Assessment of depression, stress, anxiety and oral health-related quality of life in individuals with sjögren’s syndrome: case control pilot study.
Objective: Sjögren’s syndrome (SS) is a chronic auto-immune inflammatory systemic disease, in which the infiltration of mo-nonuclear cells in the exocrine glands leads to physiological and morphological changes. This pilot case-control study aims to describe the profile, evaluate the oral condition, quality of life (QoL) and psychological condition, through complete clinical examination, OHIP-14 and DASS-21 questionnaires.
Materials and Methods: The study was conducted with seven individuals with a final diagnosis of SS (case group [CG]), and seven individuals with symptoms of dry mouth (control group [GCO]), consulting at the institution from January to November 2021. participants were selected by free demand and those previously seen at the institution with a diagnosis of SS between 19 and 70 years of age. The questionnaire OHIP-14 was applied to assess the patient’s quality of life, where seven dimensions are assessed, subdivided into 14 questions through the Lickert scale (0 to 4) assigned by the individual and which quantifies the impact of oral health on QoL. The questionnaire DASS-21 assessed the psychological condition of the patient, which presents seven questions for each emotional state (depression, anxiety, and stress), totaling 21 questions. The general clinical condition, evolution of SS, oral clinical condition, and the profile of this population were related to QoL factors and psychological conditions, using these assessment instruments.
Results: There was no statistically significant difference between the groups regarding stimulated salivary flow. The only symptom with a statistically significant difference in the CG was difficulty in phonation (p< 0.001). The dimensions related to functional limitation and physical pain showed the most expressive results (p=0.004) (p=0.025), showing a strong negative impact on the QoL of the CG individuals, and the dimension related to disability was the least affected (p=0.684). The analysis of depression, anxiety, and stress did not show statistically significant results between the groups; however, in the CG, 5 (71.42%) individuals showed a severe degree of depression, anxiety, and stress.
Conclusions: Individuals in the case group showed some changes, with a strong negative impact on QoL compared to the control group.
Keywords: Sjogren’s syndrome; Quality of life; Depression; Anxiety; Stress, psychological; Case-control studies.
2. Soto-Rojas AE, Kraus A. The oral side of Sjögren syndrome. Diagnosis and treatment. A review. Arch Med Res. 2002;33(2):95-106. doi: 10.1016/s0188-4409(01)00371-x. PMID: 11886706.
3. Napeñas JJ, Rouleau TS. Oral complications of Sjögren’s syndrome. Oral Maxillofac Surg Clin North Am. 2014;26(1):55-62. doi: 10.1016/j.coms.2013.09.004. PMID: 24287193.
4. Felberg S, Dantas PE. Diagnóstico e tratamento da síndrome de Sjögren [Sjögren’s syndrome: diagnosis and treatment]. Arq Bras Oftalmol. 2006;69(6):959-63. Portuguese. doi: 10.1590/s0004-27492006000600032. PMID: 17273698.
5. Larrarte JPM. Pineda YR. Sjogren syndrome. Revista Cubana de Medicina. 2010;49(2):61-76.
6. Reksten TR. Jonsson MV. Sjogren’s Syndrome Na Update on Epidemiology and Current Insights on Pathophysiology. Oral Maxillofacial Surg Clin N Am. 2014;26(1):1-12. doi: 10.1016/j.coms.2013.09.002.
7. Vivino FB, Bunya VY, Massaro-Giordano G, Johr CR, Giattino SL, Schorpion A, Shafer B, Peck A, Sivils K, Rasmussen A, Chiorini JA, He J, Ambrus JL Jr. Sjogren’s syndrome: An update on disease pathogenesis, clinical manifestations and treatment. Clin Immunol. 2019;203:81-121. doi: 10.1016/j.clim.2019.04.009. Epub 2019 Apr 29. PMID: 31022578.
8. Mavragani CP, Moutsopoulos HM. The geo-epidemiology of Sjögren’s syndrome. Auto-immun Rev. 2010;9(5):A305-10. doi: 10.1016/j.autrev.2009.11.004. Epub 2009 Nov 10. PMID: 19903539.
