Rheumatolgy Flashcards
What does arthritis mean
Inflammation of the joints
What is arthrosis?
Non inflammatory joint disease
What is arthralgia
Joint pain
When are parathyroid glands at risk
During thyroid gland surgery
What is the function of parathyroid hormone
Maintains serum calcium level
Increases calcium release from bone
Reduces renal calcium excretion
What do both primary and secondary hyperthyroidism both result in?
They both result in increased bone re absorption
Give some reasons that people may experience low vitamin D
Low sunlight exposure - housebound, dark skinned in northern country
Poor GI absorption - poor nutrition or small intestinal disease leading to malabsorption
Drug interactions - carbamazepine, phenytoin
Why may people with dark skin in Northern countries experience
vitamin D problems
This is because there skin absorbs sunlight less efficiently due to pigment in the skin.
What is osteomalacia?
The bone is formed normally, the normal osteiod matrix is formed however it is not calcified properly.
Normal amounts of osteiod but INADEQUATE mineralisation of the tissue making the bone more soft
What is osteoporosis?
The mineral and matrix are correct however there is less of it so the correct bone mass is not achieved
The bone that is there is normally mineralised there but there just isn’t enough of it.
Osteomalacia is the term given to this disease after bone formation is completed, what is called if it happens during bone formation and why do the bones bend
Rickets
They are both related to calcium deficiency, the serum calcium is preserved at the expense of bone mineralisation.
Therefore when calcium is in short supply during one formation the bones that are formed are soft and tend to bend to pressure
What are three things that are important to test when testing for osteomalacia and how would they present
Serum calcium - decreased
Serum phosphate - decreased
Alakaline phosphatase - very high
When is peak bone mass age
24-35 years
As grow older bone mass reduces
Why do males have a higher peak bone mass than women
Peak bone mass is artificially boosted by oestrogen but as this is los during menopause that protection is lost and there is a rapid decrease in bone mass, it will even out.
Peak with me is higher therefore it takes men longer to loose enough bone mass to reach the osteoporosis point that it does for women.
What is kyphosis and what disease is this a effect of
This is the bending forward of the spine and this causes the vertebral bodies to collapse due to the upper body weight.
This can be seen in osteoporosis
What is scoliosis and what can this be seen as an effect od
Shifting of the lateral vertebrae caused by the upper weight compression causing them to stoop forward
This can be seen as an effect of osteoporosis
What are two ways to increase your peak bone mass
Excercise and high dietary calcium intake
As much as hormone replacement therapy can reduce a persons risk of osteoporosis what can it increase the risk of
Breast cancer and endometrial cancer risk
How do biphosphonates prevent osteoporosis
They act to prevent osteoclast action by poisoning osteoclasts and reducing their numbers
The reduction in osteoclasts, means there is less bone removed and more bone mass preserved
What is the relevance of bisphophonates to dentistry
Must be careful when extracting teeth and must always refer to SDCEP guidelines
What are three symptoms patients may complain of when they experience joint pain?
Pain
Immobility stiffness
Loss of function
Why might someone get bony swelling?
If the inflammatory process has taken place over many years and caused osteophytes to form at the edges of the joints
What is crepitus
Noise made by the bone ends moving usually associated with the loss of normal cartilagenous covering of bone ends
What is arthrogrpahy
Radiopaque die is injected into the joint to outline the articular surfaces and the joint capsule
what are two common causes of acute monoarthropathies ( actute arthritis of a single joint)
Infection - septic arthritis
Crystal arthopathy - gout
What is gout caused by
In gout Uric acid crystals are deposited in the joints and these crystals cause irritation to the joint surface which causes swelling and inflammation
This causes significant pain
Why can gout be seen following chemotherapy
Uric acid is a metabolic product from nucleic acid, so following chemotherapy the cancer treatment will have killed cancer cells and the nucleic acid from these cells will be processed producing a large surge in Uric acid in the blood.
