RheumatoiRheumatoid Arthritisd Arthritis

Priscilla Garcia, Jennifer Klocki, Reina Ligeralde, Dorinda Priscilla Garcia, Jennifer Klocki, Reina Ligeralde, Dorinda ThomasThomasDEH 26DEH 265.15.085.15.08

Patient ProfilePatient Profile

Name – Rume AritisName – Rume Aritis Gender – FemaleGender – Female Age – 45Age – 45 Occupation – Occupation –

StenographerStenographer Marital Status – MarriedMarital Status – Married Ethnicity – CaucasianEthnicity – Caucasian

Medical HistoryMedical History

Chief complaint – TMJ soarness, dry Chief complaint – TMJ soarness, dry mouth, and teeth sensitivitymouth, and teeth sensitivity

Dental History – Dental History – Patient has difficulty opening the jawPatient has difficulty opening the jaw 4/07 - last dental exam, BWX, and FM scale4/07 - last dental exam, BWX, and FM scale 4/05 - last FMX4/05 - last FMX

Medical History – Medical History – Patient presents with recurrent finger ache Patient presents with recurrent finger ache

and painand pain Rheumatoid arthritis since 1999Rheumatoid arthritis since 1999

More Medical HistoryMore Medical History

Medications – Medications – Gold sodium thiomalate – helps slow down Gold sodium thiomalate – helps slow down

the disease process and decrease the disease process and decrease inflammationinflammation Dental implications: stomatitis, gingivitis and Dental implications: stomatitis, gingivitis and

glossitisglossitis Aspirin – helps reduce painAspirin – helps reduce pain

Dental implications: increased bleedingDental implications: increased bleeding Prednisone – used for inflammationPrednisone – used for inflammation

Dental implications: none notedDental implications: none noted

Vitals – BP: 125/74, P:78, R:17Vitals – BP: 125/74, P:78, R:17 ASA IIIASA III

DefinitionDefinition

An autoimmune disease of unknown An autoimmune disease of unknown origin that is characterized by origin that is characterized by symmetric inflammation of the joints, symmetric inflammation of the joints, especially of the hands, feet, and kneesespecially of the hands, feet, and knees

Incidence and Incidence and PrevalencePrevalence

Estimates of prevalence range 1-2% of Estimates of prevalence range 1-2% of the population.the population.

Disease onset usually occurs from ages Disease onset usually occurs from ages 35-50 years.35-50 years.

Severity of the disease varies widely Severity of the disease varies widely from patient to patient and from time to from patient to patient and from time to time within the same patient.time within the same patient.

May is National Arthritis Month.

More Incidence More Incidence and Prevalenceand Prevalence

3:1 women to men ratio 3:1 women to men ratio implies implies involvement of sex hormones in the involvement of sex hormones in the susceptibility and sensitivity of the susceptibility and sensitivity of the diseasedisease

Suggested factors in playing Suggested factors in playing predisposing roles:predisposing roles: Psychosocial stressPsychosocial stress EducationEducation Socioeconomic statusSocioeconomic status

EtiologyEtiology

Unknown causeUnknown cause

Evidence seems to implicate an Evidence seems to implicate an interrelationship of infectious agents, interrelationship of infectious agents, genetics, and autoimmunity.genetics, and autoimmunity.

Currently, circumstantial evidence Currently, circumstantial evidence suggests that food may play a role in suggests that food may play a role in the origin and treatment.the origin and treatment.

PathophysiologyPathophysiology

1.1. Edema of the Edema of the synovium synovium thickening and thickening and folding to excessive, folding to excessive, proliferative, proliferative, invasive granulation invasive granulation tissue = pannustissue = pannus

2.2. Marked infiltration Marked infiltration of lymphocytes and of lymphocytes and plasma cells into plasma cells into the capsulethe capsule

3.3. Granulation tissue Granulation tissue covers the articular covers the articular surfaces and destroys surfaces and destroys the cartilage and the cartilage and subchondral bone subchondral bone through enzymatic through enzymatic activity extending to activity extending to capsule and ligaments capsule and ligaments distension and rupturedistension and rupture

4.4. New bone or fibrous New bone or fibrous tissue is deposited tissue is deposited fusion or loss of mobilityfusion or loss of mobility

ComplicationsComplications

The life expectancy of persons with The life expectancy of persons with severe RA is shortened by 10-15 years.severe RA is shortened by 10-15 years.

