Vol. 125 No.

3 March 2018

Relationship between sjögren syndrome and periodontal

status: A systematic review
Luana de Goés Soares, DDS,a Ricardo Lopes Rocha, MSc,a Elizabete Bagordakis, PhD,a Endi Lanza Galvão, MSc,b
Dhelfeson Willya Douglas-de-Oliveira, MSc,a,c and Saulo Gabriel Moreira Falci, PhDa

Objective. This study aimed to examine whether Sjögren syndrome (SS) is related to periodontal status.
Study Design. A systematic review was performed on the basis of PRISMA (PROSPERO: CRD42017055202). A search was per-
formed in the PubMed/MEDLINE, LILACS, Web of Science, and Science Direct databases. Hand searches and review of the gray
literature were also performed. Three researchers independently selected studies, extracted data, and assessed methodologic quality.
Studies that correlated primary and/or secondary SS with plaque index, gingival index, probing depth, and bleeding on probing
were included. The risk of bias was estimated on the basis of the Newcastle-Ottawa scale.
Results. Seventeen studies were included in the review and 9 included in the meta-analysis, with a total of 518 and 544 pa-
tients, with or without SS, respectively. The mean difference of plaque index (0.29; 95% confidence interval [CI] 0.17-0.41),
gingival index (0.52; 95% CI 0.14-0.89), and bleeding on probing (9.92; 95% CI 4.37-15.47) were larger in patients with SS
than in controls. In primary SS (0.47; 95% CI 0.10-0.83) and secondary SS (0.74; 95% CI 0.10-1.38), only the mean gingival
index was larger compared with that in control group. The majority of the included studies were judged as having a high risk of
bias.
Conclusions. The present review did not provide strong evidence that periodontal status is affected by SS. (Oral Surg Oral Med
Oral Pathol Oral Radiol 2018;125:223–231)

Sjögren syndrome (SS) is a chronic autoimmune disease
characterized by progressive loss of salivary and lacri-
mal gland functions.1 It has a high incidence rate in
women, being more prevalent in the 55- to 65-year age
group.2,3 The syndrome can be classified as primary, when
there is only a glandular dysfunction, or secondary, when
there are other associated autoimmune diseases.4 To date,
therapeutic strategies to treat SS are mainly palliative,
with no treatment having proven efficacy in modifying
the course of the disease.3
Involvement of the salivary glands leads to decrease
in salivary flow and alteration in saliva quality, affect-
ing oral health and making the patient more prone to caries
activity, development of fungal infections, dysphagia, and
dysguesia.5 Normal functioning of the salivary glands has
critical importance in oral health maintenance.6 Saliva
plays a role in plaque initiation, maturation, and metab-
olism by mechanically cleaning the oral surfaces,
neutralizing acids produced by bacteria, and control-
ling bacterial activity. Consequently, calculus formation
and periodontal disease may be influenced by salivary
flow and composition.7,8
Oral manifestations have been reported in patients with
SS,9 and some of the manifestations have not yet been
a
Department of Dentistry, Federal University of Jequitinhonha and
Mucuri Valleys, Diamantina, MG, Brazil.
b
René Rachou Research Center, Oswaldo Cruz Fundation, Belo
Horizonte, Brazil.
c
Department of Periodontology, Federal University of Minas Gerais,
Belo Horizonte, MG, Brazil.
Received for publication Oct 25, 2017; accepted for publication Nov
19, 2017.
© 2017 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
https://doi.org/10.1016/j.oooo.2017.11.018
shown to have a significant association with SS despite
being found in clinical practice.10 The presence of a poor
periodontal status in these patients is part of this group
of manifestations still without proven association with
SS.11
Xerostomia, characterized as a dry mouth sensation,
is reported in the literature as a risk factor for the de-
velopment of periodontal disease.12 However, the findings
of studies that have reported a relationship between SS
and periodontal status are conflicting, with some proving
this relationship13,14 and others refuting it.15,16 Early and
accurate diagnosis of SS can help prevent SS and ensure
adequate treatment of oral complications associated with
the syndrome.10 In this sense, knowing the association
between periodontal status and SS is important for a
correct approach to the management of these patients.
