musculoskeletal/CT disease Flashcards
1
Q
define arthritis
A
inflammation of the joint
2
Q
define arthrosis
A
non-inflammatory joint disease
3
Q
define arthralgia
A
joint pain
4
Q
bone is mineralised what?
A
connective tissue
5
Q
what are the 3 main features of bone?
A
Load bearing, dynamic, self-repairing
6
Q
bone is dynamic, what does this mean?
A
bone continuously changing - resorbed by osteoclasts, formed by osteoblasts - adapt to changes in stress in the environment and repair
7
Q
bone formation requires the correct levels of what 3 things?
A
Calcium, phosphate and vitamin D
8
Q
Bone and calcium
Bone forms a ? store
? Ca moves from the bone into the ?? and calcium moves from the ? into the extracellular fluid
Ca is lost through the ? and ?
A
calcium
exchangeable
extracellular fluid
gut
gut
urine
9
Q
calcium and bone
Ca levels must be maintained at a specific level as it is involved in ? and ? function
Bone and ?? work together and the use of ? helps promote the correct location of Ca
? increases Ca release from ? by ? and ? renal Ca ?
A
nerve
muscle
Extracellular fluid
PTH
PTH
bone
osteoclasts
reduces
excretion
10
Q
what is osteomalacia?
A
Normal amounts of osteoid matrix formed but doesn’t mineralised properly -> soft and more pliable
11
Q
if osteomalacia occurs during bone formation (children), what is this called?
A
rickets
12
Q
if osteomalacia occurs after bone formation (adults) what is this called?
A
osteomalacia
13
Q
what is osteomalacia and rickets caused by?
A
calcium deficiency
14
Q
cause of osteomalacia
Reduction in plasma ?, increased ? secretion, ? bone ? to release ?, ?? increases ? Ca ?
A
Ca
PTH
osteoclastic
resorption
ca
vitamin D
intestinal
absorption
15
Q
what affect does osteomalacia have on bone?
A
Bones bend under pressure - bowing
16
Q
what affects does hypocalcaemia have on the body? 3
A
Muscle weakness
Carpal muscle spasm and facial twitching from VII tapping
17
Q
investigations for osteomalacia
Serum Ca -> decreased
Serum phosphate -> decreased
Alkaline phosphate -> very high
Plasma creatinine -> increase if renal cause
Plasm PTH -> increase if secondary hyperparathyroidism
A
Serum Ca -> decreased
Serum phosphate -> decreased
Alkaline phosphate -> very high
Plasma creatinine -> increase if renal cause
Plasm PTH -> increase if secondary hyperparathyroidism
18
Q
in osteomalacia why is serum phosphate decreased?
A
osteomalacia is often caused by vitamin D deficiency, vitamin D is responsible for the absorption of Ca AND phosphate
19
Q
in osteomalacia why is alkaline phosphate very high?
A
due to increased osteoblastic activity
20
Q
in osteomalacia why is plasma creatinine increased?
A
if renal cause because the kidneys are meant to filter it out into the urine - kidney disease
21
Q
how does kidney disease lead osteomalacia?
A
kidneys produce an enzyme that converts vitamin D into its active form, kidney disease means less is active leading to vitamin D deficiency
22
Q
in osteomalacia why does plasma PTH increase?
A
increases in response to low Ca
secondary hyperparathyroidism - lots of PTH produced not caused by parathyroid gland damage
23
Q
how is osteomalacia managed? 4
A
correct the cause
- Control GI disease - malabsorption
- Sunlight exposure
- Dietary vitamin D
- control kidney disease
24
Q
what is osteoporosis?
