March 1, 2005 • www.efamilypracticenews.com Musculoskeletal Disorders 63

Most Sjögren’s Some Atypical Symptoms Should Also Patients Negative Spark Suspicion of Sjögren’s Syndrome

For RA Antibodies BY HEIDI SPLETE bleeds, otitis, and sinusitis can be recurring. Senior Writer Ǡ Oral. Severe dry mouth can cause swallowing BY KATE JOHNSON Ten of the patients (7.5%), problems, which may lead to malnourishment Montreal Bureau tested positive for anti-CCP, F ORT L AUDERDALE, FLA. — Sjögren’s syn- and excessive weight loss. Patients may also have and 7 (5.2%) tested positive for drome is the second most common autoimmune accelerated caries, loss of dentition, and malfunc- ost patients with primary AKA. This compared to data disorder that affects the musculoskeletal system, tioning dentures. MSjögren’s syndrome test from an unpublished study and yet the average time to diagnosis is 6 years, said Ǡ Dermatologic/Vascular. Skin rashes are com- negative for anti-cyclic citrulli- showing a 68.9% prevalence of Yvonne Sherrer, M.D., at a meeting sponsored by mon, and skin eruptions and purpura may occur. nated peptide antibody and anti- anti-CCP in patients with the Sjögren’s Syndrome Foundation. Raynaud’s phenomenon is a typical vascular man- keratin antibodies, in contrast to rheumatoid arthritis by other Although the cause of Sjögren’s is still unknown, ifestation. Vasculitis is always a concern in Sjö- patients with rheumatoid arthri- investigators. researchers suspect that a combination of genet- gren’s patients, but symptoms vary depending on tis, a new study shows. “To our knowledge, this is ic, environmental, and hormonal factors con- the location of the inflammation in the body. However, primary Sjögren’s the first study to analyze the tribute to predisposition for the disease. Indeed, for Ǡ Gastrointestinal. Patients may suffer from syndrome should not be ruled prevalence of anti-CCP and every male with the syndrome, an estimated nine esophageal dysmotility. In severe cases, they are at out in patients testing positive AKA in a cohort of patients women are affected, underscoring the relevance of increased risk for pancreatitis, hepatitis, or at- for these antibodies, reported J. with primary Sjögren’s syn- hormonal influences. rophic gastritis. E. Gottenberg from Bicetre drome,” they reported. Inflammation of the exocrine glands, the com- Ǡ Hematologic. Anemia, blood dyscrasias, and Hospital in Le Kremlin Bicetre, “Our study confirms that mon denominator of Sjögren’s syndrome, most cryoglobulinemias are rare but may occur. France and colleagues (Ann. anti-CCP and AKA may be de- obviously affects the eyes, mouth, and vagina, said Ǡ Pulmonary. Lung involvement and coronary in- Rheum. Dis. 2005;64:114-7). tected in patients with no ra- Dr. Sherrer, medical director and director of clin- volvement are rare but can develop due to dryness The clinical manifestations diographic evidence of ero- ical research at the Centre for Rheumatology, Im- of bronchial tubes. Other potential manifestations of Sjögren’s syndrome and sions after a long follow-up.” munology, and Arthritis in Fort Lauderdale. include bronchitis, bronchitis obliterans-organized rheumatoid arthritis may be The possibility that patients Typically, Sjögren’s occurs in the context of a pneumonia, and interstitial fibrosis. very similar, and the preva- with anti-CCP antibodies could previously diagnosed autoimmune disorder, such Ǡ Neurologic. Neuropathies tend to be less sym- lence of rheumatoid factor is be prone to developing as lupus, rheumatoid arthritis, or scleroderma. metrical in Sjögren’s patients, compared with oth- the same in both conditions, rheumatoid arthritis should not The following less typical symptoms may also er conditions. Central nervous system disorders noted the authors. be ruled out, noted the authors. warrant suspecting Sjögren’s syndrome: might manifest as changes in cognitive function or The study involved 134 pa- “It is known that anti-CCP Ǡ Ocular. In addition to extreme dry eyes, patients as seizures. tients who fulfilled the Ameri- can be present years before the may suffer from conjunctivitis, keratitis, blephari- Ǡ Musculoskeletal. More often than not, patients can-European Consensus first signs of rheumatoid tis, ulcerations, and perforations. with Sjögren’s have arthralgia, rather than arthri- Group criteria for primary Sjö- arthritis. In three anti- Ǡ Ears, Nose, and Throat. Tracheal dryness caus- tis, but secondary Sjögren’s patients may have gren’s syndrome, and who did CCP–positive patients with es a chronic dry cough in some patients. Nose- concurrent arthritis or myositis. not fulfill American College of polysynovitis, the use of Rheumatology criteria for DMARDs [disease-modifying rheumatoid arthritis. anti-rheumatic drugs] might Criteria for Primary Sjögren’s Syndrome Patients were tested for anti- have prevented progression to cyclic citrullinated peptide rheumatoid arthritis,” they he diagnosis of primary Sjögren’s syn- 3. The patient must have at least one of two (anti-CCP) antibodies using en- wrote. Tdrome requires that patients meet at least ocular signs: zyme-linked immunosorbent They recommend that anti- four of the following six criteria: Ǡ Unanesthetized Schirmer’s test result of 5 assay, while anti-keratin anti- CCP–positive patients receive 1. The patient must have at least one of mm/5 minutes or less in both eyes. bodies (AKA) were assessed us- cautious clinical and radi- three ocular symptoms: Ǡ Positive vital dye staining. ing indirect immunofluores- ographic follow-up to confirm Ǡ Dry eyes for less than 3 months. 4. The patient must have at least one of cence. Tests were also done for that their disease does not Ǡ Need to use artificial tears more than three three signs of poor salivary gland function: rheumatoid factor and Sjö- evolve into rheumatoid arthritis. times daily. Ǡ Abnormal salivary scintigraphy. gren’s syndrome antibodies, However, the fact that the Ǡ Sensation of a foreign body in the eye. Ǡ Abnormal parotid sialography. and patients were clinically anti-CCP–positive patients had 2. The patient must have at least one of Ǡ Unstimulated salivary flow rate of 0.1 evaluated for the presence of a mean disease duration of 11 three oral symptoms: mL/minute or less. synovitis and extraglandular years without erosions sug- Ǡ Persistent dry mouth for more than 3 5. Positive lip biopsy. involvement. gests that “the production of months. 6. Positive anti-SSA or anti-SSB tests. Radiographs of the hands anti-CCP antibodies ... could Ǡ Swollen salivary glands. and feet were taken to rule out be less intimately related to Ǡ Need to add extra liquid to the mouth in or- Source: “The New Sjögren’s Syndrome Hand- the presence of erosions that the pathogenesis of rheuma- der to swallow. book” (New York: Oxford University Press, 2005) would indicate a primary diag- toid arthritis than was previ- nosis of rheumatoid arthritis. ously hypothesized.” ■ Lifestyle Modifications May Reduce Dental Decay in Sjögren’s Patients