To the best of our knowledge, to date, no systematic
review on this important issue has been undertaken. Thus,
the objective of the present systematic review was to eval-
uate if SS is related to a poor periodontal status in patients
with SS in comparison with controls.
MATERIALS AND METHODS
This systematic review was conducted according to the
Preferred Reporting Items for Systematic Reviews and
Statement of Clinical Relevance
Patients with Sjögren syndrome trend to present with
poor periodontal condition. Appropriate treatment and/
or preventive strategies should be recommended to
these patients. Clinical management should attempt
to prevent greater involvement of the periodontium.

223
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224 de Soares et al.
Meta-Analyzes (PRISMA) statement17 and registered in
PROSPERO (CRD42017055202). As this study did not
involve humans or animals, approval by appropriate com-
mittees was exempted. The PECO (Patients, Exposure,
Comparison, and Outcomes) issue addressed by this sys-
tematic review was: Would patients with SS compared
with patients without the syndrome have a worse peri-
odontal status?
Eligibility criteria
Original studies that evaluated the association between
primary and/or secondary SS and periodontal status were
included, without restriction on language or publica-
tion date. These studies included one or more of the
following: plaque index (PI), probing depth (PD), bleed-
ing on probing (BOP), and gingival index (GI). Cases
reports, studies with fewer than 10 patients, literature
reviews, opinion articles, letters to the editor, clinical trials,
animal studies, short communications, and abstracts in
conference proceedings were excluded.
Search strategy
The literature search was conducted through Novem-
ber 2016 in four databases: PubMed/MEDLINE, LILACS
(accessed by Virtual Health Library- VHL), Web of
Science, and Science Direct. The gray literature was in-
vestigated through Google Scholar. The following
keywords were used and adapted for each database:
“Sjögren syndrome” AND “periodontitis” OR “peri-
odontal index” OR “gingival index” OR “dental plaque
index” OR “bleeding on probing” OR “gingival”. To
perform the search in Science Direct, the “journal” and
“Medicine and Dentistry” filters were used. A manual
search on the references of the articles included in the
review was also performed to identify relevant studies
not identified by the search strategy created.
After performing the search, the studies were trans-
ferred to the End Note program (End Note, Thomson
Reuters, version ×7) and duplicates were removed. Then,
the titles and abstracts of all articles identified by the
search strategy were evaluated independently by three
reviewers (LGS, RLR, and EB) according to the eligi-
bility criteria. Disagreements as to the text reading in full
were settled by discussion among the reviewers. All ab-
stracts that did not provide enough information on the
inclusion and exclusion criteria were selected for eval-
uation of the full text.
Data extraction
Using standardized forms, the same three reviewers in-
dependently conducted data extraction with respect to the
studies’ methodologic characteristics and their results,
including author, year of publication, country, study
design, sample size, and characteristics, such as age,
gender, evaluated periodontal indexes, and outcome.
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Risk of bias assessment
The risk of bias assessment was carried out by using the
Newcastle-Ottawa scale adapted for cross-sectional
studies,18 which consists of a 3-dimensional evaluation:
selection (subdivided into 3 enquiries) comparability (2
enquiries) and results (2 enquiries). This scale allows a
study to score a maximum of 8 points. In the evalua-
tion of the “selection” domain, in the “representativeness
of the sample” enquiry, articles that presented a sample
calculation scored 1 point and those which the sample
were representative of the community scored 1 point. In
the “exposure verification” enquiry, the studies that used
the European Community criteria for the diagnosis of SS19
scored 1 point and those that evaluated PI, GI, PD, and
BOP scored 1 point. For the “comparability” domain,
smoking was considered the main confounding factor to
be controlled for periodontal status,20 and studies that con-
trolled this factor received 1 point and 1 more point when
the confounding factors age and gender were also con-
trolled in the study. In the evaluation of the “outcomes”
domain, the studies received 2 points when the evalua-
tion of the patients was blind and independent, 1 point
when charts were used for data analysis, and 0 points
when these data were not described. In the “statistical
analysis” enquiry, the studies received 1 point when this
item was clearly reported and appropriate.
