Dental Dental Management of Management of

Patients withPatients withRheumatology Rheumatology

DisordersDisorders11

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 ArthritisPseudogout

(CPPA)

Septic Arthritis

Introduction..Introduction.. Is it Arthritis or Arthralgia?Is it Arthritis or Arthralgia? Is it Monoarthritis or Is it Monoarthritis or

Polyarthritis ?Polyarthritis ? Is it Musculoskeletal emergencies ?Is it Musculoskeletal emergencies ?

RED FLAG CONDITIONSRED FLAG CONDITIONS

FRACTUREFRACTURE

SEPTIC ARTHRITISSEPTIC ARTHRITIS

GOUT/PSEUDOGOUTGOUT/PSEUDOGOUT

NERVE OR VESSEL PROBLEMSNERVE OR VESSEL PROBLEMS Fever or unexplained weight lossFever or unexplained weight loss History of carcinomaHistory of carcinoma Immuno-supressionImmuno-supression Ill health or presence of other medical illnessIll health or presence of other medical illness Night painNight pain Progressive painProgressive pain

Sorting it OutSorting it Out

INFLAMMATORY

DEGENERATIVE

CHRONIC PAIN

What are the Symptoms?What are the Symptoms?

UnusualUnusualPossiblyWeight Loss

NeverNeverPossiblyFever

RapidSlowRapidLoss of Function

SevereMildNew and SevereFatigue

> 1 hour15-20 minutes> 1 hourMorning Stiffness

NoNoYesJoint Redness

NoYesYesJoint Swelling

NoYesYesJoint Pain

Chronic PainDegenerativ

eInflammator

y

Arthralgia..Arthralgia..

FibromyalgiaFibromyalgia BursitisBursitis TendinitisTendinitis HypothyroidismHypothyroidism Neuropathic painNeuropathic pain Metabolic bone diseaseMetabolic bone disease DepressionDepression

Monoarthritis..Monoarthritis.. TraumaTrauma Infection:Infection:

± Skin lesion.± Skin lesion. Nongonococcal bacterial infections: large Nongonococcal bacterial infections: large

joints.joints. Mycobacterial and fungal infection.Mycobacterial and fungal infection.

Crystal induced arthritisCrystal induced arthritis Monosodium Urate crystals (MPJ) - GoutMonosodium Urate crystals (MPJ) - Gout Calcium pyrophosphate dihydrate crystals Calcium pyrophosphate dihydrate crystals

(knee) - Pseudogout(knee) - Pseudogout Systemic Rheumatoid diseases:Systemic Rheumatoid diseases:

Seronegative spodyloarthropathy Seronegative spodyloarthropathy (Reactive (Reactive arthritis, psoriatic arthritis, Inflammatory BD..)arthritis, psoriatic arthritis, Inflammatory BD..)

RARA OsteoarthritisOsteoarthritis

Polyarthritis..Polyarthritis..

Rheumatoid ArthritisRheumatoid Arthritis Systemic lupus ErythrematosusSystemic lupus Erythrematosus Viral arthritisViral arthritis Reiter’s diseaseReiter’s disease Psoriatic arthritis Psoriatic arthritis Reactive arthritisReactive arthritis

Migratory Arthritis..Migratory Arthritis..

Differential diagnosis:Differential diagnosis: Rheumatic feverRheumatic fever GonococcemiaGonococcemia MeningococcemiaMeningococcemia Viral ArthritisViral Arthritis SLESLE Acute LeukemiaAcute Leukemia

Rheumatic Fever..Rheumatic Fever..

Majer Criteria:Majer Criteria:1- 1- Carditis Carditis 2-2- Polyarthritis Polyarthritis 3- 3- ChoreaChorea

4-4- Erythema Marginatum Erythema Marginatum 5- 5- Subcutaneous Subcutaneous nodulesnodules

● Minor criteria:Minor criteria: 1- Arthralgia 2- Ferver 3- Acute phase 1- Arthralgia 2- Ferver 3- Acute phase reactant reactant (ESR, (ESR, CRP).CRP).

