Rheumatology Flashcards
Rheumatology Definition
- Branch of medicine devoted to the diagnosis and therapy of rheumatic diseases
- Rheumatic disease: a condition that affects joint or connective tissue
Examples of rheutmatology diseases
Autoimmune ones:
- Rheumatoid arthritis
- Sjorgen’s syndrome
- Systemic Lupus Erythematous
- Scleroderma
Osteoarthritis
Aetiopathogenesis of autoimmune diseases
-Unknown cause
-Combination of genetic and environmental factors
-Associated with MHC molecules
RA: HLA-DR4
SLE: HLA-DR3
Progressive Systemic Sclerosis: HLA-DR3
-Autoimmune: serology often positive for a variety of autoantibodies
-Histology shows evidence of immune involvement
Important auto-antibodies found in serology of rheumatoid diseases
RA: Rheumatoid factor
- Non specific marker so may be associated with many other autoimmune diseases
- Still useful though
SLE: ANA-dsDNA (antinuclear antibodies)
PSS: Scl 70
Sjorgen’s: Ro, La, RF
Rheumatoid Factor in Rheumatic Diseases
- RF is an autoantibody against the Fc portion of IgG and different RFs can recognise parts of the IgG-Fc
- May be any isotope but is directed to Fc IgG
- Can be IgM or IgG RF
- Many conditions can have positive RFs
- For example, RA, Sjorgen’s and cryglobulinemia
What should you do if you have a clinical suspicious of rheumatoid arthritis (investiations)
- RF directed to Fc IgG
- In RA, 80%
- Check RF in blood
- Also ask for antibodies to CCP
- 95% specific to RA
Clinical Features of Rheumatoid Arthritis
What joints are commonly affected
Any other clinical features
Specific deformaties
- Affects multiple joints (usually more than 5)
- Symmetrical
- Metacarpophalangeal and proximal interphalangeal joints
- Tends to affect small joints (hands and feet), sometimes medium joints (wrists, elbows and knees) but rarely large joints (hips_
- Pain, swelling, warm, red and pain
- Morning stiffness
- Malaise
- Limited movement and deformity
- Patients may get specific deformaties
- Ulnar Deviation: of MCP joint
- Swelling of the PIP joint
- Swan Neck of IP joints (Z shapes thumb)
- If RA has been going on for a while, it destroys the joints and causes muscle wasting
- Become stiff
-Extra-articular symptoms include fever, malaise, low appetite and weakness
- Organ Specific clinical features include:
- Rheumatoid nodules: pressure points eg. elbows. Rarely in the lungs, heart or sclera
- Increased risk of atherosclerosis: heart attack or stroke
- Anaemia
- Interstitial lung fibrosis
- Pleural effusions (progressive SOB)
Pathology of rheumatoid arthritis
- Cytokines and immune cells lead to proliferation of synovial cells, creating a pannus
- Granulation tissue forms at the edges of the synovial lining
- Thick, swollen synovial membrane with granulation tissue forms a pannus
- Over time, the pannus can cause damage to the cartilage, other soft tissue and also erode bone through osteoclastic action
- Progressive osteopenia, loss of joint space and bone loss
- Loss of joint space and bone loss visible on radiographs
Diagnosis of RA
- Blood tests
- Look for RF and anti-CCP antibodies
- X-rays shows decreasing density around affected joints, soft tissue swelling, narrowing of the joint space and bony erosions
Complications of RA
-Rheumatoid nodules
Necrotising granuloma
- Tendon rupture
- Normochromic, normocytic anaemia
- Nerve entrapment (Eg. median nerve)
-Vasculitis
Can lead to digital gangrene if vasculitis is untreated
-Atlanto-axial subluxation
Occurs due to erosion of the odontoid process and/or the trasnverse ligaments connecting the cervical spine to the skull
-Eye complications
Episcleritic (inflammation of the sclera)
Treatment of RA
Analgesia (NSAIDs reduce pain and swelling)
DMARDs (Disease modifying anti rheumatic medications)- methotrexate, hydroxychloroquinone for mild to moderate
TNFa blockage eg. infliximab, etanercept