Data analysis
All analyzes were performed by using software R (version
3.3.1) with the “meta” and “metafor” packages. The effect
estimates were obtained by comparing the mean values
of the interest’s variables for each group, namely, pres-
ence of SS (experimental group) and absence of SS
(control group), and were expressed as the mean differ-
ence (MD) between the groups. The statistical
heterogeneity between the results of the studies was evalu-
ated by using the I2 inconsistency test, in which values
above 25% and 50% were considered indicative of mod-
erate and high heterogeneity, respectively. Calculations
were performed by using a random effect model, since
the I2 value was greater than 0 in all analyses. The 95%
confidence interval (CI) was considered to contain the
true values of the means.21
RESULTS
Selection of studies
The search strategy resulted in 1505 results, of which 721
were duplicates; 763 studies were excluded after reading
the title and abstract; and the remaining 21 papers were
considered to be potentially relevant and were read in
full. One article was excluded because it was a short
communication22 and another because it was a letter to
the editor.23 The study of Jorkjend et al. was excluded
because its sample was composed of patients only sus-
pected of having SS but without diagnostic confirmation.24
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Volume 125, Number 3
Fig. 1. Flow chart of the included studies.
The study of Forsberg et al. was not included because
it was about another syndrome. 25 Ultimately, 17
studies13-16,21,26-37 met the eligibility criteria and were
included in this review. The included articles contrib-
uted 518 patients with SS and 544 patients without
the syndrome. However, only 9 studies provided
sufficient information and were included in the
meta-analysis13,14,16,26,29,31,34-37 with 303 patients with SS
and 288 patients without the syndrome (Figure 1). The
study by Antoniazzi et al.26 was not included in the meta-
analysis because it provided a standardized error, not
standard deviation.
Characteristics of the studies
The studies included were published between 1989 and
2010, the majority (53%) of them originating from
Europe.14-16,21,27,28,31,32,34 One paper was published in
French,21 another in Russian,33 and all other studies were
reported in the English language literature.13-16,26-32,34-37 The
mean age of study patients ranged from 32 to 65 years,
and the predominant gender in the samples was female
(12.4 : 1). In most studies, the European Community Cri-
teria for the diagnosis of SS was used, except for 3 studies
REVIEW ARTICLE
de Soares et al. 225
that used another method.14,15,31 Two did not describe the
diagnostic criteria.28,33 The sample sizes of the control
and SS groups in the studies ranged from 1329 to 206.36
Groups of healthy individuals and those with SS were
not homogeneous among the studies. In the SS groups,
the syndrome was not always described as primary or
secondary.13,31 Some studies composed their samples only
with patients with primary SS,15,21,22,32,34,35,37 whereas in
others a differentiation between primary and secondary
SS was established.14,16,26-30 In most studies, the control
group was composed of healthy individuals and matched
to the study group.13-16,22,26,28-31,34,35,37 Only one study pre-
sented a control group composed of patients with other
autoimmune diseases,27 and two studies included pa-
tients presenting xerostomia.21,27 The main characteristics
of the included studies are presented in Table I.
Risk of bias
Of the studies included in the systematic review,
11 (64.7%) used validated measures for data
collection,13,14,16,21,26,27,29,30,32,35,36 and 6 (35.3%) controlled
for the main confounding factor as well as an addition-
al factor.13,14,26,30,32,35 No studies performed blinding of the
 226 de Soares et al.
ORAL MEDICINE
Table I. Characteristics of included studies
Author (Year of Periodontal
publication) Country Study design Sample size Age (SD or range) Gender (F/M) index evaluated Conclusion
Antoniazzi et al. (2009)26 Brazil Cross-sectional CG (19) CG(49.8 ± 12.8) CG (19/0) PI, GI, PD, CAL, BOP SS negatively affects the periodontal condition.
SS1 (11) SS1 (48.1 ± 13.4) SS1 (11/0)
SS2 (08) SS2 (53.8 ± 11.6) SS2 (8/0)
Boutsi et al. (2000)27 Greece Cross-sectional SS1 (08) SS (48.8 ± 15.4) SS (23/1) PI, GI, PD, CAL There are no differences in periodontal status between
SS2 (16) CG1 (47.1 ± 13.8) CG1 (26/1) SS patients compared with CG1 and CG2.
