criteria must be met for a diagnosis of SS:

1. Positive serum anti-SSA and/or anti-SSB or [positive rheumatoid factor and ANA ≥1:320];

2. Ocular staining score ≥ 3;3. Focal lymphocytic sialadenitis with a score ≥ 1 focus/

4 mm2 in labial salivary gland biopsies.43 A review of both sets of criteria found substantial agree-

ment in the results, with no evident advantage for either, leading to the conclusion that a better understanding of the disease was needed for diagnostic improvements.44

Table 1. Oral manifestations of Sjögren syndrome

Table 2. Criteria for Sjögren syndrome

Dry, parched oral mucosa Erythematous oral mucosa

Dry or cracked lips Parched appearance to tongue

Retained food or debris Increased level of plaque

Salivary gland enlargement Dental caries – typically cervically, incisally and at cusp tips

Recurrent caries at cervical margins Dental erosion

Gingivitis and periodontal disease Dry throat

Candidal infections Lymphoma

More information on the criteria and secondary SS can be found in the document by Vitali et al.42

Ocular Symptoms (at least one): Symptoms of dry eyes for at least 3 months; A foreign body sensation in the eyes; Use of artificial tears 3 or more times/day

Oral Symptoms (at least one): Symptoms of dry mouth for at least 3 months; Recurrent or persistently swollen salivary glands; Need for liquids to swallow dry foods

Ocular Signs (at least one): Abnormal Schirmer’s test, (without anesthesia; ≤5 mm/5 minutes); Positive vital dye staining of the eye surface

Histopathology: Lip biopsy showing focal lymphocytic sialoadenitis (focus score ≥1/4 mm2)

Oral Signs (at least one): Unstimulated whole salivary flow (≤1.5 ml in 15 minutes); Abnormal parotid sialography; Abnormal salivary scintigraphy

Autoantibodies (at least one): Anti-SSA (Ro) or Anti-SSB (La), or both

DENTAL LEARNING

6

Salivary Diagnostics A proteolytic peptide biomarker for SS has been discov-

ered, using bioinformatics and high-resolution mass spec-trometry on individual samples of unstimulated saliva from patients with and without SS.45 This peptide was consistent-ly only present in patients with SS, and may have potential as a simpler way to diagnose this syndrome,45 without the

need for invasive tests and the associated discomfort. A second potential biomarker, CXCL13, is a B-cell chemokine that is elevated from salivary glands and systemically in patients with SS.46 Early identification of patients prior to clinical manifestations may also become possible, based on findings of autoantibodies predictive of SS. Eighty-two per-cent of patients (n=117) with autoantibodies following di-agnosis had these present up to 20 years earlier (median 4.3-5.1 years). Ro 60, Ro 52 and La are antigens that consist of RNA binding proteins, and autoantibodies target these. Anti-Ro/SSA and anti-La/SSB antibodies were predictive for primary SS. Anti-Ro 60/SSA and anti-Ro 52/SSA were most predictive, respectively 25% and 100%, especially for early-onset disease and disease severity.47

Management of the Oral Complications of Sjögren Syndrome

Thorough oral hygiene, stimulation of saliva, palliative care and/or treatment to relieve dry mouth and its associated symptoms, and treatment to prevent and manage the other potential complications of dry mouth are required. Areas of focus include professional care, periodic recalls, oral hygiene, palliative care and treatment for dry mouth, and the preven-tion and treatment of dental caries, erosion, periodontal disease and (other) oral infections.

Professional Care Regular extra- and intra-oral examinations and recalls are es-

sential. Patients should be assessed for periodontal disease, dental erosion and dental caries at each recall appointment, and preven-tive and maintenance care provided and recommended. Advice should be provided to patients on beneficial home care and habits, and on what to avoid. Recall visits may be required more frequently than every 6 months to prevent, detect and manage oral disease.48 In addition, a thorough soft tissue examination is necessary, and care taken to check for signs of lymphoma given the increased risk level in patients with SS.

Oral HygieneThorough oral hygiene is essential. Patients should be

Figure 5 . Dry eye and Rose Bengal staining of the cornea in a patient with Sjögren syndrome

Figure 6. Diagram of Schirmer's test

The test strips are applied and the amount of tear liquid absorbed into the strip is measured. Image: Jmarchn/Wikimedia

© 2016 American College of Rheumatology. Used with permission.

Note the corneal abrasions resulting from dry eye, visible as reddish-purple flecks after using Rose Bengal stain.

7October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

advised to brush twice daily using a soft-bristled toothbrush and a fluoride toothpaste. Patients may find dry mouth toothpastes and lubricating gels that alleviate dry mouth and contain fluoride are helpful. These contain lubricating agents and do not contain sodium lauryl sulfate.48 Antibacterial toothpastes help to control plaque and gingivitis, and may also reduce halitosis. Daily interdental cleaning is also im-portant. Rinsing with baking soda (water with 1 teaspoon of baking soda) helps to counteract bacterial and erosive acids, and to prevent demineralization, by increasing the intraoral pH. A chewable lozenge that contains bicarbonate as a buff-ering agent, calcium carbonate and arginine is also available (BasicBites, Ortek Therapeutics Inc.). Denture hygiene using a brush and denture cleansers will remove debris and micro-organisms. Denture use at night should be discouraged.49 The selection of, and recommendations for, oral care products should be based on clinical efficacy, safety, and the needs and preferences of the individual patient.

