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BDS3 BAMS > Rheumatology - Rheumatoid Arthritis > Flashcards

Rheumatology - Rheumatoid Arthritis Flashcards

1
Q

What is RA?

A
  • Initially a disease of the synovium with gradual inflammatory joint destruction (but this is part of a mulit-system disease)
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2
Q

What are the 2 different patterns of joint involvement in RA?

A
  • Sero-positive RA
  • Sero-negative RA
  • Depending on which one of the 2 above the person has - this significantly changes the pattern of the disease
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3
Q

What is sero-positive RA?

A
  • Rheumatoid factor is present
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4
Q

What is sero-negative RA?

A
  • Rheumatoid factor is NOT present
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5
Q

What is the most common serious joint disease?

A
  • Rheumatoid arthritis
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6
Q

What is the prevalence of RA in the population in %?

A

1%

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7
Q

How many females pre-menopause are affected by RA?

A
  • 6:1
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8
Q

Hoe many females post-menopause are affected by RA?

A
  • 3:1
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9
Q
  • When is the peak incidence of RA?
A
  • Peaks in 3rd to 5td decades (20-50yrs)
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10
Q

Is RA a disease of old age?

A
  • No, it starts fairly early in life and progresses slowly from there
  • Often RA patient’s don’t have any outward signs in the early stages and middle stages of the disease and there is often confusing of it amongst the population
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11
Q

What is RA and what does it affect?

A
  • It is a symmetrical polyarthritis and it affects all of the synovial joints in the body
  • This includes the toes, ankles, knees, and all of the joints in the arm and the shoulder and also in the neck
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12
Q

Give examples of symptoms of RA? (4)

A

Slow onset:

  • Initially hands and feet
  • Proximal spread
  • Potentially ALL synovial structures
  • Symmetrical polyarthritis
  • Occ. onset with systemic symptoms
  • Fever, weight loss, anaemia
  • These systemic symptoms are due to the fact that RA is a manifestation of a systemic illness that is being targeted more to the joints and the synovium than to other internal tissues
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13
Q

Give examples of other symptoms of RA? (8)

A
  • Fatigue
  • Morning sickness
  • Joint stiffness
  • Joint pain
  • Minor joint swelling
  • Fever
  • Numbness and tingling (in extremities)
  • Decrease in range of motion
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14
Q

What are early signs of RA? (3)

A
  • Symmetrical synovitis of metacarpal pharyngeal joints
  • Symmetrical synovitis of proximal interpharyngeal joints
  • Symmetrical synovitis of wrist joints
  • These changes will cause joint swelling and stiffness and pain and will eventually lead to destruction of the joint so that in the late stages RA has lost the ability of the joint to remain its natural integrity
  • This means that the bones are no longer restricted in the directions in which they can move when tendons attached to the bones are activated
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15
Q

What are the late signs of RA? (4)

A
  • Ulnar deviation of fingers at MCP joints
  • Hyperextension of PIP joints - ‘swan neck’ deformity
  • ‘z’ deformity thumb (hyperflexion of MCP, hyperextension of IP joint)
  • Eventually subluxation of the wrist will result
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16
Q

What is the progression of RA over years like?

A
  • As time goes on gradually there is loss of the definition of the joints and loss of the stability of the joints such that eventually the joint positions and the joint functions are completely disturbed
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17
Q

Give further examples of late signs of RA? (4)

A
  • Complete subluxation of the wrist
  • Loss of abduction and external rotation of shoulders
  • Flexion of elbows and knees
  • Deformity of the feet & ankles
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18
Q

For patients with RA what kind of change are replacement joints for?

A
  • A FUNCTIONAL change
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19
Q

Although we see external changes in joints, it is only one aspect of the disease process which produces changes throughout the body to a greater or lesser extent. What are extra-articular features of RA? (8)

A
  • Due to systemic vasculitis (inflammation of blood vessels)
  • present in 75% of patients
  • Psoriasis in some patients
  • give much more agressive form of RA and in younger patients - ‘psoriatic arthritis)
  • Eye involvement:
  • Scleritis & episcleritis
  • Dry eyes, Sjogren’s syndrome
  • Subcutaneous nodules (pressure points)
  • Amyloidosis
  • Pulmonary inflammation
  • Neurological
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20
Q

What is scleritis?

A

Scleritisis a severe, destructive, vision-threatening inflammation involving the deep episclera and sclera.

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21
Q

What is episcleritis?

