Gougerot-Sjögren syndrome (SGS) is an immune disease primarily affecting the exocrine glands . Due to lymphocytic infiltration of the salivary or lacrimal glands , or even sometimes both; the main clinical manifestations are salivary and / or ocular dryness . The dentist is generally called upon for complications as well as oral discomfort caused by quantitative and qualitative instabilities in saliva. In particular, it plays an important role in the discovery and early diagnosis of this disease. It can prevent complications by educating patients about oral hygiene , as well as by monitoring the course of the pathology.
A little history
The first description of the syndrome thus came to us from the Polish surgeon Mikulicz Radecki , who in 1892 described a subject presenting bilateral swelling of the parotid glands and lacrimal glands with a mononuclear infiltrate . Gougerot individualized this syndrome in 1925, which included all mucous dryness. He attributed it to atrophy of the glands. It was in 1933 that the Swedish ophthalmologist Henrik Sjögren described clinical and histological manifestations found in 19 women suffering from dry mouth and eyes. Sjögren uses the term keratoconjunctivitis sicca to define eye damage and distinguish it from dry eyes caused by vitamin A deficiency.
What is Gougerot-Sjögren disease?
It is a syndrome known as an autoimmune disease characterized by a progressive degeneration of the exocrine glands , which has the effect of causing dryness of the mucous membranes as well as the conjunctiva. Histologically, the syndrome is characterized by lymphoid infiltration of the exocrine glands, in particular the salivary and lacrimal glands, as well as the biological production of large amounts of autoantibodies (FAN, anti-SSA, anti-SSB, rheumatoid factor). If the disease seems isolated, it is a primary SGS , on the other hand, if there are associated autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus, etc.), then it is called secondary SGS .
The prevalence of primary SMS is estimated between 0.1 and 0.6% according to the American-European consensus standard. The disease generally affects mostly women (90%) between 30 and 40 years old.
How do you develop this disease?
This pathology generally occurs in subjects with a genetic autoimmune predisposition characterized by a high prevalence of HLA B8 and DR3 haplotypes. In this specific area, damage to the epithelial cells of the exocrine glands , as secondary to a viral infection , will induce the development of chronic inflammation , which is characterized by the infiltration of lymphocytes composed of T lymphocytes and B lymphocytes, as well as the formation of germinal centers. This inflammation will be self-sustaining and will cause the gland to malfunction , and subsequently, its destruction.
What are the mechanisms at the origin of dryness of the mucous membranes?
Destruction of the glands alone cannot shed light on this dysfunction. At the onset of the disease, lymphocytic infiltration is focal and some glands are still intact . In addition, no correlation is established between lymphocyte infiltration and changes in salivary flow. However, the remaining glands may malfunction, causing discomfort; this failure would be due to abnormalities of the autonomic nervous systemhaving, among other things, the control of tear and salivary secretion. As the autonomic nervous system does not do its job properly, this deficiency could in fact be linked to auto-antibodies turning against the muscarinic M3 receptors (which have the role of controlling the water secretion of the lacrimal and salivary glands via the membrane expression of aquaporin 5, which also appears to be defective in the case of SGS).
Ultimately, the dryness would be due to glandular destruction , but also to a deficit of the autonomic nervous system as well as a defect in the membrane expression of aquaporin 5 . These pathophysiological data open up interesting prospects for the treatment of SGS.
What are the symptoms of Gougerot-Sjögren disease?
Symptoms are dominated by ocular and oral involvement due to their frequency; it is found in 90% of SMS. The patient complains of difficulty in swallowing , a lack of stability of his removable dentures , the appearance of caries , chronic burns of the oral mucosa , an intolerance to spicy or acidic foods , an inability to eat dry food or to talk continuously for a few minutes .
The onset of symptoms is insidious and the progression is slow. The oral mucosa becomes dull, sticky and fragile . The tongue is red, striped, cracked, and the lake of saliva usually present on the floor of the mouth is often nonexistent.
The Candida infection is very common result in the SMS; it could affect 70% of patients and occurs in different forms: acute pseudomembranous candidiasis (thrush), erythematous candidiasis , angular cheilitis (perlèche), sub-prosthetic stomatitis , etc.
Some naturopathic advice to reduce the symptoms of Gougerot-Sjögren’s autoimmune disease?
