DENTAL IMPLICATIONS of RHEUMATOID ARTHRITIS

Report
Dental Management of
Rheumatoid and
Osteoarthritic Patients
Steven Karpas, DMD
Paula K. Friedman, DDS, MSD, MPH
Geriatric Dentistry Fellow
Boston University School of Medicine/
Dept. of Geriatrics
Boston University Henry M. Goldman
School of Dental Medicine
Director of Geriatric Dentistry Fellowship
Boston University Henry M. Goldman
School of Dental Medicine
Disclosure
 Neither authors have no actual or potential
conflict of interest in relation to this
presentation discuss today.
Outlines
1. Public Health of Chronic conditions
2. Highlights of Arthritis:
a. Rheumatoid Arthritis and
b. Osteoarthritis
3. Dental Implications of Rheumatoid Arthritis and
Osteoarthritis
4. Summary
5. Recommendations
Common
Medical
Conditions
in Older
Adults
Arthritis
Cancer
COPD
Diabetes
Heart Disease
Hypertension
Mental Health Conditions
Osteoporosis
Parkinson Disease
Stroke
Scully, S. and Ettinger, R. (2007) The Influence of systemic diseases on oral health care in older adults.
JADA;138(9 supplement):7S-14S.
Multiple Chronic Conditions Among Medicare
Fee-For-Service Beneficiaries, 2010
Arthritis
• In 2002, 51% of adults 75 years and over
• Arthritis increases with age
• Arthritis annually results in:

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36 million ambulatory care visits
744,000 hospitalizations
9,367 death
19 million people with activity limitations
Heimick, C., et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States,
Arthritis & Rheumatism, 58(1), 15-25, 2008
• Term used to describe more than 100 different
conditions that affect joints as well as
other parts of the body
Arthritis
• Most prevalent chronic health problems and one of
the nation’s most common causes of disability in the
elderly population
•
Inflammatory or degenerative process involving joints
• Today’s presentation will focus on Rheumatoid
Arthritis and Osteoarthritis
[CDC. Prevalence of disabilities and associated health conditions among adults – United States, 1999. MMWR 2001; 50: 120 – 5.]
Arthritis
Etiology
• The most cause of inflammatory arthritis in older
patients
 Rheumatoid Arthritis
• The most common cause of non-inflammatory
arthritis in older patients
 Osteoarthritis (degenerative joint disease--DJD)
Rheumatoid Arthritis
Incidence + Prevalence
• Prevalence estimates 1%- 2% U.S.
population/increasing each
decade
• Disease onset between 35-50
years
• Females > males 3:1
• Incidence varies with age
• 20 in a 100,00 for men
40 in a 100,00 for women
• Lifelong disease
Predisposing Factors
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Sex hormones
Socioeconomic status
Education
Psychosocial stress
What is RA?
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Systemic autoimmune disease
Synovial inflammation /cartilage erosion
Pain
Swelling
Morning stiffness
Symmetrical presentation
Typically affects the peripheral joints
Rheumatoid Arthritis
Lab work
• Rheumatoid factor
 50% positive in early disease
 80% of patients will develop a positive
rheumatoid factor during the disease
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•
•
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Increased sedimentation rate
C-reactive protein
Anti-CCP (cyclic citrullinated peptide)
CBC-thrombocytopenia and anemia
Joints Affected
Digits, wrists, feet, and
knees
Involvement of the
shoulders, hips and TMJ
Involvement of the
cervical spine and
sacroiliac joint is rare
Criteria for the
Diagnosis of
Rheumatoid
Arthritis
Signs and Symptoms:
Morning stiffness
Arthritis of three or more
joint areas
Arthritis of hand joints
Symmetric arthritis
Rheumatoid nodules
Positive Serum rheumatoid
factor
Radiographic changes
• At least four must be present for a diagnosis of rheumatic arthritis
Aletaha D, Neogl T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against
Rheumatism collaborative initiative [Ann Rheum Dis. 2010; 69(9): 1583.]
