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| Ava J. Wu, DDS | Frederick B. Vivino, MD, FACR |
Sponsor: This activity is sponsored by The Foundation for Better Health Care.
Grantor: The Foundation for Better Health Care (FBHC) gratefully acknowledges Daiichi Pharmaceutical Co. for its support of this program through an educational grant to the FBHC.
Overview
Sjörgren's syndrome (SS) is an autoimmune inflammatory disorder of the exocrine glands. Primary SS is a serious disorder and, while relatively rare, it is the second most common autoimmune disease, impacting 1 to 4 million Americans. It occurs 10 times more often in women than in men; onset typically occurs between ages 45 and 55. Dry mouth caused by SS can lead to dental erosion, dysphagia, oral infections, and discomfort. It is of paramount importance for primary care physicians (PCPs) to recognize the etiology, types, epidemiology, and pathogenesis of SS to achieve recognition so that appropriate intervention for improved patient mortality, morbidity, and quality of life can be expedited.
Intended Audience
This activity is designed for physicians and allied health professionals, such as nurse practitioners, nurses, and physician assistants, who provide women with principal and preventative healthcare.
Needs Assessment
Through needs assessment surveys, literature searches, advisory board suggestions, and previous meeting evaluations, The Foundation for Better Health Care has determined a need to address the current state of knowledge regarding the diagnosis and management of Sjörgren's syndrome.
Content Validation
The FBHC validates the content of its CME activities through a peer review process and by utilizing evidence-based
medicine sources throughout the planning and implementation of its activities. Adopting the levels of
evidence used by the American Academy of Family Physicians1 and the principles of evidence-based medicine
outlined by Sackett et al,2 the FBHC rates the level of evidence of the literature used to determine needs and
learning objectives, as well as all data cited and presented.
All recommendations involving clinical medicine are based on evidence that is accepted within the profession
of medicine as adequate justification for their indications and contraindications in the care of patients. Further,
all scientific research referred to, reported, or used in support or justification of a patient care recommendation
conforms to the generally accepted standards of experimental design, data collection, and analysis.
Levels of Evidence1
- Level A (randomized controlled trial [RCT]/meta-analysis)
- Level B (other evidence): A well-designed, nonrandomized clinical trial. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions. Includes lower-quality RCTs, clinical cohort studies, and case-controlled studies with nonbiased selection of study participants and consistent findings. High-quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings, are also included
- Level C (consensus/expert opinion)
- Siwek J, Gourlay ML, Slawson DC, Shaughnessy AF. How to write an evidence-based clinical review article. Am Fam Physician. 2002;65:251-258.
- Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 2005.
Learning Objectives
Upon completion of this activity, participants should be able to:
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Review the various diagnostic tests available for Sjörgren's syndrome and appropriately utilize them to make earlier and better diagnoses for improved patient mortality and morbidity
- Umehara I, Yamada I, Murata Y, Takahashi Y, Okada N, Shibuya H. Quantitative evaluation of salivary gland scintigraphy in Sjörgren's syndrome. J Nucl Med. 1999;40:64 69. [Evidence Level C]
- Zandbelt MM, Wentink JR, de Wilde PC, van Damme PA, van de Putte LB, van den Hoogen FH. The synergistic value of focus score and IgA% score of sublabial salivary gland biopsy for the accuracy of the diagnosis of Sjörgren's syndrome: a 10-year comparison. Rheumatology (Oxford). 2002;41:819 823. [Evidence Level B]
- Kalk WW, Mansour K, Vissink A, et al. Oral and ocular manifestations in Sjörgren's syndrome. J Rheumatol. 2002;29:924 930. [Evidence Level B]