Managing and Treating Dry Mouth• Saliva substitute sprays (OTC) contain a thickening

agent making them viscous to ‘moisturize’ the oral mucosa, and are portable.16,50 Xanthan gum and and mucin may pro-vide better wetting and flow than carboxymethylcellulose in sa-liva substitutes, and may be preferred for patients with SS.21-55

• Dry mouth gels and rinses (OTC) typically contain glycerine, hydroxyethylcellulose, or carboxymethylcellulose, as the moisturizing/lubricating agent; buffering agents (calcium bicarbonate); antibacterial agents; or, combinations of these. Moisturizing gels are thick, and their use at night is recom-mended as they adhere for long periods of time to the mucosa.

• Supersaturated calcium phosphate rinses (Rx) have been found in some studies to relieve dry mouth and to improve taste perception, ease of eating, drinking and swallowing.57-60 Origi-nally, this type of rinse came as two vials containing solutions mixed immediately before use. An effervescent tablet version has now been developed (Caphasol, EUSA Pharma), and powder sachets that are mixed with water immediately before use are available (NeutraSal, Orapharma; SalivaMAX, Forward Sci-ence). In one study, patients with xerostomia reported an average

rating of 9 (1 = ‘dry as a desert’ and 10 = normal), compared with an average score of 2 before using a supersaturated calcium phosphate rinse containing sodium bicarbonate for 28 days in one study (n=60; 30 control and 30 test).57 Functional improve-ments ranged from 80% for eating, 90% for swallowing and talking, and 93% for drinking.57 In the same study, the average salivary pH increased from 5.9 to 7.57

• A time-release mucoadhesive disc with xylitol, that aids oral moisturization/lubrication is also available (XyliMelts, OraCoat) as well as a mucoadhesive patch (Oramoist, DenTek).

• Dry mouth lozenges that can be chewed or sucked to help moisturize oral mucosa and provide relief from dry mouth.

• Applying vitamin E oil directly to the mucosa (or from a capsule with a hole in it) is also recommended for relief, 2 or 3 times daily.61

There is currently insufficient data to make specific evidence-based recommendations on interventions for the pal-liative relief of dry mouth.49 However, individual studies have demonstrated relief—in some cases without increasing saliva-tion,58 including for patients with severe hyposalivaton.51,53,57-61

Sialogogues Pilocarpine hydrochloride (Salagen; MGI Pharma) and

cevimeline hydrochloride (Evoxac; Daiichi-Sankyo) are indicated for severe hyposalivation associated with SS. Both are cholin-ergic agents that stimulate salivary gland function. Pilocarpine is prescribed at a dose of 5 mg, four times daily for at least 12 weeks to provide clinical benefit5 and use must be ongoing to keep this benefit. Cevimeline is prescribed at a dose of 30 mg, 3 times daily.5 Both pilocarpine and cevimeline are clinically effec-tive.62-66 Sialogogues have potentially serious side effects such as dizziness, alterations in vision and stomach upset and, rapid or slowed heart rate.67

Recommending Lifestyle Adjustments and ChoicesPatients should be advised to sip water frequently, and to suck sugar-free lozenges or small ice chips to relieve dry mouth. Eating softer foods, and sipping water frequently during meals, helps make chewing and swallowing food easier, and choosing favorite foods and flavors helps

DENTAL LEARNING

8

stimulate saliva. Spicy foods may cause irritation and are not well-tolerated; general advice is to avoid these. Chewing sugar-free gum ad libitum helps to stimulate saliva between meals.68,69 Xylitol gum may help as part of a preventive program,70 and chewing gum with casein phosphopeptide-amorphous calcium phosphate is another option. Using a humidifier at home (and not a dehumidi-fier) may help, especially at night when salivary flow is lowest.48 If lips are dry, patients can apply a lip balm to relieve dryness.

Preventing and Controlling Oral DiseaseThe ADA recommendations for in-office preventive care

for at-risk patients age 6 and over is application of 5% sodium fluoride varnish or 1.23% 4-minute APF gel at least every 3 or 6 months.71 Silver diamine fluoride is now also available in the US, and has been shown to be effective in arresting and preventing dental caries.72 These are off-label uses for both types of products. At-home use of a prescription-level fluoride once or twice daily increases protection against dental caries and is recommended for at-risk patients.73 Fluorides also help strengthen tooth structure against erosive acid challenges.74-76 Rinsing with an alcohol-free fluoride mouth rinse is of adjunctive benefit against caries, and has been recommended when the mouth feels dry or after eating/drinking;73 Alcohol-containing rinses should be avoided as these have a drying effect and can cause irritation.

