Sjogren's Syndrome Support Group
Sjogren's syndrome is an autoimmune disorder in which immune cells attack and destroy the exocrine glands that produce tears and saliva. It also associated with rheumatic disorders such as rheumatoid arthritis, and it is rheumatoid factor positive in 90 percent of cases.
A human being normally produces approximately 1.5 liters of saliva per day. There is a typical diurnal circadian
rhythm in the production of that saliva with one peak in the mid-morning followed by a relative decrease until
the second peak occurs around early evening. Saliva flow normally is decreased at night. Saliva is produced
by several glands: the submandibular glands (which lie bilaterally just under the posterior jaw) produce most of
the quantity of saliva (45%) and it is a mixed fluid with both mucous (thick, stringy fluid) and water but containing
most of the proteins; the paired parotid glands (which are in the mid-face just in front of the ears) produce
primarily serous (or watery) fluid and accounts for about 35% of the total quantity; the sublingual glands (again in a pair just beneath the anterior tongue) are much smaller and contribute
only about 10% of the total volume; and finally there are hundreds of
small minor salivary glands in the lips, palate and throat which contribute
a relatively small, but important portion of natural salivary flow.
The normal quantity of saliva naturally provides necessary oral lubrication
and moisture to assure comfort and function for the individual, but saliva does
much more than that. At least equally as important as this volume of saliva, if
not more so, is the composition of saliva, which is rich in constituents which
have potent digestive, coating, protective, antimicrobial, antiacid, lubricative
and homeostatic properties. Saliva is much more than water. In fact, saliva contains
approximately 60 important, protective constituents including: immunoglobulins,
electrolytes, buffers, antimicrobial enzymes, digestive enzymes and
many others, all of which make saliva an essential contributor to the health and
homeostasis of the oral cavity. This is the reason that water or artificial salivas
are a poor substitute; none of them have the rich composition of ones own
natural saliva. In attempting to effectively manage Sjgrens, most clinicians
will prescribe secretogogues (salivary stimulating drugs) in order to facilitate
the production of natural saliva with all of its beneficial constituents from the
salivary glands.
Obviously, when saliva is diminished in quantity and altered in composition,
as in Sjgrens, deterioration of the oral soft and mineralized tissues will
most certainly occur. This is especially significant over time. A major (defining)
characteristic of Sjgrens is progressive inflammation of the salivary glands
accompanied by decreased salivary flow (hyposalivation). Often, since Sjgrens
is an insidious condition which gradually progresses over time, the affected
person may not realize the diminishment of saliva until it reaches a critical
point, typically below 50%.
When a person has less than 50% of normal saliva in both quantity and
composition, many deleterious complications occur in the oral cavity. With
this hyposalivation, the patient can suffer acute as well as long term problems
including: glossitis (inflamed tongue), glossodynia (burning tongue), mucositis
(inflamed oral tissues, including the throat), parotid (or other salivary) gland
hypertrophy (swelling) - which may be periodic and short-term or long term (in
which case close monitoring is needed due to the potential to develop lymphoma),
angular cheilosis (sores and cracking at the corners of the lips), dysgeusia
(taste dysfunction ) secondary infections (such as Candidiasis or thrush) and a
significantly increased dental caries rate. (nearly 100 times that of normal!)
Patients with Sjgrens and hyposalivation also demonstrate increased levels of dysphagia (swallowing problems) as compared to normal.
Studies have shown that patients with Sjgrens have difficulty
tasting, tolerating and swallowing certain foods. Of
course this may result in digestive and nutritional intake
inadequacies.
Among its many beneficial constituents, saliva has been
shown to be rich in antimicrobial proteins which have potent
antifungal and antibacterial properties, thus it plays
an important role in host defense and protection from
yeasts such as Candida (yeast) species. Therefore with the
reduction in salivary flow in Sjgrens, Candida infections
become very common.
A few recent studies have also indicated that patients
with Sjgrens exhibit more periodontal (gum) disease,
especially clinical attachment loss. Page 1 :-)
rhythm in the production of that saliva with one peak in the mid-morning followed by a relative decrease until
the second peak occurs around early evening. Saliva flow normally is decreased at night. Saliva is produced
by several glands: the submandibular glands (which lie bilaterally just under the posterior jaw) produce most of
the quantity of saliva (45%) and it is a mixed fluid with both mucous (thick, stringy fluid) and water but containing
most of the proteins; the paired parotid glands (which are in the mid-face just in front of the ears) produce
primarily serous (or watery) fluid and accounts for about 35% of the total quantity; the sublingual glands (again in a pair just beneath the anterior tongue) are much smaller and contribute
only about 10% of the total volume; and finally there are hundreds of
small minor salivary glands in the lips, palate and throat which contribute
a relatively small, but important portion of natural salivary flow.
