Rheumatoid Arthritis

Question 1

what is rheumatoid arthritis

Answer 1

initially a disease of the synovium with gradual inflammatory joint destruction
multi system disease & different joint patterns seen
it is a symmetrical polyarthritis that can affect all joints in the body
most common serious join disease peaks 20-50yrs of age 6:1 females pre menopause, 3:1 post menopause

Question 2

2 types of rheumatoid arthritis

Answer 2

different pattern of joint involvement
1. sero-positive RA; rheumatoid factor (RF) present
2. sero-negative RA; RF not present

Question 3

early signs of RA

Answer 3

• symmetrical synovitis of MCP joints (metacarpal phalangeal)
• symmetrical synovitis of PIP joints ( proximal interphalangeal)
• symmetrical synovitis of wrist joints

Question 4

symptoms of RA

Answer 4

slow onset; initially hands & feet, proximal spread, potentially all synovial structures
symmetrical polyarthritis
occasional onset with systemic symptoms i.e. fever, weight loss, anaemia, morning stiffness, joint stiffness, pain

Question 5

late signs of RA

Answer 5

• ulnar deviation of fingers at MCP joints
• hyperextension of PIP joints ‘swan neck’ deformity
• ‘Z’ deformity of thumb; hyperflexion of MCP & hyperextension of IP joint
• lost ability to maintain directional integrity
• subluxation of wrist
• loss of abduction & external rotation of shoulders
• deformity of feet & ankles

Question 6

extra articular features of RA

Answer 6

• inflammation of blood vessels due to systemic vasculitis
• psoriasis
• eye involvement - scleritis, dry eyes, sjogrens
• subcutaneous nodules
• amyloidosis
• pulmonary inflammation

Question 7

investigations regarding RA

Answer 7

radiographs: erosions, loss of joint space, deformity, joint destruction, 2ndary osteoarthritis
blood: normochromic, normocytic anaemia

Question 8

treatment of RA

Answer 8

holistic
aim to improve quality of life via physio, occupational therapy, surgery, drug therapy

Question 9

drug therapy in most cases of RA

Answer 9

analgesics - paracetamol / co-codamol
NSAIDs - often combined with anti-PUD agents
disease modifying drugs - methotrexate
steroids - intra articular

Question 10

drug therapy in moderate / severe cases

Answer 10

immune modulators - azathioprine
biologics - TNF alpha inhibitors e.g. infliximab

Question 11

surgery options in RA

Answer 11

excision of inflamed tissue
joint replacement / fusion

Question 12

dental aspects of RA

Answer 12

disability from disease - reduced dexterity/access to care
sjogrens - dry eyes / mouth
drug effects:
bleeding - NSAIDs & sulphasalazine
infection risk - steroids. azathioprine
oral lichenoid reactions
oral ulceration - methotrexate
chronic anaemia - GA problems

Question 13

seronegative spondyloarthritis v RA

Answer 13

differs in that SS is focussed mostly on axial skeleton
ankylosing spondylitis - fusion of facet joints & anterior aspect of vertebrae which becomes stiff so difficult for ptx to twist & bend

Question 14

features of SAs

Answer 14

association with HLA-B27
infection likely as a precipitant
often symmetrical peripheral arthritis
ocular & mucocutaneous manifestations

Question 15

effects of ankylosing spondylitis

Answer 15

disabling progressive lack of axial movement
lower back pain
limited back & neck movement
limited chest expansion
kyphosis - here due to bone fusion, in OA due to bone loss

Question 16

treatment for AS

Answer 16

same as RA:
analgesics & NSAIDs
physio
occupational therapy
disease modifying drugs
immune modulators

Question 17

dental aspects of AS

Answer 17

GA hazardous - limited mouth opening & neck flexion
TMJ involvement rare but possible