Diagram of Knee Joint
Normal Knee Joint
Knee Joint with Inflammation
Frontal images of both the right and left wrists show advanced changes of rheumatoid arthritis with soft tissue swelling (yellow arrows),
narrowing of the radiocarpal joint space (blue arrow). erosions (red arrows), and destruction of the ulnar styloid (green arrow). The
intercarpal joints are destroyed as re all of the carpal-metacarpal joints of both hands. Note the symmetric appearance of the disease
Signs and Symptoms of
Rheumatoid Arthritis
Constitutional symptoms include the following:
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Fatigue
Loss of appetite
Loss of weight
Low-grade fever
Morning stiffness
Rheumatoid Arthritis
Unknown
Causes
Foods
Genetics
Etiology
Infectious
Agent
Vitamins
Autoimmunity
Dermatologic
•Rheumatoid
nodules
•Carditis
•Pericarditis
Cardiovascular
Pulmonary
•Pleuritis
•Intrapulmonary
nodules
•Interstitial fibrosis
Neurologic
•Peripheral
neuropathy
•Entrapment
neuropathies
Hematologic
Musculoskeletal
•Anemia
•Thrombocytosis
•Skeletal muscle
weakness
•Osteoporosis
Complications
• Disability secondary to joint deformity
• Toxic effect of drug therapy
• Intracardiac rheumatoid nodule causing valvular
and/or conduction abnormalities
• Pleural, subpleural disease, interstitial fibrosis
• Median nerve entrapment
• Systemic amyloidosis and vasculitis
• Sjogren’s Syndrome
Rheumatoid Arthritis
Medical Management
Palliative treatment – No cure exists
Treatment goals:
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Reduce joint inflammation and swelling
Relieve pain and stiffness
Encourage normal function
Stop joint damage
Prevent disability and disease-related morbidity
Behavioral health management
Rheumatoid Arthritis
Medical Management
A basic early treatment program
• Patient education
• Rest
• Exercise
• Physical therapy
• Drugs-aspirin or NSAIDS
Non-Pharmacologic Treatment
• Early intervention before joint damage
• Exercise and mobility emphasis
Swimming
 Avoid joint stress
• Patient education
• Appropriate diet and avoid excessive body
weight
What is
role of
medication
for RA?
•Maintain
function
•Decrease
inflammation
•Facilitate
healing
•Pain reduction
What Drugs are used?
• Anti-inflammatory Drugs
• DMARDS
Pharmacologic Treatment
Anti-inflammatory
medications
DMARDs
Salicylates (aspirin)
/NSAIDS
Gold- rarely
Azathioprine- rarely
Methotrexate
Sulasalazine
Leflunomide
COX-2 inhibitors (Celebrex)
Hydroxychloroquine
Penicillamine
Tofacitinib
Corticosteroids
TNF-alpha blocking agents
(etanercept, infliximab and
adalimumab)
ASA or NSAIDs
• Relieve pain and inflammation
• Increased risk of upper GI ulcerations—
encourage increased water intake
• Increased risk of hepatotoxicity and
nephrotoxicity
• Most common sign aspirin toxicity-tinnitus
Cox 2 Inhibitors (Celebrex)
• Have decreased upper GI side effects and
nephrotoxicity
• Has an increased risk of potentially fatal
cardiovascular events
Corticosteroids
• Used in severe disease
• Short-term use
• Long-term effects:
 Hyperglycemia, edema, osteonecrosis, myopathy, peptic
ulcer disease, hypokalemia, osteoporosis, depression,
psychosis, adrenal suppression and an increased risk of
infection
Disease Modifying Antirheumatic
Drugs (DMARDs)
Side Effects
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Nausea/vomiting
Rash
Sore throat
Nasal congestion
Oral ulcerations
Stomatitis
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Tender/swollen gums
Muscle aches, reduces
folic acid levels
• Infections
• Dizziness
• Bleeding
Rheumatoid Arthritis
Medical Management
• Rest, controlled exercise, splint
• Anti-inflammatory medications, COX-2 inhibitors
(Celebrex), salicylates (aspirin), corticosteroids and
NSAIDS
• Disease-Modifying Anti-Rheumatic Drugs (DMARDS)
• Surgery –maximize function, minimize deformity
*Removal inflamed joint lining
*Joint replacement
*Joint fusions
Osteoarthritis
Osteoarthritis
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•
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Most common type of arthritis
Disease onset is gradual
Degenerative joint disease--DJD
