The Crunchy Allergist 0:05
Are you sick of the fatigue and fog fed up with unpredictable flares hangry from the super restrictive diets. Hello, and welcome to success with sjogrens a podcast empowering naturally minded and scientifically grounded women looking to reduce or even eliminate their sjogrens symptoms. Hi, I'm your host Dr. Kara Wada, a fellow sjogrens spoony triple board certified allergy immunology and lifestyle medicine physician, coach, medical educator, and mom. As a reminder, although I am a physician, I'm not your physician, and this podcast is for educational purposes only. Welcome, everyone, thank you so much for joining us with this episode. On this episode of the successful sjogrens Podcast. I am super duper excited to welcome Dr. Gillian Rigert, who is not only a physician, but also a dentist, she is an oral health expert. And we're going to talk about all things mouth and health related to sjogrens, today. I'm gonna let her introduce herself and share a little bit more and we're just gonna jump right in.
Dr. Jillian Rigert, MD DDS 1:17
Thank you. And thank you so much for the opportunity. I'm so excited to be part of this wonderful work that you're creating and resource for Sjogren's patients. So absolutely. My name is Julian Rigert, and I have formal training in dentistry, medicine and oral medicine, and not a lot of people know what oral medicine is. So just kind of been short. We're oral health providers that focus on the combination of medicine and dentistry. And it's the oral manifestations of systemic diseases. So really great opportunity to integrate the medical and dental backgrounds I have.
The Crunchy Allergist 1:52
Awesome. So what is the typical day look like for you?
Dr. Jillian Rigert, MD DDS 1:56
It's interesting for oral medicine, you know, when people tell me what kind of career... trajectory do oral medicine providers have, I would say it's very diverse. Currently, I am a post doc research fellow in the department of radiation oncology. So I do have a focus right now on head neck cancer research, and specifically reducing side effects from radiation. And we can talk about how that relates to the dry mouth that patients with sjogrens are experiencing the kind of the similarities and the differences between those conditions. But also I think, learning from each other, I think can be a lot of benefit about how to manage the symptoms of oral dryness.
The Crunchy Allergist 2:41
Absolutely. I talk a lot. So it's been interesting as an allergist, I'm in to a unique situation at Ohio State where I practice in that I am hired through the Department of Otolaryngology or EMT, which is actually very rare for like an allergist, immunologist, typically, we would be in either internal medicine or pediatrics, which is kind of what our original boards are in. But in being in that department, I get to work with the head and neck cancer surgeons and talk with them about dryness and oral cancer prevention and all those sorts of things. So another kind of area of overlap that I realized that we had. So this is kind of a side note, but we we discovered recently that Jillian actually was a teammate with my sister in undergrad, they ran cross country together.
Dr. Jillian Rigert, MD DDS 3:38
I didn't even think about that. I'm currently wearing my Augustana Track and Field shout out to OGGY grads, but yeah, you can go on with with this crazy relationship that we've discovered about it.
The Crunchy Allergist 3:51
It's been such a kind of a small world serendipitous kind of introduction, ... that we're you know, we're from kind of the not Chicago part of Illinois and all of this, our paths now have have recrossed so when we talk about kind of oral health and Sjogren's I know so much of the issues come from dryness, what in particular kind of about the dryness creates kind of those issues.
