Dental Management of Patients with Rheumatology Disorders

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Dental Management of Patients withRheumatology
Disorders

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Pathological Classification of Rheumatic
Disorders
Rheumatoid arthritis Connective tissue
disorder Spondarthritis
Autoimmune Disorder Crystal
Arthropathy Infection
Joint Disorder
Inflammatory Disorder
Gouty Arthritis Pseudogout (CPPA)
Degenerative Disorder O.A
Septic Arthritis
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Introduction..

• Is it Arthritis or Arthralgia?
• Is it Monoarthritis or Polyarthritis ?
• Is it Musculoskeletal emergencies ?

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RED FLAG CONDITIONS

• FRACTURE
• SEPTIC ARTHRITIS
• GOUT/PSEUDOGOUT
• NERVE OR VESSEL PROBLEMS
• Fever or unexplained weight loss
• History of carcinoma
• Immuno-supression
• Ill health or presence of other medical
  illness
• Night pain
• Progressive pain

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Sorting it Out
INFLAMMATORY
DEGENERATIVE
CHRONIC PAIN
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What are the Symptoms?
Chronic Pain
Degenerative
Inflammatory
No
Yes
Yes
Joint Pain
No
Yes
Yes
Joint Swelling
No
No
Yes
Joint Redness
gt 1 hour
15-20 minutes
gt 1 hour
Morning Stiffness
Severe
Mild
New and Severe
Fatigue
Rapid
Slow
Rapid
Loss of Function
Never
Never
Possibly
Fever
Unusual
Unusual
Possibly
Weight Loss
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Arthralgia..

• Fibromyalgia
• Bursitis
• Tendinitis
• Hypothyroidism
• Neuropathic pain
• Metabolic bone disease
• Depression

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Monoarthritis..

• Trauma
• Infection
• Skin lesion.
• Nongonococcal bacterial infections large joints.
• Mycobacterial and fungal infection.
• Crystal induced arthritis
• Monosodium Urate crystals (MPJ) - Gout
• Calcium pyrophosphate dihydrate crystals (knee) -
  Pseudogout
• Systemic Rheumatoid diseases
• Seronegative spodyloarthropathy (Reactive
  arthritis, psoriatic arthritis, Inflammatory
  BD..)
• RA
• Osteoarthritis

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Polyarthritis..

• Rheumatoid Arthritis
• Systemic lupus Erythrematosus
• Viral arthritis
• Reiters disease
• Psoriatic arthritis
• Reactive arthritis

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Migratory Arthritis..

• Differential diagnosis
• Rheumatic fever
• Gonococcemia
• Meningococcemia
• Viral Arthritis
• SLE
• Acute Leukemia

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Rheumatic Fever..

• Majer Criteria
• 1- Carditis 2- Polyarthritis
  3- Chorea
• 4- Erythema Marginatum 5- Subcutaneous nodules

• Minor criteria
• 1- Arthralgia 2- Ferver 3- Acute
  phase reactant
  
  
  
  (ESR, CRP).
• 4- Prolong PR interval 5- Evidence
  of group A streotococcal infection (AST, Throat
  culture)

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History.. Age Sex

• lt30 SLE, Ankylosis spodylitis, Reactive
  Arthritis.
• 30-50 RA, Systemic sclerosis, Gout.
• gt50 OA, Pseudogout, PMR
• Any Age group Psoriatic arthritis, Enteropathic
  arthritis
• gtFemale
• SLE, RA, OA, Systemic sclerosis, PMR.
• MaleFemale
• Psoriatic arthritis, Enteropathic arthritis
  Pseudogout, .
• gtMale
• Gout, Reactive Arthritis, Ankylosis
  spodylitis,

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History.. Symptoms

• Site
• Symmetrical RA, SLE, Systemic sclerosis
• AsymmetricalOA
• Large joints OA
• DIP OA, Psoriatic arthritis
• MCP, PIP RA, SLE
• 1st MTP Gout, OA
• Spine OA, Ankylosis spodylitis, Psoriatic
  arthritis, Reactive arthritis
• Shoulder PMR

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Physical Examination..