A
Reduced quantity of normally mineralised bone
25
remember osteoporosis is an inevitable age related change
26
what endocrine risk factors are there for osteoporosis? 3
oestrogen (menopause) deficiency
testosterone deficiency
Cushing's syndrome (increased corticosteroid blood levels)
27
what patient risk factors are there for osteoporosis?
inactivity
smoking
alcohol
poor dietary Ca
28
what medical drugs are risk factors for osteoporosis?
steroids and anti-epileptics
29
what effects does osteoporosis have on the body? 2
Increased bone fracture risk
Vertebrae compress and crack
30
what happens as a result of vertebrae compression and cracks from osteoporosis? 4
Height loss
Kyphosis - rounding of the upper spine
Scoliosis - lateral shift of vertebrae
Nerve root compression - back pain
31
how is osteoporosis prevented? 2
Build maximal peak bone mass (occurs at age 24-35) through exercise and dietary calcium
Reduce rate of bone mass loss
32
how is the rate of bone mass loses reduced in osteoporosis?
exercise
Ca intake
reduce hormone related effects - HRT
reduce drug related effect - steroids and anti-epileptic
consider preventative drugs
- Bisphosphonates reduce the number of osteoclasts so less bone can be removed preserving it
33
name 3 symptoms of joint disease?
Pain
Immobility stiffness
Loss of function
34
what are the signs of joint disease? 4
Swelling
Deformity
Redness
Crepitus
35
what are the 3 types of swelling from joint disease?
fluctuant, bony or synovial
36
how does joint disease lead to deformity?
destruction causes change in joint surfaces, bones meet differently changing the external appearance of the joint
37
in joint disease what does redness suggest?
Suggests inflammation due to infection and high vascular content
38
what is crepitus from joint disease?
Noise made by the bone during moving due to loss of cartilaginous covering to the bone ends
39
what investigations are done for joint disease? 4
radiography
blood test
arthroscopy and biopsy
40
what blood tests are done to investigate joint disease?
Inflammatory markers - C-reactive protein
Autoimmune disease - rheumatoid factors
Extractable nuclear antigens
Anti DS-DNA, anti-nuclear antibody
41
what is acute monoarthropathies?
Acute inflammation of a single joint
42
name 2 common causes of acute monoarthropathies (acute inflammation of one joint)
Infection - septic arthritis
Crystal arthropathy - gout
43
acute monoarthropathies
In gout ??? cause irritation to the joint surface which causes ? and I?
uric acid crystals
swelling
inflammation
44
what is the cause of gout?
hyperuricaemia - high levels of uric acid in the blood
drug induced, genetics, nucleic acid breakdown (chemo), tumour
45
what joint is usually affected by gout?
big toe
46
what is the one time of gout?
rapid
47
how is gout treated?
NSAIDs
48
what drug should u avoid prescribing with gout?
aspirin as it interferes with the removal of uric acid
49
in gout Drug treatments my give oral ulceration
50
osteoarthritis is a degenerative joint disease. what joints does it affect?
affects the weight bearing joints or joint damage -> knees and hips
51
symptoms of osteoarthritis 3
Pain - worse during activity, better with rest
Brief morning stiffness
Slowly progressive over years
52
what are the signs of osteoarthritis
(radiographs)
radiographs
- Loss of joint space and subchondral sclerosis
- Osteophyte lipping at joint edge
joint swelling and deformity
53
what alters the disease progression of osteoarthritis?
nothing
54
how is pain managed in osteoarthritis without medication? 3
Increasing muscle strength around the joint
Weight loss
Walking aids
55
what drugs are used to treat the pain of osteoarthritis?
NSAIDs
56
prosthetic replacement can be done for osteoarthritis. what is the reason for this?
pain not function
57
what is the dental aspect of chronic NSAID use? 2
Oral ulceration
Bleeding tendency - anti-platelet
58
what is the dental consideration for joint replacements?
