The eyes and mouth will be examined for dryness to determine how severe the problem is. One technique to assess eye dryness is to use staining tests. Two staining tests are known as Rose Bengal staining and lissamine green staining. Rose Bengal and lissamine green staining involves applying a dye (colored substance) on the surface of the eyeball. Cells in the eye that have been eroded by dryness will absorb this stain whereas healthy cells will not.

The doctor will examine the eyes with a light to tell if any staining occurred. If the cells of the conjunctiva of the eye become stained with the colored substance, this is consistent with dryness of the eyes. The conjunctiva is a clear layer that covers and protects the inside of the eyelids and the front part of the sclera (the white part of the eyes). The doctor may use a lamp (called a split lamp) that magnifies the eye. This allows the doctor to tell whether the outside of the eye is inflamed and how severe the dryness is.

Schirmer's tests can be used to measure tear production. The Schirmer I tests involve placing a thin paper strip under the lower eyelid for a certain period of time (usually 5 minutes). The paper strip is then removed and the length of the strip that is wet from tears is measured. The measurement is compared to the length of the strip that should be wet in people with normal tear production. People with Sjogren's syndrome usually produce less than 8 millimeters of tears. The Schirmer II test is similar, but it uses a cotton swab to stimulate a tear reflex inside the nose.

The doctor will also examine the mouth for dryness and to see if any of the major salivary glands are enlarged. A dry mouth will usually look red and sticky and the saliva is usually thick. The lips may be dry and cracked and the corners of the mouth may have sores. Tooth decay is another sign of a dry mouth. The doctor may take a sample of the saliva to test its quality and to see how much of it is being produced.

Measurement of the flow of saliva can also be performed when assessing dry mouth. X-rays can be taken of the glands that produce saliva. This type of x-ray is known as a sialogram. A sialogram detects a dye that is injected into the parotid gland (see above). The dye is injected through a small duct in the mouth. A duct is a tube that allows fluids and/or substances to pass through it, especially those produced by glands.

A small tissue sample of tiny salivary glands from the inside of the lower lip can be performed to look for abnormalities. The tissue sample is examined under a microscope. If inflammation and a particular pattern of lymphocytes are found in the tissue sample during this examination (types of white blood cells), the test is positive for Sjogren's syndrome. This test is the best way to tell if a dry mouth is caused by Sjogren's syndrome. If this test is positive and the patient has a dry mouth and dry eyes, the patient is generally considered to have Sjogren's syndrome. Nevertheless, the doctor may do additional tests to determine what other parts of the body have been affected.

Blood tests can be performed to determine the presence of antibodies formed in response to two antigens known as Ro and La. See the previous section on causes of Sjogren's syndrome to read more about antibodies and antigens. The antibodies to Ro are known as anti-Ro (also known as SS-A or SS-Ro). The antibodies to La are known as anti-La (also known as SS-B or SS-La). Together, these antibodies are known as Sjogren's antibodies. The presence of these antibodies in pregnant women can cause a rash in the infant that goes away in a few months. In rare cases, these antibodies are associated with heart problems in the newborn.

People who only have Sjogren's syndrome and no other autoimmune disorders are more likely to have the anti-Ro and anti-La antibodies present in their blood compared to people who have Sjogren's syndrome and another autoimmune disorder. People with Sjogren's syndrome and no other autoimmune disorders are more like to have anti-nuclear antibodies (ANAs) in their blood. Anti-nuclear antibodies are antibodies that are directed against the body. You can have Sjogren's syndrome, however, without having ANAs in the blood.

Blood tests may be performed to look for other types of antibodies. For example, there are types of antibodies known as gamma globulins and immunoglobulins that everyone has in their blood, but are present in increased levels in people with Sjogren's syndrome. Antibodies formed against the thyroid may be present in the blood of people with Sjogren's syndrome. As was discussed earlier, an inflamed thyroid gland sometimes happens to people with Sjogren's syndrome. The inflamed thyroid is caused by antibodies formed against the thyroid. These antibodies, known as thyroid antibodies, travel from the salivary glands into the thyroid.