F ORT L AUDERDALE, FLA. merely sugar free because the ly, and avoid smoking and drink- Salivary substitutes can inter- mouth, and they don’t whiten — The chronic dry mouth that latter won’t prevent tooth decay, ing alcohol. While some patients act poorly with other medica- your teeth that much. characterizes Sjögren’s syndrome said Dr. Kusnick, a general den- may realize they need to avoid tions, so physicians should in- Other rules for basic oral can accelerate dental decay in ap- tist in private practice in Sunrise, acidic juices, such as orange and quire about all medications health apply and if patients proximately 70% of patients with Fla., and a specialist in cosmetic grape, many carbonated drinks, before prescribing them. snack, remind them to rinse their the disease, Steven J. Kusnick, and reconstructive dentistry. including diet sodas, also contain “The earlier we catch a prob- mouths with water afterwards to D.D.S., said at a meeting spon- Over-the-counter products that acid and should be avoided. lem, such as a cavity, the easier it reduce dryness. sored by the Sjögren’s Syndrome contain xylitol include Smints, a Two prescription salivary sub- is to treat,” so regular checkups Fluoride varnish can be helpful Foundation. brand of mints that stimulate stitute medications—pilocarpine are key. Dr. Kusnick also recom- to prevent decay in high-risk pa- Patients who attempt to man- saliva and have xylitol as the first (Salagen) and cevimeline (Evox- mends that his Sjögren’s patients tients, Dr. Kusnick noted. In pa- age their dry mouth symptoms ingredient, Koolerz gum in any ac)—can be an effective adjunct to use a standard, nonwhitening tients with gumline decay, pow- with gum or mints should be ad- flavor, and Starbucks gum. lifestyle modifications, but many toothpaste. Whitening tooth- er toothbrushes can be helpful in vised to use products that contain Other tips include reminding patients are deterred by their side pastes have an ingredient that getting the fluoride into the gum the natural sweetener xylitol in- patients to drink water through- effects, which include flushing, makes teeth more sensitive, irri- area. stead of looking for ones that are out the day, use lip balm regular- sweating, and headaches. tates the soft tissues of the —Heidi Splete