Sjögren's syndrome is a chronic autoimmune disease that occurs when the body's immune system attacks moisture-producing glands, including the salivary (in the mouth) and lacrimal (tear-producing) glands of the eyes. This leads to a lack of saliva and tears production that causes painfully dry mouth and eyes. Over time, the autoimmune damage can progress to cause damage to the muscles, kidneys, intestines, liver, and other vital organs. A functional medicine approach to Sjögren's uncovers and addresses the root causes of autoimmunity and inflammation that underlie the disease.
The prevalence of Sjögren's is estimated to be approximately 3% of people 50 years or older, with around 10 million worldwide suffering from this condition. Close to 90 percent of patients with Sjögren's are female. While the onset can vary, symptoms most commonly begin in the 40s.
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Sjogren's Signs & Symptoms
The most common symptoms of Sjögren's syndrome are collectively called the sicca syndrome and include:
- Dry eyes (keratoconjunctivitis sicca) that can burn, feel gritty like there is sand in them, or itch.
- Dry mouth (xerostomia) can make it difficult to speak or swallow, cause a sore throat or mouth sores, or feel like it is full of cotton.
Over time, this dryness in the eyes and mouth can lead to further complications. Chronically dry eyes are at increased risk for infection and damage to the cornea (the eye's clear, protective outer layer).
Chronically dry mouth can lead to difficulty eating and swallowing. It may contribute to the development of tooth damage, such as dental cavities, chipping, breaking, and loss of teeth. A dry mouth may also increase the risk of gingivitis (gum inflammation) and oral yeast infections (candida) that may cause pain and burning.
The autoimmune attack that occurs in Sjögren's can also damage other parts of the body, including the:
- joints
- skin
- thyroid
- kidneys
- pancreas
- liver
- lungs
- sinuses
- blood vessels
- nerves (in the central nervous system and peripheral nervous system, including the autonomic nervous system)
In addition to the mouth and eyes, the skin and other mucous membranes, like the vagina, can become dry. Mucous membranes in the respiratory tract and throat can lead to a persistent dry cough. Joint and muscle pain and stiffness with mild swelling are common, even without co-occurring rheumatoid arthritis. Inflammation of small blood vessels (vasculitis) can cause rashes and tissue damage, most commonly on the lower legs. Sun-sensitive rashes may also occur, especially on the back, chest, face, and arms. Damage to nerves can result in peripheral neuropathy that causes numbness and tingling, especially in the feet.
Sjogren's Possible Causes
Sjögren's involves a dysregulated immune response where the body attacks itself. The autoimmune attack in Sjögren's occurs due to the interaction of different infectious, microbiome, and hormonal factors in someone with a genetic predisposition.
Other Autoimmune Diseases
The most common underlying correlation behind Sjogren's is other underlying autoimmune diseases.
About half of those with Sjögren's have other autoimmune connective tissue disorders, such as rheumatoid arthritis, lupus, and scleroderma. People with Celiac disease, autoimmune thyroid disease, antiphospholipid syndrome, and sarcoidosis are also at risk.
Genetic predisposition
Certain gene variations that influence the immune system (MHC class II gene region HLA-DR and HLA-DQ alleles) are associated with a greater risk of developing Sjögren's.
Infections
One risk factor for developing Sjögren's is exposure to viruses, including chronic hepatitis C virus, cytomegalovirus (CMV), and Epstein–Barr virus. These infections can provoke auto-antibody production due to molecular mimicry that initiates inflammation and autoimmunity that damage the moisture-secreting glands.
Microbiome
Emerging research shows that alterations in the diversity of the oral, ocular, and intestinal bacteria and other microbes (microbiota) play a role in the development of Sjögren's. Several factors influence the numbers, composition, and diversity of intestinal microbiota, such as gender, dietary habits, smoking, infections, age, stress, and other exposures. A healthy gut microbiome contains a high diversity of microbes. In contrast, a loss of diversity may lead to dysbiosis or imbalances between commensal and pathogenic bacteria that can contribute to inflammation and increase the risk of autoimmunity.
Risk Factors
- Sjögren's is more prevalent in women than in men (9:1)
- Other Underlying Autoimmune Diseases
Complications
A dry mouth can contribute to a higher risk of dental problems, such as tooth decay and infection, while dry eyes can increase the risk of eye infections or damage to the eye's outer surface (cornea).