The normal quantity of saliva naturally provides necessary oral lubrication
and moisture to assure comfort and function for the individual, but saliva does
much more than that. At least equally as important as this volume of saliva, if
not more so, is the composition of saliva, which is rich in constituents which
have potent digestive, coating, protective, antimicrobial, antiacid, lubricative
and homeostatic properties. Saliva is much more than water. In fact, saliva contains
approximately 60 important, protective constituents including: immunoglobulins,
electrolytes, buffers, antimicrobial enzymes, digestive enzymes and
many others, all of which make saliva an essential contributor to the health and
homeostasis of the oral cavity. This is the reason that water or artificial salivas
are a poor substitute; none of them have the rich composition of ones own
natural saliva. In attempting to effectively manage Sjgrens, most clinicians
will prescribe secretogogues (salivary stimulating drugs) in order to facilitate
the production of natural saliva with all of its beneficial constituents from the
salivary glands.
Obviously, when saliva is diminished in quantity and altered in composition,
as in Sjgrens, deterioration of the oral soft and mineralized tissues will
most certainly occur. This is especially significant over time. A major (defining)
characteristic of Sjgrens is progressive inflammation of the salivary glands
accompanied by decreased salivary flow (hyposalivation). Often, since Sjgrens
is an insidious condition which gradually progresses over time, the affected
person may not realize the diminishment of saliva until it reaches a critical
point, typically below 50%.
When a person has less than 50% of normal saliva in both quantity and
composition, many deleterious complications occur in the oral cavity. With
this hyposalivation, the patient can suffer acute as well as long term problems
including: glossitis (inflamed tongue), glossodynia (burning tongue), mucositis
(inflamed oral tissues, including the throat), parotid (or other salivary) gland
hypertrophy (swelling) - which may be periodic and short-term or long term (in
which case close monitoring is needed due to the potential to develop lymphoma),
angular cheilosis (sores and cracking at the corners of the lips), dysgeusia
(taste dysfunction ) secondary infections (such as Candidiasis or thrush) and a
significantly increased dental caries rate. (nearly 100 times that of normal!)
Patients with Sjgrens and hyposalivation also demonstrate increased levels of dysphagia (swallowing problems) as compared to normal.
Studies have shown that patients with Sjgrens have difficulty
tasting, tolerating and swallowing certain foods. Of
course this may result in digestive and nutritional intake
inadequacies.
Among its many beneficial constituents, saliva has been
shown to be rich in antimicrobial proteins which have potent
antifungal and antibacterial properties, thus it plays
an important role in host defense and protection from
yeasts such as Candida (yeast) species. Therefore with the
reduction in salivary flow in Sjgrens, Candida infections
become very common.
A few recent studies have also indicated that patients
with Sjgrens exhibit more periodontal (gum) disease,
especially clinical attachment loss. Page 1 :-)
It is very important for the patient with hyposalivation
to seek and obtain a diagnosis. There are several
conditions besides Sjgrens which can cause hyposalivation.
The precise diagnostic criteria for Sjgrens remain
controversial, although there are specific laboratory tests
available for the major diagnostic categories of salivary
and tear production, histopathologic changes and serological
inflammatory markers. In the Sjgrens clinic at
the University of Minnesota, and many other clinics, the
modified European criteria (2002) are used. Minor salivary gland histopathology
Labial salivary gland histopathology has almost universally
been accepted as the prima facia diagnostic indicator
for definitive diagnosis of Sjgrens. Recent data confirm
this test, although the timing of obtaining the biopsy is
important, so as not to perform the biopsy too early in the
process. The classic histopathology of the minor salivary
glands in Sjgrens is a lymphocytic infiltration which includes
benign lymphosialadenopthy [focal lymphocytic sialadenitis
or BLEL (benign lymphoepithelial lesion) in the
major salivary glands]. The benign lymphosialadenopthy
may manifest as parotid hypertrophy (swelling), particularly
in patients with primary Sjgrens. Small clusters of
intralobular ducts enlarge to eventually replace the acinar
epithelial parenchyma. The lesion is comprised of primarily
CD-4+ T-cell lymphocytes along with late acquisition
of polyclonal B-cells and plasma cells. In the lymphocytic
foci approximately 75% are T-cells with 5-10% B-cells. As the inflammatory process progresses over time, fibrosis
and atrophy of the salivary glands occur and hyposalivation
progresses. Progression to lymphoma is a possibility
in Sjgrens, and although quite rare (only 1-3 % of all
Sjgrens patients) does require continuous monitoring.Sialometry
Sialometry (measurement of salivary secretion function)
is useful both as an initial screening tool for hyposalivation
associated with Sjgrens as well as to assess the
level of severity of Sjgrens. Salivary flow collection must
be performed precisely according to the type of gland and
over a period of at least five minutes (often up to fifteen
minutes) in order to be valuable as a diagnostic technique.