Calcium phosphate products may also be recommend-ed. In one study (n=134) daily use of prescription-level fluoride toothpaste, combined with up to 3 to 4 times daily use of supersaturated calcium and phosphate rinse, resulted in statistically significant reductions in coronal and root caries, and remineralization of existing caries lesions (p<0.0001) in patients with severe xerostomia.77 Paste containing fluoride and casein phosphopeptide-amorphous calcium phosphate may also be applied at night and left on the teeth, and provides a source of calcium, phosphate and fluoride.48,78 Pastes and gels con-taining calcium and phosphate, and amorphous calcium phosphate, are also available.

Advice should be given to patients to avoid foods, drinks and habits that increase the risk for dental caries and erosion. (Table 3) Based on recent data, patients should also be advised to avoid brushing for at least 1 hour after eating or drinking anything acidic (or after exposure to other extrinsic or intrinsic erosive acids), to reduce the risk of erosive tooth wear.79

Treating Oral Candidal InfectionsOral candidiasis can be treated with topical nystatin, of-

ten applied as a cream or ointment.80 Nystatin ointment can be applied in a thin layer 4 times daily for 14 days to treat intra-oral fungal infections as well as to the commissures of the lip to treat candidal angular cheilitis.81 Nystatin and chlorhexidine gluconate rinse should not be used together because they counteract each other.82 While nystatin rinse is also available for the treatment of widespread intra-oral candidal infection, this contains sucrose and would increase the already-elevated risk of dental caries in this patient population.81 Other options include nystatin pastilles, am-photericin lozenges and miconazole gel. Nausea, vomiting and diarrhea are side effects of nystatin and miconazole.81,83 If a denture wearer is experiencing candidiasis, he/she can be advised to clean the denture, leave it out at night and soak it in chlorhexidine gluconate rinse.81 Probiotics have also been suggested as a potential treatment for the reduction and treatment of oral candiasis.84

Table 3. Advice on reducing caries and erosion risk

Rinse with water and one teaspoon to increase the intraoral pH after exposure to acids

Maintain a low-sugar diet

Avoid eating foods or drinking liquids containing sugar

Avoid sucking candies or chewing gum containing sugar

Avoid acidic foods, drinks, vegetables, fruits and chewing gum

Avoid acidic or sour candies

Avoid carbonated drinks and alcohol

Avoid caffeine and alcohol, which are both acidic and also exacerbate dry mouth

Avoid street drugs, which are also drying and detrimental to health

9October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

Tobacco CessationSmoking tobacco exacerbates dry mouth, increases the

risk for periodontal disease and with more severe and rapid progression, and it is the greatest risk factor for oral can-cer.85-87 Recent studies also indicate a role in dental caries and autoimmune diseases.88 Patients who use tobacco should be advised to stop and be given advice on how to quit and/or a referral.89-91

Emerging and Potential Treatments for Patients with SS

Novel treatments being investigated and/or already in use include acupuncture, electrical nerve stimulation, and extra-oral and intra-oral reservoir hydration devices includ-ing in full dentures.92-94 Overall, there is currently insufficient evidence on the efficacy of electrostimulation devices in relieving the discomfort associated with dry mouth, and low evidence on the effects of acupuncture.95 While most care for dry mouth is palliative, treatment with interferon (IFN) holds promise for SS sufferers; interferon increased whole saliva by 16.8% in one study, believed to be the result of inhibition of IL-2 and IL-6, and increased salivary flow.26 IFN-alpha loz-enges may enhance saliva flow in primary SS patients.96 In the future, stem cell therapy may hold promise as an option to help restore salivary flow.97 Potential therapies for the future include the development of artificial salivary glands.

ConclusionsSjögren syndrome significantly impacts oral and systemic

health. Oral manifestations of this disease include parched oral mucosa, discomfort, increased risk for caries and erosion, in-creased prevalence of candida infections, and other conditions. Patients also are at greater risk than the general population for non-Hodgkin’s lymphoma. Frequent recalls and care are required for patients with SS. Management of the oral com-plications of this syndrome requires palliative care/treatment of dry mouth, preventive care and maintenance. In addition, patients should be given advice on home care and habits, and on behaviors to avoid. Novel and potential future treatments for palliative and preventive care, including the use of preven-

tive agents and rinses, holds promise for the management of this disease. Finally, by testing genetically and using biomarkers in the future, it may be possible to screen and identify at-risk individuals sooner and to provide earlier intervention.

