Dry Eyes and Dry Mouth: Common Causes, and When to Think of Sjögren’s

Written by AT. Chintan Dalal, N.D. · Reviewed by Dr Krushal Pabari, Clinical Team, Cure4Pain · Updated 30 October 2026

Key facts

Dry eyes and a dry mouth usually come from an everyday cause, such as a medicine or older age, rather than Sjögren’s; the NHS says a dry mouth is rarely a sign of anything serious [1]. Hundreds of medicines can reduce saliva, according to the US National Institute of Dental and Craniofacial Research [2], and dry mouth affected 21% of adults aged 50 and over in a 2026 meta-analysis of 37 studies [3]. Sjögren’s syndrome, now also called Sjögren disease, is a condition in which the immune system attacks the glands that make tears and saliva, according to the NHS [4]. It is far less common: about 61 people with primary Sjögren’s per 100,000 in a 2015 meta-analysis of 21 studies, with women affected about 10 times more often than men [5]. Sjögren’s is worth discussing with a doctor when dryness is daily for more than 3 months, a question in the 2016 American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) criteria, or comes with swollen salivary glands, aching joints or extreme tiredness, symptoms listed by the NHS [6] [4]. The 2016 ACR/EULAR classification criteria give anti-Ro (SSA) antibodies and a lip biopsy 3 points each and eye and saliva tests 1 point each, and need a total of 4 or more [6]. Low vitamin D is also linked with dry eye, in a 2020 meta-analysis of 10 studies [7]. Non-Hodgkin lymphoma is more likely with Sjögren’s, according to the NHS, and the 2025 British Society for Rheumatology guideline gives a lifetime risk of 5% to 10%, so its warning signs should be reported promptly [4] [8].

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What causes dry eyes and dry mouth at the same time?

Dry eyes and a dry mouth at the same time can come from a medicine, older age or a condition such as diabetes; dry air and long screen time add to dry eyes, and mouth breathing adds to a dry mouth. Sjögren’s is one possible cause, and doctors look for the others first: a 2015 review says that when Sjögren’s is suspected, the first step is to rule out other diagnoses [9].

Cause or link	Dry eyes	Dry mouth
Medicines	Some antidepressants and blood pressure medicines [10]; eye drops with preservatives [11]	Some medicines for high blood pressure, depression and bladder control [12]; at age 60 and over, the risk was greatest with urinary incontinence medicines [13]
Older age	A risk factor from age 50 [10] [14]	21% of adults aged 50 and over in a 2026 meta-analysis [3], yet “not a normal part of aging”, says the US National Institute of Dental and Craniofacial Research [2]
Screens, air and breathing	Odds 1.32 times higher with screen use in a 2022 meta-analysis of 48 studies [15], mainly through fewer blinks [16]; air conditioning, heating, wind and dust [10]	Breathing through the mouth at night [1]; sleep apnoea [17]
Diabetes	Odds 2.30 times higher with diabetes in a 2025 meta-analysis of 23 studies [18], and 1.15 times higher in a broader 2022 meta-analysis of risk factors [15]	Lower saliva flow with diabetes in a 2022 meta-analysis of 22 observational studies, low certainty of evidence [19]
Thyroid disease	Odds 1.60 times higher with thyroid disease in a 2022 meta-analysis [15]	More dry mouth in a small study of 40 people with Hashimoto’s [20]
Being female, menopause	Odds 1.56 times higher in women [15]; after menopause, hormone therapy went with more dry eye in a cohort of 25,665 women [21]	Medicines and other illnesses predicted it better than menopause, a 2026 editorial notes [22]
Other	Contact lenses, LASIK and cataract surgery [11]; smoking and alcohol [10]; depression [15]	Dehydration, anxiety, cancer treatment and oral thrush [1]; HIV [2]

Most of these figures come from observational studies, so they show links rather than proof of cause. If you suspect a medicine, ask the doctor who prescribed it; the NHS advises not to stop a prescribed medicine without medical advice [1]. Our articles explain HbA1c and prediabetes and snoring, mouth breathing and sleep apnoea.

Can a vitamin deficiency cause dry eyes or dry mouth?

Vitamin A deficiency can cause dry eyes, and the US National Eye Institute lists too little vitamin A as a risk factor [14]; the evidence for vitamin D and omega-3 is less settled. For dry mouth, our PubMed search in October 2026 found no systematic review showing a direct link with a vitamin deficiency.

