Rheumatoid Arthritis

Question 1

What is rheumatoid arthritis?

Answer 1

Initially a disease of the synovium with gradual inflammatory joint destruction

Question 2

Patterns of joint involvement in rheumatoid arthritis

Answer 2

sero-positive RA
- rheumatoid factor present
sero-negative RA
- rheumatoid factor not present

Question 3

Rheumatoid arthritis prevalence

Answer 3

most common serious joint disease
- 1%
- 6.1% female pre menopause
- 3.1% female post menopause

Question 4

Rheumatoid arthritis peak age

Answer 4

20-50 years

Question 5

Rheumatoid arthritis - symptoms

Answer 5

slow onset
- initially hands and feet
- proximal spread
- potentially all synovial structures
symmetrical poly arthritis
occasional onset with systemic symptoms
- fever, weight loss, anaemia

Question 6

Rheumatoid arthritis - early signs

Answer 6

• symmetrical synovitis of MCP joints
• symmetrical synovitis of PIP joints
• symmetrical synovitis of wrist joints

Question 7

Rheumatoid arthritis - late signs

Answer 7

ulnar deviation of fingers at MCP joints
hyperextension of PIP joints
- “swan neck” deformity
“z” deformation of thumb
- hyperflexion of MCP
- hyperextension of IP joint
subluxation of the wrist
loss of abduction and external rotation of shoulders
flexion of elbows and knees
deformity of feet and ankles

Question 8

extra articular features of RA

Answer 8

inflammation of blood vessels
- due to systemic vasculitis
psoriasis in some patients
- gives more aggressive form of RA and in younger patients
- ‘psoriatic arthritis’
eye involvement
- dry eyes, Sjorgrens syndrome
- scleritis and episcleritis
- pulmonary inflammation

Question 9

Rheumatoid arthritis - investigations

Answer 9

radiographs
- erosions, loss of joint space, deformity
- joint destruction and secondary osteoarthritis
blood
- normochromic, normocytic anaemia

Question 10

rheumatoid arthritis - treatment

Answer 10

aim to improve quality of life
combinations of:
- physiotherapy
- occupational therapy
- drug therapy
- surgery

Question 11

aims of physiotherapy when treating rheumatoid arthritis

Answer 11

keep patient active for as long as possible
active and passive exercises to:
- maintain muscle activity
- improve joint stability
- maintain joint position

Question 12

aims of occupational therapy when treating rheumatoid arthritis

Answer 12

maximising residual function
providing aids to independent living
assessment and alteration at home

Question 13

Drug therapy for rheumatoid arthritis

Answer 13

analgesics
- paracetamol, cocodamol
NSAIDs
- often combined with anti-PUD agents
Disease modifying drugs
- hydroxychloroquine, methotrexate
steroids
- intra-articular

Question 14

Drug therapy in moderate and severe cases of RA

Answer 14

immune modulators
- azathioprine
- mycophenolate
- biologics - TNF inhibitors such as infliximab, adalimumab
steroids
- oral prednisolone

Question 15

Rheumatoid arthritis - surgery

Answer 15

• excision of inflamed tissue
• joint replacement
• joint fusion
• osteotomy

*patients often have a poor medical condition for surgery

Question 16

RA - prognosis

Answer 16

10% spontaneously remit
- remainder have fluctuating course
RF and late onset = worse prognosis
10% severely disabled
- remainder have mild/moderate disability

Question 17

Rheumatoid arthritis complications

Answer 17

• peptic ulcer disease - NSAIDs
• infection
• extra-articular
• Drugs

Question 18

Rheumatoid arthritis dental aspects

Answer 18

disability from the disease
- reduced dexterity
- access to care
sjorgrens syndrome
- dry mouth
joint replacements
drug effects
- bleeding - NSAIDs
- infection risk - steroids, azathioprine
- oral lichenoid reactions - hydroxycloroquine
- oral ulceration - methotrexate
- oral pigmentation - hydroxycloroquine

Question 19

Ankylosing spondylitis prevalence

Answer 19

95% have HLA-B27
- 10% caucasians have HLA-B27
- 0.5% of these get ankylosing spondylitis
8:1 male predominance
onset about 20 years - rare after 45 years
20% also have large joint disease

Question 20

Ankylosing spondylitis effects

Answer 20

disabling progressive lack of axial movement
symmetrical other joint involvement -e.g. hips

results in:
- lower back pain
- limited back and neck movement - restriction of turning spine
- limited chest expansion - compromised breathing
- cervical spine tipped forward restricting movement

Question 21

ankylosing spondylitis treatment

Answer 21

generally same as rheumatoid arthritis
- analgesia and NSAIDs
- physiotherapy
- occupational therapy
- DMDs
- immune modulators
- surgery where appropriate for joint replacement

Question 22

Ankylosing spondylitis dental aspects

Answer 22

GA hazardous
- limited mouth opening
- limited neck flexion
TMj involvement possible but rare except in psoriatic arthritis