Transcript Document

Dental Management of
Patients with
Rheumatology Disorders
1
Pathological Classification of Rheumatic Disorders
Rheumatoid arthritis
Autoimmune
Disorder
Connective tissue disorder
Spondarthritis
Joint
Disorder
Inflammatory
Disorder
Crystal
Arthropathy
Infection
Gouty Arthritis
Pseudogout (CPPA)
Degenerative
Disorder
O.A
Septic Arthritis
Introduction..
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Is it Arthritis or Arthralgia?
Is it Monoarthritis or Polyarthritis ?
Is it Musculoskeletal emergencies ?
RED FLAG CONDITIONS
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FRACTURE
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SEPTIC ARTHRITIS
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GOUT/PSEUDOGOUT
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NERVE OR VESSEL PROBLEMS
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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
What are the Symptoms?
Inflammatory
Degenerative
Chronic Pain
Joint Pain
Yes
Yes
No
Joint Swelling
Yes
Yes
No
Joint Redness
Yes
No
No
> 1 hour
15-20 minutes
> 1 hour
New and Severe
Mild
Severe
Rapid
Slow
Rapid
Fever
Possibly
Never
Never
Weight Loss
Possibly
Unusual
Unusual
Morning Stiffness
Fatigue
Loss of Function
Arthralgia..
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Fibromyalgia
Bursitis
Tendinitis
Hypothyroidism
Neuropathic pain
Metabolic bone disease
Depression
Monoarthritis..
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Trauma
Infection:
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Crystal induced arthritis
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Monosodium Urate crystals (MPJ) - Gout
Calcium pyrophosphate dihydrate crystals (knee) Pseudogout
Systemic Rheumatoid diseases:
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± Skin lesion.
Nongonococcal bacterial infections: large joints.
Mycobacterial and fungal infection.
Seronegative spodyloarthropathy (Reactive arthritis, psoriatic
arthritis, Inflammatory BD..)
RA
Osteoarthritis
Polyarthritis..
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Rheumatoid Arthritis
Systemic lupus Erythrematosus
Viral arthritis
Reiter’s disease
Psoriatic arthritis
Reactive arthritis
Migratory Arthritis..
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Differential diagnosis:
 Rheumatic
fever
 Gonococcemia
 Meningococcemia
 Viral Arthritis
 SLE
 Acute Leukemia
Rheumatic Fever..
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Majer Criteria:
1- Carditis
2- Polyarthritis
3- Chorea
4- Erythema Marginatum 5- Subcutaneous nodules
● Minor criteria:
1- Arthralgia
(ESR, CRP).
2- Ferver
3- Acute phase reactant
4- Prolong PR interval
5- Evidence of group A
streotococcal infection (AST, Throat culture…)
History.. Age & Sex
<30= SLE, Ankylosis spodylitis, Reactive Arthritis.
 30-50= RA, Systemic sclerosis, Gout.
 >50= OA, Pseudogout, PMR
 Any Age group= Psoriatic arthritis, Enteropathic arthritis
 >Female:
SLE, RA, OA, Systemic sclerosis, PMR.
 Male=Female:
Psoriatic arthritis, Enteropathic arthritis Pseudogout, .
 >Male:
Gout, Reactive Arthritis, Ankylosis spodylitis,
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History.. Symptoms
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Site:
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Symmetrical= RA, SLE, Systemic sclerosis
Asymmetrical=OA
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
Physical Examination..
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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..
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General Examination:
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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…)
Laboratory & Radiology Studies..
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Can be misleading.
Basic: CBC, Urinalysis, U&E, LFT.
Acute phase reactant: ESR, CRP.
Uric acid concentration= Gout
Synovial fluid analysis= infection, crystal induced arthritis,
inflammatory..
Antibody tests:
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ANA= SLE
Anti-dsDNA= SLE
Anti-native DNA, anti-Sm= SLE
RF= RA
Anti-CCP antibody=RA
X-ray:
MRI:
Rheumatoid Arthritis
A chronic nonsuppurative inflammatory destruction of the joints
Rheumatoid Arthritis..
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Incidence
1-3% of general population
 Genetic predisposition
 Female to male ratio 3:1
 Average age of onset of 40 years
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History..
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Malaise
Fever
Fatigue
Weight loss
Myalgias
Difficulty performing activities of daily living
Examination..
