Symptom Management for Dry Eyes and Mouth Associated with Sjogren’s Syndrome

By Laura Corrales and Swamy Venuturupalli, MD, F.A.C.R.

Sjogren’s Syndrome (SS) is an autoimmune disease whose cardinal symptoms are dry eyes and mouth. This is because the immune system mistakenly targets the moisture-producing glands of the body, including the tear-producing glands of the eyes and saliva-producing glands of the mouth [1]. However, SS is not limited to the salivary and lacrimal glands, but can affect the entire body.

Most common symptoms reported by patients:

Symptom-Management for Dry Eyes:

The two main causes for dry eyes are a decreased secretion from the tear-producing glands in the eyes and loss of tears due to excess evaporation. Fortunately, some simple modifications in daily activities can help to greatly alleviate symptom severity [2].

• Use of eye-drops that do not contain preservatives, which may increase eye irritation.
• Practice blinking, ideally 5-6 times per minute. This is especially important when looking at a computer screen or reading, as the amount of blinking decreases.
• Protect eyes from drafts, breezes, wind, or smoke.
• Utilize humidifiers in rooms where the majority of time is spent, including the bedroom.
• Limit eye makeup to the lid, do not place on the sensitive skin below the lashes.

If over-the-counter remedies do not improve symptom severity, additional treatment options are available. These are usually prescribed by physicians:

• Punctual occlusions, or small plugs. They are inserted into the small opening of the eyelid through a minor office procedure where tears normally drain away to help retain moisture for the eye [3].
• Cyclosporine ophthalmic emulsion (Restasis®) is a prescription that works to suppress eye irritation that may disrupt tear production [4].
• Hydroxylpropyl cellulose (Lacrisert®) is an eye insert that dissolves throughout the day, which promotes continual moisture and protects against eye irritation [5].

In case these measures do not work, we suggest seeing an ophthalmologist who specializes in treating dry eyes to try other techniques for treating dry eye.

Symptom-Management for Dry Mouth:

The feeling of dry mouth occurs because there is no moisture (provided by your saliva) to permit easy movement of the tongue, lips and cheeks over the teeth and roof of the mouth. This results in speaking, swallowing, and even the breakdown of food, becoming more difficult. As saliva is the natural lubricant and antimicrobial defense of the mouth, decreased production may result in increased risk of cavities and oral infection [6].

For individuals who can produce saliva, albeit in smaller quantity, some simple modifications may help to alleviate some of the symptoms.

• Use of oil-based lip-balm may help sooth dry or cracked lips.
• Mouth soreness can be alleviated by mouth rinse, ointment or gel that can be applied to the sore areas of the mouth.
• Consumption of sugar-free and carbonated-free water with a small amount of oil, especially before speaking and eating, may be beneficial.
• Sugar-free candy or gum may help to stimulate saliva production.
• Saliva substitutes may help provide a feeling of wetness in the mouth.

If at-home-remedies do not alleviate symptoms, two prescription drugs are available for saliva stimulation (Pilocarpine® and Cevimeline®). Both stimulate saliva production, but their effect is temporary. More importantly, they may not protect against oral infection, as pharmacological stimulation increases the amount, but not the protein content of saliva, which is necessary for digestion and antimicrobial benefit [7, 8].

The Importance of Dental Hygiene for Dry Mouth:

Individuals that have low or no saliva production should be highly vigilant of what they consume, as they are at an increased risk for cavity development [9, 10]. Here are some suggestions that may help in cavity prevention.

• Use of fluoride-based toothpaste.
• Brushing twice, daily, especially before sleep is critical for plaque removal.
• Patients should limit or completely remove the intake of sugar. Excess sugar is not only bad for teeth, but overall health, and may not help symptom management for SS.

Conclusion:

We hope this provides you with some relatively easy modifications that may be beneficial in overall symptom management and quality of life. Please remember, these are general suggestions, you will need to try different combinations and approaches that best suit your symptom management, and as always, seek physician guidance when symptom relief is not improved or worsens. Additionally, all patients with Sjogren’s should be under the care of a rheumatologist to make sure that they do not develop autoimmune problems involving the internal organs (extra-glandular manifestations of Sjogren’s).

References:

1. Tzioufas, A.G. and H.M. Moutsopoulos, Sjögren’s syndrome, in European Handbook of Dermatological Treatments. 2015, Springer. p. 883-889.
2. Hessen, M., S. Karakus, and E.K. Akpek, Management of Dry Eye in Sjögren’s Syndrome. Current Treatment Options in Rheumatology, 2015. 1(3): p. 292-304.
3. Goto, E., et al., Improved functional visual acuity after punctal occlusion in dry eye patients. American journal of ophthalmology, 2003. 135(5): p. 704-705.
4. Sall, K., et al., Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. Ophthalmology, 2000. 107(4): p. 631-639.
5. Wander, A.H. and B.H. Koffler, Extending the duration of tear film protection in dry eye syndrome: review and retrospective case series study of the hydroxypropyl cellulose ophthalmic insert. The ocular surface, 2009. 7(3): p. 154-162.
6. Wu, A.J., Management of Salivary Hypofunction in Sjögren’s Syndrome. Current Treatment Options in Rheumatology, 2015. 1(3): p. 255-268.
7. Zero, D., et al. Sjogren’s Syndrome Foundation (SSF) Clinical Practice Guidelines for Oral Disease Management: Caries Prevention. in SCANDINAVIAN JOURNAL OF IMMUNOLOGY. 2015. WILEY-BLACKWELL 111 RIVER ST, HOBOKEN 07030-5774, NJ USA.
8. von Bültzingslöwen, I., et al., Salivary dysfunction associated with systemic diseases: systematic review and clinical management recommendations. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 2007. 103: p. S57. e1-S57. e15.
9. Soto-Rojas, A.E. and A. Kraus, The oral side of Sjögren syndrome. Diagnosis and treatment. A review. Archives of medical research, 2002. 33(2): p. 95-106.
10. Al-Hashimi, I., The management of Sjoögren’s syndrome in dental practice. The Journal of the American Dental Association, 2001. 132(10): p. 1409-1417.