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Henrik Sj&#246;gren&#44; who reported the cases of 19 women presenting with ocular dryness&#44; the great majority of whom had rheumatoid arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> There are 2 types of Sj&#246;gren&#39;s syndrome&#44; pSS&#44; which occurs as an isolated disease&#44; and secondary &#40;sSS&#41;&#44; which is associated with other autoimmune diseases&#44; such as rheumatoid arthritis and systemic lupus erythematosus&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4</span></a> The pathogenesis of pSS has been related to immunological&#44; inflammatory&#44; genetic&#44; epigenetic&#44; environmental&#44; hormonal and infectious factors&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The prevalence of pSS ranges from 0&#46;5&#37; to 4&#37; of the general adult population&#46; It is diagnosed more frequently in women than in men&#44; in a proportion of 9&#58;1&#44; and it usually presents between the fourth and sixth decade of life&#44; although it can appear at any age&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4&#44;6&#44;7</span></a> It is widely reported throughout the world&#44; although it is most prevalent among Caucasians&#46; As there are few symptoms&#44; especially in the early stages&#44; the disease is underreported&#44; and there can be a considerable delay in the diagnosis&#44; with a mean interval between symptom onset and definitive diagnosis of 3&#46;5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The classification criteria for pSS include clinical signs and objective tests to detect dry eye and mouth&#44; characteristic serological abnormalities &#40;presence of anti-Ro&#47;SSA and&#47;or anti-La&#47;SSB&#41;&#44; and compatible histopathological findings in minor salivary glands &#40;focal lymphocytic sialadenitis&#44; with a focus score &#8805;1&#59; a focus is defined as an aggregate of at least 50 lymphocytes and the score&#44; as the number of such foci in a surface area of 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of salivary gland tissue&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> At the present time&#44; the classification criteria most widely employed are those proposed by the American-European Consensus Group in 2002 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> The American College of Rheumatology and the <span class="elsevierStyleItalic">Sj&#246;gren&#39;s International Collaborative Clinical Alliance</span> have recently drawn up new classification criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Presenting Symptoms</span><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of the patients with pSS first note dryness in the mouth and&#47;or eyes&#46; Mouth dryness makes it difficult to speak correctly and to taste and chew food properly&#46; Dry mouth is frequently the first complaint of these patients&#44; who constantly need to chew gum or suck on hard candy to stimulate the production of saliva&#44; and who wake up several times a night to drink large amounts of water&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;11</span></a> Thus&#44; dry mouth has an important impact on the quality of life of patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Individuals with dry mouth usually consult first with their primary care physicians&#44; who&#44; in many cases&#44; do not have the means to determine whether the dryness reported by the patient is real &#40;hyposalivation&#41; or subjective &#40;xerostomia&#41;&#46; It is essential to establish this difference because many individuals of advanced age&#44; mostly women&#44; have burning mouth syndrome &#40;BMS&#41;&#44; a complex condition that produces&#44; among other symptoms&#44; a subjective sensation of dry mouth that cannot be detected in supplemental tests&#46; Burning mouth syndrome is characterized by the presence of a burning sensation in the oral mucosa&#44; despite normal analytical findings and no decrease in salivary flow&#46; It is encountered most often in women from the age of 40 years on&#46; Its prevalence ranges between 0&#46;7&#37; and 7&#37;&#44; and is higher among postmenopausal women&#44; in whom the prevalences is as high as 12&#37;&#8211;18&#37;&#46; This syndrome frequently affects the tip and lateral edges of the tongue&#44; lips&#44; and hard and soft palate&#46; Patients with BMS also experience pain&#44; loss of taste sensitivity and xerostomia&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is also necessary to rule out other possible causes of dry mouth&#44; such as alterations in afferent stimuli&#44; central nervous system disorders&#44; dysfunction of the afferent pathways of the autonomic nervous system&#44; chronic salivary gland inflammation &#40;of immunological and nonimmunological origin&#41;&#44; use of drugs associated with xerostomy<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; psychological disorders&#44; use of tobacco and other drugs&#44; systemic diseases&#44; treatment with head and neck radiotherapy and dehydration&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> If the primary care physician findings no modifiable cause associated with xerostomia&#44; the patient should be referred to a dental professional for a complete check-up&#59; if there is any datum in the patient&#39;s history or finding in the physical examination that suggests Sj&#246;gren&#39;s syndrome&#44; the patient should also be referred to a rheumatologist&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">On other occasions&#44; the first specialist consulted by a patient with dry mouth is his or her dentist&#46; The dentist should determine whether the patient has hyposalivation by recording a thorough clinical history&#44; which should include&#44; among other tools&#44; a questionnaire on dry mouth that reflects how xerostomia affects the quality of life of the patient<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#8211;14</span></a>&#59; this will document all the symptoms reported by the patient and the medications he or she takes&#46; In addition&#44; the salivary flow should be measured &#40;sialometry&#41;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> and the severity of the mouth dryness as perceived by the patient should be quantified using a visual analog scale&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Certain data from the clinical interview point toward hyposalivation&#58; difficulty in speaking&#44; chewing and swallowing&#44; altered taste and a constant need to drink water &#40;even at night&#41;&#46; Likewise&#44; there is a series of clinical signs associated with hyposalivation&#58; the presence of dry&#44; fissured lips and a coated&#44; erythematous and fissured tongue&#46; It is also common to find stringy saliva &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; angular cheilitis&#44; rampant caries in atypical locations &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#44; occlusal wear&#44; gland inflammation&#44; mucositis and oral ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> When the dentist detects the presence of hyposalivation and can find no local cause&#44; in addition to attempting to alleviate the symptoms&#44; he or she should refer the patient&#44; together with a detailed report&#44; to the primary care physician who&#44; in turn&#44; should refer the patient to the rheumatologist for the study of the systemic disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Characteristic Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome</span><p id="par0050" class="elsevierStylePara elsevierViewall">The majority of the oral manifestations encountered in patients with pSS are the consequence of the hypofunction of the salivary glands&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;17</span></a> In the following subsections&#44; we describe&#44; separately and in detail&#44; each of the oral signs and symptoms that can be observed in patients with pSS &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Salivary Gland Hypofunction</span><p id="par0055" class="elsevierStylePara elsevierViewall">The 3 pairs of major salivary glands &#40;parotid&#44; submandibular and sublingual&#41; account for 90&#37; of the whole saliva output&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> Adults normally produce saliva at a rate of 0&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#47;min or 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a> Salivary output is a regulated process&#46; An increased saliva production is achieved through the stimulation of chemical and&#47;or mechanical processes&#44; basically chewing and food intake&#59; between meals&#44; the production decreases&#44; reaching nearly zero during sleep&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Saliva is basically composed of water&#44; but also contains electrolytes&#44; proteins&#44; glycoproteins&#44; enzymes&#44; like defensins&#44; proteases&#44; histatins and lysozymes&#44; and other molecules with biological and biochemical properties that are essential for the maintenance of the physiology of the oral environment&#46; The microbiological composition of saliva plays a fundamental role&#59; in patients with decreased salivary flow&#44; there is an alteration of the composition of the oral bacterial plaque&#46; The total bacterial count in saliva in patients with pSS is similar to that of control patients&#44; but a decrease in salivary flow is related to an increase in the concentration of certain microorganisms&#44; such as <span class="elsevierStyleItalic">Lactobacillus acidophilus</span>&#44; <span class="elsevierStyleItalic">Streptococcus mutans</span> and <span class="elsevierStyleItalic">Candida albicans</span>&#44; which may be the origin of a higher incidence of caries and candidiasis in these patients&#46; In contrast&#44; the microorganisms related to periodontal disease are not more abundant in patients with pSS&#46; Thus&#44; there has been no evidence of an increase in periodontitis in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Saliva facilitates correct speech&#44; lubricates the mucosa&#44; has a buffer or barrier effect&#44; remineralizes the tooth enamel&#44; helps to taste food and to form the food bolus&#44; initiates the process of digestion and has defense mechanisms that protect against infections&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> Likewise&#44; it forms a coating on the hard and soft tissues of the oral cavity that protects and maintains the moisture&#44; not only of the mouth&#44; but of the oropharynx and esophagus as well&#46; Moreover&#44; the components of saliva act as buffers against changes in pH in the oral cavity&#44; and salivary proteins can be absorbed by the tooth surfaces&#44; forming an organic film in which the demineralization and remineralization of dental tissues take place&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Thus&#44; the decrease in saliva production in patients with pSS results in the development of caries&#44; infection &#40;candidiasis&#41;&#44; a burning sensation in the mouth&#44; glossodynia &#40;a burning sensation in the tongue&#41;&#44; dysphagia&#44; dysgeusia &#40;an alteration in the sense of taste&#41;&#44; difficulty in speaking correctly&#44; oral lesions&#44; salivary gland inflammation and gastroesophageal reflux&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Caries</span><p id="par0070" class="elsevierStylePara elsevierViewall">Caries are due to the breakdown of the hard tissues of the teeth by the acids produced by dental plaque&#46; There are many factors associated with a higher incidence of caries&#44; such as diet &#40;composition and eating frequency&#41;&#44; hygiene&#44; education and awareness of the problem&#44; health expectations and the characteristics of the saliva &#40;amount&#44; composition&#44; buffering capacity&#44; capacity for oral sugar clearance&#44; fluoride concentration&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a> Patients with hyposalivation also have a decreased secretion of immunoglobulin A&#44; an antibody responsible for the oral mucosal immunity that prevents dental