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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

Adrienne J. Yoon, D.D.S.

November 18, 2004

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Autoimmune Disorders

  • Hashimoto’s Disease

  • Rheumatoid Arthritis

  • Sjogrens Syndrome

  • Systemic Lupus Erythematosus

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Hashimoto’s Disease

A chronic inflammatory disease of the thyroid

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  • Most common cause of primary thyroid deficiencies (thyroid “burns” out)

  • Common in women and adolescents

  • Familial predisposition

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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

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Medical Management

  • Thyroid hormone replacement once in the hypothyroid phase

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Dental Management

  • Aggressively treat infections

  • Avoid thyrotoxic crisis

  • Closely monitor vitals

  • Stress management

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Rheumatoid Arthritis

A chronic nonsuppurative inflammatory destruction of the joints

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  • 3% of general population

  • Genetic predisposition

  • Female to male ratio 3:1

  • Average age of onset of 40 years

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  • 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

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Signs and Symptoms

  • Polyarthritis sometimes associated with fever and weight loss

  • Joint pain

  • Generalized fatigue

  • “Gelling” phenomenon

    morning stiffness; difficult to resume motion

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Extra-Articular Manifestations

  • 20% of patients have rheumatoid nodules

  • Carpel tunnel sydrome

  • Synovial cysts

  • Pleuropulmonary disease

  • Systemic rheumatoid vasculitis

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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

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Medical Management

  • NSAIDs

  • Glucocorticoids

  • Immunosuppression

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Dental Management

  • AHA Guidelines

  • Short dental appointments

  • Assess if aspirin or NSAIDs are affecting platelet function

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Sjogren’s Syndrome

Inflammation of the lacrimal and salivary glands

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  • 0.2-3.0% of population

  • More common in females

  • 15% of patients with rheumatoid arthritis

  • 30% of patients with SLE

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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

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Interstitial nephritis

Interstitial lung fibrosis

Primary biliary cirrhosis (PBC)

Raynaud’s phenomenon

Peripheral neuropathies


Extra-glandular Signs and Symptoms

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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

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Medical Management

  • Local manifestations can be treated symptomatically

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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


  • Pain control for enlarged salivary glands

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Systemic Lupus Erythematosus

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

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  • Females are affected 8-10 times more than men

  • Average age is 31 years

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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

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Laboratory Values

  • 95% of patients have elevated ANA

  • 70% of patient have antibodies directed against double-stranded DNA

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Medical Management

  • Avoid excessive exposure to sunlight

  • NSAIDS for mild active disease with antimalarial drugs

  • Topical corticosteroids

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Dental Management

  • AHA Guidelines

  • Assess adrenal function for possible suppression

  • Consult with physician regarding systemic manifestation

  • Assess if NSAIDS are affecting platelet function