A

Episcleritisis an inflammatory condition affecting the episcleral tissue between the conjunctiva (the clear mucous membrane lining the inner eyelids and sclera) and the sclera (the white part of the eye) that occurs in the absence of an infection.

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22
Q

What is amyloidosis?

A

Amyloidosisis the name for a group of rare, serious conditions caused by a build-up of an abnormal protein calledamyloidin organs and tissues throughout the body. The build-up ofamyloidproteins (deposits) can make it difficult for the organs and tissues to work properly.

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23
Q

What investigations would we do when testing for RA? (2)

A
  • Radiographs

- Blood

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24
Q

What are we looking for in radiographs when looking for RA?

A
  • Erosions, loss of joint space, deformity

- Joint destruction & secondary osteoarthritis

25
Q

What are we looking for in blood tests when looking for RA?

A
  • Normochomic, normocytic anaemia

- This is often present in patient’s with RA and this is due to failure of red blood cell stimulation

26
Q

What is normochromic anaemia?

A
  • Normochromicanemia is a form of anemia in which the concentration of hemoglobin in the red blood cells is within the standard range, but there is an insufficient number of red blood cells.
27
Q

What is normocytic anaemia?

A
  • Normocytic anemiais a blood problem. It means you have normal-sized red blood cells, but you have a low number of them
28
Q

How would we treat RA? (6)

A
  • hollistic management
  • Aim to improve quality of life

Combinations of:

  • Physiotherapy
  • Occupational therapy
  • Drug therapy
  • Surgery
29
Q

How can physiotherapy be helpful in treating a patient with RA?

A
  • To maintain the current function of the joints for as long as possible
30
Q

How can occupational therapy be helpful in treating a patient with RA?

A
  • Maximise independent living ability by using occupational therapy to keep the patient active and managing at home
31
Q

How can drug therapy be helpful in treating a patient with RA?

A
  • Can be used to slow down the disease process and to improve pain
32
Q

How can surgery be helpful in treating a patient with RA?

A
  • Can be helpful where joint stability has been lost to replace joints to allow function again
33
Q

What is the aim of physiotherapy? (4)

A
  • Aim to keep the patient active for as long as possible

Active and passive exercises:

  • To maintain muscle activity
  • To improve joint stability
  • To maintain joint position
34
Q

What is the aim of occupational therapy? (3)

A
  • Maximising residual function
  • Providing aids to independent living
  • Assessment and alteration of home
35
Q

Give examples of drugs that are used in most cases of RA? (4)

A
  • Analgesics
  • NSAID’s (often combined with anti-PUD agents where appropriate)
  • Disease modifying drugs
  • Steroids (inter-articular)
36
Q

Give examples of 2 analgesics which can be used to treat RA?

A
  • Paracetamol

- Cocodamol

37
Q

Give examples of disease modifying drugs which can be used to treat RA and why are they used? (6)

A
  • Hydrocychloroquine, methotrexate
  • Less commonly now: sulphasalzine, penacillamine, gold
  • These can be used because this is an immune based disease
  • They are frequently used to slow down the immune process and slow down the damage to the joints
38
Q

How can intra-articular steroids be used to treat RA?

A
  • These can be injected into the joint space where there are particular areas of inflammation or trouble
  • This is not a usual treatment in the early and moderate stages of disease
39
Q

What kinds of drug therapy could be used in moderate and severe cases of RA? (2)

A
  • Immune modulators

- Steroids - oral prednisolone

40
Q

What kinds of immune modulators could be used in moderate and severe cases of RA? (3)

A
  • Azthioprine
  • Mycophenolate
  • Biologics
41
Q

Give examples of biologics which can be used in the drug therapy of moderate to severe cases of RA and explain why these are used? (6)

A
  • TNF inhibitors - infliximab, adalimumab, entanercept
  • Rituximab (CD20) % tocilizumab (IL6r)
  • These drugs are increasingly used in moderate cases due to the benefit they give to the patients quality of life and the prevention of significant disability from disease progression
42
Q

What kinds of surgery can we use to treat RA? (5)

A
  • Excision of inflamed tissue
  • Joint replacement
  • Joint fusion
  • Osteotomy
  • Remember - patients often have a poor medical condition for surgery
43
Q

What are the chances of a patient with RA spontaneously remitting after surgery?

A
  • 10%

- Remainder have fluctuating course

44
Q

What % of people with RA are severely disabled after surgery?

