**7. Alternative types of salivary gland biopsies in SS**

The main alternative types of salivary gland biopsies in SS are parotid gland biopsy and sublingual gland biopsy. Parotid gland biopsy allows the clinician to monitor the disease progression and to assess the effect of an intervention treatment in SS. Parotid tissue can be harvested easily, repeated biopsies from the same parotid gland are possible, and the histopathologic results can be compared with other diagnostic results derived from the same gland, such as secretory function, sialographic appearance, and ultrasonography. Furthermore, parotid biopsy is better in the identification of lymphomas. The main possible complications are facial nerve damage, Frey's syndrome, and development of sialoceles and salivary fistulae. A temporary change in sensation in the skin area of the incision is also a well-documented complication after parotid biopsy. Some patients might also develop preauricular hypothesis, although this is usually temporary. Furthermore, in SS, the salivary gland tissue is replaced by fatty tissue, and the risk of harvesting fatty tissue is thereby increased if done by inexperienced physicians. Parotid biopsy is particularly recommended in pediatric patients in whom SS is suspected and who have a negative minor salivary gland biopsy result. Incisional biopsy of the parotid gland overcomes most of the disadvantages of labial biopsy. When evaluating the parotid and labial biopsy, sensitivity and specificity are comparable, estimated to be 78 and 86%, respectively. Comparative studies suggest that both procedures sublingual and parotid biopsy—retain a diagnostic potential comparable to that of lip biopsy and may be associated with lower postoperative morbidity. A comparison of sublingual gland biopsy with labial gland biopsy is better than that of labial gland biopsy, whereas the specificity of the latter is greater than that of the former. Sublingual gland biopsy is a relatively safe procedure, although the postoperative complications of sublingual salivary gland biopsy include ligaturing the Wharton duct, resulting from the placement of sutures, bleeding, and swelling in the floor of the mouth. Damage to the lingual nerve related to this biopsy technique has never

**63**

**Table 3.**

**Table 3**.

*Laryngological and Dental Manifestations of Sjögren's Syndrome*

merely used the criteria for labial gland biopsies [24–28].

been reported in the literature. No specialized histopathologic criteria have been established for the diagnosis of SS after a sublingual gland biopsy, and researchers

The rate of dry mouth in SS ranged from 41% at initial diagnosis to 84% 10 years after diagnosis. Hyposalivation or xerostomia measured by sialometry is one of the objective clinical criteria in the diagnosis of SS. According to the current classification criteria of SS, an unstimulated salivary flow rate of 0.1 ml/minute in sialometry gives a score of 1 to the weighted sum of 5 items. Dryness is also a subjective symptom of SS and is associated with many clinical implications. There are two possible sources of hyposalivation. The first possible origin is the presence of mononuclear cell aggregates around the ducts and acini of salivary glands resulting in functional and structural alterations of these glands and impairing their secretory function. In addition to the direct relationship between mononuclear cell infiltrations and secretory function, there are alternative pathways, such as induction of apoptosis of epithelial glands, alterations in aquaporin distribution, or inhibition of neurotransmission by antimuscarinic antibodies, lead to impaired glandular homeostasis. The second proposed hypothesis is the destruction of the duct and acinar cells of the salivary glands, and neural degeneration and/or the inhibition of nerve transmission. Hyposialia or decreased salivation can lead to xerostomia with clinical oral symptoms [29]. Dry mouth is associated with both objective and subjective signs and symptoms. The most common complaints related to dry mouth are presented in

In SS, the gingiva and mucosa of the oral cavity are not protected by salivary mucins, leading to less lubrication of the tissues. This can cause signs such as oral mucosal inflammation, mucosal sloughing, erythematous mucosa, and traumatic ulcers. Patients may demonstrate depapillation of the tongue in advanced cases. With time, the concentration of lactoferrin, potassium and cystatin C in saliva grows, while the amylase and carbonic anhydrase concentration drops. Decreased secretion of saliva, the loss of its buffer properties, and a lower concentration of saliva proteins such as histatins, mucins, IgA, and proteins rich in proline and statherins increase the risk of opportunistic infections, mainly fungal infections by *Candida albicans*. The prevalence of *Candida albicans* is >68% in patients with SS. Oral candidiasis may be asymptomatic or may show as fissured tongue, rhomboid mid-tongue, nonspecific ulcerations, prosthetic stomatopathies, or generalized candidiasis. It most often takes the form of chronic candidiasis, and less often of pseudodiphtheritic candidiasis. Candida infections often present as atrophic or erythematous candidiasis and are associated with a burning mouth, which is described by approximately one-third of patients with SS. In SS patients,

*DOI: http://dx.doi.org/10.5772/intechopen.85687*

**8. Oral involvement and xerostomia**

A dryness of the mouth in the morning and at night

A predisposition to aphthae, ulcers, and mouth sores

*The most common complaints related to dry mouth.*

A frequent need to sip water A lip dryness, exfoliation, fissuring

A dysphagia A dysgeusia

A burning sensation in the mouth

been reported in the literature. No specialized histopathologic criteria have been established for the diagnosis of SS after a sublingual gland biopsy, and researchers merely used the criteria for labial gland biopsies [24–28].