Antibiotic prophylaxis may be required but usually not needed
59
Rheumatoid arthritis is initially a disease of the ? with gradual ???
synovium
inflammatory joint destruction
60
rheumatoid arthritis
There are different patterns of joint involvement dependent on whether rheumatoid factor (autoantibody) is present
? - rheumatoid factor present
? - rheumatoid factor not present
reumatoid factor
sero-positive
sero-negative
61
symptoms of rheumatoid arthritis 7
Slow onset (hands and feet) then spread to potentially all synovial structures
Symmetrical polyarthritis - synovitis
Can get systemic symptoms due to RA being a manifestation of a systemic illness
Fatigue
Morning stiffness
Joint pain, swelling and stiffness
Decreased range of motion
62
early signs of Rheumatoid arthritis 3
Symmetrical synovitis of
- Metacarpal joints
- Proximal metacarpal joints
- Wrist joints
63
late signs of rheumatoid arthritis
destruction of the joint
Subluxation of wrist
Loss of abduction and external rotation of shoulders
Flexion of elbows and knees
Deformity of the feet and ankles
64
what are the two investigations done for rheumatoid arthritis
radiographs
blood tests
65
how does osteoarthritis present on radiographs? 5
erosions, loss of joint space, deformity , joint destruction and secondary osteoarthritis
66
how does osteoarthritis present in blood tests?
normochromic normocytic anaemia - RBCs normal in colour and size but there are few of them
67
what medicines are used to manage rheumatoid arthritis?
analgesics
NSAIDs
disease modifying drugs
- hydroxychloroquine and methotrexate
steroids
68
what surgeries can be done to restore the function from rheumatoid arthritis? 4
Excision of inflamed synovium
Joint replacement
Joint fusion
Osteotomy
69
what alters the disease progression of rheumatoid arthritis?
disease modifying drugs can slow the progress of the disease
- hydroxychloroquine
- methotrexate
70
complications from rheumatoid arthritis
Increased risk of ?
Higher risk of ???
? manifestations
inflammation of ??
Secondary ? syndrome
? - pressure points
? - amyloid fibrils build up in organs and tissues - can lead to kidney failure and death
Drugs
infection
peptic ulcer disease
pulmonary
blood vessels
Sjogren's
subcutaneous nodules
amyloidosis
71
dental aspects of the drugs taken for rheumatoid arthritis
NSAIDs and sulfasalazine (DMARD) can cause -> ?
steroids, azathioprine (immune modulator) can cause -> ?
sulfasalazine, gold and hydroxychloroquine (disease modifying drug) can cause -> ?
methotrexate can cause -> ?
hydroxychloroquine can cause?
bleeding
infection risk
oral lichenoid reactions
oral ulceration
oral pigmentation
72
Atlanto-occipital instability arises from RA
what is it?
Damage to the ligaments in the neck which can result in slipping of the structures in the upper part of the neck so more chance of ligaments rupturing if trauma occurs and bones infringing onto the spinal chord causing spinal damage.
73
name a sero-negative spondyloarthritides
Ankylosing spondylitis
74
what is ankylosing spondylitis?
Spinal joint arthritis
75
how does ankylosing spondylitis differ from rheumatoid arthritis?
is on axial skeleton (neck and vertebrae)
76
ankylosing spondylitis causes what?
Narrowed and inflamed discs and fusion of the vertebrae leads to challenges turning, twisting and bending
77
ankylosing spondylitis is associated with what?
Associates with HLA-B27
78
what are the effects of ankylosing spondylitis? 4
Lower back pain
Limited back and neck movement
Limited chest expansion - breathing compromised as bones fused
Kyphosis - cervical spine tipping forward due to bone fusion
79
what is the treatment for ankylosing spondylitis? 4
Analgesia and NSAIDs to manage pain
Physiotherapy and occupational therapy to maintain function and independent living
Disease modifying drugs and immune modulators to slow the progression
Surgery to restore function
80
dental aspects of ankylosing spondylitis
Difficulty lying down
GA hazardous due to limited mouth opening and neck flexion
TMJ involvement possible
81
what are the two types of connective tissue disease?
autoimmune diseases
vasculitic diseases
82
remember autoimmune disease is a spectrum disorder that can present as multiple conditions
83
is Systemic lupus erythematosis (SLE) a autoimmune or vasculitic connective tissue disease?
autoimmune disease
84
what are the two types of the autoimmune disease Systemic lupus erythematosis (SLE)
discoid lupus
systemic lupus
85
what is discoid lupus?
tissue changes with no blood autoantibodies
86
what is systemic lupus?
organ changes and autoantibodies
87
what antibodies are in the connective tissue autoimmune disease systemic lupus erythematosis? 3
Anti-nuclear antibody (ANA)
Anti-double-strand DNA (dsDNA
Anti-Ro antibody (Ro)
88
what causes the connective tissue autoimmune disease systemic lupus erythematosis?