• Joint
• Soft tissue swelling, warm, effusion
  Inflammation.
• Inflammation signs extended Septic arthritis,
  crystal induced arthritis, fracture.
• Passive motion (N), active(??) Bursitis,
  Tendinitis, Muscle injury.
• Passive motion (??), active(??) Synovitis

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Physical Examination..

• General Examination
• Parotid enlargement, oral ulceration, heart
  murmurs, pericardial or pleural friction rubs,
  crackle systemic disease.
• Fever Infection, reactive arthritis, RA, SLE,
  Crystal induced arthritis
• Subcutaneous nodules RA, RHD, Gout (tophi)
• Skin manifestations Psoriasis, RA, SLE
• Eye disease (keratoconjunctivitis sicca, uveitis.
  Conjunctivitis, episcleritis)

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Laboratory Radiology Studies..

• Can be misleading.
• Basic CBC, Urinalysis, UE, LFT.
• Acute phase reactant ESR, CRP.
• Uric acid concentration Gout
• Synovial fluid analysis infection, crystal
  induced arthritis, inflammatory..
• Antibody tests
• ANA SLE
• Anti-dsDNA SLE
• Anti-native DNA, anti-Sm SLE
• RF RA
• Anti-CCP antibodyRA
• X-ray
• MRI

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Rheumatoid ArthritisA chronic nonsuppurative
inflammatory destruction of the joints
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Rheumatoid Arthritis..

• Incidence
• 1-3 of general population
• Genetic predisposition
• Female to male ratio 31
• Average age of onset of 40 years

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History..

• Malaise
• Fever
• Fatigue
• Weight loss
• Myalgias
• Difficulty performing activities of daily living

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Examination..

• Joint affected
• swelling
• tenderness
• warmth
• decreased range of motion
• Atrophy of the interosseous muscles
• deformities

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4 Diagnosis.. ACR Criteria criteria present gt 6
wks

• Morning stiffness gt 1 hour
• Arthritis of 3 joints areas (PIP, MCP, wrist,
  elbow, knee, ankle, and MTP)
• Arthritis of hand joints (wrist, MCP, PIP)
• Symmetric arthritis

• Rheumatoid nodules
• RF
• Radiographic changes
• Erosions
• Unequivocal periarticular osteopenia

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Synovitis
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RA - hands
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Deformities..
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Swan neck and Boutonniere
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Rheumatoid Arthritis
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Extra-Articular Manifestations..

• Rheumatoid nodule
• Cardiovascular
• Pulmonary
• GI Renal
• Hematological
• Skin
• Vasculitis
• Neurological
• Ocular

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Rheumatoid nodules
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Vasculitis
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Ocular

• Sicca symptoms
• Episcleritis
• Scleritis
• Scleromalacia Perforance

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Head Neck Manifestations

• Rheumatoid Arthritis may involve the TMJ.
• 55 Affected
• 70 with radiographic evidence of TMJ involvement
• Juvenile form may lead to Retrognathia

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Head and Neck Manifestations

• Cricoarytenoid joint
• Most common cause of cricoarytenoid arthritis
• 30 patients hoarse
• Exertional dyspnea, ear pain, globus
• Hoarseness
• Rheumatoid nodules, recurrent nerve involvement
• Stridor
• local/systemic steroids
• Conductive Hearing Loss
• Ossicular chain involvement
• Sensory Neural Hearing Loss
• Unexplained
• Assoc. with rheumatoid nodules
• Cervical spine
• Subluxation

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Laboratory ..

• Hematologic parameters
• Anaemia
• Thrombocytosis
• ? Serum iron IBC
• ? Serum globuline
• ? ALP
• ? Acute phase reactant ( ESR / CRP )
• Immunological parameters ( RF ) / ANF 50 )
• Synovial fluid analysis (WBC gt 2000/mm3 )

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Laboratory

• Rheumatoid Factor
• Ig M Antibody against the Fc fragment of Ig G
• Not sensitive
• 80 of RA patients
• RF patients more likely to have
• More severe disease
• Extraarticular manifestations
• Anti-cyclic citrullinated peptide (Anti-CCP )
• Specificity 90
• Sensitivity 50-80

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RF is not specific for RA.