Anti b cell monoclonal antibodies eg. rituximab
Dental Relevance of RA
- Hand deformity: oral hygiene, blister packs
- Carpal tunnel syndrome: impingement of the median nerve of the wrist
- Atlanto-axial subluxation during GA
- TMJ dysfunction
- Sjorgens syndrome (associated with rheumatoid as a secondary event)
- Anaemia
- Complications of systemic treatment
Sjorgen’s syndrome definition
- Common autoimmune disease
- Typically affecting women
- Immune cells attack the exocrine glands (glands that secret into a duct)
- Sialadenitis (inflammation of all the salivary glands including the minor ones)
- Most commonly affected are the salivary glands and lacrimal glands
Classification of Sjorgens syndrome
Primary:
- Occurs alone
- For example Sicca syndrome
- Dry eyes, mouth and vagina
Secondary:
- Occurs with other autoimmune diseases
- Rheumatoid arthritis
- Progressive systemic sclerosis
- SLE
Clinical Features of Sjorgens
Sicca symptoms-95% of cases
Dryness of skin, mouth eyes and vagina
-If lacrimal glands are involved:
Swelling
Keratoconjinctivitis
Dry eyes, itchy, redness, blurry and burning
-If salivary glands are involved:
Xerostomia
Difficulty tasting, swallowing along with cracks and fissures appearing in the mouth
Swollen parotid glands often visible (also other salivary glands)
Increased risk of dental caries, loss of teeth and candida infections
Smooth, lobulated tongue, angular stomatitis, angular chelitis
-If nose and respiratory patches are involved:
Ulceration and perforation of the nasal septum
-If larynx involved
Difficulty speaking
What would you expect to see doing an EO and IO of a patient with Sjorgens and risks that these patients carry
- Swelling of salivary and lacrimal glands may be visible
- May be palpable
- Dry mouth
- Mirror sticking to the mucosa/tongue
- No pooling of saliva
- Smooth, lobulated tongue
- Red tongue
- Angular chelitis
- Angular stomatitis
- Caries
- Periodontal risk
- Candida
- Many dental infections
Investigations and diagnosis of Sjorgens syndrome
Sialometry: measure the salivary flow Unstimulated whole salivary flow Normal >0.2ml/min Simulated parotid flow Normal >0.4ml/min
Schirmer test
- How many tears can you produce in a given period
- Anaesthetise the eye first then apply filter paper to the lower lid
- Sjorgens is when it moistens less than 5mm in 5mins
- Normal is more than 15mm of wetting
Blood Test:
- FBC
- Presence of Anti-SSA and Anti-SSB antibodies
- Ro and La autoantibodies
Ultrasound has largely replaced sialography
Labial gland biopsy (minor gland)
Dental relevance of Sjorgens
- Dry mouth
- Challacombes
- No pooling
- Swelling of salivary glands/lacrimal glands
- Complications of systemic treatment
-Dental caries, loss of teeth, candida
Treatment of sjorgens
- Suppression of the immune response (corticosteroids)
- Increased exocrine secretions such as pilocarpine
Systemic Lupus Erythematosus definition
- Affects multiple organs
- Disease affecting the skin
- Reddening of the skin
- Can affect any tissue/organ
- Multi-system disease
Variants of SLE
Discoid lupus (DLE): scarring skin lesions/oral
Subacute cutaneous (SCLE): rash, systemic disease
SLE
Anti-phospholipid antibody
Drug-Induced
Aetiopathogenesis of SLE
- Unknown cause but related to genetics and the environment
- Triggers include UV light and infection
- Widespread vasculitis of capillaries, arterioles and venules
- Type III Hypersensitivity reaction
- Drug induced lupus like syndrome
Investigations of SLE
ESR raised
CRP normal
ANA+
Double stranded DNA ab+
RF +
Complement- reduced
Skin biopsy
Clinical Features of SLE
11 diagnostic criteria. If 4 or more are met, then Lupus is diagnosed
Skin:
- Macular rash
- Discoid rash
- Photosensitivity rash (appears in areas exposed to the sun)
Mucosa
-Ulcers
Serosa (outer surface of mucosa)
- Pleuritis
- Pericarditis
Joints
- Arthrits