Genetic predisposition but environmental trigger - allergy triggers immune system
89
dental aspects of LSE 7
Anaemia - oral ulceration and GA risk
Thrombocytopenia - bleeding risk
Renal disease - impaired drug metabolism
Drug reactions can trigger photosensitivity
- Butterfly zygomatic rash
Steroid and immunosuppressive therapy - malignancy risk
Lichenoid oral reactions
Oral pigmentation from hydroxychloroquine use
90
what is anti phospholipid antibody syndrome?
Group of lupus pts who have a marker in their blood termed lupus anticoagulant
91
what is lupus anticoagulant?
Not a true anticoagulant - blood only anticoaguable in test tube not body
92
what specific antibodies are present in phospholipid antibody syndrome (lupus)? 2
Antiphospholipid (aPL)
Anticardiolipin (aCL)
93
what is primary phospholipid antibody syndrome (lupus)?
no other disease associated with it
94
what is secondary phospholipid antibody syndrome (lupus)?
associated with other conditions of the type - lupus, rheumatoid arthritis or Sjogren's
95
phospholipid antibody syndrome (lupus)
Pt are ? putting them at risk of ??? and ??
pt are often on ? - don’t stop without advice of a clinician
hypercoaguable
deep vein thrombosis
pulmonary emboli
anticoagulants
96
what is systemic sclerosis (scleroderma)
autoimmune connective tissue disease
Elastic tissue of the body is replaced by connective fibrous tissue -> loss of ability to stretch and bend tissues such as the skin as joints and muscles moves
97
features of systemic sclerosis (scleroderma)
sclerodactyly
Telangiectasia
Nailfold capillaroscopy
Raynaud's
Loss of elasticity is also internal - bowel problems
Renal failure
malabsorption
98
what is sclerodactyly?
Contractures of the fingers as the skin will no longer stretch around the joints - cant straighten fingers
99
what is telangiectasia?
Little haemangiomas on the face
100
what is nailfold capillararoscopy
Little haemangiomas in the nail beds
101
what is Raynaud's?
blood vessel narrowing - commonly fingers - can lead to necrosis
102
what antibodies are found in systemic sclerosis (scleroderma)? 2
Localised - anticentromere antibodies
Generalised - anti-Scl-70 antibodies
103
dental aspects of systemic sclerosis (scleroderma)
Involvement of peri-oral tissues - can't open mouth properly
Dysphagia and reflux oesophagitis - dental erosion and swallowing difficulties
Drug metabolism - cardiac and renal vasculitis disease
Widening of PDL space
104
what is sjogrens syndrome? 3
undifferentiated connective tissue disease
autoimmune disease - associated with autoantibodies but is not caused by them
complement activation cuases tissue damage of salivary and lacrimal glands
105
what autoantibodies r associated with sjogren's syndrome? 3
Anti-nuclear antibody (ANA)
Anti-Ro antibody (Ro)
Anti-La antibody (La)
106
what are the 3 main groups of sjogren's syndrome?
sicca syndrome
primary sjogren's
secondary sjogren's
107
what is sicca syndrome Sjögren's syndrome?
only dry eyes and mouth
108
what is primary sjogren's syndrome?
not associated with any other disease
109
what is secondary Sjögren's syndrome?
associated with another connective tissue disease
110
oral and dental implications of Sjögren's syndrome?