9. Guellec D, Cornec D, Jousse-Joulin S, Marhadour T, Marcorelles P, Pers JO, Saraux A, Devauchelle-Pensec V. Diagnostic value of labial minor salivary gland biopsy for Sjögren’s syndrome: a systematic review. Autoimmun Rev. 2013;12(3):416-20. doi: 10.1016/j.autrev.2012.08.001. Epub 2012 Aug 7. PMID: 22889617.
10. Santos L, Barbalho J, Bartoli M, Amaral M, Vasconcelos B. Primary Sjogren’s syndrome - case report. Rev. Cir. Traumatol. Buco-Max-Fac. 2013;13(2):63-68.
11. Margaix-Munõz M. Bagán JV. Poveda R. Jiménez Y. Sarrión G. Sjogren’s syndrome of the oral cavity. Review and update. Med Oral Patol Oral Oral Cir Bucal. 2009;1(14): 325-30.
12. Franceschini F, Cavazzana I, Andreoli L, Tincani A. The 2016 classification criteria for primary Sjogren’s syndrome: what’s new? BMC Med. 2017 Mar 31;15(1):69. doi: 10.1186/s12916-017-0837-1. PMID: 28359271; PMCID: PMC5374666.
13. Błochowiak K, Olewicz-Gawlik A, Polańska A, Nowak-Gabryel M, Kocięcki J, Witmanowski H, Sokalski J. Oral mucosal manifestations in primary and secondary Sjögren syndrome and dry mouth syndrome. Postepy Dermatol Alergol. 2016 Feb;33(1):23-7. doi: 10.5114/pdia.2016.57764. Epub 2016 Feb 29. PMID: 26985175; PMCID: PMC4793060.
14. Márton K, Boros I, Varga G, Zelles T, Fejérdy P, Zeher M, Nagy G. Evaluation of palatal saliva flow rate and oral manifestations in patients with Sjögren’s syndrome. Oral Dis. 2006;12(5):480-6. doi: 10.1111/j.1601-0825.2005.01224.x. PMID: 16910919.
15. González S, Sepúlveda D, González MJ, Molina C. Oral manifestations and their treatment in Sjogren’s syndrome. Oral Diaseases 2014;20(2):153-161. doi:10.1111/odi.12105.
16. Hamad AA. Interventions for dry mouth and hyposalivation in Sjögren’s syndrome: a systematic review and meta-analysis. Oral Dis. 2019;25(4):1027-47. doi: 10.1111/odi.12952.
17. Karaiskos D, Mavragani CP, Makaroni S, Zinzaras E, Voulgarelis M, Rabavilas A, Moutsopoulos HM. Stress, coping strategies and social support in patients with primary Sjögren’s syndrome prior to disease onset: a retrospective case-control study. Ann Rheum Dis. 2009;68(1):40-6. doi: 10.1136/ard.2007.084152. Epub 2008 Feb 14. PMID: 18276740.
18. Cui Y, Xia L, li L,Zhao Q,ChenS, Gu ZAnxiety and depression in primary Sjögren’s syndrome: a cross-sectional study. BMC Psychiatry. 2018;18(1):131. doi: 10.1186/s12888-018-1715-x.
19. Barrios R, Bravo M, Gil-Montoya JA, Martínez-Lara I, García-Medina B, Tsakos G. Oral and general health-related quality of life in patients treated for oral cancer compared to control group. Health Qual Life Outcomes. 2015;13:9. doi: 10.1186/s12955-014-0201-5. PMID: 25613348; PMCID: PMC4311475.
20. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol. 2005;33(4):307-14. doi: 10.1111/j.1600-0528.2005.00225.x. PMID: 16008638.
