Rheumatoid arthritis Flashcards
What is the definition of Rheumatoid Arthritis?
A chronic auto immune systemic illness characterised by a symmetrical polyarthritis and other systemic features.
Which joints are most commonly affected by Rheumatoid Arthritis?
Small joints of hands (MCPs, PIPs), wrists, and feet (MTPs).
What is the prevalence of Rheumatoid Arthritis in the general population?
Approximately 1% of the population.
What is the female to male ratio for Rheumatoid Arthritis?
3:1.
More females
At what age does Rheumatoid Arthritis typically onset?
Peak age in the 4th/5th decade but may occur at any age from 16 years.
What is the genetic contribution to the incidence of Rheumatoid Arthritis?
Estimated to be ~50-60%.
Genetic predisposition
HLA-DRb1 gene - common gene in RA
Name environmental factors that contributes to Rheumatoid Arthritis.
Cigarette smoking.
Chronic infection e.g. periodontal disease (p.gingivalis)
EBV and parvovirus B19
What are some symptoms of Rheumatoid Arthritis?
Joint pain
Morning stiffness >30 mins
Immobility
Poor function
Systemic symptoms
List some specific extra-articular manifestations of Rheumatoid Arthritis.
- Eyes
- Lungs
- Nerves
- Skin
- Kidneys
What is the significance of gum disease in patients with Rheumatoid Arthritis?
65% of RA patients had gum disease compared to 28% of non-RA patients.
What are common laboratory tests for investigating Rheumatoid Arthritis?
- FBC
- Kidney function
- Liver function
- CRP
- ESR
What is the purpose of the Disease Activity Score (DAS28)?
To assess disease activity in Rheumatoid Arthritis.
What type of drugs are DMARDs?
Disease Modifying Anti Rheumatic Drugs
Biologic therapy, targeted synthetic, conventional synthetic DMARDs
TNF-a inhibitors
What is a key characteristic of biologic DMARDs?
They target key aspects of the inflammatory cascade and are typically large complex proteins.
Name one class of biologics used in the treatment of Rheumatoid Arthritis.
TNFα inhibitors.
True or False: Biologics come with a higher cost compared to traditional DMARDs.
True.
What is a common oral health issue associated with RA medications?
Increased risk of infections, including thrush.
What should be done with DMARDs/Biologics if there is an ongoing infection?
They should be withheld.
What is a common recommendation for RA patients experiencing mouth dryness?
Frequent sips of water and using sugar-free gums.
Rheumatology?
medical specialty that focuses on diagnosing and treating conditions that cause inflammation in the muscles, bones, joints, and internal organs.
Aetiology of RA?
Genetic
Environmental
Hormonal
what are hormonal contributing factors to RA?
Early age menopause, low testosterone level in men
Pathogenesis of RA?
Smoking / genetic factors
Gene starts to change, produce foreign protein
Lymph node and spleen react to foreign body - immune response
Citrulline
Local inflammation
Produce anti citrulline peptide
activation of osteoclasts
Second hit: immune complexes, increased vascular permeability, complement fixation
- destruction of joint tissue
signs of RA?
Joint swelling
Tenderness
Warmth, redness
Limitation of movement
Sign of early RA>
synovitis
Non specific systemic/extra-articular symptoms of RA?
Fatigue/lassitude
Weight loss
Anaemia
Long term systemic symptoms of RA?
CVS
Malignancy
Extra-articular manifestations of RA?
RA increase gum disease?
Yes, perio and gingivitis
TMJ pain also
- Bacteria like P. gingivalis and Aggregatibacter actinomycetemcomitans (Aa) are present in both RA and gum disease
- RA medication can cause oral health problems
- Joint problems can make it difficult to clean your teeth
Poor OHI can trigger RA too
TMJ and RA?
Pain, swelling, limitation of the jaw opening
RA and Sjögren’s syndrome?
Autoimmune condition affecting salivary and tear gland result in lack of
salivary and tear secretion cause significant dryness of mouth and eye.
Coincide with RA
Joint in hand affected by RA?
MCP
Management of RA?
- Early and aggressive intervention is the key to obtaining optimal outcomes in the management of RA
- Effective suppression of inflammation will improve symptoms and prevent joint damage and disability
- stop osteoclasts from eroding joints
pharmacological therapy for managing RA?
Meds take 3 months to work
- give anti-inflammatory , if need more then steroid.
DMARD therapy?
Disease Modifying Anti Rheumatic Drugs
(conventional, non biologic)
A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have slow onset effect on disease activity and retard disease
progression. Traditionally, these have been associated with identifiable toxicity profiles and risk of occasional serious adverse event.
classes of biologics?
- TNFα inhibitors (x5)
- IL-1 inhibitors (Anakinra)
- Anti B Cell therapies (CD20, Rituximab)
- Anti T Cell therapies (Abatacept)
- IL-6 inhibitors (Tocilizumab, Sarilumab)
- Oral kinase inhibitors
Issues with biologics?
Toxicity: minor eg injection site reaction
Increase risk of Infection
Malignancy
Cost: £9500 Vs. £50
Effect of RA medications on the mouth?
1- Increase risk of infections including thrush
2- Methotrexate can cause mucositis which can lead to mouth ulcers.
- especially in higher dodse or if they forget to take folic acid.
3- Remember to withhold DMARDs/Biologics if there is ongoing
infection requiring antibiotic or if they are going to complex dental procedure.
Targeted synthetic DMARDs (tsDMARDS)?
Inhibitors with low selectivity, inhibiting the signalling of the broad range cytokines
role of conventional synthetic DMARDs?
Non-targeted suppression of the overactive immune system
example of csDMARDs?
Methotrexate
RA patients and oral health? Summary
-Rheumatoid patients needs regular follow up with dentists and Oral hygienist to ensure eradication of oral infections.
- Withhold DMARDs /Biologics If you are dealing with Infection
and consult with us if you are planning oral surgery.
- with Mouth Dryness
Frequent sips of water , avoid Tea , Coffee and Tobacco
Sugar free gums, Artificial saliva and high Florid tooth paste.
- Remember TMJ and cervical disc disease involvement when you examine RA patients.
