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Oral, ocular symptoms among patients with RA may be secondary Sjögren’s syndrome
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Oral and ocular symptoms among patients with rheumatoid arthritis may be secondary Sjögren's syndrome and should be investigated with salivary biopsy, according to researchers at the Universidade Federal de Pernambuco in Brazil.
The researchers recruited 46 patients with rheumatoid arthritis (RA), 20 patients with RA and secondary Sjögren’s syndrome (sSS) from a rheumatology clinic and 52 healthy participants from an oral medicine unit. Eleven patients were men and 107 were women. Patients’ mean age was 50.4 years in the RA group, 57.7 years in the group with both RA and sSS, and 42.3 years among healthy participants.
Diagnosis of RA was made by a rheumatologist based on by the American College of Rheumatology (ACR) criteria. The diagnosis of sSS was made according to the classification criteria proposed by the American-European Consensus Group. Healthy participants were evaluated to exclude autoimmune disorders, and patients with history of head and neck radiation therapy, hepatitis-C, HIV/AIDs, a diagnosis of sarcoidosis, amyloidosis or graft-versus-host disease were excluded.
Minor salivary gland (MSG) biopsies were performed on all participants, and salivary flow was measured in the morning after patients were asked to refrain from eating, drinking or smoking for 90 minutes. Schirmer’s test was conducted with all participants to assess eye moisture. Laboratory data collected included antibodies against cyclic citrullinated peptides (anti-CCP), rheumatoid factor (RF), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
Disease activity score (DAS28) was calculated in patients. A DAS28 of up to 2.6 was considered remission. Low disease activity was considered a DAS28 2.6 to 3.2, moderate disease activity was a DAS28 of between 3.2 and 5.1, and high disease activity was a DAS28 5.1 or higher. Mean disease activity was higher in the group with RA compared with the group with RA and sSS, according to the researchers.
The researchers suggested MSG biopsies to all participants, but the procedure was required in patients with RA in whom a diagnosis of sSS had not been established. All biopsies were performed in the left lower lip by using a superficial linear incision to obtain a 1-mm to 2-mm sample 1 cm away from midline, and a minimum of four up to seven mucus salivary gland lobules were removed from the submucosa. Microscope analysis was performed by an oral pathologist.
Labial biopsies were performed in 22 patients with RA and in 18 patients with RA and sSS. Glandular infiltrate consistent with sSS was seen in four patients (18.2%) with RA and in seven (38.9%) of the patients with RA and sSS.
Xerophthalmia was reported by 39.1% of patients with RA and by 90% of patients with RA and sSS. Schirmer’s test revealed 95% of patients with RA and sSS and 39.5% of patients with RA met classification criteria.
Serum levels of RF and anti-CCP were higher in both subgroups of patients with RA, according to the researchers. Patients with RA who present a cluster of ocular and oral symptoms should be given a MSG, according to the researchers. - by Shirley Pulawski
Disclosure: The research was supported by the Brazilian National Council for Scientific and Technological Development (CNPq/No.481469/2012-5) and the Pernambuco Research Foundation (FACEPE/No.1978-4.02/12).
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