References1. Mutlu S, Scully C. The person behind the eponym: Henrik Sjögren (1899-1986). J Oral Pathol Med. 1993;22(10):439.2. García-Carrasco M, Ramos-Casals M, Rosas J, et al. Primary Sjögren syn-drome: clinical and immunologic disease patterns in a cohort of 400 patients. Medicine (Baltimore). 2002;81(4):270-280.3. Mavragani CP, Moutsopoulos HM. The geoepidemiology of Sjögren syn-drome. Autoimmun Rev. 2010;9(5):A305-10.4. Sullivan DA, Bélanger A, Cermak JM, et al. Are Women With Sjogren’s Syn-drome Androgen-deficient? J Rheumatol. 2003;30:2413-9. 5. Fox RI, Kang HI. Pathogenesis of Sjögren syndrome. Rheum Dis Clin North Am. 1992;18:517-38. 6. Daniels TE. Evaluation, differential diagnosis, and treatment of xerostomia. J Rheumatol Suppl. 2000;61:6-10.7. Mathews SA, Kurien BT, Scofield RH. Oral manifestations of Sjögren syn-drome. J Dent Res. 2008;87(4):308-18.8. Jensen SB, Vissink A. Salivary gland dysfunction and xerostomia in Sjögren syndrome. Oral Maxillofac Surg Clin North Am. 2014;26(1):35-53. 9. Jensen DH, Oliveri RS, Trojahn Kølle SF, et al. Mesenchymal stem cell therapy for salivary gland dysfunction and xerostomia: a systematic review of preclinical studies. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(3):335-342.e1. 10. Porter SR. Xerostomia: prevalence, assessment, differential diagnosis and implications for quality of life. Oral Dis. 2010;16:501-2.11. Nederfors T. Xerostomia and hyposalivation. Adv Dent Res. 2000;14:48-56.12. Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and treat-ment. J Am Dent Assoc. 2003;134:61-9.13. Valdez IH, Fox PC. Interactions of the salivary and gastrointestinal systems. I. The role of saliva in digestion. Dig Dis. 1991;9:125-132.14. Vissink A, Panders AK, Gravenmade EJ, Vermey A. Treatment of oral symp-toms in Sjögren syndrome. Scand J Rheumatol Suppl. 1986;61:270-3.15. Gupta A, Epstein JB, Sroussi H. Hyposalivation in elderly patients. J Can Dent Assoc. 2006;72:841-6.16. Vissink A, Panders AK, s-Gravenmade EJ, Vermey A. Treatment of oral symp-toms in Sjögren syndrome. Scand J Rheumatol Suppl. 1986;61:270-3.17. Tzioufas AG, Voulgarelis M. Update on Sjögren syndrome autoimmune epithelitis: from classification to increased neoplasias. Best Pract Res Clin Rheu-matol. 2007;21(6):989-1010.18. Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Sjögren syndrome. Arch Intern Med. 2004;164(12):1275-84.19. Tincani A, Andreoli L, Cavazzana I, et al. Novel aspects of Sjögren syndrome in 2012. BMC Medicine. 2013;11:93:1-17.20. Jensen S, Pedersen A, Vissink A, et al. A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer. 2010; 18:1039-60.21. Navazesh M, Christensen CM, Brightman VJ. Clinical criteria for the diagno-sis of salivary gland hypofunction. J Dent Res. 1992;71:1363-9.22. Ghezzi EM, Lange LA, Ship JA. Determination of variation of stimulated salivary flow rates. J Dent Res. 2000;79:1874-8.

DENTAL LEARNING

10

23. Humphrey SP, Williamson RT. A review of saliva: normal composition, flow, and function. J Prosthet Dent. 2001;85:162-9.24. Antoniazzi RP, Miranda LA, Zanatta FB, et al. Periodontal conditions of indi-viduals with Sjögren syndrome. J Periodontol. 2009;80(3):429-35.25. Streckfus C, Bigler L, Navazesh M, Al-Hashimi I. Cytokine concentrations in stimulated whole saliva among patients with primary Sjögren syndrome, secondary Sjögren syndrome, and patients with primary Sjögren syndrome re-ceiving varying doses of interferon for symptomatic treatment of the condition: a preliminary study. Clin Oral Investig. 2001;5(2):133-5.26. Zalewska A, Knas M, Waszkiewicz N, et al. Rheumatoid arthritis patients with xerostomia have reduced production of key salivary constituents. Oral Med Oral Pathol Oral Radiol. 2013;115(4):483-90.27. Błochowiak K, Olewicz-Gawlik A, Polanska A, et al. Oral mucosal manifesta-tions in primary and secondary Sjögren syndrome and dry mouth syndrome. Adv Dermatol Allergol. 2016;33(1):23-7. 28. Boutsi EA, Paikos S, Dafni UG, et al. Dental and periodontal status of Sjögren syndrome. J Clin Periodontol. 2000;27(4):231-5.29. Young W, Khan F, Brandt R, Savage N, Razek AA, Huang Q. Syndromes with salivary dysfunction predispose to tooth wear: Case reports of congenital dysfunction of major salivary glands, Prader-Willi, congenital rubella, and Sjögren syndromes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(1):38-48.30. Young WG, Khan F. Sites of dental erosion are saliva-dependent. J Oral Rehab. 2002;29:35-43.31. Canena JM, Leitao JH, Pinto AS, et al. Esophageal motility and gastro-esophageal reflux disease (GERD) in primary Sjögren syndrome. Gastroenterol 2000;118(4):Apr 1, 2000. Abstract 5595. 32. Jensdottir T, Nauntofte B, Buchwald C, et al. Effects of sucking acidic candies on saliva in unilaterally irradiated pharyngeal cancer patients. Oral Oncol. 2006;42(3):317-22. 33. Wagoner SN, Marshall TA, Qian F, Wefel JS. In vitro enamel erosion associ-ated with commercially available original-flavor and sour versions of candies. J Am Dent Assoc. 2009;140(7):906-13.34. Likar‐Manookin K, Stewart C, Al‐Hashimi I, et al. Prevalence of oral lesions of autoimmune etiology in patients with primary Sjögren syndrome. Oral Diseases. 2013;19(6):598-603. 35. Kuru B, McCullough MJ, Yilmaz S, Porter SR. Clinical and microbiological studies of periodontal disease in Sjögren syndrome patients. J Clin Periodontol. 2002;29(2):92-102.36. Rhodus NL, Michalowicz BS. Periodontal status and sulcular Candida albi-cans colonization in patients with primary Sjögren Syndrome. Quintessence Int. 2005;36(3):228-33.37. Ergun S, Cekici A, Topcuoglu N, et al. Oral status and Candida coloni-zation in patients with Sjögren Syndrome. Med Oral Patol Oral Cir Bucal. 2010;15(2):e310-5.38. Pers JO, d'Arbonneau F, Devauchelle-Pensec V, et al. Is periodontal disease mediated by salivary BAFF in Sjögren syndrome? Arthritis Rheum. 2005;52(8):2411-4.39. Leung KCM, McMillan MC, Leung WK. Yeast within supra-gingival plaque in Sjögren syndrome patients. Abstract 3427. IADR/AADR/CADR 83rd General Session (March 9-12, 2005), Baltimore, MD.40. Yan Z, Young AL, Hua H, Xu Y. Multiple oral Candida infections in patients with Sjögren syndrome – prevalence and clinical and drug susceptibility profiles. J Rheumatol. 2011;38:2428-31.41. Navazesh M, Kumar SK. Measuring salivary flow: challenges and opportuni-ties. J Am Dent Assoc. 2008;139 Suppl:35S-40S.42. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjögren syndrome: a revised version of the European criteria proposed by the American-

