Sjögren's Syndrome (SHOW-grins)
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Sjögren's (SHOW-grins) syndrome is an autoimmune
disease--that is, a disease in which the immune system turns against the
body's own cells. In Sjögren's syndrome, the immune system targets
moisture-producing glands and causes dryness in the mouth and eyes.
Other parts of the body can be affected as well, resulting in a wide
range of possible symptoms.
Normally, the immune system works to protect us from
disease by destroying harmful invading organisms like viruses and
bacteria. In the case of Sjögren's syndrome, disease-fighting cells
attack the glands that produce tears and saliva (the lacrimal and
salivary glands). Damage to these glands keeps them from working
properly and causes dry eyes and dry mouth. In technical terms, dry eyes
are called keratoconjunctivitis sicca, or KCS, and dry mouth is called
xerostomia. Your doctor may use these terms when talking to you about
The disease can affect other glands too, such as those in
the stomach, pancreas, and intestines, and can cause dryness in other
places that need moisture, such as the nose, throat, airways, and
You might hear Sjögren's syndrome called a rheumatic
disease. A rheumatic disease causes inflammation in joints, muscles,
skin, or other body tissue, and Sjögren's can do that. The many forms of
arthritis, which often involve inflammation in the joints, among other
problems, are examples of rheumatic diseases. Sjögren's is also
considered a disorder of connective tissue, which is the framework of
the body that supports organs and tissues (joints, muscles, and
Sjögren's syndrome is classified as either primary
or secondary disease. Primary Sjögren's occurs by itself, and
secondary Sjögren's occurs with another disease. Both are systemic
disorders, although the symptoms in primary are more
In primary Sjögren's syndrome, the doctor can trace
the symptoms to problems with the tear and saliva glands. People
with primary disease are more likely to have certain antibodies
(substances that help fight a particular disease) circulating in
their blood than people with secondary disease. These antibodies
are called SS-A and SS-B. People with primary
Sjögren's are more likely to have antinuclear antibodies (ANAs) in
their blood. ANAs are autoantibodies, which are directed against
In secondary Sjögren's syndrome, the person had an
autoimmune disease like rheumatoid arthritis or lupus before
Sjögren's developed. People with this type tend to have more
health problems because they have two diseases, and they are also
less likely to have the antibodies associated with primary
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The main symptoms are
Dry eyes--Your eyes may be red and burn and itch.
People say it feels like they have sand in their eyes. Also, your
vision may be blurry, and bright light, especially fluorescent
lighting, might bother you.
Dry mouth--Dry mouth feels like a mouth full of
cotton. It's difficult to swallow, speak, and taste. Your sense of
smell can change, and you may develop a dry cough. Also, because you
lack the protective effects of saliva, dry mouth increases your
chances of developing cavities and mouth infections.
Both primary and secondary Sjögren's syndrome can affect
other parts of the body as well, including the skin, joints, lungs,
kidneys, blood vessels, and nervous system, and cause symptoms such
When Sjögren's affects other parts of the body, the
condition is called extraglandular involvement because the problems
extend beyond the tear and salivary glands. These problems are described
in more detail later.
Finally, Sjögren's can cause extreme fatigue that can
seriously interfere with daily life.
In the autoimmune attack that causes Sjögren's,
disease-fighting cells called lymphocytes target the glands that
produce moisture--primarily the lacrimal (tear) and salivary
(saliva) glands. Although no one knows exactly how damage occurs,
damaged glands can no longer produce tears and saliva, and eye and
mouth dryness result. When the skin, sinuses, airways, and vaginal
tissues are affected, dryness occurs in those places,
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Experts believe 1 to 4 million people have the disease.
Most--90 percent---are women. It can occur at any age, but it usually is
diagnosed after age 40 and can affect people of all races and ethnic
backgrounds. It's rare in children, but it can occur.
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Researchers think Sjögren's syndrome is caused by a
combination of genetic and environmental factors. Several different
genes appear to be involved, but scientists are not certain exactly
which ones are linked to the disease since different genes seem to play
a role in different people. For example, there is one gene that
predisposes Caucasians to the disease. Other genes are linked to
Sjögren's in people of Japanese, Chinese, and African American descent.