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Joint affected
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swelling
tenderness
warmth
decreased range of motion
Atrophy of the interosseous muscles
deformities
≥ 4 Diagnosis.. ACR Criteria criteria
present > 6 wks
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Morning stiffness > 1
hour
Arthritis of ≥ 3 joints
areas (PIP, MCP, wrist,
elbow, knee, ankle, and
MTP)
Arthritis of hand joints
(wrist, MCP, PIP)
Symmetric arthritis
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Rheumatoid nodules
RF+
Radiographic changes
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Erosions
Unequivocal periarticular
osteopenia
Synovitis
RA - hands
Deformities..
Swan neck and Boutonniere
Rheumatoid Arthritis
Extra-Articular Manifestations..
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Rheumatoid nodule
Cardiovascular
Pulmonary
GI & Renal
Hematological
Skin
Vasculitis
Neurological
Ocular
Rheumatoid nodules
Vasculitis
Ocular
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Sicca symptoms
Episcleritis
Scleritis
Scleromalacia Perforance
Head & Neck Manifestations
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Rheumatoid Arthritis may involve the TMJ.
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55% Affected
70% with radiographic evidence of TMJ involvement
Juvenile form may lead to Retrognathia
Head and Neck Manifestations
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Cricoarytenoid joint
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Hoarseness
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Ossicular chain involvement
Sensory Neural Hearing Loss
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local/systemic steroids
Conductive Hearing Loss
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Rheumatoid nodules, recurrent nerve involvement
Stridor
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Most common cause of cricoarytenoid arthritis
30% patients hoarse
Exertional dyspnea, ear pain, globus
Unexplained
Assoc. with rheumatoid nodules
Cervical spine
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Subluxation
Laboratory ..
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Hematologic parameters
Anaemia
 Thrombocytosis
 ↓ Serum iron & IBC
 ↑ Serum globuline
 ↑ ALP
 ↑ Acute phase reactant ( ESR / CRP )
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Immunological parameters ( RF ) / ANF “50 % )
Synovial fluid analysis (WBC > 2000/mm3 )
Laboratory
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Rheumatoid Factor
Ig M Antibody against the Fc fragment of Ig G
 Not sensitive
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80% of RA patients
RF+ patients more likely to have
More severe disease
 Extraarticular manifestations
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Anti-cyclic citrullinated peptide (Anti-CCP )
Specificity = 90%
 Sensitivity = 50-80%
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RF is not specific for RA.
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Other autoimmune disease
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Chronic infection
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Hep B/C, SBE, Viral, Parasites, TB
Pulmonary inflammation
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Sjogren’s syndrome , Systemic Lupus
Sarcoid, IPF, Silicosis, Asbestosis
Malignancy
Healthy – 4% young;
5-25% > age 60
Radiography
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Periarticular osteopenia
Symmetric joint space loss
Marginal erosions
Absence of productive changes
Best films for diagnosis:
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Bilateral Hand Arthritis Series
Bilateral Foot Series
Larger joints may not show erosions early due to
thicker cartilage.
Treatment
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Physical therapy, daily exercise, splinting, joint protection
Salicylates, NSAIDS, DMARDs , hydroxychloroquine,
immunosuppressive agents , Steroids
Cyclosporin-A
Prognosis
 10-15 yrs of disease
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Aggressive Treatment Early!
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
Dental Management
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Short dental appointments
Assess if Aspirin or NSAIDs are affecting platelet
function
Osteoarthritis?
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Most common form of arthritis
Middle-aged to elderly
Gradual pain, worse with use
F= M up to age 55; after 55 F>M
Obesity, history of trauma
Cartilage irregularity
10-20% of these symptomatic
Only small percentage present for help
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Joints affected
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Hands – DIP, PIP, CMC thumb
Hips, knees, ankles, great toes
Cervical and lumbar spine
Osteoarthritis
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Mechanical symptoms ( Pain on activity),Stiffness
Bony swelling, crepitus
DIP (Heberden)
Clinical subsets
PIP (Bouchard) Generalised OA
Primary / nodal OA
1st CMCJ,
Erosive OA
Neck,
Lower back,
Hips,
Knees,
1st MTP
Osteoarthritis Radiology
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( Correlate poorly with symptoms )
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Four cardinal features:
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Joint space narrowing
Sclerosis
Subchondral cysts
Osteophytes
OA Management
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Pain Relief
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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 )
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? 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)
Gout?
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Disease of Monosodium urate crystal deposition in
tissues of and around joints
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Adult men, peaks in ages 40’s to 50’s
Urate Overproduction (<10%) vs
Under Excretion (90%)
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Three stages:
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Asymptomatic hyperuricemia
Acute intermittent gout
Chronic tophaceous gout
Definitive dx by aspiration of fluid
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Gout?
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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
Septic Arthritis
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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
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