Rheumatology I Flashcards
What are autoimmune diseases
When the immune system recognition fails or malfunctions. Antibodies and T cells produced and directed against self
What may initiate autoimmune disease
- Defect in immunological tolerance
- Presence of sequestrated antigen
- Infection e.g. viruses
- Drugs e.g. methyldopa
- Chemicals
What are the common features of autoimmune disease
- Female pre-disposition
- Positive family history
- Response to immunosuppressant treatment
- Patients often liable to develop other autoimmune diseases
- Raised ESR and CRP, serum protein levels also usually raised
- Hypergammaglobulinaemia
What are the general features of non-organ specific autoimmune disease
- Also called ‘connective tissue’ conditions
- Clinical manifestation is diverse i.e. multi-systemic
- Unified by the detection of non-specific autoantibodies in serum and various tissues
- Disease producing process are caused by hypersensitivity reactions to see components
What is rheumatology
Branch of medicine concerned with the investigation, diagnosis and management of:
- Joint disorders
- Bone diseases
- Muscles and soft tissues diseases
Gives some examples of rheumatological diseases
- Rheumatoid arthritis
- Ankylosing spondylitis
- SLE
- Sjogren’s syndrome
- Osteoporosis
- Carpal tunnel syndrome
- Paget’s disease
What is rheumatoid arthritis
Chronic multisystem autoimmune disease characterised by autoantibody (RF, an IgM) directed against IgG
Immune complex formation leading to complement activation, synovial inflammation and destructive joint disease
What joints tend to be involved with rheumatoid arthritis
- Wrists
- Index and middle metacarpophalangeal joints
- Proximal interphalangeal joints
- Metatarsophalangeal joints
- Shoulders
- Elbows
- Hips
- Knees
- Ankles
- Upper cervical spine
What are the clinical features of acute rheumatoid arthritis
- Insidious onset Systemic features: - Early morning stiffness of affected joints - Generalised afternoon fatigue - Malaise - Anorexia - Generalised weakness - Occasionally low-grade fever Joint Features: - Pain - Swelling and stiffness
What are the clinical features of chronic rheumatoid arthritis
- Joints are often held in flexion to minimise pain
- Joint capsular distension
- Flexion contractures - fixed deformities
- Ulnar deviation of the fingers
- Swan-neck deformities
- Boutonniere deformities
- Stretching of the joint capsule - joint instability
- Wrist synovitis compressing the median curve- carpal tunnel syndrome
What are the pulmonary clinical features of rheumatoid arthritis
- Pulmonary fibrosis
- Pleurisy
- Pleural effusion
What are the cardiovascular clinical features of rheumatoid arthritis
- Pericarditis
- Myocarditis
- Vasculitis
- Valvulitis
What are the cervical spine clinical features of rheumatoid arthritis
- Atlantoaxial subluxation
- Spinal cord compression
What are the lymphatic clinical features of rheumatoid arthritis
Lymphadenopathy
What are the renal clinical features of rheumatoid arthritis
Secondary amyloidosis
What are the ocular clinical features of rheumatoid arthritis
- Scleritis
- Uveitis
- Keratoconjunctivitis Wicca
What are the serological findings of rheumatoid arthritis
- RF +ve in ~70%
- Anti-CCP/ACPA +ve ~95%
What inflammatory markers are associated with rheumatoid arthritis
Elevated CRP and ESR
What would the X-ray of hands and wrists show in a patient with rheumatoid arthritis
- Soft tissue swelling
- Narrowing of joint space
- Joint erosion, subluxation and deformity
- Periarticular osteoporosis
What are the FBC findings in a patient with rheumatoid arthritis
- Normocytic anaemia
- Neutropenia
- Thrombocytosis
What are the protein electrophoresis findings with rheumatoid arthritis
Hypergamma-globulinaemia
What management options can be used to relieve symptoms of rheumatoid arthritis
- Acetaminophen
- NSAIDs
- Intra-articular corticosteroids
- DMARDs - relieve symptoms and slow joint damage
- Surgery
- Supportive measures: smoking cessation, rest, splints and appliances, nutrition and exercise
Name some DMARDs that can be used to treat rheumatoid arthritis
Non-biologic agents - Methotrexate, gold, antimalarials, sulfasalazine, penicillamine, azathioprine, cyclosporin, cyclophosphamide
Biologic agents - adalimumab, certolizumab, etanercept, infliximab, rituximab
What is the dental relevance of rheumatoid arthritis
- Medication - ulcerations, lichenoid reactions, thrombocytopenia and neutropenia
- Sjogren syndrome - xerostemia, candidiasis, caries, sialodenitis
- Atalanto-axial joint subluxation = sudden extension of neck from headrest adjustment, during endotracheal intubation
What does ankylosing spondylitis affect
The axial skeleton (spine) and large peripheral joints
Describe the early stage clinical presentation of ankylosing spondylitis
- Nocturnal low back pain and morning stiffness relieved by activity
- Para-spinal muscle spasm
- Worsening pain and tenderness in the sacroiliac region due to sacroiliitis