People with Sjogren's syndrome sometimes have a substance known as rheumatoid factor (RF) in their blood. Rheumatoid factor is a type of antibody that is often found in the blood of people with rheumatoid arthritis. Rheumatoid arthritis is a disorder in which the body's defense system attacks its own tissues, causing inflammation of bone joints. Rheumatoid factor can be detected with blood tests. Blood tests may also reveal the presence of abnormal proteins known as cryoglobulins. The presence of cryoglobulins represents a risk of lymphoma (see earlier).

The doctor may perform a blood test to check the sedimentation rate (also known as the sed rate). The sedimentation rate is the speed at which red blood cells settle to the bottom of a column of blood in a glass tube. Red blood cells are cells that help carry oxygen in the blood. The reason that the doctor will want to check the sedimentation rate is because certain inflammatory conditions can increase the speed at which the red blood cells settle to the bottom of the tube.

The doctor will likely also perform routine blood tests to check that the liver and kidneys are functioning properly, that the blood sugar level is normal, and that the correct number of various types of blood cells (such as red and white blood cells) are present. A urine test may also be performed to see if Sjogren's syndrome has affected the kidneys. A chest X-ray may be performed to make sure that the lungs are not inflamed.

HOW ARE PROBLEMS WITH THE BRAIN, SPINE, AND NERVES DIAGNOSED THAT ARE ASSOCIATED WITH SJOGREN'S SYNDROME?

There are several ways in which problems with the brain, spinal cord, (and nerves outside the brain and spinal cord) can be diagnosed. One way is through an Magnetic Resonance Imaging (also known as MRI) scan of the brain or spine. MRI scans produce extremely detailed pictures of the inside of the body by using very powerful magnets and computer technology.

A spinal tap (also known as a lumbar puncture) may be performed to diagnose problems with the brain or spine. A spinal tap is a procedure in which a needle is inserted into a space inside the spinal canal for the purpose of removing some of the cerebrospinal fluid. Cerebrospinal fluid is the fluid that cushions the brain and spinal cord. The spinal canal is the space between the spinal cord and the bony structure that surrounds it. Another way to diagnose problems with the nerves is by taking a part of a specific nerve out and performing tests on it. This is known as a nerve biopsy.

WHAT TYPE OF DOCTOR CAN DIAGNOSE SJOGREN'S SYNDROME?

There are many different types of doctors that can diagnose Sjogren's syndrome. Usually, a rheumatologist will work with a number of different specialists to make a diagnosis and coordinate treatment. A rheumatologist is a type of doctor that specializes in diseases of the joints, bones, and muscles. Types of doctors that may be involved in the diagnosis of Sjogren's syndrome include allergists, dentists, dermatologists (skin doctors), pulmonologists (lung specialists), otolaryngologists (ear, nose, and throat doctor), and neurologists (doctors specializing in the brain, spine, and nerves).

Other doctors that may be involved in a diagnosis of Sjogren's syndrome include gastroenterologists, gynecologists, ophthalmologists, and urologists. A gastroenterologist is a doctor that specializes in the digestive system. A gynecologist is a doctor that specializes in the female reproductive system. An ophthalmologist is a medical doctor that specializes in ophthalmology, which is the science that deals with the structure, functions, and diseases of the eye, as well as the diagnosis and treatment of such diseases. A urologist is a doctor that specializes in the urinary tract of males and females and of the male reproductive system. The urinary tract is the part of the body that deals with the formation and release of urine (pee).

HOW IS SJOGREN'S SYNDROME TREATED?

Unfortunately, there is no known cure for Sjogren's syndrome. There has also yet to be a treatment found that can restore the release of fluids that moisten the body. Treatment is used to ease the signs and symptoms and differs for each person. Of course, talk to your doctor first to determine what treatment is right for you. We have divided this treatment topic into sections below.

