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Editors
Robert I. Fox, MD, Ph.D. Carla M. Fox, RN
Scripps Memorial Hospital & Research Scripps Memorial Hospital & Research
Foundation Foundation
Rheumatology Clinic Rheumatology Clinic
La Jolla, CA 92037, USA La Jolla, CA 92037, USA

ISBN 978-1-60327-956-7 e-ISBN 978-1-60327-957-4

DOI 10.1007/978-1-60327-957-4
Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2011932791

© Springer Science+Business Media, LLC 2011

All rights reserved. This work may not be translated or copied in whole or in part without the
written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street,
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Preface

“He who studies medicine without books

sails an uncharted sea,
but he who studies medicine without patients
does not go to sea at all.”
—Sir William Osler (1849–1916)

Symptoms of dry eyes and dry mouth negatively affect the “quality of life” of
the patient with Sjögren’s Syndrome (SS). Patients have equated the “impact
of sicca symptoms” at a level of disability equal to moderate angina and
would be willing to “trade two to four years of (their) life expectancy” to
be free of these symptoms. For example, a dry mouth alters the types of foods
a patient can eat and thus interferes with “eating together.” Eating serves far
more than nutrition needs and represents a major part of social interaction
for women at home, business, and relaxation with friends. Dry eyes interfere
with the ability to use a computer for prolonged periods at work or at home,
since staring at a computer screen involves a markedly decreased blink rate
and exacerbates symptoms of aqueous tear deficiency.
Extraglandular manifestations can range from vasculitis to lymphopro-
liferative infiltrates of many organs. SS patients have a markedly increased
risk incidence of lymphoma. Many older patients diagnosed with systemic
lupus erythematosus (SLE) actually have SS. Since the correct diagnosis is
not made for many years in most patients, their symptoms and signs due to
glandular involvement are not adequately recognized and treated. Even in
rheumatology, SS is not listed in the “Primer of Rheumatic Diseases,” a major
teaching instrument for residents and fellows in training.
This volume differs from other recent review publications that have
appeared in “current opinion journals” or review volumes largely written by
specialists in a single medical specialty. We have included a distinguished
panel of authors in a broad spectrum of basic science, clinical, and surgi-
cal disciplines. Further, we have included authors from multiple areas of the
world where SS has been studied.
Pathogenic studies reviewed in this volume include genetics and pro-
teomics as well as cytokines and lymphoid regulation. The authors also
emphasize that SS represents the intersection of the immune, secretory,
and neural regulatory axes. An understanding of pathogenesis provides the
backbone for understanding current diagnostic and therapeutic approaches.
Further, basic science and astute clinical observation are the routes to future
improved therapies.

v
vi Preface

Since the SS patient sees a wide variety of clinical and surgery spe-
cialists, we have included authors from many of the relevant areas to
review their specialty’s approach to diagnosis and therapy. For example,
the management of SS often involves Ophthalmology, Oral Medicine, Oral
Surgery, Otolaryngology, Gastroenterology, Dermatology, Nephrology, Chest
Medicine, Hematology and Oncology, Neurology, and Rheumatology. Each
specialty has been given the task of providing useful clinical hints as well
as their “pearls of wisdom.” By integrating the expertise by these eminent
scholars in their respective clinical fields, we try to accomplish the funda-
mental goal of this book—to present cutting-edge diagnosis and therapeutic
approaches to SS in one authoritative source.
The collaborative efforts of contributors in this book geographically span
Europe, the Middle East, Asia, India, Australia, as well as the USA. This
collection of enlightening chapters not only reflects our goal to recognize
the outstanding contributions of each of these groups located around the
world, but also emphasizes that the “medical world” is increasingly a global
community composed of patients and their physicians.
In different regions of the world, the disease may have subtly different
presentations, and the available diagnostic and therapeutic resources are dra-
matically different. Our patients increasingly present to us from different parts
of the world, and they also travel to different regions for work or holiday. The
inclusion of authors from around the world renders this resource an intercon-
nective conduit between US rheumatologists and our counterparts throughout
the world, in order to provide a universal spectrum of educational and clinical
resources for our SS patients as well as for ourselves.
It is our hope that the reader finds this book to be a useful “first stop on
Osler’s journey” toward the procurement and utilization of reputable informa-
tion that promotes the superior medical and nursing care that our courageous
Sjögren’s patients deserve.
We also wish to express our profound gratitude to: (a) our esteemed
Authors, (b) our developmental editor Judi Brown, and (c) Springer
Science+Business Media, for the immense amount of time, effort, and vision
dedicated to the inception and evolution of this volume—without this degree
of synergistic collaboration, this book would not have been possible.