How can gout be prevented in a patient receiving chemotherapy be prevented from developing gout
The effects if gout can to some extent be reduced by pre-hydrating the person so their renal flow and renal out put are maximised before the chemo starts and then as nucleic acids are broken down they are washed away before the uric acid blood plasma levels get too high
What kind of drugs can cause hyperuricaemia
Thiazide diuretics
What is hyperuricaemia?
High uric acid levels in the blood
What drug would the dentist avoid prescribing to a patient that has gout
Avoid aspirin
This interferes with uric acid removal
Allopurinol is a treatment given to lower uric acid levels in the blood. What dental side affect can this cause
This may cause oral ulceration
What happens in osteoarthritis
As the cartilage does not repair properly over many years the cartilaginous layers on the top of the bone ends becomes thinner and thinner until it disappears all together
Radiographically what are the signs of osteoarthritis
There will be a loss of joint space - because the cartilaginous layer has been reduced
There will be subdural sclerosis - thickening of the bone under the cartilaginous layer as the bone is having more force transmitted to it because of the less cushioning from the cartilage.
For osteoarthritis there is no treatment that can alter the disease progression.
What is prosthetic replacement used for?
This is used for PAIN rather than a functional problem
Pain is often the limiting factor in this disease.
What is a dental aspect of osteoarthritis
These patients may have difficulty in accessing care
Their limited mobility may lead them to have difficulties with oral hygiene and accessing the surgery
What are the two different patterns of joint development in rheumatoid arthritis
Sero-positive RA — rheumatoid factor preset
And
Sero-negative RA- rheumatoid factor NOT present
This significantly changes the pattern of diease
Name three symptoms of rheumatoid arthritis
Morning stiffness
Joint stiffness
Minor joint swelling
Numbness and tingling
What kind of arthritis is rheumatoid arthritis
Symmetrical polyarthritis
Why are there sometimes systemic symptoms in rheumatoid arthritis
Systemic symptoms are due to the fact that rheumatoid is simply a manifestation of a systemic illness which is being targeted at synovial joints with rather internal tissues
What pharyngeal joints are affected in osteoarthritis
Distal pharyngeal joints
What joints in the fingers can exhibit symmetrical synovitis as an early sign of rheumatiod arthritis
Metacarpal pharyngeal and proximal interproximal joints
If a patient presents to you with swan neck deformity of the fingers, ulnar deviation of metacarpophalangeal joints and bony deformity of the thumb.
What could this possibility be a late sign of
Rheumatoid arthritis
What is a late presenting symptom of RA which may be seen to the dentist?
Sjögren’s syndrome
How is RA treated
It is holistic management -aiming to improve the quality of the patients life. Aim to keep the patient active for as long as possible.
Aim to maintain current function of the patient
Drug therapy is also used.
What are some dental aspects of RA
Disability from disease - leads to reduced dexterity and limited access too care
Sjögren’s syndrome - dry eyes and mouth
Drug effects - bleeding (NSAIDS), oral ulceration from methotrexate
What is atlanto-occipital instability
Ligaments can become weakened and can lead to slipping of structures in the upper neck.
Sudden trauma to the neck more likely the ligaments will rupture and bones will impinge into space intended for spinal cord causing significant damage.
Must be careful in GA as ligaments don’t provide sufficient support of RA patient
What is the difference between ankylosing spondylitis and rheumatoid arthritis.
Difference from RA is that the primary focus of the disease is the axial skeleton whereas RA affects peripheral tissues more but it can affect the spine
In ankylosing spondylitis fusion of the vertebrae cause issue to turn and twist and bend.
What disease is HLA-B27 associated with
Ankylosing spondylitis
What is kyphosis
Loss of vertebral height anteriorly meaning spine will gradually tip forward- this is due to bone fusion
What are the dental aspects of someone with ankylosing spondylitis
GA can be hazourdous for these patients as they have limited mouth opening and limited neck flexion.