Dr. Jillian Rigert, MD DDS 4:24
Yeah, so for patients with oral dryness, I think it's important to mention that it can be caused by a lot of different things. So most commonly we just think medications are huge proponent of oral dryness, and then in contrast to Sjogren's, but that Sjogren's is an autoimmune disease which affects the function of the main selberg glands, which are the parotid gland, you think of a comparison where patients that are having medication related oral dryness may have something that's reversible or not related to the actual function of their slight salivary glands. And then when you think about the Patients that I am currently researching for, their oral dryness is related to radiation induced damage to their silver glands. So similarities between patients with Sjogren's and patients with radiation is that there may be a reduced function of the salivary glands that result in overall decreased amount of saliva. But having dry mouth, that's a symptom that you're experiencing. So a patient may actually have adequate saliva and still feel that their mouth is dry, because they've had a drop in their baseline amount of saliva. Versus patients with Sjogren's they may have, I mean often have, they come in with dry mouth, and they also have reduced saliva. And the important distinction is that saliva is very important for oral for oral health, it helps to lubricate the mouth and helps to prevent infection, it helps to cleanse the teeth and it also helps in the remineralization of teeth. So when you start to lose your saliva, then you're losing all those protective factors for not only your teeth, but the oral tissue. And what you might notice is difficulty in swallowing your mouth so dry, you might get some frictional irritation. When it comes to the teeth, you don't have the properties that help remineralize the teeth and cleanser teeth. So you might have increased plaque accumulation and increased cavities. And the the saliva that helps with the infections, since it's lower. Patients with dryness of their mouth have a change in their oral environment with reduced immune cells. So they often get they're at risk for fungal infections. So it's just really important, it becomes more important to always important, you know what to keep the mouth very clean, but it becomes more important to be meticulous about oral hygiene to really focus on creating environment that would reduce the amount of damage to the chief. And we can talk about how to do that when it comes to considerations in the diet. And then also considerations to oral hygiene products such as flooring to be very important.
The Crunchy Allergist 7:16
What what sorts of things should sjogrens patients be you know conscientious of when they're thinking about diet? Are there certain things they should avoid, or certain things they should try to maybe add into their diet?
Dr. Jillian Rigert, MD DDS 7:29
Absolutely, I know you and I are both just tremendous advocates of trying to limit the amount of restriction that patients face because there's increasing anxiety, you know, with the autoimmune condition, it can cause a lot of problems with anxiety and trying to do things that are preventing the damage. And so from a non restrictive point of view, I'll talk about diet as relates to tea. And just put that as a disclaimer, I am a strong anti diet advocate, a person that has had problems with restriction is now promotes trying to keep your diet as comprehensive as possible. However, the things that do damage teeth, if you're drinking anything carbonated, whether it's diet or not, it is acidic. So the acid in the mouth can cause problems with softening of the teeth and erosion. And then if you have any sugar, the sugar can stick to the teeth. And especially if you're not cleansing the teeth with the saliva, it starts to feed the bacteria and bacteria eat sugar. And then I'd like to say they poop out acid. So it creates even more acid damage to the teeth, which is actually what causes problems with dental caries. And then just being more meticulous with the oral hygiene. So if you're eating, and you eat frequently, and then that doesn't really give the opportunity for the oral environment to kind of buffer back up into a place where the teeth are remineralizing.
The Crunchy Allergist 8:57
Okay.
Dr. Jillian Rigert, MD DDS 8:58
So if I were to try to say from a teeth only standpoint, like I said, We don't like to restrict, I don't want to create rules that aren't meant to be there. But I was just trying to say, you know, what can we be mindful of, it's trying not to eat all the time throughout the day. So not the grazing, it would be better for the teeth, if we are eating a meal, allowing time for the oil environment to get back to neutral so that the teeth are in a less soft state because there's it helps neutralize the oral environment so it's not in an acidic state. Does that make sense? I'm trying to explain it too much at one time.
The Crunchy Allergist 9:36
so they have some breaks kind of if you can
Dr. Jillian Rigert, MD DDS 9:39
And after you eat. So most people say oh you want to brush right after you eat that's actually not accurate. You want to wait so if you had normal saliva, it takes about 30 minutes for the for the oil environment to get back to about a neutral state. So after we eat or drink anything unless it's water, our mouth is going to create some acid that help us digest it. So after our meal, we want to give it some time to rebalance itself before we brush, because if we brush early, that's when the teeth are in that softer state. And again, this is getting pretty, like pretty much into the grid of oh my gosh, I need to do everything I possibly can. But just to put that out there that you know, if you're noticing increase where the teeth that's something to be mindful of. And then if people are snacking throughout the day, that just keeps the oral environment in that acidic state. So it's it's increasing the risk for damage to the teeth.
The Crunchy Allergist 10:30
And I'm guessing that probably also includes me like lingering and sipping my coffee all morning, probably not ideal.
Dr. Jillian Rigert, MD DDS 10:39
It well it depends if that coffee has sugar and things in it. That's one thing versus if it's black coffee, that may not be as problematic.