La Jolla, California Robert I. Fox

Carla M. Fox
Contents

Part I Introduction

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Robert I. Fox and Carla M. Fox
2 A Note from Sweden: Recollection of Henrik Sjögren . . . . . 11
Elke Theander and Frank A. Wollheim
3 Myths, Pearls, and Tips Regarding Sjögren’s Syndrome . . . 15
Robert I. Fox, Manuel Ramos-Casals, and John H. Stone
4 Providing Information to Referring Physicians and Patients . 35
Robert I. Fox and Carla M. Fox

Part II Classification Criteria and Disease Status Activity,

Histology of Salivary Gland Biopsy, and Imaging

5 Current Concepts on Classification Criteria

and Disease Status Indexes in Sjögren’s Syndrome . . . . . . 59
Claudio Vitali, Chiara Baldini, and Stefano Bombardieri
6 Histopathology and Glandular Biopsies
in Sjögren’s Syndrome . . . . . . . . . . . . . . . . . . . . . . 73
Roland Jonsson, Kathrine Skarstein, and Malin V. Jonsson
7 Imaging Technology in Sjögren’s Syndrome:
Non-invasive Evaluation of the Salivary Glands . . . . . . . . 83
Jonn Terje Geitung and Malin V. Jonsson

Part III Mechanisms of Pathogenesis

8 Genomics and Viruses in Sjögren’s Syndrome . . . . . . . . . 93

Kathy L. Moser and John B. Harley
9 Autoantibodies and Autoantigens in Sjögren’s Syndrome . . . 111
Kazuhisa Nozawa, Minoru Satoh, Seunghee Cha,
Yoshinari Takasaki, and Edward K.L. Chan

vii
viii Contents

10 B-cell Epitopes of Sjögren’s Syndrome-Related

Autoantigens Ro/SSA and La/SSB . . . . . . . . . . . . . . . 133
Athanasios G. Tzioufas, John G. Routsias,
and Haralampos M. Moutsopoulos
11 Neurobiology and Hormonal Control of Lacrimal
and Salivary Gland Function . . . . . . . . . . . . . . . . . . 151
Yrjö T. Konttinen, Alberto Vivó Porcar, Pauliina
Porola, Katja Koskenpato, María Lorés Rodriguez,
Raimo Pöllänen, Vasily Stegaev, Liisa Virkki,
Michelle Spaan, and Beata D. Przybyla

Part IV Clinical and Therapeutic Considerations

12 Overview of Management of Dry Eye Associated with

Sjögren’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . 179
Paul E. Michelson and Robert I. Fox
13 Pathogenesis: Emphasis on Dry Eye and the Role of
the Lacrimal Functional Unit in Sjögren’s Syndrome . . . . . 203
Michael E. Stern and Stephen C. Pflugfelder
14 Oral and Dental Manifestations of Sjögren’s
Syndrome: Current Approaches to Diagnostics
and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Malin V. Jonsson, Nicolas Delaleu,
Mihaela C. Marthinussen, and Roland Jonsson
15 Etiology and Pathogenesis of Sjögren’s Syndrome
with Special Emphasis on the Salivary Glands . . . . . . . . . 243
Nicolas Delaleu, Menelaos N. Manoussakis,
Haralampos M. Moutsopoulos, and Roland Jonsson
16 Otolaryngologic Manifestations of Sjögren’s
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Jacqui E. Allen and Peter C. Belafsky
17 Extraglandular Manifestations of Sjögren’s
Syndrome (SS): Dermatologic, Arthritic, Endocrine,
Pulmonary, Cardiovascular, Gastroenterology,
Renal, Urology, and Gynecologic Manifestations . . . . . . . 285
Robert I. Fox
18 Therapy of Dermatologic, Renal, Cardiovascular,
Pulmonary, Gynecologic, Gastro-enterologic,
Urologic and Fibromyalgia Manifestations Including
Special Considerations at the Time of Surgery . . . . . . . . . 317
Robert I. Fox and Carla M. Fox
19 Current Treatment of Extraglandular Manifestations
with Disease-Modifying and Immunosuppressive Agents . . . 337
Athanasios G. Tzioufas and Haralampos M. Moutsopoulos
Contents ix