They can be difficult to treat as they cannot lie flat in the chair due to the curvature of their spine and access to the patients mouth can be tricky
Why would drugs such as hyrdoxychloroquine and methotrexate ( disease modifying drugs) be used in the treatment of rheumatoid arthritis?
This is because it is an immune based diease
These drugs will slow down the immune process and slow the destruction of the joints
Why s the gender predomiance in ankylosing spondylitis unusual?
Because it is predominantly males that are affected by this disease which is unusual in autoimmune diseases
What is the main affect of ankylosing spondylitis?
Disabling progressive lack of axial movement
The patients spine does not flex and bend and twist.
This results in low back pain, limited back and neck movement and often there breathing can be compromised
What are vasculitic diseases and how are they categorised?
They are problems within the blood vessel wall and it is categorised by the size of the verse
Generally how are connective tissue diseases managed
They are managed dependant on disease activity - mainly through immune suppression - through immune modulating treatment such as hydroxychloroquine and methotrexate.
What is the connective tissue disease that has every system involved?
Lupus
How does systemic lupus erthymatosis present in the mouth
Looks similar to lichen planus
What diease would butterfly zygomatic rash be seen in?
Systemic lupus erythematosis
This is photosensive reaction and it affects this area as it is the most exposed to sunlight
What are some dental aspects of SLE?
Chronic anemia - leading to an oral ulcerations risk
Lichenoid oral reactions
Bleeding tendency - thrombocytopenia ( check platelet count)
Why is GA a risk in patients with SLE
Due to their risk of chronic anaemia
What is an oral consequence of hydroxychloroquine use
It can cause oral pigmentation on the palate
Looks like Black shadow on roof of mouth
What is the lupus anticoagulant
This is a marker found in the blood of some patients with lupus. It anticoagulates blood in a test tube but not in a patient.
It indicates a ‘subtype’ of lupus patient
What is antiphospholipid antibody syndrome characterised by?
Recurrent thrombosis.
These patients are anticoagulated with warfarin and tend to deal well
Why should anticoagulant treatment never be stooped in anti-phospholipid antibody syndrome
Because the thrombosis risk will quickly come back and the patient will be at risk of a fatal Pulmonary embolism
What are the three associated ( not causing) antibodies of Sjögren’s syndrome
ANA,Ro and La
What are the main systems associated with Sjögren’s syndrome
Dry eyes and dry mouth
Major involvement of salivary glands and can lead to xerostomia and oral disease
What is systemic sclerosis
It is when the elsastic tissue of the body is replaced by connective fibourus tissue - excessive collagen deposition
Therefore loosing the ability to be able to stretch and bend tissues.
What are some hidden interaction problems that can happen in systemic sclerosis
Elastic tissue has been lost internally.
The oesphagous will not be able to allow the food bolus to pass
The gut will not allow the easy peristalsis of food
What are some dental aspects of systemic sclerosis?
Limited mouth opening - not possible to do most resortative work or extractions
Limited tongue movement
Due to the connective tissue changes there will be widening of the periodontal ligament space and therefor no dental mobility
How may giant cell arteritis present to the dentist
Headache/facial pain
It affects distribution of ECA up the side of the neck and also inside face and into the central artery of the retina ( blindness)
What is poly myalgia rheumatica?
It is a diesease of the elderly with affects large blood vessels. It affects mainly around the shoulder hip and joint region
Pain and morning stiffness
What kind of blood vessel disease is Kawasaki disease
Medium vasculitic disease
What would you see clinically in Kawasaki diease and who does it mainly affect?
It is mainly a disease of children
Fever and lymphadenopathy
Crusting cracked tongue
Strawberry tongue
Peeling rash on hand and feet
What is wegeners granuloatosis and how does it present orally
It is an inflammatory condition of the small blood vessels
It can lead to destruction of hard and soft tissues of teh face and oral cavity
When is fibromyalgia used as a diagnosis
Used by rheumatologists when there are symptoms without any evidence of active diease
Systems would be muslce and joint pain but there is nothin found on examination