4- Prolong PR interval 5- Evidence of 4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat group A streotococcal infection (AST, Throat culture…)culture…)

History.. Age & SexHistory.. Age & Sex <30=<30= SLE, Ankylosis spodylitis, Reactive SLE, Ankylosis spodylitis, Reactive

Arthritis.Arthritis. 30-50=30-50= RA, Systemic sclerosis, Gout.RA, Systemic sclerosis, Gout. >50=>50= OA, Pseudogout, PMROA, Pseudogout, PMR Any Age group=Any Age group= Psoriatic arthritis, Enteropathic Psoriatic arthritis, Enteropathic

arthritisarthritis >Female:>Female: SLE, RA, OA, Systemic sclerosis, PMR.SLE, RA, OA, Systemic sclerosis, PMR. Male=Female:Male=Female: Psoriatic arthritis, Enteropathic arthritis Psoriatic arthritis, Enteropathic arthritis

Pseudogout, .Pseudogout, . >Male: >Male: Gout, Reactive Arthritis, Ankylosis spodylitis,Gout, Reactive Arthritis, Ankylosis spodylitis,

History.. SymptomsHistory.. Symptoms

Site:Site: Symmetrical=Symmetrical= RA, SLE, Systemic sclerosis RA, SLE, Systemic sclerosis Asymmetrical=Asymmetrical=OAOA Large joints=Large joints= OA OA DIP=DIP= OA, Psoriatic arthritis OA, Psoriatic arthritis MCP, PIP=MCP, PIP= RA, SLE RA, SLE 11stst MTP= MTP= Gout, OA Gout, OA Spine=Spine= OA, Ankylosis spodylitis, Psoriatic OA, Ankylosis spodylitis, Psoriatic

arthritis, Reactive arthritisarthritis, Reactive arthritis Shoulder=Shoulder= PMR PMR

Physical Examination..Physical Examination..

Joint:Joint: Soft tissue swelling, warm, effusion…=Soft tissue swelling, warm, effusion…=

Inflammation.Inflammation. Inflammation signs extended=Inflammation signs extended= Septic Septic

arthritis, crystalarthritis, crystal induced arthritis, induced arthritis, fracture.fracture.

Passive motion (N), active(↓↓)=Passive motion (N), active(↓↓)= Bursitis, Bursitis, Tendinitis, Muscle injury.Tendinitis, Muscle injury.

Passive motion (↓↓), active(↓↓)=Passive motion (↓↓), active(↓↓)= SynovitisSynovitis

Physical Examination..Physical Examination..

General Examination:General Examination: Parotid enlargement, oral ulceration, heart Parotid enlargement, oral ulceration, heart

murmurs, pericardial or pleural friction rubs, murmurs, pericardial or pleural friction rubs, crackle…=crackle…= systemic disease.systemic disease.

Fever= Fever= Infection, reactive arthritis, RA, SLE, Infection, reactive arthritis, RA, SLE, Crystal induced arthritis…Crystal induced arthritis…

Subcutaneous nodules=Subcutaneous nodules= RA, RHD, Gout (tophi)RA, RHD, Gout (tophi) Skin manifestations=Skin manifestations= Psoriasis, RA, SLE…Psoriasis, RA, SLE… Eye diseaseEye disease (keratoconjunctivitis sicca, uveitis. (keratoconjunctivitis sicca, uveitis.

Conjunctivitis, episcleritis…)Conjunctivitis, episcleritis…)

Laboratory & Radiology Studies..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= Uric acid concentration= GoutGout Synovial fluid analysis= Synovial fluid analysis= infection, crystal induced infection, crystal induced

arthritis, inflammatory..arthritis, inflammatory.. Antibody tests:Antibody tests:

ANA= ANA= SLESLE Anti-dsDNA= Anti-dsDNA= SLESLE Anti-native DNA, anti-Sm= Anti-native DNA, anti-Sm= SLESLE RF= RF= RARA Anti-CCP antibody=Anti-CCP antibody=RARA

X-ray: X-ray: MRI:MRI:

Rheumatoid ArthritisRheumatoid ArthritisAA chronic nonsuppurative inflammatory destruction of chronic nonsuppurative inflammatory destruction of

the jointsthe joints

Rheumatoid Arthritis..Rheumatoid Arthritis..

