## 4 Discussion
Moreover, positivity to anti-SSA might differ from positivity to anti-SSB. It is postulated that patients with isolated anti-SSB antibodies form a different phenotype among SS patients characterized by more severe systemic manifestations [39]. Similar phenotypic differences were found for SS patients with both anti-Ro60 and anti-Ro52 co-occurrence and patients with anti-Ro60 alone and anti-Ro52 alone. Patients with both anti-Ro60 and anti-Ro52 had a significantly increased prevalence of FLS with FS \(\geq\) 1, ANA \(\geq\) 1:320, RF, and parotid gland ultrasound scores compared to patients with either anti-Ro60 or anti-Ro52 alone. Although these serologic profiles are predisposed to some phenotypic features of SS and are markers of glandular inflammation, there was no correlation between the anti-Ro60/Ro52 profile and dry mouth [40]. Contrary to these results, [PERSON] et al. detected that SS patients with combined anti-Ro52 and anti-Ro60 antibodies were more likely to suffer from xerophthalmia and xerostomia than patients with isolated anti-Ro52 or anti-Ro60 antibodies. The proportion of patients with glandular involvement was significantly higher in patients with combined anti-Ro52 and anti-Ro60 antibodies than in patients with isolated anti-Ro60 antibodies [41; 42]. However, after division into smaller serology subgroups, the small sample size may have prevented a possible correlation from being found between anti-SSA/SSB positivity and the occurrence of dry mouth. Another research finding was the correlation between xerostomia and xerophthalmia. SS patients who reported dry mouth also complained of dry eyes. There was a statistically significant difference in xerophthalmia between SS patients with and without xerostomia. Although there was no difference in [PERSON]'s test between patients with and without xerostomia, it appears that both dry mouth and dry eye coexist and are components of sicca syndrome in SS patients. This finding is consistent with previous findings, which showed that xerostomia and dry eye symptoms are both relatively common in the older adult population. In addition, they are associated and moderately concurrent. Patients with symptomatic dry eye had higher Summated Xerostomia Inventory-Dutch Version scores than those without [43]. The routine evaluation of xerostomia symptoms should be part of the assessment of dry eye patients and vice versa [43]. Furthermore, parasympathetic drugs used to increase salivary secretion can improve lacrimal secretion and reduce overall symptoms of sicca syndrome [44]. This positive correlation is typical of exocrinopathies such as SS. The symptoms of ocular and oral sicca are closely related. A previous study conducted among patients with rheumatic diseases showed that the majority (85.7%) of xerostomic patients were also xerophthalmia positive [45]. Another possible explanation for the lack of correlations between FS and phenotypic features of SS and xerostomia is the modifying effect of tobacco smoking on focal lip sialdenitis [46; 47]. Although previous studies revealed that present or past smoking does not disturb salivary gland function and does not change unstimulated or stimulated whole salivary flow, cigarette smoking is negatively associated with FLS and FS in SS patients. Cigarette smoking reduces glandular FS, and this correlation is dose-dependent. FS decreases with the number of cigarettes smoked per week [40]. [PERSON] et al. found that current smokers have a reduced frequency of abnormal FS in the labial salivary gland biopsy compared to patients who never smoked. The frequency of non-focal saladenitis or normal biopsy findings is increased in smokers [47]. From this perspective, not considering smoking could have significantly impacted the final results of the study. These findings show that present and former cigarette smokers suffering from SS should not be referred for a labial salivary gland biopsy. Therefore, abnormal FS in present and former cigarette smokers should be approached with great caution in SS diagnosis.