caries&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The force of the salivary flow and the action of the tongue&#44; cheeks and lips on the teeth mobilize the bacteria in the cavity&#46; In patients with pSS&#44; food gets trapped on the vestibular surfaces of the teeth due to the poor lubrication and the lack of mechanical action of the saliva&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">These patients have a higher incidence of caries and&#44; moreover&#44; the caries appear on the surface&#44; near the root of the tooth and at other atypical sites like the lingual surface&#44; incisal edge and cusp of the teeth &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6&#44;17</span></a> In addition&#44; the regulation of the salivary pH is poorer in these patients&#46; For example&#44; after the consumption of sweets&#44; the pH is lowered&#59; however&#44; the saliva of individuals with pSS does not act as an effective buffer and&#44; thus&#44; their risk of caries increases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The greater number of caries means that these patients visit the dentist more often&#44; lose more teeth and have more restored teeth in comparison with control subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fungal Infections</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with pSS have a higher prevalence of oral fungal infections&#44; mainly candidiasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;21</span></a> This infection occurs due to the reduction in the output of saliva and in its buffering capacity&#46; The clinical presentation of oral candidiasis can take several forms&#58; erythematous lesions&#44; candidiasis affecting the mucosa covered by the prostheses of denture-wearers and pseudomembranous candidiasis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; At extraoral sites&#44; it can lead to angular cheilitis&#44; which is characterized by dry&#44; fissured&#44; erythematous lesions in the corners of the mouth&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a> Chronic erythematous candidiasis&#44; mainly involving the tongue&#44; palate and corners of the mouth&#44; can affect up to 70&#37;&#8211;80&#37; of the patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;17&#44;22</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Other Lesions of the Oral Mucosa</span><p id="par0090" class="elsevierStylePara elsevierViewall">The saliva plays a fundamental role in the lubrication of the oral mucosa&#44; preventing damage due to trauma or friction&#46; Patients with pSS can develop traumatic lesions after eating foods that are coarse or abrasive&#44; like toast or potato chips&#44; due to the dryness of the mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Individuals with pSS can have dry&#44; fissured lips and lingual depapillation&#46; The tongues of patients with hyposalivation look like ground meat&#44; and are dry&#44; fissured and sticky to the touch&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;20&#44;22</span></a> In addition&#44; these patients usually tolerate poorly their partial or complete dentures&#44; since saliva forms a film that aids in the retention of these prostheses and&#44; when the output is reduced&#44; the stability is weakened&#46; In turn&#44; dentures usually produce traumatic lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17&#44;23</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Orofacial Pain</span><p id="par0100" class="elsevierStylePara elsevierViewall">The symptom that normally accompanies xerostomia in pSS is the burning sensation in the mouth&#44; or oral burning&#44; also referred to as glossodynia&#46; In these patients&#44; this sensation is mainly due to hyposalivation&#44; and can become worse if they develop candidiasis or take drugs that favor the reduction in salivary output&#46; In these cases&#44; it is important to perform a differential diagnosis involving other conditions that produce an oral burning sensation such as anemia&#44; oral lesions and BMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Five to 20&#37; of the patients with pSS can develop peripheral nervous system disorders that complicate the symptomatology&#46; The most common condition involving the cranial nerves is trigeminal neuropathy&#44; which is normally bilateral and progressive&#44; and is characterized by numbness or paresthesia&#44; with or without pain&#46; Sensory neuropathies are more frequent than motor dysfunction&#44; which&#44; if it develops&#44; can affect the facial nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;24</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Dysphagia&#47;dysgeusia</span><p id="par0110" class="elsevierStylePara elsevierViewall">Because of dry mouth&#44; patients with pSS have difficulty chewing&#44; speaking and swallowing food&#46; To enable them to swallow food&#44; they have to drink greater amounts of water&#46; They also tend to tolerate highly flavorful foods poorly because of the altered taste sensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Salivary Gland Inflammation</span><p id="par0115" class="elsevierStylePara elsevierViewall">The enlargement of the salivary glands is characteristic of pSS &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The parotid gland is affected in 30&#37;&#8211;40&#37; of these patients&#46; The inflammation of a single gland can be due&#44; among other things&#44; to an infection&#59; however&#44; if it persists over time&#44; the possibility of a lymphoma must be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Bilateral swelling of the parotid glands can be found in 25&#37;&#8211;60&#37; of the patients with pSS&#44; and can be acute or chronic&#46; When acute&#44; it can be bilateral or unilateral&#44; it is usually accompanied by pain and is usually due to the obstruction of the salivary glands by a mucous plug&#44; which is formed when the major part of the saliva is produced by the mucin-secreting cells&#46; It will sometimes be necessary to eliminate the mucus by endoscopy and&#44; in those cases in which more than one bacterial infection develops&#44; in which pus usually appears in Stensen&#39;s duct &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; antibiotic therapy appropriate for oral flora &#40;gram-positive cocci&#41; will be administered&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The inflammation can affect the parotid and&#47;or submandibular glands&#46; The inflammatory infiltrate is mixed&#44; with T and B cells and abundant cytokine secretion that promote local chemotaxis&#44; exacerbating the gland inflammation&#46; In these cases&#44; the glands are painful on palpation&#44; but pus is not expelled via the excretory duct&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Gastroesophageal Reflux</span><p id="par0130" class="elsevierStylePara elsevierViewall">Gastroesophageal reflux is a frequent finding in patients with pSS&#46; The most common symptoms are acid indigestion&#44; or heartburn&#44; and regurgitation&#46; The reflux can also produce oral lesions&#44; especially dental erosion&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Oral Lesions of Autoimmune Etiology</span><p id="par0135" class="elsevierStylePara elsevierViewall">In the medical literature&#44; there are studies that demonstrate a certain association between pSS and the presence of oral lesions of autoimmune etiology&#44; such as lichen planus&#44; recurrent aphthous stomatitis&#44; mucous membrane pemphigoid and pemphigus vulgaris&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Complications</span><p id="par0140" class="elsevierStylePara elsevierViewall">The major orofacial complications in pSS are tooth loss&#44; which makes it difficult for the patient to eat&#44; and the development of lymphoma&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The high rate of caries in patients with pSS is associated with frequent tooth loss&#46; Lost teeth can be replaced by removable prostheses or dental implants&#46; Due to the dryness of the mouths of these patients&#44; dentures are poorly retained&#44; irritate the mucosa and are not well tolerated&#46; There are dentures with reservoirs for artificial saliva&#44; but the scientific literature on the subject reports contradictory results&#46; There are few studies on treatment with dental implants and most involve small numbers of patients and case reports&#44; but the results appear to be promising&#46; Dental implant treatment in patients with pSS can be recommended to rehabilitate these individuals&#44; as the disease does not affect bone health or osseointegration&#46; Certain drugs that can affect the procedure&#44; such as corticosteroids or bisphosphonates&#44; should be taken into account&#46; Thus&#44; before undertaking implantation&#44; dentists should consult with their patients&#8217; rheumatologists&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;27&#44;28</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with pSS are at higher risk of developing lymphoma than the general public&#44; a difference that varies depending on the series &#40;standardized incidence ratio &#91;SIR&#93; 2&#46;52&#8211;48&#46;1&#41;&#46; Five to 10&#37; of the patients will develop lymphoma over a 10-year period&#46; The majority are B-cell lymphomas and&#44; undoubtedly&#44; the most common type is mucosa-associated lymphoid tissue &#40;MALT&#41; lymphoma&#44; although paraproteinemia&#44; light-chain gammopathy&#44; T-cell lymphoma and Hodgkin&#39;s lymphoma have also been reported&#46; MALT lymphoma is usually low-grade &#40;stage I or II in 70&#37;&#41; and indolent&#44; with low tumor mass&#59; it is nodal in 15&#37; of the cases&#44; extranodal in 46&#37;&#44; and nodal and extranodal in 29&#37;&#59; lactate dehydrogenase and &#946;<span class="elsevierStyleInf">2</span>-microglobulin levels are usually normal&#59; in 20&#37; of the cases&#44; it is detected at more than one extranodal site&#59; it can affect regional lymph nodes&#59; and there is bone marrow infiltration in 7&#37;&#46; The most common symptoms are&#58; parotid swelling and the absence of B symptoms &#40;fever&#44; weight loss&#44; night sweats&#41;&#46; It is most often found in the salivary glands&#44; especially the parotid glands&#59; other reported sites are stomach&#44; nasopharynx&#44; skin&#44; liver&#44; kidney and lung&#46; The transformation to lymphoproliferative malignancy is characterized by the early development of certain features&#58; parotid enlargement&#44; splenomegaly&#44; lymphadenopathy&#44; cutaneous vasculitis&#44; hypocomplementemia&#44; cryoglobulinemia&#44; anemia&#44; lymphopenia&#44; CD4&#43; lymphopenia&#44; neutropenia and anti-Ro&#47;La antibodies&#46; The detection of these predictive markers is crucial for the clinical follow-up and therapeutic intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Therapeutic Strategies in Dry Mouth</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Strategies for Increasing Salivary Flow</span><p id="par0155" class="elsevierStylePara elsevierViewall">For individuals with dry mouth&#44; it is essential that the attempt be made to achieve adequate levels of saliva in order to eliminate the symptoms&#44; prevent caries and infections&#44; and enable them to speak&#44; eat and swallow properly&#46; For this purpose&#44; there are different therapies that will be utilized in accordance with the degree of oral dryness&#46; It is absolutely crucial that patients not be led to have false expectations&#44; since it is not always possible to satisfy their needs&#46; Below we suggest the use of different treatments depending on the severity of the hyposalivation&#44; either by means of salivary stimulants &#40;local or systemic&#41; or using saliva substitutes &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Local salivary stimulants</span>&#58; saliva production can be stimulated with sugarless chewing gum&#44; which raises the pH and buffering capacity&#44; and sugarless hard candy&#44; especially lemon-flavored&#44; which stimulates the taste buds&#44; thus favoring the output of