The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 139, No 3, 291-299.
© 2008 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Supplemental Data
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Stewart, C. M.
Right arrow Articles by Reeves, W. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Stewart, C. M.
Right arrow Articles by Reeves, W. H.

CLINICAL PRACTICE

JADA Continuing Education

Salivary Dysfunction and Quality of Life in Sjögren Syndrome

A Critical Oral-Systemic Connection



Carol M. Stewart, MS, DDS, MS, Kathleen M. Berg, PhD, Seunghee Cha, DDS, PhD and Westley H. Reeves, MD


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The importance of oral health to systemic health and quality of life (QOL) is gaining attention. Although several studies have examined generic (general) QOL in Sjögren syndrome (SS), little information exists on the effect of oral health on QOL and relationships among self-reported oral health, systemic health and objective clinical measures of health. The authors conducted this study to characterize these relationships in a sample of patients with SS.

Methods. Thirty-nine patients with a diagnosis of SS ascertained by means of the 2002 American-European Consensus criteria completed both the Oral Health Impact Profile (OHIP-14) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) QOL questionnaires. OHIP-14 measures pain; functional limitation; and psychological, emotional and social disability associated with the mouth. SF-36 measures physical and emotional health and the ability to perform usual activities. Additional measures included the number of self-reported autoimmune symptoms and an index of disease damage. Statistical analysis was performed by using hierarchical regression analysis.

Results. Both generic and oral health–related QOL were poor in these patients. Specifically, the findings indicated that salivary flow rate was correlated significantly with both Disease Damage Index and OHIP-14 ratings, the number of autoimmune symptoms was correlated significantly with both oral and generic QOL, and oral health accounted for a significant percentage of variance in SF-36 domains of general health and social function.

Conclusions. Oral health appears to have an independent influence on general QOL in patients with SS. These findings underscore the importance of proactive dental management of the oral manifestations of SS.

Clinical Implications. Dentists and physicians must work collaboratively to maintain oral health and quality of life for patients with Sjögren syndrome. The dentist should address patients’ concerns of xerostomia and hyposalivation in an aggressive manner.

Key Words: Sjögren syndrome; xerostomia; quality of life; Medical Outcomes Study 36-Item Short-Form Health Survey; Oral Health Impact Profile

Abbreviations: AECC: American-European Consensus Criteria. • AI: Autoimmune. • DDI: Disease Damage Index. • OHIP-14: Oral Health Impact Profile. • QOL: Quality of life. • RA: Rheumatoid arthritis. • SD: Standard deviation. • SF-36: Medical Outcomes Study 36-Item Short-Form Health Survey. • SLE: Systemic lupus erythematosus. • SS: Sjögren syndrome.

Sjögren syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltration of the exocrine glands and symptoms of persistent oral and ocular dryness. Symptoms may be limited to a local effect on the salivary and lacrimal glands or extend to include widespread involvement of multiple organ systems.1 The disorder may occur alone (primary SS) or in combination with another rheumatic disease, such as systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA), in which case it is classified as secondary SS. The disease affects women more frequently than men, with a reported female-to-male ratio of 9:1. Although SS has been described in children and adolescents,2,3 the onset of symptoms occurs most often during middle age.4 Depending on the classification criteria applied, estimates of its prevalence in the adult population range from 0.5 to 3.0 percent,5 making it one of the most common autoimmune disorders.

Although patients with SS invariably report dryness of the mouth, eyes or both, symptoms such as extreme fatigue, myalgia, arthralgia and psychological distress also occur frequently.4,6–8 Mucous membranes in the airways and gastrointestinal tract may be affected, and approximately one-third of patients with SS experience autoimmune involvement of the pulmonary, renal, vascular or nervous systems.9 Because hyposalivation puts patients with SS at risk of experiencing numerous oral problems, oral health also is a significant issue for this population. In addition to the reduction in unstimulated salivary flow,7 patients with SS experience changes in the composition of saliva that increase their susceptibility to dental caries and early tooth loss.10–12 Additional problems include an increased incidence of oral candidiasis and ulceration,13,14 changes in taste sensation and difficulty wearing dentures owing to dryness of the oral mucosa.15 Activities of daily life also may be affected severely. Patients frequently experience difficulty chewing and swallowing food,16 difficulty speaking and embarrassment or self-consciousness in social situations as a result of oral symptoms.17

