Rheumatology I Flashcards
1. Introduce rheumatology and autoimmunity 2. Knowledge of classification and common features of autoimmune diseases 3. Identify and recognise signs and symptoms of inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and sjogrens syndrome) 4. Knowledge of special investigations used to establish diagnosis of inflammatory arthritis and their findings 5. Understand the impact of inflammatory arthritis and management of oral health
What is an autoimmune disease and what can it be initiated by
When the immune system produces antibodies and T cells against the self which can be initiated by
- Defects in immunological tolerance
- Presence of sequestrated antigen
- Infections e.g. viruses
- Drugs e.g. methyl dopa
- Chemicals
What are the common features of autoimmune diseases
- Females
- Positive family history
- Responsive to immunosuppression treatment
- Patients are likely to develop another autoimmune condition
- Raised ESR, CRP and serum protein levels
- Hypergammaglobulinaemia
Why is there raised ESR, CRP and serum proteins in autoimmune condiitons
Electrolyte sedimentary rate = Higher because there is more fibrinogen released which causes RBCs to stick together
C-reactive protein = Higher because it binds to the damaged cells thus aids the complement system by helping phagocytosis
Serum protein = Higher because these are immunoglobulins
List non-organ specific autoimmune conditions
- Rheumatoid arthritis
- SLE
- Sjogren’s syndrome
- Systemic sclerosis
- Reynaud disease
- Behcets disease
- Polymyositis
- Dermatomyositis
- Scleroderma
List organ/cell-specific autoimmune conditions
- Pernicious anaemia
- Hashimoto’s thyroiditis
- Myasthenia gravis
- Pemphigus vulgaris
- Benign mucus membrane pemphigoid
- Diabetes mellitus (TI)
- Autoimmune haemolytic anaemia
- Idiopathic thrombocytopenic purpura
- Idiopathic Addison’s disease
Describe non-organ specific autoimmune diseases
These are connective tissue conditions which have multi-systemic manifestations unified by the detection of non-specific antibodies in serum/tissues - disease producing processes are caused by hypersensitivity reactions
Give examples of inflammatory arthritis
- Rheumatoid arthritis
- Psoriatic arthritis
- Ankylosing spondylitis
Give examples of connective tissue disorders
- SLE
- Scleroderma
- Dermatomyositis and polymyositis
- Sjogren’s syndrome
Give examples of metabolic bone disorders
- Osteoporosis
- Paget’s disease
- Gout and pseudo gout
Give examples of musculoskeletal disorders
- Tennis elbow
- Carpel tunnel syndrome
- Fibromyalgia
Give examples of degenetory arthritis
Osteoarthritis
What is rheumatoid arthritis and describe its epidemiology
A non-organ specific chronic autoimmune disease characterised by autoantibody RF (Rheumatoid factor = IgM) against IgG
Immune complex formation leads to complement activation, synovial inflammation and destructive joint disease
This is more common in females aged 35-50 which are predisposed due to HLA-DR4 genotype and triggered by viruses and smoking which maintain joint inflammation
What are the clinical features of rheumatoid arthritis
Joints involved include: wrists, index and middle finger metacarpophalangeal joints, proximal interphalangeal joints, metatarsophalangeal joints, shoulders, elbow, hip, knees, ankles and upper cervical spine (TMJ in late stage)
Outline the clinical features of acute rheumatoid arthritis
- Insidious gradual onset
- Early morning stiffness of joints
- Afternoon fatigue
- Malaise and loss of appetite (anorexia)
- Low-grade fever
- Symmetrical joint pain, swelling and stiffness
Outline the clinical features of chronic rheumatoid arthritis
Joints are held in flexion to minimise pain: Joint capsular distention and flexion contractures form = fixed deformities
- Ulnar deviation of fingers (distally)
- Swan-neck deformaties (DIP flexion, PIP extension)
- Boutonniere deformities (DIP extension, PIP flexion)
