Transcript Rheumatoid Arthritis

Rheumatoid
Arthritis
Priscilla, Jennifer, Reina, Dorinda
DEH 26
5.15.08
Patient Profile
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Name – Rume Aritis
Gender – Female
Age – 45
Occupation – Stenographer
Marital Status – Married
Ethnicity – Caucasian
Medical History
 Chief complaint – TMJ soarness, dry mouth, and
teeth sensitivity
 Dental History –
 Patient has difficulty opening the jaw
 4/07 - last dental exam, BWX, and FM scale
 4/05 - last FMX
 Medical History –
 Patient presents with recurrent finger ache and pain
 Rheumatoid arthritis since 1999
More Medical History
 Medications –
 Gold sodium thiomalate – helps slow down
the disease process and decrease inflammation
 Dental implications: stomatitis, gingivitis and
glossitis
 Aspirin – helps reduce pain
 Dental implications: increased bleeding
 Prednisone – used for inflammation
 Dental implications: none noted
 Vitals – BP: 125/74, P:78, R:17
 ASA III
Definition
 An autoimmune disease of unknown origin
that is characterized by symmetric
inflammation of the joints, especially of the
hands, feet, and knees
Incidence and Prevalence
 Estimates of prevalence range 1-2% of the
population.
 Disease onset usually occurs from ages 35-50
years.
 Severity of the disease varies widely from
patient to patient and from time to time within
the same patient.
May is National Arthritis Month.
More Incidence
and Prevalence
 3:1 women to men ratio  implies
involvement of sex hormones in the
susceptibility and sensitivity of the disease
 Suggested factors in playing predisposing
roles:
 Psychosocial stress
 Education
 Socioeconomic status
Etiology
 Unknown cause
 Evidence seems to implicate an
interrelationship of infectious agents,
genetics, and autoimmunity.
 Currently, circumstantial evidence suggests
that food may play a role in the origin and
treatment.
Pathophysiology
1.
Edema of the
3.
synovium 
thickening and folding
to excessive,
proliferative, invasive
granulation tissue =
pannus
Granulation tissue covers
the articular surfaces and
destroys the cartilage and
subchondral bone through
enzymatic activity extending
to capsule and ligaments 
distension and rupture
2.
Marked infiltration of
lymphocytes and
plasma cells into the
capsule
New bone or fibrous tissue
is deposited  fusion or loss
of mobility
4.
Complications
 The life expectancy of persons with severe RA
is shortened by 10-15 years.
 This increased mortality rate usually is
attributed to
 Pulmonary and renal disease
 Infection
 Gastrointestinal bleeding
Accompanying Complications
Skin ulcers
Muscle atrophy
Pericarditis
TMJ involvement
Anemia
Pulmonary interstitial
fibrosis
Neutropenia
Keratoconjunctivitis
sicca (Sjögren’s
syndrome)
Digital gangrene
Amyloidosis
Thrombocytopenia
Splenomegaly (Felty’s
syndrome)
Signs and Symptoms
 The usual onset of rheumatoid arthritis is gradual
and subtle.
 A patient will first experience fatigue and weakness
with joint muscle aches.
 Then there is painful joint swelling of the hands and
feet, spreading to several joints, and then progress to
other joints symmetrically.
 Joint involvement gradually progresses to
immobility, contractures, subluxation, deviation, and
other deformities.
Joints Most
Commonly Affected
Fingers
Wrists
Ankles
TMJ (often
involved in
up to 75%
of patients)
Knees
Elbows
Feet
Medical Management
Medical Management
 Early diagnosis and treatment for rheumatoid
arthritis is vital.
 It can noticeably decrease the disability and
pain and very likely lengthen the life span.
 Treatment approach is palliative (alleviating
illness) because there is no cure that exists for
this disease.
