This document discusses Sjogren's syndrome, halitosis, and treatment of oral submucous fibrosis. It provides information on: Sjogren's syndrome - An autoimmune disease that attacks the exocrine glands. It most commonly affects women after menopause. Causes include genetic and environmental factors. Symptoms include dry mouth and eyes. Halitosis - Bad breath from oral or non-oral sources. Intraoral causes include poor oral hygiene, periodontal disease, and tongue coating. Extraoral causes include gastrointestinal and respiratory issues. Volatile sulfur compounds produced by bacteria are the main contributors to odor. Treatment of oral submucous fibrosis - There is no surgery available

2. Sjogren syndrome,
Halitosis &
Treatment of OSF
Dr. Tahmasub Faraz Tayyab
BDS, FCPS (OMFS)

3. Sjögren's syndrome
 Pronounced as “shohgrinz syndrome”.
 It is an autoimmune disease in which immune cells attack
and destroy the exocrine glands.
 It is the second most common autoimmune disease after
SLE (Systemic lupus erythematous).
 Although Sjögren's occurs in all age groups in men and
women, it is most common in women.
 Nine out of ten Sjögren's patient are women and the
average age of onset is after the menopause.

4. Causes of Sjögren's syndrome
 The cause of Sjögren's syndrome is not exactly known.
 Maybe by a combination of genetic and environmental
factors.
 Only the presence of the gene doesn’t cause Sjögren's
syndrome. An external trigger is said to activate the
immune system.
 The immune system responds even when there are no
foreign substances to fight off.
 This inflammatory response causes the body’s white blood
cells to attack and destroy certain moisture producing
glands.

6. Clinical Types
 This disease is caused by an immune-mediated inflammation of
salivary,lacrimal and sweat glands as Sicca Syndrome or with internal
organ involvement.
Clinical Types
 PRIMARY SS - Alone.
 SECONDARY SS - associated underlying connective tissue
diseases (RA / SLE / Scleroderma )
 SICCA SYNDROME – Xerophthalmia + Xerostomia – Internal
Organ / Bone Inv

8. Signs and symptoms
 The hall mark symptom of this disease is
generalized dryness.
 Dryness of :
 Mouth (Xerostomia) Eye (Keratoconjuctivitis sicca)

9. Signs and symptoms
 Teeth – multilpe carries and early loss

10. Signs and symptoms
 Chronic oral candidiasis is frequent.
 Parotid Gland Enlargement

11. Signs and symptoms
SKIN MANIFESTATIONS (50%)
Xeroderma, pruritus and scaling
Annular erythema, Papular Erythema including Sweet’s-like
lesions.
Raynaud’s syndrome
Hyperglobulinemic Purpura
Vitiligo
Sweating abnormalities
Cutaneous Amyloidosis
Alopecia—diffuse and generalized

12. Signs and symptoms
Other Manifestations
Joint symptoms: Arthralgia and arthritis
Myalgia and myositis
ENT : Sinusitis / Hearing Loss
GI : GERD , Esophageal spasm and dysmotility , Celiac disease
Resp : Interstitial pneumonitis, pulmonary fibrosis and pulmonary hypertension
xerotrachea
Nephro : Interstitial nephritis, Renal Tubular Acidosis
Neuro : migraine, neuropathies, cerebral vasculitis
Risk of lymphoma is 44 times greater than the general population.

13. Diagnosis
 SS patients of both primary and secondary Sjögren’s syndrome have marked
hypergammaglobulinemia (IgG>IgA>IgM),ANA(>50%) elevated total protein and
sedimentation rate.
 Anti-Ro and Anti-La Antibodies occur in approximately 60% of patients with
Sjögren's syndrome
 Histolgy of skin shows an absence of sebaceous glands and decrease in the
sweat glands

14. Diagnosis
Biopsy of labial salivary glands
 lymphocytic and plasma cells infiltrate,
Two excretory ducts and 3 mucous salivary gland acini are seen

15. Diagnosis
SCHIRMER’S TEST
This test consists of placing a small strip of filter paper
inside the lower eyelid (conjunctiva sac). The eyes are
closed for 5 minutes. The paper is then removed and
the amount of moisture is measured. <5 mm in 5
minutes is positive for SS

16. Rose Bengal Dye Test
 Rose Bengal (4,5,6,7-tetrachloro-2',4',5',7'-tetraiodofluorescein) is a stain.
Its sodium salt is commonly used in eye drops to stain damaged
conjunctiva and corneal cells and thereby identify damage to the eye.

