Rheumatoid Arthritis

Priscilla Garcia, Jennifer Klocki, Reina Ligeralde, Dorinda ThomasDEH 265.15.08

Patient ProfileName Rume AritisGender FemaleAge 45Occupation StenographerMarital Status MarriedEthnicity Caucasian

Medical HistoryChief complaint TMJ soarness, dry mouth, and teeth sensitivity

Dental History Patient has difficulty opening the jaw4/07 - last dental exam, BWX, and FM scale4/05 - last FMX

Medical History Patient presents with recurrent finger ache and painRheumatoid arthritis since 1999

More Medical HistoryMedications Gold sodium thiomalate helps slow down the disease process and decrease inflammationDental implications: stomatitis, gingivitis and glossitisAspirin helps reduce painDental implications: increased bleedingPrednisone used for inflammationDental implications: none noted

Vitals BP: 125/74, P:78, R:17

ASA III

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

Incidence and PrevalenceEstimates 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 Prevalence3:1 women to men ratio implies involvement of sex hormones in the susceptibility and sensitivity of the disease

Suggested factors in playing predisposing roles:Psychosocial stressEducationSocioeconomic status

EtiologyUnknown 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

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

This increased mortality rate usually is attributed to Pulmonary and renal diseaseInfectionGastrointestinal bleeding

Accompanying Complications

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

Medical Management

Medical ManagementEarly 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 swellingRelieve pain and stiffnessHelp and promote normal function

Goals are accomplished by:Patient educationRest ExercisePhysical therapyNSAIDs

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 long-term outcome. (i.e. DMARDs disease- modifying 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 patients 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 CompoundsHelpful 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 ulcerationsEczematous rashesNeutropeniaThrombocytopenia

Other DrugsAntimalarial DrugsChloroquine or hydroxychloroquineThese drugs are used in combination with aspirin or corticosteroids.Side effects include eye damage and blue-black intraoral pigmentation.

CorticosteroidsPrednisone or prednisolone Most effective for reducing inflammationManages acute symptomsSignificant adverse effect is adrenal suppression; therefore, long-term usage is avoided.

Immunosuppressive TherapyEffective 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 diseaseMethotrexate used in combination with other agentsMost popular regimen is methotrexate, hydroxychloroquine, and sulfasalazine. More effective than single-drug regimensDoes 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 therapyVariety of surgical procedures include:ArthroscopySynovectomyArthroplastyTotal joint replacement

Dental Management

Considerations Prior to Dental TreatmentPatient comfort

Drug considerations

Joint prosthesis

TMJ involvement

Oral hygiene capability

Patient ComfortAppointments 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 :AspirinNSAIDSCorticosteroidsDMARDsImmunosuppressive agents

Aspirin Drug ConsiderationsAspirin with NSAIDsAnalgesicCan cause prolonged bleedingUsually not clinically significant (does not put disease in remission)

Aspirin with corticosteriodsHigh risk for prolonged bleedingNeed to determine bleeding timeMost accurate test is the PFA-100 (platelet function analyzer) Bleeding time should be under 20 minutes.

Other Drug ConsiderationsDMARDs e.g. gold compound, penicillamine, sulfasalazineCause suppression of the bone marrow anemia, agranulocytosis, and thrombocytopeniaNeed recent lab tests such as RBC count, WBC count, and bleeding time

CorticosteroidsUsed for control of active disease, should be used for a short period of timeIf used for a long period of time hyperglycemia, edema, osteonecrosis, immune suppression, and infection

Joint ProsthesisIn 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 Involvement45-75% 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 patients 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 CapabilityPatient has less dexterity due to pain in the joints

Alter OHI to customize the patients specific needs.Power toothbrushes, floss aids, irrigators, even modifying the tooth brush handleBe empathetic and patient.

Some Toothbrush ModificationsA 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.

Quiz1. What is rheumatoid arthritis?

A. an immune deficiency disease of unknown origin that is characterized by symmetric inflammation of the joints

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

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

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 Questions4. 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

Answers1. 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 Answers4. symmetrical, gradual and subtle onset, fatigue and weakness with joint muscle aches, immobility, morning stiffness

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

More Answers6. 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 Answers9. 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 Questions1. 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, Sjgrens syndrome

Questions?

Arthritis is a nonspecific term that means inflammation of the joints.

Although arthritis comprises a group of more than 60 important diseases, the most common forms encountered and can serve as models for the other forms are RA, osteoarthritis, systemic lupus erythematosus, Lyme disease, and Sjgrens syndrome.Determination of prevalence is somewhat difficult to determine because of lack of well-defined markers of the disease.

RA is a pleomorphic disease with variable expression. The most progressive period of the disease occurs during the earlier years; thereafter, it slows.

More than 50% of patients gradual onset20% follow a monocyclic course that abates within 2 years10% experience relentless crippling that leads to nearly complete disabilityThe remainder follow a polycyclic or progressive course.

The long-term prognosis for people with abrupt onset of disease is similar to that for people with gradual disease onset.

The course and severity of RA are unpredictable, but the disorder is characterized by remissions and exacerbations.One theory suggests that a viral agent alters the immune system in a genetically predisposed individual, leading to destruction of synovial tissues.

Many persons who develop RA have a genetic predisposition that occurs in the form of a tissue marker called HLA-DR4; however, not everyone with this tissue type develops the disease.

Studies to date are of limited value, and further research is warranted.The fundamental abnormality involves microvascular endothelial cell activation and injury.

Synovium the inner lining of the joint capsuleNeutropenia an abnormal decrease in the number of neutrophils in the blood

Keratoconjunctivitis sicca dry eyes

Gangrene necrosis or death of soft tissue due to obstructed circulation, usually followed by decomposition and putrefaction

Amyloidosis a waxy, translucent substance, composed primarily of protein fibers, that is deposited in various organs of animals in certain diseases

Splenomegaly enlargement of the spleenSubluxation a partial dislocation, a sprainRheumatoid arthritis is an autoimmune inflammation which causes destruction targeted at the synovial fluid, causes formation of pannus (invasive granulated tissue), and destroys cartilage and bone.

Patients are in pain so achieving comfort is very important.Be aware of the side effects from the drugs.

Knowing about these drugs will aid in treatment planning.DMARDS = disease modifying antirheumatic dugsThe rule of thumb is to premed the patient for 2 years after the surgery. Rheumatoid arthritis is a progressive disease so we need to correct problems ASAP because it is much harder to complete dental treatment when patients are disabled and crippled.

A lack of strength because of arthritis, stroke, or other such illness can make even holding the handle of a toothbrush difficult.

A solution to this problem could be to put the toothbrush in a Velcro strap; stick the toothbrush handle into a tennis ball or slide it in a bicycle handlebar grip. You can also carefully wrap the handle of the toothbrush with aluminum foil to make it bulky and easier to hold. A solution to this problem could be to put the toothbrush in a Velcro strap. You can also carefully wrap the handle of the toothbrush with aluminum foil to make it bulky and easier to hold.