Simply having one of these genes will not cause a person to develop the
disease, however. Some sort of trigger must activate the immune
Scientists think that the trigger may be a viral or
bacterial infection. It might work like this: A person who has a
Sjögren's-associated gene gets a viral infection. The virus stimulates
the immune system to act, but the gene alters the attack, sending
fighter cells (lymphocytes) to the eye and mouth glands. Once there, the
lymphocytes attack healthy cells, causing the inflammation that damages
the glands and keeps them from working properly. These fighter cells are
supposed to die after their attack in a natural process called
apoptosis, but in people with Sjögren's syndrome, they continue to
attack, causing further damage. Scientists think that resistance to
apoptosis may be genetic.
The possibility that the endocrine and nervous systems
play a role is also under investigation.
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The doctor will first take a detailed medical history,
which includes asking questions about general health, symptoms, family
medical history, alcohol consumption, smoking, or use of drugs or
medications. The doctor will also do a complete physical exam to check
for other signs of Sjögren's.
You may have some tests, too. First, the doctor will want
to check your eyes and mouth to see whether Sjögren's is causing your
symptoms and how severe the problem is. Then, the doctor may do other
tests to see whether the disease is elsewhere in the body as well.
Common eye and mouth tests are
Schirmer test--This test measures tears to see
how the lacrimal gland is working. It can be done in two ways: In
Schirmer I, the doctor puts thin paper strips under the lower eyelids
and measures the amount of wetness on the paper after 5 minutes.
People with Sjögren's usually produce less than 8 millimeters of
tears. The Schirmer II test is similar, but the doctor uses a cotton
swab to stimulate a tear reflex inside the nose.
Staining with vital dyes (rose bengal or lissamine
green)--The tests show how much damage dryness has done to the
surface of the eye. The doctor puts a drop of a liquid containing a
dye into the lower eye lid. These drops stain on the surface of the
eye, highlighting any areas of injury.
Slit lamp examination--This test shows how severe
the dryness is and whether the outside of the eye is inflamed. An
ophthalmologist (eye specialist) uses equipment that magnifies to
carefully examine the eye.
Mouth exam--The doctor will look in the mouth for
signs of dryness and to see whether any of the major salivary glands
are swollen. Signs of dryness include a dry, sticky mouth; cavities;
thick saliva, or none at all; a smooth look to the tongue; redness in
the mouth; dry, cracked lips; and sores at the corners of the mouth.
The doctor might also try to get a sample of saliva to see how much
the glands are producing and to check its quality.
Salivary gland biopsy of the lip--This test is
the best way to find out whether dry mouth is caused by Sjögren's
syndrome. The doctor removes tiny minor salivary glands from the
inside of the lower lip and examines them under the microscope. If the
glands contain lymphocytes in a particular pattern, the test is
positive for Sjögren's syndrome.
Because there are many causes of dry eyes and dry mouth,
the doctor will take other possible causes into account. Generally, you
are considered to have definite Sjögren's if you have dry eyes, dry
mouth, and a positive lip biopsy. But the doctor may decide to do
additional tests to see whether other parts of the body are affected.
These tests may include
Routine blood tests--The doctor will take blood
samples to check blood count and blood sugar level, and to see how the
liver and kidneys are working.
Immunological tests--These blood tests check for
antibodies commonly found in the blood of people with Sjögren's
syndrome. For example:
Antithyroid antibodies are created when
antibodies migrate out of the salivary glands into the thyroid gland.
Antithyroid antibodies cause thyroiditis (inflammation of the
thyroid), a common problem in people with Sjögren's.
Immunoglobulins and gamma globulins are
antibodies that everyone has in their blood, but people with Sjögren's
usually have too many of them.
Rheumatoid factors (RFs) are found in the blood
of people with rheumatoid arthritis, as well as in people with
Sjögren's. Substances known as cryoglobulins may be detected; these
indicate risk of lymphoma.
Similarly, the presence of antinuclear antibodies
(ANAs) can indicate an autoimmune disorder, including
Sjögren's antibodies, called SS-A (or
SS-Ro) and SS-B (or SS-La), are specific
antinuclear antibodies common in people with Sjögren's. However, you
can have Sjögren's without having these ANAs.
Chest x ray--Sjögren's can cause inflammation in
the lungs, so the doctor may want to take an x ray to check
Urinalysis--The doctor will probably test a
sample of your urine to see how well the kidneys are working.
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Because the symptoms of Sjögren's are similar to those of
many other diseases, getting a diagnosis can take time--in fact, the
average time from first symptom to diagnosis ranges from 2 to 8 years.