20 Lymphoproliferation and Lymphoma in Sjögren’s

Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Justin Pijpe, Hendrika Bootsma, and Gustaaf W. van Imhoff
21 Fatigue, Dryness, and Quality of Life as Clinical Trial
Outcomes in Primary Sjögren’s Syndrome . . . . . . . . . . . 357
Simon J. Bowman
22 The Neurological Manifestations of Sjögren’s
Syndrome: Diagnosis and Treatment . . . . . . . . . . . . . . 373
Robert I. Fox and Julius Birnbaum

Part V The Views from Japan, China, India, and Australia

23 New Approaches for the Management of Dry Mouth

in Sjögren’s Syndrome in Japan . . . . . . . . . . . . . . . . . 405
Yoichi Nakagawa and Ichiro Saito
24 New Approaches for the Management of Dry Mouth
and Dry Eye in Sjogren’s Syndrome in Japan . . . . . . . . . 415
Kazuo Tsubota
25 Sjögren’s Syndrome in Australia: Clinical Practice
and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Tom Gordon and Maureen Rischmueller
26 Primary Sjögren’s Syndrome: Report from India . . . . . . . 425
Ramnath Misra, Sapan Pandya, and Debashish Danda
27 Sjögren’s Syndrome in China . . . . . . . . . . . . . . . . . . 429
Jing He and Zhan-Guo Li
28 Sjögren’s Syndrome in China . . . . . . . . . . . . . . . . . . 433
Chak-sing Lau
29 Sjögren’s Syndrome in Israel: A Scientific Point
of View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Moshe Tishler and Yehuda Shoenfeld

Part VI Future Perspectives

30 Looking into the Future—The EULAR Disease

Activity Scores: Toward a Consensual Evaluation
of Primary Sjogren’s Syndrome . . . . . . . . . . . . . . . . . 443
Raphaèle Seror, Philippe Ravaud, Claudio Vitali,
Simon J. Bowman, and Xavier Mariette
31 Looking into the Crystal Ball: Initiatives from the
Sjögren’s Syndrome Foundation That Will Impact
Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Elaine Alexander, Frederick B. Vivino,
Steven E. Carsons, and Katherine Morland Hammitt
x Contents

32 Biological Treatment for Sjögren’s Syndrome . . . . . . . . . 459

Philip L. Cohen and Pamela Traisak
33 Looking into the Future—Emerging Therapies Based
on Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Jacques-Eric Gottenberg and Xavier Mariette
34 Into the Future: Autonomic Neuropathy, MicroRNAs,
and Gene Therapy . . . . . . . . . . . . . . . . . . . . . . . . 483
Ilias Alevizos, John A. Chiorini, and Nikolay P. Nikolov
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Contributors

Ilias Alevizos Sjögren’s Syndrome Clinic, National Institute of Dental and

Craniofacial Research, Bethesda, MD, USA, [email protected]
Elaine Alexander Sjögren’s Syndrome Foundation Medical and Scientific
Advisory Board, San Diego, CA, USA, [email protected]
Jacqui E. Allen Department of Otolaryngology, University of Auckland,
Auckland, New Zealand, [email protected]
Chiara Baldini Rheumatology Unit, University of Pisa, Pisa, Italy,
[email protected]
Peter C. Belafsky The Center for Voice and Swallowing, University
of California at Davis, Davis, CA, USA, [email protected]
Julius Birnbaum Division of Rheumatology, The Jerome L. Greene
Sjögren’s Syndrome Center, Johns Hopkins Bayview Medical Center,
Baltimore, MD, USA, [email protected]
Stefano Bombardieri Rheumatology Unit, University of Pisa, Pisa, Italy,
[email protected]
Hendrika Bootsma Department of Rheumatology and Clinical
Immunology, University of Groningen, Groningen, The Netherlands;
University Medical Center, Groningen, The Netherlands,
[email protected]
Simon J. Bowman Department of Rheumatology, University Hospitals
Birmingham, Birmingham, England, [email protected]
Steven E. Carsons SUNY at Stony Brook School of Medicine, Stony
Brook, NY, USA; Division of Rheumatology, Allergy and Immunology,
Winthrop-University Hospital, Mineola, NY, USA, [email protected]
Seunghee Cha Department of Oral Surgery and Diagnostic Sciences,
University of Florida College of Dentistry, Gainesville, FL, USA;
Department of Oral Biology, University of Florida College of Dentistry,
Gainesville, FL, USA, [email protected]fl.edu
Edward K.L. Chan Department of Oral Biology, University of Florida
College of Dentistry, Gainesville, FL, USA, echan@ufl.edu