CG1 (27) CG2 (46.5 ± 10.2) CG2 (29/0)
CG2 (29)
Çelenligil et al. (1998)28 Turkey Cross-sectional SS1 (12) SS1 (44/10-60) SS1 (8/4) PI, BOP, PD, PeI SS contributes to the increase of periodontal disease.
SS2 (05) SS2 (45/25-60) SS2 (5/0)
CG (14) CG (–) CG (14/-)
Ergun et al. (2010)14 Turkey Cross-sectional SS1 (14) SS (53.27/26-78) – BOP, PI, PD, SS increase the risk of periodontitis.
SS2 (23) CG (54.27/25-94)
CG (37)
Escalona and Rivera (2004)29 Venezuela Cross-sectional SS1 (04) SS1 (54.7) SS1 (4/0) PI, GI, PD Patients with SS had higher PI and GI rates compared
SS2 (03) SS2 (55) SS2 (3/0) with those in control group.
CG (06) CG (32) CG (4/2)
Kuru et al. (2002)16 England Cross-sectional SS1 (08) SS1 (61.2 ± 14.4) SS1 (8/0) PI, GI, BOP, PD, CAL, GR There are no difference between periodontal
SS2 (10) SS2 (60.6 ± 11.8) SS2 (10/0) condition of healthy patients and with SS1 and
CG (11) CG (61.8 ± 13.09 CG (11/0) SS2.
Leung et al. (2004)30 China Cross-sectional SS1 (26) SS1 (51.4 ± 14.3) SS1 (24/2) PI, CI, CAL Periodontal status of SS1 group was more
SS2 (25) SS2 (43.3 ± 10.9) SS2 (24/1) compromised compared with CG and SS2.
CG (29) CG (44 ± 10.7) CG (27/2)
Márton et al. (2006)31 Hungary Cross-sectional SS (49) SS (55 ± 11) SS (46/3) PD, BOP Decrease of periodontal health of patients with SS.
CG (43) CG (49 ± 15) CG (39/4)
Najera et al. (1997)13 USA Cross-sectional SS (25) SS (60.92 ± 13.52) SS (23/2) PI, GI, BOP, CAL, PD SS group had a 2.2 times risk of having periodontitis
CG (24) CG (58.29 ± 12.09) CG (22/2) compared with control group.
Pedersen et al. (1999)32 Norway Cross-sectional SS1 (16) SS1 (40-82) SS1 (14/2) PI, GI, PD SS group had more oral findings compared with CG.
CGy (13) CGy (20-33) CGy (12/1)
CGa (14) CGa (39-70) CGa (13/1)
Pers et al. (2005)21 France Cross-sectional SS1 (15) SS1 (44-81) SS1 (13/2) PI, BOP, PD, GI SS predispose patients to periodontal disease by
CG2 (15) CG2 (39-82) CG2 (12/3) increasing BAFF.
CG3 (10) CG3 (43-74) CG3 (6/4)
Pozharitskaia et al. (1989)33 Russia Cross-sectional SS (35) SS (29-70) – PI, Pel Further care with periodontal health is required in
CG (35) CG (29-70) patients with SS.
Ravald and List (1998)34 Sweden Cross-sectional SS1 (21) SS1 (64/44-75) SS1 (20/1) PI, PD, BOP Similar periodontal condition between SS1 e GC
CG (21) CG (65/44-78) CG (20/1) groups.
Rhodus and Michalowicz (2005)35 USA Cross-sectional SS1 (10) SS1 (56.7/43-74) SS1 (10/0) PD, CAL, PI, GI Greater gingival retraction and loss of insertion in
CG (10) CG (52.6/ 32-65) CG (10/0) patients with SS1.
Schiodt et al. (2001)15 Denmark Cross-sectional SS1 (57) SS1 (62/27-84) SS1 (53/4) BOP, PD, CI SS1 is not associated with the increased risk of
CG (80) CG (60/31-81) CG (80/0) periodontal disease.