During those years, depending on the symptoms, a person might see a
number of doctors, any of whom may diagnose the disease and be involved
in treatment. Usually, a rheumatologist (a doctor who specializes in
diseases of the joints, muscles, and bones) will coordinate treatment
among a number of specialists. Other doctors who may be involved
Dermatologist (skin specialist)
Gastroenterologist (digestive disease
Gynecologist (women's reproductive health
Neurologist (nerve and brain specialist)
Ophthalmologist (eye specialist)
Otolaryngologist (ear, nose, and throat
Pulmonologist (lung specialist)
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Treatment is different for each person, depending on what
parts of the body are affected. But in all cases, the doctor will help
relieve your symptoms, especially dryness. For example, you can use
artificial tears to help with dry eyes and saliva stimulants and mouth
lubricants for dry mouth. Treatment for dryness is described in more
If you have extraglandular involvement, your doctor--or
the appropriate specialist--will also treat those problems. Treatment
may include nonsteroidal anti-inflammatory drugs for joint or muscle
pain, saliva- and mucus-stimulating drugs for nose and throat dryness,
and corticosteroids or drugs that suppress the immune system for lung,
kidney, blood vessel, or nervous system problems. Hydroxychloroquine,
methotrexate, and cyclophosphamide are examples of such
immunosuppressants (drugs that suppress the immune system).
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Artificial tears can help. They come in different
thicknesses, so you may have to experiment to find the right one. Some
drops contain preservatives that might irritate your eyes. Drops without
preservatives don't usually bother the eyes. Nonpreserved tears
typically come in single-dose packages to prevent contamination with
At night, an eye ointment might provide more relief.
Ointments are thicker than artificial tears and moisturize and protect
the eye for several hours. They may blur your vision, which is why some
people prefer to use them while they sleep.
Hydroxypropyl methylcellulose (Lacriserts*) is a chemical
that lubricates the surface of the eye and slows the evaporation of
natural tears. It comes in a small pellet that you put in your lower
eyelid. When you add artificial tears, the pellet dissolves and forms a
film over your own tears that traps the moisture.
Another alternative is surgery to close the tear ducts
that drain tears from the eye. The surgery is called punctal occlusion.
For a temporary closure, the doctor inserts collagen or silicone plugs
into the ducts. Collagen plugs eventually dissolve, and silicone plugs
are "permanent" until they are removed or fall out. For a longer lasting
effect, the doctor can use a laser or cautery to seal the ducts.
* Brand names included in this booklet are
provided as examples only, and their inclusion does not mean that these
products are endorsed by the National Institutes of Health or any other
Government agency. Also, if a particular brand name is not mentioned,
this does not mean or imply that the product is
Don't use artificial tears that irritate your
eyes--try another brand or preparation.
Nonpreserved drops may be more
Blink several times a minute while reading or
working on the computer.
Protect your eyes from drafts, breezes, and
Put a humidifier in the rooms where you spend the
most time, including the bedroom, or install a humidifier in
your heating and air conditioning unit.
Don't smoke and stay out of smoky
Apply mascara only to the tips of your lashes so
it doesn't get in your eyes. If you use eyeliner or eye shadow,
put it only on the skin above your lashes, not on the sensitive
skin under your lashes, close to your eyes.
Ask your doctor whether any of your medications
contribute to dryness and, if so, how to reduce that effect.
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If your salivary glands still produce some saliva, you can
stimulate them to make more by chewing gum or sucking on hard candy.
However, gum and candy must be sugar free because dry mouth makes you
extremely prone to cavities. Take sips of water or another sugar free
drink often throughout the day to wet your mouth, especially when you
are eating or talking. Note that you should take sips of water--drinking
large amounts of liquid throughout the day will not make your mouth any
less dry. It will only make you urinate more often and may strip your
mouth of mucus, causing even more dryness. You can soothe dry, cracked
lips by using oil- or petroleum-based lip balm or lipstick. If your
mouth hurts, the doctor may give you medicine in a mouth rinse,
ointment, or gel to apply to the sore areas to control pain and
If you produce very little saliva or none at all, your
doctor might recommend a saliva substitute. These products mimic some of
the properties of saliva, which means they make the mouth feel wet, and
if they contain fluoride, they can help prevent cavities. Gel-based
saliva substitutes tend to give the longest relief, but all saliva
products are limited since you eventually swallow them.