- Brennan MT, Sankar V, Leakan RA, et al. Risk factors for positive minor salivary gland biopsy findings in Sjörgren's syndrome and dry mouth patients. Arthritis Rheum. 2002;47:189 195. [Evidence Level B]
- Niemela RK, Takalo R, Paakko E, et al. Ultrasonography of salivary glands in primary Sjörgren's syndrome. A comparison with magnetic resonance imaging and magnetic resonance sialography of parotid glands. Rheumatology (Oxford). 2004;43:875 879. [Evidence Level B]
- Vissink A, Kalk WW, Mansour K, et al. Comparison of lacrimal and salivary gland involvement in Sjörgren's syndrome. Arch Otolaryngol Head Neck Surg. 2003;129:966 971. [Evidence Level B]
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Recognize the diverse presentation of symptoms and comorbidities associated with SS to address all manifestations of the disease and prevent potential complications for improved patient response to care
- Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Sjogren syndrome. Arch Intern Med. 2004;164:1275 1284. [Evidence Level C]
- Theander E, Manthorpe R, Jacobsson LT. Mortality and causes of death in primary Sjörgren's syndrome: a prospective cohort study. Arthritis Rheum. 2004;50:1262 1269. [Evidence Level B]
- Ramos-Casals M, Anaya JM, Garcia-Carrasco M, et al. Cutaneous vasculitis in primary Sjogren syndrome: classification and clinical significance of 52 patients. Medicine (Baltimore). 2004;83:96 106. [Evidence Level B]
- Manoussakis MN, Georgopoulou C, Zintzaras E, et al. Sjörgren's syndrome associated with systemic lupus erythematosus: clinical and laboratory profiles and comparison with primary Sjörgren's syndrome. Arthritis Rheum. 2004;50:882 891. [Evidence Level B]
- Bernacchi E, Amato L, Parodi A, et al. Sjörgren's syndrome: a retrospective review of the cutaneous features of 93 patients by the Italian Group of Immunodermatology. Clin Exp Rheumatol. 2004;22:55 62. [Evidence Level B]
- Koseki M, Maki Y, Matsukubo T, Ohashi Y, Tsubota K. Salivary flow and its relationship to oral signs and symptoms in patients with dry eyes. Oral Dis. 2004;10:75 80. [Evidence Level B]
- Walker J, Gordon T, Lester S, et al. Increased severity of lower urinary tract symptoms and daytime somnolence in primary Sjörgren's syndrome. J Rheumatol. 2003;30:2406 2412. [Evidence Level B]
- D'Arbonneau F, Ansart S, Le Berre R, Dueymes M, Youinou P, Pennec YL. Thyroid dysfunction in primary Sjörgren's syndrome: a long-term followup study. Arthritis Rheum. 2003;49:804 809. [Evidence Level B]
- Lundstrom IM, Lindstrom FD. Iron and vitamin deficiencies, endocrine and immune status in patients with primary Sjörgren's syndrome. Oral Dis. 2001;7:144 149. [Evidence Level C]
- Stevenson HA, Jones ME, Rostron JL, Longman LP, Field EA. UK patients with primary Sjörgren's syndrome are at increased risk from clinical depression. Gerodontology. 2004;21:141 145. [Evidence Level B]
- Tonami H, Matoba M, Kuginuki Y, et al. Clinical and imaging findings of lymphoma in patients with Sjogren syndrome. J Comput Assist Tomogr. 2003;27:517 524. [Evidence Level C]
- Garcia-Carrasco M, Siso A, Ramos-Casals M, et al. Raynaud's phenomenon in primary Sjörgren's syndrome.Prevalence and clinical characteristics in a series of 320 patients. J Rheumatol. 2002;29:726 730. [Evidence Level B]
- Strombeck B, Ekdahl C, Manthorpe R, Jacobsson LT. Physical capacity in women with primary Sjörgren's syndrome: a controlled study. Arthritis Rheum. 2003;49:681 688. [Evidence Level B]
- Rhodus NL, Colby S, Moller K, Bereuter J. Quantitative assessment of dysphagia in patients with primary and secondary Sjörgren's syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79:305 310. [Evidence Level C]
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Evaluate the treatment options for SS and implement them into your practice for more successful and patient-specific treatment regimens
- Sankar V, Brennan MT, Kok MR, et al. Etanercept in Sjörgren's syndrome: a twelve-week randomized, double-blind, placebo-controlled pilot clinical trial. Arthritis Rheum. 2004;50:2240 2245. [Evidence Level B]
- Ono M, Takamura E, Shinozaki K, et al. Therapeutic effect of cevimeline on dry eye in patients with Sjörgren's syndrome: a randomized, double-blind clinical study. Am J Ophthalmol. 2004;138:6 17. [Evidence Level B]