• Vitamin A: the US National Eye Institute lists not getting enough vitamin A as a risk factor for dry eye [14]. Deficiency is rare in well-resourced countries but is rising in at-risk children, a 2022 review reports [23].
• Vitamin D: in a 2020 meta-analysis of 10 studies with 18,919 people, vitamin D deficiency went with worse dry eye symptoms and less tear production [7]. In two small randomised trials of people with dry eye and vitamin D deficiency, 100 people in 2023 and around 90 in 2020, adding vitamin D to lubricating drops improved tear tests [24] [25].
• Vitamin D in Sjögren’s: vitamin D levels were lower in people with Sjögren’s than in healthy controls in a 2023 meta-analysis of 9 studies [26], but a 2023 genetic study found no evidence that low vitamin D causes Sjögren’s or that Sjögren’s lowers vitamin D [27]. The 2025 British Society for Rheumatology guideline recommends checking vitamin D levels at baseline in Sjögren’s [8]. Our PubMed search in October 2026 found no randomised trial of vitamin D in Sjögren’s.
• Omega-3: the US National Eye Institute lists low intake as a risk factor [14], yet in the 2018 DREAM trial of 535 people with moderate to severe dry eye, omega-3 for 12 months did no better than an olive oil placebo [28].

How common is Sjögren’s among people with dry eyes and a dry mouth?

Sjögren’s is uncommon overall but more likely when dry eye is significant: 11.6% of 327 people with clinically significant dry eye from too few tears had it, in a multicentre trial reported in 2012 [29]. A 2015 meta-analysis of 21 studies found about 61 people with primary Sjögren’s per 100,000, or about 43 per 100,000 in population-based studies [5].

• Significant dry eye: among 327 people with clinically significant aqueous-deficient dry eye (too few tears) in a multicentre trial, 38 (11.6%) had Sjögren’s, and 9 were newly diagnosed [29].
• Late diagnosis: the median time from first dryness symptoms to diagnosis was 115 weeks, a little over 2 years, in a 2021 study of 1,970 people with primary Sjögren’s in Taiwan [30].
• In India: in a 2015 south Indian hospital cohort of 332 people with primary Sjögren’s, only 8.3% mentioned dryness on their own at the first visit, and over a third had severe systemic disease needing immune-suppressing treatment [31].

What are the signs that dryness could be Sjögren’s?

The main signs that dryness could be Sjögren’s are daily dryness for more than 3 months, in the 2016 ACR/EULAR criteria [6], and swollen salivary glands, aching muscles and joints and extreme tiredness, according to the NHS [4]. No single sign proves Sjögren’s.

• Persistent dryness: the 2016 ACR/EULAR criteria begin with five questions: daily, troublesome dry eyes for more than 3 months; a repeated feeling of sand or gravel in the eyes; tear substitutes more than 3 times a day; a daily dry mouth for more than 3 months; and often needing liquids to swallow dry food [6].
• Swollen salivary glands: in the cheeks, neck and under the jaw, according to the NHS [4]. In a 2022 Latin American cohort of 668 people with primary Sjögren’s, 36.2% had parotid gland swelling, generally before or at diagnosis [32].
• Whole-body symptoms: aching muscles and joints and extreme tiredness, according to the NHS [4]. At least 70% of people have features beyond the glands, such as inflammatory arthritis or skin, blood, nerve or lung involvement, according to the 2025 British Society for Rheumatology guideline [8].
• Other dryness and mouth problems: dry, itchy skin, vaginal dryness, a lasting cough, a hoarse voice, tooth decay and gum disease [4].
• Another autoimmune disease: Sjögren’s can occur alongside another rheumatic disease [8], such as rheumatoid arthritis or lupus.
• Who is affected: Sjögren’s affects women far more often than men, and people with it had an average age of 56 in a 2015 meta-analysis [5]; a 2015 south Indian cohort reported a younger age of onset [31]. In children and adolescents, recurrent parotid swelling is one of the most common features, according to the 2025 British Society for Rheumatology guideline [8].

Which tests diagnose Sjögren’s?

Sjögren’s is diagnosed from blood tests, eye tests, a saliva flow test and sometimes a lip biopsy, read together. The NHS says a GP first checks for more common causes and may then refer you for these tests [4]. The 2016 American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) classification criteria score them like this [6]:

Test	What counts	Points
Anti-Ro (SSA) antibody blood test	Positive	3
Lip biopsy of a small salivary gland	Clusters of immune cells, with a focus score of 1 or more	3
Eye staining test	Ocular staining score of 5 or more	1
Schirmer tear test	Tears wet 5 mm or less of a paper strip in 5 minutes	1
Unstimulated saliva flow	0.1 mL a minute or less	1

A total of 4 or more meets the 2016 ACR/EULAR criteria in people with signs or symptoms suggesting Sjögren’s; in the final validation cohort, sensitivity was 96% and specificity 95% against expert judgement [6]. These are classification criteria, though they are often used in diagnosis, according to the 2025 British Society for Rheumatology guideline [8].