21. Antony MM, Bieling PJ, Cox, BJ, Enns MW, Swinson, RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological assessment. 1998;10(2):176. https://doi.org/10.1037/1040-35126.96.36.199
22. Tárzia, O. Halitosis: a challenge that has cure. Rio de Janeiro: EPUB, 2003.
23. Flink H, Bergdahl M, Tegelberg A, Rosenblad A, Lagerlöf F. Prevalence of hyposalivation in relation to general health, body mass index and remaining teeth in different age groups of adults. Community Dent Oral Epidemiol. 2008;36(6):523-31. doi: 10.1111/j.1600-0528.2008.00432.x. Epub 2008 Apr 14. PMID: 18422708.
24. Hackett KL, Deane KH, Strassheim V, Deary V, Rapley T, Newton JL, Ng WF. A systematic review of non-pharmacological interventions for primary Sjögren’s syndrome. Rheumatology (Oxford). 2015;54(11):2025-32. doi: 10.1093/rheumatology/kev227. Epub 2015 Jun 30. PMID: 26135587; PMCID: PMC4603277.
25. Pierce JL, Tanner K, Merrill RM, Miller KL, Kendall KA, Roy N. Swallowing Disorders in Sjögren’s Syndrome: Prevalence, Risk Factors, and Effects on Quality of Life. Dysphagia. 2016;31(1):49-59. doi: 10.1007/s00455-015-9657-7. Epub 2015 Oct 19. PMID: 26482060.
26. Pache P, Da Silva Santos T, Juarez Vieira Teixeira J, Obici S. Clinical manifestations and comorbidities of Sjogren’s syndrome: a systematic review. Uningá J. 2017;30(2):2178-2571.
27. Miyamoto ST, Valim V, Fisher BA. Health-related quality of life and costs in Sjögren’s syndrome. Rheumatology (Oxford). 2021;60(6):2588-2601. doi: 10.1093/rheumatology/key370. PMID: 30770918.
28. Gomes RS, Brandalise R, Alba GP, Flato UA, Júnior JE.Síndrome de Sjögren primária. Rev Bras Clin Med. 2010;8(3):254-65.
29. Barbosa Leal Giafferis R, Valente Soares Junior LA, da Silva Santos PS, Moura Chicrala G. Therapeutic strategies available for xerostomy and hyphosalivation in irradiated head and neck patients: manual for healthcare professionals. Rev Uningá, Maringá. 2017;54(1):45-58.
30. Stewart CM, Berg KM, Cha S, Reeves WH. Salivary dysfunction and quality of life in Sjögren syndrome: a critical oral-systemic connection. J Am Dent Assoc. 2008;139(3):291-9; quiz 358-9. doi: 10.14219/jada.archive.2008.0158. PMID: 18310733.
31. Al-Ezzi MY, Pathak N, Tappuni AR, Khan KS. Primary Sjögren’s syndrome impact on smell, taste, sexuality and quality of life in female patients: A systematic review and meta-analysis. Mod Rheumatol. 2017;27(4):623-629. doi: 10.1080/14397595.2016.1249538. Epub 2016 Nov 14. PMID: 27760487.
32. Kamel UF, Maddison P, Whitaker R. Impact of primary Sjogren’s syndrome on smell and taste: effect on quality of life. Rheumatology (Oxford). 2009;48(12):1512-4. doi: 10.1093/rheumatology/kep249. Epub 2009 Sep 14. PMID: 19752179.
33. Enger TB, Palm Ø, Garen T, Sandvik L, Jensen JL. Oral distress in primary Sjögren’s syndrome: implications for health-related quality of life. Eur J Oral Sci. 2011;119(6):474-80. doi: 10.1111/j.1600-0722.2011.00891.x. PMID: 22112034.
34. Rusthen S, Young A, Herlofson BB, Aqrawi LA, Rykke M, Hove LH, Palm Ø, Jensen JL, Singh PB. Oral disorders, saliva secretion, and oral health-related quality of life in patients with primary Sjögren’s syndrome. Eur J Oral Sci. 2017;125(4):265-271. doi: 10.1111/eos.12358. Epub 2017 Jun 23. PMID: 28643390.
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. © 2023.