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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.. Is it Arthritis or Arthralgia? Is it Monoarthritis or Polyarthritis ? Is it Musculoskeletal emergencies ? 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 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.. Fibromyalgia Bursitis Tendinitis Hypothyroidism Neuropathic pain Metabolic bone disease Depression Monoarthritis.. Trauma Infection: Crystal induced arthritis Monosodium Urate crystals (MPJ) - Gout Calcium pyrophosphate dihydrate crystals (knee) Pseudogout Systemic Rheumatoid diseases: ± Skin lesion. Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection. Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) RA Osteoarthritis Polyarthritis.. Rheumatoid Arthritis Systemic lupus Erythrematosus Viral arthritis Reiter’s disease Psoriatic arthritis Reactive arthritis Migratory Arthritis.. Differential diagnosis: Rheumatic fever Gonococcemia Meningococcemia Viral Arthritis SLE Acute Leukemia Rheumatic Fever.. 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, History.. Symptoms Site: 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.. 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 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…) Laboratory & Radiology Studies.. 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: 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.. Incidence 1-3% of general population Genetic predisposition Female to male ratio 3:1 Average age of onset of 40 years History.. Malaise Fever Fatigue Weight loss Myalgias Difficulty performing activities of daily living Examination.. Joint affected swelling tenderness warmth decreased range of motion Atrophy of the interosseous muscles deformities ≥ 4 Diagnosis.. ACR Criteria criteria present > 6 wks 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 Rheumatoid nodules RF+ Radiographic changes Erosions Unequivocal periarticular osteopenia Synovitis RA - hands Deformities.. Swan neck and Boutonniere Rheumatoid Arthritis Extra-Articular Manifestations.. Rheumatoid nodule Cardiovascular Pulmonary GI & Renal Hematological Skin Vasculitis Neurological Ocular Rheumatoid nodules Vasculitis Ocular Sicca symptoms Episcleritis Scleritis Scleromalacia Perforance Head & Neck Manifestations Rheumatoid Arthritis may involve the TMJ. 55% Affected 70% with radiographic evidence of TMJ involvement Juvenile form may lead to Retrognathia Head and Neck Manifestations Cricoarytenoid joint Hoarseness Ossicular chain involvement Sensory Neural Hearing Loss local/systemic steroids Conductive Hearing Loss Rheumatoid nodules, recurrent nerve involvement Stridor Most common cause of cricoarytenoid arthritis 30% patients hoarse Exertional dyspnea, ear pain, globus Unexplained Assoc. with rheumatoid nodules Cervical spine Subluxation 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 > 2000/mm3 ) 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% RF is not specific for RA. Other autoimmune disease Chronic infection Hep B/C, SBE, Viral, Parasites, TB Pulmonary inflammation Sjogren’s syndrome , Systemic Lupus Sarcoid, IPF, Silicosis, Asbestosis Malignancy Healthy – 4% young; 5-25% > age 60 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. Treatment Physical therapy, daily exercise, splinting, joint protection Salicylates, NSAIDS, DMARDs , hydroxychloroquine, immunosuppressive agents , Steroids Cyclosporin-A Prognosis 10-15 yrs of disease 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 Short dental appointments Assess if Aspirin or NSAIDs are affecting platelet function Osteoarthritis? 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 Joints affected Hands – DIP, PIP, CMC thumb Hips, knees, ankles, great toes Cervical and lumbar spine Osteoarthritis 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 ( Correlate poorly with symptoms ) Four cardinal features: Joint space narrowing Sclerosis Subchondral cysts Osteophytes 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) Gout? Disease of Monosodium urate crystal deposition in tissues of and around joints Adult men, peaks in ages 40’s to 50’s Urate Overproduction (<10%) vs Under Excretion (90%) Three stages: Asymptomatic hyperuricemia Acute intermittent gout Chronic tophaceous gout Definitive dx by aspiration of fluid 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 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