• ANA and ENA: the 2025 British Society for Rheumatology guideline advises ANA (antinuclear antibody) as a screening test when there is clinical suspicion, and ENA (extractable nuclear antigen) antibodies even if ANA is negative when suspicion is high [8]. In a 2026 meta-analysis, 8.1% of ANA-negative samples from people with suspected connective tissue disease were ENA positive [33]. Our guide to CRP, ESR and ANA explains these reports.
• Ultrasound: salivary gland ultrasound had a pooled sensitivity of 80% and specificity of 90% in a 2020 meta-analysis [34], but it is not one of the 2016 criteria items.
• Your medicines: anticholinergic medicines can dry the eyes and mouth, so the 2016 ACR/EULAR criteria advise testing after a sufficient interval off them [6]. Only the prescribing doctor should arrange this.

Which other diseases cause dry eyes and dry mouth?

Several other diseases cause dry eyes and a dry mouth, and they are excluded before Sjögren’s is classified. The 2016 ACR/EULAR criteria list head and neck radiation treatment, active hepatitis C, AIDS, sarcoidosis, amyloidosis, graft versus host disease and IgG4-related disease [6]. Some people have dryness with no cause found, called idiopathic sicca syndrome [9].

Which doctor should you see for dry eyes and dry mouth?

For dry eyes and a dry mouth, start with your family doctor or physician. A rheumatologist is the usual specialist for Sjögren’s, working with an eye specialist and a dentist.

• Family doctor or physician: the NHS advises seeing a GP if dry mouth comes with other symptoms, “like needing to pee a lot or dry eyes”, or lasts after a few weeks of home treatment [1].
• Optician or eye specialist: the NHS advises an optician or GP if dry eyes last after a few weeks of home treatment, and they may refer you to an eye specialist for tests [10].
• Dentist: the US National Institute of Dental and Craniofacial Research advises seeing your dentist or doctor to find out why your mouth is dry [2].
• Rheumatologist: the 2025 British Society for Rheumatology guideline advises considering follow-up within rheumatology for confirmed Sjögren’s, particularly with systemic disease [8].
• Urgent help: the NHS advises an urgent GP appointment if an eye is painful and red, and emergency care for any change in sight or if it hurts to look at light [10].

Take a list of every medicine and eye drop you use, along with earlier blood reports.

What can you do for dry eyes and a dry mouth?

To help dry eyes and a dry mouth while the cause is being looked for, the NHS advises simple daily steps such as screen breaks, a humidifier, regular sips of water and sugar-free gum [10] [1].

• Eyes: clean your eyelids every day, take breaks from screens, use a humidifier, and rest from contact lenses by wearing glasses; a pharmacist can advise on eye drops, gels and ointments [10].
• Mouth: take regular sips of water, chew sugar-free gum, brush twice a day, limit alcohol, caffeine and fizzy drinks, and do not smoke; a pharmacist can advise on mouth gels, sprays and lozenges [1].

Is Sjögren’s serious? The lymphoma risk

Sjögren’s is a long-term condition, and a recognised serious risk is non-Hodgkin lymphoma, a cancer of the lymph glands. The NHS lists it among the problems people with Sjögren’s are more likely to have and describes it as rare [4], and the 2025 British Society for Rheumatology guideline gives a lifetime risk of 5% to 10% [8]. The NHS also says most people with Sjögren’s live into old age with the same life expectancy as the general population [4].

• Warning signs to report promptly: new salivary gland swelling [8]; a painless lump in the neck, armpit or groin; a high temperature or shivers; night sweats; shortness of breath; itchy skin; and sudden unexplained weight loss [35].
• What the guideline advises: the 2025 British Society for Rheumatology guideline advises offering further tests early to anyone with Sjögren’s who has new salivary gland swelling or other symptoms that might suggest lymphoma [8].

What is the treatment if it is Sjögren’s? Medicines as per guidelines

Sjögren’s treatment is matched to each problem, as set out in the 2019 European League Against Rheumatism (EULAR) recommendations and the 2025 British Society for Rheumatology guideline [36] [8]. Immune-suppressing medicines are kept for specific complications, not given routinely for dryness [8].