Oral infection
Caries risk
Denture retention
Sialosis
salivary lymphoma
111
what is sialosis?
swelling of salivary glands
112
what is salivary lymphoma?
unilateral gland size change, usually after years, caused by chronic activation of the lymphoid tissue
113
remember that Sjögren's syndrome is associated with blood autoantibodies that don’t cause the disease (they are found in healthy people) but their pattern varies from disease to disease
114
what is vasculitic disease?
Inflammation within blood vessel walls causing narrowing and ischaemia
115
vasculitic disease may present as what? 2
oral inflammatory masses or ulcers (tissue necrosis)
116
vasculitic disease is characterised by what?
the size of the blood vessel
117
name 2 large vessel vasculitis diseases
Giant cell (temporal) arteritis (commonly temporal artery involved)
Polymyalgia rheumatica
118
what is the presentation of Giant cell (temporal) arteritis? 3
headaches/facial pain
Chewing claudication - pain after chewing
◊ Occlusion of central retinal artery - blindness
119
remember Giant cell (temporal) arteritis is a facial pain emergency - if suspected as risk of blindness
120
what is the presentation of Polymyalgia rheumatica?
Mainly seen in shoulder and hip regions
Morning pain and stiffness of muscles
121
name 2 medium vessel vasculitic diseases
Polyarteritis nodosa
Kawasaki disease
122
Kawasaki disease mainly affects adults or children?
children - mucocutaneous lymph node syndrome
123
what are the clinical features of Kawasaki disease? 4
Fever and lymphadenopathy
Crusting/cracked tongue
Strawberry tongue and erythematous mucosa
Peeling rash on hands and feet
124
how is Kawasaki disease treated?
steroids and may need antibiotics to recover
125
name a small vessel vasculitic disease
Wegener's Granulomatosis
126
what is Wegener's granulomatosis?
Inflammatory condition that can lead to destruction of hard and soft tissues of the face and oral cavity
127
what is the antibody found in Wegener's granulomatosis?
antineutrophil
128
what is the appearance of Wegener's granulomatosis?
spongy red - almost strawberry like
129
what is the dental impact of vasculitis disease?
steroid precautions
- Giant cell arteritis
- Wegener's granulomatosis
- Kawasaki disease
130
when is the term fibromyalgia used?
- Used when there are symptoms but no evidence of disease - joint and muscle pain and functional disorders
131
is there a cure for connective tissue diseases?
no as there is no known cause
132
what is the management of connective tissue diseases, both immune and vasculitic? 4
Immunosuppression - dependant on the disease activity
Analgesics NSAIDs to manage joint/muscle symptoms
Immune modulating treatment
Systemic steroids - prednisolone
133
what is Sjögren's syndrome?
an autoimmune disease that causes chronic inflammation of the tear and saliva glands
134
orofacial features of sjogren's syndrome 8
Xerostomia and dry eyes
Erythema and lobulation of tongue
Difficulty talking and swallowing
Altered taste
Oral fungal and bacterial infections
Increased incidence of lymphoma
Tiredness
Salivary glands swelling
135
what is the management of Sjögren's syndrome? 2
Artificial saliva
- Orthana - oral spray - can prescribe on NHS - neutral pH
- Glandosane - oral spray - can prescribe on NHS - pH 5.75
- Salivese
- BioXtra/Biotene - can prescribe on NHS - close to neutral pH
- Salinum
Salivary stimulants
- Salivix pastilles - can prescribe on NHS - malic acid
- Sugar free gum
- Sugar free sweets
- Saliva stimulating tablets
136
how are fungal infections managed (candida)
Anti-fungals
- Nystatin (rinse)
- Miconazole (gel)
137
what chairside advise is given to a pt with sjogren's syndrome? 4
Topical fluoride application
OHI
Dietary advice - sugar free
Atomiser - water
138
how is Sjögren's syndrome managed during appts? 6
Vaseline to lips
Lubricate mucosa with 3-in-1
Wet mirror
Retract tissues with wet swab
Offer water frequently
Avoid suction where possible