This increased mortality rate usually is This increased mortality rate usually is attributed to attributed to Pulmonary and renal diseasePulmonary and renal disease InfectionInfection Gastrointestinal bleedingGastrointestinal bleeding

Accompanying Accompanying ComplicationsComplications

Skin ulcersSkin ulcers

PericarditisPericarditis

AnemiaAnemia

NeutropeniaNeutropenia

Keratoconjunctivitis Keratoconjunctivitis sicca (Sjögren’s sicca (Sjögren’s syndrome)syndrome)

Digital gangreneDigital gangrene

Muscle atrophyMuscle atrophy

TMJ involvementTMJ involvement

Pulmonary Pulmonary interstitial fibrosisinterstitial fibrosis

AmyloidosisAmyloidosis

ThrombocytopeniaThrombocytopenia

Splenomegaly Splenomegaly (Felty’s syndrome)(Felty’s syndrome)

Signs and SymptomsSigns and Symptoms

The usual onset of rheumatoid arthritis is The usual onset of rheumatoid arthritis is gradual and subtle. gradual and subtle.

A patient will first experience fatigue and A patient will first experience fatigue and weakness with joint muscle aches.weakness with joint muscle aches.

Then there is painful joint swelling of the Then there is painful joint swelling of the hands and feet, spreading to several joints, hands and feet, spreading to several joints, and then progress to other joints and then progress to other joints symmetrically.symmetrically.

Joint involvement gradually progresses to Joint involvement gradually progresses to immobility, contractures, subluxation, immobility, contractures, subluxation, deviation, and other deformities.deviation, and other deformities.

Joints Most Joints Most Commonly AffectedCommonly Affected

FingersFingers

AnklesAnkles

KneesKnees

ElbowsElbows

WristsWrists

TMJ TMJ (often (often involved involved in up to in up to 75% of 75% of patients)patients)

FeetFeet

Medical Management Medical Management

Medical ManagementMedical Management

Early diagnosis and treatment for rheumatoid arthritis is Early diagnosis and treatment for rheumatoid arthritis is vital.vital.

It can noticeably decrease the disability and pain and It can noticeably decrease the disability and pain and very likely lengthen the life span.very likely lengthen the life span.

Treatment approach is palliative (alleviating illness) Treatment approach is palliative (alleviating illness) because there is no cure that exists for this disease.because there is no cure that exists for this disease.

Medical Management Medical Management

Treatment Goals:Treatment Goals: Reduce joint inflammation and Reduce joint inflammation and

swellingswelling Relieve pain and stiffnessRelieve pain and stiffness Help and promote normal functionHelp and promote normal function

Goals are accomplished byGoals are accomplished by:: Patient educationPatient education Rest Rest ExerciseExercise Physical therapyPhysical therapy NSAIDsNSAIDs

Medical Management Medical Management

Drugs for the Drugs for the management of management of RA have been RA have been divided into two divided into two groups:groups:

1. Control joint pain and 1. Control joint pain and swelling. (i.e. NSAIDs)swelling. (i.e. NSAIDs)

2. Limit joint damage and 2. Limit joint damage and improve long-term outcome. improve long-term outcome. (i.e. DMARDs – disease- (i.e. DMARDs – disease- modifying antirheumatic dugs)modifying antirheumatic dugs)

NSAIDs = Drugs That NSAIDs = Drugs That Control Joint Pain and Control Joint Pain and SwellingSwelling

Effective for pain, swelling, and stiffnessEffective for pain, swelling, and stiffness Most effective and safest for patientsMost effective and safest for patients Start patient on three-grain tablets 4X a Start patient on three-grain tablets 4X a

day, then adjust according to patient’s day, then adjust according to patient’s responseresponse

Too much aspirin can result in aspirin Too much aspirin can result in aspirin toxicity. toxicity. Common sign = tinnitus (ringing, buzzing, or Common sign = tinnitus (ringing, buzzing, or

hissing heard in the ear)hissing heard in the ear) If this occurs, decrease the dosage.If this occurs, decrease the dosage.