18. Revised classification criteria for
Sjogren’s Syndrome
1. Ocular symptoms : at least one of -
 Dry eyes for more than 3 months
 Sensation of sand or gravel in the eyes
 Need for tear substitutes more than 3 times a day
2. Oral Symptoms : at least one of –
 Dry mouth for more than 3 months
 Recurrently or Persistently swollen salivary glands
 Need liquids to swallow dry food
3. Ocular Signs –at least one the following two tests positive
 Schirmer’s test
 Rose Bengal score

19. Revised classification criteria for
Sjogren’s Syndrome
4. Histopathology: in minor salivary glands, focal lymphocytic sialoadenitis (focus score ≥1).
5. Salivary gland involvement: a positive result for at least one of the following diagnostic
tests:
1 Unstimulated whole salivary flow (≤1.5 ml in 15 min)
2 Parotid sialography showing punctate,
cavitary, or destructive pattern, without evidence of obstruction in the major ducts
3 Salivary scintigraphy showing delayed uptake, reduced concentration
6. Laboratory Abnormality (one must be present)
Anti-SS-A(Ro) or Anti SS-B(La)(more specific)
ANA
IgM rheumatoid factor

21. Criteria
For primary SS
 In patients without any potentially associated disease, primary SS may be
defined as follows:
 a. The presence of any four of the six items is indicative of primary SS, as long
as either item 4 (Histopathology) or 6 (Serology) is positive.
 b. The presence of any three of the four objective criteria items (that is, items
3, 4, 5, 6)
For secondary SS
 In patients with a potentially associated disease, the presence of item 1 or item
2 plus any two from among items 3, 4, and 5 may be considered as indicative of
secondary SS

23. Treatment for dry skin
 There is no surgery available for treating dry skin.
Some moisture providing
Substitutes are:
 Heavy moisturizers.
 Use of sunscreen with at
least SPF 15.

24. Treatment for dry eyes
Artificial tears.
 To provide moisture to the eyes.
 Cyclosporine eye drops reduce
inflammation of tear glands.
Moisture chamber spectacles.

25. Surgery for eyes
 Plugging of tear ducts
 It reduces the mount of tears
drained from the eye.
 Collagen or silicone plugs are
inserted into the ducts for a
temporary closure.
 Collagen plug eventually dissolves
but silicone plug stays until they fall
out or are removed.

26. Halitosis

27. Halitosis
 Halitosis is a general term used to define an unpleasant or
offensive odour emanating from the breath regardless of
whether the odour originates from oral or non-oral sources
 Originates from two Latin words
 Halitus → breath
 Osis → disease
 odur originates from oral or non-oral sources
 Halitosis is a crippling social problem with a common complaint
of up to one-third of the general population

28. Terminology

29. Classification
• Genuine halitosis
 Physiologic halitosis
 Pathologic halitosis
(i) Intra-oral (80-90%)
(ii) Extra-oral (10-20%)
• Pseudo halitosis
• Halitophobia.

31. Genuine halitosis
 Physiological halitosis
 Morning breath odour, tobacco smoking & certain foods &
medications.
 Pathological halitosis
 intra oral or extra oral origin
 90% of patients → oral cavity
 Bacteria, volatile sulphur compounds.