• Other autoimmune disease
• Sjogrens syndrome , Systemic Lupus
• Chronic infection
• Hep B/C, SBE, Viral, Parasites, TB
• Pulmonary inflammation
• Sarcoid, IPF, Silicosis, Asbestosis
• Malignancy
• Healthy 4 young 5-25 gt age 60

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Radiography

• Periarticular osteopenia
• Symmetric joint space loss
• Marginal erosions
• Absence of productive changes
• Best films for diagnosis
• Bilateral Hand Arthritis Series
• Bilateral Foot Series
• Larger joints may not show erosions early due to
  thicker cartilage.

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Treatment

• Aggressive Treatment Early!
• Physical therapy, daily exercise, splinting,
  joint protection
• Salicylates, NSAIDS, DMARDs , hydroxychloroquine,
  immunosuppressive agents , Steroids
• Cyclosporin-A
• Prognosis
• 10-15 yrs of disease
• 50 fully employed
• 10 incapacitated
• 10-20 remission
• Persistent active cases more than 1 year likely
  to lead to joint deformities.
• Periods of activity cases have better prognosis.
• Mortality rate 2.5 times than generalpopulation

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Dental Management

• Short dental appointments
• Assess if Aspirin or NSAIDs are affecting
  platelet function

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Osteoarthritis?

• Most common form of arthritis
• Middle-aged to elderly
• Gradual pain, worse with use
• F M up to age 55 after 55 FgtM
• Obesity, history of trauma
• Cartilage irregularity
• 10-20 of these symptomatic
• Only small percentage present for help
• Joints affected
• Hands DIP, PIP, CMC thumb
• Hips, knees, ankles, great toes
• Cervical and lumbar spine

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Osteoarthritis

• Mechanical symptoms ( Pain on activity),Stiffness
• Bony swelling, crepitus
• DIP (Heberden)
• PIP (Bouchard)
• 1st CMCJ,
• Neck,
• Lower back,
• Hips,
• Knees,
• 1st MTP

Clinical subsets Generalised OA Primary / nodal
OA Erosive OA
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Osteoarthritis Radiology

• ( Correlate poorly with symptoms )
• Four cardinal features
• Joint space narrowing
• Sclerosis
• Subchondral cysts
• Osteophytes

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OA Management

• Pain Relief
• Simple/compound analgesics, exercises
• Glucosamine sulphate, patellar taping
• Topical capsaicin/NSAID acupuncture
• Oral NSAIDs COX2s, gastro-protection
• Injections peri-articular, intra-articular
• Joint Replacement (Referral guidance hip/knee OA
  )
• ? Infection same day
• Rapid deterioration/severe disability (2/52 hip,
  soon locally agreed knee)
• Symptoms impair QOL routine
• Giving way despite Rx soon (knee only)
• Acute inflammation (gout, haemarthrosis,
  pseudogout) 2/52 (knee only)

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Gout?

• Disease of Monosodium urate crystal deposition in
  tissues of and around joints
• Adult men, peaks in ages 40s to 50s
• Urate Overproduction (lt10) vs
• Under Excretion (90)
• Three stages
• Asymptomatic hyperuricemia
• Acute intermittent gout
• Chronic tophaceous gout
• Definitive dx by aspiration of fluid

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Gout?

• Onset before 25 should raise the question of
  unusual form of gout , specific enzyme defect
• A single joint involve in 85-90 of first attack
• 90 acute attacks in great toe, next in order of
  frequency are the ankles, heels, knees, wrists,
  fingers and elbows
• Acute gouty bursitis-- prepatella, olecranon
• Chronic
• Tophi

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Septic Arthritis

• Septic arthritis is inflammation of a synovial
  membrane with purulent effusion into the joint
  capsule, usually due to bacterial infection.
• It is an emergency- it can destroy a joint
  extremely quickly and (v.rarely) lead to sepsis
  and death
• Frequency
• 2-10 cases per 100,000 in the general population.
  
• 30-70 cases per 100,000 in immunosuppressed/
  joint prosthesis