Medical Management
 Treatment Goals:
 Reduce joint inflammation and swelling
 Relieve pain and stiffness
 Help and promote normal function
 Goals are accomplished by:
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Patient education
Rest
Exercise
Physical therapy
NSAIDs
Medical Management
 Drugs for the
management of RA
have been divided
into two groups:
 1. Control joint pain
and swelling. (i.e.
NSAIDs)
 2. Limit joint damage
and improve longterm outcome. (i.e.
DMARDs – diseasemodifying
antirheumatic dugs)
NSAIDs = Drugs That Control
Joint Pain and Swelling
 Effective for pain, swelling, and stiffness
 Most effective and safest for patients
 Start patient on three-grain tablets 4X a day, then
adjust according to patient’s response
 Too much aspirin can result in aspirin toxicity.
 Common sign = tinnitus (ringing, buzzing, or hissing
heard in the ear)
 If this occurs, decrease the dosage.
 May result in prolonged bleeding
Gold Compounds
 Helpful in decreasing inflammation and
slowing down the progress of the disease
 Gold compound therapy must be carefully
supervised.
 Incidence of side effects is high. This includes:
 Buccal ulcerations
 Eczematous rashes
 Neutropenia
 Thrombocytopenia
Other Drugs
 Antimalarial Drugs
 Corticosteroids
 Chloroquine or
hydroxychloroquine
 These drugs are used in
combination with aspirin or
corticosteroids.
 Side effects include eye
damage and blue-black
intraoral pigmentation.
 Prednisone or
prednisolone
 Most effective for
reducing
inflammation
 Manages acute
symptoms
 Significant adverse
effect is adrenal
suppression;
therefore, long-term
usage is avoided.
Immunosuppressive
Therapy
 Effective in treating severe RA
 Slows down the progression of the disease and
decreases the damage to bones adjacent to
joints
 Drugs include methotrexate, azathioprine,
cyclosporine, and tumor necrosis factor (TNF)
inhibitors
 Side effects include liver disease, lung
inflammation, oral ulcerations, and increased
susceptibility to infection
Combination Therapy
 For patients with moderate to severe disease
 Methotrexate used in combination with other
agents
 Most popular regimen is methotrexate,
hydroxychloroquine, and sulfasalazine.
 More effective than single-drug regimens
 Does not appear to be hazardous and should be
considered as initial treatment in patients with
early, active RA
Surgery
 Used to relieve severe pain
and improve function of
severely deformed joints that
do not respond to medication
and physical therapy
 Variety of surgical procedures
include:
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Arthroscopy
Synovectomy
Arthroplasty
Total joint replacement
Dental Management
Considerations Prior to
Dental Treatment
 Patient comfort
 Drug considerations
 Joint prosthesis
 TMJ involvement
 Oral hygiene capability
Patient Comfort
 Appointments should
be kept short.
 Encourage patient to
change seating
positions frequently.
 Be creative, and use
pillows or rolled towels
to support deformed or
crippled limbs.
Drug Considerations
 Patient may be taking :
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Aspirin
NSAIDS
Corticosteroids
DMARDS
Immunosuppressive agents
Aspirin Drug Considerations
 Aspirin with NSAIDs
 Analgesic
 Can cause prolonged bleeding
 Usually not clinically significant (does not put
disease in remission)
 Aspirin with corticosteriods
 High risk for prolonged bleeding
 Need to determine bleeding time
 Most accurate test is the PFA-100 (platelet
function analyzer)
 Bleeding time should be under 20 minutes.
Other Drug Considerations
 DMARDs
 e.g. gold compound, penicillamine, sulfasalazine
 Cause suppression of the bone marrow  anemia,
agranulocytosis, and thrombocytopenia
 Need recent lab tests such as RBC count, WBC
count, and bleeding time
 Corticosteroids
 Used for control of active disease, should be used
for a short period of time
 If used for a long period of time  hyperglycemia,
edema, osteonecrosis, immune suppression, and
infection
Joint Prosthesis
 In some patients, the arthritis is chronic and
causes destruction of a joint structure to the
point where the patient needs a prosthetic joint
(usually the hip knee or shoulder).
