Rheumatoid Arthritis Flashcards
What is rheumatoid arthritis?
Initially is a disease of the synovium with gradual inflammatory joint destruction
There are different patterns of joint involvement in rheumatoid depending on what?
if the patient is sero-positive (rheumatoid factor present) or sero -negative (no rheumatoid factor present)
Rheumatoid affects what sex more?
Females
What joints does rheumatoid arthritis affect?
Synovial joints
It is a symmetrical polyarthritis (affects more than one joint and symmetrical joints)
Note: the changes in the joint are diff from osteoarthritis
What are the symptoms of rheumatoid arthritis?
- slow onset (initially hands and feet then proximal spread then potentially all synovial joints)
- joint pain
- joint stiffness
- minor joint swelling
- fatigue
- morning stiffness
- numbness and tingling
- decrease in range of motion
- occasionally systemic symptoms such as fever, weight loss and anaemia
Whata are some early signs of RA?
- Symmetrical synovitis of the metacarpal pharyngeal joints (MCP)
- Symmetrical synovitis of the proximal interpharyngeal joint (PIP)
- Symmetrical synovitis of the wrist joints
What are some late signs of RA to do with the hand?
- ulnar deviation of fingers at MCP joints (tendons pull fingers to ulnar side of the hand)
- hyperextension of PIP joints
- “swan-neck” deformity
- “Z” deformity of thumb
- hyperflexion of MCP
- hyperextension of IP joint
The bones are no longer restricted in the way in which they can move - can hyperextend
Why is it harder for patients with RA to grip?
tendons arent pullings the fingers in the right direction to allow it
What are some late symptoms of RA (not to do with the hand)?
- subluxation of the wrist
- Pull of tendons move them out of position
- loss of abduction and external rotation of shoulders
- flexion of elbows and knees
- deformity of the feet & ankles
Patient would have significant loss of function - can’t grip, lift or walk
What’s the diff in why patients with RA get joint replacement than patients with osteoarthritis?
OA is for the pain
RA is to replace function
What are some extra-articular features of RA?
- •Eye involvement
- •scleritis & episcleritis,
- •dry eyes, Sjögrens syndrome
- •Subcutaneous nodules
- •pressure points
- •Amyloidosis
- •Pulmonary inflammation
- •Neurological
- Inflammation of blood vessels
What investigations can be done for RA?
- Radiographs
- erosions, loss of joint space, deformity
- joint destruction & secondary osteoarthritis
- CT and MRI increasingly used
- Blood
- normochomic, normocytic anaemia
What treatments are there for RA? What is the aim of these treatments?
Aim to improve quality of life and maintian current function of joints as much as possible to keep P independent.
Treatment is a holistic management with combo’s of:
- physiotherapy
- occupational therapy
- drug therapy
- surgery
What is done in physio as treatment for RA and why? What is the aim of this treatment?
Aim is to keep the patient active for as long as possible!
- active and passive exercises
- to maintain muscle activity
- to improve joint stability
- to maintain joint position
What is done with occupational therapy for patients with RA?
- maximising the residual function
- providing aids to independent living
- assessment & alteration of home
What drugs are RA patients on in most cases?
- analgesics
- paracetamol, cocodamol
- NSAIDs
- Often combined with anti-PUD agents
- Disease Modifying Drugs
- hydroxychloroquine, methotrexate,
- Less commonly now: sulphasalzine, penacillamine, gold,
- Steroids - intra-articular (into the joint space that has inflammation)
In more severe RA cases, what other drugs might the P be on?
- Immune modulators
- Azathioprine
- Mycophenolate
- Biologics
- TNF inhibitors - infliximab, adalimumab, entanercept
- Rituximab (CD20) & tocilizumab (IL6r)
- Steroids – oral prednisolone
What are the surgery options for patients with RA?
- excision of inflamed tissue
- joint replacement
- joint fusion
- osteotomy
Note: Remember that the patients often have a poor medical condition for surgery
Whats the prognosis for patients with RA?
- 10% spontaneously remit
- remainder have fluctuating course
- RF and late onset have worse prognosis
- 10% severely disabled
- remainder have mild/moderate disability
What complications of RA should you remember?
- infection
- peptic ulcer disease
- extra-articular
- Drugs
What are the dental aspects of the disease?
- disability from the disease
- reduced dexterity
- access to care
- Sjögren’s syndrome
- Joint replacements
- multiple - large & small joints
- dont normally need prophylaxis
- Drug effects
- Chronic anaemia (GA problems and dont give sedation outwith hospital)
What drug effects of RA should we be aware of as dentists?
- bleeding - NSAIDs & sulphasalazine
- infection risk - steroids, azathioprine
- oral lichenoid reactions
- gold, sulphasalazine, hydroxychloroquine
- oral ulceration - methotrexate
- oral pigmentation – hydroxychloroquine
Patients with RA may have atlanto-occipital instability, what does this mean?
Theres damage to the ligaments in the neck which connect the face to the upper cervical vertebrae
If there was a sudden big trauma to the bck bigger chance of lgament rupture and cuase spinal damage
What is sero-negative spondyloarthritides?
Range of diff conditions that overlap .
Primary focus of the disease is on the axial skeleton
ankylsing spondylitis - The joints of the spine become inflamed and there is fusion of the vertebrae
What are the effects of ankylosing spondylitis?
- Disabling progressive lack of axial movement
- symmetrical other joint involvement – e.g.hips
Results in:
- low back pain
- limited back and neck movement – turning spine restricted (bone fusion)
- limited chest expansion – breathing compromised (bone fusion)
- cervical spine tipped forward (Kyphosis)
- movements restricted
How is ankylosing spndylitis treated?
- Generally the same as Rheumatoid Arthritis:
- Analgesia &NSAIDs
- Physiotherapy
- Occupational therapy
- DMDs
- Immune modulators
- Surgery where appropriate for joint replacement
What are the denta aspects of ankylosing spondylitis?
- GA hazardous
- limited mouth opening
- limited neck flexion
- TMJ involvement possible, but rare except in Psoriatic Arthritis