Flee from mucosal drying environments:
Learn to recognize and avoid places with low humidity (stores and offices with air conditioning), exposure to wind , dusty places , irritants and cigarette smoke .
Take care of your oral hygiene:
Oral hygiene must be rigorous and regular!
- Brush your teeth after each meal with a soft surgical toothbrush and fluoridated toothpaste.
- Choose a non-aggressive mouthwash (bicarbonate water).
- Use dental jets as well as periodontal wires for cleaning interdental spaces.
- Systematically clean and brush the removable prostheses which will be placed each night in an antiseptic solution.
The role of water:
The replacement of the missing secretion can be obtained easily by frequently drinking sips of water. This does not necessarily have to be swallowed, it can only be used for rinsing. However, water does not adequately moisten and lubricate the oral mucosa and teeth.
Stimulate your salivary secretion:
When the residual salivary secretion is high enough, chewing sugarless chewing gum is a good stimulus. If it is insufficient, the chewing gum sticks to the teeth. Sucking on dried fruits like peaches and nectarines can also stimulate salivary secretion .
Are there any natural treatments to stimulate the exocrine glands?
Treatment is tailored to the severity of the symptoms. The clinical picture is very variable ranging from an asymptomatic state to a very severe form. Most patients with SGS only require topical treatment for sicca syndrome. In general, drugs that can worsen sicca syndrome should be avoided (retinoids, beta blockers, antihistamines, etc.). The main goal of treatment is to improve patient comfort .
There are several artificial saliva that contain methylcellulose; some contain animal mucin to decrease viscosity. They are presented in different galenic forms (liquid, lozenge or chewing gum). There are also other saliva substitutes such as polyethylene oxide or polysaccharide extracts from flax seeds .
The first appears to be more effective than methylcellulose in reducing the symptoms of xerostomia, the second gives satisfactory results in about 75% of patients. Polyacrylic acid and xanthan gum (“xanthan gum”) products have been developed and evaluated in patients with SGS. This latest study has shown that there are subgroups of patients in whom a particular form of substitute is more clinically effective . Highly mucoadhesive polymers such as polyacrylic acid are recommended for patients with extremely poor saliva flow.
On the other hand, patients who still have a moderate salivary flow have more improvement with the substitutes having moderate mucous adhesion and good elastic properties (xanthan gum). Indeed, these polymers improve the physicochemical properties of the residual saliva , which leads to an increase in humidification and lubrication. Residual salivary secretion is stimulated by non-specific mechanical stimuli or taste. Citric acid, for example, causes taste stimulation while chewing gum uses both modalities.
The pilocarpine naturally contained in Jaborandi officinal is a muscarinic receptor gonist with cholinergic action. Its mechanism of action is to increase salivary secretion, and to a lesser extent tear secretion .
Replacement eye drops:
The treatment of dry eye syndrome mainly involves eye drops like artificial tears.
Medical bibliographic sources and clinical trials :
- Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Gougerot-Sjögren syndrome. Arch Intern Med 2004
- Mariette X. Pathophysiology of Gougerot-Sjögren syndrome. Ann Med Intern 2003
- Moutsopoulos HM. Sjogren’s syndrome: autoimmune epithelitis. Clin Immunol Immunopathol 1994
- Fox RI. Sjogren’s syndrome. Lancet 2005
- Steinfeld S, Cogan E, King LS, Agre P, Kiss R, Delporte C. Abnormal distribution of aquaporin-5 water channel protein in salivary glands from Sjogren’s syndrome patients. Lab Invest 2001
- Gentric-Tilly A. Syndrome de Gougerot-Sjögren du sujet âgé. Ann Med Interne 2002
- Korsten MA, Rosman AS, Fishbein S, Shlein RD, Goldberg HE, Biener A. Chronic xerostomia increases esophageal acid exposure and is associated with esophageal injury. Am J Med 1991
- Vissink A, De Jong HP, Busscher HJ, Arends J, Gravenmade EJ. Wetting properties of human saliva and saliva substitutes. J Dent Res 1986
- Johansson G, Andersson G, Attstrom R, Glantz PO, Larsson K. The effect of Salinum on the symptoms of dry mouth: a pilot study. Gerodontology 1994
- Van der Reijden WA, van der Kwaak H, Vissink A, Veerman EC, Amerongen AV. Treatment of xerostomia with polymer-based saliva substitutes in patients with Gougerot-Sjögren syndrome. Arthritis Rheum 1996