Rheumatoid Arthritis and Seronegative Spondyloarthritides

Question 1

What is rheumatoid arthritis?

Answer 1

Initially a disease of the synovium with gradual inflammatory joint destruction

Question 2

How common is rheumatoid arthritis?

Answer 2

Most common serious joint disease
1% prevalence
6:1 female pre-menopause
3:1 female post-menopause
Peaks 20-50 years

Question 3

What are the symptoms of RA?

Answer 3

Slow onset
Initially hands and feet, proximal spread, potentially affecting all synovial structures
Symmetrical poly arthritis
Fever, weight loss and anaemia

Question 4

What are the early signs of RA?

Answer 4

Symmetrical synovisitis of MCP joints, PIP joints and wrist joints

Question 5

What are the late signs of RA?

Answer 5

Ulnar deviation of fingers at MCP joints
Swan neck
Z deformity of thumb
Subluxation of the wrist
Loss of abduction and external rotation of shoulders
Flexion of elbows and knees
Deformity of the feet and ankles

Question 6

What are the extra-articular features of RA?

Answer 6

Inflammation of blood vessels due to systemic vasculitis
Psoriasis
Eye involvement - scleritis, Sjögren’s syndrome
Subcutaneous nodules
Amyloidosis
Pulmonary inflammation
Neurological problems

Question 7

What investigations are carried out for RA?

Answer 7

Radiographs may show erosions, loss of joint space, deformity, joint destruction and secondary osteoarthritis
Bloods may show normochomic and normocytic anaemia

Question 8

How is RA treated?

Answer 8

Holistic management
Aim to improve quality of life
Combo of physiotherapy, occupational therapy, drug therapy and surgery

Question 9

How is physiotherapy used to treat RA?

Answer 9

Aim to keep the patient active for as long as possible
Active and passive exercises to maintain muscle activity, improve joint stability and maintain joint position

Question 10

How is occupational therapy used to treat RA?

Answer 10

Maximising the residual function
Providing aids to independent living
Assessment and alteration of home

Question 11

What drugs are used to treat most cases of RA?

Answer 11

Analgesics - paracetamol, cocodamol
NSAIDS
Disease modifying drugs - methotrexate
Intra-articular steroids

Question 12

What drugs can be used to treat moderate and severe cases of RA?

Answer 12

Immune modulators - azathioprine, biológicas such as TNF inhibitors
Steroids - oral prednisolone

Question 13

What surgeries can be used to treat RA?

Answer 13

Excision of inflamed joint
Joint replacement
Joint fusion
Osteotomy

Question 14

What is the prognosis for RA?

Answer 14

10% spontaneously remit
Remainder have fluctuating course
RF and late onset have worse prognosis
10% severely disabled
Remainder have mild/moderate disability

Question 15

What are the dental aspects of RA?

Answer 15

Disability from disease - reduced dexterity and access to care
Sjögren’s syndrome - association of CT disease and dry mouth
Joint replacements
Chronic anaemia - GA problems

Question 16

What are the drug effects of RA?

Answer 16

Bleeding - NSAIDS
Infection risk - steroids and azathioprine
Oral lichenoid reactions
Oral ulceration
Oral pigmentation

Question 17

Give examples of different rheumatology diseases?

Answer 17

Crystal arthropathies
Osteoarthritis
Rheumatoid arthritis
Sero-negative Spondyloarthitides

Question 18

Give examples of seronegative spondyloarthritides

Answer 18

Ankylosing spondylitis - spinal joint arthritis
Reiter’s disease
Arthritis of IBD

Question 19

What are the common features of SAs

Answer 19

Associated with HLA-B27 antigens
Infection likely as a cause
often is symmetrical peripheral arthritis
Has ocular and mucotaneous manifestations

Question 20

How common is ankylosing spondylitis?

Answer 20

95% of cases have HLA-B27
10% Caucasians have this antigen, 0.5% of these get it
8:1 males
Onset about 20 years
20% have large joint disease as well

Question 21

What are the effects of ankylosing spondylitis?

Answer 21

Disabling progressive lack of axial movement such as hips

Question 22

What can ankylosing spondylitis result in?

Answer 22

Low back pain
Limited back and neck movement
Limited chest expansion
Cervical spine tipped forward

Question 23

How is ankylosing spondylitis treated?

Answer 23

Generally same as RA:
- Analgesics and NSAIDS
- Physiotherapy
- Occupational therapy
- Disease modifying drugs
- Immune modulators
- Surgery where appropriate for joint replacement

Question 24

What are the dental aspects of ankylosing spondylitis?

Answer 24

GA hazardous as limited mouth opening and neck flexion
TMJ involvement possible but rare except in psoriatic arthritis

Question 25

What is ankylosing spondylitis?

Answer 25

Narrowed and inflamed discs causing fusion of the vertebrae