Describe the late stage clinical presentation of ankylosing spondylitis
- Hip joint involvement - severe hip arthritis
- Kyphosis
- Loss of lumbar lordosis
- Fixed bent-forward posturing
What are the ocular clinical presentations of ankylosing spondylitis
Recurrent acute uveitis
What are the cardiovascular clinical presentations of ankylosing spondylitis
- Aortic insufficiency
- Aortitis
- Angina
- Pericarditis
- Cardiac conduction abnormalities
What are the pulmonary clinical presentations of ankylosing spondylitis
- Compromised pulmonary function
- Limited chest expansion
What are the clinical presentations of the tendons in patients with ankylosing spondylitis
Achilles and patellar tendinitis
What are the early findings of spine x-ray imaging in patients with ankylosing spondylitis
Symmetric changes:
- Subchondral erosions - sclerosis or later narrowing and eventually fusions in the sacroiliac joints
- Upper lumbar vertebral squaring with sclerosis at the corners
- Spotty ligamentous calcification
What are the late findings of spine x-ray imaging in patients with ankylosing spondylitis
- Bamboo spine appearance, resulting from prominent syndesmophytes
- Diffuse paraspinal ligamentous calcification
- Osteoporosis
Besides X rays what special investigations are used for patients with ankylosing spondylitis
FBC
Inflammatory markets/acute phase reactants
What are the management options and treatment goals of ankylosing spondylitis
- Management similar to rheumatoid arthritis Treatment goals: - Pain relief - Maintaining joint range of motion - Preventing end-organ damage
What are the dental relevances of ankylosing spondylitis
- Problems with giving GA due to restricted mouth opening, respiratory and possibly cardiac complications
- TMJ involvement in 10%
- Patient may have difficulty placing neck on headrest
What is affected by psoriatic arthritis
- Distal interphalangeal joints of fingers and toes
- Can also affect spine and sacroiliac joints
- Resembles RA but usually milder
- Psoriasis of the skins/nails may precede or follow joint involvement
What is needed for psoriatic arthritis diagnosis
- Usually based on clinical findings
- ESR is often normal
- Radiograph may help but routine blood tests are unhelpful
What are the management options of psoriatic arthritis
- Treat with drug therapy similar to RA and sometimes with phototherapy
- Analgesia, NSAIDs and intra-articular corticosteroids can be used
- Anti TNF drugs control both arthritis and the skin lesions
What are the dental relevances of psoriatic arthritis
- May rarely affect TMJ
- Oral mucosa psoriasis lesions are occasionally seen on histology
- Methotrexate or anti-TNF agents may cause oral ulcers
What is reactive arthritis (reiter’s syndrome)
- A triad of arthritis, urethritis, conjunctivitis
What may reactive arthritis follow on from and who is usually affected by it
- Typically affects males
- May follow gut infections like salmonella or sexually transmitted infections
- Reactive arthritis usually begins 1-2 weeks after infection
What are the management options of reiter’s syndrome (reactive arthritis)
- No specific diagnostic test
- WCC and ESR raised
- Antibiotics, NSAIDs, steroids injections physiotherapy
What are the dental relevances of reactive arthritis
- Migratory glossitis-like pattern lesion on the oral mucosa
- Oral ulcerations may also be frequent
What is sjogren’s syndrome characterised by
Autoimmune exocrinopathy characterised by lymphocyte infiltration and progressive acinar destruction into the salivary and lacrimal glands
What are the 2 classifications of sjogren’s syndrome and the symptoms associated with each
Primary (sicca syndrome): - Dry mouth - Dry eyes (keratoconjunctivitis sicca) Secondary: - Dry mouth and eye - Connective tissue disease
Who is most commonly affected by sjogren’s syndrome
Male:Female = 1:9
What is the dental relevance of sjogren’s syndrome
- Xerostemia: candidiasis, caries, denture issues, disturbed taste, ascending sialodenitis
- Early onset lymphocytic infiltration: swelling of parotid gland
- Late onset lymphocytic infiltration: indicative of progression to lymphoma
- Secondary sjogren syndrome: anaemia
How is sjogren’s syndrome managed
- Dry mouth: sipping sugar free drinks, salivary substitutes
- Oral candidiasis: Nystatin rinses/amphocterin mix
- Ascending parotitis: antibiotic therapy
- Preventative dental care
What are the ocular clinical features of sjogren’s syndrome
Keratoconjunctivitis Sicca
What are the oral clinical features of sjogren’s syndrome
- Xerostemia
- Lobulated tongue
- Infections - sialadenitis, caries, candidiasis
What serological findings indicate Sjogren’s syndrome
- Antinuclear antibodies
- Anti-Ro (SS-A) or La (SS-B)
- Increased ESR
- Hypergammaglobulinaemia (RF)
What oral findings indicate Sjogren’s syndrome
- Sialometry (<1.5ml/15min without stimulation)
- Estimation of parotid salivary flow rate (>1ml/min without stimulation)
- Labial gland biopsy
What ocular findings indicate Sjogren’s syndrome
Schimer test (Impaired lacrimation)