xi
xii Contributors

John A. Chiorini Department of Molecular Physiology and Therapeutics

Branch, National Institute of Dental and Craniofacial Research, Bethesda,
MD, USA, [email protected]
Philip L. Cohen Section of Rheumatology, Department of Medicine,
Temple University School of Medicine, Philadelphia, PA, USA,
[email protected]
Debashish Danda Department of Clinical Immunology and
Rheumatology, Christian Medical College, Vellore, India,
[email protected]
Nicolas Delaleu Broegelmann Research Laboratory, The Gade Institute,
University of Bergen, Bergen, Norway; Rheumatology Clinic, Scripps
Memorial Hospital and Research Foundation, La Jolla, CA, USA,
[email protected]
Carla M. Fox Rheumatology Clinic, Scripps Memorial Hospital and
Research Foundation, La Jolla, CA, USA, [email protected]
Robert I. Fox Rheumatology Clinic, Scripps Memorial Hospital and
Research Foundation, La Jolla, CA, USA, [email protected]
Jonn Terje Geitung Haraldsplass Deaconess University Hospital, Bergen,
Norway, [email protected]; [email protected]
Tom Gordon Department of Immunology, Flinders Medical Center,
Flinders, Australia, t.gordon@flinders.edu.au
Jacques-Eric Gottenberg Centre de Recherche Biomédical Strasbourgeois
(CRBS), Hôpitaux Universitaires de Strasbourg, Université de Strasbourg,
Strasbourg, France, [email protected]
Katherine Morland Hammitt Sjögren’s Syndrome Foundation,
Lynchburg, VA, USA, [email protected]
John B. Harley Division of Rheumatology, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH, [email protected]
Jing He Department of Rheumatology and Immunology, People’s
Hospital, Peking University Medical School, Beijing, China,
[email protected]
Gustaaf W. van Imhoff Department of Hematology, University of
Groningen, Groningen, The Netherlands; University Medical Center,
Groningen, The Netherlands, [email protected]
Malin V. Jonsson Institute of Medicine - Section for Rheumatology,
University of Bergen, Bergen, Norway, [email protected]
Roland Jonsson Broegelmann Research Laboratory, The Gade Institute,
University of Bergen, Bergen, Norway; Department of Rheumatology,
Haukeland University Hospital, Bergen, Norway,
[email protected]
Contributors xiii

Yrjö T. Konttinen Department of Medicine, Biomedicum Helsinki,

Helsinki University Central Hospital, Helsinki, Finland; ORTON
Orthopaedic Hospital of the ORTON Foundation, Helsinki, Finland; COXA
Hospital for the Joint Replacement, Tampere, Finland,
yrjo.konttinen@helsinki.fi
Katja Koskenpato Department of Medicine, Biomedicum Helsinki,
Helsinki University Central Hospital, Helsinki, Finland,
katja.koskenpato@helsinki.fi
Chak-sing Lau Division of Rheumatology and Clinical Immunology,
Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong
Kong, China, [email protected]
Zhan-Guo Li Department of Rheumatology and Immunology, People’s
Hospital, Peking University Medical School, Beijing, China,
[email protected]
Menelaos N. Manoussakis Department of Pathophysiology, School of
Medicine, University of Athens, Athens, Greece, [email protected]
Xavier Mariette Assistance Publique-Hôpitaux de Paris (AP-HP),
Hôpital Bicêtre, Institut Pour la Santé et la Recherche Médicale (INSERM)
U 1012, Université Paris-Sud 11, Le Kremlin Bicêtre, France,
[email protected]
Mihaela C. Marthinussen Section for Cariology, Department of Clinical
Dentistry, Faculty of Medicine and Dentistry, Bergen,
[email protected]
Paul E. Michelson Eye Care of La Jolla, Scripps Memorial Hospital,
La Jolla, CA, USA; UCSD School of Medicine, La Jolla, CA, USA,
[email protected]
Ramnath Misra Department of Immunology, Sanjay Gandhi Post
Graduate Institute of Medical Sciences, Lucknow, India,
[email protected]
Kathy L. Moser Arthritis and Immunology Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK, USA, [email protected]
Haralampos M. Moutsopoulos Department of Pathophysiology, School of
Medicine, University of Athens, Athens, Greece, [email protected]
Yoichi Nakagawa Second Department of Oral and Maxillofacial Surgery,
Tsurumi University School of Dental Medicine, Yokohama, Japan,
[email protected]
Nikolay P. Nikolov Sjögren’s Syndrome Clinic, National Institute
of Dental and Craniofacial Research, Bethesda, MD, USA,
[email protected]
Kazuhisa Nozawa Department of Rheumatology and Internal Medicine,
Urayasu Hospital Juntendo University, Chiba, Japan; Institute for
xiv Contributors