European Consensus Group. Ann Rheum Dis. 2002; 61:554-8.43. Shiboski SC, Chiboski CH, Criswell LA, American College of Rheumatology Classification Criteria for Sjögren Syndrome: A Data-Driven, Expert Consensus Approach in the SICCA Cohort. Arthritis Care Res (Hoboken). 2012;64(4):475-87.44. Rasmussen A, Ice JA, Li H. Comparison of the American-European Consen-sus Group Sjögren syndrome classification criteria to newly proposed American College of Rheumatology criteria in a large, carefully characterized sicca cohort. Ann Rheum Dis. 2014;73(1): doi:10.1136/annrheumdis-2013-203845.45. Zoukhri D, Rawe I, Singh M, et al. Discovery of putative salivary biomarkers for Sjögren syndrome using high resolution mass spectrometry and bioinformat-ics. J Oral Sci. 2012;54:61-70. Available at: https://www.jstage.jst.go.jp/article/josnusd/54/1/54_1_61/_pdf.46. Baker OJ, Edgerton M, Kramer JM, Ruhl S. Saliva-microbe interactions and salivary gland dysfunction. Adv Dent Res. 2014;26(1):7-14.47. Theander E, Jonsson R, Sjöström B, et al. Prediction of Sjögren Syn-drome Years Before Diagnosis and Identification of Patients With Early Onset and Severe Disease Course by Autoantibody Profiling. Arthritis Rheumatol. 2015;67(9):2427-36.48. John Hopkins Jerome L. Greene Sjögren Syndrome Center, Baer A, Papas A, Singh M, Sciubba J. Preventing Dental Decay: A Guide for Salivary Hypofunc-tion Patients. Available at: http://www.hopkinssjogrens.org/disease-information/treatment/preventing-dental-decay/.49. Furness S, Worthington HV, Bryan G, et al. Interventions for the management of dry mouth: topical therapies. Cochrane Database of Systematic Reviews. 2011;12:CD008924.50. Ramos-Casals M, Brito-Zerón P, Sisó-Almirall A, Bosch X, Tzioufas AG. Topi-cal and systemic medications for the treatment of primary Sjögren syndrome. Nat Rev Rheumatol. 2012;8:399-411.51. Shahdad SA, Taylor C, Barclay SC, et al. A double-blind, crossover study of Biotène Oralbalance and BioXtra systems as salivary substitutes in patients with post-radiotherapy xerostomia. Eur J Cancer Care (Engl). 2005;14(4):319-26.52. Sugiura Y, Soga Y, Tanimoto I, et al. Antimicrobial effects of the saliva substi-tute, Oralbalance, against microorganisms from oral mucosa in the hematopoi-etic cell transplantation period. Support Care Cancer. 2008;16(4):421-4. 53. Epstein JB, Emerton S, Le ND, Stevenson-Moore P. A double-blind crossover trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with xerostomia following radiation therapy. Oral Oncol.1999;35(2):132-7.54. Van der Reijden WA, Van der Kwaak H, Vissink A, et al. Treatment of xero-stomia with polymer-based saliva substitutes in patients with Sjögren syndrome. Arthritis Rheum. 1996;39:57-69. 55. Vissink A, s-Gravenmade EJ, Panders AK, et al. A clinical comparison be-tween commercially available mucin- and CMC-containing saliva substitutes. Int J Oral Surg. 1983;12:232-8.56. Silvestre FJ, Minguez MP, Suñe-Negre JM. Clinical evaluation of a new artificial saliva in spray form for patients with dry mouth. Med Oral Patol Oral Cir Bucal. 2009;14(1):E8-E11.57. Fritz JA. The efficacy of NeutraSal in patients with medication-induced xero-stomia. 2011. Available at: www.neutrasal.com. 58. Levin EZ. Management of xerostomia and microflora with supersaturated calcium phosphate rinse. 2013. Available at: www.neutrasal.com.59. Papas AS, Clark RE, Martuscelli G, et al. A prospective, randomized trial for the prevention of mucositis in patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant. 2003;8:705-12.60. Singh ML, Papas AS. Long-term clinical observation of dental caries in sali-vary hypofunction patients using a supersaturated calcium-phosphate remineral-izing rinse. J Clin Dent. 2009;20(3):87-92.61. Sjögren Syndrome Foundation. Simple Solutions for Treating Dry Mouth.

