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Observe, record,
tabulate,
communicate.
We should endeavor to determine what
type of patient has a disease, instead of
just what disease the patient has .
RHEUMATIC DISEASES
over 100 different arthritic diseases
 > 40 million Americans
 > 8 million disabled
 > $ 20 billion annually

RHEUMATIC DISEASES
–
–
–
–
–
–
modern : >1800
not equivalent to “arthritis”
chronic degenerative joint diseases
Female = 2.5 x Male
genetic : HLA-DR4
socioeconomic, education, psychosocial stress
RHEUMATIC DISEASES

general characteristics( signs & symptoms)
PAIN
 INFLAMMATION
 musculoskeletal stiffness
 musculoskeletal swelling
 musculoskeletal aches
 musculoskeletal limitations
 disability
 deformity

RHEUMATIC DISEASES

Laboratory tests
increased RF ~80%; 1:1280; non-Dx
 higher = RA; poorer Px
 increased ESR
 increased ANA ~50%
 LE
 IgG
 SSA/SSB

Rheumatic Fever and
Rheumatic Heart Disease








acute inflammatory condition
following group A streptococci infection
autoimmune reaction
arthralgia
> 75% < 20 y.o.
~95% of all heart disease in children
third world = 30-40 % of all CVD all ages
U.S. 100,000 cases; 6500 deaths per yr.
RHEUMATOID ARTHRITIS
chronic, inflammatory, destructive joint
disease
 wide range of severity
 ankles, cervical spine, elbows; hips, knees,
 proximal interphalangeal joints


shoulders, tarsals, TMJ, wrists
RHEUMATOID ARTHRITIS

MANAGEMENT
COMPREHENSIVE
 MULTIDISCIPLINARY
 CORTICOSTERIODS

– SYSTEMIC ; LOCAL INJECTIONS
– PREDNISONE, PREDNISOLONE
GOLD, ANTI-MALARIAL, PENICILLAMINE
 SULFASALAZINE
 BIOLOGICS- TNFa- antagonists
 IMMUNOSUPPRESSIVES

– IMMURAN, METHOTREXATE
RHEUMATOID ARTHRITIS

TMD
– pain, tenderness, stiffness, crepitus,
– swelling, limited mandibular opening
– fibrosis, ankylosis
– bleeding, infection
– neutropenia , thrombocytopenia, anemia
– adrenal suppression
Osteoarthritis of the TMJ
degenerative joint disease
 most common intracapsular disorder
 40% > 40 y.o. who were ASx
 osteophytes
 steroids ( intra-articular)
 surgery

Sjögren’s syndrome
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Secondary
Sjogren's
Syndrome
Xerophthalmia
keratoconjunctivitis
sicca
Xerostomia
salivary gland
dysfunction
Inflammatory
connective tissue
disease
Diagnostic criteria for SS(EC)
4:6 *




ocular symptoms(1:3)
daily dry eye >3mos
sand or gravel sens.
tear substitutes >tid





ocular signs (1:2)
Shirmer’s test
(<5mm/5min)
Rose Bengal score
(>4 - vBs)
Diagnostic criteria for SS (EC)
4:6 *




oral symptoms (1:3)
daily dry >3 mos.
swollen glands
must drink liquids to
swallow food




salivary function (1:3)
+ scintigraphy
+ sialography
WUSF <1.5ml/15 min.
(0.1ml/min.)
Diagnostic criteria for SS (EC)
4:6 *



labial histology*
focus score / 4mm
>50 mononuclear cells



Autoantibodies*
anti-SS-Ro or
anti-SS-La

Sjögren’s syndrome (SS) on a histopathological
level is a benign lymphosialadenopathy which
includes autoimmune lymphocytic infiltration of
the salivary glands. Oral clinical manifestations of
SS typically include : hyposalivation,
glossitis, mucositis, angular cheilosis,
and increased caries rate.
SLE
renal disease
 cardiac valvular disease
 anemia
 thrombocytopenia
 leukopenia
 arthritis
 TMD

5-22 %
18-74 %
70 %
25 %
45 %
90 %
60 %
SLE

systemic complications :
–
–
–
–
–
lab tests: CBC, platelets, BUN, creatinine
leukopenia, steriods, etc. = prone to infection
need for antibiotics ( IE ?)
adrenal suppression
bleeding
Paget’s, Osteomyelitis,
Osteoporosis, Fibrous
dysplasia
osteolytic/osteoblastic
 bleeding
 bone deformities & tooth loss
 infection
 radiographs
 lab tests:

CBC, Ca, P, alkaline phosphatase
 bone biopsy

SCLERODERMA
tightened, hard skin: face, hands, fingers
 internal organ involvement
 microstomia
 tightened perioral skin
 SGD
 periodontal disease
 painful RAS-type ulcerations

TREATMENT

CORTICOSTEROIDS
topical
 systemic
 intralesional


IMMUNOSUPPRESIVE agents
topical
 systemic
 intralesional

Corticosteroid use: routine
dental procedures
Rx>2 wks. d/c w/i 30 days= Rx previous
 d/c Rx > 30 days ago
=
none
 topical
=
none
 current Rx( any dose)
=
none
 alt. day Rx
= tx on that day
 Monitor BP, good anesthesia, post-op
analgesia, etc.