saliva&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6&#44;11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Other alternatives&#44; much more complex and costly&#44; have also been proposed&#44; such as vibro-tactile stimulation of salivary output&#44; which stimulates the residual secretory capacity through modulation of the autonomic reflex arc that regulates salivation&#59; this is carried out by means of intraoral electrostimulation devices&#46; At the present time&#44; the scientific evidence is too limited to establish the effectiveness of electrostimulation in the treatment of xerostomia or hyposalivation in patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic salivary stimulants</span>&#58; cholinergic drugs are used to treat xerostomia and xerophthalmia&#46; Among them&#44; that most widely studied and utilized is pilocarpine &#40;at doses of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h before meals and before bedtime&#44; with a maximum of 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; It does not produce good results in all the patients and has contraindications and secondary effects that limit its use &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; These drugs should be used in patients with residual salivary gland function&#46; Studies show an improvement in oral dryness with these agents in up to 60&#37;&#8211;70&#37; of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;11&#44;31&#8211;37</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Saliva substitutes</span>&#58; there is a wide variety of products to reduce the sensation of dry mouth in patients with pSS&#46; They all contain substances with an aqueous component supplemented with calcium&#44; phosphate and fluoride ions&#46; These products prevent demineralization and are available in mouthwash&#44; gel and spray form and in intraoral devices&#46; There are no conclusive studies on their efficacy in the prevention of dental caries&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;37&#44;38</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Patients with pSS should avoid the use of irritants such as alcohol and tobacco&#44; and oral hygiene is essential&#46; Water with sodium bicarbonate&#44; tea and saline solutions should be used with caution since&#44; in abundance&#44; they eliminate the small amounts of mucous saliva from the oral tissues&#44; a circumstance that can increase the sensation of dry mounth&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Strategies to Prevent Caries</span><p id="par0185" class="elsevierStylePara elsevierViewall">In the treatment of caries&#44; it is essential to evaluate the oral status of the patients and the risk factors that favor the development of new caries&#46; Patients with pSS must be involved in their oral care&#44; applying proper oral hygiene practices&#44; avoiding cariogenic foods and visiting their dentists as frequently as they are recommended to&#46; A rheumatologist and a dentist should evaluate a patient&#39;s medical and dental records&#46; Factors including diet &#40;intake and frequency of the consumption of sugar-sweetened products&#41;&#44; salivary flow&#44; caries activity &#40;number of new caries&#44; for example&#44; each year&#41;&#44; hygiene measures and the use of specific products to prevent caries &#40;fluoride&#41; should be taken into account for the purpose of modifying the bad habits the patient may have&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Oral hygiene depends on the skill of each individual&#46; The dentist should instruct the patient on how to put into practice correct oral hygiene&#44; as there are studies that show that careful oral hygiene with fluoride toothpaste is effective in controlling the development and progression of caries&#46; However&#44; the benefits of the use of fluoride in the control of dental caries are lost if they are not accompanied by good plaque control&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">With respect to diet&#44; it is necessary to know the total food intake&#46; The patient should be asked to record all the foods and beverages consumed over one week to enable the dentist to indicate the modifications to be introduced&#46; A high intake of sugar-sweetened products results in a greater number of caries&#59; moreover&#44; if the sugar-sweetened products are consumed between the main meals&#44; the risk of dental caries increases even more&#46; These patients are also recommended to avoid drinking beverages with a high sugar content &#40;sucrose&#44; maltose and lactose&#41; and carbonated beverages&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Calorie-free sweeteners &#40;aspartame&#44; acesulfame potassium&#44; cyclamate and saccharine&#41; do not produce caries&#44; as they are not metabolized into acids&#46; Sugar alcohols like sorbitol and xylitol have low cariogenic potential&#46; Sorbitol is fermented by oral bacteria&#44; but the acid production is low&#46; Xylitol is not fermented by oral streptococci and&#44; thus&#44; does not lower the salivary pH&#59; moreover&#44; it appears to have a bacteriostatic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Chemical control of dental plaque is utilized to reduce the adhesion and growth of the microorganisms present in the plaque&#46; These compounds are available in sprays&#44; gels&#44; varnishes&#44; chewing gums&#44; toothpastes and mouthwashes&#46; Those most widely used are<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Chlorhexidine&#58; a bacteriostatic agent that inhibits certain enzymes that interfere with bacterial accumulation&#46; The combination of this compound with fluoride hinders the progression of dental caries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Xylitol&#58; does not promote dental caries&#44; reduces the number of bacteria and appears to inhibit glycolysis&#46; It is present in many dental hygiene products&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Fluoride&#58; prevents dental caries&#46; Its application in the dentist&#39;s office and at home&#44; together with a controlled diet and dental hygiene measures&#44; is highly important&#46; It is found in gels&#44; varnishes &#40;normally applied in the dentist&#39;s office&#41; and mouthwashes&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">In addition to these 3 substances&#44; new products are being studied&#46; Probiotics interfere with the formation of the dental pellicle&#44; disturb the ecosystem of dental plaque and produce substances that inhibit bacterial growth&#59; in some cases&#44; they also modulate or stimulate the patient&#39;s immune response&#46; In dentistry&#44; these substances are employed in the prevention of caries&#44; periodontal disease and oral candidiasis&#44; despite there being no conclusive results in this respect&#46; Phosphoproteins&#47;phosphopeptides serve to stabilize the calcium and phosphate of the teeth&#46; They are present in natural substances such as saliva and milk&#44; and there are studies that demonstrate that they inhibit demineralization and promote remineralization&#46; Mouthwashes with these components have been utilized in patients with pSS&#44; and have exhibited little efficacy in the control of caries&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Rheumatologist&#8211;dentist Relationship</span><p id="par0230" class="elsevierStylePara elsevierViewall">For the correct diagnosis and management of the pSS patient&#44; it is essential that there be a close relationship between the rheumatologist and the dentist&#46; When a patient with xerostomia visits the dentist&#44; the latter should pay special attention to the signs of dry mouth described above&#44; rule out other conditions &#40;the use of certain medications and other diseases&#41; and quantify the stimulated and unstimulated salivary output&#46; If hyposalivation is confirmed &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41; and the patient has no other diseases related to that condition&#44; the dentist should consider the need for a biopsy of the minor salivary glands and refer the patient to the rheumatologist for completion of the study&#46; The rheumatologist should refer any possible pSS patient to the dentist for a complete oral evaluation and the necessary supplemental studies&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">The dentist will establish the recommendations in terms of hygiene&#44; diet and oral treatment depending on the severity of the condition&#44; and schedule appointments with the dental clinic&#44; which&#44; during the first year&#44; should be at intervals of no more than 3 months&#59; this will enable the dentist to assess the risk of new caries and the response to treatment&#46; If the patient were to have grade 1 involvement &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41; and developed no caries during the first year&#44; the appointments could be scheduled for every 6 months&#46; The quantification of stimulated and unstimulated salivary output should be performed at least once a year and after any change in therapy&#44; especially if the treatments are systemic&#46; This will enable an objective evaluation of the patient&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Correct and smoothly flowing communication between the dentist and the rheumatologist is essential&#46; Knowing all the changes observed in the patient and therapeutic modifications would enable both professionals to strengthen those aspects of the patient&#39;s behavior that could improve his or her oral status&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In conclusion&#44; we feel that it is important that the patient with pSS receive a correct diagnosis of the oral manifestations&#44; correct guidance on dietary and hygienic measures and correct management of hyposalivation&#44; for the purpose of increasing the production of saliva and reducing the production of caries and oral infections&#46; To achieve this&#44; a good rheumatologist&#8211;dentist relationship is imperative and indispensable&#44; and the outcome will be the correct treatment of these patients&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical Disclosures</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span></span>"
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          "titulo" => "Characteristic Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome"
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              "identificador" => "sec0020"
              "titulo" => "Salivary Gland Hypofunction"
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              "titulo" => "Orofacial Pain"
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              "titulo" => "Salivary Gland Inflammation"
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            0 => "Sj&#246;gren syndrome"
            1 => "Dry mouth"
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            0 => "S&#237;ndrome de Sj&#246;gren"