Complications, such as pneumonia, pancreatitis, and vasculitis, may develop during the course of the disease.
How is Sjögren's Syndrome Diagnosed?
Diagnosis of Sjögren's is made by assessing symptoms, completing a physical examination, carrying out blood tests to look at specific types of antibodies, and conducting special studies to look for objective evidence of dry eyes and dry mouth.
The American College of Rheumatology/European League Against Rheumatism has developed international classification criteria for diagnosing Sjögren's. The classification requires four out of the six criteria. These include eye symptoms, eye signs, mouth symptoms, positive histopathology (markers seen on biopsied tissue looked at under the microscope), salivary gland involvement, and imaging of the salivary glands (sialography), or antibodies to anti-SSA and anti-SSB.
- Eye examinations can be done with special staining of the cornea (the clear protective outer layer of the eye) and conjunctiva (the white connective tissue covering the eyeball) that detect dry spots and damage to the outer surface of the eyes caused by chronic dryness.
- Blood tests can look for autoantibodies that are classic for Sjögren's, including anti-nuclear antibodies (ANA), anti-SSA/Ro, SSB/La antibodies, or rheumatoid factor.
- Biopsy of the minor salivary glands (usually taken from the inner lower lip) may also help to confirm a diagnosis, especially if autoantibodies are absent.
What Kind of Doctor Treats Sjögren's Syndrome?
Since Sjögren affects the body overall, a team of multiple specialty doctors is usually involved in managing the condition. These include rheumatologists who help to manage autoimmune and rheumatic conditions, ophthalmologists to assess the eyes, dentists to deal with damage to teeth and gums, otolaryngologists/ear, nose, and throat (ENT) doctors, and primary care physicians or internists. Many patients also seek help from Complementary and Alternative Medicine and Functional Medicine practitioners.
Functional Medicine Labs to Test for Root Cause of Sjogren's
Testing for Autoantibodies
Autoantibodies that are classic for Sjögren's can help assess the condition and other autoimmune diseases like lupus and rheumatoid arthritis. These can be detected by blood tests, including
- Anti-SSA/Ro and anti-SSB/La antibodies are specific antibodies for Sjögren's, with around seventy percent of patients positive for SS-A and 40 percent for SS-B;
- Anti-nuclear antibodies (ANA) react against normal components of cell nuclei and are present in about 80 percent of Sjögren's patients; and
- Rheumatoid factor is present in 75 to 95 percent of Sjogren's patients and can also indicate rheumatoid arthritis.
Assessing Organ Function and Inflammation
A complete blood count (CBC) and comprehensive metabolic profile (CMP), including liver function tests, help screen for liver and bile duct problems and assess electrolytes, blood glucose, and kidney health to look at any complications resulting from the condition.
Inflammation markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) assess inflammation levels throughout the body.
Screening for Infections
Since Hepatitis C viral infection seems to be involved in the development of Sjögren's in a subset of patients, blood tests can be used to detect current or past infection.
Similarly, infection with the Epstein-Barr virus (EBV) and cytomegalovirus (CMV), common members of the herpes virus family, may contribute to the development of Sjögren's syndrome by increasing the risk of an autoimmune attack on the body. Blood testing can assess past or active infection with EBV or CMV.
Microbiome and Gut Health
To assess the state of the microbiome, which is known to play a role in the development of Sjögren's, a comprehensive stool test can be used to measure amounts of healthy and unbalanced gut bacteria (dysbiosis), inflammatory markers, leaky gut, parasites, and yeast.
Conventional Treatment for Sjogren's
Depending on which parts of the body are impacted and the extent of the disease, conventional treatment for Sjögren's aims to decrease inflammation in affected glands, slow the progression of autoimmune attack, and increase moisture in the eyes and mouth.
Dry Eye Treatment
Prescription eye drops or artificial tears such as cyclosporine (Restasis) or lifitegrast (Xiidra) may be used to moisten the eyes and relieve irritation. Punctal plugs are small silicone plugs that can be inserted into the tear ducts to block the ducts, so tears stay on the eyes, keeping them moist. A similar approach can be taken with surgery to close the ducts permanently.