For patients with SS, as with patients who have other chronic disorders, clinicians have focused treatment on minimizing the effect of the disease on patients’ quality of life (QOL). However, there is increasing evidence that objective measures of disease activity and physician assessments of damage may be poor indicators of the effect of the disease from the patient’s perspective. Although the symptoms of SS vary widely in severity, studies examining QOL issues consistently have reported low levels of perceived health and well-being in patients with SS.18–23 The reduction in health-related QOL is comparable with that seen in patients with disorders such as RA or SLE, whose symptoms generally are thought to be more disabling.19,20

Within the past two decades, recognition that oral disease may have serious social and psychological consequences24 has resulted in the development of measures designed to assess the effect of various oral problems on patients’ everyday lives.25,26 One approach, exemplified by the 2000 U.S. surgeon general’s report on oral health in America,27 proposes an intrinsic oral-systemic link and conceptualizes oral health as an integral component of general health.28 In support of this model, oral health–related QOL has been reported to be an independent predictor of self-rated general health and psychological variables such as depression, self-esteem and life satisfaction.17,29–31

It has been argued that oral-specific QOL measures are more sensitive to variations in the severity of oral symptoms than are generic (general) QOL measures and, therefore, are more useful in assessing the effect of oral disease on patients’ well-being.25,31

In our study, we re-examined QOL issues in patients with SS. One objective of the study was to characterize the relationship between both generic and oral health–related QOL and clinical measures of disease status in a sample of patients with SS. A second objective was to assess the unique contribution of oral health to more general measures of health and well-being. Because xerostomia and hyposalivation are believed to have a considerable effect on social relationships, as well as on perceptions of overall health,32 we decided to focus on the contributions of oral health to generic measures of both general health and social functioning. If we found a link, it would strengthen further the critical importance of the dental team in the management of the care of patients with SS.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Subjects. The initial study group consisted of 39 consecutive patients (37 women, two men) referred to the University of Florida College of Dentistry Oral Medicine Clinic (Gainesville) from the University of Florida College of Medicine Division of Rheumatology and Clinical Immunology (Gainesville) for evaluation of sicca symptoms. An oral medicine clinician (C.M.S.) gave eligible patients information about the study and invited them to participate at the time of their scheduled clinic visit. After signing an informed written consent, patients completed self-administered, pencil-and-paper versions of the Oral Health Impact Profile (OHIP-14)33 and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)34 questionnaires. The oral medicine clinician performed an oral examination and an unstimulated whole salivary flow rate assessment during the same clinic visit as a part of routine patient care. The University of Florida Health Science Center Institutional Review Board reviewed and approved all procedures.

Clinical measures. Oral examination. After updating the patient’s medical history, the oral medicine clinician performed an oral examination to ensure an absence of acute dental problems that could skew the patient’s response to the questionnaires or alter his or her salivary flow rate.

Unstimulated whole salivary flow rate. Two clinicians (C.M.S. and S.C.) collected patients’ unstimulated whole saliva by means of the drooling method between 2:30 and 4:30 pm. Patients refrained from oral hygiene procedures, smoking, eating and drinking for at least two hours before the test session. Patients sat comfortably in an upright position while they allowed their saliva to flow into a preweighed vessel for 15 minutes. The two clinicians then reweighed the sealed containers to determine the weight of saliva expectorated. They determined unstimulated salivary flow rate by means of gravitation by using a scale with an accuracy to 0.01 gram. Presuming that 1 g of saliva is equivalent to 1 milliliter, they expressed measured volume as flow rate in milliliters per minute.35,36

Disease Damage Index. The research coordinator (K.M.B.) and a clinician (C.M.S.) calculated a measure of autoimmune-mediated organ system damage for each participant by using information collected from the rheumatology medical record. As published by Vitali and colleagues,37 the index consists of 15 specific items associated with SS, grouped into six general categories of systems affected by SS (that is, oral/salivary damage, ocular damage, neurological damage, pleuropulmonary damage, renal impairment and lymphoproliferative disease) and weighted from 1 to 5 according to their severity. The highest weight (5) is assigned to potentially life-threatening items such as lymphoproliferative disease and the lowest weight (1) to items such as salivary flow impairment.