TMJ Involvement
 45-75% of patients with rheumatoid arthritis have
TMJ involvement
 Patient will have decreased jaw function, mobility,
and maximum opening; increased tenderness,
swelling, and stiffness
 These factors hinder the patient’s diet  nutrition
counseling
 Loss of condylar height can create an open bite and
also causes sleep apnea.
 Moist warm towels can relieve pain.
Oral Hygiene Capability
 Patient has less dexterity due to pain in
the joints
 Alter OHI to customize the patient’s
specific needs.
 Power toothbrushes, floss aids,
irrigators, even modifying the tooth
brush handle
 Be empathetic and patient.
Some Toothbrush
Modifications
 A lack of strength because of
arthritis can make even
holding the handle of a
toothbrush difficult.
 A solution to this problem
could be to stick the
toothbrush handle into a
tennis ball or slide it in a
bicycle handlebar grip.
Quiz
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1. What is rheumatoid arthritis?
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A. an immune deficiency disease of unknown
origin that is characterized by symmetric
inflammation of the joints
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B. an autoimmune disease of unknown origin that
is characterized by symmetric inflammation of the
joints
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C. an immune deficiency disease of unknown
origin that is characterized by asymmetric
inflammation of the joints
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D. an autoimmune disease of unknown origin that
is characterized by asymmetric inflammation of the
joints
2. Disease onset usually occurs
from ages 25-55 years. Rheumatoid
arthritis is more prevalent in
women than men by a 2:1 ratio.
 A. Both statements are TRUE.
 B. Both statements are FALSE.
 C. The first statement is TRUE, and the
second statement is FALSE.
 D. The first statement is FALSE, and the
second statement is TRUE.
3. Rheumatoid arthritis
 A. has an unknown cause.
 B. is caused by infectious agents.
 C. is caused by genetics and autoimmunity.
 D. is caused by food.
More Quiz Questions
 4. List 3 characteristics of RA.
 5. Name 3 joints that may be affected by
RA.
 6. What are some dental modifications that
can be made for a patient with RA?
 7. What is the major side effect of a
corticosteroid after a long period of use?
 8. What does DMARD stand for?
9. Aspirin is the most effective and safest drug
for patients. Aspirin can be prescribed in large
doses but can cause toxicity.
 A. Both statements are TRUE.
 B. Both statements are FALSE.
 C. The first statement is TRUE, and the
second statement is FALSE.
 D. The first statement is FALSE, and the
second statement is TRUE.
10. Treatment goals for RA:
 A. reduce joint inflammation and
swelling
 B. relieve pain and stiffness
 C. encourage normal function
 D. all of the above
 E. none of the above
Answers
 1. B. an autoimmune disease of unknown origin
that is characterized by symmetric inflammation
of the joints
 2. B. Both statements are FALSE. (35-50 years of
age, 3:1 women: men)
 3. A. has an unknown cause.
RA Answers
 4. symmetrical, gradual and subtle onset,
fatigue and weakness with joint muscle
aches, immobility, morning stiffness
 5. fingers, wrists, feet, ankles, knees,
elbows, TMJ
More Answers
 6. modification of OHI, use towels or
pillows and/or bite blocks to achieve
comfort, have short appointments
 7. immune suppression
 8. drug modifying anti-rheumatic drug
Even More Answers
 9. A. Both statements are TRUE.
 10. D. all of the above
Bonus Questions
 1. Spell what RA stands for.
 2. What percentage of patients have a
gradual onset of the disease?
 3. Out of more than 60 important
diseases related to arthritis, name 3.
Answers to Bonus Questions
 1. R-h-e-u-m-a-t-o-i-d a-r-t-h-r-i-t-i-s
 2. More than 50%
 3. Osteoarthritis, SLE, Lyme disease,
Sjögren’s syndrome
Questions?