Rheumatoid Arthritis

1. Rheumatoid Arthritis Priscilla Garcia, Jennifer Klocki, Reina Ligeralde, Dorinda Thomas DEH 26 5.15.08

2. Patient Profile • Name – Rume Aritis • Gender – Female • Age – 45 • Occupation – Stenographer • Marital Status – Married • Ethnicity – Caucasian

3. Medical History • Chief complaint – TMJ soarness, dry mouth, and teeth sensitivity • Dental History – • Patient has difficulty opening the jaw • 4/07 - last dental exam, BWX, and FM scale • 4/05 - last FMX • Medical History – • Patient presents with recurrent finger ache and pain • Rheumatoid arthritis since 1999

4. More Medical History • Medications – • Gold sodium thiomalate – helps slow down the disease process and decrease inflammation • Dental implications: stomatitis, gingivitis and glossitis • Aspirin – helps reduce pain • Dental implications: increased bleeding • Prednisone – used for inflammation • Dental implications: none noted • Vitals – BP: 125/74, P:78, R:17 • ASA III

5. Definition • An autoimmune disease of unknown origin that is characterized by symmetric inflammation of the joints, especially of the hands, feet, and knees

6. Incidence and Prevalence • Estimates of prevalence range 1-2% of the population. • Disease onset usually occurs from ages 35-50 years. • Severity of the disease varies widely from patient to patient and from time to time within the same patient. May is National Arthritis Month.

7. More Incidence and Prevalence • 3:1 women to men ratio  implies involvement of sex hormones in the susceptibility and sensitivity of the disease • Suggested factors in playing predisposing roles: • Psychosocial stress • Education • Socioeconomic status

8. Etiology • Unknown cause • Evidence seems to implicate an interrelationship of infectious agents, genetics, and autoimmunity. • Currently, circumstantial evidence suggests that food may play a role in the origin and treatment.

9. Pathophysiology

11. Complications • The life expectancy of persons with severe RA is shortened by 10-15 years. • This increased mortality rate usually is attributed to • Pulmonary and renal disease • Infection • Gastrointestinal bleeding

12. Accompanying Complications

13. Signs and Symptoms • The usual onset of rheumatoid arthritis is gradual and subtle. • A patient will first experience fatigue and weakness with joint muscle aches. • Then there is painful joint swelling of the hands and feet, spreading to several joints, and then progress to other joints symmetrically. • Joint involvement gradually progresses to immobility, contractures, subluxation, deviation, and other deformities.

14. Joints Most Commonly Affected

15. Medical Management

16. Medical Management • Early diagnosis and treatment for rheumatoid arthritis is vital. • It can noticeably decrease the disability and pain and very likely lengthen the life span. • Treatment approach is palliative (alleviating illness) because there is no cure that exists for this disease.

17. Medical Management • Treatment Goals: • Reduce joint inflammation and swelling • Relieve pain and stiffness • Help and promote normal function • Goals are accomplished by: • Patient education • Rest • Exercise • Physical therapy • NSAIDs

18. Medical Management • Drugs for the management of RA have been divided into two groups: • 1. Control joint pain and swelling. (i.e. NSAIDs) • 2. Limit joint damage and improve long-term outcome. (i.e. DMARDs – disease- modifying antirheumatic dugs)

19. NSAIDs = Drugs That Control Joint Pain and Swelling • Effective for pain, swelling, and stiffness • Most effective and safest for patients • Start patient on three-grain tablets 4X a day, then adjust according to patient’s response • Too much aspirin can result in aspirin toxicity. • Common sign = tinnitus (ringing, buzzing, or hissing heard in the ear) • If this occurs, decrease the dosage. • May result in prolonged bleeding

20. Gold Compounds • Helpful in decreasing inflammation and slowing down the progress of the disease • Gold compound therapy must be carefully supervised. • Incidence of side effects is high. This includes: • Buccal ulcerations • Eczematous rashes • Neutropenia • Thrombocytopenia

21. Antimalarial Drugs Chloroquine or hydroxychloroquine These drugs are used in combination with aspirin or corticosteroids. Side effects include eye damage and blue-black intraoral pigmentation. Corticosteroids Prednisone or prednisolone Most effective for reducing inflammation Manages acute symptoms Significant adverse effect is adrenal suppression; therefore, long-term usage is avoided. Other Drugs

22. Immunosuppressive Therapy • Effective in treating severe RA • Slows down the progression of the disease and decreases the damage to bones adjacent to joints • Drugs include methotrexate, azathioprine, cyclosporine, and tumor necrosis factor (TNF) inhibitors • Side effects include liver disease, lung inflammation, oral ulcerations, and increased susceptibility to infection

23. Combination Therapy • For patients with moderate to severe disease • Methotrexate used in combination with other agents • Most popular regimen is methotrexate, hydroxychloroquine, and sulfasalazine. • More effective than single-drug regimens • Does not appear to be hazardous and should be considered as initial treatment in patients with early, active RA

24. Surgery • Used to relieve severe pain and improve function of severely deformed joints that do not respond to medication and physical therapy • Variety of surgical procedures include: • Arthroscopy • Synovectomy • Arthroplasty • Total joint replacement

25. Dental Management

26. Considerations Prior to Dental Treatment • Patient comfort • Drug considerations • Joint prosthesis • TMJ involvement • Oral hygiene capability

27. Patient Comfort • Appointments should be kept short. • Encourage patient to change seating positions frequently. • Be creative, and use pillows or rolled towels to support deformed or crippled limbs.

