Rheumatology and bone disease Flashcards
What is rheumatology?
Branch of medicine dealing with joint, bone and muscle disease
Diseases normally inflammatory
Most diseases are autoimmune with systemic manifestations
Can present either with arthritis or thro’ systemic (oral) features
Rheumatologists need to look in the mouth, dentists need to know when to refer to rheumatology
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Rheumatic disease overview
Non- inflammatory -osteoarthritis Inflammatory -rheumatoid Arthritis -reactive arthritis/ seronegative arthritis -systemic lupus erythematosus -vasculitis -scleroderma -behcets -dermatomyositis/ polymyositis **
Oral manifestations necessary to diagnosis
Sjögrens Syndrome
-primary
-secondary
Behcets Disease
Rheumatoid arthritis
Disease of synovial joints
Affects 1% population
Auto-immune, systemic inflammatory illness
Symmetrical joint inflammation and deformity
“Extra-articular” features
Rheumatoid arthritis: the pain
Inflammatory joint pain
- early morning stiffness (>30 min)
- stiffness after rest
- ease with use/ exercise
- swelling
- may have “flu-like” symptoms
- anti-inflammatory drugs: NSAIDs e.g. Ibuprofen - may be helpful
Sjögren’s syndrome
-“sicca syndrome” or Mikulicz’s disease
Auto-immune inflammatory disorder of exocrine glands
-lacrimal, salivary, nasal, laryngeal, tracheal and vaginal glands.
-xerostomia + keratoconjunctivitis sicca
Marked lymphocytic infiltration destroying the gland architecture and function
Affected glands may be initially swollen, inflamed, tender and later atrophic
Inflammation
Red (rubor)
Hot (calor)
Painful (dolor)
Swollen (tumour)
Rheumatoid arthritis can lead to
Progressive joint deformity
- Z thumb deformity
- Swelling and subluxation of MCPJs
- Spares DIPJs
- Ulnar deviation of fingers (e.g. swan neck deformity)
- “Boggy” swelling (could be warm and tender but quite firm)
Sjögren’s syndrome histology (biopsy)
Lymphotic infiltration of salivary gland showing disruption of the normal glandular architecture
Rheumatoid arthritis: extra-articular features
Lungs -nodules (collection of inflammatory cells) -lung fibrosis -pleural effusions CV -pericardial inflammation/ effusions -myocarditis -valve inflammation Kidneys -amyloidosis Skin -rheumatoid nodules -vasculitis Secondary Sjögren's syndrome
Blood tests: rheumatoid arthritis
Anaemia (normocytic, normochromic?)
High/ low platelets
High inflammatory marker
-C reactive protein (CRP), erythrocyte sedimentation rate (ESR)
Auto-antibodies
-up to 75% positive for RF (rheumatoid factor) and/ or anti-CCP (cyclic citrullinated peptide)
Xrays - rheumatoid arthritis
Early
-osteopenia (thinning) around joints: "periarticular osteopenia"
-soft tissue swelling
Late
-erosions
-joint space narrowing
-subluxation/ dislocation
-fusion ("ankylosis")Treatment for rheumatoid arthritis: immediate relief
NSAIDs e.g. Ibuprofen
Steroids
-injected into joint/ IM/ IV/ oral
Treatment for rheumatoid arthritis: control of disease (immunosuppressive)
DMARDs (Disease Modifying Anti-Rheumatic Drugs)
-e.g. methotrxate, sulfasalazine, leflunomide, hydroxychloroquine
Biologic drugs (all either SC or IV injections so will not appear on pt’s prescription list from GP)
-anti TNF (tumour necrosis factor) e.g. Infliximab, Adalimumab, Etanercept
-B cell depletion (anti CD20) e.g. Rituximab
-others e.g. Tocilizumab (anti IL 6), Abatacept (T cell blocker), Jak
Side effects of rheumatoid arthritis treatment
Infection -all increase risk -for biologic drugs: reactivation of TB Bone Marrow Toxicity -low white cell count/ low platelets/ pancytopenia Hepatotoxic -abnormal liver tests (rise in enzymes) Gastric upset -nausea, diarrhoea, flatulence Skin rashes *advise all pts to stop dmards/ biologic drugs for duration of course of antibiotics and for up to 2 weeks afterwards*
Methotrexate (DMARD)
Prescribed as once weekly dose: 15-25 mg/wk (2.5mg tabs)
Never co-prescribe with Trimethoprim/ Septrin
-risk of severe bone marrow suppression: all anti-folate drugs
Lung complications
-pneumonia
-fibrosis?
