hello I'm Michael Girk, editor of the journal of the
american dental association with me here today i got Dr. Zero from indiana university
who's going to talk about an upcoming article in the april issue of jada Dr. Zero
welcome thank you very much and i want to thank you and the Journal the American
Dental Association for this opportunity to represent my co-authors on the
article as well as to thank the sjogren's syndrome foundation for
supporting this guidelines development process so this article is about the
clinical practice guidelines for or on management's of patients with sjögren
disease and I have asked Dr. zero to come here today to elaborate and give us
some more insights about the disease as well as the management of these patients
so let's start with Sharon is an autoimmune connective tissue disorder
are they on the other disorders so we should be concerned about yes there are
a number of other orders disorders that are a similar disease padded and they
would include lupus scleroderma and probably the may be the number one
disease which would be rheumatoid arthritis these kontek these connective
tissue diseases involved with immune response directed specifically at
connective tissue which are structural components that hold the cells together
so obviously you being in a carry ology carry ologist you are concerned about
reduced salivary flow and the risk of developing carries in patients sjogren's
disease so the other connective tissue disorders do they presents with the same
type of side effects well first of all sjogren's is is has the most severe
effect on the salivary glands and results in the most severe reduction in salivary
flow in patients but these other disorders I mentioned the other
autoimmune disease I mentioned earlier they also can increase salary flow but
generally to a lesser extent in the article you mentioned specifically that
dentist should be part of their coordinating team of treating these
patients specifically where do you see the dentist
fit in in coordination as well as how the dentist can benefit the patient
first of all I think the the dentist can be involved in the initial diagnosis
stage sometimes these conditions are not diagnosed two very very late stage in
the disease and when the patient has already suffered a lot of damage to the
teeth so if we can identify patients and typically this occurs in middle-aged
woman it occurs at a much higher frequency and woman than men so in that
age group we can focus in a little bit if we seize some of the clinical signs
of decreased salivary flow and these include increased carries problems with
obviously a presentation or try them out lack of pooling was alive on the floor
of the mouth enlarge parotid glands the chipping and breaking of teeth
associated with erosive tooth wear difficulty eating food and swallowing
difficulty speaking these are many things that a dentist can ask questions
about and drill down a little bit and identify this patient as potentially
sjogren's patient if they have decreased salivary flow I think there's a
tendency in dentistry I see this also in the clinic at our dental school when
students see patients with decreased salivary flow associated with numerous
medications that have that side effect they immediately make that Association
we're not really doing a differential diagnosis I think sjogren's and any
patient that presents with decrease salivro should be part of the differential
diagnosis so what other systemic signs or symptoms would you look for
specifically in the sugar and patient in that case well Sjogren's patients first
of all it is a systemic disease it's a chronic and progressive systemic disease
so these patients can present with fatigue muscle and joint pain GI
motility problems and also peripheral peripheral neuropathies so patients have
these complaints or these symptoms this could also be an indication they're a
sjogren's patient and the thing about the eyes as well well
again I think one of the most important questions to ask once you associate the
patients having some decrease salary flow is to ask the question do they have
dry eyes but there is a need to drill down a little bit some patients again as
I mentioned earlier it may not realize they had this problem and if they have
pain in their eyes if they have burning in their eyes if they have a sensitivity
to light if they have frequent eye infections this could be an indication
that they have sjogren's so to practice guidelines specifically deals with carys
prevention could you elaborate a little bit more on it exactly what are the
recommendations what should we do yes I can and first of all if we just go from
the article there was really a general recommendation strong recommendation for
the use of fluoride however i use my understanding of the evidence in
relationship to fluorid and some of that comes actually from evidence-based
reviews that were supported by the center for evidence-based dentistry on
professionally applied fluorides if we combine that evidence for high-risk
patients and apply it to with Sjogren's patient who must be considered a
high-risk patient these patients would benefit in my mind from first of all
frequent recall at least every three months they would benefit from topical
fluoride applications every three months which could be either with using
fluoride varnish or an a PF at one point two three percent fluoride a PF
treatment gel so that would be maybe the first thing that the dentist should be
doing on a regular basis was these patients but also we know that of the
the concentration of fluorid toothpastes also matters and so high concentration