Progressive pathological change of the hyaline
cartilage + bony joints
• Vertebrae, hips, knees, and distal interphalangeal
joints of fingers
Osteoarthritis
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Chronic joint failure
Degradation of cartilage/bone
Minimal inflammation
Immobility
Pain on rotation
Negligible morning stiffness
Bony enlargements, specially affecting hands
Osteoarthritis
Symptoms
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Joint pain which gets worse with use
No association with prolonged morning stiffness
Joint pain <30 min
Joint stiffness
Joint noises or crepitus
Loss of function
Swelling not usually seen
Unilateral joint involvement
Chronic Joint Destruction
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Prosthetic Joints
Hip
Knee
Shoulder
Elbow
Wrist
Ankle
Guidelines for antibiotic prophylaxis
Osteoarthritis
Prevalence
• 14% of adults > 25 years
• 34% of adults > 65 years
• Affects almost all
adults by age 80
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Gender
• Before age 55, occurs
equally in both genders
• After age 55, more
common in females
80% of people over age 50 have radiographic OA
80% of people over age 75 have symptomatic OA
Diagram of Knee Joint
Normal Knee Joint
Knee Joint with Osteoarthritis
Osteoarthritis
Joint Damage
• Repeat impact load
• Unexpected load
• High velocity load
Osteoarthritis Changes
• Loss of cartilage
• Sclerosis of bone
• Bone cysts
• Osteophyte formation
• Stretch of joint capsule
• Joint instability
• Joint space narrowing
• And/or bony sclerosis
Joint
infection
Aging
Mechanical
and molecular
joint changes
Obesity
Single or
repeated
injury
Metabolic
disorders
Abnormal
motion
Osteoarthritis
Risk Factors
Osteoarthritis
Finger nodules
Osteoarthritis
Signs
• Bony enlargement
• Heberden’s nodes
• Bouchard’s nodes
• With or without non-inflammatory joint effusions
• Crepitus with range of motion
• Restricted range of motion
Osteoarthritis
Medical Management
• There is no cure for OA
• Management focuses on relieving symptoms and improving
function
Osteoarthritis
Treatment Goals
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Patient education
Physical therapy
Weight control
Exercise – can sometimes stop or reverse OA of hip and knee
Orthotics
Bracing
Modify ADLs -bathing, dressing, transferring, toileting, eating
Medications (Acetaminophen, Aspirin, NSAIDS)
Surgery
Treatment of OA
Pharmacologic
• Acetaminophen
• NSAIDS
• Topical Capsaicin
• Intra-articular
glucocorticoids
• Narcotic analgesics
Non-Pharmacologic
• Bracing
• Orthotics
• Strength training
• Weight loss
• Joint replacement
Rheumatoid
Arthritis
Osteoarthritis
Multiple symmetric joint
involvement
Usually one or two joints
involved
Significant joint inflammation
Morning joint stiffness for
longer than 1 hour
Systemic manifestations
(fatigue, weakness, malaise)
Symmetric swelling of proximal
interphalangeal joints
Joint pain usually without
inflammation
Joint stiffness < 30 min/
worsens during the day
Non symmetrical swelling of
the distal interphalangeal joints
Osteoarthritis and
Rheumatoid Arthritis
Mobility Limitations
• Arthritis in the hand, finger(s), elbow, shoulder, and/or neck
can affect one’s ability to provide good daily oral care
• Modified manual toothbrush handles or electric toothbrushes
(wide handle) can help to accommodate for lost mobility
• Interdental cleaners/brushes can assist when flossing is not
possible
• Increase frequency of oral prophylaxes and examinations
Osteoarthritis
Oral Clinical Findings
• No specific findings
• Dental caries and gingivitis can develop due to poor
oral hygiene caused by dexterity limitation
Implications for Oral Care
• Total joint replacement patients may need prophylactic
antibiotics
Patients with Severe Disease May
Need
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Floss holders
Toothpicks
Irrigation devices
Mechanical toothbrushes
Suggested Toothbrush
Modifications
From the Dental Care Every Day: A Caregiver’s Guide. NIH Publication No. 11-5191. Available at:
http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/DentalCareEveryDay.htm.