IncidenceIncidence 1-3% of general population1-3% of general population Genetic predispositionGenetic predisposition Female to male ratio 3:1Female to male ratio 3:1 Average age of onset of 40 yearsAverage age of onset of 40 years

History..History..

MalaiseMalaise FeverFever Fatigue Fatigue Weight loss Weight loss Myalgias Myalgias Difficulty performing activities of Difficulty performing activities of

daily livingdaily living

Examination..Examination..

Joint affected Joint affected swellingswelling tenderness tenderness warmth warmth decreased range of motion decreased range of motion

Atrophy of the interosseous Atrophy of the interosseous muscles muscles

deformities deformities

≥ ≥ 4 4 Diagnosis.. ACR Diagnosis.. ACR CriteriaCriteria criteria present > 6 criteria present > 6

wkswks Morning stiffness > Morning stiffness >

1 hour1 hour Arthritis of ≥ 3 joints Arthritis of ≥ 3 joints

areas (PIP, MCP, areas (PIP, MCP, wrist, elbow, knee, wrist, elbow, knee, ankle, and MTP)ankle, and MTP)

Arthritis of hand Arthritis of hand joints (wrist, MCP, joints (wrist, MCP, PIP)PIP)

Symmetric arthritisSymmetric arthritis

Rheumatoid Rheumatoid nodulesnodules

RF+RF+ Radiographic Radiographic

changeschanges ErosionsErosions Unequivocal Unequivocal

periarticular periarticular osteopeniaosteopenia

SynovitisSynovitis

RA - handsRA - hands

Deformities..Deformities..

Swan neck and Swan neck and BoutonniereBoutonniere

Rheumatoid ArthritisRheumatoid Arthritis

Extra-Articular Extra-Articular Manifestations..Manifestations..

Rheumatoid noduleRheumatoid nodule Cardiovascular Cardiovascular Pulmonary Pulmonary GI & RenalGI & Renal HematologicalHematological SkinSkin VasculitisVasculitis Neurological Neurological Ocular Ocular

Rheumatoid nodulesRheumatoid nodules

VasculitisVasculitis

OcularOcular

Sicca symptomsSicca symptoms EpiscleritisEpiscleritis ScleritisScleritis Scleromalacia Scleromalacia

PerforancePerforance

Head & Neck Head & Neck ManifestationsManifestations

Rheumatoid Arthritis may involve the Rheumatoid Arthritis may involve the TMJ. TMJ.

55% Affected55% Affected

70% with radiographic evidence of TMJ 70% with radiographic evidence of TMJ involvementinvolvement

Juvenile form may lead to RetrognathiaJuvenile form may lead to Retrognathia

Head and Neck Head and Neck ManifestationsManifestations

Cricoarytenoid jointCricoarytenoid joint Most common cause of cricoarytenoid arthritisMost common cause of cricoarytenoid arthritis 30% patients hoarse30% patients hoarse Exertional dyspnea, ear pain, globusExertional dyspnea, ear pain, globus

HoarsenessHoarseness Rheumatoid nodules, recurrent nerve involvementRheumatoid nodules, recurrent nerve involvement

StridorStridor local/systemic steroidslocal/systemic steroids

Conductive Hearing LossConductive Hearing Loss Ossicular chain involvementOssicular chain involvement

Sensory Neural Hearing LossSensory Neural Hearing Loss UnexplainedUnexplained Assoc. with rheumatoid nodulesAssoc. with rheumatoid nodules