Renally excreted
-reduce dose/ stop or contact us if pt develops new renal impairment
Contra-indicated in both men and women pre-conception
Nausea, mouth ulcers
Biologic drugs
Much greater infection risk
-stop 2 weeks prior to surgery/ significant procedure
-restart 2 weeks later or when wounds healing
-remember to ask your pt if they are on on of these
-contact us
Reactivation of TB/ Hep B & C
Relatively contra-indicated if pt develops cancer
May cause/ exacervate MS (anti-TNF)
“Rheumatoid neck”
Erosive change at C1/ C2 (and lower levels)
Leading to subluxation at atlanto-axial level or at subaxial levels or both
Important to recognise “rheumatoid neck” because instability can lead to neurological deficit from spinal cord compression
-neck slightly off to one side
May be a problem with intubation or positioning a pt in dental chair
Anatomy of atlanto-axial joint / subluxation
Dens can push back into SC and cause injury (of C2 - axis)
-usually preotected by ligament, this is disrupted by erosive change in rheumatoid arthritis
Atlas (C1)
Rheumatoid pts in dental chair
Ask about neck pain
Ask about known “rheumatoid neck”
When positioning pt, check no new neck pain develops or neurological symptoms such as pins and needles/ numbness in arms/ hands/ legs
Pre-intubation: flexion and extension xrays of cervical spine and discuss with anesthetist
Caries/ gingivitis in RA
Poor hand/ neck/ shoulder function can impair dental hygiene
Immuno-suppressive drugs may compound this
Remember many RA pts have co-existent osteoporosis, so may well be on bisphosphonates too (jaw necrosis)
> evidence that gingivitis/ caries may be trigger for RA in genetically susceptible individuals
JIA: Juvenile idiopathic arthritis
Inflammatory arthritis occurring before age of 16
Up to 40% “grow out of it” by adulthood
Many different patterns of arthritis
Jaw underdevelopment
-TMJ inflammation leads to altered mandibular growth
-malocclusion, micrognathia
-pain, biomechanical problems
Sponyloarthropathy
Akylosing spondilitis Reactive arthritis Enteropathic arthritis (Crohns/ UC) Psoriatic arthritis --all overlapping and all associated with genetic tissue type HLA B27)
Akylosing spondilitis
Inflammatory spinal pain
-progressive new bone formation/ calcification in spine = severe limitation of movement –> bamboo spine
-sacro-ilitis
More common in men than women
Biologic drugs
Can have rigid, fused neck (risk of fracture) and/ or atlanto-axial subluxation
Common features of spondyloarthropathy
Enthesitis -inflammation of junction between tendon/ ligament and bone -e.g. achilles tendon, tennis elbow Dactylitis -"sausage finger" or "sausage toe" -combination of joint and tendon sheath inflammation Skin/ nail psoriasis Psoriatic arthritis DIPJ involvement Inflammatory eye disease -iritis (anterior uveitis) IBD -Crohns/ UC Large joint oligoarthritis
Psoriatic arthritis
Psoriasis: common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin
Doesn’t spare DIPJ
Nail pitting
Dactylitis
Osteoarthritis
Degenerative process, probably with exaggerated repair response
Leads to pain, stiffness, deformity, < joint movement, joint instability
> with age
Occupation/ hobbies > risk
E.g. footballers - knees, typists - hands and wrists
X-rays in OA
Los of joint space
Osteophytes
Sub-chondral sclerosis
OA treatment
Physiotherapy/ exercises Weight loss (lower limb joints) Paracetamol, co-codamol, NSAIDS Surgery as final resort -for uncontrolled pain -joint failure e.g. knee giving way
Gout
Hot, red, swollen, painful
Type of arthritis
Can be in any joint
Urate crystals precipitate out from bloodstream into joints/ soft tissues
Induces intense neutrophil-led inflammatory response
-needle shaped urate crystals
Why does gout happen?
