Rheumatology and bone disease

Question 1

What is rheumatology?

Answer 1

Branch of medicine dealing with joint, bone and muscle disease
Diseases normally inflammatory
Most diseases are autoimmune with systemic manifestations
Can present either with arthritis or thro’ systemic (oral) features
Rheumatologists need to look in the mouth, dentists need to know when to refer to rheumatology
*** AND GRAPH

Question 2

Rheumatic disease overview

Answer 2

Non- inflammatory
-osteoarthritis
Inflammatory
-rheumatoid Arthritis
-reactive arthritis/ seronegative arthritis
-systemic lupus erythematosus
-vasculitis
-scleroderma
-behcets
-dermatomyositis/ polymyositis
**

Question 3

Oral manifestations necessary to diagnosis

Answer 3

Sjögrens Syndrome
-primary
-secondary
Behcets Disease

Question 4

Rheumatoid arthritis

Answer 4

Disease of synovial joints
Affects 1% population
Auto-immune, systemic inflammatory illness
Symmetrical joint inflammation and deformity
“Extra-articular” features

Question 5

Rheumatoid arthritis: the pain

Answer 5

Inflammatory joint pain

• early morning stiffness (>30 min)
• stiffness after rest
• ease with use/ exercise
• swelling
• may have “flu-like” symptoms
• anti-inflammatory drugs: NSAIDs e.g. Ibuprofen - may be helpful

Question 6

Sjögren’s syndrome

-“sicca syndrome” or Mikulicz’s disease

Answer 6

Auto-immune inflammatory disorder of exocrine glands
-lacrimal, salivary, nasal, laryngeal, tracheal and vaginal glands.
-xerostomia + keratoconjunctivitis sicca
Marked lymphocytic infiltration destroying the gland architecture and function
Affected glands may be initially swollen, inflamed, tender and later atrophic

Question 7

Inflammation

Answer 7

Red (rubor)
Hot (calor)
Painful (dolor)
Swollen (tumour)

Question 8

Rheumatoid arthritis can lead to

Answer 8

Progressive joint deformity

• Z thumb deformity
• Swelling and subluxation of MCPJs
• Spares DIPJs
• Ulnar deviation of fingers (e.g. swan neck deformity)
• “Boggy” swelling (could be warm and tender but quite firm)

Question 9

Sjögren’s syndrome histology (biopsy)

Answer 9

Lymphotic infiltration of salivary gland showing disruption of the normal glandular architecture

Question 10

Rheumatoid arthritis: extra-articular features

Answer 10

Lungs
-nodules (collection of inflammatory cells)
-lung fibrosis
-pleural effusions
CV
-pericardial inflammation/ effusions
-myocarditis
-valve inflammation
Kidneys
-amyloidosis
Skin
-rheumatoid nodules
-vasculitis
Secondary Sjögren's syndrome

Question 11

Blood tests: rheumatoid arthritis

Answer 11

Anaemia (normocytic, normochromic?)
High/ low platelets
High inflammatory marker
-C reactive protein (CRP), erythrocyte sedimentation rate (ESR)
Auto-antibodies
-up to 75% positive for RF (rheumatoid factor) and/ or anti-CCP (cyclic citrullinated peptide)

Question 12

Xrays - rheumatoid arthritis

Answer 12

Early
-osteopenia (thinning) around joints: "periarticular osteopenia"
-soft tissue swelling
Late
-erosions
-joint space narrowing
-subluxation/ dislocation
-fusion ("ankylosis")

Question 13

Treatment for rheumatoid arthritis: immediate relief

Answer 13

NSAIDs e.g. Ibuprofen
Steroids
-injected into joint/ IM/ IV/ oral

Question 14

Treatment for rheumatoid arthritis: control of disease (immunosuppressive)

Answer 14

DMARDs (Disease Modifying Anti-Rheumatic Drugs)
-e.g. methotrxate, sulfasalazine, leflunomide, hydroxychloroquine
Biologic drugs (all either SC or IV injections so will not appear on pt’s prescription list from GP)
-anti TNF (tumour necrosis factor) e.g. Infliximab, Adalimumab, Etanercept
-B cell depletion (anti CD20) e.g. Rituximab
-others e.g. Tocilizumab (anti IL 6), Abatacept (T cell blocker), Jak

Question 15

Side effects of rheumatoid arthritis treatment

Answer 15

Infection
-all increase risk
-for biologic drugs: reactivation of TB
Bone Marrow Toxicity
-low white cell count/ low platelets/ pancytopenia
Hepatotoxic
-abnormal liver tests (rise in enzymes)
Gastric upset 
-nausea, diarrhoea, flatulence
Skin rashes
*advise all pts to stop dmards/ biologic drugs for duration of course of antibiotics and for up to 2 weeks afterwards*