The Crunchy Allergist 10:47
Awesome. I do like my coffee black so we'll put that in. Okay, let me drift is not so great, because it still is carbonated even though it doesn't have the sugar. Still. Yeah, not the best.
Dr. Jillian Rigert, MD DDS 10:59
Yeah, exactly. So it's the carbonated or if people are sipping Mountain Dew, you know, I mean, I say Mountain Dew, that's usually one that wears it down. But sodas in general, again, we just distinguish it's even diet sodas, they're acidic, or people I see people with energy drinks, I used to be an energy drink consumer, it's done tremendous damage to my teeth. I think everyone needs to avoid those. And then sipping juices sipping. People don't think about it. But even like crystal lights acidic, and Gatorade or sports drinks, if you're sipping that throughout the day, that that can create some teeth were into some concerns with having your mouth in a sick state. And then of course, if there's sugar, or acid then just increasing problems for your teeth.
The Crunchy Allergist 11:44
Um, so... you mentioned, kind of segwaying that there are some other things we can do in regards to like our oral hygiene routines that can be really helpful, what would some of those kind of tips and tricks be?
Dr. Jillian Rigert, MD DDS 11:59
Yeah, I would recommend so you over the counter toothpaste has a little bit less concentration than fluoride than if you would get a prescription. So I would recommend getting a prescription toothpaste from your dentist. Because fluoride increases the hardness of your teeth it integrates into the enamel structure and increases the hardness of the enamel. So that reduces the caries risk of cavities risk. And there's also options if you were to get fluoride trays, and you can get fluoride gel and have prolonged contact time with the fluoride and that can help with some of the resistance towards that early decay.
The Crunchy Allergist 12:39
So getting I know my dentist offers like when I go in for my cleaning kind of that fluoride treatment. So that would definitely be something worth kind of taking advantage of.
Dr. Jillian Rigert, MD DDS 12:48
Yeah, absolutely.
The Crunchy Allergist 12:50
I'm a little curious and there are some other kind of toothpaste products that are out there in kind of the natural sphere that are fluoride free but have this hydroxyapatite, any thoughts kind of on that or is that kind of something up and coming or to look out for...
Dr. Jillian Rigert, MD DDS 13:07
Hydroxyappatites normally in tooth structure and what happens is that the fluoride is a little bit creates a little bit more hardness because it will exchange with that hydroxyl group so that would just be advocating for normal tooth it's not I don't see it as a better benefit than the fluoride and I would still recommend getting a product with fluoride.
The Crunchy Allergist 13:28
Awesome.
Dr. Jillian Rigert, MD DDS 13:29
The things that you know, it's a great to mention that the different types of other so many different types of toothpaste out there. And of course we mentioned having a prescription for it if you're wanting to balance that with the non prescription because a prescription can be a little bit more costly. And some people once the mouth gets dry, might have a little bit more gum irritation. And so those really strong minty toothpaste might cause a little bit of burning and so if you go towards a more mild flavoring of toothpaste that might help mitigate and be a little bit more comfortable on the you know, not causing so much sensitivity on the gums. And I've noticed some people say the I don't want to give name brands but things that have too many chemicals or have what we call SRO. Yeah, yeah certainly more sulfate, Yeah, you'll notice you know if you're starting to get some irritation and just looking I like keep it simple you know keep it as simple as possible. The whitening toothpaste can have more abrasive effect that's how that whitening works out avoid those if you're trying to reduce damage should achieve I would stay away from charcoal toothpaste. That's something I really have no problem with. But that's my opinion or true
The Crunchy Allergist 14:39
Charcoal mask just for fun.
Dr. Jillian Rigert, MD DDS 14:41
Don't touch the teeth with them, please. Again, that's an abrasive substance that I would recommend avoiding and then with the dryness of the mouth so we really want the saliva as I was mentioning has great protective factors. So if you're looking at stimulating your own saliva, which would be good We can talk a little bit more about what I would do in the diagnostic testing phase to, to see how your saliva glands are working and how beneficial it would be to try to stimulate them in order to produce as much as your own saliva as possible. That only that only has great effects for the mouth, but also to try to keep your products from draining so that you're not getting infections and clogging up the product ducts. But from a mouth standpoint, if we can simulate saliva, get some of the protective factors, that would be great. And there are things out there that are lozenges that you would suck on, many of can be acidic. So that acid you know, if you can find ones that are not acidic, that would be better, just because that acid even though it does stimulate saliva can cause some damage to the teeth. And you'll see many products on the market. Now I have seen a booming market for Dry Mouth products, and have you I would love to hear from from your perspective, if there's any that you've noticed were better than others.
