Dental Management of Patients with Rheumatology Disorders 1

Joint Disorder Degenerative Disorder O.A Inflammatory Disorder Rheumatoid arthritis Connective tissue disorder Spondarthritis Autoimmune Disorder Crystal Arthropathy Infection Pathological Classification of Rheumatic Disorders Gouty Arthritis Pseudogout (CPPA) Septic Arthritis

Introduction.. Is it Arthritis or Arthralgia? Is it Arthritis or Arthralgia? Is it Monoarthritis or Polyarthritis ? Is it Monoarthritis or Polyarthritis ? Is it Musculoskeletal emergencies ? Is it Musculoskeletal emergencies ?

RED FLAG CONDITIONS FRACTURE FRACTURE SEPTIC ARTHRITIS SEPTIC ARTHRITIS GOUT/PSEUDOGOUT GOUT/PSEUDOGOUT NERVE OR VESSEL PROBLEMS NERVE OR VESSEL PROBLEMS Fever or unexplained weight loss Fever or unexplained weight loss History of carcinoma History of carcinoma Immuno-supression Immuno-supression Ill health or presence of other medical illness Ill health or presence of other medical illness Night pain Night pain Progressive pain Progressive pain

Sorting it Out INFLAMMATORY DEGENERATIVE CHRONIC PAIN

What are the Symptoms? Unusual PossiblyWeight Loss Never PossiblyFever RapidSlowRapidLoss of Function SevereMildNew and SevereFatigue > 1 hour15-20 minutes> 1 hourMorning Stiffness No YesJoint Redness NoYes Joint Swelling NoYes Joint Pain Chronic PainDegenerativeInflammatory

Arthralgia.. Fibromyalgia Fibromyalgia Bursitis Bursitis Tendinitis Tendinitis Hypothyroidism Hypothyroidism Neuropathic pain Neuropathic pain Metabolic bone disease Metabolic bone disease Depression Depression

Monoarthritis.. Trauma Trauma Infection: Infection: ± Skin lesion. ± Skin lesion. Nongonococcal bacterial infections: large joints. Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection. Mycobacterial and fungal infection. Crystal induced arthritis Crystal induced arthritis Monosodium Urate crystals (MPJ) - Gout Monosodium Urate crystals (MPJ) - Gout Calcium pyrophosphate dihydrate crystals (knee) - Pseudogout Calcium pyrophosphate dihydrate crystals (knee) - Pseudogout Systemic Rheumatoid diseases: Systemic Rheumatoid diseases: Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) RA RA Osteoarthritis Osteoarthritis

Polyarthritis.. Rheumatoid Arthritis Rheumatoid Arthritis Systemic lupus Erythrematosus Systemic lupus Erythrematosus Viral arthritis Viral arthritis Reiter’s disease Reiter’s disease Psoriatic arthritis Psoriatic arthritis Reactive arthritis Reactive arthritis

Migratory Arthritis.. Differential diagnosis: Differential diagnosis: Rheumatic fever Rheumatic fever Gonococcemia Gonococcemia Meningococcemia Meningococcemia Viral Arthritis Viral Arthritis SLE SLE Acute Leukemia Acute Leukemia

Rheumatic Fever.. Majer Criteria: Majer Criteria: 1- Carditis 2- Polyarthritis 3- Chorea 4- Erythema Marginatum 5- Subcutaneous nodules ● Minor criteria: 1- Arthralgia 2- Ferver 3- Acute phase reactant (ESR, CRP). 1- Arthralgia 2- Ferver 3- Acute phase reactant (ESR, CRP). 4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat culture…) 4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat culture…)

History.. Age & Sex <30= SLE, Ankylosis spodylitis, Reactive Arthritis. <30= SLE, Ankylosis spodylitis, Reactive Arthritis = RA, Systemic sclerosis, Gout = RA, Systemic sclerosis, Gout. >50= OA, Pseudogout, PMR >50= OA, Pseudogout, PMR Any Age group= Psoriatic arthritis, Enteropathic arthritis Any Age group= Psoriatic arthritis, Enteropathic arthritis >Female: >Female: SLE, RA, OA, Systemic sclerosis, PMR. SLE, RA, OA, Systemic sclerosis, PMR. Male=Female: Male=Female: Psoriatic arthritis, Enteropathic arthritis Pseudogout,. Psoriatic arthritis, Enteropathic arthritis Pseudogout,. >Male: >Male: Gout, Reactive Arthritis, Ankylosis spodylitis, Gout, Reactive Arthritis, Ankylosis spodylitis,

History.. Symptoms Site: Site: Symmetrical= RA, SLE, Systemic sclerosis Symmetrical= RA, SLE, Systemic sclerosis Asymmetrical=OA Asymmetrical=OA Large joints= OA Large joints= OA DIP= OA, Psoriatic arthritis DIP= OA, Psoriatic arthritis MCP, PIP= RA, SLE MCP, PIP= RA, SLE 1 st MTP= Gout, OA 1 st MTP= Gout, OA Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis Shoulder= PMR Shoulder= PMR

Physical Examination.. Joint: Joint: Soft tissue swelling, warm, effusion…= Inflammation. Soft tissue swelling, warm, effusion…= Inflammation. Inflammation signs extended= Septic arthritis, crystal induced arthritis, fracture. Inflammation signs extended= Septic arthritis, crystal induced arthritis, fracture. Passive motion (N), active(↓↓)= Bursitis, Tendinitis, Muscle injury. Passive motion (N), active(↓↓)= Bursitis, Tendinitis, Muscle injury. Passive motion (↓↓), active(↓↓)= Synovitis Passive motion (↓↓), active(↓↓)= Synovitis

Physical Examination.. General Examination: General Examination: Parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease. Parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease. Fever= Infection, reactive arthritis, RA, SLE, Crystal induced arthritis… Fever= Infection, reactive arthritis, RA, SLE, Crystal induced arthritis… Subcutaneous nodules= RA, RHD, Gout (tophi) Subcutaneous nodules= RA, RHD, Gout (tophi) Skin manifestations= Psoriasis, RA, SLE… Skin manifestations= Psoriasis, RA, SLE… Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…) Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…)

Laboratory & Radiology Studies.. Can be misleading. Can be misleading. Basic: CBC, Urinalysis, U&E, LFT. Basic: CBC, Urinalysis, U&E, LFT. Acute phase reactant: ESR, CRP. Acute phase reactant: ESR, CRP. Uric acid concentration= Gout Uric acid concentration= Gout Synovial fluid analysis= infection, crystal induced arthritis, inflammatory.. Synovial fluid analysis= infection, crystal induced arthritis, inflammatory.. Antibody tests: Antibody tests: ANA= SLE ANA= SLE Anti-dsDNA= SLE Anti-dsDNA= SLE Anti-native DNA, anti-Sm= SLE Anti-native DNA, anti-Sm= SLE RF= RA RF= RA Anti-CCP antibody=RA Anti-CCP antibody=RA X-ray: X-ray: MRI: MRI:

Rheumatoid Arthritis A chronic nonsuppurative inflammatory destruction of the joints

Rheumatoid Arthritis.. Incidence Incidence 1-3% of general population 1-3% of general population Genetic predisposition Genetic predisposition Female to male ratio 3:1 Female to male ratio 3:1 Average age of onset of 40 years Average age of onset of 40 years

History.. Malaise Malaise Fever Fever Fatigue Fatigue Weight loss Weight loss Myalgias Myalgias Difficulty performing activities of daily living Difficulty performing activities of daily living

Examination.. Joint affected Joint affected swelling swelling tenderness tenderness warmth warmth decreased range of motion decreased range of motion Atrophy of the interosseous muscles Atrophy of the interosseous muscles deformities deformities

≥ 4 Diagnosis.. ACR Criteria criteria present > 6 wks Morning stiffness > 1 hour Morning stiffness > 1 hour Arthritis of ≥ 3 joints areas (PIP, MCP, wrist, elbow, knee, ankle, and MTP) Arthritis of ≥ 3 joints areas (PIP, MCP, wrist, elbow, knee, ankle, and MTP) Arthritis of hand joints (wrist, MCP, PIP) Arthritis of hand joints (wrist, MCP, PIP) Symmetric arthritis 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 Rheumatoid nodule Cardiovascular Cardiovascular Pulmonary Pulmonary GI & Renal GI & Renal Hematological Hematological Skin Skin Vasculitis Vasculitis Neurological Neurological Ocular Ocular

Rheumatoid nodules

Vasculitis

Ocular Sicca symptoms Sicca symptoms Episcleritis Episcleritis Scleritis Scleritis Scleromalacia Perforance Scleromalacia Perforance

Head & Neck Manifestations Rheumatoid Arthritis may involve the TMJ. Rheumatoid Arthritis may involve the TMJ. 55% Affected 55% Affected 70% with radiographic evidence of TMJ involvement Juvenile form may lead to Retrognathia

Head and Neck Manifestations Cricoarytenoid joint Cricoarytenoid joint Most common cause of cricoarytenoid arthritis Most common cause of cricoarytenoid arthritis 30% patients hoarse 30% patients hoarse Exertional dyspnea, ear pain, globus Exertional dyspnea, ear pain, globus Hoarseness Hoarseness Rheumatoid nodules, recurrent nerve involvement Rheumatoid nodules, recurrent nerve involvement Stridor Stridor local/systemic steroids local/systemic steroids Conductive Hearing Loss Conductive Hearing Loss Ossicular chain involvement Ossicular chain involvement Sensory Neural Hearing Loss Sensory Neural Hearing Loss Unexplained Unexplained Assoc. with rheumatoid nodules Assoc. with rheumatoid nodules Cervical spine Cervical spine Subluxation Subluxation

Laboratory.. Hematologic parameters Hematologic parameters Anaemia Anaemia Thrombocytosis Thrombocytosis ↓ Serum iron & IBC ↓ Serum iron & IBC ↑ Serum globuline ↑ Serum globuline ↑ ALP ↑ ALP ↑ Acute phase reactant ( ESR / CRP ) ↑ Acute phase reactant ( ESR / CRP ) Immunological parameters ( RF ) / ANF “50 % ) Immunological parameters ( RF ) / ANF “50 % ) Synovial fluid analysis (WBC > 2000/mm3 ) Synovial fluid analysis (WBC > 2000/mm3 )

Laboratory Rheumatoid Factor Rheumatoid Factor Ig M Antibody against the Fc fragment of Ig G Ig M Antibody against the Fc fragment of Ig G Not sensitive Not sensitive 80% of RA patients 80% of RA patients RF+ patients more likely to have RF+ patients more likely to have More severe disease More severe disease Extraarticular manifestations Extraarticular manifestations Anti-cyclic citrullinated peptide (Anti-CCP ) Anti-cyclic citrullinated peptide (Anti-CCP ) Specificity = 90% Specificity = 90% Sensitivity = 50-80% Sensitivity = 50-80%

RF is not specific for RA. Other autoimmune disease Other autoimmune disease Sjogren’s syndrome, Systemic Lupus Sjogren’s syndrome, Systemic Lupus Chronic infection Chronic infection Hep B/C, SBE, Viral, Parasites, TB Hep B/C, SBE, Viral, Parasites, TB Pulmonary inflammation Pulmonary inflammation Sarcoid, IPF, Silicosis, Asbestosis Sarcoid, IPF, Silicosis, Asbestosis Malignancy Malignancy Healthy – 4% young; 5-25% > age 60 Healthy – 4% young; 5-25% > age 60

Radiography Periarticular osteopenia Periarticular osteopenia Symmetric joint space loss Symmetric joint space loss Marginal erosions Marginal erosions Absence of productive changes Absence of productive changes Best films for diagnosis: Best films for diagnosis: Bilateral Hand Arthritis Series Bilateral Hand Arthritis Series Bilateral Foot Series Bilateral Foot Series Larger joints may not show erosions early due to thicker cartilage. Larger joints may not show erosions early due to thicker cartilage.

Treatment Aggressive Treatment Early! Aggressive Treatment Early! Physical therapy, daily exercise, splinting, joint protection Physical therapy, daily exercise, splinting, joint protection Salicylates, NSAIDS, DMARDs, hydroxychloroquine, immunosuppressive agents, Steroids Salicylates, NSAIDS, DMARDs, hydroxychloroquine, immunosuppressive agents, Steroids Cyclosporin-A Cyclosporin-A Prognosis Prognosis yrs of disease yrs of disease 50% fully employed 50% fully employed 10% incapacitated 10% incapacitated 10-20% remission 10-20% remission Persistent active cases more than 1 year likely to lead to joint deformities. Persistent active cases more than 1 year likely to lead to joint deformities. Periods of activity cases have better prognosis. Periods of activity cases have better prognosis. Mortality rate 2.5 times than generalpopulation Mortality rate 2.5 times than generalpopulation

Dental Management Short dental appointments Short dental appointments Assess if Aspirin or NSAIDs are affecting platelet function Assess if Aspirin or NSAIDs are affecting platelet function

Osteoarthritis? Most common form of arthritis Most common form of arthritis Middle-aged to elderly Middle-aged to elderly Gradual pain, worse with use Gradual pain, worse with use F= M up to age 55; after 55 F>M F= M up to age 55; after 55 F>M Obesity, history of trauma Obesity, history of trauma Cartilage irregularity Cartilage irregularity 10-20% of these symptomatic 10-20% of these symptomatic Only small percentage present for help Only small percentage present for help Joints affected Joints affected Hands – DIP, PIP, CMC thumb Hands – DIP, PIP, CMC thumb Hips, knees, ankles, great toes Hips, knees, ankles, great toes Cervical and lumbar spine Cervical and lumbar spine

Osteoarthritis Mechanical symptoms ( Pain on activity),Stiffness Mechanical symptoms ( Pain on activity),Stiffness Bony swelling, crepitus Bony swelling, crepitus DIP (Heberden) DIP (Heberden) PIP (Bouchard) PIP (Bouchard) 1 st CMCJ, 1 st CMCJ, Neck, Neck, Lower back, Lower back, Hips, Hips, Knees, Knees, 1 st MTP 1 st MTP Clinical subsets Generalised OA Primary / nodal OA Erosive OA

Osteoarthritis Radiology  ( Correlate poorly with symptoms )  Four cardinal features:  Joint space narrowing  Sclerosis  Subchondral cysts  Osteophytes

OA Management Pain Relief Pain Relief Simple/compound analgesics, exercises Simple/compound analgesics, exercises Glucosamine sulphate, patellar taping Glucosamine sulphate, patellar taping Topical capsaicin/NSAID; acupuncture Topical capsaicin/NSAID; acupuncture Oral NSAIDs – COX2s, gastro-protection Oral NSAIDs – COX2s, gastro-protection Injections – peri-articular, intra-articular Injections – peri-articular, intra-articular Joint Replacement (Referral guidance hip/knee OA ) Joint Replacement (Referral guidance hip/knee OA ) ? Infection – same day ? Infection – same day Rapid deterioration/severe disability (2/52 hip, soon – ‘locally agreed’ knee) Rapid deterioration/severe disability (2/52 hip, soon – ‘locally agreed’ knee) Symptoms impair QOL – routine Symptoms impair QOL – routine Giving way despite Rx– soon (knee only) Giving way despite Rx– soon (knee only) Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee only) Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee only)

Gout? Disease of Monosodium urate crystal deposition in tissues of and around joints Disease of Monosodium urate crystal deposition in tissues of and around joints Adult men, peaks in ages 40’s to 50’s Adult men, peaks in ages 40’s to 50’s Urate Overproduction (<10%) vs Urate Overproduction (<10%) vs Under Excretion (90%) Under Excretion (90%) Three stages: 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 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 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 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 Acute gouty bursitis-- prepatella, olecranon Chronic Chronic Tophi Tophi

Septic Arthritis Septic arthritis is inflammation of a synovial membrane with purulent effusion into the joint capsule, usually due to bacterial infection. 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 It is an emergency- it can destroy a joint extremely quickly and (v.rarely) lead to sepsis and death Frequency: Frequency: 2-10 cases per 100,000 in the general population cases per 100,000 in the general population cases per 100,000 in immunosuppressed/ joint prosthesis cases per 100,000 in immunosuppressed/ joint prosthesis