3 - Rheumatoid arthritis Flashcards
What is rheumatoid arthritis?
- multi system disease
- disease of synovium with gradual inflammatory joint destruction
- symmetrical polyarthritis that affects mainly peripheral joints
- different pattern of disease and joint involvement depending if sero-positive/-negative
What is sero-positive rheumatoid arthritis?
Rheumatoid factor present
What is sero-negative rheumatoid arthritis?
Rheumatoid factor not present
What are the symptoms of RA?
- slow onset
- initially in hands and feet but can spread to all synovial structures
- symmetrical polyarthritis
- pain, morning stiffness, swelling and general joint stiffness common
- systemic symptoms included fatigue, fever, numbness and tingling, decreased range of movement
What are early signs of RA?
- symmetrical synovitis of MCP joints
- symmetrical synovitis of PIP joints
- symmetrical synovitis of wrist joints
What is synovitis?
- inflammation of the synovium
- swelling, stiffness and pain that eventually leads to destruction of joint
What are late signs of RA?
- deformation of hands, feet and ankles common
- ulnar deviation of fingers at MCP
- hyperextension of PIP joints (swan necking)
- “Z” deformity of thumb (hyperflexion of MCP and hyperextension of IP)
- subluxation of wrist
- loss of abduction and external rotation of shoulders
- flexion of elbows and knees
- loss of function including walking
What are the extra-articular features of RA?
- caused by systemic vasculitis
- psoriasis
- scleritis and episcleritis
- dry eyes, Sjögren’s syndrome
- subcutaneous nodules
- amyloidosis
- pulmonary inflammation
- neurological issues
What investigations can be done for RA?
Radiographs/CT/MRI
- look for erosion, loss of joint space, deformity
- joint destruction/secondary osteoarthritis
Blood
- normocytic, normochromic anaemia (failure of RBC stimulation)
How do you treat RA?
- holistic management
- aim to maintain current function
- combination of physiotherapy, OT, drug therapy and surgery
Describe physiotherapy used for RA.
- aim to keep patient as active as possible for as long as possible
- both active and passive exercises
- improve joint stability
- maintain joint position
- delay onset of debilitating disease
Describe occupational therapy used for RA.
- maximising residual function for those with limited manual ability
- provide aids for independent living
- assessment and alteration of home to maintain independence (chair lift, wet room etc)
Describe the drug therapy used in RA.
- analgesics (paracetamol, cocodamol)
- NSAIDs (combined with anti-PUD agents)
- disease modifying drugs (to slow immune process)
- steroids (intra-articular)
- immune modulators (used as disease gets more severe)
- oral steroids
Give an example of disease modifying drugs used in RA.
- hydroxychloroquine
- methotrexate
Give an example of immune modulating drugs used in RA.
Biologics - TNF inhibitors (eg infliximab, adalimumab)
Give an example of oral steroids used in RA.
Prednisolone
Describe surgery used in RA.
- excision of inflamed tissue (synovium)
- joint replacement (FOR FUNCTION)
- joint fusion
- osteotomy
What is the prognosis for RA?
- 10% spontaneously remit
- sero-positive and late onset have worse prognosis
- 10% are left severely disabled
- most have mild/moderate disease
What are common extra-articular complications of RA?
- infection
- PUD
- polypharmacy
What are the dental aspects of RA?
- disability leads to reduced dexterity (OH) and difficulty accessing care
- Sjögren’s syndrome causes xerostomia (high caries risk)
- joint replacements (do not usually require AB prophylaxis)
- chronic anaemia affects GA
What are the oral manifestations of using NSAIDs?
Bleeding tendency
What are the oral manifestations of using the drug sulphasalazine?
- bleeding tendency
- oral lichenoid reaction
What are the oral manifestations of using the drug hydroxychloroquine?
- oral lichenoid reaction
- oral pigmentation
What are the oral manifestations of using the drug methotrexate?
Oral ulceration
What is Atlanto-occipital instability?
- supporting ligaments are weakened
- structure can slip more easily
- sudden trauma may can rupture which would allow the dens to impinge on spinal cord causing severe damage
What is seronegative spondyloarthritides?
- arthritis of axial skeleton
- can lead to ankylosing spondylitis
- fusion of vertebrae
What causes SA?
- associated with gene HLA-B27
- infection often triggers
Describe the manifestation of SA.
- symmetrical peripheral arthritis
- ocular and mucocutaenous manifestation (renters syndrome)
What are the symptoms of ankylosing spondylitis?
- disabling progressive lack of axial movement
- symmetrical involvement of other joints eg hips
- low back pain
- limited neck/back movement
- limited chest expansion which compromises breathing
- kyphosis
How do you treat ankylosing spondylitis?
- analgesia and NSAIDs
- physiotherapy
- OT
- DMDs
- immune modulators
- surgery where appropriate
What are the dental aspects of ankylosing spondylitis?
GA is dangerous due to limited mouth opening and neck flexion and cannot sit in chair properly
