TR: When and how do you incorporate dentists and ophthalmologists into your patients’ care teams?
DD: Everyone with SjD needs to be seen by an ophthalmologist, and you can use the 2016 ACR-EULAR classification criteria for SjD to remember what dryness measures are important.5 Look for an OSS in the ophthalmology notes. It’s the most useful and tells you if dryness is inflammatory or not. A Schirmer’s test tells you if the patient isn’t making tears, but it’s nonspecific. For example, a patient with dysautonomia isn’t making tears, but the dryness isn’t due to inflammation.
The OSS is helpful for management, too. Dry eye should be treated aggressively, with no visible surface dry patches, keratoconjunctivitis or keratitis. Start with over-the-counter eye drops, but if persistent, step up to prescription eye drops like topical cyclosporine, and/or procedural interventions if necessary. A patient could be scarring down the surface of their eyes if dryness isn’t well controlled, and ophthalmology can make sure this isn’t occurring with their fancy equipment.
CJ: Because patients with SjD are at increased risk of dental complications, it’s recommended they see their dentist more often than the average person, typically three or even four times per year. However, dental insurance often refuses to cover the cost of the extra visits. When this occurs, we should advocate for our patients by writing a letter of necessity to the insurance company, explaining that the extra visits are justified by an underlying medical illness. You can find a letter template for this on the Sjögren’s Foundation website (www.sjogrens.org).
I’d also like to add that clinical practice guidelines for the oral management of SjD strongly recommend the use of topical fluoride in SjD patients with dry mouth to help prevent cavities, yet many are not on this important preventive treatment despite frequent dental visits. I typically prescribe sodium fluoride products with 5,000 ppm (hint: they have ‘5000’ in the name).
I instruct patients to brush their teeth with their usual toothpaste, floss, then rinse like they normally do each evening. Then afterward, brush their teeth with the prescription fluoride paste just to coat the teeth, spit out the excess and go to bed. If they want to rinse the fluoride, wait 30 minutes before doing so to give it time to work.
TR: Any other favorite SjD pearls to share with our readers?
CJ: Using sicca symptoms as the sole method of screening for SjD is a mistake. Look for objective evidence of dryness whenever you suspect SjD. A lot of patients with SjD are misdiagnosed as ‘just having fibromyalgia,’ when five minutes of objective testing (e.g., sialometry or Schirmer’s testing) could lead to a bona fide autoimmune diagnosis, potentially changing that person’s life.