Number of autoimmune symptoms. During regular clinic visits, patients routinely completed a review of systems that included 40 common symptoms of autoimmune disorders. The instructions directed patients to check all items they had experienced within the previous 10 days. These included general symptoms such as fatigue and depression, as well as items designed to survey involvement of skin, hair, muscles and joints and renal, cardiovascular, pulmonary and gastrointestinal systems. For this analysis, we interpreted the number of items checked as a subjective measure of current disease activity.

Health-related QOL measures. SF-36. SF-36 has established reliability and validity34 and has been used widely in clinical populations, including patients with SS.18,20,22 It is based on a multidimensional model of health, and it provides a generic measure of health status in eight domains: physical functioning, role limitations due to physical problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health. All subscales are coded so that higher values indicate better health, higher levels of function or less pain. For all eight domains, we calculated and expressed standardized raw sub-scale scores as deviations from 1998 U.S. population norms by using formulas specified by the developer of the SF-36 survey. Because the sample was predominantly middle-aged and female, we used the norms for women aged 55 to 64 years.38

OHIP-14. OHIP-1433 is a shortened form of the 49-item scale developed by Slade and Spencer.26 (Editor’s note: This tool and the Disease Damage Index can be found in the online version of this article at "http://jada.ada.org".) It consists of 14 questions designed to measure the frequency of problems associated with the teeth, mouth or dentures. Participants answered questions that assessed their oral health in seven dimensions: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. Using a five-point scale ranging from 0 (never) to 4 (very often), participants rated how frequently they had experienced each item addressed in the 14 questions during the past six months. We then summed the unweighted ratings for the 14 questions to yield subscale scores for each of the seven dimensions (range, 0–8 based on responses to two questions in each category) and a single summary score with a possible range of 0 to 56 based on combined scores for each of the seven dimensions. For both measures, higher scores indicated more frequent problems and poorer oral health.

Data analysis. Because the distribution for salivary flow rates was skewed, we used a square-root transformation to analyze these data. QOL ratings were not available for one patient, and analyses involving these measures included data from only 38 participants. For this sample size, we estimated statistical power to be 0.86 for detection of a five-point deviation from SF-36 norms. We examined associations between clinical measures and self-ratings of oral and generic health-related QOL by means of parametric correlational analysis. We used hierarchical regression analysis to determine the contribution of self-rated oral health to the generic SF-36 domains of general health and social functioning. We considered probability levels of P < .05 to be statistically significant.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Tables 1Go and 2Go show demographic information, descriptive statistics and intercorrelations for study variables. Mean age of the sample was 59.9 years (range, 23–81 years; standard deviation [SD], 12.4); average time since onset of symptoms was 9.8 years (range, 1–42 years; SD, 8.6). Eighty-nine percent were white. Thirty-one patients met the 2002 American-European Consensus Criteria (AECC) for primary SS,39 and the remaining eight met the criteria for secondary SS. For the latter group, coexisting autoimmune diseases included SLE (three patients), RA (three patients) and limited scleroderma (two patients).


View this table:
[in this window]
[in a new window]

  		TABLE 1 Demographic and clinical data for 39 patients.

 

View this table:
[in this window]
[in a new window]

  		TABLE 2 Correlations* among study measures.

 
Thirty-eight patients (97 percent) reported experiencing symptoms of dry mouth, and 36 (92 percent) reported having dry eyes as well. The number of reported autoimmune symptoms averaged 11 of a possible 40. The mean unstimulated whole salivary flow rate for the sample was 0.073 mL/minute. An unstimulated whole salivary flow rate of less than 0.1 mL/minute is consistent with objective hyposalivation and fulfills the AECC for SS.39 None of the patients took prescription cholinergic receptor agonists to promote oral and ocular secretions during this study.

Figure 1Go shows mean scores for the seven dimensions of OHIP-14. The mean OHIP summary score was 23.7. Mean ratings varied only slightly across the seven dimensions and were highest for physical pain and psychological discomfort and lowest for handicap. As shown in Table 2Go, poorer oral health, as indexed by the OHIP-14 summary score, correlated significantly with both lower salivary flow rates and more numerous autoimmune symptoms.