11October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

Available at: www.sjogrens.org.62. Wu CH, Hsieh SC, Lee KL, et al. Pilocarpine hydrochloride for the treatment of xerostomia in patients with Sjögren syndrome in Taiwan—a double-blind, placebo-controlled trial. J Formos Med Assoc. 2006;105(10):796–803.63. Papas AS, Fernandez MM, Castano RA, et al. Oral pilocarpine for symptom-atic relief of dry mouth and dry eyes in patients with Sjögren syndrome. Adv Exp Med Biol. 1998;438:973-8.64. Nusair S, Rubinow A. The use of oral pilocarpine in xerostomia and Sjögren syndrome. Semin Arthritis Rheum. 1999;28:360-7.65. Rhodus NL. Oral pilocarpine HCl stimulates labial (minor) salivary gland flow in patients with Sjögren syndrome. Oral Dis. 1997;3:93-8.66. Fife RS, Chase WF, Dore RK, et al. Cevimeline for the treatment of xerosto-mia in patient’s with Sjögren syndrome: a randomized trial. Arch Intern Med. 2002;162(11):1293-300.67. MedicineNet. Pilocarpine and Salagen. http://www.medicinenet.com/pilocarpine-oral/article.htm68. Itthagarun A, Wei SH. Chewing gum and saliva in oral health. J Clin Dent. 1997;8(6):159-62.69. Bots CP, Brand HS, Veerman EC, et al. Chewing gum and a saliva substitute alleviate thirst and xerostomia in patients on haemodialysis. Nephrol Dial Trans-plant. 2005;20(3):578-84. 70. Edgar WM. Sugar substitutes, chewing gum and dental caries--a review. Br Dent J. 1998;184(1):29-32.71. Weyant RJ, Tracy SL, Anselmo T et al. Topical fluoride for caries prevention. Executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279-91.72. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet". J Dent Res. 2009;88(2):116-25.73. Jenson L, Budenz AW, Featherstone JDB, et al. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35(1):714-23.74. Ren Y-F, Liu X, Fadel N, et al. Preventive effects of dentifrice containing 5000 ppm fluoride against dental erosion in situ. J Dent. 2011;39(10):672-8.75. Carvalho TS, Colon P, Ganss C, et al. Consensus report of the European Fed-eration of Conservative Dentistry: erosive tooth wear—diagnosis and manage-ment. Clin Oral Invest. 2015;19:1557–61.76. Wiegand A, Hiestand B, Sener B, et al. Effect of TiF4, ZrF4, HfF4 and AmF on erosion and erosion/abrasion of enamel and dentin in situ. Arch Oral Biol. 2010 Mar;55(3):223-8.77. Singh ML, Papas AS. Long-term clinical observation of dental caries in sali-vary hypofunction patients using a supersaturated calcium-phosphate remineral-izing rinse. J Clin Dent. 2009;20(3):87-92.78. Felix DH, Luker J, Scully C. Oral Medicine: 4. Dry Mouth and Disorders of Salivation. Dental Update; December 2012:738-43.79. Choi S, Park KH, Cheong Y, et al. Potential effects of tooth-brushing on human dentin wear following exposure to acidic soft drinks. J Microsc. 2012247(2):176-85. 80. Worthington HV, Clarkson JE, Khalid T, et al. Interventions for treating oral candidiasis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2010;(7):CD001972. 81. Akpan A, Morgan R. Oral candidiasis. Postgrad Med J. 2002;78:455-9. 82. Barkvoll P, Attramadal A. Effect of nystatin and chlorhexidine digluconate on Candida albicans. Oral Surg Oral Med Oral Pathol. 1989;67:279-81.83. Pappas PG, Kauffman CA, Andes D, et al; Infectious Diseases Society of America. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(5):503-535.70.84. Matsubara VH, Bandara HM, Mayer MP, Samaranayake LP. Probiotics as