Cervical spineCervical spine SubluxationSubluxation

Laboratory ..Laboratory .. Hematologic parametersHematologic parameters

AnaemiaAnaemia ThrombocytosisThrombocytosis ↓ ↓ Serum iron & IBCSerum iron & IBC ↑ ↑ Serum globulineSerum globuline ↑ ↑ ALPALP ↑ ↑ Acute phase reactant ( ESR / CRP )Acute phase reactant ( ESR / CRP )

Immunological parameters Immunological parameters ( RF ) / ANF ( RF ) / ANF “50 % ) “50 % )

Synovial fluid analysis Synovial fluid analysis (WBC > (WBC > 2000/mm32000/mm3 ))

LaboratoryLaboratory Rheumatoid FactorRheumatoid Factor

Ig M Antibody against the Fc fragment of Ig Ig M Antibody against the Fc fragment of Ig GG

Not sensitiveNot sensitive 80% of RA patients80% of RA patients

RF+ patients more likely to haveRF+ patients more likely to have More severe diseaseMore severe disease Extraarticular manifestationsExtraarticular manifestations

Anti-cyclic citrullinated peptide Anti-cyclic citrullinated peptide (Anti-CCP )(Anti-CCP )

Specificity = 90%Specificity = 90% Sensitivity = 50-80%Sensitivity = 50-80%

RF is not RF is not specificspecific for RA. for RA.

Other autoimmune diseaseOther autoimmune disease Sjogren’s syndrome , Systemic LupusSjogren’s syndrome , Systemic Lupus

Chronic infectionChronic infection Hep B/C, SBE, Viral, Parasites, TBHep B/C, SBE, Viral, Parasites, TB

Pulmonary inflammation Pulmonary inflammation Sarcoid, IPF, Silicosis, AsbestosisSarcoid, IPF, Silicosis, Asbestosis

MalignancyMalignancy Healthy – 4% young; 5-25% > age 60Healthy – 4% young; 5-25% > age 60

RadiographyRadiography

Periarticular osteopeniaPeriarticular osteopenia Symmetric joint space lossSymmetric joint space loss Marginal Marginal erosionserosions Absence of productive changesAbsence of productive changes Best films for diagnosis:Best films for diagnosis:

Bilateral Hand Arthritis SeriesBilateral Hand Arthritis Series Bilateral Foot SeriesBilateral Foot Series

Larger joints may not show erosions early Larger joints may not show erosions early due to thicker cartilage.due to thicker cartilage.

TreatmentTreatment Aggressive Treatment Early!Aggressive Treatment Early!

Physical therapy, daily exercise, splinting, joint Physical therapy, daily exercise, splinting, joint protectionprotection

Salicylates, NSAIDS, Salicylates, NSAIDS, DMARDsDMARDs , , hydroxychloroquine, immunosuppressive agents , hydroxychloroquine, immunosuppressive agents , SteroidsSteroids

Cyclosporin-ACyclosporin-A PrognosisPrognosis

10-15 yrs of disease10-15 yrs of disease 50% fully employed50% fully employed 10% incapacitated10% incapacitated 10-20% remission10-20% remission

Persistent active cases more than 1 year likely to lead Persistent active cases more than 1 year likely to lead to joint deformities.to joint deformities.

Periods of activity cases have better prognosis.Periods of activity cases have better prognosis. Mortality rate 2.5 times than generalpopulationMortality rate 2.5 times than generalpopulation

Dental ManagementDental Management

Short dental appointmentsShort dental appointments Assess if Aspirin or NSAIDs are Assess if Aspirin or NSAIDs are

affecting platelet functionaffecting platelet function

Osteoarthritis?Osteoarthritis? Most common form of arthritisMost common form of arthritis Middle-aged to elderlyMiddle-aged to elderly Gradual pain, worse with useGradual pain, worse with use F= M up to age 55; after 55 F>MF= M up to age 55; after 55 F>M Obesity, history of traumaObesity, history of trauma Cartilage irregularityCartilage irregularity 10-20% of these symptomatic10-20% of these symptomatic Only small percentage present for help Only small percentage present for help