toothpaste prescription strength toothpaste are also indicated in these patients and
I would recommend that they brush at least twice a day and possibly three
times a day and that most importantly that they would brush before they went
to bed because that's the most most important time to apply fluoride
staying with fluoride for a moment you write an article the evidence for
fluoride use is weak because investigators in only one
study on the 13 look specifically at patients for sjogren's disease yet in the
table clinical questions recommendations who cares prevention you rate the
recommendation as strong correct could you elaborate on that yes I can there
are many systems to evaluate evidence and make recommendations the in at the
start of this process this was an extensive review of these different
systems and it was decided by the sjogren's foundation in developing these
clinical practice guidelines that they would adopt a system developed by the
American Society of Clinical Oncology ASCO and so in in that system of
developing guidelines it leads a little bit more room for including expert
opinion into into rating the strength of the evidence so where other systems
might be a little more strict on this so this in this process we included
clinicians acted both academic as well as community clinicians we included
hygienists we included patients we included a vast catchment of people who
who had some interest in this area with stakeholders and based on their input we
actually increased the strength of the recommendation from moderate to strong
because of those recommendations and we went through the process it's a modified
Delphi process and in doing so we raised the recommendation to a strong Category
a strong reading convention fluoride is to any way we can increase the salivary
function in these patients yes along with fluoride I think probably the next
major omnis was covered in the article as well even though again the evidence
was rated as weakest because he had no evidence basically that it can prevent
caries but there's a pharmacological approaches the typical approaches
involve pilocarpine hydrochloride as well as some have trouble saying this
but savilamine hydrochloric which is another class of
drugs which can be used to increase salivary flow so the increasing
salivary flow in patients that still have residual Glen capacity of course
because the disease kept progressed at a point where they don't can be very
helpful not only in preventing helping prevent possibly dental caries but also
improving the patient's quality of life which is a very important issue in these
patients and in addition to that recommending sugar-free candies lozenges
that sort of thing to stimulate salivary flow and also chewing sugar-free gum is
indicated in these patients in the patients that can chew gum so saliva
also protect us from developing Candida infection my assumption is that these
patient may develop some candidiasis yes there's a much higher incidence of
candidiasis in this patient population as well as patients with decreased
salivary flow in general and in those in those patients who are developing a
candle affection they should be can be prescribed topical antifungal agents and
in the patient's witness is not working well you can also go on with systemic
antifungals so refractory cases we can go to systemic antifungal medication
correct wonderful this sugar and disease is almost like a prototype for the
autumn um connective tissue disorders the same protocols or the same clinical
practice guidelines that you recommend an article could we apply it to other
patients as well with hyper salivation absolutely so a lot of the information
that we obtained to support the recommendations for sjögren patients
actually came from studies done on patients with which were had decreased
salivary flow as an effect of side effect of medications as well as
patients that hadn't had had neck radiation as well as other other
diseases so in any patient that has decreased salivary flow which would be
considered high risk for the heart tissue the two complications that
increase carries increased dental erosion as well as the coastal
complications by candidiasis as well as ulseration
these patients would benefit from this protocol that's what we're recommending
here now when you talk about carries my assumption is that you are specifically
talk about cervical carries well typically in adults would decrease
salivary flow we see this pattern of cervical carries which can be very
destructive to the teeth can even lead lead to breaking of teeth and
undermining of teeth so the pattern is typically cervical caries or cervical
carries around the necks of the teeth one other thing if I can go back would
be is not to lose sight that of the role that oral hygiene can play and of also
of dietary modification so in these patients they really need fastidious
oral hygiene and so reinforcing oral hygiene every three months on these
patients is very important in improving their techniques and also modifying
their diet sugar is a main driver of caries in all patients but in a salivary
dysfunction population a patient with decreased salivary flow diet is is
really a main driver and so sugar needs to be really severely restricted
especially between meals and these patients and using sugar substitutes
like xylitol and zovitol is also a good line of action wonderful Dr. Zero, I want
to thank you very much for coming here and sharing your insight and expertise
with our readers thank you very much it was really my pleasure thank you
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