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            2 => "Xerostom&#237;a"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary Sj&#246;gren&#39;s syndrome is a chronic systemic autoimmune disease that causes destruction of lacrimal and salivary glands&#46; The most common and earliest symptoms are oral and ocular dryness&#46; Dry mouth makes talking difficult&#44; tasting and chewing properly&#44; impairing quality of life of these patients&#46; The most common oral signs and symptoms are hyposialia with or without xerostomia&#44; tooth decay&#44; fungal infections&#44; traumatic oral lesions&#44; dysphagia&#44; dysgeusia&#44; and inflammation of salivary glands&#46; There are different therapeutic strategies&#44; depending on the severity of each case&#44; and the increase in the amount of saliva&#44; to reduce the number of cavities and oral infections&#46; It is particularly important to establish a close relationship between the dentist and the rheumatologist in order to make an early and correct diagnosis&#44; promoting appropriate dietary and hygiene measures&#44; as well as to treat and prevent potential oral complications&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Sj&#246;gren primario &#40;SSp&#41; es una enfermedad autoinmune sist&#233;mica cr&#243;nica&#44; que cursa con destrucci&#243;n del tejido glandular lagrimal y salival&#46; Sus s&#237;ntomas m&#225;s frecuentes y tempranos son la sequedad oral y ocular&#46; La sequedad oral dificulta que el paciente hable&#44; deguste y mastique correctamente&#44; lo que disminuye la calidad de vida del enfermo&#46; Los signos y s&#237;ntomas orales m&#225;s frecuentes son la hiposialia con o sin xerostom&#237;a&#44; la caries dental&#44; las infecciones f&#250;ngicas&#44; las lesiones orales traum&#225;ticas&#44; la disfagia&#44; la disgeusia y la inflamaci&#243;n de las gl&#225;ndulas salivales&#46; Existen distintas estrategias terap&#233;uticas en funci&#243;n de la gravedad de cada caso que aumentan la cantidad de saliva y disminuyen el n&#250;mero de caries e infecciones orales&#46; Por ello&#44; es de especial importancia establecer una relaci&#243;n cercana entre el dentista y el reumat&#243;logo que permita hacer un diagn&#243;stico temprano y correcto&#44; fomentar las medidas diet&#233;ticas e higi&#233;nicas adecuadas&#44; tratar y prevenir las posibles complicaciones orales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez-Pintor RM&#44; Fern&#225;ndez Castro M&#44; Hern&#225;ndez G&#46; Afectaci&#243;n oral en el paciente con s&#237;ndrome de Sj&#246;gren primario&#46; Manejo multidisciplinar entre odont&#243;logos y reumat&#243;logos&#46; Reumatol Clin&#46; 2015&#59;11&#58;387&#8211;394&#46;</p>"
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        "etiqueta" => "Fig&#46; 7"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Glossy&#44; depapillated tongue due to hypersalivation in a patient with primary Sj&#246;gren&#39;s syndrome&#46; The image also shows a papilloma on the dorsum of the tongue and fractured incisal edges of the upper teeth&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ocular symptoms&#58; a positive response to at least one of the following questions&#58;Have you had daily&#44; persistent&#44; troublesome dry eyes for at least 3 months&#63;Do you have a recurrent sensation of sand or gravel in the eyes&#63;Do you use artificial tears more than 3 times a day&#63;Oral symptoms&#58; a positive response to at least one of the following questions&#58;Have you had a daily feeling of dry mouth for at least 3 months&#63;Do you had recurrent or persistent swelling of the salivary glands&#63;Do you frequently drink liquids to aid in swallowing dry food&#63;Ocular signs&#44; that is&#44; objective evidence of ocular involvement defined as a positive result for at least one of the following tests&#58;Schirmer&#39;s I test&#44; performed without anesthesia &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>mm in 5<span class="elsevierStyleHsp" style=""></span>min&#41;Rose bengal score or other ocular dye score &#40;&#62;4 according to van Bijsterveld&#39;s scoring system&#41;Histopathology of minor salivary glands &#40;obtained using apparently healthy mucosa&#41;&#58; focal lymphocytic sialoadenitis&#44; with a focus score<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#59; a focus is defined as an aggregate of at least 50 lymphocytes and the score&#44; as the number of such foci in a surface area of 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of minor salivary glandSalivary gland involvement&#44; objective evidence of salivary gland involvement defined by a positive result for at least one of the following diagnostic tests&#58;Unstimulated whole salivary flow &#40;&#60;1&#46;5<span class="elsevierStyleHsp" style=""></span>ml in 15<span class="elsevierStyleHsp" style=""></span>min&#41;Parotid sialography showing the presence of diffuse sialectasias &#40;punctate&#44; cavitary or destructive pattern&#41;&#44; with no evidence of obstruction in the major ducts&#44; according to the scoring system of Rubin and HoltSalivary scintigraphy showing a reduced concentration or delayed excretion of the tracer&#44; according to the method proposed by Schall et al&#46;Autoantibodies&#58; presence in serum of the following autoantibodies&#58;Antibodies to Ro&#40;SSA&#41; or La&#40;SSB&#41; antigens&#44; or bothRevised guidelines for the classification of primary Sj&#246;gren&#39;s syndrome&#58; in patients with no potentially associated disease&#44; primary Sj&#246;gren&#39;s syndrome should be defined as follows&#58;The presence of any 4 of the above 6 items indicating primary Sj&#246;gren&#39;s syndrome&#44; as long as item 4 &#40;histopathology&#41; and 6 &#40;serology&#41; are positiveThe presence of any 3 of the 4 objective criteria &#40;for example&#44; items 3&#44; 4&#44; 5 and 6&#41;The classification tree procedure represents a valid alternative method for classification&#44; although it should be properly used in clinical-epidemiological studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Primary Sj&#246;gren&#39;s Syndrome Proposed by the American-European Consensus Group&#46;</p>"
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        "etiqueta" => "Table 2"
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        "tabla" => array:1 [
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">According to this group&#44; patients with Sj&#246;gren&#39;s syndrome should meet 2 of the following 3 conditions</span>&#58;Presence of anti-Ro&#47;SSA and&#47;or anti-La&#47;SSB or presence of rheumatoid factor and ANA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;320Keratoconjunctivitis sicca with ocular staining score of 3 or higher &#40;provided the individual is not currently using eye drops for glaucoma and has not had corneal surgery or cosmetic eyelid surgery during the preceding 5 years&#41;Minor salivary gland biopsy revealing focal lymphocytic sialadenitis with a focus score greater than 1 per 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of gland tissue&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Primary Sj&#246;gren&#39;s Syndrome Proposed by the American College of Rheumatology and Sj&#246;gren&#39;s International Collaborative Clinical Alliance&#46;</p>"
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        "etiqueta" => "Table 3"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anorexic agentsAnxiolyticsAnticonvulsantsTricyclic antidepressantsAntiemeticsAntihistaminicsAntiparkinsonian drugsAntipsychoticsBronchodilatorsDecongestantsDiureticsMuscle relaxantsNarcotic analgesicsSedativesAntihypertensive drugsAntiarthritic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Drugs Associated With the Presence of Xerostomia&#46;</p>"
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      10 => array:7 [
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Salivary hypofunctionCariesFungal infectionsOral traumaLip drynessOrofacial painDysphagiaDysgeusiaSwollen salivary glandsGastroesophageal refluxOral lesions of autoimmune etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome&#46;</p>"
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&#44; sporadic discomfort on eating dry or course foodsNo signs of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;25<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Education and modification of dietElimination&#44; if possible&#44; of xerostomia-related medicationAvoidance of alcohol and tobacco useHydration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild intermittent discomfort not only when eatingNo evidence of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#60;0&#46;25 and<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#60;1 and &#62;0&#46;7<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grade 1&#58;Use of sugarless chewing gum and sugarless lemon-flavored hard candyUse of saliva substitutes&#58; gel and spray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent constant discomfort not only when eatingDifficulty in eating&#44; swallowing and speakingSigns of oral dryness can be observedUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;7<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grades 1 and 2&#58;Use of artificial salivaIf there is no improvement with artificial saliva&#44; use of systemic stimulants &#40;after salivary gland biopsy to determine whether there is a certain degree of salivary function&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Permanent discomfortGreat difficulty in eating&#44; swallowing and speakingAdvanced signs of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grades 1&#44; 2 and 3&#58;Consider the use of intraoral devices with artificial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Therapeutic Strategies to Increase Salivary Flow According to Severity of Oral Dryness in Patients With Primary Sj&#246;gren&#39;s Syndrome&#46;</p>"
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        "etiqueta" => "Table 6"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Secondary effects</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Profuse sweating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nausea-vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sialorrhea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tearing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Miosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bradycardia&#47;tachycardia&#47;atrioventricular block&#47;other arrhythmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vasodilation&#47;flushing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polyuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nervousness&#47;seizures&#47;tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Constipation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Flu-like syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Contraindications</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Uncontrolled bronchial asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic obstructive pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any eye disease in which the induction of miosis is contraindicated &#40;iritis&#44; angle closure glaucoma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pregnancy&#47;breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Allergic reaction to the drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Secondary Effects and Contraindications of Pilocarpine&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:38 [
            0 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification criteria of Sj&#246;gren&#39;s syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;V&#46; Goules"
                            1 => "A&#46;G&#46; Tzioufas"
                            2 => "H&#46;M&#46; Moutsopoulos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaut.2015.07.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Autoimmun"
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                        "volumen" => "48&#47;49"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26227560"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sj&#246;gren&#39;s syndrome&#58; an update on epidemiology and current insights on pathophysiology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "T&#46;R&#46; Reksten"
                            1 => "M&#46;V&#46; Jonsson"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.coms.2013.09.002"
                      "Revista" => array:6 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24287189"
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                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0205"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A clinicopathologic study of Mikulicz&#39;s disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;S&#46; Morgan"
                            1 => "B&#46; Castleman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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Review Article
Oral Involvement in Patients With Primary Sjögren's Syndrome. Multidisciplinary Care by Dentists and Rheumatologists
Afectación oral en el paciente con síndrome de Sjögren primario. Manejo multidisciplinar entre odontólogos y reumatólogos
Rosa María López-Pintora, Mónica Fernández Castrob,
Corresponding author
monfercas@yahoo.es

Corresponding author.