May result in prolonged bleedingMay result in prolonged bleeding

Gold CompoundsGold Compounds

Helpful in decreasing inflammation and slowing down the progress of Helpful in decreasing inflammation and slowing down the progress of the diseasethe disease

Gold compound therapy must be carefully supervised.Gold compound therapy must be carefully supervised. Incidence of side effects is high. This includes:Incidence of side effects is high. This includes:

Buccal ulcerations Eczematous rashes Neutropenia Thrombocytopenia

Other DrugsOther Drugs Antimalarial DrugsAntimalarial Drugs

Chloroquine or Chloroquine or hydroxychloroquinehydroxychloroquine

These drugs are used in These drugs are used in combination with combination with aspirin or aspirin or corticosteroids.corticosteroids.

Side effects include eye Side effects include eye damage and blue-black damage and blue-black intraoral pigmentation.intraoral pigmentation.

CorticosteroidsCorticosteroids Prednisone or Prednisone or

prednisolone prednisolone Most effective for Most effective for

reducing reducing inflammationinflammation

Manages acute Manages acute symptomssymptoms

Significant adverse Significant adverse effect is adrenal effect is adrenal suppression; suppression; therefore, long-therefore, long-term usage is term usage is avoided.avoided.

Immunosuppressive Immunosuppressive TherapyTherapy

Effective in treating severe RAEffective in treating severe RA Slows down the progression of the Slows down the progression of the

disease and decreases the damage to disease and decreases the damage to bones adjacent to jointsbones adjacent to joints

Drugs include methotrexate, Drugs include methotrexate, azathioprine, cyclosporine, and tumor azathioprine, cyclosporine, and tumor necrosis factor (TNF) inhibitorsnecrosis factor (TNF) inhibitors

Side effects include liver disease, lung Side effects include liver disease, lung inflammation, oral ulcerations, and inflammation, oral ulcerations, and increased susceptibility to infectionincreased susceptibility to infection

Combination Therapy Combination Therapy For patients with moderate to severe diseaseFor patients with moderate to severe disease Methotrexate used in combination with other Methotrexate used in combination with other

agentsagents Most popular regimen is methotrexate, Most popular regimen is methotrexate,

hydroxychloroquine, and sulfasalazine. hydroxychloroquine, and sulfasalazine. More effective than single-drug regimensMore effective than single-drug regimens Does not appear to be hazardous and should Does not appear to be hazardous and should

be considered as initial treatment in patients be considered as initial treatment in patients with early, active RAwith early, active RA

Surgery Surgery

Used to relieve severe pain Used to relieve severe pain and improve function of and improve function of severely deformed joints severely deformed joints that do not respond to that do not respond to medication and physical medication and physical therapytherapy

Variety of surgical Variety of surgical procedures include:procedures include: Arthroscopy Synovectomy Arthroplasty Total joint replacement

Dental ManagementDental Management

Considerations Prior to Considerations Prior to Dental TreatmentDental Treatment

Patient comfortPatient comfort

Drug considerationsDrug considerations

Joint prosthesisJoint prosthesis

TMJ involvementTMJ involvement

Oral hygiene capabilityOral hygiene capability

Patient ComfortPatient Comfort

Appointments should be Appointments should be kept short.kept short.

Encourage patient to Encourage patient to change seating positions change seating positions frequently. frequently.

Be creative, and use Be creative, and use pillows or rolled towels pillows or rolled towels to support deformed or to support deformed or crippled limbs.crippled limbs.