• Dry eyes and mouth: preservative-free lubricating eye drops, a heated eyelid compress and saliva substitutes; pilocarpine or cevimeline when some gland function remains [8] [36].
• Fatigue with systemic symptoms, or high immunoglobulins: a trial of hydroxychloroquine [8].
• Inflammatory arthritis: methotrexate [8].
• Specific organ complications: short-term steroids, azathioprine, mycophenolate, leflunomide or cyclophosphamide [36] [8].
• Severe, organ-threatening disease: rituximab, with belimumab as rescue treatment [8].

Our Sjögren’s syndrome page gives the full detail, including the clinical trials.

How we assess and manage Sjögren’s at Cure4Pain

At Cure4Pain, Sjögren’s is managed within integrative rheumatology: guideline medicines, with supervised vitamin D therapy and a nutritional layer added alongside them, never in their place.

• Medicines: at Cure4Pain, Dr Krushal Pabari prescribes and adjusts these medicines as per guidelines, under clinical guidance from Team Cure4Pain, in coordination with your existing consulting physician, eye specialist and dentist; never stop or change them on your own.
• Tests: for suspected or diagnosed Sjögren’s, we read a panel of about 100 markers, adding tests for your condition when clinically indicated: ANA by the IFA method, ENA antibodies such as anti-Ro and anti-La, and vitamin D at baseline, as the 2025 British Society for Rheumatology guideline advises [8], with immunoglobulins, complement and protein electrophoresis. We read these with your eye and dental reports and any biopsy results.
• Eyes and mouth: we review practical daily care at each visit and refer you to an eye specialist and a dentist.
• Supervised vitamin D therapy (Coimbra Protocol-based methods): used as an immune modulator, with no fixed dose for every person; the dose is set for each person and adjusted to blood tests every 6 to 8 weeks. This vitamin D therapy is not part of the 2019 EULAR or 2025 British Society for Rheumatology recommendations [36] [8], and our PubMed search in October 2026 found no trial of the Coimbra Protocol in Sjögren’s. Our methods are derived from the work of Dr Coimbra. The general upper limit of vitamin D for adults is 4,000 IU a day, according to the US National Institutes of Health [37]; please never copy doses from the internet.
• Not used: Cure4Pain does not offer acupuncture or needling for Sjögren’s.

This is our clinic practice; individual results vary, and further studies are needed. Read more on our Coimbra Protocol page.

If Sjögren’s has been suspected or diagnosed and you would like your reports reviewed, you can book a consultation, online from anywhere or at our Mumbai clinic.

Frequently asked questions

What autoimmune disease causes dry eyes and dry mouth?

Sjögren’s syndrome is the best-known one: the immune system attacks the glands that make tears and saliva. Lupus can also cause dry eyes, according to the US National Eye Institute. [4] [14]

Why are my eyes and mouth dry at night?

Breathing through the mouth at night, from a blocked nose or sleeping with the mouth open, can cause a dry mouth, according to the NHS, and a 2024 literature review links sleep apnoea with it. Air conditioning and heating can dry the eyes, the NHS adds. [1] [17] [10]

Can a vitamin deficiency cause dry eyes?

Vitamin A deficiency can cause dry eyes, according to the US National Eye Institute, which lists it as a risk factor. Low vitamin D is linked with worse dry eye symptoms and fewer tears in a 2020 meta-analysis, and in two small randomised trials in people with vitamin D deficiency, adding vitamin D to lubricating drops improved tear tests, but neither trial was in people with Sjögren’s. [14] [7] [24] [25]

Can diabetes cause dry eyes and a dry mouth?

Diabetes is linked with both. Meta-analyses found the odds of dry eye 2.30 times higher in 23 studies in 2025 and 1.15 times higher in a broader 2022 analysis, a 2022 meta-analysis of 22 observational studies found lower saliva flow with low certainty of evidence, and the US National Institute of Dental and Craniofacial Research says diabetes can cause dry mouth. [18] [15] [19] [2]

What is the Schirmer test for Sjögren’s?

The Schirmer test measures how far tears wet a paper strip placed on the lower eyelid in 5 minutes. A result of 5 mm or less scores 1 point in the 2016 ACR/EULAR classification criteria. [6] [28]

Can menopause cause dry eyes and dry mouth?