, Gonzalo Hernándeza
a Departamento de Medicina y Cirugía Bucofacial, Facultad de Odontología, Universidad Complutense de Madrid, Madrid, Spain
b Servicio de Reumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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It is diagnosed more frequently in women than in men&#44; in a proportion of 9&#58;1&#44; and it usually presents between the fourth and sixth decade of life&#44; although it can appear at any age&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4&#44;6&#44;7</span></a> It is widely reported throughout the world&#44; although it is most prevalent among Caucasians&#46; As there are few symptoms&#44; especially in the early stages&#44; the disease is underreported&#44; and there can be a considerable delay in the diagnosis&#44; with a mean interval between symptom onset and definitive diagnosis of 3&#46;5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The classification criteria for pSS include clinical signs and objective tests to detect dry eye and mouth&#44; characteristic serological abnormalities &#40;presence of anti-Ro&#47;SSA and&#47;or anti-La&#47;SSB&#41;&#44; and compatible histopathological findings in minor salivary glands &#40;focal lymphocytic sialadenitis&#44; with a focus score &#8805;1&#59; a focus is defined as an aggregate of at least 50 lymphocytes and the score&#44; as the number of such foci in a surface area of 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of salivary gland tissue&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> At the present time&#44; the classification criteria most widely employed are those proposed by the American-European Consensus Group in 2002 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> The American College of Rheumatology and the <span class="elsevierStyleItalic">Sj&#246;gren&#39;s International Collaborative Clinical Alliance</span> have recently drawn up new classification criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Presenting Symptoms</span><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of the patients with pSS first note dryness in the mouth and&#47;or eyes&#46; Mouth dryness makes it difficult to speak correctly and to taste and chew food properly&#46; Dry mouth is frequently the first complaint of these patients&#44; who constantly need to chew gum or suck on hard candy to stimulate the production of saliva&#44; and who wake up several times a night to drink large amounts of water&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;11</span></a> Thus&#44; dry mouth has an important impact on the quality of life of patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Individuals with dry mouth usually consult first with their primary care physicians&#44; who&#44; in many cases&#44; do not have the means to determine whether the dryness reported by the patient is real &#40;hyposalivation&#41; or subjective &#40;xerostomia&#41;&#46; It is essential to establish this difference because many individuals of advanced age&#44; mostly women&#44; have burning mouth syndrome &#40;BMS&#41;&#44; a complex condition that produces&#44; among other symptoms&#44; a subjective sensation of dry mouth that cannot be detected in supplemental tests&#46; Burning mouth syndrome is characterized by the presence of a burning sensation in the oral mucosa&#44; despite normal analytical findings and no decrease in salivary flow&#46; It is encountered most often in women from the age of 40 years on&#46; Its prevalence ranges between 0&#46;7&#37; and 7&#37;&#44; and is higher among postmenopausal women&#44; in whom the prevalences is as high as 12&#37;&#8211;18&#37;&#46; This syndrome frequently affects the tip and lateral edges of the tongue&#44; lips&#44; and hard and soft palate&#46; Patients with BMS also experience pain&#44; loss of taste sensitivity and xerostomia&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is also necessary to rule out other possible causes of dry mouth&#44; such as alterations in afferent stimuli&#44; central nervous system disorders&#44; dysfunction of the afferent pathways of the autonomic nervous system&#44; chronic salivary gland inflammation &#40;of immunological and nonimmunological origin&#41;&#44; use of drugs associated with xerostomy<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; psychological disorders&#44; use of tobacco and other drugs&#44; systemic diseases&#44; treatment with head and neck radiotherapy and dehydration&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> If the primary care physician findings no modifiable cause associated with xerostomia&#44; the patient should be referred to a dental professional for a complete check-up&#59; if there is any datum in the patient&#39;s history or finding in the physical examination that suggests Sj&#246;gren&#39;s syndrome&#44; the patient should also be referred to a rheumatologist&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">On other occasions&#44; the first specialist consulted by a patient with dry mouth is his or her dentist&#46; The dentist should determine whether the patient has hyposalivation by recording a thorough clinical history&#44; which should include&#44; among other tools&#44; a questionnaire on dry mouth that reflects how xerostomia affects the quality of life of the patient<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#8211;14</span></a>&#59; this will document all the symptoms reported by the patient and the medications he or she takes&#46; In addition&#44; the salivary flow should be measured &#40;sialometry&#41;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> and the severity of the mouth dryness as perceived by the patient should be quantified using a visual analog scale&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Certain data from the clinical interview point toward hyposalivation&#58; difficulty in speaking&#44; chewing and swallowing&#44; altered taste and a constant need to drink water &#40;even at night&#41;&#46; Likewise&#44; there is a series of clinical signs associated with hyposalivation&#58; the presence of dry&#44; fissured lips and a coated&#44; erythematous and fissured tongue&#46; It is also common to find stringy saliva &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; angular cheilitis&#44; rampant caries in atypical locations &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#44; occlusal wear&#44; gland inflammation&#44; mucositis and oral ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> When the dentist detects the presence of hyposalivation and can find no local cause&#44; in addition to attempting to alleviate the symptoms&#44; he or she should refer the patient&#44; together with a detailed report&#44; to the primary care physician who&#44; in turn&#44; should refer the patient to the rheumatologist for the study of the systemic disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Characteristic Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome</span><p id="par0050" class="elsevierStylePara elsevierViewall">The majority of the oral manifestations encountered in patients with pSS are the consequence of the hypofunction of the salivary glands&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;17</span></a> In the following subsections&#44; we describe&#44; separately and in detail&#44; each of the oral signs and symptoms that can be observed in patients with pSS &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Salivary Gland Hypofunction</span><p id="par0055" class="elsevierStylePara elsevierViewall">The 3 pairs of major salivary glands &#40;parotid&#44; submandibular and sublingual&#41; account for 90&#37; of the whole saliva output&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> Adults normally produce saliva at a rate of 0&#46;4<span class="elsevierStyleHsp" style=""></span>ml&#47;min or 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a> Salivary output is a regulated process&#46; An increased saliva production is achieved through the stimulation of chemical and&#47;or mechanical processes&#44; basically chewing and food intake&#59; between meals&#44; the production decreases&#44; reaching nearly zero during sleep&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Saliva is basically composed of water&#44; but also contains electrolytes&#44; proteins&#44; glycoproteins&#44; enzymes&#44; like defensins&#44; proteases&#44; histatins and lysozymes&#44; and other molecules with biological and biochemical properties that are essential for the maintenance of the physiology of the oral environment&#46; The microbiological composition of saliva plays a fundamental role&#59; in patients with decreased salivary flow&#44; there is an alteration of the composition of the oral bacterial plaque&#46; The total bacterial count in saliva in patients with pSS is similar to that of control patients&#44; but a decrease in salivary flow is related to an increase in the concentration of certain microorganisms&#44; such as <span class="elsevierStyleItalic">Lactobacillus acidophilus</span>&#44; <span class="elsevierStyleItalic">Streptococcus mutans</span> and <span class="elsevierStyleItalic">Candida albicans</span>&#44; which may be the origin of a higher incidence of caries and candidiasis in these patients&#46; In contrast&#44; the microorganisms related to periodontal disease are not more abundant in patients with pSS&#46; Thus&#44; there has been no evidence of an increase in periodontitis in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Saliva facilitates correct speech&#44; lubricates the mucosa&#44; has a buffer or barrier effect&#44; remineralizes the tooth enamel&#44; helps to taste food and to form the food bolus&#44; initiates the process of digestion and has defense mechanisms that protect against infections&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> Likewise&#44; it forms a coating on the hard and soft tissues of the oral cavity that protects and maintains the moisture&#44; not only of the mouth&#44; but of the oropharynx and esophagus as well&#46; Moreover&#44; the components of saliva act as buffers against changes in pH in the oral cavity&#44; and salivary proteins can be absorbed by the tooth surfaces&#44; forming an organic film in which the demineralization and remineralization of dental tissues take place&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Thus&#44; the decrease in saliva production in patients with pSS results in the development of caries&#44; infection &#40;candidiasis&#41;&#44; a burning sensation in the mouth&#44; glossodynia &#40;a burning sensation in the tongue&#41;&#44; dysphagia&#44; dysgeusia &#40;an alteration in the sense of taste&#41;&#44; difficulty in speaking correctly&#44; oral lesions&#44; salivary gland inflammation and gastroesophageal reflux&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Caries</span><p id="par0070" class="elsevierStylePara elsevierViewall">Caries are due to the breakdown of the hard tissues of the teeth by the acids produced by dental plaque&#46; There are many factors associated with a higher incidence of caries&#44; such as diet &#40;composition and eating frequency&#41;&#44; hygiene&#44; education and awareness of the problem&#44; health expectations and the characteristics of the saliva &#40;amount&#44; composition&#44; buffering capacity&#44; capacity for oral sugar clearance&#44; fluoride concentration&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;17</span></a> Patients with hyposalivation also have a decreased secretion of immunoglobulin A&#44; an antibody responsible for the oral mucosal immunity that prevents dental caries&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The force of the salivary flow and the action of the tongue&#44; cheeks and lips on the teeth mobilize the bacteria in the cavity&#46; In patients with pSS&#44; food gets trapped on the vestibular surfaces of the teeth due to the poor lubrication and the lack of mechanical action of the saliva&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">These patients have a higher incidence of caries and&#44; moreover&#44; the caries appear on the surface&#44; near the root of