At least two drugs that stimulate the salivary glands to
produce saliva are available. These are pilocarpine and cevimeline. The
effects last for a few hours, and you can take them three or four times
a day. However, they are not suitable for everyone, so talk to your
doctor about whether they might help you.
People with dry mouth can easily get mouth infections.
Candidiasis, a fungal mouth infection, is one of the most commonly seen
in people with Sjögren's. It most often shows up as white patches inside
the mouth that you can scrape off, or as red, burning areas in the
mouth. Candidiasis is treated with antifungal drugs. Various viruses and
bacteria can also cause infections; they're treated with the appropriate
antiviral or antibiotic medicines.
Natural saliva contains substances that rid the
mouth of the bacteria that cause cavities and mouth infections, so
good oral hygiene is extremely important when you have dry mouth.
Here's what you can do to prevent cavities and infections:
Visit a dentist at least three times a year to
have your teeth examined and cleaned.
Rinse your mouth with water several times a day.
Don't use mouthwash that contains alcohol because alcohol is
Use fluoride toothpaste to gently brush your
teeth, gums, and tongue after each meal and before bedtime.
Nonfoaming toothpaste is less drying.
Floss your teeth every day.
Avoid sugar. That means choosing sugar-free gum,
candy, and soda. If you do eat or drink sugary foods, brush your
teeth immediately afterward.
Look at your mouth every day to check for redness
or sores. See a dentist right away if you notice anything
unusual or have any mouth pain or bleeding.
Ask your dentist whether you need to take fluoride
supplements, use a fluoride gel at night, or have a protective
varnish put on your teeth to protect the enamel.
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The autoimmune response that causes dry eyes and mouth can
cause inflammation throughout the body. People with Sjögren's often have
skin, lung, kidney, and nerve problems, as well as disorders of the
digestive system and connective tissue. Following are examples of
About half of the people who have Sjögren's have dry skin.
Some experience only itching, but it can be severe. Others develop
cracked, split skin that can easily become infected. Infection is a risk
for people with itchy skin, too, particularly if they scratch
vigorously. The skin may darken in infected areas, but it returns to
normal when the infection clears up and the scratching stops.
To treat dry skin, apply heavy moisturizing creams and
ointments three or four times a day to trap moisture in the skin.
Lotions, which are lighter than creams and ointments, aren't recommended
because they evaporate quickly and can contribute to dry skin. Also,
doctors suggest that you take only a short shower (less than 5 minutes),
use a moisturizing soap, pat your skin almost dry, and then cover it
with a cream or ointment. If you take baths, it's a good idea to soak
for 10 to 15 minutes to give your skin time to absorb moisture. Having a
humidifier in the bedroom can help hydrate your skin, too. If these
steps don't help the itching, your doctor might recommend that you use a
skin cream or ointment containing steroids.
Some patients who have Sjögren's, particularly those who
have lupus, are sensitive to sunlight and can get painful burns from
even a little sun exposure, such as through a window. So, if you're
sensitive to sunlight, you need to wear sunscreen (at least SPF 15)
whenever you go outdoors and try to avoid being in the sun for long
periods of time.
Vaginal dryness is common in women with Sjögren's
syndrome. Painful intercourse is the most common complaint. A vaginal
moisturizer helps retain moisture, and a vaginal lubricant can make
intercourse more comfortable. Vaginal moisturizers attract liquid to the
dry tissues and are designed for regular use. Vaginal lubricants should
be used only for intercourse--they don't moisturize. Oil-based
lubricants, such as petroleum jelly, trap moisture and can cause sores
and hinder the vagina's natural cleaning process. A water-soluble
lubricant is better.
Regular skin creams and ointments relieve dry skin on the
outer surface of the vagina (the vulva).
Dry mouth can cause lung problems. For example, aspiration
pneumonia can happen when a person breathes in food instead of
swallowing it (dry mouth can keep you from swallowing food properly),
and the food gets stuck in the lungs. Pneumonia can also develop when
bacteria in the mouth migrate into the lungs and cause infection, or
when bacteria get into the lungs and coughing doesn't remove them. (Some
people with Sjögren's don't produce enough mucus in the lungs to remove
bacteria, and others are too weak to be able to cough.) Pneumonia is
treated with various antibiotics, depending on the person and the type
of infection. It is important to get treatment for pneumonia to prevent
lung abscess (a hole in the lung caused by severe infection).