Seck-Diallo et al. (2009)36 Senegal Cross-sectional CG (103) CG (–) CG (–) PI, GI, PD, CAL SS patients have more risk to develop periodontal
SS1 (36) SS1 (46.7 ± 2.5) SS1 (31/5) disease.
SS2 (67) SS2 (48.2 ± 1.4) SS2 (63/4)
Tseng et al. (1991)37 USA Cross-sectional CG (14) CG (53.7 ± 8.9) CG (14/0) PI, GI, PD, BOP, CI, CAL Influence of SS on indexes was not observed.
SS (52.9 ± 11.6)

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SS1 (14) SS (14/0)

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BOP, bleeding on probing; CAL, clinical attachment level; CG, healthy control group; CG1, control group with autoimmune disease; CG2, control group with xerostomia; CG3, control group with periodontal disease;
CGa, control group (aged); CGy, control group (young); CI, calculus index; GI, gingival Index; GR, gingival retraction; N, number of teeth; PD, probing depth; PeI, periodontal index; PI, plaque index; SS, Sjögren
syndrome; SS1, primary Sjögren syndrome; SS2, secondary Sjögren syndrome.
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Volume 125, Number 3 de Soares et al. 227

Table II. Risk of bias evaluation of the reviewed studies

Selection Comparability Outcome
Representativeness Sample Ascertainment of Based on design Assessment of Statistical
Author (Year) of the sample(1) Size (2) exposure (3) and analysis (4) outcome (5) test (6) Total
Antoniazzi et al. (2009)26 – ★ ★★ ★★ – ★ 6/8
Boutsi et al. (2000)27 – – ★★ ★ – ★ 4/8
Çelenligil et al. (1998)28 – – ★ ★ – ★ 3/8
Ergun et al. (2010)14 – – ★★ ★★ – ★ 5/8
Escalona and Rivera (2004)29 – – ★★ – – ★ 3/8
Kuru et al. (2002)16 – – ★★ ★ – ★ 4/8
Leung et al. (2004)30 – – ★★ ★★ – ★ 5/8
Márton et al. (2006)31 – – ★ ★ – ★ 3/8
Najera et al. (1997)13 – – ★★ ★★ – ★ 5/8
Pedersen et al. (1999)32 – – ★★ ★★ – ★ 5/8
Pers et al. (2005)21 – – ★★ ★ – – 3/8
Pozharitskaia et al. (1989)33 – – ★ – – – 1/8
Ravald and List (1998)34 – – ★ ★ – ★ 3/8
Rhodus and Michalowicz (2005)35 – – ★★ ★★ – ★ 5/8
Schiodt et al. (2001)15 ★ ★ ★ ★ – ★ 5/8
Seck-Diallo et al. (2009)36 – – ★ ★ – ★ 4/8
Tseng et al. (1991)37 – – ★ ★ – ★ 3/8
Selection: (1) (a) truly representative of the average in the target population or (b) somewhat representative of the average in the target population
(1 star), (c) selected group of users, (d) no description; (2) (a) justified and satisfactory (1 star), (b) not justified; (3) (a) validated measurement
tool (2 stars) or (b) non-validated measurement tool, but the tool is available or described (1 star), (c) no description of the measurement tool.
Comparability: (1) (a) the study controlled for the most important factor (Smoking habit) (1 star), (b) the study controlled for any additional factor
(1 star). Outcome: (1) (a) independent blind assessment or (b) record linkage (2 stars), (c) no description; (2) (a) the statistical test used to analyze
the data is clearly described and appropriate, and the measurement of the association is present (1 star), (b) the statistical test is not appropriate,
not described, or incomplete.

Fig. 2. Forest plot of Sjögren syndrome association with (A) plaque index; (B) gingival index; (C) probing depth; and (D) bleed-
ing on probing.

evaluator, and 15 studies presented clear and appropri-
ate statistical analyses.13-16,26-32,34-37 In two studies, the
samples were calculated,15,26 with only one showing a rep-
resentative sample of the community.15 The methodologic
quality assessment of the 17 studies, using the Newcastle-
Ottawa scale adapted for cross-sectional studies, is
presented in Table II.