Whole, unstimulated salivary flow rates typically tend
to be very low in Sjgrens patients (0- 0.2 ml/min.) as
compared to normal unstimulated whole salivary flow rates
(0.5-1.2 ml/min.). Stimulated whole saliva (by chewing
paraffin) will of course be higher (0.05-0.4 ml/min) but still
substantially lower than normal salivary flow (1.0-2.0 ml/
min.) The parotid glands appear to be affected more than
other glands by the chronic inflammatory process with
Sjgrens. Minor (usually labial) salivary glands may also be
used (unstimulated or stimulated) to collect and quantify
saliva in order to assess salivary dysfunction as well as the
efficacy of therapy. Imaging
Radiographic findings may appear in advanced stages of
fibrosis of the salivary glands. Sialograms are performed
by injecting a radiocontrast dye into the salivary ductal
system prior to conventional radiography. Sialograms may
reveal punctate radiopaque calcifications, or if more advanced,
there are larger, lobular calcifications. Sialectasis in
portions of the ductal system may occur or appear dilated
or may appear with areas of absent acinar parenchyma.
Sialography has been shown to be much more accurate
in demonstrating the level of salivary gland destruction in
Sjgrens. There is some concern both over the invasiveness
and untoward side-effects of sialography as well as its
unreliability as related to histopathology. Scintigraphy
Salivary scintigraphy with 99m Tc (sodium pertechnetate,
a radioisotope of technetium) can be performed to
assess the function of the salivary glands by measuring the
rate and density of technetium uptake. The radioactive sodium pertechnetate is quantified in the major salivary
glands one hour after it has been intravenously injected.
This technique is very accurate in assessment of the severity
of salivary gland pathology as the quantity of 99m Tc
uptake in the glands or likewise in the saliva is proportionally
reduced.
Sialochemistry (measurement of the constituents of
saliva) may provide some interesting insight into the
prognosis and progression of oral disease because of the
alterations in the protective constituents in the saliva of the
patient with Sjgrens. While the chemistry of saliva does
reveal a somewhat characteristic profile for Sjgrens, at the
present time sialochemistry is not considered diagnostic.
Typically in Sjgrens there is an increase in secretory Ig-A,
lactoferrin, total protein and sodium and chloride ions,
with decreases in lysozyme, potassium and phosphate ions.
However these constituents vary between parotid and sub- mandibular glandular fluid and whole saliva and whether
the saliva is unstimulated or stimulated. Future research
may improve the sensitivity and specificity for sialochemistry
as a diagnostic and prognostic tool for Sjgrens. nterpretation of diagnostic tests
As with many rheumatic disorders, Sjgrens may be
insidiously progressive and may require many years to
fully manifest as detected by the various laboratory tests.
Subtle changes in serological values (i.e., ESR, ANA, etc.)
may precede overt diagnostic levels by several years. On
the other hand patients may exhibit symptoms of dry eyes
or dry mouth without the presence of definitive diagnostic
markers. Consequently, these patients should not
automatically be ruled-out as Sjgrens, but rather followed
at periodic intervals with laboratory tests in order
to determine changes in their status over time. In any case,
patients with signs and symptoms of Sjgrens should be
managed accordingly.
In fact the swelling has gone down not sure if it's plaquenil or my diet. I had TMJ bad so maybe my jaw was swollen so hard to know when ten things go wrong at once.
This is a really long article and it was just released this week to the public. I found it extremely informative. This is the latest up to date information even for your own doctor.
I have a few questions though.
1. What is the difference between inflamed tongue and burning tongue?
2. Does that mean our saliva helps us digest our food and maybe the lack of it has something to do with my digestive problems?
3. My tongue hurts real bad whenever I eat ice cream. Does yours do that? It hurts so much I don't even eat ice cream anymore.
4. My tongue hurts when I suck on some kinds of mints. Does yours do that?
Lace:)
YES your stomach issues are directly related to poor saliva flow. It talks about it there. I use probiotics for that.
Honestly I don't eat ice cream I cannot remember the last time. But ice doesn't hurt my tongue. I get lactose intolerant at times so dairy is minimal. I used to run a gym/fitness director and my diet has always been fairly good.
I did go off the rails a few times but not for long.
Some people have no saliva at all and they probably have more tongue and mouth sores. Mine is really low but the mouth spray has enzymes in it.
Next time you see your rheumy bring a list of questions. I do that every time he obliges he actually loves to answer them. He is an indian doctor so I have him slow it down so I can understand him. He is a super nice guy. He laughs.
I guess the question is CAN your doctor answer them. Some hedge and haw and you know right away they simply don't know.
Saliva imo is the single biggest issue we can have with digestion and dental caries. 100 times more likely to have dental issues.
People need to protect themselves with whatever evoxac or mouth sprays or any of the saliva drugs.
Gonna order some and see how it is compared to the others I've tried. Some nice flavors too.