32. Intra oral origin
 poor oral hygiene, dental caries, periodontal diseases in
particular NUG, NUP, periodontitis, pericoronitis, dry socket,
other oral infections, tongue coating & oral carcinoma.
 The role of tongue coatings in the aetiology of oral malodour
has been extensively documented.
 Tongue coatings include desquamated epithelial cells, food
debris, bacteria and salivary proteins and provide an ideal
environment for the generation of VSCs and other compounds
that contribute to malodour

33. Extra oral origin
 10-20%
 gastro intestinal diseases
 infections or malignancy in respiratory tract
 Chronic sinusitis and tonsillitis
 stomach, intestine, liver or kidney affected by systemic diseases

34. Examples of systemic pathological conditions
that cause halitosis
 Systemic condition Characteristic odour
Diabetes mellitus Acetone , sweet fruity.
Renal failure Urine or ammonia
Liver failure Fresh cadaver
Tuberculosis/ lung abscess Foul, putrefactive
Internal hemorrhage/ blood disorders Decomposed blood
Fever , dehydration Odour due to xerostomia and poor oral
hygiene

35. Pseudo halitosis
 Apparently healthy individuals
Halitophobia
 exaggerated fear of having halitosis
 also referred as delusional halitosis
 considered variant of monosymptomatic hypochondrial psychosis.

36. Etiology
 Halitosis generally arises as a result of the bacterial
decomposition of food particles, cells, blood and some chemical
compounds of the saliva.
 Moss, 1998

37. Etiology (Contd.)
 Volatile sulphur compounds → hydrogensulphide [H2S, rotten
egg smell], dimethyl sulphide [(CH3)2S, rotten cabbage smell,
and methyl mercaptan [CH3SH, fecal smell].
 Non - sulphur containing substances → diamines [cadaverine
(cadaver smell) and putrescine (rotting meat smell), acetone and
acetaldehyde

38. Etiology (Contd.)
 Common causes of halitosis
1) Local Causes
A
Oral
diseases
Food
impaction
ANUG
Acute
gingivitis
Adult and
aggressive
periodontitis
Pericoronitis
Dry socket
Xerostomia
Oral
ulceration
Oral
malignancy

39. B

40.  C
VOLATILE
FOOD STUFF
GARLIC ONIONS SPICES

41.  2) SYSTEMIC CAUSES
Acute febrile illness
Leukaemias
Respiratory tract infection (usually upper)
Helicobacter pylori infection
Pharyngo-oesophageal diverticulum
Gastro-oesophageal reflux disease
Pyloric stenosis or duodenal obstruction
Hepatic failure (fetor hepaticus)
Renal failure (end stage)
Diabetic ketoacidosis
Trimethylaminuria
Hypermethioninaemia
Menstruation (menstrual breath)

42. Role of volatile sulphur compounds in the
pathogenesis of halitosis
Major compounds implicated in halitosis
 VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl sulfide &
Dimethyl disulfide.
 Polyamides - Putrescein, Cadaverine, Skatole, Indole.
 Short chain FA - Butyric, Propionic, Valeric & Isovaleric acid.
 Others - Acetone, Acetaldehyde, Ethanol diacyl.

43.  It increases the permeability of oral mucosa and crevicular
epithelium. It impairs oxygen utilization by host cells, and reacts
with cellular proteins, and interferes with collagen maturation.
 It also increases the collagen solubility.
 It decrease the DNA synthesis.
 It increases the secretion of collagenases, prostaglandins from
fibroblasts.
 VSC reduce the intracellular pH; inhibit cell growth, and
periodontal cell migration.

44. Diet
+bacteria+
epithelial
cells
Peptides/
proteins Amino acids
Putrefaction
products
Oral
malodor

45. Diagnosis
Self assessment tests
Whole mouth malodor (Cupped breath)
The subjects are instructed to smell the odor emanating from their
entire mouth by cupping their hands over their mouth and
breathing through the nose. The presence or absence of malodor
can be evaluated by the patient himself/herself.

46. Wrist lick test
Subjects are asked to extend their tongue and lick their wrist in a
perpendicular fashion. The presence of odor is judged by smelling
the wrist after 5 seconds at a distance of about 3 cm.

47. Spoon test
Plastic spoon is used to scrape and scoop material from the back
region of the tongue. The odor is judged by smelling the spoon
after 5 seconds at a distance of about 5 cm organoleptically.