The Crunchy Allergist 16:01
Knock on wood. So I've been really fortunate the last like, you know, not quite a year of having like, pretty good control of my symptoms without so haven't had to jump into it. But I've had a lot of patients and and friends and colleagues, also with sjogrens, who've liked kind of xylitol containing products, I don't know if that's a good one that you would recommend. But I've had pretty good success with that. And actually had a patient who's a dentist, say at least reassure me that that was okay, from an oral health standpoint,
Dr. Jillian Rigert, MD DDS 16:35
From an oral you are, that's one that we think is protective, because the bacteria can't metabolize it as well. So just in terms of that, I've got my puppy right here, which is a good segue xylitol is toxic for dogs. So okay, products that you have, you know, this is of course true with most things that are not meant for dogs, but this can be deadly for dogs. So the xylitol products are great. Keep them away from your pets, if you have gone that has xylitol, he hears me now shout out to Reach the pet therapy dog team that started on zoom so wants to be involved in all zoom visits. But so so for you know if patients so I know that you've mentioned some on your first introduction to your awesome podcast about primary and secondary Sjogren. So if a patient has any joint issues, because if they have any rheumatoid disease or anything like that, if a person is experiencing muscle soreness, anything like that, then I might stay away from gum that could create some exacerbations of those symptoms. And stay towards the other products that have the xylitol that would be fine. And if a patient were to come in and not have a lot of saliva to stimulate, that's when we start thinking more about the protect-, like the symptom relief, more of just getting artificial saliva, and that's just more for comfort.
The Crunchy Allergist 18:02
And would that be something along the lines of like biotene type products, like the gels or...
Dr. Jillian Rigert, MD DDS 18:09
Yeah, and that's a lot of trial. Yeah, that's a lot of trial and error in terms of which products people like there's been very inconsistent feedback when I asked and a lot of it has to do with the level of dryness. So sometimes when your mouth is not very dry, like if or just not bothering you enough to start using the products, like you mentioned, then starting if you started wanting to start then maybe the ones that are more like water would be fine. Or if you're saying you know what, my mouth is just a little bit dry, I want something a little extra one out and about, then people like the spray something that they can bring with. And other spray some feedback that I heard which was extremely valuable, which is why I love hearing more from not only from like my textbook perspective, but this is real life and I love to hear from patients actually experiencing the dryness is they were using edible oil like coconut oil, grapeseed oil and a little spray coating the mouth and then potentially spitting it out or just coating it enough that it helped. They said they helped with eating speaking and things like that. So depending if you have pretty severe dryness of your mouth, and it's really causing social issues or trouble eating that would be something to try again, that's not scientific evidence, but you know, your motivation. Really great.
The Crunchy Allergist 19:24
It's interesting and I use similar things for my patients who are experiencing the dryness in their sinuses. So, um, there is for instance, a nasal spray with Xylitol called Xlear that, you know, will try for similar kind of thing. And then I recommend coconut oil at night like uncanny ability to um, so I guess kind of thinking, you know, of course the tissues are slightly different, but it's still mucosa kind of in that area that you could have similar benefits with them.
Dr. Jillian Rigert, MD DDS 19:56
Yeah, and there's some there'll be some studies and it's this controversial that is coconut oil can be beneficial to reduce bacterial or fungal overgrowth. And of course, I haven't done my own studies, but I value when people can use natural products and there's I don't see harm. When it comes to oil, just be mindful, you know, oil and Xylitol can cause GI distress or problems with the gut. And if you're noticing loose stools, or increase gas or anything like that, then you might want to turn it down or if it's associated with those products, so
The Crunchy Allergist 20:27
yeah, and then the other thing I think about with coconut oil, too, is it's a solid at room temperature. So if you are like rinsing your mouth out, you want to spit it into the trash, not on your sink, so that you have a plumbing bill as well. And then the place I found to get it, like at a very reasonable rate is Costco, you can literally get like this giant vat of it. That will last you for quite a long time.
