Arthritis Flashcards
what is bone made of
a calcified extracellular matrix (ECM)
made of inorganic ions
what are osteoblasts
make bone by secreting collagen and calcium salts
what is an osteocyte
derived from osteoblasts and sits in a small chamber called a lacuna
it maintains the bone
what are osteoprogenitor cells
stem cells in the bone that make new osteoblasts as osteoblasts cant divide into new ones
what are osteoclasts
bone resorption
they come from white blood cells
osteoclasts cause proteolytic enzymes and hydrochloric acid to resorb bone
what is bone homeostasis
this means that there is no net gain or loss of bone
what are the different types of bone that are laid down
- first woven bone/immature bone
- secondary bone is split into:
-cortical/lamellar- dense, compact
-cancellous- spongy- this is below the roots of teeth
how does vitamin D relate to bone formation
vitamin D increases calcium and phosphate
vitamin D comes from sunlight or diet e.g. fish
vit D increases the uptake of calcium in the small intestine
what are rickets
curved legs from vit D deficiency
what does the parathyroid gland do
secretes the parathyroid hormone(PTH) which increases calcium and phosphate in the blood by promoting the kidneys to make vit D and reabsorb calcium into the blood
what are the 2 types of thyroid gland malfunctions
- primary hyperparathyroidism
- secondary hyperparathyroidism
what is primary hyperparathyroidism
increased parathyroid hormone levels
often due to an adenoma (benign tumouor)
what does secondary hyperthyroidism do
-it causes calcium salts in CKD chronic kidney disease
- it compensates for this the parathyroid gland secretes more parathyroid hormone
- it increases bone resorption
- it leads to renal osteodystrophy (when the kidneys cant maintain calcium and phosphate levels )
how does hyperparathyroidism affect the jaws
very rare but can present as central giant cell granuloma
if a pt has this alongside hyperthyroidism it is termed- brown tumour of hyperparathyroidism
what are the stages of bone fractures
- the early infalmmatory stage
- the repair stage
- the remodelling stage
what does the early inflammatory phase of bone fractures consist of
- bleeding occurs at the fracture site and forms a hematoma (blood clot)
- inflammatory cells and fibroblasts infiltrate the site - TNF (tumour necrosis factor) alpha, IL1,6,10,12, TGF (transforming growth factor)
- blood vessels go into the hematoma and granulation tissue forms
-
what does the repair stage of bone fractures consist of
-the granulation tissue formed in the inflammatory stage turns to callus
- primary callus turns to secondary callus by endochondral ossification
- osteoids are secreted into the area forming new bone
cartilage calcified due to BMPs, TGF-betas, IGFs, osteocalcin, collagen I, V and XI
- collagen forms in the area forming new bone
what does the remodelling stage of bone fractures consist of
redistribute compact and oven bone
orgnised osteoblastic and osteoclastic activity coordinates remodelling
what factors impact bone fracture healing
blood supply to the fracture
infections
if the fracture is closed or compound (pierces the skin)
the amount of bone or soft tissue loss
diabetes, radiotherapy, long term corticosteroids use (a steroid anti inflammatory e.g.eczema cream)
use of NSAIDS (IBUPROFEN, aspirin a non steroid anti inflammatory)
smoking
nutritional status
risk of future falls
name the bone diseases we need to know about
name the arthritides we need to know about
bone diseases-
osteogenesis imperfecta
osteopetrosis
osteopenia and osteoporosis
pagets disease
arthritides-
osteoarthritis
rheumatoid arthritits
ankylosing spondilitis
what is osteogenesis imperfecta
- inherited condition where defects of collagen stop normal biomineralisaiton of the bone
- caused by a type 1 collagen mutation
- partial or complete absence of collagen
- :. brittle bones
- grey/blue discolouration of sclera
oral features:
skeletal class 3 pattern
open bite
impacted molars
thin grey brown enamel
delayed or premature eruption
dentine can look opalescent - dentinogenesis imperfecta
what is osteoPETrosis
a genetic condition where osteoclasts dont resorb bone
bone becomes harder and more marble like :. less flexible when stressed
- bone becomes more dense and opaque on radiographs
- more inorganic component of bone :. bone marrows hematopoietic ability (making blood vessels decrease)
delayed tooth eruption can lead to nerve entrapment :. low blood supply
what is osteopenia and osteoporisis
osteopenia = bone has thinned
the degree of bone thinness using a DEXA scanner
osteopenia= -1 to -2.5
osteoporosis- lower than -2.5
can happen due to a bit D deficiency in youngsters
it Is normal to some degree in adults due to lack of bone protecting oestrogen after menopause and androgen in males
osteoporosis:
affects mainly vertebra, femur and wrists
can happen to people with COPD from coughing
kyphosis can occur - spine bends forward
what factors increase bone loss
