Saliva is one of those things in life that patients don’t really appreciate until it is gone. Without saliva, they couldn’t eat a cracker without having to drink something. Food would not taste as good because substances need to be solubilized to be delivered to their taste buds, and their teeth would constantly rub against their tongue and cheeks, causing painful ulcers. Without saliva, patients would not even be able to carry on a conversation without coughing or worrying that everyone could see their lips get caught up on their teeth or see the goop accumulate in the corners of their mouth.
Personal Impact on Patients
When most practitioners hear that a patient has a dry mouth, their immediate response is that it’s no big deal and the patient should just drink some water. But I will never forget the conversation I had with one of my patients while I was working at the Sjögren’s Syndrome Clinic at the National Institute of Dental and Craniofacial Research.
He was a 49-year old basketball coach, and part of his job was to run up and down the court yelling out plays and instructions to his team. His mouth was so dry due to his lack of ability to produce saliva because of his Sjögren’s, he was unable to perform the duties of a job he loved and had to retire early.
I’ve had countless Sjögren’s patients tell me that they don’t even feel like socializing anymore because they are so self-conscious about how their speech has changed due to their dryness, their tongue feels so large that friends have noticed they now talk with a lisp, and some are embarrassed because they constantly get lipstick stuck to their teeth.
Those are just examples of quality of life issues that go along with the dry mouth aspect of Sjögren’s. The effect of Sjögren’s also can be felt in the patient’s pocketbook. A study by Segal et al showed that dental expenses were 3 times higher in Sjögren’s patients compared with controls.1
Your Role as a Practitioner
These dental issues not only are frustrating to these patients, they can be frustrating to the dental provider as well. How often have you placed beautiful fillings in patients with dry mouth only to have them come back in about 18 months with recurrent decay?
So you then get these patients on topical fluoride, and they still come back months later with either recurrent decay, even though they are using the topical fluoride, or open margins because the fluoride itself is corroding the margins of glass ionomer restorations. Not only that, but now you’re developing back pains as you contort your body to try to drill out the cervical caries that is now wrapping around the entire neck of tooth No. 7.
And then there’s the second guessing:
“Should I use a glass ionomer or regular composite?”
“Should I place an amalgam, or would a crown be better?”
“Maybe I should just extract this tooth and place an implant. But what are the issues with placing an implant in a patient with an autoimmune disease?”
Until 2016, no standard of care existed for the management of Sjögren’s. The Sjögren’s Syndrome Foundation (SSF), with the assistance of hundreds of dentists, developed and published clinical practice guidelines to standardize patient care and give dentists and other oral care professionals a roadmap of how to treat and manage their Sjögren’s patients.2
I’ve also encouraged some of my medication-induced xerostomic patients to become members of the SSF so they could get a copy of the group’s Product Directory to help them find masticatory, gustatory, or even coating agents to help relieve their symptoms.
As far as salivary stimulants go, we dentists still only have 2 agents at our disposal: pilocarpine and cevimiline. But during the past decade or so, there has been tremendous interest in biologic agents to treat the systemic components of Sjögren’s, and there is hope that it may impact on salivary function as well.3
Dry mouth is a common early symptom of Sjögren’s, and dentists are often on the frontline of diagnosis and play an important role in symptom and dental disease management. Dentists also play a key role in identifying when a patient with dry mouth is actually dealing with an overlying systemic disorder.
For example, a patient with dry mouth with a high caries rate who also experiences dry eyes, joint pain, and fatigue could fit the profile of a Sjögren’s patient. Dentists can then make an appropriate referral, typically to an oral medicine specialist or rheumatologist, who could help to get that patient diagnosed and treated sooner and more effectively.
References
- Segal B, Bowman SJ, Fox PC, et al. Primary Sjögren’s syndrome: health experiences and predictors of health quality among patients in the United States. Health Qual Life Outcomes. 2009;7:46.
- Sjögren’s Syndrome Foundation. Sjögren’s Syndrome Foundation’s clinical practice guidelines. Oral management: caries prevention in Sjögren’s patients. https://www.sjogrens.org/files/research/OralCPG.pdf. Accessed March 27, 2017.
- Carsons SE, Vivino FB, Parke A, et al. Treatment guidelines for rheumatologic manifestations of Sjögren’s syndrome: use of biologic agents, management of fatigue, and inflammatory musculoskeletal pain. Arthritis Care Res (Hoboken). 2016 Jul 7. [Epub ahead of print]
Dr. Sankar specializes in oral medicine and is currently the director of the Oral Medicine Clinic at Brigham and Women’s Hospital (BWH), an attending in the Oral Medicine Residency program at BWH/Harvard School of Dental Medicine, and an attending at Dana Farber Cancer Institute in Boston. She received her master’s degree in clinical research from Duke University and is board certified by the American Board of Oral Medicine. In addition to having been a member of the American Academy of Oral Medicine for 20 years, she currently serves as secretary for the academy. And, she holds a Fellowship in dental surgery from the Royal College of Surgeons of Edinburgh.
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