the tooth and at other atypical sites like the lingual surface&#44; incisal edge and cusp of the teeth &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6&#44;17</span></a> In addition&#44; the regulation of the salivary pH is poorer in these patients&#46; For example&#44; after the consumption of sweets&#44; the pH is lowered&#59; however&#44; the saliva of individuals with pSS does not act as an effective buffer and&#44; thus&#44; their risk of caries increases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The greater number of caries means that these patients visit the dentist more often&#44; lose more teeth and have more restored teeth in comparison with control subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Fungal Infections</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with pSS have a higher prevalence of oral fungal infections&#44; mainly candidiasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;21</span></a> This infection occurs due to the reduction in the output of saliva and in its buffering capacity&#46; The clinical presentation of oral candidiasis can take several forms&#58; erythematous lesions&#44; candidiasis affecting the mucosa covered by the prostheses of denture-wearers and pseudomembranous candidiasis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; At extraoral sites&#44; it can lead to angular cheilitis&#44; which is characterized by dry&#44; fissured&#44; erythematous lesions in the corners of the mouth&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a> Chronic erythematous candidiasis&#44; mainly involving the tongue&#44; palate and corners of the mouth&#44; can affect up to 70&#37;&#8211;80&#37; of the patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;17&#44;22</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Other Lesions of the Oral Mucosa</span><p id="par0090" class="elsevierStylePara elsevierViewall">The saliva plays a fundamental role in the lubrication of the oral mucosa&#44; preventing damage due to trauma or friction&#46; Patients with pSS can develop traumatic lesions after eating foods that are coarse or abrasive&#44; like toast or potato chips&#44; due to the dryness of the mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Individuals with pSS can have dry&#44; fissured lips and lingual depapillation&#46; The tongues of patients with hyposalivation look like ground meat&#44; and are dry&#44; fissured and sticky to the touch&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;20&#44;22</span></a> In addition&#44; these patients usually tolerate poorly their partial or complete dentures&#44; since saliva forms a film that aids in the retention of these prostheses and&#44; when the output is reduced&#44; the stability is weakened&#46; In turn&#44; dentures usually produce traumatic lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17&#44;23</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Orofacial Pain</span><p id="par0100" class="elsevierStylePara elsevierViewall">The symptom that normally accompanies xerostomia in pSS is the burning sensation in the mouth&#44; or oral burning&#44; also referred to as glossodynia&#46; In these patients&#44; this sensation is mainly due to hyposalivation&#44; and can become worse if they develop candidiasis or take drugs that favor the reduction in salivary output&#46; In these cases&#44; it is important to perform a differential diagnosis involving other conditions that produce an oral burning sensation such as anemia&#44; oral lesions and BMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Five to 20&#37; of the patients with pSS can develop peripheral nervous system disorders that complicate the symptomatology&#46; The most common condition involving the cranial nerves is trigeminal neuropathy&#44; which is normally bilateral and progressive&#44; and is characterized by numbness or paresthesia&#44; with or without pain&#46; Sensory neuropathies are more frequent than motor dysfunction&#44; which&#44; if it develops&#44; can affect the facial nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;24</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Dysphagia&#47;dysgeusia</span><p id="par0110" class="elsevierStylePara elsevierViewall">Because of dry mouth&#44; patients with pSS have difficulty chewing&#44; speaking and swallowing food&#46; To enable them to swallow food&#44; they have to drink greater amounts of water&#46; They also tend to tolerate highly flavorful foods poorly because of the altered taste sensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;17</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Salivary Gland Inflammation</span><p id="par0115" class="elsevierStylePara elsevierViewall">The enlargement of the salivary glands is characteristic of pSS &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The parotid gland is affected in 30&#37;&#8211;40&#37; of these patients&#46; The inflammation of a single gland can be due&#44; among other things&#44; to an infection&#59; however&#44; if it persists over time&#44; the possibility of a lymphoma must be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Bilateral swelling of the parotid glands can be found in 25&#37;&#8211;60&#37; of the patients with pSS&#44; and can be acute or chronic&#46; When acute&#44; it can be bilateral or unilateral&#44; it is usually accompanied by pain and is usually due to the obstruction of the salivary glands by a mucous plug&#44; which is formed when the major part of the saliva is produced by the mucin-secreting cells&#46; It will sometimes be necessary to eliminate the mucus by endoscopy and&#44; in those cases in which more than one bacterial infection develops&#44; in which pus usually appears in Stensen&#39;s duct &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; antibiotic therapy appropriate for oral flora &#40;gram-positive cocci&#41; will be administered&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The inflammation can affect the parotid and&#47;or submandibular glands&#46; The inflammatory infiltrate is mixed&#44; with T and B cells and abundant cytokine secretion that promote local chemotaxis&#44; exacerbating the gland inflammation&#46; In these cases&#44; the glands are painful on palpation&#44; but pus is not expelled via the excretory duct&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Gastroesophageal Reflux</span><p id="par0130" class="elsevierStylePara elsevierViewall">Gastroesophageal reflux is a frequent finding in patients with pSS&#46; The most common symptoms are acid indigestion&#44; or heartburn&#44; and regurgitation&#46; The reflux can also produce oral lesions&#44; especially dental erosion&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Oral Lesions of Autoimmune Etiology</span><p id="par0135" class="elsevierStylePara elsevierViewall">In the medical literature&#44; there are studies that demonstrate a certain association between pSS and the presence of oral lesions of autoimmune etiology&#44; such as lichen planus&#44; recurrent aphthous stomatitis&#44; mucous membrane pemphigoid and pemphigus vulgaris&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Complications</span><p id="par0140" class="elsevierStylePara elsevierViewall">The major orofacial complications in pSS are tooth loss&#44; which makes it difficult for the patient to eat&#44; and the development of lymphoma&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The high rate of caries in patients with pSS is associated with frequent tooth loss&#46; Lost teeth can be replaced by removable prostheses or dental implants&#46; Due to the dryness of the mouths of these patients&#44; dentures are poorly retained&#44; irritate the mucosa and are not well tolerated&#46; There are dentures with reservoirs for artificial saliva&#44; but the scientific literature on the subject reports contradictory results&#46; There are few studies on treatment with dental implants and most involve small numbers of patients and case reports&#44; but the results appear to be promising&#46; Dental implant treatment in patients with pSS can be recommended to rehabilitate these individuals&#44; as the disease does not affect bone health or osseointegration&#46; Certain drugs that can affect the procedure&#44; such as corticosteroids or bisphosphonates&#44; should be taken into account&#46; Thus&#44; before undertaking implantation&#44; dentists should consult with their patients&#8217; rheumatologists&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;27&#44;28</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with pSS are at higher risk of developing lymphoma than the general public&#44; a difference that varies depending on the series &#40;standardized incidence ratio &#91;SIR&#93; 2&#46;52&#8211;48&#46;1&#41;&#46; Five to 10&#37; of the patients will develop lymphoma over a 10-year period&#46; The majority are B-cell lymphomas and&#44; undoubtedly&#44; the most common type is mucosa-associated lymphoid tissue &#40;MALT&#41; lymphoma&#44; although paraproteinemia&#44; light-chain gammopathy&#44; T-cell lymphoma and Hodgkin&#39;s lymphoma have also been reported&#46; MALT lymphoma is usually low-grade &#40;stage I or II in 70&#37;&#41; and indolent&#44; with low tumor mass&#59; it is nodal in 15&#37; of the cases&#44; extranodal in 46&#37;&#44; and nodal and extranodal in 29&#37;&#59; lactate dehydrogenase and &#946;<span class="elsevierStyleInf">2</span>-microglobulin levels are usually normal&#59; in 20&#37; of the cases&#44; it is detected at more than one extranodal site&#59; it can affect regional lymph nodes&#59; and there is bone marrow infiltration in 7&#37;&#46; The most common symptoms are&#58; parotid swelling and the absence of B symptoms &#40;fever&#44; weight loss&#44; night sweats&#41;&#46; It is most often found in the salivary glands&#44; especially the parotid glands&#59; other reported sites are stomach&#44; nasopharynx&#44; skin&#44; liver&#44; kidney and lung&#46; The transformation to lymphoproliferative malignancy is characterized by the early development of certain features&#58; parotid enlargement&#44; splenomegaly&#44; lymphadenopathy&#44; cutaneous vasculitis&#44; hypocomplementemia&#44; cryoglobulinemia&#44; anemia&#44; lymphopenia&#44; CD4&#43; lymphopenia&#44; neutropenia and anti-Ro&#47;La antibodies&#46; The detection of these predictive markers is crucial for the clinical follow-up and therapeutic intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Therapeutic Strategies in Dry Mouth</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Strategies for Increasing Salivary Flow</span><p id="par0155" class="elsevierStylePara elsevierViewall">For individuals with dry mouth&#44; it is essential that the attempt be made to achieve adequate levels of saliva in order to eliminate the symptoms&#44; prevent caries and infections&#44; and enable them to speak&#44; eat and swallow properly&#46; For this purpose&#44; there are different therapies that will be utilized in accordance with the degree of oral dryness&#46; It is absolutely crucial that patients not be led to have false expectations&#44; since it is not always possible to satisfy their needs&#46; Below we suggest the use of different treatments depending on the severity of the hyposalivation&#44; either by means of salivary stimulants &#40;local or systemic&#41; or using saliva substitutes &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Local salivary stimulants</span>&#58; saliva production can be stimulated with sugarless chewing gum&#44; which raises the pH and buffering capacity&#44; and sugarless hard candy&#44; especially lemon-flavored&#44; which stimulates the taste buds&#44; thus favoring the output of saliva&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6&#44;11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Other alternatives&#44; much more complex and costly&#44; have also been proposed&#44; such as vibro-tactile stimulation of salivary output&#44; which stimulates the residual secretory capacity through modulation of the autonomic reflex arc that regulates salivation&#59; this is carried out by means of intraoral electrostimulation devices&#46; At