Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
- disease of the synovial with gradual inflammatory joint destruction
What are the two different patterns of joint involvement in rheumatoid arthritis?
- seropositive rheumatoid arthritis
- rheumatoid factor present
- seronegative rheumatoid arthritis
- rheumatoid factor not present
How can the typical pattern of rheumatoid arthritis be described and what joints does it affect?
symmetrical polyarthritis affecting all synovial joints in the body (toes, ankles, knees, arms, shoulder, neck)
What are the symptoms of rheumatoid arthritis?
- slow onset
- starts with hands and feet
- proximal spread
- potentially all synovial structures
- symmetrical
- onset with systemic symptoms
- fatigue
- numbness and tingling
- weight loss
- anaemia
- joint swelling, stiffness and pain
What are the early signs of rheumatoid arthritis?
- symmetrical synovitis of metacarpal phalangeal joints
- symmetrical synovitis of proximal phalangeal joints
- symmetrical synovitis of the wrist joints
What are the late signs of rheumatoid arthritis?
- joint integrity is lost so direction is not controlled, movement is not restricted
- ulnar devotion of the fingers at the metacarpal phalangeal joint
- hyperextension of the proximal phalangeal joints
- “swan neck deformity”
- destruction of bone ends
- tendon pulls bone back further
- “Z” deformity of thumb
- hyperflexion of metacarpal joint
- hyperextension of proximal pharyngeal joints
- ‘boutonniere deformity)
- subluxation of wrist
- loss of abduction and external rotation of shoulders
- deformity of feet and ankles
What are the possible extra-articular features of rheumatoid arthritis?
- systemic vasculitis
- inflammation of blood vessels
- psoriasis
- more aggressive forms of rheumatoid arthritis
- usually younger patients
- ‘psoriatic’ arthritis
- eye involvement
- scleritis and episcleritis
- dry eyes
- Sjögren’s syndrome
- subcutaneous nodules
- pressure points
- amyloidosis
- amyloid produced as a result of synovial inflammation
- pulmonary inflammation
- neurological effects
What investigations are performed for rheumatoid arthritis and what do they look for?
- radiographs
- erosions
- loss of joint space
- deformity
- joint destruction
- secondary osteoarthritis
- blood
- normochromic normocytic anaemia
- CT and MRI
- joints
- increasingly used
How is rheumatoid arthritis treated?
- physiotherapy
- maintain current function and action
- occupational therapy
- maximise independent living
- drug therapy
- slow disease process
- reduce pain
- surgery
- replacement joints when stability is lost
- restoration of function
What is the aim of physiotherapy for rheumatoid arthritis and what does it involve?
- keep the patient active for as long as possible
- delay onset of debilitating disease
- active and passive exercise
- maintains muscle activity
- improves joint stability
- maintains joint position
What is the aim of occupational therapy for rheumatoid arthritis and what does it involve?
- maximising residual function
- providing aids to independent living
- assessment and alteration of home
- facilitating a safe and healthy life
- specialised utensils, wet room, stair lift etc.
What is the aim of drug therapy for rheumatoid arthritis in the majority of cases and what does it involve?
- pain relief and potential slow of disease progression
- analgesics
- paracetamol
- cocodamol
- NSAIDs
- often combined with anti-peptic ulcer disease agent
- disease modifying drugs
- hydroxychloroquine
- methotrexate
- used to slow immune process therefore damage to joints
- less commonly sulphasalazine, penacillamine, gold
- steroids
- intra-articular injections
- to target particular areas of inflammation
- common in early and moderate stages of disease
What is the aim of drug therapy for rheumatoid arthritis in moderate and severe cases and what does it involve?
- immune modulators
- azathioprine
- mycophenolate
- biologics
- TNF alpha inhibitors (infliximab, adalimumab, etanercept)
- leukocyte modulators (rituximab-CD20, tocilizumab-IL6r)
- steroids
- oral prednisolone
What is the aim of surgery for rheumatoid arthritis and what does it involve
- restoration of joint function
- excision of inflamed tissue
- inflamed synovial causes joint destruction
- joint replacement
- dysfunctional joint removed
- replaces with prosthetic joint
- joint fusion
- osteotomy
What is the prognosis for rheumatoid arthritis?
- 10% have spontaneous remit
- 90% have fluctuating course
- rheumatoid factor and late onset have worse prognosis
- 10% severely disabled
- 90% mild/moderate disability
- gets worse with time, can be slowed with medication
What are the dental aspects of rheumatoid arthritis?
- disability from disease
- reduced dexterity
- access to care challenging
- Sjögren’s syndrome
- connective tissue disease
- dry eyes and mouth
- potential increased caries risk
- joint replacement
- multiple large and small joints
- drug effects
- increased bleeding
- NSAIDs
- sulphasalazine - infection risk
- steroids
- azathioprine - oral mucosal lichenoid reactions
- gold
- sulphasalazine
- hydroxychloroquinine - oral ulceration
- methotrexate - oral pigmentation
- hydroxychloroquinine
- increased bleeding
- chronic anaemia
- GA problems
What is Atlanta-occipital instability?
- increased risk of damage to the ligaments in the neck
- ligaments attached to the dens of the axis
- ligament more likely to rupture
- bones impinge on spinal cord
- significant damage caused
- important consideration for general anaesthetics
What are seronegative spondyloarthritides
- seronegative disease affecting mostly the axial skeleton
- ankylosing spondylitis
- spinal joint arthritis
- Reiter’s disease
- arthritis of irritable bowel disease
What is ankylosing spondylitis?
- disabling progressive lack of axial movement
- fusion of the facet joints in the vertebrae
- vertebrae not able to move relative to each other
- other symmetrical joints affected
- hips
- symptoms
- low back pain
- limited back and neck movement
- reduced flexing, bending and twisting
- rigidly focussed ahead - limited chest expansion
- chest compressed by fused spinal joints
- respiratory diseases may be made worse - cervical spine tipped forward
- kyphosis
- spine tips due to bone fusion
What are the features of seronegative spondyloarthritides?
- associated with HLA-B27 (human leukocyte antigen)
- infection may act as a precipitant
- environmental factor may act as trigger
- symmetrical and peripheral arthritis
- ocular and mucocutaneous manifestations
- Reiter’s syndrome
How is ankylosing spondylitis treated?
- same as rheumatoid arthritis?
- analgesia and NSAIDs
- physiotherapy
- oculomotor therapy
- disease modifying drugs
- immune modulators
- joint replacement surgery
- different biologics used
What are the dental aspects of ankylosing spondylitis?
- GA hazardous
- limited mouth opening
- limited neck flexion
- difficult to access service
- cannot lie flat
- access to mouth challenging
- TMJ involvement
- possible but rare
- common is psoriatic arthritis
