Dental Management of Patients with Autoimmune Disorders - PowerPoint PPT Presentation

Dental Management of Patients with Autoimmune Disorders

Adrienne J. Yoon, D.D.S.

November 18, 2004

• Hashimoto’s Disease
• Rheumatoid Arthritis
• Sjogrens Syndrome
• Systemic Lupus Erythematosus

Hashimoto’s Disease

A chronic inflammatory disease of the thyroid

• Most common cause of primary thyroid deficiencies (thyroid “burns” out)
• Common in women and adolescents
• Familial predisposition

• 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

• Thyroid hormone replacement once in the hypothyroid phase

• Aggressively treat infections
• Avoid thyrotoxic crisis
• Closely monitor vitals
• Stress management

Rheumatoid Arthritis

A chronic nonsuppurative inflammatory destruction of the joints

• 3% of general population
• Genetic predisposition
• Female to male ratio 3:1
• Average age of onset of 40 years

• 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

• Polyarthritis sometimes associated with fever and weight loss
• Joint pain
• Generalized fatigue
• “Gelling” phenomenon

morning stiffness; difficult to resume motion

• 20% of patients have rheumatoid nodules
• Carpel tunnel sydrome
• Synovial cysts
• Pleuropulmonary disease
• Systemic rheumatoid vasculitis

• 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

• NSAIDs
• Glucocorticoids
• Immunosuppression

• AHA Guidelines
• Short dental appointments
• Assess if aspirin or NSAIDs are affecting platelet function

Sjogren’s Syndrome

Inflammation of the lacrimal and salivary glands

• 0.2-3.0% of population
• More common in females
• 15% of patients with rheumatoid arthritis
• 30% of patients with SLE

• Dry mouth, skin, eyes, nose and vagina
• Tongue becomes fissured and exhibits atrophy of the papillae
• Oral mucosa red and tender
• Parotid enlargement

Vasculitis

Interstitial nephritis

Interstitial lung fibrosis

Primary biliary cirrhosis (PBC)

Raynaud’s phenomenon

Peripheral neuropathies

Scleroderma

• High erythrocyte sedimentation rate and serum immunoglobulin levels (IgG)
• 75% of patients have RF regardless of rheumatoid arthritis
• Antinuclear antibodies (ANA) also present

• Local manifestations can be treated symptomatically

• 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

• Females are affected 8-10 times more than men
• Average age is 31 years

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

• 95% of patients have elevated ANA
• 70% of patient have antibodies directed against double-stranded DNA

• Avoid excessive exposure to sunlight
• NSAIDS for mild active disease with antimalarial drugs
• Topical corticosteroids

• AHA Guidelines
• Assess adrenal function for possible suppression
• Consult with physician regarding systemic manifestation
• Assess if NSAIDS are affecting platelet function