W19 71 rheumatology and connective tissue disorders Flashcards
What is osteoarthritis?
Mechanical joint disease
Non-inflammatory arthritis
Wear of the cartilage occurs and new bone is formed at the margins of the joints
What does osteoarthritis affect?
Many joints:
TMJ and cervical spine - pain on movement, restricted movement
Other joints
What is rheumatoid arthritis?
Chronic multi systemic disease. Inflammatory arthritis - persistent. Affects synovial lining of joints, bursae and tendons. Characterised by joint pain, swelling and stiffness. Characterisation: polyarticular, symmetrical, hand joints
How do you diagnose rheumatoid arthritis?
Blood tests:
- rheumatoid factor RF - antibodies, when positive seropositive
- anti-CCP antibodies (ACPA)
- acute phase reactants (APR)
Radiographic changes - looking for erosions or joint space narrowing
Image of the joints in RA - PG675
Look at image :)
What common joints can be involved in RA?
TMJ
Cervical spine
Atlanto-axial joint
What are some systemic manifestations of RA?
Constitutional - weight loss, fatigue
Organ specific - eye, mouth, skin, lungs, nerves, heart, bone
What are nodules?
Areas of pressure, internal. Result from small vessel vasculitis with fibrin oil necrosis forming the centre of the nodule. Can occur in RA.
What disease can affect the lacrimal and salivary glands secondary to RA and what does this cause?
(Secondary) Sjrogren’s syndrome to RA
Dry eyes, dry mouth, dental caries
Describe inflammatory eye disease from RA
Epicleritis
Scleritis - may progress to scleromalacia
Corneal melt
Drugs can cause toxicity in the eyes: steroids can lead to cataract; chloroquine can lead to retinopathy
How might RA affect the lungs?
Fibrosing alveolitis
Pulmonary nodules
Describe what osteoporosis is (bone loss) caused by RA by the imbalance of bone remodelling
Bone resorption process mediated by osteoclasts
Cytokines involved in inflammation in the synovial accelerate osteoclasts differentiation by upregulating RANKL, leading to bone loss in RA. More prone to bone loss and bone fracture.
What dental disease is prevalent in RA?
Periodontitis and tooth loss
(strength of relation not confirmed yet)
What is the aim for management of RA?
Early intervention to control inflammation and prevent structural damage and prevent loss of function
How do you manage RA?
NSAIDs
Disease modifying anti-rheumatic drugs (eg methotrexate) - control progression, inflammation and damage
Steroids - not used long term due to side effects
Biological therapies (eg anti-TNF therapy)
What if TNF?
A very powerful inflammatory cytokines, with effects at many levels eg on osteoclast activation
What are the destructive effects of TNF? PG680 IMAGE
Effects on osteoclasts, synoviocytes and chondrocytes to cause:
Bone resorption leading to bone erosion; join inflammation leading to pain and swelling; cartilage degradation leading to join space narrowing
What are some seronegative spondyloarthropathies?
Ankylosing spondylitis (AS)
Psoriatic arthritis (PsA)
Reactive arthritis
Crohn’s disease/UC associated arthritis
What is common between the seronegative spondyloarthropathies?
These disease groups affect the skin, eyes, gut, and joints
Common genetic risk factor - HLA B27
What is anthesis?
Anthesis = where the tunnel attaches to the bone
What is ankylosing spondylitis?
Spondylitis and arthritis
Arthritis of the spine, can be affected at many levels but also the saccryl joints and the coccyx.
Causes enthesitis and new bone formation - causes hard time moving the spine/joints
What is psoriatic arthritis?
Causes nail pitting, arthritis, swollen digits.
Complex polygenic autoimmune disease with diverse clinical features
Can affect skin, joints, eyes and many systemic parts
Sacrolytis is a prominent feature
What other oral condition can come from diseases of rheumatology eg lupus and arthritis and medication use?
Mucosal ulcers
What is anterior uveitis?
Eye involvement in ankylosing spondylitis
Inflammation of the uveal tract
Symptoms: painful, red eyes, photophobia, floaters, blurred vision
How do you manage spondyloarthropathies?
NSAIDs
Disease modifying anti-rheumatic drugs eg methotrexate for psoriatic arthritic
Steroids - to control active disease but much less than in RA
Biologic therapies (anti-TNF therapy)
What connective tissue diseases and vasculitis are there?
SLE, systemic sclerosis, Sjögren’s syndrome
Behçet’s disease, Temporal arteritis
SLE, systemic lupus erythematous is a multisystemic disease. What can it affect?
Rashes, hair loss, mouth ulcers
Inflammatory arthritis and myositis
Renal disease
Pulmonary disease
Neurological disease
Haematological disease
Connective tissue disease and vasculitis eg SLE, might come with antiphospholipid syndrome where platelets are low. What is the issue with this?
Thrombosis occurs so clots are a problem in these patients, so need to take anticoagulants for life.
What other diseases are common in lupus too?