• DRY EYES: Artificial (fake) teardrops can be used to make the eyes less dry. These drops are available by prescription or over the counter. The tears come in different thicknesses. Thicker drops do not need to be used as often. However, the thicker drops can collect along the eyelids and lead to blurry vision. Some drops contain preservatives so they last on the shelf of the store longer. These preservatives can cause eye irritation and discomfort in some people. Drops without preservatives usually do not bother the eyes. Drops without preservatives come in single dose packages so they do not become contaminated with bacteria.

  Eye ointments are also available, which are drops that are thicker than artificial tears. They moisturize the eyes and protect the eyes for several hours. Eye ointments can cause blurry vision, which is why they tend to provide more relief at night, during sleep.

  Another option for dry eyes is to use Lacriserts (Hydroxypropyl methylcellulose), which are small pellets of chemicals that contain artificial tears to wet the surface of the eye. Lacriserts are tucked under the lower eyelid once a day. Once artificial tears are added to Lacriserts, the pellets dissolve and forms a film over the tears, trapping the moisture.

  Soft contact lenses that can be moistened often are recommended for people that use contact lenses. Wearing glasses throughout the day can also decrease dryness of the eyes. Blinking several times a minute while working on the computer or watching TV is usually helpful as well.

  In severe cases, a procedure called punctal occlusion may be recommended, in which the tear drain of the eye is closed. Normally, the tears leave he eye through two tiny openings (known as lacrimal puncta) in the corner of the eye nearest the nose. Extra tears drain down these openings and empty into the nose. This explains why the nose gets runny when someone cries a lot. By plugging up the tear drains, the extra tears cannot flow into the nose, and stay in the eye longer.

  The plugs can be temporary or "permanent." Temporary plugs are made of collagen (a type of fiber) and slowly dissolve. The "permanent" plugs are made of silicone. Silicone is a compound (combined substance) that is partly made of silicon (a non-metallic element). The word "permanent" is placed in quotes because the doctor can easily remove these plugs or the plugs eventually fall out. For a longer lasting effect, the doctor can perform surgery to seal the tear drains. The surgery can be done with a laser or through cauterization. Cauterization is the application of heated instruments or destructive chemicals to tissues to destroy tissues, promote healing within tissues, or stop bleeding.

• DRY MOUTH: Drinking a lot of sugar free liquids (especially water) frequently helps to reduce dryness in the mouth. Frequent sips of such drinks throughout the day will be most helpful to people with dry mouth when they are talking or eating. It is important to take sips of liquids rather than to drink large amounts of liquids. Drinking large amounts of liquids will only make you pee more and can cause even more dryness by stripping the mouth of mucus (a thick slippery fluid).

  If the salivary glands are still producing some saliva, it is possible to stimulate them to make more saliva. This can be done by using sugar free candies, sugar free gum, or lemon drops. Consuming foods and drinks that are sugar free is important because they will not cause tooth decay.

  Good dental care is very important since the decreased saliva can lead to tooth decay. This means flossing once a day, avoiding sugar, visiting the dentist three times a year for a teeth cleaning and exam, and rinsing the mouth with water several times a day. The mouth should be checked for redness and sores on a daily basis. The dentist should be contacted if anything unusual is noted or if any bleeding or pain in the mouth occurs.

  Mouthwash with alcohol should be avoided because alcohol is drying. If you cannot avoid sugar, doctors recommend brushing your teeth immediately after you eat or drink something with sugar. Some dentists may recommend placing a protective covering over the teeth to prevent cavities.

  Flouride gels, fluoride supplements, and liquids with minerals in it can be prescribed by a doctor so that the proper chemical balance in the mouth can be restored. Flouride is a mineral that is useful in preventing tooth decay by strengthening the covering of the tooth. Most people that use fluoride gels use them at night. There are toothpastes available that also contain fluoride. Toothpaste that does not foam is less drying. The teeth, gums, and tongue should be brushed gently after each meal and before bedtime.