Drug ConsiderationsDrug Considerations

Patient may be taking :Patient may be taking : AspirinAspirin NSAIDSNSAIDS CorticosteroidsCorticosteroids DMARDsDMARDs Immunosuppressive agentsImmunosuppressive agents

Aspirin Drug Aspirin Drug ConsiderationsConsiderations

Aspirin with NSAIDsAspirin with NSAIDs AnalgesicAnalgesic Can cause prolonged bleedingCan cause prolonged bleeding Usually not clinically significant (does not Usually not clinically significant (does not

put disease in remission) put disease in remission)

Aspirin with corticosteriodsAspirin with corticosteriods High risk for prolonged bleedingHigh risk for prolonged bleeding Need to determine bleeding timeNeed to determine bleeding time

Most accurate test is the PFA-100 (platelet Most accurate test is the PFA-100 (platelet function analyzer) function analyzer)

Bleeding time should be under 20 minutes.Bleeding time should be under 20 minutes.

Other Drug Other Drug ConsiderationsConsiderations

DMARDs DMARDs e.g. gold compound, penicillamine, sulfasalazinee.g. gold compound, penicillamine, sulfasalazine Cause suppression of the bone marrow Cause suppression of the bone marrow

anemia, agranulocytosis, and thrombocytopeniaanemia, agranulocytosis, and thrombocytopenia Need recent lab tests such as RBC count, WBC Need recent lab tests such as RBC count, WBC

count, and bleeding timecount, and bleeding time

CorticosteroidsCorticosteroids Used for control of active disease, should be Used for control of active disease, should be

used for a short period of timeused for a short period of time If used for a long period of time If used for a long period of time

hyperglycemia, edema, osteonecrosis, immune hyperglycemia, edema, osteonecrosis, immune suppression, and infectionsuppression, and infection

Joint ProsthesisJoint Prosthesis

In some patients, the arthritis is chronic In some patients, the arthritis is chronic and causes destruction of a joint and causes destruction of a joint structure to the point where the patient structure to the point where the patient needs a prosthetic joint (usually the hip needs a prosthetic joint (usually the hip knee or shoulder).knee or shoulder).

TMJ InvolvementTMJ Involvement

45-75% of patients with rheumatoid arthritis 45-75% of patients with rheumatoid arthritis have TMJ involvementhave TMJ involvement

Patient will have decreased jaw function, Patient will have decreased jaw function, mobility, and maximum opening; increased mobility, and maximum opening; increased tenderness, swelling, and stiffnesstenderness, swelling, and stiffness

These factors hinder the patient’s diet These factors hinder the patient’s diet nutrition counselingnutrition counseling

Loss of condylar height can create an open bite Loss of condylar height can create an open bite and also causes sleep apnea.and also causes sleep apnea.

Moist warm towels can relieve pain.Moist warm towels can relieve pain.

Oral Hygiene CapabilityOral Hygiene Capability

Patient has less dexterity due to Patient has less dexterity due to pain in the jointspain in the joints

Alter OHI to customize the Alter OHI to customize the patient’s specific needs.patient’s specific needs. Power toothbrushes, floss aids, Power toothbrushes, floss aids,

irrigators, even modifying the irrigators, even modifying the tooth brush handletooth brush handle

Be empathetic and patient.Be empathetic and patient.

Some Toothbrush Some Toothbrush ModificationsModifications

A lack of strength because A lack of strength because of arthritis can make even of arthritis can make even holding the handle of a holding the handle of a toothbrush difficult. toothbrush difficult.

A solution to this problem A solution to this problem could be to stick the could be to stick the toothbrush handle into a toothbrush handle into a tennis ball or slide it in a tennis ball or slide it in a bicycle handlebar grip. bicycle handlebar grip.

