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Sjögren's syndrome: An important confounder in evaluation of oral features in systemic sclerosis

Oral manifestations of SSc are usual ; however, they are not part of the diagnostic criteria for this disease, whereas oral manifestations are essential for the diagnosis of Sjögren's syndrome (SSj). SSc is complicated by xerostomia in up to 30%–40% of SSc patients (Bajraktari et al., 2015 ; Crincoli et al., 2016). Etiology of xerostomia includes salivary gland fibrosis or concomitant SSj. Yet, SSc patients with concomitant SSj or serology suggestive of SSj were not excluded from the study and it is not clear what diagnostic procedures were complete for patients suspected of SSj (Gomes da Silva et al., 2019). Studies examining pathologies that share clinical and/or serological characteristics such as connective tissue diseases should provide an exhaustive characterization of studied population. Avouac et al. prospectively studied consecutive SSc patients and found a 68% prevalence of sicca syndrome (Avouac et al., 2006). Further investigation of labial salivary gland biopsies revealed that 58% SSc patients with sicca syndrome (xerophthalmia, xerostomia or positive findings on the Schirmer I test) had glandular fibrosis and 23% had concomitant SSj confirmed by lymphocytic sialadenitis. SSc patients have lower salivary flow rates and lower salivary pH values compared to healthy individuals (Jung, Martin, Schmittbuhl, & Huck, 2017). Decreased saliva production in SSc has been found to be associated with SSj‐related antibodies (Ro 52/TRIM‐21, SSA/Ro 60, either/or SSB/La) (Baron et al., 2015). In previous studies, decreased saliva production did not correlate with disease severity in SSc patients (Baron et al., 2015 ; Wangkaew et al., 2006)). Furthermore, oral involvement in SSc patients was not related with systemic features probably due to inclusion of SSc patients with concomitant SSj or SSj‐related antibodies. In this study, SSc patients with concomitant SSj had higher modified Rodnan skin score (p = .03), used in evaluating skin involvement in SSc, more severe disease, and reduced salivary gland function (Gomes da Silva et al., 2019). SSc patients with concomitant SSj or SSj‐ related antibodies were not excluded in these studies and thus had a great impact on the results and drawn conclusions (Avouac et al., 2006 ; Baron et al., 2015 ; Gomes da Silva et al., 2019 ; Wangkaew et al., 2006). A recent study in SSc patients without concomitant SSj or SSj‐related antibodies has confirmed impaired unstimulated and stimulated salivary flow regardless of disease subset (Knaś et al., 2014). In our previous study, we have confirmed that low socioeconomic status and physician assessment of disease severity were positively associated with oral health‐related quality of life in SSc patients (Parat et al., 2018). Concomitant SSj was a key exclusion criteria and assessment included questionnaire for xerostomia and xerophthalmia, Schirmer's I test, unstimulated whole salivary flow, minor salivary gland biopsy, and assessment of anti‐ Ro/La antibodies. In conclusion, we believe that patients with concomitant SSj or serology suggestive of SSj should be excluded in future oral health studies in SSc patients or studies should be controlled for this confounder to reduce heterogeneity between studies.

Sjögren's syndrome, systemic sclerosis

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