- Alves MB, Motta AC, Messina WC, Migliari DA. Saliva substitute in xerostomic patients with primary Sjörgren's syndrome: a single-blind trial. Quintessence Int. 2004;35:392 396. [Evidence Level B]
- Zandbelt MM, de Wilde P, van Damme P, Hoyng CB, van de Putte L, van den Hoogen F. Etanercept in the treatment of patients with primary Sjörgren's syndrome: a pilot study. J Rheumatol. 2004;31:96 101. [Evidence Level B]
- Khurshudian AV. A pilot study to test the efficacy of oral administration of interferon-alpha lozenges to patients with Sjörgren's syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:38 44. [Evidence Level B]
- Theander E, Horrobin DF, Jacobsson LT, Manthorpe R. Gammalinolenic acid treatment of fatigue associated with primary Sjörgren's syndrome. Scand J Rheumatol. 2002;31:72 79. [Evidence Level A]
- Fife RS, Chase WF, Dore RK, et al. Cevimeline for the treatment of xerostomia in patients with Sjogren syndrome: a randomized trial. Arch Intern Med. 2002;162:1293 1300. [Evidence Level A]
- Petrone D, Condemi JJ, Fife R, Gluck O, Cohen S, Dalgin P. A double-blind, randomized, placebo-controlled study of cevimeline in Sjörgren's syndrome patients with xerostomia and keratoconjunctivitis sicca. Arthritis Rheum. 2002;46:748 754. [Evidence Level A]
- Johansson G, Andersson G, Edwardsson S, Bjorn AL, Manthorpe R, Attstrom R. Effects of mouthrinses with linseed extract Salinum without/with chlorhexidine on oral conditions in patients with Sjörgren's syndrome. A double-blind crossover investigation. Gerodontology. 2001;18:87 94. [Evidence Level B]
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Underscore the association of SS with underlying autoimmune connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma and highlight the positive impact that referral to a rheumatologist has on improving patient outcomes
- Fox RI. Sjörgren's syndrome. Lancet. 2005;366:321-331. [Evidence Level C]
- Alamanos Y, Tsifetaki N, Voulgari PV, Venetsanopoulou AI, Siozos C, Drosos AA. Epidemiology of primary Sjörgren's syndrome in north-west Greece, 1982-2003. Rheumatology (Oxford). 2006;45:187-191. [Evidence Level B]
- Nakamura H, Kawakami A, Eguchi K. Mechanisms of autoantibody production and the relationship between autoantibodies and the clinical manifestations in Sjörgren's syndrome. Transl Res. 2006;148:281-288. [Evidence Level C]
- Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjörgren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002;61:554-558. [Evidence Level C]
Accreditation
The Foundation for Better Health Care is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians. The Foundation for Better
Health Care takes responsibility for the content, quality, and
scientific integrity of this CME activity.
Credit Designation
The Foundation for Better Health Care designates this educational
activity for a maximum of 1.5 AMA PRA Category 1
Credit(s)™. Physicians should only claim credit commensurate
with the extent of their participation in the activity.
This activity has been evaluated and approved by the Continuing Education
Approval Program of the National Association of Nurse Practitioners in
Women's Health for 1.5 contact hours of continuing
education. NPWH Activity no CE 06-15. Each participant
should claim only those contact hours that he/she actually spent in the
educational activity.
Method of Clinician Participation
View the archived symposium and complete the posttest at www.fbhc.org/cme/posttests.
A minimum score of 80% must be obtained for credit to be awarded by the
FBHC. There is no fee for this activity. Credit for the posttest is
available until July 18, 2008.
Identifying and Resolving Conflicts of Interest
The FBHC requires all planning committee members, faculty, teachers,
authors, and staff of a CME activity to identify all relevant financial
relationships that benefit the individual and his or her spouse or
partner in any financial amount within the past 12 months. Such
relationships may create the opportunity to affect the content of CME
regarding the products or services of the commercial interest.