Suggested Toothbrush
Modifications
Velcro strap modified to hold brush
Handle enlargement by cutting slit
in tennis ball
From the Dental Care Every Day: A Caregiver’s Guide. NIH Publication No. 11-5191. Available at:
http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/DentalCareEveryDay.htm.
Wide elastic or rubber band to hold brush
Handle enlargement by attaching a
bicycle grip to the handle
Rheumatoid Arthritis
Oral Clinical Findings
• Temporo-mandibular joint disease (TMD) may be
present
• Limitation of mouth opening secondary to TMD
• Dental caries and gingivitis can develop
• Poor oral hygiene caused by dexterity limitation
• Xerostomia (medications)
Dental Significance
• Patient at risk for poor oral hygiene
• TMJ: Pain, occlusal changes, limited oral intake,
decreased nutritional intake, mastication and oral
hygiene
• Decreased mobility may affect access to care
• Anterior open bite, limited intraoral opening, and
possible joint ankylosis
• Neutropenia, thrombocytopenia due to medications
Rheumatoid Arthritis
Implications for Oral Care
• Arthritis medications may prolong bleeding tendency,
immune suppression and increase susceptibility for oral
bacterial, fungal and viral infections
• Total joint replacement patients may need prophylactic
antibiotics
• Medications such as methrotrexate, D-peniciliamine, gold
salts, DMARDs and/or corticosteroids may develop
abnormal liver function, CBC values or platelet count
Rheumatoid Arthritis
Implications for Oral Care
• Steroids may cause adrenal suppression
• More frequent recall/hygiene appointments may be
needed
• Modified oral health aids may be indicated
• Consider fluoride/Peridex supplementation
Rheumatoid Arthritis
Implications for Oral Care
• Oral hygiene neglect secondary to impaired
dexterity
• Patients may need assistance in/out of dental
chair
• Severe RA limits neck hyperextension
Specific Management Consideration
• Schedule short appointments and consider
patient ‘s ideal time of the day
• Ensure physical comfort
• Drug considerations:
• ASA, NSAID: impaired hemostasis
• DMARDs: get CBC with platelets
• Corticosteroid: risk of adrenal suppression
• Prosthetic Joints: may require abx guidelines
Where Do We Go From Here?
Dentist
Physical
therapist
Physician
Dental
Hygienist
Arthritis Summary
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Serious systemic disease
Painful
Patient Fatigue
Leads to significant disability
Difficulty with oral care
Drugs can affect risk of infection + bleeding
Tailor dental treatment plan to the individual, their degree
of disability, their comorbid conditions, age, and their
drugs
• Contact physician for questions
Arthritis Summary
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Determine the type of rheumatic disease affecting your patient.
Determine spine involvement and mobility status.
Provide TMD care if TMJ involvement.
Have patient move neck themselves when positional changes
needed
Do not rotate neck yourself (negatively affects patient, upper
extremity nerve pains)
Inquire on cervical spine instability
Transfer assistance to dental chair
Consider short appointments
Arthritis Summary
• Utilize lumbar pillow, lambswool chair cover
• Know patients current medications
• Confirm any steroid use for two weeks or longer in the
past two years.
• Follow “the rule of twos” prior to major surgery
• Consult physician
• All infection should be aggressively treated
• Xerostomia….saliva substitutes, frequent recalls, oral
candidiasis
Daily Oral Care Recommendations
• Brush with a soft bristle toothbrush for two minutes, twice
each day, and replace your toothbrush every 3 months. Try an
electric toothbrush to make brushing more efficient.
• Floss daily to remove plaque and food particles located where
brushing cannot reach, such as below the gumline.
• Rinse each day with an anti-microbial mouthwash to reduce
bacteria and help prevent gingivitis.
• Visit your dentist or dental hygienist every 6 months for
professional cleaning and routine checkup. If you notice signs
of gum disease, such as bleeding or swollen gums, see your
dentist as soon as possible and follow the recommended
treatment plan.

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