Diagnostic Testing
Testing related to establishing a diagnosis should be protocol driven, Dr. Baer said, and it is important to be rigorous in the diagnostic approach. Establishing a diagnosis is a precursor to appropriate management and frequently requires collaboration between the rheumatologist, ophthalmologist, and oral medicine specialist. “This is probably the only rheumatic disease where we routinely need collaboration for diagnosis,” Dr. Baer said.
There are questions surrounding lip biopsies, and the procedure has pros and cons. It is an important criterion for accurate disease classification, Dr. Baer said, and it is necessary if “the evidence for an underlying autoimmune process is equivocal.” The procedure is not without risks, and interpreting the test is difficult. On average, persistent lip numbness after a biopsy occurs in 3% to 5% of patients, according to reported series, Dr. Baer noted. Proper interpretation requires the harvest of four to seven individual glands, which makes it important to ensure that the biopsy technique yields adequate tissue. Misinterpretation of these biopsies is common, so Dr. Baer recommended requesting protocol-driven interpretation from the pathologist. (You can download more information about labial salivary gland biopsy at http://sicca.ucsf.edu/Labial_Salivary_Gland_Assessment.doc and http://sicca.ucsf.edu_LSG_bx_Grading_SOP. Correct interpretation of the biopsy is critical to making an accurate diagnosis, Dr. Baer noted.
Fatigue and Pain
“There is another side to this story,” Dr. Baer said. He advised attendees not to be too quick to attribute symptoms of fatigue, pain, and sicca to fibromyalgia, even if the patient lacks SSA and SSB antibodies. Fatigue is common and reported in up to 70% of Sjögren’s patients, he noted. Chronic pain also occurs in Sjögren’s, and paradoxically it has been shown to be more severe in patients who lack SSA/SSB antibodies.2 Similarly, Sjögren’s patients with a painful small fiber sensory neuropathy have a lower frequency of SSA/SSB antibodies. These observations suggest that chronic pain may be a marker of a distinct disease process that occurs independently of the traditional immunologic disease markers in Sjögren’s. It may still be autoimmune in origin, Dr. Baer added.
Therapeutic Interventions
Various symptomatic and systemic therapies may be used, but none have been shown to be disease modifying. Patients with salivary hypofunction should see their dentists on a quarterly basis for cleanings and professional fluoride treatments, Dr. Baer recommended, and the daily use of prescription fluoride toothpaste is helpful. Dry eye care involves the frequent application of artificial tears during the day and a tear gel at night. Punctal occlusion may be very helpful, and many ophthalmologists advocate the use of topical cyclosporine drops.