  There is also artificial saliva that people with dry mouth can use. Artificial saliva is most useful for people that produce very little saliva or none at all. Artificial saliva makes the mouth feel wet. Some artificial salivas contain fluoride, which helps prevent cavities. Salivart, a type of artificial saliva, comes in a spray can and is easy to use. The problem with all artificial salivas is that they all work for a limited time, since they are eventually swallowed. Artificial saliva can last as long as two hours. Those that contain gel in it tend to provide the longest relief.

  The doctor may prescribe Salagen (pilocarpine hydrochloride) to treat dry mouth, because this medication increases the production of saliva. Salagen can cause increased sweating and headaches. Another medication given for dry mouth is Exovac (also known as Cevimeline). Exovac causes certain glands in the mouth to produce more saliva. Exovac also has side effects associated with it, such as sweating, runny/stuffy nose, and nausea. It can less commonly cause itching, difficulty breathing, and fast breathing. Occurrence of any of these less common side effects should lead one to call the doctor immediately. The effects of Salagen and Exovac lasts for a few hours. The products can be used three to four times a day.

  To make it easier to talk, people with Sjogren's syndrome are usually told by doctors not to clear the throat before speaking. Sipping on water, chewing gum, or sucking on a candy helps improve the ability to speak as opposed to clearing the throat. Humming, making an "h" sounds, or laughing gently prior to speaking can help the vocal cords come together so that sounds are produced. Clearing the throat does the same thing, but is rough and irritating to the vocal cords.

  Medications that increase saliva and mucus can decrease dryness in the nose and throat. Dried and/or cracked lips can be treated with lip balm or lipstick that contains oils or petroleum jelly (such as Vaseline). For mouth pain, the doctor can prescribe a mouth rinse that contains medication to control pain and inflammation. The doctor can also prescribe a gel or ointment to rub on sore areas to control pain and inflammation.

• DRY SKIN: Using heavy moisture creams and ointments when the skin is still damp can help trap moisture and can improve dry skin. Such creams are usually used about three to four times a day. Lotions, which are not as heavy as creams or ointments, are usually not recommended because they evaporate fast, a process that can cause dry skin.

  People with dry skin are usually recommended by their doctor to avoid washing with hot water and to avoid soaking the hands in water or using cleaning solutions. Short showers of less than 5 minutes are generally recommended. Moisturizing soaps can be helpful to clean oneself with. Patting the skin, instead of rubbing it, can be helpful. After patting the skin down is when the moisturizing creams should be used.

  For people that take baths, staying in the tub for 10 to 15 minutes is generally recommended because it gives the body a chance to absorb moisture. Rubber gloves should be used when doing dishes or housecleaning. The doctor can help someone with Sjogren's syndrome avoid medications that can decrease body fluids (see above).

  Avoiding smoking or exposure to smoke can be helpful to people with Sjogren's syndrome because smoke increases dryness. Avoiding windy, breezy, and drafty environments can also help one reduce dryness. Avoiding prolonged sun exposure and use of sunscreen (at least SPF 15) when going outdoors is generally recommended because many people with Sjogren's syndrome (especially those with lupus; see earlier section) get painful burns even with a small amount of sun exposure.

  Use of a humidifier in the bedroom can help moisten the skin. Regarding makeup, it is advised by many doctors to only apply mascara to the tips of the eyelashes so that it does not get in the eyes. Also, eye shadow or eyeliner is often recommended to be placed on the skin above the eyelashes as opposed to the sensitive skin under the eyelashes that is close to the eyes.

  Dryness on the outer part of the vagina can be treated with skin creams and ointments. Due to the risk of not being able to have sexual intercourse without pain because of a dry vagina, a moisturizer can be used inside the vagina to make it wet. This, in turn, would make sex more comfortable. Lubricants, as opposed to moisturizers, do not help the vagina retain moisture. This is why doctors recommend lubricants for sexual intercourse only. There are different types of lubricants. Lubricants that contain oil, such as petroleum jelly, trap moisture, but can cause sores and can interfere with the natural cleaning process of the vagina. Lubricants that dissolve in water are generally better to use.