Raynaud’s phenomenon, Livedo reticularis, alopecia
What is Raynaud’s phenomenon?
Blood vessels narrow reducing blood flow to hands. Fingers become cold and white. Feeling of ions and needles and numbness. Fingers then turn blue and red. Sometimes painful.
What is livedo reticularis?
Mottled reticulated vascular pattern that appears like a lace-like purplish discolouration of the lower extremities.
What is scleroderma?
Skin thickening
Difficulty opening mouth
Raynaud’s syndrome
Internal organ disease - lungs, kidneys, gut
Skin changes
What skin changes occur in scleroderma?
Inflammatory, indurative then atopic phase
Oedema, tightening, thickening, waxy feel
Loss of function in hands, arms, legs
Chest involvement
Telangeclasia
What is Sjögren’s syndrome?
A slowly progressive inflammatory disease affecting primarily the exocrine glands (eg salivary glands). Lymphocyte infiltrates these glands. Characteristic autoantibodies - Ro, La.
Causes mucosal dryness - eyes, mouth, genital tract
What extra-glandular disease might come from Sjogren’s?
Poly arthritis, lungs, kidneys, liver, blood vessels
What other autoimmune diseases might Sjogren’s be associated with?
RA, SLE, systemic sclerosis, polymyositis (fibromyalgia)
Can present as a secondary disease to these conditions
What are the types of vasculitis?
Temporal arteritis or giant cell arteritis (GCA)
Symptoms of vasculitis
Headache, scalp tenderness, jaw claudication, fatigue
Visual loss (permanent) if not treated quickly
How can ENT disease present in patients with vasculitis?
Granulomatosis with polyangitis (GPA) (rare)
Bloody nasal discharge
Nasal crusting
Nasal collapse
Stridor
Shortness of breath
Cough and haemoptysis
Renal involvement
What is the treatment for most connective tissue diseases and vasculitis?
Steroids
Immunosuppressants eg methotrexate, cyclophosphamide
Anticoagulants in SLE and anti-phospholipid syndrome
What is Paget’s disease?
A metabolic bone disease causing excess bone turnover
What is Paget’s disease characterised by?
Bone pain, bone deformity and fracture, vascular bone, bleeding, hypercementosis of teeth and fracture
Affects maxilla more than mandible
Can have enlarged skull with cotton wool appearance on radiograph
How is Paget’s disease treated?
Bisphosphonates
What are the risk factors for developing ONJ from bisphosphonates?
Potency of bisphosphonate (highest for zoledronate), route of administration, cumulative dose, duration and type of malignant disease, concomitant treatment, smoking, comorbid conditions and history of dental disease
Which patients have a higher risk of developing ONJ from bisphosphonates?
Risk of osteonecrosis of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease
What should you advise patients starting bisphosphonates?
All patients should have a dental check-up before bisphosphonate treatment or asap after starting treatment.
Is ONJ from bisphosphonates common?
Rare. Usually occurs in associated with dental surgery or dental infection but can also occur spontaneously.
Relatively uncommon but potentially serious side effect of treatment with either bisphosphonates or denosumab
What do the international task force say on ONJ recommendations?
Completion of dental work prior to initiation of antiresorptive therapy
Use antibiotics before and after procedure
Antimicrobial mouth rinsing
Appropriate closure of wound following surgery
Maintenance of good oral hygiene
Discontinuation of BPs should be made via clinical judgement.
When might you want to discontinue bisphosphonates?
Not needed in low risk osteoporosis patients
Maybe needed in patients who require extensive invasive oral surgery and in those with multiple risk factors for ONJ (eg glucocorticoids treatment, diabetes, immune deficiencies, smoking etc), and to restart when bone has healed?
FLOW DIAGRAMS FOR TISK OF ONJ AND MANAGEMENT PG690
VIEW AND PRINT!
When should you review healing post extraction in patients on bisphosphonates?
8 weeks
What is fibromyalgia?
Widespread pain, above and below the diaphragm. Classic tender points. Characterised by >=11/18 tender points.
What overlap does fibromyalgia overlap with other diagnoses?
Temporomandibular syndrome
Irritable bowel syndrome
Headache syndromes
All can cause sleep disturbance
What is treatment for fibromyalgia?
Analgesics to control pain - often including codeine
Antidepressants to help sleep/muscle relaxation - eg amytriptiline, fluoxetine
Anti-seizure drugs to help pain and sleep - eg gabapentin or pregabalin
Graded exercise programme, relaxation techniques, self care programmes
What things could cause pain on chewing?
TMJ - osteoarthritis, RA, ankylosing spondylitis etc
Bone involvement eg Paget’s
Vasculitis eg temporal arteritis
Pain syndrome
Salivary glands
Sinuses
Ear
Neurological eg trigeminal neuralgia
What rheumatological diseases might cause mouth ulcers?
Arthrides - reactive arthritis
Connective tissue disease and vasculitides - Behçet’s disease, SLE
Drugs
Infective eg HIV
Bowel disease eg Crohn’s disease, coeliac disease