Figure 1
View larger version (56K):
[in this window]
[in a new window]

  		Figure 1. Mean scores for each of the seven dimensions of the Oral Health Impact Profile. Error bars represent one standard error above the mean. Source: Slade.33

 
Figure 2Go (page 296) illustrates mean scores for the eight domains of SF-36, standardized and expressed as deviations from 1998 U.S. norms for women aged 55 to 64 years.38 Mean SF-36 scores were significantly below group norms for all eight health dimensions. Although there was little variation across the eight domains, scores generally were lowest (further below the norms) for physical measures and the ability to fulfill social and emotional roles. Correlations between clinical variables and SF-36 domains (Table 3Go, page 296) generally were low to moderate in size. Increased age was associated significantly with higher ratings of bodily pain (P < .05), and longer disease duration was associated with both increased pain and lower ratings of mental health (P < .05). Patients with secondary SS reported having lower levels of physical function, vitality and mental health than did those with primary SS (P < .05). The Disease Damage Index was correlated significantly and negatively with only the general health domain of SF-36 (P < .01). The self-reported autoimmune symptom count correlated significantly with all eight SF-36 domains, and the OHIP-14 sum correlated significantly with five domains, with the most significant being the domains of general health (P < .01) and social functioning (P < .01).


Figure 2
View larger version (65K):
[in this window]
[in a new window]

  		Figure 2. Mean norm-based scores for eight domains of the Medical Outcomes Study 36-Item Short-Form Health Survey, expressed as deviations from 1998 U.S. population norms for women aged 55 to 64 years. Error bars represent the upper 95 percent confidence limit of the mean. A single asterisk indicates P < .05; double asterisks indicate P < .01. Source: Ware and Sherbourne.34

 

View this table:
[in this window]
[in a new window]

  		TABLE 3 Descriptive statistics and correlations* between study measures and SF-36{dagger} domains.

 
We performed hierarchical regression analyses to assess the independent contribution of oral health status to the SF-36 domains of general health and social functioning. The results indicated that ratings of oral health accounted for a significant amount of the variance in both general health and social functioning beyond what was accounted for by disease damage and self-reported autoimmune symptoms (Table 4Go, page 297). Variance accounted for by oral health was 12 percent (P < .01) and 18 percent (P < .01) of the total variance in general health and social functioning, respectively. The final models accounted for 53 percent of the variance in self-rated general health (P < .001) and 38 percent of the variance in self-rated social functioning (P < .001).


View this table:
[in this window]
[in a new window]

  		TABLE 4 Summary of hierarchical regression analyses for SF-36* general health and social functioning domains.

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
The first objective of our study was to examine both generic and oral health–related QOL in a sample of patients with SS. In agreement with results from existing reports, we found that generic QOL as indexed with SF-36 is reduced significantly in patients with SS, emphasizing the widespread effect of the disease on all aspects of patients’ lives.

As we expected, patients’ oral health–related QOL was poor, and they made frequent oral complaints. In agreement with findings from previous reports,40–43 we found that lower salivary flow rates were associated significantly with poorer oral health as indexed with the OHIP-14 summary score (P < .01). Reported OHIP-14 summary scores for the general population have ranged from 5.7 to 8.5,44–46 much below the mean of 23.7 for our patients with SS. Correlations with the OHIP-14 summary score were significant for both the unstimulated salivary flow rate and the autoimmune symptom count, indicating that patients who reported having more frequent oral problems also experienced the lowest flow rates and a greater number of autoimmune symptoms than those who had fewer oral problems.

Salivary flow rate correlated significantly and negatively with disease damage, reflecting a trend toward more severe hyposalivation and xerostomia in patients with greater severity of autoimmune symptoms. However, none of the measures of disease severity were related significantly to disease duration.

Although oral dryness is considered a hallmark symptom of SS, salivary flow rate was not significantly associated with ratings of generic QOL. In contrast, generic QOL ratings correlated significantly with both the total number of self-reported autoimmune symptoms and the extent of physician-assessed disease damage. Correlations between generic QOL and number of symptoms were larger and more consistent across SF-36 domains than were correlations between QOL and the index of disease damage, which was significant only for the domain of general health. Although generic QOL ratings may be relatively insensitive to variations in salivary flow rate, they appear to reflect the total burden of the disease on patients’ daily lives.