48. Saliva odor test
Involves having the subject expectorate approx. 1-2 ml of saliva
into a petridish. The dish is covered immediately, incubated at 370
C for five minutes and then presented for odor evaluation at a
distance of 4 cm from the examiner’s nose.

49. Dental floss test
Unwaxed floss is passed through interproximal contacts.

50. OBJECTIVE TESTS
 Organoleptic measurement
 Gas chromatography (GC)
 Sulphide monitoring

51. Organoleptic measurement (sniff test)
 Organoleptic measurement is a sensory test scored on the basis of
the examiner’s perception of a subject’s oral malodor.
 Organoleptic measurement can be carried out simply by sniffing
the patient’s breath and scoring the level of oral malodor.

52.  By inserting a translucent tube (2.5 cm diameter, 10 cm length)
into the patient’s mouth and having the person exhale slowly, the
breath, undiluted by room air, can be evaluated and assigned an
organoleptic score.
 The tube is inserted through a privacy screen (50cm-70cm) that
separates the examiner and the patient. The use of a privacy
screen allows the patient to believe that they have undergone a
specific malodor examination rather than the direct-sniffing
procedure.

54. Organoleptic Scores (0- 5) By Rosenberg ,
Mulloch Et Al 1991
 0 - No appreciable odor
 1 - Barely noticeable odor
 2 - Slight but noticeable odor
 3 - Moderate odor
 4 - Strong odor
 5 - Extremely foul odor

55. VOLATILE SULFIDE MONITOR
 This electronic (Haiimeter, InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen sulfide and methyl-
mercaptan , but without discriminating between them.

56. Gas Chromatography (GC):
 GC, performed with apparatus equipped with a flame photometric
detector, is specific for detecting sulphur in mouth air.
 It measures directly the three VSC methyl mercaptan, hydrogen sulfide
and dimethyl sulfide.
 GC is considered the gold standard for measuring oral malodor.
 This device can analyze air, saliva, crevicular fluid for a volatile
component.

58. Electronic nose
 Tanaka M et al used these electronic noses to clinically assess oral malodor
and examined the association between oral malodor strength and oral health
status.

59. Halitox System:
 Quick and simple
 Detects VSCs and poly amines
 It detects both VSC and polyamines in the sample.
 The absorbent point given with the kit is inserted into the
pocket.
 Left in place for 1 minute.
 Submerge the absorbent point tip in the toxin reagent .
 Wait for 5 minutes and see for yellow color in the specimen on
the scale of 0-5, which is directly proportional to the level of
toxins in the sample.

60. BANA test:
 Used to determine the proteolytic activity of certain oral anaerobes that
contribute to oral malodor.

61. PREVENTIVE MEASURES
Preventive measures rather than curative aspects are highly
recommended.
 Visit dentist regularly
 Periodical tooth cleaning by dental professional.
 Brushing of teeth twice daily with appropriate brushing techniques and for
a duration of 2-3 mins.
 Use of a tongue scraper to get rid of the lurking odour causing bacteria in
the tongue surface.

62.  Flossing after brushing to remove food particles stuck in between the tooth
surfaces.
 Limit intake of strong odour species.
 Limit sugar and caffeine intake.
 Drink plenty of liquids.
 Chew sugar free gum for a minute when mouth feels dry.
 Eat fresh fibrous vegetables such as carrots.

63. MANAGEMENT:
 Treatment needs (TN) for halitosis have been categorized into 5 classes in order to
provide guidelines for clinicians in treating halitosis patients:
 Treatment of physiologic halitosis (TN-1),
 Oral pathologic halitosis (TN-1 and TN-2), and
 Pseudo-halitosis (TN-1 and TN-4) should be the responsibility of a dentist,
 However, treatment of extra-oral pathologic halitosis (TN-3) or halitophobia (TN-5)
should be undertaken by a physician or medical specialist such as a psychiatrist or
psychologist.

64. (i) Mechanical reduction of intraoral nutrients and
micro-organisms
(ii)Chemical reduction of oral microbial load
(iii) Rendering malodorous gases nonvolatile
(iv) Masking the malodor.