Question 16

Methotrexate (DMARD)

Answer 16

Prescribed as once weekly dose: 15-25 mg/wk (2.5mg tabs)
Never co-prescribe with Trimethoprim/ Septrin
-risk of severe bone marrow suppression: all anti-folate drugs
Lung complications
-pneumonia
-fibrosis?
Renally excreted
-reduce dose/ stop or contact us if pt develops new renal impairment
Contra-indicated in both men and women pre-conception
Nausea, mouth ulcers

Question 17

Biologic drugs

Answer 17

Much greater infection risk
-stop 2 weeks prior to surgery/ significant procedure
-restart 2 weeks later or when wounds healing
-remember to ask your pt if they are on on of these
-contact us
Reactivation of TB/ Hep B & C
Relatively contra-indicated if pt develops cancer
May cause/ exacervate MS (anti-TNF)

Question 18

“Rheumatoid neck”

Answer 18

Erosive change at C1/ C2 (and lower levels)
Leading to subluxation at atlanto-axial level or at subaxial levels or both
Important to recognise “rheumatoid neck” because instability can lead to neurological deficit from spinal cord compression
-neck slightly off to one side
May be a problem with intubation or positioning a pt in dental chair

Question 19

Anatomy of atlanto-axial joint / subluxation

Answer 19

Dens can push back into SC and cause injury (of C2 - axis)
-usually preotected by ligament, this is disrupted by erosive change in rheumatoid arthritis
Atlas (C1)

Question 20

Rheumatoid pts in dental chair

Answer 20

Ask about neck pain
Ask about known “rheumatoid neck”
When positioning pt, check no new neck pain develops or neurological symptoms such as pins and needles/ numbness in arms/ hands/ legs
Pre-intubation: flexion and extension xrays of cervical spine and discuss with anesthetist

Question 21

Caries/ gingivitis in RA

Answer 21

Poor hand/ neck/ shoulder function can impair dental hygiene
Immuno-suppressive drugs may compound this
Remember many RA pts have co-existent osteoporosis, so may well be on bisphosphonates too (jaw necrosis)
> evidence that gingivitis/ caries may be trigger for RA in genetically susceptible individuals

Question 22

JIA: Juvenile idiopathic arthritis

Answer 22

Inflammatory arthritis occurring before age of 16
Up to 40% “grow out of it” by adulthood
Many different patterns of arthritis
Jaw underdevelopment
-TMJ inflammation leads to altered mandibular growth
-malocclusion, micrognathia
-pain, biomechanical problems

Question 23

Sponyloarthropathy

Answer 23

Akylosing spondilitis
Reactive arthritis
Enteropathic arthritis (Crohns/ UC)
Psoriatic arthritis
--all overlapping and all associated with genetic tissue type HLA B27)

Question 24

Akylosing spondilitis

Answer 24

Inflammatory spinal pain
-progressive new bone formation/ calcification in spine = severe limitation of movement –> bamboo spine
-sacro-ilitis
More common in men than women
Biologic drugs
Can have rigid, fused neck (risk of fracture) and/ or atlanto-axial subluxation

Question 25

Common features of spondyloarthropathy

Answer 25

``` Enthesitis -inflammation of junction between tendon/ ligament and bone -e.g. achilles tendon, tennis elbow Dactylitis -"sausage finger" or "sausage toe" -combination of joint and tendon sheath inflammation Skin/ nail psoriasis Psoriatic arthritis DIPJ involvement Inflammatory eye disease -iritis (anterior uveitis) IBD -Crohns/ UC Large joint oligoarthritis ```

Question 26

Psoriatic arthritis

Answer 26

Psoriasis: common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin Doesn't spare DIPJ Nail pitting Dactylitis

Question 27

Osteoarthritis

Answer 27

Degenerative process, probably with exaggerated repair response Leads to pain, stiffness, deformity, < joint movement, joint instability > with age Occupation/ hobbies > risk E.g. footballers - knees, typists - hands and wrists

Question 28

X-rays in OA

Answer 28

Los of joint space Osteophytes Sub-chondral sclerosis

Question 29

OA treatment

Answer 29

``` Physiotherapy/ exercises Weight loss (lower limb joints) Paracetamol, co-codamol, NSAIDS Surgery as final resort -for uncontrolled pain -joint failure e.g. knee giving way ```

Question 30

Gout

Answer 30

Hot, red, swollen, painful Type of arthritis Can be in any joint Urate crystals precipitate out from bloodstream into joints/ soft tissues Induces intense neutrophil-led inflammatory response -needle shaped urate crystals

Question 31

Why does gout happen?