The second objective of the study was to assess the unique contribution of oral health ratings to the SF-36 domains of general health and social function. Viewed as a component of overall health, oral health would be expected to contribute to general health through mechanisms such as protection from systemic infection, chewing, swallowing and absence of pain and to social function through self-esteem, communication and facial esthetics.28 Using hierarchical regression analysis to control for the effects of autoimmune symptoms and disease damage, we found that ratings of oral health–related QOL accounted for a significant percentage of the variance in both general health and social functioning. These results indicate that the poor oral health associated with xerostomia has a significant effect on patients’ perceptions of their overall health and well-being beyond any effects attributable to other symptoms or damage associated with the disease. These findings suggest that the relationship between oral and systemic QOL also is of clinical significance for physicians and dentists treating patients with SS. Comprehensive management of the care of patients with SS requires a multidisciplinary core team consisting of the dentist, primary care physician, rheumatologist and ophthalmologist.

As these data indicate, oral health appears to have an independent influence on generic QOL in patients with SS. These findings underscore the need for dentists to manage the oral aspects of SS in an aggressive and proactive manner. Oral management by the dental team must include an individualized treatment plan that addresses the severity of the salivary dysfunction. To minimize oral problems such as recurrent decay, oral ulcers and candidiasis, clinicians should recommend that patients with SS schedule frequent dental visits, undergo periodontal prophylaxis every four to six months and follow a customized fluoride use program. It may be helpful to suggest that patients use sugar-free lozenges and chewing gum to enhance salivary flow. Clinicians should explain that salivary stimulants sweetened with xylitol are preferable because of their anticariogenic potential.47 When treating patients with hyposalivation, clinicians may consider prescribing cholinergic receptor agonist drugs such as pilocarpine and cevimeline. However, these medications are not appropriate for patients with narrow-angle glaucoma, uncontrolled asthma and certain cardiac conditions. If the dentist is uncertain about the patient’s systemic status, he or she should consult with the patient’s rheumatologist before prescribing these medications.


   CONCLUSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Dentists play a pivotal role in the management of the care of patients with SS. They are in a key position to identify initial signs and symptoms and arrange for a complete rheumatological evaluation. For dental patients with SS, the results of this report underscore the importance of facilitating optimal oral health to promote the QOL. These findings further support the importance of the oral-systemic connection and the need for dentists and physicians to work collaboratively to maintain the health and well-being of patients with SS.


   FOOTNOTES
 

Dr. Stewart is an associate professor, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida College of Dentistry, and co-director, University of Florida Center for Autoimmune Diseases, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida College of Dentistry, Gainesville. Address reprint requests to Dr. Stewart at PO Box 100414, J.H. Miller Health Science Center (JHMHC), University of Florida College of Dentistry, Gainesville, Fla. 32610, e-mail "cstewart{at}dental.ufl.edu".


Dr. Berg is a research coordinator, Center for Autoimmune Diseases, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida College of Dentistry, Gainesville.


Dr. Cha is an assistant professor, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida College of Dentistry, Gainesville.


Dr. Reeves is a professor and the chair, Rheumatology and Clinical Immunology, College of Medicine, University of Florida, Gainesville, and co-director, University of Florida Center for Autoimmune Diseases, Gainesville.


Disclosure: None of the authors reported any disclosures.


This project was funded by the University of Florida Center for Autoimmune Diseases, Gainesville.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Jonsson RR, Dowman SJ, Gordon T. Sjögren’s syndrome. In: Koopman W, ed. Arthritis and Allied Conditions: A Textbook in Rheumatology. 15th ed. Philadelphia: Lippincott Williams and Wilkins; 2004:1681–1705.

  2. Flaitz CM. Parotitis as the initial sign of juvenile Sjögren’s syndrome. Pediatr Dent 2001;23(2):140–142.[Medline]

  3. Hearth-Holmes M, Baethge BA, Abreo F, Wolf RE. Autoimmune exocrinopathy presenting as recurrent parotitis of childhood. Arch Otolaryngol Head Neck Surg 1993;119(3):347–349.[Abstract/Free Full Text]

  4. Bjerrum K, Prause JU. Primary Sjögren’s syndrome: a subjective description of the disease. Clin Exp Rheumatol 1990;8(3):283–288.[Medline]

  5. Delaleu N, Jonsson R, Koller MM. Sjögren’s syndrome. Eur J Oral Sci 2005;113(2):101–113.[Medline]

  6. Barendregt PJ, Visser MR, Smets EM, et al. Fatigue in primary Sjögren’s syndrome. Ann Rheum Dis 1998;57(5):291–295.[Abstract/Free Full Text]

  7. Pederson AM, Reibel J, Nauntofte B. Primary Sjögren’s syndrome (pSS): subjective symptoms and salivary findings. J Oral Path Med 1999;28(7):303–311.

