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Dental Management of Patients with Autoimmune Disorders. Adrienne J. Yoon, D.D.S. November 18, 2004. Autoimmune Disorders. Hashimoto’s Disease Rheumatoid Arthritis Sjogrens Syndrome Systemic Lupus Erythematosus. Hashimoto’s Disease. A chronic inflammatory disease of the thyroid.

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dental management of patients with autoimmune disorders

Dental Management of Patients with Autoimmune Disorders

Adrienne J. Yoon, D.D.S.

November 18, 2004

autoimmune disorders
Autoimmune Disorders
  • Hashimoto’s Disease
  • Rheumatoid Arthritis
  • Sjogrens Syndrome
  • Systemic Lupus Erythematosus
hashimoto s disease

Hashimoto’s Disease

A chronic inflammatory disease of the thyroid

incidence
Incidence
  • Most common cause of primary thyroid deficiencies (thyroid “burns” out)
  • Common in women and adolescents
  • Familial predisposition
laboratory values
Laboratory Values
  • Assay the free thyroxine (T4) level
  • Primary thyroid disease: TSH levels are elevated
  • Secondary thyroid disease: caused by pituitary dysfunction and TSH level is normal or borderline
medical management
Medical Management
  • Thyroid hormone replacement once in the hypothyroid phase
dental management
Dental Management
  • Aggressively treat infections
  • Avoid thyrotoxic crisis
  • Closely monitor vitals
  • Stress management
rheumatoid arthritis

Rheumatoid Arthritis

A chronic nonsuppurative inflammatory destruction of the joints

incidence9
Incidence
  • 3% of general population
  • Genetic predisposition
  • Female to male ratio 3:1
  • Average age of onset of 40 years
pathogenesis
Pathogenesis
  • Synovium is transformed into hyperplastic chronically inflammed tissue
  • Intimal lining increases in size due to local proliferation of fibroblast-like cells and macrophage-like synoviocytes
  • Prominent angiogenesis
  • Rheumatoid factor is synthesized in the synovium and detected in synovial fluid
signs and symptoms
Signs and Symptoms
  • Polyarthritis sometimes associated with fever and weight loss
  • Joint pain
  • Generalized fatigue
  • “Gelling” phenomenon

morning stiffness; difficult to resume motion

extra articular manifestations
Extra-Articular Manifestations
  • 20% of patients have rheumatoid nodules
  • Carpel tunnel sydrome
  • Synovial cysts
  • Pleuropulmonary disease
  • Systemic rheumatoid vasculitis
laboratory values13
Laboratory Values
  • High elevation of rheumatoid factor (RF)
  • Antinuclear antibody (ANA) detected in about 50% of patients
  • Active phase: patients have elevated erythrocyte sedimentation rate (ESR)
  • Some affected patients have mild anemia
medical management14
Medical Management
  • NSAIDs
  • Glucocorticoids
  • Immunosuppression
dental management15
Dental Management
  • AHA Guidelines
  • Short dental appointments
  • Assess if aspirin or NSAIDs are affecting platelet function
sjogren s syndrome

Sjogren’s Syndrome

Inflammation of the lacrimal and salivary glands

incidence17
Incidence
  • 0.2-3.0% of population
  • More common in females
  • 15% of patients with rheumatoid arthritis
  • 30% of patients with SLE
signs and symptoms18
Signs and Symptoms
  • Dry mouth, skin, eyes, nose and vagina
  • Tongue becomes fissured and exhibits atrophy of the papillae
  • Oral mucosa red and tender
  • Parotid enlargement
extra glandular signs and symptoms
Lymphadenopathy

Vasculitis

Interstitial nephritis

Interstitial lung fibrosis

Primary biliary cirrhosis (PBC)

Raynaud’s phenomenon

Peripheral neuropathies

Scleroderma

Extra-glandular Signs and Symptoms
laboratory values20
Laboratory Values
  • High erythrocyte sedimentation rate and serum immunoglobulin levels (IgG)
  • 75% of patients have RF regardless of rheumatoid arthritis
  • Antinuclear antibodies (ANA) also present
medical management21
Medical Management
  • Local manifestations can be treated symptomatically
dental management22
Dental Management
  • Prevention of caries

daily use of fluoride, frequent recalls

  • Enhance salivary output

sugarless gum/candy, saliva substitutes (salivart, biotene, oral balance, mouth kote, glandosane, prescription medication (salagen, ` evoxac)

  • Treatment of oral candidiasis

antifungals

  • Pain control for enlarged salivary glands
systemic lupus erythematosus

Systemic Lupus Erythematosus

A chronic multisystem disease of unknown origin that exhibits wide variations in its clinical expression and disease course

incidence24
Incidence
  • Females are affected 8-10 times more than men
  • Average age is 31 years
signs and symptoms25
Fever, weight loss, arthritis, fatigue, and general malaise

Butterfly rash on the malar area and nose

40-50% of patients have affected kidneys

Cardiac involvement

-Libman-sacks endocarditis found in 50% of patients upon autopsy

-pericarditis, myocarditis, endocarditis, CAD

Oral lesions

-5-25% of patients have affected palate, buccal mucosa, and gingiva

Signs and Symptoms
laboratory values26
Laboratory Values
  • 95% of patients have elevated ANA
  • 70% of patient have antibodies directed against double-stranded DNA
medical management27
Medical Management
  • Avoid excessive exposure to sunlight
  • NSAIDS for mild active disease with antimalarial drugs
  • Topical corticosteroids
dental management28
Dental Management
  • AHA Guidelines
  • Assess adrenal function for possible suppression
  • Consult with physician regarding systemic manifestation
  • Assess if NSAIDS are affecting platelet function
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