The FBHC has created the FBHC Committee to Identify and Resolve
Conflicts of Interest, which reviews Faculty and Staff Disclosure
Statements, identifies and resolves conflicts of interest, and
determines the level of participation of planning committee members,
faculty members, teachers, and authors.
Faculty
Frederick Vivino, MD
Chief, Division of Rheumatology
PENN Presbyterian Medical Center
Director, Penn Sjögren's Syndrome Center
Clinical Associate Professor of Medicine
University of Pennsylvania School of Medicine
Philadelphia, PA
Ava J. Wu, DDS
Associate Clinical Professor
Co-Director, Sjögren's Syndrome Clinic
University of California, San Francisco
San Francisco, CA
Independent Reviewer
Margaret Nachtigall, MD
Assistant Professor
New York University Medical Center
New York, New York
Faculty and Reviewer Disclosures
It is the policy of The Foundation for Better Health Care to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty are expected to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of their presentation(s). The following relationships have been disclosed:
Frederick Vivino, MD
- Research Support: MGI Pharma, Inc
- Speaker's Bureau: Daiichi Pharmaceutical Co Ltd
- Consultant: Daiichi Pharmaceutical Co Ltd, Genentech, Inc
Ava J. Wu, DDS
- Nothing to disclose
Margaret Nachtigall, MD
- Nothing to disclose
FBHC Staff Disclosure
The FBHC, in keeping with the ACCME's Essential Areas and their Elements and Standards for Commercial Support, has asked each FBHC staff member who has developed and/or reviewed content for this activity to disclose to learners all financial relationships, including those of their spouse or partner, with the manufacturer(s) of any pharmaceutical product(s), device(s), or providers of commercial services in any financial amount within the past 12 months. The FBHC staff members have disclosed the following:
Eresso Aga, Scientific Director
- Nothing to disclose
LaTanya Brown, Project Director
- Nothing to disclose
Michelle Dien, Project Director
- Nothing to disclose
Annika Dronge, MD, Medical Director
- Nothing to disclose
Susan Duff, Managing Editor
- Nothing to disclose
Louise Farkas, Sr. Editor/Writer
- Nothing to disclose
Michael Hite, CEO
- Nothing to disclose
Lauren Janay, Content Coordinator
- Nothing to disclose
Nancy Larsen, Consultant
- Nothing to disclose
Nina Leeds, PhD, Scientific Director
- Nothing to disclose
Andrew McCrea, PhD, Executive Director
- Stock ownership: Abbottt Laboratories, Baxter Healthcare, Eli Lilly and Co, GlaxoSmithKline, Johnson & Johnson, Merck & Co, Inc, Novartis Pharmaceuticals Corp, Pfizer Inc, Proctor & Gamble, Roche Pharmaceuticals, sanofi-aventis, Schering-Plough Corp, Wyeth Pharmaceuticals
Natacha Menar, Sr. Editor/Writer
- Nothing to disclose
Sejal Patel, Senior Account Manager
- Nothing to disclose
Judy Seraphine, Consultant
- Nothing to disclose
Simone Stromer, MD, Medical Director
- Nothing to disclose
Emilie Wang, PhD, Scientific Director
- Nothing to disclose
Diane Zuckerman, RPh, Consultant
- Nothing to disclose
FBHC Disclosure Statement
The views expressed are those of the author(s). It should not be inferred or assumed that this publication expresses the views of Daiichi Sankyo, or any other manufacturer of pharmaceuticals. The Foundation for Better Health Care (FBHC) is an independent professional organization that does not endorse specific products of any pharmaceutical concern. This FBHC CME activity has been independently planned by the FBHC.
All rights reserved, including translation into other languages. No part of this Webcast may be reproduced or transmitted in any form or by any means-electronic or mechanical, including photocopying, recording, or storage in information storage and retrieval systems-without permission in writing from The Foundation for Better Health Care, 33 East 33nd Street, 8th Floor, New York, NY 10016.

July 18, 2007
Expiration date:
July 18, 2008
Estimated time to complete:
1.5 hours