Dr. Jillian Rigert, MD DDS 20:57
That's awesome. No, it's good for you. I really enjoyed that. And thank you for bringing it up. Yeah, and
The Crunchy Allergist 21:03
I just get like a little, um, you could use like a little glass jar, like leftover from jelly or jam or whatever, and kind of keep some at your bedside or up in the bathroom. So that you're not taking up all of that, you know, bathroom real estate with a kid that
Dr. Jillian Rigert, MD DDS 21:19
I would laugh so hard. That would be fun to visit somebody with that. Oh, like they're starting a trend. Right?
The Crunchy Allergist 21:24
Yeah. And I mean, I will say a fair number of my patient like my eczema patients do like it for skin too. And of course, then you probably would go through it a little bit faster.
Dr. Jillian Rigert, MD DDS 21:34
Yeah, yeah. And for dryness of the mouth, too. There's also some prescriptions that we could either the primary care doctor, rheumatologist, medicine provider or dentist can prescribe depending on how frequently they see you, they would want to, you know, be a main provider for you. And they stimulate so pilocarpine and cevimeline and can be offered and this is dependent on pros vs. cons of you. So this would be patient base, you know, there are some contraindications to those products. And the positive things is they can stimulate the salivary glands if they are if your salivary glands are functioning pretty well. The downsides are the side effects that are usually limiting is excessive sweating, some GI distress and increased urination. So again, but those just to know bottom in case that's something that people want to ask their physicians about. And see if it might be something that be beneficial.
The Crunchy Allergist 22:30
And it looks like there are some things kind of coming down the pipeline too I was looking earlier today we're recording this on January 12. So just to kind of give some context, but there is like an, there are some new biologics that are coming out that are geared towards and being studied as treatments specifically for sjogrens. But one of the markers they're looking at in their effectiveness is the amount of saliva that's produced in these patients and tears as well. But for this particular one Illuma Mab, which hopefully I'm pronouncing that correctly, they did see over the 24 weeks some increase in saliva production. So I think, pretty exciting to see kind of this immune,... it's a monoclonal antibody that essentially dials down B cell. Essentially, the B cell attack on those tissues in two different ways. And so it's exciting to see some other targeted treatments that may help to kind of in a whole different kind of way than what we currently have.
Dr. Jillian Rigert, MD DDS 23:41
That's awesome, because a lot of the, you know, for from an oral medicine perspective, I think my main role would be more symptom management, and of course, a rheumatologist or a primary care would be providing the systemic, no really tackling because when we think sugar into thinking, we really got to tackle the autoimmune component and like you said, dial down what's going wrong? So that I always think, you know, it's, I love working with rheumatologist and, and trying to figure out how we can do that while also helping with that symptom relief. So some of the medications that are providing now, just to kind of put in another oral medicine role is, you know, if the under underlying autoimmune conditions being treated with an immune suppressant like methotrexate or things like that, that can actually it's associated with some oral lesions. So as your provider I might be working with, if it's a rheumatologist prescribing that and say, oh, there's some oral lesions, one we have to figure out what they are, it could be from the immunosuppressant or another autoimmune condition condition like lupus, they may actually be associated with oral lesion. So that's, it's so great to have that integration of a team. And it's just thinking about your your mentioning of delayed diagnosis and things like that. Just the importance I think sjogrens is an awesome example of how important it is to make sure that you're having good communication between all of your health care providers. Because if you know if you come to one person and you say I have dryness in my mouth, and then you go to the ent, you say, I have dryness in my eyes, and then you go to the rheumatologist that, you know, I have soreness in my joints, but no one communicates or maybe, you know, of course, the rheumatologist probably know all will know all of those, but I'm just you know, making a point about...
The Crunchy Allergist 25:29
You're in that small, you know, that short visit appointment, things can easily kind of get lost between the cracks. The other thing I'm thinking about that probably comes into your purview, and especially with your your research area, too. That we want to be conscientious of any, like lumps or bumps that may kind of develop in kind of the Midlands. And I'm trying to like, but also prevention of oral cancer as well. And so, I guess, are there any ways or things that you would think about to kind of recommend to our listeners?
