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
Incidence • Most common cause of primary thyroid deficiencies (thyroid “burns” out) • Common in women and adolescents • Familial predisposition
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 • Thyroid hormone replacement once in the hypothyroid phase
Dental Management • Aggressively treat infections • Avoid thyrotoxic crisis • Closely monitor vitals • Stress management
Rheumatoid Arthritis A chronic nonsuppurative inflammatory destruction of the joints
Incidence • 3% of general population • Genetic predisposition • Female to male ratio 3:1 • Average age of onset of 40 years
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 • Polyarthritis sometimes associated with fever and weight loss • Joint pain • Generalized fatigue • “Gelling” phenomenon morning stiffness; difficult to resume motion
Extra-Articular Manifestations • 20% of patients have rheumatoid nodules • Carpel tunnel sydrome • Synovial cysts • Pleuropulmonary disease • Systemic rheumatoid vasculitis
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 Management • NSAIDs • Glucocorticoids • Immunosuppression
Dental Management • AHA Guidelines • Short dental appointments • Assess if aspirin or NSAIDs are affecting platelet function
Sjogren’s Syndrome Inflammation of the lacrimal and salivary glands
Incidence • 0.2-3.0% of population • More common in females • 15% of patients with rheumatoid arthritis • 30% of patients with SLE
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
Lymphadenopathy Vasculitis Interstitial nephritis Interstitial lung fibrosis Primary biliary cirrhosis (PBC) Raynaud’s phenomenon Peripheral neuropathies Scleroderma Extra-glandular Signs and Symptoms
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 Management • Local manifestations can be treated symptomatically
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 A chronic multisystem disease of unknown origin that exhibits wide variations in its clinical expression and disease course
Incidence • Females are affected 8-10 times more than men • Average age is 31 years
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 Values • 95% of patients have elevated ANA • 70% of patient have antibodies directed against double-stranded DNA
Medical Management • Avoid excessive exposure to sunlight • NSAIDS for mild active disease with antimalarial drugs • Topical corticosteroids
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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