Data analysis
Four studies assessed PI (n = 164),13,14,26,29,37 which was
significantly higher in the group of patients with SS
(MD = 0.29; 95% CI 0.17-0.41) (Figure 2A). Four other
studies assessed GI (n = 296),13,26,29,36,37 which was also
higher in the group with the SS (MD = 0.52; 95% CI 0.14-
0.89) (Figure 2B). There was no difference in PD between
the SS group and the control group (MD = 0.34; 95% CI
−0.23 to 0.92) (Figure 2C). However, BOP (n = 215) was
higher in the group of patients with the SS (MD = 9.92;
95% CI 4.37-15.47) (Figure 2D).
For these results, the distinction parameter between
primary and secondary SS was not considered. When ex-
clusively evaluating patients with primary SS, only GI
was significantly higher in the group with the disease
(MD = 0.47; 95% CI 0.10-0.83) (Figure 3A).
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228 de Soares et al.
Fig. 3. Forest plot of primary Sjögren syndrome association with (A) plaque index; (B) gingival index; (C) probing depth; and
(D) bleeding on probing.
Fig. 4. Forest plot of association between secondary Sjögren syndrome and gingival index.
There were no differences in PI (MD = 0.18; 95% CI
−0.13 to 0.49) (Figure 3B), PD (MD = 0.45; 95% CI
−0.29 to 1.18) (Figure 3C) and BOP (MD = −1.36; 95%
CI −11.0 to 8.27) (Figure 3D) between patients with
primary SS and those without the syndrome.
The results for secondary SS also revealed a signifi-
cant increase in GI in this group compared with the group
without the disease (MD = 0.74; 95% CI 0.10-1.38)
(Figure 4).
DISCUSSION
SS is characterized by lymphocytic infiltration of the sal-
ivary and lacrimal glands leading to dry mouth and dry
eyes.13 However, there is no consensus with regard to pa-
tients with SS experience experiencing more severe
periodontal complications compared with controls,
considering that divergent results have been
published.13,16,27,28,35,37,38 However, the results of our meta-
analysis suggest poor periodontal status in the SS groups
than in the control groups. No clear evidence could be
derived, mainly because of the poor methodologic quality
of the studies included in our review.
The reviewed studies evaluated periodontal status by
means of periodontal indexes, such as PD, PI, and
BOP.13-16,21,26-32,34-37 Among the indexes evaluated in this
review, the most relevant was found to be BOP because
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March 2018
bleeding indicates that there is inflammation at the site
evaluated.39 However, BOP, by itself, does not provide
conclusive information because during probing, bleed-
ing can originate from the marginal gingiva and not from
the bottom of the pocket. It is important to note that these
studies did not diagnose the patient as having or not
having periodontal disease.
In the evaluation of primary SS, GI was the only index
that showed a significant association in the present meta-
analysis. However, other studies examining periodontal
indexes in patients with primary SS found no increase
in susceptibility to periodontal disease.22,32,37,40 The use
of GI, PD, and BOP poses certain difficulties. These
indexes could cause subjectivity because each examin-
er may apply different pressures to the probe, and even
with a single examiner, probing can hardly be uniform
throughout the survey.41 Few studies have assessed such
indexes in patients with secondary SS, and we found no
significant differences with regard to each of the exam-
ined periodontal index, except for GI.16,26,29,36
For more than three decades, several studies have tried
to relate SS to poor periodontal status, but differences
in study design, composition of control groups, and pre-
sentation of results made it impossible to include some
articles in our meta-analysis.15,27,34 To better utilize the
results of studies, standardization of the criteria for the
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Volume 125, Number 3
diagnosis of periodontal disease is required to establish
the gold standard.42,43 For example, the study by Schiodt
et al. found that use of a proper scoring system for
periodontal indexes made it impossible to use them in
the meta-analysis.15 In the study by Celenligil et al., who
observed a greater predisposition to poor periodontal status
in patients with SS, data were presented as graphs, making
it impossible to include them in the meta-analysis.28
Another fact that limited the inclusion of other studies
in the meta-analysis was that patients with SS were com-
pared with patients with other syndromes or xerostomia,
not with healthy patients.27,32
The majority of the included studies had low scores
in the risk of bias assessment, indicating that they had
a high risk of bias. The variables that most contributed
to this were absence of sample calculation and a non-
representative sample. Sample size calculations enable
researchers to draw robust conclusions even from a limited
amount of information and allow for generalization of
results.44 Low sample sizes of studies may limit the va-
lidity of their results and may compromise sample power.