Corticosteroid use:
complex dental procedures
Rx>2 wks. d/c w/i 30 days= Rx previous
 Rx d/c > 30 days ago
=
none
 topical
=
none
 current Rx( any dose)
=
double +
 alt. day Rx
= double + tx on that day
 Monitor BP, good anesthesia, post-op + Rx
+ analgesia, etc.

Dental management




diagnosis; severity
systemic complications
musculoskeletal limitations
pain
 medications; anti-inflammatory agents



oral manifestations
neutropenia ; thrombocytopenia; anemia
Infections(LPJI)
Prevention of late Prosthetic
joint infections
Joint ADA/AAOS guidelines
1997
Late Prosthetic Joint
Infections






Wahl’s myths:
#1: There are similarities between IE
(PVE) and LPJI.
NO.
#2: Dental treatment is a probable cause
of LPJI.
NO.
#3: Animal experiments document
dental bacteremias as cause of LPJI.
NO.
#4: To protect patients DDS should
always cover patients with PJ.
NO.
Late Prosthetic Joint
Infections
infection rate > 1%
 >70% staph
Pallusch
 >1000 PJ pts., 6 yrs. - no prophylaxis=
0 LPJIs
Ainscow
 4 cases of LPJI cultured= no oral pathogen
Batzokas
 other prosthetic- synthetic implants

Prevention of late Prosthetic
joint infections: 1997 changes
ADA/AAOS advisory statement
 medical consultation with Orthopod
 No prophylaxis for pins, rods, screws,
plates, wires, implants, etc.
 healthy patient: < 2 yrs. after TJR
 chronic RA or other infection of TJR
 immunocompromised patients

Prevention of late Prosthetic
joint infections: 1997 changes
Immunocompromised patients
 IDDM
 chronic CTD: RA, SLE, etc.
 immunosuppressive drugs or irradiation
 hemophilia or other blood dyscrasias
 malnourishment
 HIV

Late Prosthetic Joint
Infections
Benefits of prophylaxis DO NOT
necessarily outweigh potential
risks especially considering
antimicrobial resistance, costs,
risk of anaphylaxis, etc.
 Little, Rhodus, et.al.; JADA 1991
…. Orthopedic surgeons ~ 90 %
recommend antibiotic prophylaxis for dental Tx
 SO…BE CAREFUL WHAT YOU ASK FOR !

Prevention of late Prosthetic
joint infections: 1997 changes
Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op
 Cephazolin; 1 g; IM/IV; 1 hr. pre-op
 Clindamycin; 600mg.; po; 1 hr. pre-op

Thanks!!
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QUIZ
fold sheet and put
your name on back
I know you do another course evaluation,
but this is more for my own information in
order to improve learning
 I will respect your confidentiality and my
secretary will record your name and after
the course is complete and the grade
submitted, I’ll review your responses

QUIZ
fold sheet and put
your name on back
I liked the format of this course.
 A. true
 B. false

QUIZ
fold sheet and put
your name on back
I learned as much ( or MORE) from the
peer presentations as I would have from the
instructor
 A. true
 B. false

QUIZ
fold sheet and put
your name on back
I learned more from working on my group’s
presentation.
 A. true
 B. false

QUIZ
fold sheet and put
your name on back
The book was very helpful.
 A. true
 B. false

QUIZ
fold sheet and put
your name on back
The group presentations were much better
than straight lectures.
 A. true
 B. false

QUIZ
Please RANK the top three presentations.
1
2
3

Cases
Problem-solving process
GUIDES- when and where to get information
(look it up !)

Competencies……
Exam







40 objective( MC- TF ?s): form Midterm
Allergies(5-6), Bleeding (5-6), Thyroid (34),blood dyscrasias(5-6), pregnancy (4-5),
Neurological(4-5), HIV(4-5), Behavioral (2-3)
Open book case…just like those in class
Do the obj. first then you’ll get the case
Friday, Dec. 7 at 7:30 am
1:30 ONLY !!
**