  8. Valtysdottir ST, Gudbjornsson B, Hallgren R, Hetta J. Psychological well-being in patients with primary Sjögren’s syndrome. Clin Exp Rheumatol 2000;18(5):597–600.[Medline]

  9. Venables PJ. Management of patients presenting with Sjogren’s syndrome. Best Pract Res Clin Rheumatol 2006;20(4):791–807.[Medline]

  10. Pedersen AM, Bardow A, Nauntofte B. Salivary changes and dental caries as potential oral markers of autoimmune salivary gland dysfunction in primary Sjogren’s syndrome. BMC Clin Pathol 2005;5(1):4–16.[Medline]

  11. Leung KC, McMillan AS, Leung WK, Wong MC, Lau CS, Mok TM. Oral health condition and saliva flow in southern Chinese with Sjögren’s syndrome. Int Dent J 2004;54(3):159–165.[Medline]

  12. Sreebny LM. Saliva in health and disease: an appraisal and update. Int Dent J 2000;50(3):140–161.[Medline]

  13. Almstahl A, Kroneld U, Tarkowski A, Wikstrom M. Oral microbial flora in Sjögren’s syndrome. J Rheumatol 1999;26(1):110–114.[Medline]

  14. Lundstrom IM, Lindstrom FD. Subjective and clinical oral symptoms in patients with primary Sjögren’s syndrome. Clin Exp Rheumatol 1995;13(6):725–731.[Medline]

  15. Binon PP, Fowler CN. Implant-supported fixed prosthesis treatment of a patient with Sjögren’s syndrome: a clinical report. Int J Oral Maxillofac Implants 1993;8(1):54–58.[Medline]

  16. Rhodus NL, Colby S, Moller K, Bereuter J. Quantitative assessment of dysphagia in patients with primary and secondary Sjögren’s syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(3):305–310.[Medline]

  17. Baker SR, Pankhurst CL, Robinson PG. Utility of two oral health-related quality-of-life measures in patients with xerostomia. Community Dent Oral Epidemiol 2006;34(5):351–362.[Medline]

  18. Thomas E, Hay EM, Hajeer A, Silman AJ. Sjögren’s syndrome: a community-based study of prevalence and impact. Br J Rheumatol 1998;37(10):1069–1076.[Abstract/Free Full Text]

  19. Sutcliffe N, Stoll T, Pyke S, Isenberg DA. Functional disability and end organ damage in patients with systemic lupus erythematosus (SLE), SLE and Sjögren’s syndrome (SS), and primary SS. J Rheumatol 1998;25(1):63–68.[Medline]

  20. Strombeck B, Ekdahl C, Manthorpe R, Wikstrom I, Jacobsson L. Health-related quality of life in primary Sjögren’s syndrome, rheumatoid arthritis and fibromyalgia compared to normal population data using SF-36. Scand J Rheumatol 2000;29(1):20–28.[Medline]

  21. Lwin CT, Bishay M, Platts RG, Booth DA, Bowman SJ. The assessment of fatigue in primary Sjögren’s syndrome. Scand J Rheumatol 2003;32(1):33–37.[Medline]

  22. Belenguer R, Ramos-Casals M, Brito-Zeron P, et al. Influence of clinical and immunological parameters on the health-related quality of life of patients with primary Sjögren’s syndrome. Clin Exp Rheumatol 2005;23(3):351–356.[Medline]

  23. Champey J, Corruble E, Gottenberg JE, et al. Quality of life and psychological status in patients with primary Sjögren’s syndrome and sicca symptoms without autoimmune features. Arthritis Rheum 2006;55(3):451–457.[Medline]

  24. Reisine ST, Fertig J, Weber J, Leder S. Impact of dental conditions on patients’ quality of life. Community Dent Oral Epidemiol 1989;17(1):7–10.[Medline]

  25. Allen PF. Assessment of oral health related quality of life. Health Qual Life Outcomes 2003;1(1):40–47.[Medline]

  26. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994;11(1):3–11.[Medline]

  27. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md.: National Institutes of Health, National Institute of Dental and Craniofacial Research; 2000. NIH publication 00–4713.