Answer 31

Pt has high serum urate (before attack; urate may be falsely low during attack) Causes of high urate: -genetic predisposition (enzyme defects) -renal impairment -diuretics -dehydration -inter-current illness -high alcohol/ fructose/ red meat/ shellfish diet -part of "metabolic syndrome" - central obesity, diabetes, high BP, high cholesterol

Question 32

Treatment of gout

Answer 32

``` Acute -NSAIDs -Colchicine -steroids Prevention of future attacks -urate lowering drugs e.g. allopuinol and febuxostat (both xanthine oxidase inhibitors) ```

Question 33

Severe chronic gout

Answer 33

Chronic polyarticular tophaceous gout

Question 34

CT diseases

Answer 34

Group of rare auto-immune systemic diseases Certain common features Can be life-threatening, usually due to organ involvement -e.g. renal failure (glomerulonephritis), lung fibrosis, myocarditis, cerebral involvement (vascular occlusion or vasculitis) Associated with "auto-antibodies" - antibodies directed against "self" More common in women

Question 35

CT diseases examples

Answer 35

``` SLE (lupus) Scleroderma Primary Sjogren's Polymyositis/ dermatomyositis *all associated with anti-nuclear antibody (ANA)* ```

Question 36

Common features of CT disease

Answer 36

Raynauds - vasocontriction fingers and toes in response to cold -triphasic colour change Mouth ulcer Cardio respiratory disease

Question 37

SLE

Answer 37

Non-erosive arthritis -no erosions Butterfly rash Photosensitivity

Question 38

Scleroderma or "systemic sclerosis"

Answer 38

Progressive skin thickening and tightening -e.g. oral tethering Severe Raynaud's -often leading to digital ulcers, frank tissue necrosis (digital gangrene) Can be limited to hands, feet and face (limited systemic sclerosis LcSSc) Or widespread (Diffuse systemic sclerosis DcSSc) Telangiesctasia (including inside lips), microstomia

Question 39

LcSSc

Answer 39

Also associated with pulmonary hypertension, severe acid reflux Telangiectasia, microstomia & oral tethering

Question 40

DcSSc

Answer 40

Associated with pulmonary fibrosis (often life threatening) | “Scleroderma renal crisis” – hypertensive acute renal failure

Question 41

Sjogren's syndrome

Answer 41

Primary -occurring on its own without an associated rheumatic illness but with its own systemic manifestations Secondary -occurring with rheumatic illness e.g. RA, SLE etc. -associated with other auto-immune disorder including interstitial lung disease, auto-immune liver disease etc.

Question 42

Primary Sjogren's

Answer 42

Dry eyes and mouth Associated with Ro and La antibodies High immunoglobulins, high ESR, positive Rheumatoid Factor Fatigue, joint pain

Question 43

Rare but serious complications of primary Sjogrens

Answer 43

Vasculitis (inflammation of BVs) Renal involvement (renal tubular acidosis) Neurological involvement (peripheral neuropathy) Associated with primary biliary cirrhosis (inflammation and stricture of bile ducts) 9x increase in risk of lymphoma

Question 44

atrophy Sjogren's

Answer 44

Atrophic, shrunken parotid gland | Atrophic, "shiny" glossitis

Question 45

Polymyositis and dermatomyositis

Answer 45

2 diseases associated with inflammation of muscles Causes weakness of arms and thighs Painless wasting of these muscles Both can be associated with lung fibrosis

Question 46

Polymyositis

Answer 46

Muscle involvement only

Question 47

Dermatomyositis

Answer 47

Muscles and skin Photosensitivity/ purple "heliotrope" rash around eyes Strong association with internal malignancy Swollen red face, mucosal lesions, lymphotic infiltrations of muscle fibres

Question 48

Treatment for CT diseases

Answer 48

Different for each but include: -NSAIDs/ steroids DMARDS Cytotoxic drugs (for life-threatening complications) e.g. cyclophosphamide Biologic drug e.g. Rituximab (anti-TNF drugs contra-indicated in SLE)

Question 49

Xerostomia

Answer 49

Due to a marked reduction in saliva production from all the salivary glands. Causes difficulty with chewing or swallowing food, articulation, food lodges in recesses, increased risk of dental caries, altered taste. Oral mucosa and tongue may be sore, reddened, “burn”, saliva is typically scanty and sticky

Question 50

Keratoconjunctivitis sicca

Answer 50

Common symptom complex - dry, itchy, red, sore, photophobic eyes - < tear secretion leading to conjunctival ulcers - blinking painful and irritable - eyes commonly feel “gritty"