Treating Dry Mouth
Sucking on hard candies or chewing gum that contains sweeteners like sorbitol or xylitol may help increase saliva production. Medications such as pilocarpine (Salagen) and cevimeline (Evoxac) can increase the production of saliva and sometimes tears but often come with side effects such as increased sweating, abdominal pain, flushing, and frequent urination.
Treating Joint and Organ Complications
Conventional approaches to systemic complications like joint pain often involve nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, or other arthritis medications like hydroxychloroquine (Plaquenil) or methotrexate (Trexall) that suppress the immune system.
Functional Medicine Treatment for Sjogren's
Lifestyle Changes
Lifestyle factors play an essential role in managing the symptoms and disease course of Sjögren. Staying well hydrated and maintaining good dental hygiene helps to keep the mouth moist and prevents tooth decay. Nasal saline or hyaluronic acid spray can help moisturize and clear the nasal passages to allow for breathing freely through the nose and avoiding mouth breathing. Smoking should be avoided since it can irritate and dry out the mouth and contribute to inflammation in the body overall.
Anti-Inflammatory Diet
Studies show that an anti-inflammatory diet can help balance inflammation and improve the symptoms of dry eyes and mouth. This involves a diet rich in fruits and vegetables, whole grains, lean protein, healthful fats like olive oil, and especially foods rich in omega-3 fatty acids while reducing or excluding processed foods, conventionally-raised red meats, and alcohol.
Since gluten is a common trigger of autoimmunity, removing gluten can help heal the gut and improve chronic inflammation. Reducing processed and added sugar intake is also important for balancing inflammation and maintaining good dental health.
Omega-3 Fatty Acids
Omega-3 fatty acids are involved with the regulation of inflammation and immune responses as well as salivary flow, with some studies suggesting that patients with Sjögren's have a lower intake of these essential fatty acids. Omega-3 fatty acids are found in foods such as salmon and mackerel, walnuts, and flaxseeds.
Vitamin E
Similarly, vitamin E can positively affect salivary output, dry eye, and inflammation and is found in foods like sunflower seeds, almonds, avocados, spinach, butternut squash, broccoli, olive oil, trout, and shrimp or obtained via supplementation.
Vitamin D
Vitamin D modulates the immune system and helps to balance autoimmunity. Since vitamin D deficiency is associated with dry eyes, balancing levels via supplementation and natural sunlight exposure may help manage Sjögren's.
Balancing the Microbiome
Research involving other autoimmune conditions like rheumatoid arthritis show promise for utilizing prebiotics and probiotic supplementation to improve symptoms and laboratory markers of disease. Restoring equilibrium in the gut microbiota is critical for repairing the mucosal barrier and stopping autoimmunity and excess inflammation. This may be accomplished through an individualized balanced whole foods diet incorporating pre- and probiotic-rich foods as tolerated. Fermented foods like kimchi and sauerkraut contain naturally-occurring probiotics that enhance the microbiome, while prebiotic-rich foods like artichokes, garlic, and beans can provide nourishment for healthy bacteria.
Acupuncture
From a traditional Chinese medicine perspective, Sjögren's is characterized as "dry-Bi" or "dryness impediment" that manifests as Yin deficiency, fluid exhaustion, and Blood dryness. Research has shown that focused acupuncture combined with herbal medicine positively benefits patients with Sjögren's and improves dry eye symptoms.
Summary
Sjögren's is a chronic autoimmune disease that can affect the entire body. The causes of Sjögren's are multifactorial, involving a combination of environmental factors, such as infections, microbiome imbalances, and hormone fluctuations, in a genetically predisposed individual. This results in the immune system reacting to the body's tissues, creating antibodies directed against the glands in the eyes and mouth that secrete tears and saliva. The autoimmune attack and resulting inflammation cause the most common symptoms of dry mouth, dry eyes, fatigue, and musculoskeletal pain.
The goal of treatment is to address symptoms of dry eye and mouth, prevent complications of dryness, and manage any systemic manifestations.
A functional medicine approach to Sjögren's utilizes an anti-inflammatory diet rich in probiotics and prebiotics to balance the microbiome, regulate inflammation, and reduce autoimmunity. Supplementation with vitamins E and D and omega-3 fatty acids, acupuncture, and traditional Chinese herbal medicine have also shown promise for helping improve this condition.
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