There is stretching of the joint capsule causing instability
Wrist synovitis compressing the median nerve causes carpal tunnel syndrome
What are subcutaneous rheumatoid nodules
These are clinical features of chronic rheumatoid arthritis appearing at sites of pressure and chronic irritation (elbows and knees)
Outline the extra-articular features of rheumatoid arthritis
Pulmonary: Fibrosis, pleurisy, pleural effusion
CDV: Pericarditis, myocarditis, vasculitis, valvulitis
Cervical spine: Atlanto-axial subluxation, chord compression
Lymphatic: Lymphadenopathy
Renal: Secondary amyloidosis
Haematology: Anaemia
Eyes: Scleritis, uveitis, keratoconjunctivitis sicca
What special investigations can be done for rheumatoid arthritis and what are the results found
Serology = RF + (sensitive) Anti-CCP/ACPA + (specific)
Inflammatory markers = Elevated CPR and ESR
X-rays: Soft tissue swelling, narrowing joints, joint erosion, subluxation and deformity, periarticular osteoporosis (porous bones around the joint)
FBC: Normocytic anaemia, neutropenia, thrombocytosis
Protein electrophoresis: Hypergammaglobulinaemia
What are the diagnostic criteria for rheumatoid arthritis
> = 6 definitive RA or <6 when cumulatively over time (prospectively) or retrospectively from adequate records
How is rheumatoid arthritis managed and name the drugs
No cure but remission occurs when DMARDs are started early
- Symptom-modifying drugs = acetaminophen, NSAIDs, intra-articular corticosteroids, paracetamol
- Disease-modifying anti-rheumatic drugs
- (non-biological) = methotrexate, gold, antimalarials, penicillamine, azathioprine, cyclosporin cyclophosphamide
- (biological) = adalimumab, certolizumab, etanercept, infliximab, rituximab - Surgery (replacement of damaged joints)
- Supportive measures - smoking cessation, good nutrition, exercise, splints and appliances to reduce pain
What is the dental relevance of rheumatoid arthritis
- Sudden extension of neck (when adjusting headrest or in endotracheal incubation) can cause atlanto-axial subluxation
- Restricted manual dexterity so impaired oral hygiene
- Drugs (NSAIDs, methotrexate, gold, antimalarials, azathioprine and cyclophosphamide) cause oral ulceration and lichenoid reactions and cause systemic thrombocytopenia and neutropenia
- TMJ involvement means painless limitation of opening
- Sjogren’s syndrome causes xerostomia, candidiasis, sialoadenitfs and accelerated caries
What is ankylosing spondylitis
A non-organ specific seronegative spondyloarthropathy mainly in males aged 20-40 that have HLA-B27 (caucasian) HLA-B7 (black)
This typically affects the axial skeleton and the large peripheral joints
Outline the clinical presentation of ankylosing spondylitis
- Insidious gradual onset
- Early stage :
- Nocturnal low back pain and morning stiffness (relived by activity)
- Para-spinal muscle spasm
- Worsening pain and tenderness in sacroiliac region due to sacroiliitis - Late stage :
- Hip joint involvement
- Kyphosis (hunchback)
- Loss of lumbar lordosis
- Fixed bent-forward position
Outline the systemic manifestations of ankylosing spondylitis
Eyes = recurrent acute uveitis CVS = aortic insufficiency, aortitis, angina, pericarditis, cardiac conduction abnormalities Pulmonary = compromised function, limited expansion Tendons = achilles and patellar tendinitis
Describe the early stage spinal findings for ankylosing spondylitis
Symmetric changes
- Subchondral erosions: sclerosis/narrowing and fusion of sacroiliac joints
- Upper lumbar vertebral squaring with sclerosis at corners
- Spotty ligamentous calcification
Describe the late stage spinal findings for ankylosing spondylitis
- Bamboo spine appearance (due to prominent syndesmophytes)
- Diffuse paraspinal ligamentous calcification
- Osteoporosis
Describe the special investigations for ankylosing spondylosis
Spine X-ray imaging
FBC
Inflammatory markers/ acute phase reactants