28. Drug Considerations • Patient may be taking : • Aspirin • NSAIDS • Corticosteroids • DMARDs • Immunosuppressive agents

29. Aspirin Drug Considerations • Aspirin with NSAIDs • Analgesic • Can cause prolonged bleeding • Usually not clinically significant (does not put disease in remission) • Aspirin with corticosteriods • High risk for prolonged bleeding • Need to determine bleeding time • Most accurate test is the PFA-100 (platelet function analyzer) • Bleeding time should be under 20 minutes.

30. Other Drug Considerations • DMARDs • e.g. gold compound, penicillamine, sulfasalazine • Cause suppression of the bone marrow  anemia, agranulocytosis, and thrombocytopenia • Need recent lab tests such as RBC count, WBC count, and bleeding time • Corticosteroids • Used for control of active disease, should be used for a short period of time • If used for a long period of time  hyperglycemia, edema, osteonecrosis, immune suppression, and infection

31. Joint Prosthesis • In some patients, the arthritis is chronic and causes destruction of a joint structure to the point where the patient needs a prosthetic joint (usually the hip knee or shoulder).

32. TMJ Involvement • 45-75% of patients with rheumatoid arthritis have TMJ involvement • Patient will have decreased jaw function, mobility, and maximum opening; increased tenderness, swelling, and stiffness • These factors hinder the patient’s diet  nutrition counseling • Loss of condylar height can create an open bite and also causes sleep apnea. • Moist warm towels can relieve pain.

33. Oral Hygiene Capability • Patient has less dexterity due to pain in the joints • Alter OHI to customize the patient’s specific needs. • Power toothbrushes, floss aids, irrigators, even modifying the tooth brush handle • Be empathetic and patient.

34. Some Toothbrush Modifications • A lack of strength because of arthritis can make even holding the handle of a toothbrush difficult. • A solution to this problem could be to stick the toothbrush handle into a tennis ball or slide it in a bicycle handlebar grip.

35. Quiz • 1. What is rheumatoid arthritis? • A. an immune deficiency disease of unknown origin that is characterized by symmetric inflammation of the joints • B. an autoimmune disease of unknown origin that is characterized by symmetric inflammation of the joints • C. an immune deficiency disease of unknown origin that is characterized by asymmetric inflammation of the joints • D. an autoimmune disease of unknown origin that is characterized by asymmetric inflammation of the joints

36. 2. Disease onset usually occurs from ages 25-55 years. Rheumatoid arthritis is more prevalent in women than men by a 2:1 ratio. • A. Both statements are TRUE. • B. Both statements are FALSE. • C. The first statement is TRUE, and the second statement is FALSE. • D. The first statement is FALSE, and the second statement is TRUE.

37. 3. Rheumatoid arthritis • A. has an unknown cause. • B. is caused by infectious agents. • C. is caused by genetics and autoimmunity. • D. is caused by food.

38. More Quiz Questions • 4. List 3 characteristics of RA. • 5. Name 3 joints that may be affected by RA. • 6. What are some dental modifications that can be made for a patient with RA? • 7. What is the major side effect of a corticosteroid after a long period of use? • 8. What does DMARD stand for?

39. 9. Aspirin is the most effective and safest drug for patients. Aspirin can be prescribed in large doses but can cause toxicity. • A. Both statements are TRUE. • B. Both statements are FALSE. • C. The first statement is TRUE, and the second statement is FALSE. • D. The first statement is FALSE, and the second statement is TRUE.

40. 10. Treatment goals for RA: • A. reduce joint inflammation and swelling • B. relieve pain and stiffness • C. encourage normal function • D. all of the above • E. none of the above

41. Answers • 1. B. an autoimmune disease of unknown origin that is characterized by symmetric inflammation of the joints • 2. B. Both statements are FALSE. (35-50 years of age, 3:1 women: men) • 3. A. has an unknown cause.

42. RA Answers • 4. symmetrical, gradual and subtle onset, fatigue and weakness with joint muscle aches, immobility, morning stiffness • 5. fingers, wrists, feet, ankles, knees, elbows, TMJ

43. More Answers • 6. modification of OHI, use towels or pillows and/or bite blocks to achieve comfort, have short appointments • 7. immune suppression • 8. drug modifying anti-rheumatic drug

44. Even More Answers • 9. A. Both statements are TRUE. • 10. D. all of the above

45. Bonus Questions • 1. Spell what RA stands for. • 2. What percentage of patients have a gradual onset of the disease? • 3. Out of more than 60 important diseases related to arthritis, name 3.

46. Answers to Bonus Questions • 1. R-h-e-u-m-a-t-o-i-d a-r-t-h-r-i-t-i-s • 2. More than 50% • 3. Osteoarthritis, SLE, Lyme disease, Sjögren’s syndrome

47. Questions?