Rheumatoid arthritis

Question 1

What is the definition of Rheumatoid Arthritis?

Answer 1

A chronic auto immune systemic illness characterised by a symmetrical polyarthritis and other systemic features.

Question 2

Which joints are most commonly affected by Rheumatoid Arthritis?

Answer 2

Small joints of hands (MCPs, PIPs), wrists, and feet (MTPs).

Question 3

What is the prevalence of Rheumatoid Arthritis in the general population?

Answer 3

Approximately 1% of the population.

Question 4

What is the female to male ratio for Rheumatoid Arthritis?

Answer 4

3:1.

More females

Question 5

At what age does Rheumatoid Arthritis typically onset?

Answer 5

Peak age in the 4th/5th decade but may occur at any age from 16 years.

Question 6

What is the genetic contribution to the incidence of Rheumatoid Arthritis?

Answer 6

Estimated to be ~50-60%.

Genetic predisposition

HLA-DRb1 gene - common gene in RA

Question 7

Name environmental factors that contributes to Rheumatoid Arthritis.

Answer 7

Cigarette smoking.

Chronic infection e.g. periodontal disease (p.gingivalis)

EBV and parvovirus B19

Question 8

What are some symptoms of Rheumatoid Arthritis?

Answer 8

Joint pain

Morning stiffness >30 mins

Immobility

Poor function

Systemic symptoms

Question 9

List some specific extra-articular manifestations of Rheumatoid Arthritis.

Answer 9

• Eyes
• Lungs
• Nerves
• Skin
• Kidneys

Question 10

What is the significance of gum disease in patients with Rheumatoid Arthritis?

Answer 10

65% of RA patients had gum disease compared to 28% of non-RA patients.

Question 11

What are common laboratory tests for investigating Rheumatoid Arthritis?

Answer 11

• FBC
• Kidney function
• Liver function
• CRP
• ESR

Question 12

What is the purpose of the Disease Activity Score (DAS28)?

Answer 12

To assess disease activity in Rheumatoid Arthritis.

Question 13

What type of drugs are DMARDs?

Answer 13

Disease Modifying Anti Rheumatic Drugs

Biologic therapy, targeted synthetic, conventional synthetic DMARDs

TNF-a inhibitors

Question 14

What is a key characteristic of biologic DMARDs?

Answer 14

They target key aspects of the inflammatory cascade and are typically large complex proteins.

Question 15

Name one class of biologics used in the treatment of Rheumatoid Arthritis.

Answer 15

TNFα inhibitors.

Question 16

True or False: Biologics come with a higher cost compared to traditional DMARDs.

Answer 16

True.

Question 17

What is a common oral health issue associated with RA medications?

Answer 17

Increased risk of infections, including thrush.

Question 18

What should be done with DMARDs/Biologics if there is an ongoing infection?

Answer 18

They should be withheld.

Question 19

What is a common recommendation for RA patients experiencing mouth dryness?

Answer 19

Frequent sips of water and using sugar-free gums.

Question 20

Rheumatology?

Answer 20

medical specialty that focuses on diagnosing and treating conditions that cause inflammation in the muscles, bones, joints, and internal organs.

Question 21

Aetiology of RA?

Answer 21

Genetic
Environmental
Hormonal

Question 22

what are hormonal contributing factors to RA?

Answer 22

Early age menopause, low testosterone level in men

Question 23

Pathogenesis of RA?

Answer 23

Smoking / genetic factors

Gene starts to change, produce foreign protein

Lymph node and spleen react to foreign body - immune response

Citrulline
Local inflammation
Produce anti citrulline peptide

activation of osteoclasts

Second hit: immune complexes, increased vascular permeability, complement fixation
- destruction of joint tissue

Question 24

signs of RA?

Answer 24

Joint swelling

Tenderness

Warmth, redness

Limitation of movement

Question 25

Sign of early RA>

Answer 25

synovitis

Question 26

Non specific systemic/extra-articular symptoms of RA?

Answer 26

Fatigue/lassitude Weight loss Anaemia

Question 27

Long term systemic symptoms of RA?

Answer 27

CVS Malignancy

Question 28

Extra-articular manifestations of RA?

Answer 28

Question 29

RA increase gum disease?

Answer 29

Yes, perio and gingivitis TMJ pain also - Bacteria like P. gingivalis and Aggregatibacter actinomycetemcomitans (Aa) are present in both RA and gum disease - RA medication can cause oral health problems - Joint problems can make it difficult to clean your teeth Poor OHI can trigger RA too

Question 30

TMJ and RA?

Answer 30

Pain, swelling, limitation of the jaw opening

Question 31

RA and Sjögren’s syndrome?

Answer 31

Autoimmune condition affecting salivary and tear gland result in lack of salivary and tear secretion cause significant dryness of mouth and eye. Coincide with RA

Question 32

Joint in hand affected by RA?

Answer 32

MCP

Question 33

Management of RA?

Answer 33

* Early and aggressive intervention is the key to obtaining optimal outcomes in the management of RA * Effective suppression of inflammation will improve symptoms and prevent joint damage and disability - stop osteoclasts from eroding joints

Question 34

pharmacological therapy for managing RA?

Answer 34

Meds take 3 months to work - give anti-inflammatory , if need more then steroid.

Question 35

DMARD therapy?

Answer 35

Disease Modifying Anti Rheumatic Drugs (conventional, non biologic) A group of structurally unrelated, typically small molecule drugs which have been demonstrated to have slow onset effect on disease activity and retard disease progression. Traditionally, these have been associated with identifiable toxicity profiles and risk of occasional serious adverse event.

Question 36

classes of biologics?

Answer 36

* TNFα inhibitors (x5) * IL-1 inhibitors (Anakinra) * Anti B Cell therapies (CD20, Rituximab) * Anti T Cell therapies (Abatacept) * IL-6 inhibitors (Tocilizumab, Sarilumab) * Oral kinase inhibitors

Question 37

Issues with biologics?

Answer 37

Toxicity: minor eg injection site reaction Increase risk of Infection Malignancy Cost: £9500 Vs. £50

Question 38

Effect of RA medications on the mouth?

Answer 38

1- Increase risk of infections including thrush 2- Methotrexate can cause mucositis which can lead to mouth ulcers. - especially in higher dodse or if they forget to take folic acid. 3- Remember to withhold DMARDs/Biologics if there is ongoing infection requiring antibiotic or if they are going to complex dental procedure.

Question 39

Targeted synthetic DMARDs (tsDMARDS)?

Answer 39

Inhibitors with low selectivity, inhibiting the signalling of the broad range cytokines

Question 40

role of conventional synthetic DMARDs?

Answer 40

Non-targeted suppression of the overactive immune system

Question 41

example of csDMARDs?

Answer 41

Methotrexate

Question 42

RA patients and oral health? Summary

Answer 42

-Rheumatoid patients needs regular follow up with dentists and Oral hygienist to ensure eradication of oral infections. - Withhold DMARDs /Biologics If you are dealing with Infection and consult with us if you are planning oral surgery. - with Mouth Dryness Frequent sips of water , avoid Tea , Coffee and Tobacco Sugar free gums, Artificial saliva and high Florid tooth paste. - Remember TMJ and cervical disc disease involvement when you examine RA patients.