Dr. Jillian Rigert, MD DDS 26:12
Yeah, so with, with Sjogren's, I think, you know, higher risk for lymphoma. So when it comes to checking in doing oral examination and be checking the lymph nodes in an extra oral exam, so that's another good reason to have another set of eyes and have close follow up with both and oral health provider. Because we don't take care just the mouth, you know, his head, neck, and then the salivary glands, if you're having any problems, abnormalities, to do workup about what exactly is going on? As we mentioned, if you're not expressing the glands as much, you might get some backflow the saliva and at risk for having some infections there. So yeah, absolutely getting a getting some eyes on some physical examination in order to identify those early when it comes to oral cancer. And there's two main things that we think about. So oral cancer, a higher risk would be smoking, and alcohol use combined. So if you smoke, high risk, if you smoke and drink combined, that increases your risk because the alcohol acts as a solvent for the tobacco. For all pharyngeal cancer, if you if people are hearing about that HPV, or human papilloma virus and the prevention, it's an STD. So it is you know, behavioral prevention, but also there's a vaccination out. And it's offered for for younger kids. And some people they don't, you know, may not exactly know, why am I you know, going to consider this for my child. And the reason why is you want to try to get the individual's vaccine for the exposed to HPV because it's pretty ubiquitous. And there's many different strains, some associated with more benign conditions, like the works versus the cancer, and so that HPV vaccine will help with that. And and I'm strong advocate for that as a person that is working with all head neck cancer.
The Crunchy Allergist 28:05
Yeah, that's where I was kind of trying to lead towards and, you know, that's my pediatrician hat too, on. And when I was going through kind of my, my peds part of my training at the time, it was only recommended or only approved recommended for female patients, and now it is recommended for for everyone. Because, you know, originally the thought was, we're preventing cervical cancer, but, you know, all this data has come out now, in the last, you know, 10 or so years saying, No, this is really important to prevent head and neck cancer as well. And that affects everyone. So, initially, you know, I think there's, you know, there, there's always, you know, kind of that contingent of worry, you know, for some people with vaccines, but this one has been around for quite some time is very safe. I think the biggest issue we've seen is kind of that, that response people sometimes have when they get an injection and they they need to be sitting seated or sitting down because young folks who who get kind of that startle response or that vaso vagal response, it's in part because their their cardiovascular system or their veins and everything are very flexible and so that that blood flow sometimes does not, you know, kind of kick in as quickly so be seated, especially if you have that that issue but otherwise is very well tolerated
Dr. Jillian Rigert, MD DDS 29:35
Absolutely in the risk me for what it prevents it's incredible and even more cancers like penile and anal cancer being associated. So I'm a strong advocate for I'm a strong advocate of prevention of all diseases and especially when it comes in the form of something that's pretty accessible for the main population another you know, focusing in wise with the kids not only the exposure, but then given their immune systems inadequate chance to really develop and increase their chances of preventing this disease.
The Crunchy Allergist 30:06
Yeah, I I had a classmate. So someone you know in in their thirties, um the um friends with that has just gone through treatment for anal cancer and it if we can prevent any, you know, any of those cases that we see, you know, people going through kind of the suffering, you know that you you go through with radiation surgery, chemo all of those things like is an ounce of prevention is a pound of cure.
Dr. Jillian Rigert, MD DDS 30:38
Yeah, absolutely. And back to the in working, we're relating that to the dryness of the mouth. So I joined radiation oncology because I've noticed when patients are coming to me with their oral dryness related to radiation um and related to why I'm you know, advocate of understanding how much saliva patients making is if the salivary glands are not functioning well that limits treatment options. Um And so patients with radiation are noticing the side effects are causing a lot more distress uh and it can have drastic impacts on quality of life. And you know, if the quality of life is suffering, you know, and you can prevent it through early vaccination to me. You know, huge, huge advocated. And if you've got any doubts or any questions.
The Crunchy Allergist 31:26
Yeah. Message Us.
Dr. Jillian Rigert, MD DDS 31:28
Yeah. Please message us.