How is ankylosing spondylitis managed
Similar to rheumatoid arthritis with the following treatment goals
- pain relief
- maintenance of joint motion
- preventing end-organ damage
What is the dental relevance of ankylosing spondylitis
- Problems giving GA due to restricted mouth opening, respiratory problems and cardiac complications
- TMJ involvement in 10%
- Patient has difficulty placing head on rest
What is psoriatic arthritis
Arthritis occurring in patients with psoriasis (thickening and scaling of skin due to autoimmune inflammation)
Describe the presentation of psoriatic arthritis
- Affects DIP joints of fingers and toes
- Affects spine and sacroiliac joints
- Resembles RA but is milder
- Psoriasis of skin/nails may precede or follow joint involvement
How is psoriatic arthritis managed
Treated with drug therapy similar to RA and phototherapy
- Analgesia, NSAIDs and intraarticular corticosteroids used
- Anti-TNF drugs control both arthritis and skin slesions
What is the dental relevance of psoriatic arthritis
- May affect TMJ
- Oral mucsa psoriasis lesions seen on histology
- Methotrexate/anti-TNF agents may cause oral ulcers
What is reactive arthritis ( reiter’s syndrome )
= Triad of arthritis, urethritis and conjunctivitis affecting males following gut infections e.g. salmonella or STIs e.g. chlamydia - it begins 1-2 weeks post infection
How is reactive arthritis ( reiter’s syndrome ) managed
- No specific diagnostic test
- WCC and ESR raised
- Antibiotics, NSAIDs, steroid injections and physiotherapy
What is the dental relevance of reactive arthritis ( reiter’s syndrome )
- Migratory glossitis-like pattern lesion on oral mucosa
2. Oral ulcerations may also be frequent
What is Sjogren’s syndrome
A non-organ specific autoimmune exocrinopathy characterised by
- lymphocyte infiltration
- progressive acinar destruction
which affects salivary and lacrimal glands (predominantly in females)
What presents in primary Sjogren’s syndrome (Sicca syndrome)
- Dry mouth (xerostomia)
- Dry eyes (keratoconjuctivitis sicca)
What presents in secondary Sjogren’s syndrome
- Dry mouth
- Dry eyes
- Connective tissue disease
What is the dental relevance of Sjogren’s syndrome
- Xerostomia - oral candidíases, ascendia sialodenitis, accelerated caries, hard to speak, problems with dentures, disturbed taste
- Early onset lymphatic infiltration - swelling of parotid gland
- Late onset lymphatic infiltration - indicative of progression to lymphoma
- Secondary Sjogren syndrome causes anaemia
How is Sjogren’s syndrome managed
- Sipping of water and sugar-free drinks
- Salivary substitutes
- Stimulation with sialogogues
- Chewing sugar-free gum
- Nystatin rinses/ Amphotercin mustier (for candidiasis)
- Antibiotic therapy
- Avoid cariogenic diet
- Fluoride applications and clorhexidine rinses
- Good denture hygiene
What is scleroderma
Condition that results in hard, thickened areas of skin and sometimes problems with internal organs and blood vessels - caused by the immune system attacking the connective tissue under the skin and around internal organs and blood vessels.
What is rheumatology
Branch of medicine concerned with
- joint disorders
- bone disease
- muscles and soft tissues
Explain the FBC in patients with rheumatoid arthritis
- Normocytic anaemia due to decreased bone marrow
- Neutropenia due to the increase in antibodies used up so there is lower levels of WBCs - the patient is also on immunosupressants
- Thrombocytosis due to more platelets being produced which will cause sticking
How is psoriatic arthritis diagnosed
Based on clinical findings and ESR is usually normal
Radiographs may help but FBCs are not useful
Outline clinical features of sjogrens syndrome
Ocular = keratoconjunctivitis siccs
Oral = xerostomia, lobulated tongue, infections: candidosis, caries, sialadenitis
Vaginal = dryness
Autoimmune - rheumatoid arthritis (especially in 2s)