With regard to confounding factors, it was observed
that only smoking and systemic conditions were con-
trolled in the studies included in our review.13,14,26,30
However, other factors, such as frequency of daily hygiene
practices, regular visits to the dentist, and saliva buffer
capacity should also be controlled, as these factors may
also modify an individual’s periodontal status.45 Other
parameters that may explain inflammatory mecha-
nisms, such as peculiarities of the vascular anatomy in
patients with SS described in the study of Scardina et al.,
should also be investigated because the answers to these
interesting questions may help better explain the possi-
ble relationship between periodontal status and SS.46
Several of the reviewed studies reported a significant
association between poor periodontal condition and
SS.13,14,21,26,28-32,35,36 This association can be based on the
fact that the syndrome reduces the secretions of exo-
crine glands. Consequently, the composition and flux of
saliva may be compromised, leading to the growth of mi-
croorganisms, which would compromise the periodontal
status.16,47 Another explanation proposed here is the pres-
ence of confounding variables in these studies, such as
smoking and diabetes.13,14,26 It is important to note that
these variables are considered risk factors for periodon-
tal disease,48 and studies should control for them. In
addition, periodontitis is a chronic inflammatory disease
that is most severe and prevalent among adults.49,50 It is
difficult to confirm whether SS precedes periodontitis
because the population of the reviewed studies were
adults, and the study design of all included articles were
cross-sectional. To ensure the cause-and-effect relation-
ship between these two conditions, longitudinal studies
should be performed to improve the evidence regard-
ing this issue. Another factor to consider is the increase
REVIEW ARTICLE
de Soares et al. 229
in DMF-T (decayed-missing-filled teeth) index and de-
crease of salivary power buffer, both caused by the low
flow of salivary flux in cases of SS.23,45
However, some of the reviewed studies did not find
an association between SS and poor periodontal
status.15,16,27,34,37 The low prevalence of changes in peri-
odontal conditions in patients with SS may be attributed
to less severe disease and good oral hygiene.30 More-
over, treatment for SS includes therapy with symptomatic,
traditional immunosuppressive, and immunomodulatory
medicines.51 These drugs are able to modulate the in-
flammatory response, which may affect the response in
the periodontium as well.
The absence of any association between the periodon-
tal indexes assessed and SS was explained by some
studies13,30; some of the patients with SS had great concern
about their condition, leading these patients to main-
tain good oral hygiene and seek regular dental care.15,34
There was substantial statistical heterogeneity among
the included studies, which may be related to the dif-
ferent diagnostic criteria and the characteristics and
representativeness of the samples, limiting the robust-
ness of conclusions obtained through the meta-analysis.
Although there were no statistically significant associa-
tions among all indexes surveyed, it was observed that
in most studies (except in 3 studies), periodontal indexes
showed a tendency to be higher in patients with SS.14,16,29
A more careful investigation of the oral conditions of pa-
tients complaining of subjective dryness in the mouth or
eyes should be recommended to achieve early diagno-
sis of SS, thus avoiding other oral complications, including
periodontal disease.
In future studies, it is important to adopt diagnostic
criteria for patients with SS to confirm or rule out an as-
sociation between SS and periodontal status. These studies
should have adequate sample sizes and be designed as
longitudinal, controlled studies, with study patients
matched for age, race, habits, smoking, and gender. Ad-
ditionally, odds ratio and relative risk analyses should be
performed.
CONCLUSIONS
The present review did not yield strong evidence to
confirm that periodontal status is negatively affected by
SS. PI is higher in patients with SS. Further observa-
tional studies should be performed to clarify the exact
relation between SS and poor periodontal status.
We would like to thank Prof. José Cristiano Ramos Glória,
Ricardo Tângari de Meira, and Maria Tereza Tavares for their
contributions to this study.
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