  28. Gift HC, Atchison KA. Oral health, health, and health-related quality of life. Med Care 1995;33(11 suppl):NS57–NS77.[Medline]

  29. Benyamini Y, Leventhal H, Leventhal EA. Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction. Soc Sci Med 2004;59(5):1109–1116.[Medline]

  30. Locker D, Clarke M, Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res 2000;79(4):970–975.[Abstract/Free Full Text]

  31. Allen PF, McMillan AS, Walshaw D, Locker D. A comparison of the validity of generic- and disease-specific measures in the assessment of oral health-related quality of life. Community Dent Oral Epidemiol 1999;27(5):344–352.[Medline]

  32. Reisine ST. The impact of dental conditions on social functioning and the quality of life. Annu Rev Public Health 1988;9:1–19.[Medline]

  33. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25(4):284–290.[Medline]

  34. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36), I: conceptual framework and item selection. Med Care 1992;30(6):473–483.[Medline]

  35. Navazesh M, Christensen CM. A comparison of whole mouth resting and stimulated salivary measurement procedures. J Dent Res 1982;61(10):1158–1162.[Abstract/Free Full Text]

  36. Mulligan R, Navazesh M, Wood GJ. A pilot study comparing three salivary collection methods in an adult population with salivary gland hypofunction. Spec Care Dentist 1995;15(4):154–157.[Medline]

  37. Vitali C, Palombi G, Baldini C, et al. Sjögren’s Syndrome Disease Damage Index and disease activity index: scoring systems for the assessment of disease damage and disease activity in Sjögren’s syndrome, derived from an analysis of a cohort of Italian patients. Arthritis Rheum 2007;56(7):2223–2231.[Medline]

  38. Ware JE, Kosinski MA. SF-36 Physical and Mental Health Summary Scales: A Manual for Users of Version 1. Lincoln, R.I.: Quality Metric; 2005.

  39. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61(6):554–558.[Abstract/Free Full Text]

  40. Gerdin EW, Einarson S, Jonsson M, Aronsson K, Johansson I. Impact of dry mouth conditions on oral health-related quality of life in older people. Gerodontology 2005;22(4):219–226.[Medline]

  41. Locker D. Dental status, xerostomia and the oral health-related quality of life of an elderly institutionalized population. Spec Care Dentist 2003;23(3):86–93.[Medline]

  42. Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-health-related quality of life among younger adults. Health Qual Life Outcomes 2006;4:86–92.[Medline]

  43. Ikebe K, Matsuda K, Morii K, et al. Impact of dry mouth and hyposalivation on oral health-related quality of life of elderly Japanese. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(2):216–222.[Medline]

  44. Fernandes MJ, Ruta DA, Ogden GR, Pitts NB, Ogston SA. Assessing oral health-related quality of life in general dental practice in Scotland: validation of the OHIP-14. Community Dent Oral Epidemiol 2006;34(1):53–62.[Medline]

  45. Robinson PG, Gibson B, Khan FA, Birnbaum W. Validity of two oral health-related quality of life measures. Community Dent Oral Epidemiol 2003;31(2):90–99.[Medline]

  46. Wong MCM, Lo ECM, McMillan AS. Validation of a Chinese version of the Oral Health Impact Profile (OHIP). Community Dent Oral Epidemiol 2002;30(6):423–430.[Medline]

  47. Peldyak J, Makinen KK. Xylitol for caries prevention. J Dent Hyg 2002;76(4):276–285.[Medline]




This article has been cited by other articles:


Home page
 Journal of the American Dental AssociationHome page
P. C. Fox, S. J. Bowman, B. Segal, F. B. Vivino, N. Murukutla, K. Choueiri, S. Ogale, and L. McLean
Oral involvement in primary Sjogren syndrome
J Am Dent Assoc, December 1, 2008; 139(12): 1592 - 1601.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Supplemental Data
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Stewart, C. M.
Right arrow Articles by Reeves, W. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Stewart, C. M.
Right arrow Articles by Reeves, W. H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS