1. Rheumatology Normal Anatomy andPhysiology

2. Synovial joints: Normal Anatomy 1. Bone: 2. Cartilage: 3. Synovium:

3.   1. Cartilage   2. Bone   3. Synovium

4. Synovial joints: Normal physiology Normal physiology 1. Relatively friction free movement of cartilage on cartilage 2. Lubricated by synovial fluid 3. Maintained by synovial membrane

5. Rheumatological disease: Autoimmune: Rheumatoid arthritis Non-autoimmune: osteoarthritis

6. Rheumatoid arthritis: Etiology: autoimmune (complex) Prevalence: 1 to 2% of population Onset: age 30 to 50 3:1 female to male ratio

7. RA: pathophysiology 1. Synovitis secondary to deposition of immune complexes

8. RA: pathophysiology 2. Proliferation of invasive granulation tissue: pannus formation

9. RA: pathophysiology 3. Enzymatic destruction of cartilage and bone … spreading to capsule and ligaments with loss of range of motion

10. RA: pathophysiology

11. Rheumatoid arthritis: Course: variable … remission and exacerbation 10% remission within 1-2 years 10% relentless crippling Life expectancy decreased 10-15y

12. Rheumatoid arthritis: diagnosis (four or more for diagnosis of RA) Morning stiffness (>1 HR) 3 or more joint areas affected Hand joint arthritis Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor (auto Ab 85%) Radiographic changes

13. RA: managment Goals: decrease inflammation and swelling decrease pain and stiffness increase or maintain normal function Education / rest / exercise and physical therapy

14. RA: management NSAIDs: ASA, etc. Steroids: prednisone Immunosuppressive therapy: methotrexate, cyclophosphamide TNF alpha inhibitors: etanercept and infliximab Surgery…including prostheses

15. RA: complications NSAIDs: ASA, etc. … ulcers / bleeding Steroids: prednisone … AC suppression / immunosuppression osteoporosis: patient may need to take bisphosphonates (Fosamax = alendronate) risk of ONJ

16. RA: complications Immunosuppressive therapy: methotrexate, cyclophosphamide… immunosuppression bone marrow toxicity (HgB / platelets) TNF alpha inhibitors: etanercept and infliximab Increased risk of malignancy

17. RA: dental considerations Worse in AM... morning stiffness Short appointments with position changes Ensure comfort: pillows, etc. Difficulty with oral hygiene (dexterity issue)

18. RA: dental considerations Drugs: bleeding with NSAIDs adrenal cortical suppression immune suppression bone marrow suppression Joint prostheses and need for AB prophy?????

19. RA: dental considerations TMJ involvement: >50% pain / trismus occlusal changes soft diet jaw or joint surgery

20. RA: dental considerations Association with Sjogren’s Syndrome Dry eyes Dry mouth: caries, candida Increased risk of lymphoma

21. Questions????