Antifungals in Mucosal Candidiasis. Clin Infect Dis. 2016 May 1;62(9):1143-53. 85. Mullally BH. The influence of tobacco smoking on the onset of periodontitis in young persons. Tob Induc Dis. 2004;2(2):53-65.86. Nordreyd O, Hugoson A, Grusovin G. Risk of severe periodontal disease in a Swedish adult population. A longitudinal study. J Clin Periodontol. 1999;26:608-15.87. Oral Cancer Foundation. Risk factors. Available at: http://www.oralcancer-foundation.org/cdc/cdc_chapter3.htm.88. US Department of Health and Human Services. 50 Years of Progress: A Report of the Surgeon General, 2014. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-bysection.html.89. Fiorini T, Musskopf ML, Oppermann RV, Susin C. Is there a positive effect of smoking cessation on periodontal health? A systematic review. J Periodontol. 2014;85(1):83-91.90. Chambrone L, Preshaw PM, Rosa EF, et al. Effects of smoking cessation on the outcomes of non-surgical periodontal therapy: a systematic review and individual patient data meta-analysis. J Clin Periodontol. 2013;40(6):607-15.91. Collins FM. Tobacco Cessation: Health Benefits and Interventions. 2015. Available at: www.dentallearning.net. 92. Sasportas LS, Hosford AT, Sodini MA, et al. Cost-effectiveness landscape analysis of treatments addressing xerostomia in patients receiving head and neck radiation therapy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(1):e37–e51.93. Yamamoto K, Nagashima H, Yamachika S, et al. The application of a night guard for sleep-related xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(3):e11-4.94. Hirvikangas M, Posti J, Mäkilä E. Treatment of xerostomia through use of dentures containing reservoirs of saliva substitute. Proc Finn Dent Soc. 1989;85(1):47-50.95. Furness S, Bryan G, McMillan R, et al. Interventions for the management of dry mouth: non-pharmacological interventions. Cochrane Database Syst Rev. 2013;9:CD009603. 96. Khurshudian AV. A pilot study to test the efficacy of oral administration of interferon-alpha lozenges to patients with Sjogren’s syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95(1):38–44.97. Jensen DH, Oliveri RS, Trojahn Kølle SF, et al. Mesenchymal stem cell therapy for salivary gland dysfunction and xerostomia: a systematic review of preclinical studies. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(3):335-342.e1.

WebliographyJohn Hopkins Jerome L. Greene Sjögren Syndrome Center, Baer A, Papas A, Singh M, Sciubba J. Preventing Dental Decay: A Guide for Salivary Hypofunc-tion Patients. Available at: http://www.hopkinssjogrens.org/disease-information/treatment/preventing-dental-decay/.

Sjögren Syndrome Foundation. Simple Solutions for Treating Dry Mouth. Avail-able at: www.sjogrens.org.

Tincani A, Andreoli L, Cavazzana I, et al. Novel aspects of Sjögren syndrome in 2012. BMC Medicine. 2013;11:93:1-17. Available at: https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-11-93.

Zoukhri D, Rawe I, Singh M, et al. Discovery of putative salivary biomarkers for Sjögren syndrome using high resolution mass spectrometry and bioinformat-ics. J Oral Sci. 2012;54:61-70. Available at: https://www.jstage.jst.go.jp/article/josnusd/54/1/54_1_61/_pdf.

DENTAL LEARNING

12

1. Sjögren Syndrome affects approximately __________ people in the United States.a. 2 million b. 3 million c. 4 million d. 5 million

2. The most frequent complaints in patients with Sjögren Syndrome are __________.a. dry mouth and candidiasisb. dry mouth and dry eyec. dry eye and swelling d. dry mouth and a hoarse voice

3. In patients with Sjögren Syndrome, saliva is __________.a. thinb. stringy/ropeyc. yellowd. highly basic

4. Progressive salivary gland enlargement is a classic manifestation of Sjögren Syndrome.a. Trueb. False

5. Changes in __________ are found in the saliva of patients with Sjögren Syndrome.a. cytokine expression b. the levels of antimicrobial agentsc. the amount of enzymes and other agents d. all of the above

6. Sucking on acidic candies or lemons to relieve dry mouth increases the risk of __________.a. candida infectionsb. viral infectionsc. erosiond. caries

7. Patients with Sjögren Syndrome may experience candidiasis, which always present as white patches.a. Trueb. False

8. It was found in one study that 82% of patients with autoantibodies following diagnosis had these present up to __________ years earlier. a. 10b. 15c. 20 d. 25

9. A thorough soft tissue examination is necessary, and care must be taken to check for signs of __________ given the increased risk level in patients with Sjögren Syndrome. a. squamous cell carcinoma b. lymphoma c. pemphigoid manifestationsd. nicotinic stomatitis

10. The selection of, and recommendations for, oral care products should be based on __________. a. clinical efficacy b. safety c. patient needs and preferences d. all of the above

CEQuizTo complete this quiz online and immediately download your CE verifica-tion document, visit www.dentallearning.net/MDM-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification document. We accept Visa, MasterCard, Discover, and American Express.

