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Musculoskeletal (Den 303 IHD) > Rheumatology and bone disease > Flashcards

Rheumatology and bone disease Flashcards

1
Q

What is rheumatology?

A

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
*** AND GRAPH

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2
Q

Rheumatic disease overview

A 
Non- inflammatory
-osteoarthritis
Inflammatory
-rheumatoid Arthritis
-reactive arthritis/ seronegative arthritis
-systemic lupus erythematosus
-vasculitis
-scleroderma
-behcets
-dermatomyositis/ polymyositis
**
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3
Q

Oral manifestations necessary to diagnosis

A

Sjögrens Syndrome
-primary
-secondary
Behcets Disease

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4
Q

Rheumatoid arthritis

A

Disease of synovial joints
Affects 1% population
Auto-immune, systemic inflammatory illness
Symmetrical joint inflammation and deformity
“Extra-articular” features

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5
Q

Rheumatoid arthritis: the pain

A

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
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6
Q

Sjögren’s syndrome

-“sicca syndrome” or Mikulicz’s disease

A

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

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7
Q

Inflammation

A

Red (rubor)
Hot (calor)
Painful (dolor)
Swollen (tumour)

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8
Q

Rheumatoid arthritis can lead to

A

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)
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9
Q

Sjögren’s syndrome histology (biopsy)

A

Lymphotic infiltration of salivary gland showing disruption of the normal glandular architecture

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10
Q

Rheumatoid arthritis: extra-articular features

A 
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
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11
Q

Blood tests: rheumatoid arthritis

A

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)

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12
Q

Xrays - rheumatoid arthritis

A 
Early
-osteopenia (thinning) around joints: "periarticular osteopenia"
-soft tissue swelling
Late
-erosions
-joint space narrowing
-subluxation/ dislocation
-fusion ("ankylosis")
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13
Q

Treatment for rheumatoid arthritis: immediate relief

A

NSAIDs e.g. Ibuprofen
Steroids
-injected into joint/ IM/ IV/ oral

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14
Q

Treatment for rheumatoid arthritis: control of disease (immunosuppressive)

A

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

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15
Q

Side effects of rheumatoid arthritis treatment

A 
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*
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16
Q

Methotrexate (DMARD)

A

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

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17
Q

Biologic drugs

A

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)

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18
Q

“Rheumatoid neck”

A

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

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19
Q

Anatomy of atlanto-axial joint / subluxation

A

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)

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20
Q

Rheumatoid pts in dental chair

A

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

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21
Q

Caries/ gingivitis in RA

A

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

22
Q

JIA: Juvenile idiopathic arthritis

A

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

23
Q

Sponyloarthropathy

A 
Akylosing spondilitis
Reactive arthritis
Enteropathic arthritis (Crohns/ UC)
Psoriatic arthritis
--all overlapping and all associated with genetic tissue type HLA B27)
24
Q

Akylosing spondilitis

A

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

25
Q

Common features of spondyloarthropathy

A 
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
26
Q

Psoriatic arthritis

A

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

27
Q

Osteoarthritis

A

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

28
Q

X-rays in OA

A

Los of joint space
Osteophytes
Sub-chondral sclerosis

29
Q

OA treatment

A 
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
30
Q

Gout

A

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

31
Q

Why does gout happen?

A

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

32
Q

Treatment of gout

A 
Acute
-NSAIDs
-Colchicine
-steroids
Prevention of future attacks
-urate lowering drugs e.g. allopuinol and febuxostat (both xanthine oxidase inhibitors)
33
Q

Severe chronic gout

A

Chronic polyarticular tophaceous gout

34
Q

CT diseases

A

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

35
Q

CT diseases examples

A 
SLE (lupus)
Scleroderma
Primary Sjogren's
Polymyositis/ dermatomyositis
*all associated with anti-nuclear antibody (ANA)*
36
Q

Common features of CT disease

A

Raynauds - vasocontriction fingers and toes in response to cold
-triphasic colour change
Mouth ulcer
Cardio respiratory disease

37
Q

SLE

A

Non-erosive arthritis
-no erosions
Butterfly rash
Photosensitivity

38
Q

Scleroderma or “systemic sclerosis”

A

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

39
Q

LcSSc

A

Also associated with pulmonary hypertension, severe acid reflux
Telangiectasia, microstomia & oral tethering

40
Q

DcSSc

A

Associated with pulmonary fibrosis (often life threatening)

“Scleroderma renal crisis” – hypertensive acute renal failure

41
Q

Sjogren’s syndrome

A

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.

42
Q

Primary Sjogren’s

A

Dry eyes and mouth
Associated with Ro and La antibodies
High immunoglobulins, high ESR, positive Rheumatoid Factor
Fatigue, joint pain

43
Q

Rare but serious complications of primary Sjogrens

A

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

44
Q

atrophy Sjogren’s

A

Atrophic, shrunken parotid gland

Atrophic, “shiny” glossitis

45
Q

Polymyositis and dermatomyositis

A

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

46
Q

Polymyositis

A

Muscle involvement only

47
Q

Dermatomyositis

A

Muscles and skin
Photosensitivity/ purple “heliotrope” rash around eyes
Strong association with internal malignancy
Swollen red face, mucosal lesions, lymphotic infiltrations of muscle fibres

48
Q

Treatment for CT diseases

A

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)

49
Q

Xerostomia

A

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

50
Q

Keratoconjunctivitis sicca

A

Common symptom complex

  • dry, itchy, red, sore, photophobic eyes
  • < tear secretion leading to conjunctival ulcers
  • blinking painful and irritable
  • eyes commonly feel “gritty”

Musculoskeletal (Den 303 IHD) (2 decks)

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