Joints affectedJoints affected Hands – DIP, PIP, CMC thumbHands – DIP, PIP, CMC thumb Hips, knees, ankles, great toesHips, knees, ankles, great toes Cervical and lumbar spineCervical and lumbar spine

OsteoarthritisOsteoarthritis Mechanical symptoms Mechanical symptoms ( Pain on ( Pain on

activity),Stiffnessactivity),Stiffness Bony swelling, crepitusBony swelling, crepitus DIP DIP (Heberden) (Heberden) PIP PIP (Bouchard) (Bouchard) 11stst CMCJ, CMCJ, Neck, Neck, Lower back,Lower back, Hips, Hips, Knees, Knees, 11stst MTP MTP

Clinical subsetsGeneralised OAPrimary / nodal OAErosive OA

OsteoarthritisOsteoarthritis RadiologyRadiology

( Correlate poorly with symptoms ) ( Correlate poorly with symptoms )

Four cardinal features:Four cardinal features: Joint space narrowingJoint space narrowing SclerosisSclerosis Subchondral cystsSubchondral cysts OsteophytesOsteophytes

OA ManagementOA Management Pain ReliefPain Relief

Simple/compound analgesics, exercisesSimple/compound analgesics, exercises Glucosamine sulphate, patellar taping Glucosamine sulphate, patellar taping Topical capsaicin/NSAID; acupunctureTopical capsaicin/NSAID; acupuncture Oral NSAIDs – COX2s, gastro-protectionOral NSAIDs – COX2s, gastro-protection Injections – peri-articular, intra-articularInjections – peri-articular, intra-articular

Joint ReplacementJoint Replacement (Referral guidance hip/knee (Referral guidance hip/knee OA )OA ) ? Infection – same day? Infection – same day Rapid deterioration/severe disability (2/52 hip, soon – ‘locally Rapid deterioration/severe disability (2/52 hip, soon – ‘locally

agreed’ knee)agreed’ knee) Symptoms impair QOL – routineSymptoms 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 Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee

only)only)

Gout?Gout? Disease of Monosodium urate crystal Disease of Monosodium urate crystal

deposition in tissues of and around deposition in tissues of and around jointsjoints

Adult men, peaks in ages 40’s to 50’sAdult men, peaks in ages 40’s to 50’s Urate Overproduction (<10%) vsUrate Overproduction (<10%) vs Under Excretion (90%)Under Excretion (90%) Three stages:Three stages: Asymptomatic hyperuricemiaAsymptomatic hyperuricemia Acute intermittent goutAcute intermittent gout Chronic tophaceous goutChronic tophaceous gout Definitive dx by aspiration of fluidDefinitive dx by aspiration of fluid

Gout?Gout? Onset before 25Onset before 25 should raise the question of should raise the question of

unusual form of gout , unusual form of gout , specific enzyme specific enzyme defectdefect

A single joint involve in 85-90% of first A single joint involve in 85-90% of first attackattack

90% acute attacks in 90% acute attacks in great toe,great toe, next in order next in order of frequency are the of frequency are the ankles, heels, knees, ankles, heels, knees, wrists, fingers and elbowswrists, fingers and elbows

Acute gouty bursitis-- prepatella, olecranonAcute gouty bursitis-- prepatella, olecranon ChronicChronic TophiTophi

Septic ArthritisSeptic Arthritis

Septic arthritis is inflammation of a Septic arthritis is inflammation of a synovial membrane with purulent synovial membrane with purulent effusion into the joint capsule, usually effusion into the joint capsule, usually due to bacterial infection.due to bacterial infection.

It is an emergency- it can destroy a It is an emergency- it can destroy a joint extremely quickly and (v.rarely) joint extremely quickly and (v.rarely) lead to sepsis and death lead to sepsis and death

Frequency:Frequency: 2-10 cases per 100,000 in the general 2-10 cases per 100,000 in the general

population. population. 30-70 cases per 100,000 in immunosuppressed/ 30-70 cases per 100,000 in immunosuppressed/

joint prosthesisjoint prosthesis