13October 2016

Sjögren Syndrome: Oral Health Manifestations,

Complications and Management

11. Dry mouth gels and rinses (OTC) typically contain __________.a. a moisturizing/lubricating agentb. buffering agentsc. antibacterial agentsd. combinations of moisturizing/lubricating, buffering and

antibacterial agents

12. Supersaturated calcium phosphate rinses (Rx) have been found in some studies to __________.a. relieve dry mouth and improve taste perception and ease of

eatingb. reduce oral aphthaec. substantially increase salivationd. a and c

13. A __________ is an option for the relief of dry mouth.a. spray saliva substituteb. dry mouth lozengec. saliva-stimulating oral disc or patchd. all of the above

14. Patients should be advised to avoid __________.a. bland foods b. candies, foods and drinks that contain sugar and/or are acidicc. nonalcoholic drinksd. chewing gums

15. __________ are recommended for patients with Sjögren syndrome to help protect tooth structure. a. Fluoride varnish and home-use fluoridesb. Antimicrobial varnishes c. Hydrogen peroxide rinsesd. Occlusal splints

16. If a denture wearer is experiencing candidiasis, he/she can be advised to clean the denture and to __________. a. coat it before wearing it b. leave it out at night and soak it in chlorhexidine gluconate rinse c. leave it out 4 times a day for 30 minutes and to soak it in

peroxided. any of the above

17. Patients who use tobacco should be advised to stop, and be given advice on how to quit or given a referral. a. Trueb. False

18. In one study on interferon, this was found to increase whole saliva by __________, believed to be the result of inhibition of IL-2 and IL-6. a. 14%b. 15.8%c. 16%d. 16.8%

19. Overall, there is currently ___________ evidence on the efficacy of electrostimulation devices in relieving the discomfort associated with dry mouth, and ___________ evidence on the effects of acupuncture. a. sufficient; lowb. insufficient; goodc. insufficient; lowd. sufficient; good

20. In the future, by using biomarkers and genetic testing, it may be possible to screen and identify at-risk individuals sooner and to provide earlier intervention. a. Trueb. False

14

www.dentallearning.net/DUW-ceCE ANSWER FORM (E-mail address required for processing)

*Name: Title: Speciality

*Address: NPI No.

*City: *State: *Zip: AGD Identification No.

*E-mail:

*Telephone: License Renewal Date:

Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to jriley@ims.co. COURSE EVALUATION and PARTICIPANT FEEDBACK: We encourage participant feedback pertaining to all courses. Please be sure to complete the evaluation included with the course. INSTRUCTIONS: All questions have only one answer. Participants will receive confirmation of passing by receipt of a verification certificate. Verification certificates will be processed within two weeks after submitting a completed examination. EDUCATIONAL DISCLAIMER: The content in this course is derived from current information and research based evidence. Any opinions of efficacy or perceived value of any products mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of Dental Learning. Completing a single continuing education course does not provide enough information to make the participant an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a CE verification certificate. Dental Learning, LLC is an ADA CERP recognized provider. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Please contact Dental Learning, LLC for current terms of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. Dental Learning, LLC is a California Provider. The California Provider number is RP5062. The cost for courses ranges from $19.00 to $90.00. RECORD KEEPING: Dental Learning, LLC maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of request. Dental Learning, LLC maintains verification records for a minimum of seven years. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Go Green, Go Online to www.dentallearning.net to take this course. © 2016

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES1. Describe classic signs and symptoms of Sjögren syndrome, and its prevalence;2. List and describe changes in salivary flow and composition;3. Review the oral complications of Sjögren syndrome; and,4. Review options for the management of oral complications associated with Sjögren syndrome

If you have any questions, please email Dental Learning at questions@dentallearning.net or call 888-724-5230.

COURSE SUBMISSION: 1. Read the entire course.2. Complete this entire answer sheet in

either pen or pencil.3. Mark only one answer for each question.4. Mail answer form or fax to 732-303-0555. For immediate results:1. Read the entire course.2. Go to www.dentallearning.net/DUW-ce.3. Log in to your account or register to create an

account.4. Complete course and submit for grading to

receive your CE verification certificate.

A score of 70% will earn your credits.

Dental Learning, LLC500 Craig Road, First FloorManalapan, NJ 07726

*If paying by credit card, please note:MasterCard | Visa | AmEx | Discover

*Account Number

______________________________________________

*Expiration Date

______________________________________________

The charge will appear as Dental Learning, LLC.

If paying by check, make check payable to Dental Learning, LLC.

ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED

AGD Code: 730

Price: $29 CE Credits: 2Save time and the environment by taking this course online.

COURSE EVALUATIONPlease evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor.

1. Clarity of objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

2. Usefulness of content . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

3. Benefit to your clinical practice . . . . . . . . . . . . . . . . . . . . 3 2 1

4. Usefulness of the references . . . . . . . . . . . . . . . . . . . . . . 3 2 1

5. Quality of written presentation . . . . . . . . . . . . . . . . . . . . 3 2 1

6. Quality of illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

7. Clarity of quiz questions . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

8. Relevance of quiz questions . . . . . . . . . . . . . . . . . . . . . . 3 2 1

9. Rate your overall satisfaction with this course . . . . . . . . 3 2 1

10. Did this lesson achieve its educational objectives? Yes No

11. Are there any other topics you would like to see presented in the future? __________________________________________________________________________

_______________________________________________________________________________________