The evidence on menopause and dryness is limited. Women have higher odds of dry eye, and hormone therapy after menopause went with more dry eye in a cohort of 25,665 women, though this shows a link rather than a cause. A 2026 editorial notes that medicines and other illnesses predict dry mouth better than menopause does. [15] [21] [22]

Which blood test checks for Sjögren’s?

Anti-Ro (SSA) antibody is the blood test in the 2016 ACR/EULAR classification criteria for Sjögren’s. The 2025 British Society for Rheumatology guideline uses ANA as a screening test and advises measuring ENA antibodies, which include anti-Ro, when suspicion is high. [6] [8]

Can you have Sjögren’s with a negative blood test?

Yes. A person without anti-Ro antibodies can still reach the score of 4 needed in the 2016 ACR/EULAR criteria through a lip biopsy and eye and saliva tests. The ANA test can also be negative when ENA is positive: 8.1% of ANA-negative samples from people with suspected connective tissue disease were ENA positive in a 2026 meta-analysis. [6] [33]

Can you have Sjögren’s without dry eyes or a dry mouth?

Sjögren’s can begin with other symptoms. The 2016 ACR/EULAR criteria can also apply when systemic features raise suspicion, including earlier forms before dryness appears. In a south Indian hospital cohort of 332 people with primary Sjögren’s only 8.3% mentioned dryness on their own at the first visit, though others may still have had it. [6] [31]

Is Sjögren’s dangerous?

Most people live into old age with the same life expectancy as the general population, according to the NHS. A recognised serious risk is non-Hodgkin lymphoma, which the NHS describes as rare; the 2025 British Society for Rheumatology guideline gives a lifetime risk of 5% to 10%. [4] [8]

This article is for education and does not replace medical advice. Do not start, stop or change any medicine or supplement without medical guidance.

References

1. NHS (UK National Health Service). Dry mouth. nhs.uk/conditions/dry-mouth

2. US National Institute of Dental and Craniofacial Research. Dry Mouth. nidcr.nih.gov/health-info/dry-mouth

3. Kamnoedboon P, et al. A Systematic Review and Meta-Analysis of the Global Prevalence of Dry Mouth in Older Adults. Gerodontology 2026;43(3):383-402. doi:10.1111/ger.70076

4. NHS (UK National Health Service). Sjögren’s syndrome. nhs.uk/conditions/sjogrens-syndrome

5. Qin B, et al. Epidemiology of primary Sjögren’s syndrome: a systematic review and meta-analysis. Ann Rheum Dis 2015;74(11):1983-9. doi:10.1136/annrheumdis-2014-205375

6. Shiboski CH, et al. 2016 American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sjögren’s Syndrome: A Consensus and Data-Driven Methodology Involving Three International Patient Cohorts. Arthritis Rheumatol 2017;69(1):35-45. doi:10.1002/art.39859

7. Liu J, et al. Vitamin D deficiency is associated with dry eye syndrome: a systematic review and meta-analysis. Acta Ophthalmol 2020;98(8):749-754. doi:10.1111/aos.14470

8. Price EJ, et al. British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease. Rheumatology (Oxford) 2025;64(2):409-439. doi:10.1093/rheumatology/keae152

9. Cornec D, et al. The Differential Diagnosis of Dry Eyes, Dry Mouth, and Parotidomegaly: A Comprehensive Review. Clin Rev Allergy Immunol 2015;49(3):278-87. doi:10.1007/s12016-014-8431-1

10. NHS (UK National Health Service). Dry eyes. nhs.uk/conditions/dry-eyes

11. Gomes JAP, et al. TFOS DEWS II iatrogenic report. Ocul Surf 2017;15(3):511-538. doi:10.1016/j.jtos.2017.05.004

12. US National Library of Medicine (MedlinePlus). Dry Mouth. medlineplus.gov/drymouth.html

13. Tan ECK, et al. Medications That Cause Dry Mouth As an Adverse Effect in Older People: A Systematic Review and Metaanalysis. J Am Geriatr Soc 2018;66(1):76-84. doi:10.1111/jgs.15151

14. US National Eye Institute. Dry Eye. nei.nih.gov

15. Qian L, Wei W. Identified risk factors for dry eye syndrome: A systematic review and meta-analysis. PLoS One 2022;17(8):e0271267. doi:10.1371/journal.pone.0271267

16. Wolffsohn JS, et al. TFOS Lifestyle: Impact of the digital environment on the ocular surface. Ocul Surf 2023;28:213-252. doi:10.1016/j.jtos.2023.04.004