QuizQuiz

1. What is rheumatoid arthritis?1. What is rheumatoid arthritis? A. an immune deficiency disease of unknown A. an immune deficiency disease of unknown

origin that is characterized by symmetric origin that is characterized by symmetric inflammation of the jointsinflammation of the joints

B. an autoimmune disease of unknown origin that B. an autoimmune disease of unknown origin that is characterized by symmetric inflammation of the is characterized by symmetric inflammation of the jointsjoints

C. an immune deficiency disease of unknown C. an immune deficiency disease of unknown origin that is characterized by asymmetric origin that is characterized by asymmetric inflammation of the jointsinflammation of the joints

D. an autoimmune disease of unknown origin that D. an autoimmune disease of unknown origin that is characterized by asymmetric inflammation of is characterized by asymmetric inflammation of the jointsthe joints

2. Disease onset usually 2. Disease onset usually occurs from ages 25-55 occurs from ages 25-55 years. Rheumatoid arthritis years. Rheumatoid arthritis is more prevalent in women is more prevalent in women than men by a 2:1 ratio.than men by a 2:1 ratio. A. Both statements are TRUE.A. Both statements are TRUE.

B. Both statements are FALSE. B. Both statements are FALSE.

C. The first statement is TRUE, and C. The first statement is TRUE, and the second statement is FALSE.the second statement is FALSE.

D. The first statement is FALSE, and D. The first statement is FALSE, and the second statement is TRUE.the second statement is TRUE.

3. Rheumatoid arthritis3. Rheumatoid arthritis

A. has an unknown cause.A. has an unknown cause.

B. is caused by infectious agents.B. is caused by infectious agents.

C. is caused by genetics and C. is caused by genetics and autoimmunity.autoimmunity.

D. is caused by food.D. is caused by food.

More Quiz QuestionsMore Quiz Questions 4. List 3 characteristics of RA.4. List 3 characteristics of RA.

5. Name 3 joints that may be affected by 5. Name 3 joints that may be affected by RA.RA.

6. What are some dental modifications that 6. What are some dental modifications that can be made for a patient with RA?can be made for a patient with RA?

7. What is the major side effect of a 7. What is the major side effect of a corticosteroid after a long period of use?corticosteroid after a long period of use?

8. What does DMARD stand for?8. What does DMARD stand for?

9. Aspirin is the most effective and 9. Aspirin is the most effective and safest drug for patients. Aspirin can safest drug for patients. Aspirin can be prescribed in large doses but can be prescribed in large doses but can cause toxicity.cause toxicity.

A. Both statements are TRUE.A. Both statements are TRUE.

B. Both statements are FALSE. B. Both statements are FALSE.

C. The first statement is TRUE, and C. The first statement is TRUE, and the second statement is FALSE.the second statement is FALSE.

D. The first statement is FALSE, and D. The first statement is FALSE, and the second statement is TRUE.the second statement is TRUE.

10. Treatment goals for 10. Treatment goals for RA:RA:

A. reduce joint inflammation and A. reduce joint inflammation and swellingswelling

B. relieve pain and stiffnessB. relieve pain and stiffness

C. encourage normal functionC. encourage normal function

D. all of the aboveD. all of the above

E. none of the aboveE. none of the above

Answers

1. B. an autoimmune disease of unknown 1. B. an autoimmune disease of unknown origin that is characterized by symmetric origin that is characterized by symmetric inflammation of the jointsinflammation of the joints

2. B. Both statements are FALSE. (35-50 2. B. Both statements are FALSE. (35-50 years of age, 3:1 women: men)years of age, 3:1 women: men)

3. A. has an unknown cause.3. A. has an unknown cause.

RA AnswersRA Answers

4. symmetrical, gradual and subtle 4. symmetrical, gradual and subtle onset, fatigue and weakness with onset, fatigue and weakness with joint muscle aches, immobility, joint muscle aches, immobility, morning stiffness morning stiffness

5. fingers, wrists, feet, ankles, 5. fingers, wrists, feet, ankles, knees, elbows, TMJknees, elbows, TMJ

More Answers

6. modification of OHI, use towels or 6. modification of OHI, use towels or pillows and/or bite blocks to achieve pillows and/or bite blocks to achieve comfort, have short appointmentscomfort, have short appointments

7. immune suppression7. immune suppression

8. drug modifying anti-rheumatic drug8. drug modifying anti-rheumatic drug

Even More Answers

9. A. Both statements are TRUE.9. A. Both statements are TRUE.

10. D. all of the above10. 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 Answers to Bonus QuestionsQuestions

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?Questions?