People with Sjögren's also tend to have lung problems
caused by inflammation, such as bronchitis (affecting the bronchial
tubes), tracheobronchitis (affecting the windpipe and bronchial tubes),
and laryngotracheobronchitis (affecting the voice box, windpipe, and
bronchial tubes). Depending on your condition, the doctor may recommend
using a humidifier, taking medicines to open the bronchial tubes, or
taking corticosteroids to relieve inflammation. Pleurisy is inflammation
of the lining of the lungs and is treated with corticosteroids and
nonsteroidal antiinflammatory drugs.
People with Sjögren's can develop hoarseness if
their vocal cords become inflamed as part of the disease or become
irritated from throat dryness or coughing. To prevent further
strain on your vocal cords, try not to clear your throat before
speaking. Instead, take a sip of water, chew gum, or suck on
candy. Or else make an "h" sound, hum, or laugh to gently bring
the vocal cords together so you can get sound out. Clearing your
throat does the same thing, but it's hard on the vocal cords, and
you want to avoid irritating them further.
The kidneys filter waste products from the blood and
remove them from the body through urine. The most common kidney problem
in people with Sjögren's is interstitial nephritis, or inflammation of
the tissue around the kidney's filters, which can occur even before dry
eyes and dry mouth. Inflammation of the filters themselves, called
glomerulonephritis, is less common. Some people develop renal tubular
acidosis, which means they can't get rid of certain acids through urine.
The amount of potassium in their blood drops, causing an imbalance in
blood chemicals that can affect the heart, muscles, and nerves.
Often, doctors do not treat these problems unless they
start to affect kidney function or cause other health problems. However,
they keep a close eye on the problem through regular exams, and will
prescribe medicines called alkaline agents to balance blood chemicals
when necessary. Corticosteroids or immunosuppressants are used to treat
more severe cases.
People with Sjögren's syndrome can have nerve problems.
When they do, the problem usually involves the peripheral nervous system
(PNS), which contains the nerves that control sensation and movement.
Involvement of the PNS is increasingly being recognized. Carpal tunnel
syndrome, peripheral neuropathy, and cranial neuropathy are examples of
peripheral nervous system disorders that occur in people with Sjögren's.
In carpal tunnel syndrome, inflamed tissue in the forearm presses
against the median nerve, causing pain, numbness, tingling, and
sometimes muscle weakness in the thumb and index and middle fingers. In
peripheral neuropathy, an immune attack damages nerves in the legs or
arms, causing the same symptoms there. (Sometimes nerves are damaged
because inflamed blood vessels cut off their blood supply.) In cranial
neuropathy, nerve damage causes face pain; loss of feeling in the face,
tongue, eyes, ears, or throat; and loss of taste and smell.
Nerve problems are treated with medicines to control pain
and, if necessary, with steroids or other drugs to control
Inflammation in the esophagus, stomach, pancreas, and
liver can cause problems like painful swallowing, heartburn, abdominal
pain and swelling, loss of appetite, diarrhea, and weight loss. It can
also cause hepatitis (inflammation of the liver) and cirrhosis
(hardening of the liver). Sjögren's is closely linked to a liver disease
called primary biliary cirrhosis (PBC), which causes itching, fatigue,
and, eventually, cirrhosis. Many patients with PBC have Sjögren's.
Treatment varies, depending on the problem, but may
include pain medicine, anti-inflammatory drugs, steroids, and
Connective tissue is the framework of the body that
supports organs and tissues. Examples are joints, muscles, bones, skin,
blood vessel walls, and the lining of internal organs. Many connective
tissue disorders are autoimmune diseases, and several are common among
people with Sjögren's:
Polymyositis is an inflammation of the muscles
that causes weakness and pain, difficulty moving, and, in some cases,
problems breathing and swallowing. If the skin is inflamed too, it's
called dermatomyositis. The disease is treated with corticosteroids
In Raynaud's phenomenon, blood vessels in the
hands, arms, feet, and legs constrict (narrow) when exposed to cold.
The result is pain, tingling, and numbness. When vessels constrict,
fingers turn white. Shortly after that, they turn blue because of
blood that remained in the tissue pools. When new blood rushes in, the
fingers turn red. The problem is treated with medicines that dilate
blood vessels. Raynaud's phenomenon usually occurs before dryness of
the eyes or mouth.