• PAIN, INFLAMMATION, & OTHER SYMPTOMS: Other types of treatment would be needed if Sjogren's syndrome caused pain and inflammation. This generally involves the prescription of pain medications. One group of medications that decrease inflammation is known as non-steroidal anti-inflammatories (abbreviated as NSAIDs). An example of such a medication is aspirin. NSAIDs are usually recommended for people with aching and/or swollen joints. NSAIDs should always be taken with food because they can cause stomach bleeding.

  There are types of NSAIDs available by prescription that are more powerful than those purchased over the counter without a prescription. NSAIDS are also used to treat inflammation of the lining of the lungs.

  Antidepressant medications, known as tricyclic antidepressants, are also used to decrease pain in Sjogren's syndrome, as is Neurontin. Neurontin (also known as gabapentin) is a type of antidepressant medication that is also used to treat pain.

  Steroid medications in various forms (such as pills or creams) are also used to treat pain and itchiness associated with Sjogren's syndrome because they decrease inflammation. Steroid medications are drugs that act similarly to certain steroids produced naturally in the body. Steroids are any of a large number of hormone substances with a similar and basic chemical structure. Hormones are natural chemicals produced by the body and released into the blood that have a specific effect on tissues in the body.

  A specific type of steroid medication is sometimes used to treat Sjogren's syndrome. This type of steroid medication is known as a corticosteroid and it helps decrease inflammation and slow down joint damage. Corticosteroids are a group of drugs that act similarly to a natural chemical in the body known as corticosteroid hormone. Corticosteroid hormones control the body's use of nutrients and the amount of water and salts in the urine (pee). This is why corticosteroids are sometimes used to treat kidney problems associated with Sjogren's syndrome.

  Corticosteroids are sometimes used to decrease inflammation of the windpipe, voice box, bronchial tubes, and the lining of the lungs. Bronchial tubes are airways that connect that windpipe to the lungs. If the bronchial tubes have become narrowed, making it difficult to breath, medications are available that can widen them. A humidifier can also help make it breath easier.

  The problem with corticosteroids is that they can become less effective and cause serious side effects when used for months or years. This is why doctors usually prescribe corticosteroids to treat suddenly occurring symptoms, with the goal of slowly taking the patient off the medication.

  Examples of serious side effects from corticosteroids include thinning of the bones, easy bruising, weight gain, round face, and high blood pressure. Corticosteroids can also cause diabetes mellitus. Diabetes mellitus is a complex, long-term disorder in which the body is not able to effectively use a natural chemical called insulin. Insulin's main job is to quickly absorb glucose (a type of sugar) from the blood into cells for their energy needs and into the fat and liver (a large organ that performs many chemical tasks) cells for storage.

  Medications known as alkaline agents are sometimes used to treat kidney problems associated with Sjogren's syndrome. Alkaline agents work by balancing the chemicals in the blood so that too much acid does not build up.

  An anti-malaria medication, Plaquenil (also known as Hydroxychloroquine), is sometimes used to treat Sjogren's syndrome because it seems to decrease tissue damage of the joints, skin, and other organs of the body. However, it is not very good at treating the dryness associated with Sjogren's syndrome. Malaria is a serious disease caused by parasites that is spread by mosquitoes. A parasite is any organism that lives in or on another living being, gains an advantage by doing so, but causes disadvantage to the being it is living on.

  In severe cases, drugs that decrease the response of the immune system are sometimes used. These drugs are known as immunosuppressive drugs. The purpose of using these drugs is to prevent the body from attacking itself. However, by decreasing the response of the immune system, the body is less able to fight off real infections. Examples of immunosuppressive drugs include hydroxychloroquine (Plaquenil), methotrexate (matrix), and cyclophosphamide (Cytoxan). These drugs are most likely to be used if there are problems with the kidneys, blood vessels, nerves, brain, or spine.

  If pneumonia develops, this is treated with various types of antibiotics (medications that kill bacteria) depending on the person and type of infection. Pneumonia is inflammation of the lungs due to infection.