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Dental Management of Patients with Autoimmune Disorders

Dental Management of Patients with Autoimmune Disorders. Adrienne J. Yoon, D.D.S. November 18, 2004. Autoimmune Disorders. Hashimoto’s Disease Rheumatoid Arthritis Sjogrens Syndrome Systemic Lupus Erythematosus. Hashimoto’s Disease. A chronic inflammatory disease of the thyroid.

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Dental Management of Patients with Autoimmune Disorders

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  1. Dental Management of Patients with Autoimmune Disorders Adrienne J. Yoon, D.D.S. November 18, 2004

  2. Autoimmune Disorders • Hashimoto’s Disease • Rheumatoid Arthritis • Sjogrens Syndrome • Systemic Lupus Erythematosus

  3. Hashimoto’s Disease A chronic inflammatory disease of the thyroid

  4. Incidence • Most common cause of primary thyroid deficiencies (thyroid “burns” out) • Common in women and adolescents • Familial predisposition

  5. Laboratory Values • Assay the free thyroxine (T4) level • Primary thyroid disease: TSH levels are elevated • Secondary thyroid disease: caused by pituitary dysfunction and TSH level is normal or borderline

  6. Medical Management • Thyroid hormone replacement once in the hypothyroid phase

  7. Dental Management • Aggressively treat infections • Avoid thyrotoxic crisis • Closely monitor vitals • Stress management

  8. Rheumatoid Arthritis A chronic nonsuppurative inflammatory destruction of the joints

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

  10. Pathogenesis • Synovium is transformed into hyperplastic chronically inflammed tissue • Intimal lining increases in size due to local proliferation of fibroblast-like cells and macrophage-like synoviocytes • Prominent angiogenesis • Rheumatoid factor is synthesized in the synovium and detected in synovial fluid

  11. Signs and Symptoms • Polyarthritis sometimes associated with fever and weight loss • Joint pain • Generalized fatigue • “Gelling” phenomenon morning stiffness; difficult to resume motion

  12. Extra-Articular Manifestations • 20% of patients have rheumatoid nodules • Carpel tunnel sydrome • Synovial cysts • Pleuropulmonary disease • Systemic rheumatoid vasculitis

  13. Laboratory Values • High elevation of rheumatoid factor (RF) • Antinuclear antibody (ANA) detected in about 50% of patients • Active phase: patients have elevated erythrocyte sedimentation rate (ESR) • Some affected patients have mild anemia

  14. Medical Management • NSAIDs • Glucocorticoids • Immunosuppression

  15. Dental Management • AHA Guidelines • Short dental appointments • Assess if aspirin or NSAIDs are affecting platelet function

  16. Sjogren’s Syndrome Inflammation of the lacrimal and salivary glands

  17. Incidence • 0.2-3.0% of population • More common in females • 15% of patients with rheumatoid arthritis • 30% of patients with SLE

  18. Signs and Symptoms • Dry mouth, skin, eyes, nose and vagina • Tongue becomes fissured and exhibits atrophy of the papillae • Oral mucosa red and tender • Parotid enlargement

  19. Lymphadenopathy Vasculitis Interstitial nephritis Interstitial lung fibrosis Primary biliary cirrhosis (PBC) Raynaud’s phenomenon Peripheral neuropathies Scleroderma Extra-glandular Signs and Symptoms

  20. Laboratory Values • High erythrocyte sedimentation rate and serum immunoglobulin levels (IgG) • 75% of patients have RF regardless of rheumatoid arthritis • Antinuclear antibodies (ANA) also present

  21. Medical Management • Local manifestations can be treated symptomatically

  22. Dental Management • Prevention of caries daily use of fluoride, frequent recalls • Enhance salivary output sugarless gum/candy, saliva substitutes (salivart, biotene, oral balance, mouth kote, glandosane, prescription medication (salagen, ` evoxac) • Treatment of oral candidiasis antifungals • Pain control for enlarged salivary glands

  23. Systemic Lupus Erythematosus A chronic multisystem disease of unknown origin that exhibits wide variations in its clinical expression and disease course

  24. Incidence • Females are affected 8-10 times more than men • Average age is 31 years

  25. Fever, weight loss, arthritis, fatigue, and general malaise Butterfly rash on the malar area and nose 40-50% of patients have affected kidneys Cardiac involvement -Libman-sacks endocarditis found in 50% of patients upon autopsy -pericarditis, myocarditis, endocarditis, CAD Oral lesions -5-25% of patients have affected palate, buccal mucosa, and gingiva Signs and Symptoms

  26. Laboratory Values • 95% of patients have elevated ANA • 70% of patient have antibodies directed against double-stranded DNA

  27. Medical Management • Avoid excessive exposure to sunlight • NSAIDS for mild active disease with antimalarial drugs • Topical corticosteroids

  28. Dental Management • AHA Guidelines • Assess adrenal function for possible suppression • Consult with physician regarding systemic manifestation • Assess if NSAIDS are affecting platelet function

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