Rheumatoid arthritis (RA) is severe inflammation
of the joints that can eventually deform the surrounding bones
(fingers, hands, knees, etc.). RA can also damage muscles, blood
vessels, and major organs. Treatment depends on the severity of the
pain and swelling and which body parts are involved. It may include
physical therapy, aspirin, rest, nonsteroidal anti-inflammatory
agents, steroids, or immunosuppressants.
Scleroderma causes the body to accumulate too
much collagen, a protein commonly found in the skin. The result is
thick, tight skin and damage to muscles, joints, and internal organs
such as the esophagus, intestines, lungs, heart, kidneys, and blood
vessels. Treatment is aimed at relieving pain and includes drugs, skin
softeners, and physical therapy.
Systemic lupus erythematosus (SLE) causes joint
and muscle pain, weakness, skin rashes, and, in more severe cases,
heart, lung, kidney, and nervous system problems. As with RA,
treatment for SLE depends on the symptoms and may include aspirin,
rest, steroids, and anti-inflammatory and other drugs, as well as
dialysis and high blood pressure medicine.
Vasculitis is an inflammation of the blood
vessels, which then become scarred and too narrow for blood to get
through to reach the organs. In people with Sjögren's, vasculitis
tends to occur in those who also have Raynaud's phenomenon and lung
and liver problems.
Autoimmune thyroid disorders are common with
Sjögren's. They can appear as either the overactive thyroid of Graves'
disease or the underactive thyroid of Hashimoto's. Nearly half of the
people with autoimmune thyroid disorder also have Sjögren's, and many
people with Sjögren's show evidence of thyroid disease.
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About 5 percent of people with Sjögren's develop cancer of
the lymph nodes, or lymphoma. The most common symptom of lymphoma is a
painless swelling of the lymph nodes in the neck, underarm, or groin. In
Sjögren's syndrome, when lymphoma develops it often involves the
salivary glands. Persistent enlargement of the salivary glands should be
investigated further. Other symptoms may include the following:
These symptoms are not sure signs of lymphoma. They may be
caused by other, less serious conditions, such as the flu or an
infection. If you have these symptoms, see a doctor so that any illness
can be diagnosed and treated as early as possible.
If you're worried that you might develop lymphoma, talk to
your doctor to learn more about the disease, symptoms to watch for, any
special medical care you might need, and what you can do to relieve your
Certain drugs can contribute to eye and mouth
dryness. If you take any of the drugs listed below, ask your
doctor whether they could be causing symptoms. However, don't stop
taking them without asking your doctor--he or she may already have
adjusted the dose to help protect you against drying side effects
or chosen a drug that's least likely to cause dryness.
Drugs that can cause dryness include
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Through basic research on the immune system, autoimmunity,
genetics, and connective tissue diseases, researchers continue to learn
more about Sjögren's syndrome. As they get a better understanding of the
genes involved and which environmental factors trigger disease and how,
they'll be able to develop more effective treatments. For example, gene
therapy studies suggest that we may someday be able to insert molecules
into salivary glands that will control inflammation and prevent their
destruction. Other research focuses on how the immune and hormonal
systems work in people who have Sjögren's and on the natural history of
the disease (learning how it affects people by following those who have
Researchers are also looking into the use of the salivary
stimulant pilocarpine for dry eyes. Other researchers are testing immune
modulating drugs to treat the glandular inflammation. A drug called
cevimeline has recently been approved for treating dry mouth. Work on
developing an artificial salivary gland is in progress.
The National Institute of Dental and Craniofacial Research
is conducting several studies on Sjögren's syndrome designed to help
scientists better understand, manage, and treat the disease. Some focus
on the disease's natural history, while others test potential new
treatments. Talk to your doctor if you'd like more information about
these clinical trials.
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The following organizations have information relevant to
American Academy of Dermatology
American Academy of Ophthalmology
American Association for Dental Research
American College of Rheumatology
American Dental Association
National Eye Institute
National Institute of Allergy and Infectious
National Institute of Arthritis
and Musculoskeletal and Skin Diseases Information Clearinghouse
National Institute of Dental and Craniofacial
National Institute of
Neurological Disorders and Stroke
American Autoimmune Related
Lupus Foundation of America,
The Myositis Association
for Rare Disorders, Inc.
Scleroderma Research Foundation
Sjögren's Syndrome Foundation
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