Pt has high serum urate (before attack; urate may be falsely low during attack)
Causes of high urate:
-genetic predisposition (enzyme defects)
-renal impairment
-diuretics
-dehydration
-inter-current illness
-high alcohol/ fructose/ red meat/ shellfish diet
-part of “metabolic syndrome” - central obesity, diabetes, high BP, high cholesterol
Treatment of gout
Acute -NSAIDs -Colchicine -steroids Prevention of future attacks -urate lowering drugs e.g. allopuinol and febuxostat (both xanthine oxidase inhibitors)
Severe chronic gout
Chronic polyarticular tophaceous gout
CT diseases
Group of rare auto-immune systemic diseases
Certain common features
Can be life-threatening, usually due to organ involvement
-e.g. renal failure (glomerulonephritis), lung fibrosis, myocarditis, cerebral involvement (vascular occlusion or vasculitis)
Associated with “auto-antibodies” - antibodies directed against “self”
More common in women
CT diseases examples
SLE (lupus) Scleroderma Primary Sjogren's Polymyositis/ dermatomyositis *all associated with anti-nuclear antibody (ANA)*
Common features of CT disease
Raynauds - vasocontriction fingers and toes in response to cold
-triphasic colour change
Mouth ulcer
Cardio respiratory disease
SLE
Non-erosive arthritis
-no erosions
Butterfly rash
Photosensitivity
Scleroderma or “systemic sclerosis”
Progressive skin thickening and tightening
-e.g. oral tethering
Severe Raynaud’s
-often leading to digital ulcers, frank tissue necrosis (digital gangrene)
Can be limited to hands, feet and face (limited systemic sclerosis LcSSc)
Or widespread (Diffuse systemic sclerosis DcSSc)
Telangiesctasia (including inside lips), microstomia
LcSSc
Also associated with pulmonary hypertension, severe acid reflux
Telangiectasia, microstomia & oral tethering
DcSSc
Associated with pulmonary fibrosis (often life threatening)
“Scleroderma renal crisis” – hypertensive acute renal failure
Sjogren’s syndrome
Primary
-occurring on its own without an associated rheumatic illness but with its own systemic manifestations
Secondary
-occurring with rheumatic illness e.g. RA, SLE etc.
-associated with other auto-immune disorder including interstitial lung disease, auto-immune liver disease etc.
Primary Sjogren’s
Dry eyes and mouth
Associated with Ro and La antibodies
High immunoglobulins, high ESR, positive Rheumatoid Factor
Fatigue, joint pain
Rare but serious complications of primary Sjogrens
Vasculitis (inflammation of BVs)
Renal involvement (renal tubular acidosis)
Neurological involvement (peripheral neuropathy)
Associated with primary biliary cirrhosis (inflammation and stricture of bile ducts)
9x increase in risk of lymphoma
atrophy Sjogren’s
Atrophic, shrunken parotid gland
Atrophic, “shiny” glossitis
Polymyositis and dermatomyositis
2 diseases associated with inflammation of muscles
Causes weakness of arms and thighs
Painless wasting of these muscles
Both can be associated with lung fibrosis
Polymyositis
Muscle involvement only
Dermatomyositis
Muscles and skin
Photosensitivity/ purple “heliotrope” rash around eyes
Strong association with internal malignancy
Swollen red face, mucosal lesions, lymphotic infiltrations of muscle fibres
Treatment for CT diseases
Different for each but include:
-NSAIDs/ steroids
DMARDS
Cytotoxic drugs (for life-threatening complications) e.g. cyclophosphamide
Biologic drug e.g. Rituximab (anti-TNF drugs contra-indicated in SLE)
Xerostomia
Due to a marked reduction in saliva production from all the salivary glands.
Causes difficulty with chewing or swallowing food, articulation, food lodges in recesses, increased risk of dental caries, altered taste.
Oral mucosa and tongue may be sore, reddened, “burn”, saliva is typically scanty and sticky
Keratoconjunctivitis sicca
Common symptom complex
- dry, itchy, red, sore, photophobic eyes
- < tear secretion leading to conjunctival ulcers
- blinking painful and irritable
- eyes commonly feel “gritty”
