Sjogren's Disease Flashcards
What is the definition of a dry mouth?
Decreases flow of saliva caused by failure of the salivary glands to function as normal
Name some functions of saliva
- Bolus formation
- Remineralisation of tooth tissue
- Lubrication
- Buffering capacity
- Taste aid
- Digestion: lysozyme, calprotectin
Are salivary glands under somatic or autonomic control?
- Autonomic control
What does the parasympathetic and sympathetic function control?
- Parasympathetic = secretory control
- Sympathetic = protein secretion
When medications are taken to increase salivary secretions, do they target the sympathetic or parasympathetic system?
Parasympathetic
What is the normal resting and feeding flow rate for saliva?
RESTING: 0.35ml/min
FEEDING: 2ml/min
What are some subjective (false) and objective (true) causes of xerostomia?
Subjective:
- Mouth breathing
- Psychological
- Night dryness
Objective:
- Medications
- Anxiety
- Dehydration
- Conditions causing dehydration: diabetes mellitus, cardiac and renal failure, diuretic drugs, hypovolemic shock
- Gland / nerve damage
- Sjorgens syndrome
- Irradiations and cytotoxic drugs
- Neurological damage
If drugs cause xerostomia, what may they act on?
- Directly on the glands
- Sympathetic nerves and ganglia
- Parasympathetic nerves and ganglia
- Via dehydration
Name some drugs that cause xerostomia
- Anti-Parkinson drugs
- Tricyclic depressants
- Antihistamines
- Decongestants
- Benzodiazepine
Name some clinical features of xerostomia
- Mirror or fingers sticking to mucosa
- Sticky, stringy or frothy saliva with no pooling
- Difficulty swallowing and speaking
- General oral discomfort
- Reduced denture retention
- Indirect effects: bad taste, increased caries, candidiasis, toothwear, lobulation of dorsum of tongue
What are some other history questions that should be considered with xerostomia?
- Prolonged unremitting dryness
- Abnormal taste
- Does the patient smoke?
- Drug history or history of radiotherapy
- Does the patient mouth breathing?
- Are their eyes affected?
- History of current autoimmune disease
What is the name of the clinical dryness scale and what is a severe score?
Challacombe scale
>7 is severe
What are some special investigations needed for Sjorgrens disease?
1) Salivary flow rate (10 mins)
2) Saliva sample for candida
3) Urine glucose and osmolarity
4) Serology for auto-antibodies
5) Ultrasound
6) Biopsy (of lower lip to assess salivary glands)
What is the definition of Sjorgrens syndrome and how is most commonly affected?
- Autoimmune disease which may affect all exocrine glands
- A syndrome of dry eyes and dry mouth with or without connective tissue disorder
- Can present as primary or secondary Sjorgrens
- Commoner in female
What are some features of Sjogrens syndrome?
- Failure of lacrimal secretion
- Drying of anterior conjunctiva
- Dry gritty eyes
- Burning soreness
- Cannot cry
Oral symptoms: mirror or fingers stick to mucosa, sticky&stringy saliva, discomfort swallowing and speaking, generalised oral discomfort, reduced denture retention, indirect: increased caries, candidiasis, toothwear, lobulated dorsum of tongue
Gland Swelling: parotid gland swelling in 10% of patients
What other conditions can sjorgrens present from?
- Rheumatoid arthritis
- SLE
- Polyarteritis nodosa
- Polymyositis
- Autoimmune endocrine disorders: diabetes, thyroiditis
- Scleroderma
- Autoimmune hepatitis, primary biliary cirrhosis
What are some extra-glandular features of Sjorgrens syndrome?
- Excessive fatigue
- Peripheral neuropathy
- Lymphopenia, thrombocytopenia
- Raynauds
- CNS involvement: memory loss or confusion
- Renal involvement
- Pulmonary fibrosis
What are the 6 criteria for Sjorgrens disease?
o Autoantibody – anti Ro, anti LA, ANA, FR
o Positive minor gland biopsy
o Ocular symptoms >3 months, gravel/gritty eyes, eye drops
o Oral symptoms >3 months +- gland swelling, frequent water needed
o Ocular signs – Schirmer 1 <5mm/5 mins, rose Bengal
o Salivary gland involvement – reduced flow, scintigraphy
What is the aetiology of Sjorgrens?
Autoimmune disease.
Glands get infiltrated with activated B cells.
Lymphocytes collect around the ducts and destroy acinar cells.
Raised ESR and gamma-globulin.
- Influence from virus, hormonal and genetic factors leading to activation of auto-antibodies
What are some tests for Sjorgrens disease?
Parotid flow rates.
Minor gland biopsy
Imaging glands
Blood tests
Immunoglobulin levels
Autoantibody screen
Lacrimal flow
What changes do i see on biopsy in sjogren’s syndrome?
1) Periductal lymphocytic infiltrates
2) Expansion of lymphocytic infiltrates
3) Atrophy of salivary acini
4) Ductal hyperplasia forming epimyo-epithelial islands
5) Formation of lymphoepithelial lesion (lymphocytes infiltrating into ducts)
How is MALT lymphoma linked to Sjorgrens?
- B cell proliferation predisposes development of lymphoma
- Greater risk in primary Sjogrens
- Suspect in all cases with swollen glands
Risks factors: parotid enlargement/splenomegaly, low CD4+ lymphocyte count, hypergammaglobulinemia
What is SOX syndrome?
- Sialadenitis
- Osteoarthritis
- Xerostomia
What are the main aims of treatment for Sjorgrens?
- Relief of symptoms dryness, glossodynia (burning pain of tongue)
- Salivary stimulation or replacement therapy to keep mouth moist
- Restoration of function (speech, swallowing)
- Preservation of anatomical form & structures (filiform papillae - taste)
- Dental tissues requiring repair / cosmetic improvement
- Prevention of further dental disease
- Screen for MALT lymphoma
- Management of extra glandular disease
- Manage fatigue
- Manage inflammatory arthritis
- Manage other problems (Raynaud’s,vasculitis etc)
