2003 WHRG Grant Program

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Symposia

Diagnosis of Sjogren's Syndrome with Saliva
Jane C. Atkinson, D.D.S.
Dental School, University of Maryland, Baltimore

Sjogren's syndrome (SS) is a systemic autoimmune disorder involving both the salivary and lacrimal glands, which primarily affects women. The hallmark feature of this syndrome is an intense, activated lymphoplasmacytic infiltrate in the glands that compromises production of tears and saliva. Patients commonly present with oral and ocular dryness. Other patient complaints include difficulty eating, speaking and swallowing, and burning or itching of the eyes and mouth. Over 90% of patients with primary SS are female, often in the fifth decade of life. However, it is not uncommon to diagnose the syndrome in women between the ages of 20 and 30 years. Two clinical forms of SS are recognized. Patients with primary SS have both salivary and lacrimal gland involvement, in the absence of another major connective tissue disease. Secondary SS patients have either salivary or locrimal gland disease in association with another major connective tissue disease such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE).

In the absence of major connective tissue disease, the diagnosis of SS requires objective evaluations of salivary and ocular function and health. However, new methods to evaluate the salivary component of SS appear to be required urgently as there is evidence that the current techniques, the minor salivary gland biopsy, sialography, scintigraphy and salivary flow rate determinations are significantly under-utilized. Preliminary data collected for this proposal found that salivary assessments are obtained infrequently because they either require the practitioner to find an expert to perform the procedures, the practitioner finds the procedures of little diagnostic value, or patients object to the procedures. The net effect is that most patients with SS have no assessment of their salivary disease status, which may delay or prevent the diagnosis and appropriate treatment.

The overall aim of this study is to determine if a group of salivary tests can predict the diagnosis of SS in patients with continuous oral or ocular dryness. Such an approach could increase the number of patients diagnosed by health professionals, particularly dentists who currently diagnose less than 11% of patients with SS. It would also facilitate epidemiological studies, as saliva is easily collected in the field and subjects will be more likely to participate if non-invasive techniques are used to confirm a diagnosis of SS.

This study will evaluate the efficacy of salivary tests, alone or in combination, to predict the diagnosis of SS in patients with subjective complaints and objective evidence of ocular involvement consistent with SS. The salivary tests to be evaluated are stimulated submandibular/sublingual (SM/SL) flow rates, stimulated parotid flow rates, stimulated SM/SL electrolyte concentrations, stimulated parotid electrolyte concentrations, and salivary antoantibody levels of anti-SS-A, anti-SS-B and IgA rheumatoid factor (RF).

We hypothesize the following:

An elevated [Na+] or [Cl^-] in a stimulated parotid or SM/SL sample will have a sensitivity of .90% and a specificity of <60% for predicting the diagnosis of SS using the European diagnostic criteria.
An elevated [Na+] or [Cl^-] AND either IgA RF, anti-SS-A, or anti-SS-B in a stimulated parotid or SM/SL sample will have = sensitivity and >specificity than only an elevated [Na+] or [Cl^-] in predicting the diagnosis of SS using the European diagnostic criteria.
An elevated [Na+] or [Cl^-] AND IgA RF, anti-SS-A, or anti-SS-B in a stimulated parotid or SM/SL salivary sample AND a stimulated SM/SL flow rate of <0.20 ml/min/gland will have = sensitivity and > specificity than only an elevated [Na+] or [Cl^-] AND IgA RF, anti-SS-A, or anti-SS-B for predicting the diagnosis of SS using the European diagnostic criteria.