lifestyle- high caffeine, salt, low BMI (anorexia) , alcohol, smoking, immobility
genetic factors- females, family history of osteoporosis
endocrine- early menopause
hormonal changes
amenorrheoea- lack of periods
diseases-
cushings
hyperthyroidism
hyperparathyroidism
drugs -
Glucocorticoids (aka corticosteroids) Thyroxine
Heparin
Diuretics e.g. furosemide
Cytotoxic drugs
what race are less likely to have bone loss
afro- caribbeans
what drugs prevent bone loss
bisphophonates
HRT (hormone replacement therapy)
how would you manage osteoporosis
pt lifestyle advise - vit D, low alc/smoking etc, low salt and caffeine
pain relief- AVOID NSAIDS, take para or physio
physio to stay mobile
physical aids- walking sticks
meds to prevent further bone loss-
vit D
bisphosphonates
SERMS (selective aoestrogen receptor modules
hormone replacement therapy
testosterone tx
regular med reviews with the GP
surgery to fix fractures
what is pagets disease
increased resorption from overactive osteoclasts cause a response where osteoblasts become more active and secrete larger and weaker bone
can affect 1 bone or several
common in pelvis and spine
constant dull one pain
be careful when giving lengthy dental appointments
there can be cranial nerve deficits e.g. conductive deafness if the skulls foramina is in the path of this bone growth
pagets can lead to enlarged maxillae or mandible
hypercementosis- ossifying of the PDL
what are some tx of pagets disease
bisphosphonates
analgesia
physiotherapy
surgery - if joint damage
what are the 3 types of arthritides
osteoarthritis
rheumatoid arthritis
ankylosing spondilitis
what is osteoarthritis
a wear and tear degeneration of the joints
low level chronic inflammation of the joints
effects the large weight bearing joints such as hips and knees but also some small like wrists
what are features of primary osteoarthritis
synovial softening, tearing of articular cartilage, development of subchondral bone cysts and development of bony spurs or “osteophytes” in the joint itself
due to obesity or lack of physical exercise
what are features of secondary osteoarthritis
develops following trauma of some sort, pain and stiffness in bones, fracture of the TMJ can lead to OA in the long term
how can Osteoarthritis affect daily life
mobidity rate increases
limitations in functioning
impacts daily activity
impacts quality of life
what symptoms does OA usually present with
stiffness after movement of a joint
e.g. painful knees after gardening
can be swelling of the joints but usually non inflammatory :. no redness or heat involved
with long term disease, the swelling can become bony rather than soft tissue resulting in herberdens nodes in dip joints of hands
what is the managment of OA
pt management programmes
weight loss for obese pts
physio and walking aides
topical NSAIDS
Intra-articular corticosteroid injections for single, painful joints
Intramuscular corticosteroid injections for more widespread arthritis
surgery
what surgical managements can be used to treat OA
1.Arthrocentesis or arthroscopies (direct endoscopic visualisation of the joint space +/- washing out of the joint, removal of osteophytes etc)
- Osteotomies (removal of bony deformities by surgical means)
- Arthrodesis (surgical fusion of a painful or unstable joint)
- Total joint replacements.
what is rheumatoid arthritis
this is more suddenly occuring joint problem than OA. occurs more in younger people (under 40) compared to progressively occurring in older people for OA.
It is SYMMETRICAL. both right and left sides are affected
this is a multi system disease :. doesn’t only affect joints but also systemically e.g. neurological, renal,pulmonary (see other card)
what are clinical signs of rheumatoid arthritis
“calor, dolor, rubor, tumor, functio laesa”) i.e. acombinationofheat,pain,redness,swellingandlossoffunction
early morning stiffness which takes hours to subside
what are the systemic effects of rheumatoid arthritis
opthalmological- keratoconjunctivitis sica (dry eyes), sclera etc
hematological (sjogens)
pulmonary
gastrointestinal
dermatalogical
musculoskeletal
what is ankylosing spondilitis
another chronic inflammatory arhtirits specifically affecting neck and spine
more prevalent in males
genetic predisposition- HLA-B27, HLA-B60, HLA-DR1
how does ankylosing spondilitis present
this starts by sacroilitis -inflammation of the sacro iliac joints (where the pelvis meets the spine)
this then progresses up the vertebraes until it reaches the neck
this gives a slanting forward posture known as the question mark posture
how would we manage ankylosing spondilitis in dental setting
pillow, shorter pts, adjust chair for neck support
what is the difference between ankylosing spondilitis and OA and rheumatoid arthritis
mainly targets spine over distal or periphral joints (e.g. wrists)
what commonly presents with autoimmune diseases such as OA and RA
these can go on to develop other Autoimmune diseases as they target other tissues e.g. inflammatory bowel disease and crohns