65. 1. Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum

66. 2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide
- Two-phase oil- water rinse
- Triclosan
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges

67. 3.Conversion of volatile sulfide compounds
- Metal salt solutions
- Toothpastes
- Chewing gum

68. 4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum

69. Herbal treatment:
 Herbs and essential oils can be made into very effective mouthwash remedies to
sweeten breath and help keep gums and teeth healthy fennel not only improves
digestion, but also can reduce bad breath and body odor that originates in the intestines.
 Give raw carrots as a midday treat to help scour teeth of bacteria-laden plaque, a
common cause of bad breath.
 Cardamom tea contains cineole, a potent antiseptic that kills bad-breath bacteria and
sweetens breath.

70.  Thymol, one of the constituents of thyme, is contained in antiseptic
mouthwashes.
 Neem leaf powder can be used as an effective tooth powder to fight plaque
and gingivitis when mixed with astringent herb powders and/or baking soda.
 A few drops of Tea tree oil , lemon or peppermint essential oils can be added to
warm water for an effective mouth rinse to freshen breath

71. During Follow Up
Use of a Confidant
 Research shows that the patients are generally unable to rate the intensity of
their own halitosis.
-Rosenberg et al 1995
 Therefore, the patient cannot reliably assess the effectiveness of the prescribed
therapy.
 The recommended course of action is to ask them to use another person as a
confidant.
 A confidant could be a spouse, a family member or a close friend, who is
willing to smell the patient’s breath and provide straightforward feedback.

72. Treatment Of Oral Submucous
Fibrosis

74. Treatment options
 MEDICAL / CONSERVATIVE
 SURGICAL

76. CONSERVATIVE TREATMENT OPTIONS
Steroids
 Anti inflammatory effect
Decrease fibroblastic proliferation and deposition
 relieved symptoms at an early stage of the disease
 less useful in reversing the abnormal deposition of fibrotic tissue and
restoring elasticity of the oral mucosa.
 Significantly better results have been obtained by giving local injections of
 Dexamethasone
 hyaluronidase and
 chymotrypsin

77. Dose
 40 mg triamcinolone acetonide intralesional per side/10-20 mg per site
 In weekly divided doses for 5-6 weeks
 Patient is encouraged to do mouth opening exercises with wooden spatula for 5
mins atleast 8 times per day

78. Hyaluronidase
 Breaks down hyaluronic acid
 1500 IU intra lesional
 Lowers the viscosity of the intercellular cement substances
 Decreases collagen formation.
 Hyaluronidase is much quicker in relief of painful ulceration and burning
sensation than dexamethasone, but the effect is short term

79. chymotripsinogen
 Hydrolysis ester and peptide bonds
 Proteolytic and anti inflammatory agent
 5000 IU twice weekly for 10 weeks

80. Anti helminthics
Levamisole
 Immuno modulating effect
 Scavenges free radicals
 Recommended dose is 150mg OD for 3 days twice a month×3 month
 Contraindications include
 pregnancy
 lactating mothers
 Renal failure cases

81. Collagenase
 Needs evaluation as a single modality treatment

82. vitamins
 Vit A,B,C,D,E
 These are anti oxidants and protect cells from oxidative damage
 Vit A 50,000 units once daily oral tablets
 Oral administration of vitamin A, D, B complex,vitamin E produces -13.6%
improvement in symptoms of OSF
 Combined with minerals like iron, calcium, copper, zinc and magnesium
produce up to 41% improvement in symptoms
 Beneficial response in MULTIMICRONUTRIENT THERAPY

83. Zinc / iron
 antagonises tha action of copper
 Iron supplements are also given to correct anemia because OSF patients more
prone to mucosal injury

84. lycopene
 Synthesized by plants (tomatoes)
 Powerful antioxidant
 Has singlet oxygen quenching capability which is :
 2 times beta-carotene
 10 times alpha-tocopherol.
 Daily dose – 16mg
 First line drug in OSF

85. pentoxifyllin
 Dose upto 1200 mg daily in divided dosage
 Cause vasodilatation and hence increased mucosal vascularity of OSF
 Causes neutrophil degranulation and the release of peroxides
 Promotes natural killer cell activity
 Decrease production of tumor necrosis factor, and T and B cell activation.
 Improvement in mouth opening, tongue protrusion, and relief from perioral
fibrotic bands.
 Improvement in subjective symptoms of intolerance to spices, burning
sensation of mouth, tinnitus, difficulty in swallowing and difficulty in speech

86. Nylidrin hydrochloride
 peripheral vasodilator
 Relaxes and dilates the blood vessels,
 ensuring greater blood supply to the ischemic tissues
 helps the nutritional and therapeutic measures reach the effected tissues.