the present time&#44; the scientific evidence is too limited to establish the effectiveness of electrostimulation in the treatment of xerostomia or hyposalivation in patients with pSS&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic salivary stimulants</span>&#58; cholinergic drugs are used to treat xerostomia and xerophthalmia&#46; Among them&#44; that most widely studied and utilized is pilocarpine &#40;at doses of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h before meals and before bedtime&#44; with a maximum of 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; It does not produce good results in all the patients and has contraindications and secondary effects that limit its use &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; These drugs should be used in patients with residual salivary gland function&#46; Studies show an improvement in oral dryness with these agents in up to 60&#37;&#8211;70&#37; of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;11&#44;31&#8211;37</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Saliva substitutes</span>&#58; there is a wide variety of products to reduce the sensation of dry mouth in patients with pSS&#46; They all contain substances with an aqueous component supplemented with calcium&#44; phosphate and fluoride ions&#46; These products prevent demineralization and are available in mouthwash&#44; gel and spray form and in intraoral devices&#46; There are no conclusive studies on their efficacy in the prevention of dental caries&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;37&#44;38</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Patients with pSS should avoid the use of irritants such as alcohol and tobacco&#44; and oral hygiene is essential&#46; Water with sodium bicarbonate&#44; tea and saline solutions should be used with caution since&#44; in abundance&#44; they eliminate the small amounts of mucous saliva from the oral tissues&#44; a circumstance that can increase the sensation of dry mounth&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Strategies to Prevent Caries</span><p id="par0185" class="elsevierStylePara elsevierViewall">In the treatment of caries&#44; it is essential to evaluate the oral status of the patients and the risk factors that favor the development of new caries&#46; Patients with pSS must be involved in their oral care&#44; applying proper oral hygiene practices&#44; avoiding cariogenic foods and visiting their dentists as frequently as they are recommended to&#46; A rheumatologist and a dentist should evaluate a patient&#39;s medical and dental records&#46; Factors including diet &#40;intake and frequency of the consumption of sugar-sweetened products&#41;&#44; salivary flow&#44; caries activity &#40;number of new caries&#44; for example&#44; each year&#41;&#44; hygiene measures and the use of specific products to prevent caries &#40;fluoride&#41; should be taken into account for the purpose of modifying the bad habits the patient may have&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Oral hygiene depends on the skill of each individual&#46; The dentist should instruct the patient on how to put into practice correct oral hygiene&#44; as there are studies that show that careful oral hygiene with fluoride toothpaste is effective in controlling the development and progression of caries&#46; However&#44; the benefits of the use of fluoride in the control of dental caries are lost if they are not accompanied by good plaque control&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">With respect to diet&#44; it is necessary to know the total food intake&#46; The patient should be asked to record all the foods and beverages consumed over one week to enable the dentist to indicate the modifications to be introduced&#46; A high intake of sugar-sweetened products results in a greater number of caries&#59; moreover&#44; if the sugar-sweetened products are consumed between the main meals&#44; the risk of dental caries increases even more&#46; These patients are also recommended to avoid drinking beverages with a high sugar content &#40;sucrose&#44; maltose and lactose&#41; and carbonated beverages&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Calorie-free sweeteners &#40;aspartame&#44; acesulfame potassium&#44; cyclamate and saccharine&#41; do not produce caries&#44; as they are not metabolized into acids&#46; Sugar alcohols like sorbitol and xylitol have low cariogenic potential&#46; Sorbitol is fermented by oral bacteria&#44; but the acid production is low&#46; Xylitol is not fermented by oral streptococci and&#44; thus&#44; does not lower the salivary pH&#59; moreover&#44; it appears to have a bacteriostatic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Chemical control of dental plaque is utilized to reduce the adhesion and growth of the microorganisms present in the plaque&#46; These compounds are available in sprays&#44; gels&#44; varnishes&#44; chewing gums&#44; toothpastes and mouthwashes&#46; Those most widely used are<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Chlorhexidine&#58; a bacteriostatic agent that inhibits certain enzymes that interfere with bacterial accumulation&#46; The combination of this compound with fluoride hinders the progression of dental caries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Xylitol&#58; does not promote dental caries&#44; reduces the number of bacteria and appears to inhibit glycolysis&#46; It is present in many dental hygiene products&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Fluoride&#58; prevents dental caries&#46; Its application in the dentist&#39;s office and at home&#44; together with a controlled diet and dental hygiene measures&#44; is highly important&#46; It is found in gels&#44; varnishes &#40;normally applied in the dentist&#39;s office&#41; and mouthwashes&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">In addition to these 3 substances&#44; new products are being studied&#46; Probiotics interfere with the formation of the dental pellicle&#44; disturb the ecosystem of dental plaque and produce substances that inhibit bacterial growth&#59; in some cases&#44; they also modulate or stimulate the patient&#39;s immune response&#46; In dentistry&#44; these substances are employed in the prevention of caries&#44; periodontal disease and oral candidiasis&#44; despite there being no conclusive results in this respect&#46; Phosphoproteins&#47;phosphopeptides serve to stabilize the calcium and phosphate of the teeth&#46; They are present in natural substances such as saliva and milk&#44; and there are studies that demonstrate that they inhibit demineralization and promote remineralization&#46; Mouthwashes with these components have been utilized in patients with pSS&#44; and have exhibited little efficacy in the control of caries&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Rheumatologist&#8211;dentist Relationship</span><p id="par0230" class="elsevierStylePara elsevierViewall">For the correct diagnosis and management of the pSS patient&#44; it is essential that there be a close relationship between the rheumatologist and the dentist&#46; When a patient with xerostomia visits the dentist&#44; the latter should pay special attention to the signs of dry mouth described above&#44; rule out other conditions &#40;the use of certain medications and other diseases&#41; and quantify the stimulated and unstimulated salivary output&#46; If hyposalivation is confirmed &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41; and the patient has no other diseases related to that condition&#44; the dentist should consider the need for a biopsy of the minor salivary glands and refer the patient to the rheumatologist for completion of the study&#46; The rheumatologist should refer any possible pSS patient to the dentist for a complete oral evaluation and the necessary supplemental studies&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">The dentist will establish the recommendations in terms of hygiene&#44; diet and oral treatment depending on the severity of the condition&#44; and schedule appointments with the dental clinic&#44; which&#44; during the first year&#44; should be at intervals of no more than 3 months&#59; this will enable the dentist to assess the risk of new caries and the response to treatment&#46; If the patient were to have grade 1 involvement &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41; and developed no caries during the first year&#44; the appointments could be scheduled for every 6 months&#46; The quantification of stimulated and unstimulated salivary output should be performed at least once a year and after any change in therapy&#44; especially if the treatments are systemic&#46; This will enable an objective evaluation of the patient&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Correct and smoothly flowing communication between the dentist and the rheumatologist is essential&#46; Knowing all the changes observed in the patient and therapeutic modifications would enable both professionals to strengthen those aspects of the patient&#39;s behavior that could improve his or her oral status&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In conclusion&#44; we feel that it is important that the patient with pSS receive a correct diagnosis of the oral manifestations&#44; correct guidance on dietary and hygienic measures and correct management of hyposalivation&#44; for the purpose of increasing the production of saliva and reducing the production of caries and oral infections&#46; To achieve this&#44; a good rheumatologist&#8211;dentist relationship is imperative and indispensable&#44; and the outcome will be the correct treatment of these patients&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical Disclosures</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span></span>"
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          "titulo" => "Characteristic Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Salivary Gland Hypofunction"
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              "titulo" => "Other Lesions of the Oral Mucosa"
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              "titulo" => "Orofacial Pain"
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              "titulo" => "Dysphagia&#47;dysgeusia"
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              "titulo" => "Salivary Gland Inflammation"
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              "titulo" => "Oral Lesions of Autoimmune Etiology"
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          "titulo" => "Therapeutic Strategies in Dry Mouth"
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            0 => "Sj&#246;gren syndrome"
            1 => "Dry mouth"
            2 => "Xerostomia"
            3 => "Cavities"
            4 => "Saliva flow"
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            0 => "S&#237;ndrome de Sj&#246;gren"
            1 => "Sequedad oral"
            2 => "Xerostom&#237;a"
            3 => "Caries"
            4 => "Flujo salival"