- Must be 2 or more to meet criterion
Kidneys
- Renal disease
- Abnormal urine protein
- Diffuse proliferative glomerulonephritis
- Brownish urine due to blood in urine
- Foamy becuase of protein
- Elevated creatinine in the blood
Brain
- Cerebral microinfarcts
- Neurological disorders
- Seizures
- Psychosis
- Headaches, dizziness
Blood
-Haematological disorders
-Vasculitis
Gangrene in peripheral tissues
Anti-phospholipid syndrome definition, clinical features
- Increased tendency to clotting
- Hypercoagulable states
- Deep vein thrombosis
- Arterial thrombosis
- Recurrent foetal loss
- Thrombocytopenia
- Livedo reticularis
Relevance of lupus erythematosus to dentistry
- Oral ulceration
- Complications of systemic treatment
- Candida
- +/- dry mouth
- Main differential is lichen planus
Diffuse Systemic Sclerosis clinical features
- Skin induration, flexion fingers
- Sausage gingers
- As if becomes more advanced, you get acrosclerosis and terminal tuft resorption
- Necrotic fingertips
- Hand arteriogram shows how poor the blood supply is to the finger
- Histology of PSS skin shows a lack of cells and blood vessels and thickened appearance compared to normal skin
- Facial and mouth changes
- Mouth may become smaller
- If bowel involvement, you may get diverticula (malabsorption)
- Initial arteriolar proliferation (kidney)
- Pulmonary fibrosis may also occur
CREST syndrome definition and explanation
Also known as cutaneous systemic sclerosis
Calcinosis (calcium deposition onto the skin)
Raynaud’s phenomenon (patient goes through colour change vascular abnormality that is common in many autoimmune diseases)
Oesophagus (oesophageal dismobility)
Sclerodactyl (tightening of the skin over the fingers)
Telangiectasia (small dilated blood vessels on the skin surface)
C in CREST
- Calcinosis
- Deposition of calcium in the skin
- Often in the fingertips
- Can be seen on X rays
R in CREST
- Raynauds Phenomenon
- Spasm of the arteries in the fingers
- May appear as a different colour
- Induced by cold or emotion
- Reversible skin colour change from white to blue to red
- Can progress to cyanosis and potentially gangrene
E in CREST
- Oesophagal dismotility
- Difficulty swallowing
S in CREST
Sclerodactyl
-Tightening of the skin over the fingers
T in CREST
-Telangiectasisis
Small dilated blood vessels on the skin surface
May appear on the face and tongue
Treatment of autoimmune disorders in general
- Analgesics
- Glucocorticoids for example prednisolone used in diabetes, hypertension, skin changes and osteoporosis
- Cytotoxics for example azathioprine
Rheumatoid arthritis: DMARDs especially methotrexate
TNFa blockade eg infliximab
Treatment of Raynauds
- Physical (gloves)
- Nifedipine (calcium channel antagonist)
- Losartan (angiotensin II antagonist)
Relevance of CREST to dentistry
- Notice hands etc
- Telanangiectasis on the face and tongue
- Medications
- Immunosuppression
- Microstomia
- Widened peridontal membrane
- Severe sclerodactylyl may lead to difficulty with OH
Osteoarthritis definition
- Population of over 60 years
- 10% genetic predisposition
- NOT an autoimmune disease
- Mainly synovial joint affected
- Degenerative disease of cartilage
- Stimuli include mechanical insults, biochemical abnormalities of cartilage
Classification of osteoarthritis
Primary:
- Majority of cases
- Strong family history
- Onset about 50
Secondary:
-Congenital abnormality of joints, structural disorders in children, trauma
Clinical Features of OA
- Pain- worse with use
- Morning stiffness for <30 minutes
- Disability
- Swelling- hard and bony
- Crepitus
- Muscle wasting
- Limited movement
- Joint deformity
- Monoarticular occasionally
Difference between OA and arthritis
-Morning stiffness for <30 mins in OA
>1h in arhritis
Dental relevance of OA
- Reduced mobility
- Reduced manual dexterity
- TMJ dysfunciton