Environment and Gender Specific Medicine, Juntendo University Graduate

School of Medicine, Chiba, Japan; Department of Rheumatology, Juntendo
Urayasu Hospital, Chiba, Japan, [email protected]
Sapan Pandya Department of Rheumatology, Vedanta Institute of Medical
Sciences, Ahmedabad, India, [email protected]
Stephen C. Pflugfelder Department of Ophthalmology, Baylor College of
Medicine, Houston, TX, USA, [email protected]
Justin Pijpe Department of Oral and Maxillofacial Surgery, Catharina
Hospital Eindhoven, Eindhoven, The Netherlands; University Medical
Center, Groningen, The Netherlands, [email protected]
Raimo Pöllänen Department of Medicine, Biomedicum Helsinki, Helsinki
University Central Hospital, Helsinki, Finland, raimo.pollanen@helsinki.fi
Alberto Vivó Porcar Department of Medicine, Biomedicum Helsinki,
Helsinki University Central Hospital, Helsinki, Finland,
[email protected]
Pauliina Porola Department of Medicine, Biomedicum Helsinki, Helsinki
University Central Hospital, Helsinki, Finland, pauliina.porola@helsinki.fi
Beata D. Przybyla Department of Microbiology and Immunology,
University of Arkansas for Medical Sciences, Little Rock, AK, USA,
[email protected]
Manuel Ramos-Casals Sjögren Syndrome Research Group (AGAUR),
Hospital Clinic, Barcelona, Spain, [email protected]
Philippe Ravaud Centre d’Epidomiologie Clinique, INSERM U738,
Hôpital Hotel Dieu, Paris, France, [email protected]
Maureen Rischmueller Department of Rheumatology, The Queen
Elizabeth Hospital/University of Adelaide, Adelaide, South Australia,
[email protected]
María Lorés Rodriguez Department of Medicine, Biomedicum Helsinki,
Helsinki University Central Hospital, Helsinki, Finland,
[email protected]
John G. Routsias Department of Pathophysiology, School of Medicine,
University of Athens, Athens, Greece, [email protected]
Ichiro Saito Department of Pathology, Tsurumi University School
of Dental Medicine, Yokohama, Japan, [email protected]
Minoru Satoh Division of Rheumatology and Clinical Immunology,
Department of Medicine, University of Florida, Gainesville, FL, USA;
Department of Pathology, Immunology, and Laboratory Medicine,
University of Florida, Gainesville, FL, USA,
[email protected]fl.edu
Raphaèle Seror Assistance Publique-Hopitaux de Paris, Hôpital Bicêtre,
Department of Rheumatology, Institut Pour la Santé et la Recherche
Contributors xv