            5 => "Candidiasis oral"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary Sj&#246;gren&#39;s syndrome is a chronic systemic autoimmune disease that causes destruction of lacrimal and salivary glands&#46; The most common and earliest symptoms are oral and ocular dryness&#46; Dry mouth makes talking difficult&#44; tasting and chewing properly&#44; impairing quality of life of these patients&#46; The most common oral signs and symptoms are hyposialia with or without xerostomia&#44; tooth decay&#44; fungal infections&#44; traumatic oral lesions&#44; dysphagia&#44; dysgeusia&#44; and inflammation of salivary glands&#46; There are different therapeutic strategies&#44; depending on the severity of each case&#44; and the increase in the amount of saliva&#44; to reduce the number of cavities and oral infections&#46; It is particularly important to establish a close relationship between the dentist and the rheumatologist in order to make an early and correct diagnosis&#44; promoting appropriate dietary and hygiene measures&#44; as well as to treat and prevent potential oral complications&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Sj&#246;gren primario &#40;SSp&#41; es una enfermedad autoinmune sist&#233;mica cr&#243;nica&#44; que cursa con destrucci&#243;n del tejido glandular lagrimal y salival&#46; Sus s&#237;ntomas m&#225;s frecuentes y tempranos son la sequedad oral y ocular&#46; La sequedad oral dificulta que el paciente hable&#44; deguste y mastique correctamente&#44; lo que disminuye la calidad de vida del enfermo&#46; Los signos y s&#237;ntomas orales m&#225;s frecuentes son la hiposialia con o sin xerostom&#237;a&#44; la caries dental&#44; las infecciones f&#250;ngicas&#44; las lesiones orales traum&#225;ticas&#44; la disfagia&#44; la disgeusia y la inflamaci&#243;n de las gl&#225;ndulas salivales&#46; Existen distintas estrategias terap&#233;uticas en funci&#243;n de la gravedad de cada caso que aumentan la cantidad de saliva y disminuyen el n&#250;mero de caries e infecciones orales&#46; Por ello&#44; es de especial importancia establecer una relaci&#243;n cercana entre el dentista y el reumat&#243;logo que permita hacer un diagn&#243;stico temprano y correcto&#44; fomentar las medidas diet&#233;ticas e higi&#233;nicas adecuadas&#44; tratar y prevenir las posibles complicaciones orales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez-Pintor RM&#44; Fern&#225;ndez Castro M&#44; Hern&#225;ndez G&#46; Afectaci&#243;n oral en el paciente con s&#237;ndrome de Sj&#246;gren primario&#46; Manejo multidisciplinar entre odont&#243;logos y reumat&#243;logos&#46; Reumatol Clin&#46; 2015&#59;11&#58;387&#8211;394&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ocular symptoms&#58; a positive response to at least one of the following questions&#58;Have you had daily&#44; persistent&#44; troublesome dry eyes for at least 3 months&#63;Do you have a recurrent sensation of sand or gravel in the eyes&#63;Do you use artificial tears more than 3 times a day&#63;Oral symptoms&#58; a positive response to at least one of the following questions&#58;Have you had a daily feeling of dry mouth for at least 3 months&#63;Do you had recurrent or persistent swelling of the salivary glands&#63;Do you frequently drink liquids to aid in swallowing dry food&#63;Ocular signs&#44; that is&#44; objective evidence of ocular involvement defined as a positive result for at least one of the following tests&#58;Schirmer&#39;s I test&#44; performed without anesthesia &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>mm in 5<span class="elsevierStyleHsp" style=""></span>min&#41;Rose bengal score or other ocular dye score &#40;&#62;4 according to van Bijsterveld&#39;s scoring system&#41;Histopathology of minor salivary glands &#40;obtained using apparently healthy mucosa&#41;&#58; focal lymphocytic sialoadenitis&#44; with a focus score<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#59; a focus is defined as an aggregate of at least 50 lymphocytes and the score&#44; as the number of such foci in a surface area of 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of minor salivary glandSalivary gland involvement&#44; objective evidence of salivary gland involvement defined by a positive result for at least one of the following diagnostic tests&#58;Unstimulated whole salivary flow &#40;&#60;1&#46;5<span class="elsevierStyleHsp" style=""></span>ml in 15<span class="elsevierStyleHsp" style=""></span>min&#41;Parotid sialography showing the presence of diffuse sialectasias &#40;punctate&#44; cavitary or destructive pattern&#41;&#44; with no evidence of obstruction in the major ducts&#44; according to the scoring system of Rubin and HoltSalivary scintigraphy showing a reduced concentration or delayed excretion of the tracer&#44; according to the method proposed by Schall et al&#46;Autoantibodies&#58; presence in serum of the following autoantibodies&#58;Antibodies to Ro&#40;SSA&#41; or La&#40;SSB&#41; antigens&#44; or bothRevised guidelines for the classification of primary Sj&#246;gren&#39;s syndrome&#58; in patients with no potentially associated disease&#44; primary Sj&#246;gren&#39;s syndrome should be defined as follows&#58;The presence of any 4 of the above 6 items indicating primary Sj&#246;gren&#39;s syndrome&#44; as long as item 4 &#40;histopathology&#41; and 6 &#40;serology&#41; are positiveThe presence of any 3 of the 4 objective criteria &#40;for example&#44; items 3&#44; 4&#44; 5 and 6&#41;The classification tree procedure represents a valid alternative method for classification&#44; although it should be properly used in clinical-epidemiological studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Primary Sj&#246;gren&#39;s Syndrome Proposed by the American-European Consensus Group&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:1 [
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">According to this group&#44; patients with Sj&#246;gren&#39;s syndrome should meet 2 of the following 3 conditions</span>&#58;Presence of anti-Ro&#47;SSA and&#47;or anti-La&#47;SSB or presence of rheumatoid factor and ANA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;320Keratoconjunctivitis sicca with ocular staining score of 3 or higher &#40;provided the individual is not currently using eye drops for glaucoma and has not had corneal surgery or cosmetic eyelid surgery during the preceding 5 years&#41;Minor salivary gland biopsy revealing focal lymphocytic sialadenitis with a focus score greater than 1 per 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> of gland tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Primary Sj&#246;gren&#39;s Syndrome Proposed by the American College of Rheumatology and Sj&#246;gren&#39;s International Collaborative Clinical Alliance&#46;</p>"
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anorexic agentsAnxiolyticsAnticonvulsantsTricyclic antidepressantsAntiemeticsAntihistaminicsAntiparkinsonian drugsAntipsychoticsBronchodilatorsDecongestantsDiureticsMuscle relaxantsNarcotic analgesicsSedativesAntihypertensive drugsAntiarthritic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Drugs Associated With the Presence of Xerostomia&#46;</p>"
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      ]
      10 => array:7 [
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Salivary hypofunctionCariesFungal infectionsOral traumaLip drynessOrofacial painDysphagiaDysgeusiaSwollen salivary glandsGastroesophageal refluxOral lesions of autoimmune etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Oral Signs and Symptoms in Patients With Primary Sj&#246;gren&#39;s Syndrome&#46;</p>"
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&#44; sporadic discomfort on eating dry or course foodsNo signs of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;25<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Education and modification of dietElimination&#44; if possible&#44; of xerostomia-related medicationAvoidance of alcohol and tobacco useHydration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild intermittent discomfort not only when eatingNo evidence of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#60;0&#46;25 and<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#60;1 and &#62;0&#46;7<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grade 1&#58;Use of sugarless chewing gum and sugarless lemon-flavored hard candyUse of saliva substitutes&#58; gel and spray&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent constant discomfort not only when eatingDifficulty in eating&#44; swallowing and speakingSigns of oral dryness can be observedUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;7<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grades 1 and 2&#58;Use of artificial salivaIf there is no improvement with artificial saliva&#44; use of systemic stimulants &#40;after salivary gland biopsy to determine whether there is a certain degree of salivary function&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Permanent discomfortGreat difficulty in eating&#44; swallowing and speakingAdvanced signs of oral drynessUnstimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05<span class="elsevierStyleHsp" style=""></span>ml&#47;minStimulated salivary flow<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Add to grades 1&#44; 2 and 3&#58;Consider the use of intraoral devices with artificial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Therapeutic Strategies to Increase Salivary Flow According to Severity of Oral Dryness in Patients With Primary Sj&#246;gren&#39;s Syndrome&#46;</p>"
        ]
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        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Secondary effects</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Profuse sweating&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nausea-vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sialorrhea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tearing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Miosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bradycardia&#47;tachycardia&#47;atrioventricular block&#47;other arrhythmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vasodilation&#47;flushing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polyuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nervousness&#47;seizures&#47;tremor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Constipation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Flu-like syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Contraindications</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Uncontrolled bronchial asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic obstructive pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Any eye disease in which the induction of miosis is contraindicated &#40;iritis&#44; angle closure glaucoma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pregnancy&#47;breastfeeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Allergic reaction to the drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Secondary Effects and Contraindications of Pilocarpine&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:38 [
            0 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification criteria of Sj&#246;gren&#39;s syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;V&#46; Goules"
                            1 => "A&#46;G&#46; Tzioufas"
                            2 => "H&#46;M&#46; Moutsopoulos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaut.2015.07.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Autoimmun"
                        "fecha" => "2014"
                        "volumen" => "48&#47;49"
                        "paginaInicial" => "42"
                        "paginaFinal" => "45"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26227560"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sj&#246;gren&#39;s syndrome&#58; an update on epidemiology and current insights on pathophysiology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "T&#46;R&#46; Reksten"
                            1 => "M&#46;V&#46; Jonsson"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.coms.2013.09.002"
                      "Revista" => array:6 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24287189"
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              ]
            ]
            2 => array:3 [
              "identificador" => "bib0205"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A clinicopathologic study of Mikulicz&#39;s disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;S&#46; Morgan"
                            1 => "B&#46; Castleman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13040489"
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                ]
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            ]
            3 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral manifestations and their treatment in Sj&#246;gren&#39;s syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46; Gonz&#225;lez"
                            1 => "H&#46; Sung"
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