87. Buflomedil hydrochloride
 Dose 450 mg
 When used in combination with vitamins+steroids, increased symptomatic
relief

88. Immune milk
 Cow milk immunised from human intestinal bacteria
 Modulates cytokine function
 Anti inflammatory
 45g immunised milk powder twice a day for 3 months showed :
 Improved tolerance to spicy food – 80%
 Improved mouth opening 70% patients

89. Interferon gamma
 Known anti-fibrotic cytokine
 Showed
 Reduced burning dysaesthesia
 Increased suppleness of the buccal mucosa
 Improvement in the mouth opening
 Treatment with interferon gamma showed a decreased amount of
inflammatory cell infiltrate and an altered level of cytokines compared with
the pre-treatment lesional tissue

90. Placental extracts
 Placentrex is an aqueous extract of human placenta that contains
 Nucleotides
 Enzymes
 Vitamins
 Amino acids
 Steroids
 action is “biogenic stimulation” based on Fitalov’s bio-logical stimulant concept.
 It has been suggested that it stimulates
 the pituitary and adrenal cortex,
 regulates the metabolism of tissues.
 Topical application as well as 2.0cc submucosal injections of aqueous placental
extract have been used in past with variable degree of success rate

91. Ayurvedic treatments
 Turmeric oil
 Turmeric extracts
 Decreased multinucleated giant cells
 TEA – tea polyphenols have anti oxidant properties
 Septillin, a polyherbal ayurvedic preparation in a dose of 2 tablets per day for
3 months had shown improvement in mouth opening

92. Laser treatment
 Few studies
 Lasers used are :
 CO2 laser
 KTP 532 laser

93. SURGICAL TREATMENT

94. Simple excision (Fibrotomy)
 Simple excision can lead to scarring and exacerbation of the symptoms

96. Split thickness flap
 Used in conjunction with coronoidectomy and temporalis myotomy
 High contracture rate - high recurrence rate

98. Tongue flap
 Bulky
 Require additional division surgery
 Bilateral tingue falps can cause :
 Dysarticulation
 Dysphagia
 Increased risk of aspiration
 Involvement of tongue also precludes tongue flap use

100. Nasolabial flap
 Requires second surgery
 Facial scar

102. Buccal fat pad
 Simple and easy to use
 Rich blood supply
 Epithelialisation complete within 6 weeks
 Morbidity and failure rates low
 Generally well accepted by the patient

104. Radial forearm vascularised flap
 Bipaddled radial forearm flap
 Flap length is 8–9 cm and width 2–3 cm typically
 Bridge pedicle length is 8–10 cm

107. conclusion
 No single drug regimen can provide complete relief in OSF.
 First and foremost intervention includes intensive counseling and cessation of
the habit.
 Although reversal of fibrosis is not possible, it is effective in relieving the
symptoms.
 A tailor made therapy should be designed depending on the extent, duration
and severity of the disease.
 Here various combinations of the available medications can be tried to best
suit the individual.

108.  Severe or grade III cases may require surgical intervention.
 Regular follow-up, assessment of improvement in symptoms, inter-incisal
distance, and quality of life must be reported on weekly basis.
 Keeping in mind the high malignant potential, any ulceration, sharp cusps of
teeth and ill-fitting prosthesis must be looked upon with suspicion.
 Although, no established markers have been identified to detect the risk of
malignancy in OSF, necessary corrections and histopatho-logical examination
should not be delayed whenever in doubt
 Moreover, future research needs to be focused on better standardization and
follow-up reporting