Médicale (INSERM) U 802, Université Paris-Sud 11, Le Kremlin Bicêtre,

France, [email protected]
Yehuda Shoenfeld Department of Medicine “B” and Zabludowicz Center
for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel,
[email protected]
Kathrine Skarstein Broegelmann Research Laboratory, Department
of Immunology, The Gade Institute, University of Bergen, Bergen, Norway,
[email protected]
Michelle Spaan Department of Medicine, Biomedicum Helsinki, Helsinki
University Central Hospital, Helsinki, Finland,
[email protected]
Vasily Stegaev Department of Medicine, Biomedicum Helsinki, Helsinki
University Central Hospital, Helsinki, Finland, vasily.stegaev@helsinki.fi
Michael E. Stern Inflammation Research Program, Allergan, Inc., Irvine,
CA, USA, [email protected]
John H. Stone Division of Rheumatology, Allergy, and Immunology,
Massachusetts General Hospital, Boston, MA, USA, [email protected]
Yoshinari Takasaki Department of Internal Medicine and Rheumatology,
Juntendo University School of Medicine, Tokyo, Japan,
[email protected]
Elke Theander Skane University Hospital Malmö, Malmö, Sweden,
[email protected]
Moshe Tishler Department of Medicine “B”, Asaf Harofe Medical
Center, Zerifin, Israel 70300, [email protected]
Pamela Traisak Section of Rheumatology, Department of Medicine,
Temple University School of Medicine, Philadelphia, PA, USA,
[email protected]
Kazuo Tsubota Department of Ophthalmology, Keio University School
of Medicine, Tokyo, Japan, [email protected]
Athanasios G. Tzioufas Department of Pathophysiology, School
of Medicine, University of Athens, Athens, Greece, [email protected]
Liisa Virkki Department of Medicine, Biomedicum Helsinki, Helsinki
University Central Hospital, Helsinki, Finland, liisa.m.virkki@helsinki.fi
Claudio Vitali Section of Rheumatology, Department of Internal
Medicine, Villamarina Hospital, Piombino, Italy, [email protected]
Frederick B. Vivino Division of Rheumatology, Penn Presbyterian
Medical Center, University of Pennsylvania School of Medicine,
Philadelphia, PA, USA, [email protected]
Frank A. Wollheim Lund University Hospital SUS, Lund, Sweden,
[email protected]
 Part I
Introduction
 Introduction
1
Robert I. Fox and Carla M. Fox

Keywords
Sjogren’s syndrome • Keratoconjunctivitis sicca • Ophthalmology •
Otolaryngology • Oral medicine • Gastroenterology • Neurology •
Pathogenesis • Europe • China • India • Israel • Internet

The care of the Sjogren’s syndrome (SS) patient Europe, the Middle East, South America,
is often shared by many specialists due to the Australia, and Asia as well as the USA. Different
multi-system involvement of this disease. Each medications (including herbal) and different
of these specialists reads different journals and diagnostic methods are used in various parts
rarely attends common educational meetings. of the world, based on medical resources and
Thus, each specialty has a slightly different view technology available. These chapters provide
of the “elephant” in the room. The primary goal examples about how to manage our patients
of this book is to bring together a series of experts in a cost-efficient manner and new approaches
in different disciplines to provide a common dia- to therapy. Also, it is important for “western
logue regarding diagnosis and therapy for SS. physicians” to recognize “centers of excellence”
Each chapter is written in a manner that preserves among the emerging nations of the world because
the sophistication of their respective field but that our patients increasingly travel to these regions
employs terminology that will be clear to other for business and pleasure. Our patients may
specialtists. require medical care either for a complication of
Although the rheumatologist frequently their SS or for an infection that is endogenous
becomes the central “quarterback” in the treat- to that region while travelling. It is worth noting
ment of the SS patient, he/she must be familiar that in many parts of the world (as well as
with the diagnostic procedures and therapeutic certain regions of the USA) the “primary” care
approaches of the other specialties to avoid of rheumatology patients is under the direction
medication interactions and coordination of care. of non-surgical orthopedic surgeons in part to
An additional goal for this volume is to include the shortage of available rheumatologists. This
contributors from around the world including volume also is directed to “non-rheumatologist”
who is providing care to the SS patient.
We are fortunate to have contributions in clin-
R.I. Fox () ical specialties from
Rheumatology Clinic, Scripps Memorial Hospital and
Research Foundation, La Jolla, CA, USA • Ophthalmology
e-mail: [email protected] • Oral medicine

R.I. Fox, C.M. Fox (eds.), Sjögren’s Syndrome, DOI 10.1007/978-1-60327-957-4_1, 3

© Springer Science+Business Media, LLC 2011