Rheumatoid arthritis

Question 1

Definition of rheumatoid arthritis

Answer 1

Autoimmune inflammatory disease which mainly affects the joints (symmetrical polyarthritis).

Question 2

Early signs of rheumatoid arthritis

Answer 2

Symmetrical synovitis of MCP, PIP and wrist joints.
Joint swelling, stiffness and pain.

Question 3

Late signs of rheumatoid arthritis

Answer 3

Deviation of fingers and thumb:
Ulnar deviation of fingers at MCP joints
Hyperextension of PIP joints - ‘swan neck deformity’
‘Z’ deformity of thumb - hyeprflexion of MCP & hypertension of IP joint
Subluxation of the wrist
Flexion of elbows and knees
Deformity of feet and ankles

Question 4

Psoriatic arthritis

Answer 4

A form of arthritis that affects people with psoriasis.
Affects about 30% of people with psoriasis.

Question 5

Rheumatoid arthritis risk factors

Answer 5

Females
Middle age
Family history
Smoking
Obesity

Question 6

Rheumatoid arthritis investigations

Answer 6

1. Medical history - symptoms? family history?
2. X-rays/MRI/ultrasound - will not show joint destruction in early stages
3. Blood test - high ESR & high CRP, Rheumatoid factor (note : RF can also be present in people without RA).

Question 7

Rheumatoid arthritis treatment

Answer 7

Physiotherapy = active & passive exercises to maintain muscle activity and improve joint stability.

Occupational therapy = provides aids and maximises ability for independent living.

Drug therapy = Analgesics (paracetamol/cocodamol), NSAIDs, DMARDs (hydroxychloroquine/methotrexate), steroids (intra-articular or oral prednisolone), immune modulators (azathioprine/mycophenolate), biologics (infliximab/abalimumab/rituximab).

Surgery = joint replacement (loss of function).

Question 8

RA dental aspects

Answer 8

Reduced dexterity - trouble with OH
Possible sjögren’s syndrome - dry mouth, high caries risk
Increased bleeding risk = NSAIDs
Infection risk = steroids
Oral lichenoid reactions = hydroxychloroquine
Oral ulceration = methotrexate
Oral pigmentation = hydroxychloroquine

Question 9

What are seronegative spondyloarthropathies?

Answer 9

Family of joint disorders:
- ankylosing spondylitis
- psoriatic arthritis
- inflammatory bowel disease associated arthritis
- reiter’s disease/reactive arthritis
- undifferentiated SpA

RF and anti-CCP antibodies are not elevated.

Question 10

Features of spondyloarthritis

Answer 10

Association with HLA-B27, infection likely as a precipitant (genetic predisposition and environmental trigger).
Often symmetrical peripheral arthritis.
Ocular and mucocutaneous manifestations in Reiter’s syndrome.

Question 11

Ankylosing spondylitis risk factors

Answer 11

Family history and HLA-B27 gene.
Age - under 30 years
Gender - men (x2 more likely)

Question 12

What is ankylosing spondylitis?

Answer 12

An inflammatory disease which can cause spinal vertebrae to fuse overtime.

Question 13

Symptoms of ankylosing spondylitis

Answer 13

Limited back and neck movement
Lower back pain
Kyphosis (cervical spine tipped forward)
Limited chest expansion if ribs are affected (compromised breathing).

Question 14

Ankylosing spondylitis treatment

Answer 14

Generally same treatment as RA.
Analgesia and NSAIDs
Physiotherapy and occupational therapy
DMADs
Immune modulators
Surgery

Question 15

Dental aspects of ankylosing spondylitis

Answer 15

Difficulty treating pt. - can’t lie flat on dental chair.
GA hazardous - limited mouth opening and limited neck flexion.
TMJ involvement is possible - rare except in psoriatic arthritis.