17. Maniaci A, et al. Oral Health Implications of Obstructive Sleep Apnea: A Literature Review. Biomedicines 2024;12(7). doi:10.3390/biomedicines12071382

18. Chen KY, et al. Is there a link between dry eye disease and diabetes mellitus? A systematic review and meta-analysis. J Diabetes Complications 2025;39(10):109149. doi:10.1016/j.jdiacomp.2025.109149

19. Marques RCR, et al. Salivary parameters of adults with diabetes mellitus: a systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 2022;134(2):176-189. doi:10.1016/j.oooo.2022.03.001

20. Agha-Hosseini F, et al. Evaluation of Xerostomia and salivary flow rate in Hashimoto’s Thyroiditis. Med Oral Patol Oral Cir Bucal 2016;21(1):e1-5. doi:10.4317/medoral.20559

21. Schaumberg DA, et al. Hormone replacement therapy and dry eye syndrome. JAMA 2001;286(17):2114-9. doi:10.1001/jama.286.17.2114

22. Florezi GP, et al. Xerostomia in the menopausal transition: are we measuring menopause or its comorbidities? Clinics (Sao Paulo) 2026;81:101154. doi:10.1016/j.clinsp.2026.101154

23. Song A, et al. Recognizing vitamin A deficiency: special considerations in low-prevalence areas. Curr Opin Pediatr 2022;34(2):241-247. doi:10.1097/MOP.0000000000001110

24. Najjaran M, et al. Effect of oral vitamin D supplementation on dry eye disease patients with vitamin D deficiency. Clin Exp Optom 2023;106(3):257-262. doi:10.1080/08164622.2022.2033601

25. Watts P, et al. A prospective study to assess the role of vitamin D individually and in combination with cyclosporine in the treatment of dry eye in patients with deficient serum 25(OH)D levels. Indian J Ophthalmol 2020;68(6):1020-1026. doi:10.4103/ijo.IJO_1492_19

26. Radić M, et al. Vitamin D and Sjögren’s Disease: Revealing the Connections-A Systematic Review and Meta-Analysis. Nutrients 2023;15(3). doi:10.3390/nu15030497

27. Zhao M, et al. Serum vitamin D levels and Sjogren’s syndrome: bi-directional Mendelian randomization analysis. Arthritis Res Ther 2023;25(1):79. doi:10.1186/s13075-023-03062-2

28. Asbell PA, et al. n-3 Fatty Acid Supplementation for the Treatment of Dry Eye Disease. N Engl J Med 2018;378(18):1681-1690. doi:10.1056/NEJMoa1709691

29. Liew MS, et al. Prevalence and predictors of Sjogren’s syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol 2012;96(12):1498-503. doi:10.1136/bjophthalmol-2012-301767

30. Huang YT, et al. Diagnostic Delay in Patients with Primary Sjögren’s Syndrome: A Population-Based Cohort Study in Taiwan. Healthcare (Basel) 2021;9(3). doi:10.3390/healthcare9030363

31. Sandhya P, et al. Clinical Characteristics and Outcome of Primary Sjogren’s Syndrome: A Large Asian Indian Cohort. Open Rheumatol J 2015;9:36-45. doi:10.2174/1874312901409010036

32. Valim V, et al. Parotid gland swelling in primary Sjögren’s syndrome: activity and other sialadenosis causes. Rheumatology (Oxford) 2022;61(7):2987-2992. doi:10.1093/rheumatology/keab816

33. Dhaouadi T, et al. Frequency of extractable nuclear antigen seropositivity among individuals seronegative for antinuclear antibodies on indirect immunofluorescence: a systematic review and meta-analysis. Front Immunol 2026;17:1745828. doi:10.3389/fimmu.2026.1745828

34. Ramsubeik K, et al. Diagnostic accuracy of salivary gland ultrasound in Sjögren’s syndrome: A systematic review and meta-analysis. Ther Adv Musculoskelet Dis 2020;12:1759720X20973560. doi:10.1177/1759720X20973560

35. NHS (UK National Health Service). Symptoms of non-Hodgkin lymphoma. nhs.uk/conditions/non-hodgkin-lymphoma/symptoms

36. Ramos-Casals M, et al. EULAR recommendations for the management of Sjögren’s syndrome with topical and systemic therapies. Ann Rheum Dis 2020;79(1):3-18. doi:10.1136/annrheumdis-2019-216114

37. National Institutes of Health, Office of Dietary Supplements. Vitamin D: Fact Sheet for Health Professionals. Updated 27 June 2025. ods.od.nih.gov