A
  • 10%

- remainder have mild/moderare disability

45
Q

What are possible complications of surgery for RA? (4)

A
  • Infection, PUD, Extra-articular, Drugs
46
Q

Give examples of dental aspects of RA? (5)

A
  • Disability from the disease (reduced dexterity, access to care)
  • Sjogren’s syndrome (association of CT disease the dry eyes/mouth)
  • Joint replacements (these do not usually require antibiotic prophylaxis from the dentist)
  • Drug effects
  • Chronic anaemia - GA problems
47
Q

Give examples of drug effects of RA that can couse dental complications? (5)

A
  • Bleeding (NSAID’s & sulphasalazine)
  • Infection risk (steroids, azathioprine)
  • Oral lichenoid reactions (gold, sulphasalazine, hydroxychloroquine)
  • Oral ulceration (methotrexate)
  • Oral pigmentation (hydrocychloroquine)
48
Q

What is atlanto-occipital instability?

A
  • One other issue that arises from RA is damage to the ligaments in the neck
  • Particularly the ligaments connecting the skull base to the upper cervical vertebrae - Remember there is the atlas and the axis
  • The atlas being the top vertebrae and the axis having the dens which is protruding through and has a ligament attaching to the base of the skull
  • The combination of these allows pivoting and turning of the head
  • There are ligaments in the front and the back of the neck supporting the skull - these can become weakened in RA and can lead to slipping of the structures in the upper part of the neck more easily than would be found in a healthy individual
  • Therefore if sudden trauma i applied to the neck there is more chance of the ligaments rupturing and the bones impinging into the space for the spinal cord - causing significant spinal damage
  • This will no happen easily but if the patient had lost the muscle power in the neck, for example in GA and the head was moved inappropriately the ligaments may not protect the spinal cord as they should and therefore great care should be taken with the head of a RA patient where their muscle action has been lost
49
Q

What is the difference between RA and ankylosing spondylitis?

A
  • This differs from RA in that the primary focus of the disease is on the axial skeleton
  • RA affects peripheral tissues more but can affect the spine and cervical region
  • Whereas in AS the primary process will happen in the neck and vertebral bodies of the spine and to a lesser extent in the peripheral joints
  • Therefore in a normal individual there is good movement and flexibility in the spine due to the facet joints and the cartilaginous disc but in AS these are lost and there is fusion of the facet joints and the anterior aspects of the vertebrae so that they become stiff and do not move relative to each other which leads to changes in the ability of the patient to turn, twist and bend
50
Q

Give 3 examples of seronegative spondyloarthritides?

A
  • Ankylosing spondylitis (spinal joint arthritis)
  • Reiter’s disease
  • Arthritis of Inflammatory bowel disease
51
Q

Give examples of features of SA? (4)

A
  • Association with HLA-B27
  • Infection likely as a precipitant
  • Often symmetrical peripheral arthritis
  • Ocular & mucocutaneous mandifestations
52
Q

What is the ratio of males to females who are affected by AS?

A
  • 8:1 male predominance (this is very unusual in autoimmune disease)
53
Q

When is the onset of AS usually?

A
  • Onset about 20 years - rare after 45 years
54
Q

What % of patient’s who have AS also have large joint disease (such as knee or hip problems)?

A
  • 20%
55
Q

What are the effects of AS? (2)

A
  • Disablign progressive lack of axial movement (means the patient’s spine does not flex and bend and twist - means they are rigidly focused ahead)
  • Symmetrical other joint involvement e.g. hips
56
Q

What do the effects of AS result in? (4)

A
  • Low back pain
  • Limited back and neck movement - turning spine restricted
  • Limited chest expansion- breathing compromised
  • Cervical spine tipped forward (kyphosis) - movement restricted
57
Q

How might we treat AS? (7)

A

Generally the same as RA:

  • Analgesia & NSAID’s (to control pain)
  • Physiotherapy (to maintain function)
  • Occupational therapy (to maintain function)
  • DMD’s (disease modifying drugs)
  • Immune modulators (to reduce disease progression)
  • Surgery where appropriate for joint replacement (this is for function rahter than pain)
58
Q

What are the dental aspects of AS? (3)

A
  • Most common one is difficulty in treating the patient as they cannot lie back in the dentla chair due to the curvature of the spine
  • GA hasardous (limited mouth opening, limited neck flexion)
  • TMJ involvement possible, but rare except in psoriatic arthritis

BDS3 BAMS (11 decks)

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