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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


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    1. Dental Management of Patients with Autoimmune Disorders Adrienne J. Yoon, D.D.S. November 18, 2004

    2. Autoimmune Disorders • Hashimoto’s Disease • Rheumatoid Arthritis • Sjogrens Syndrome • Systemic Lupus Erythematosus

    3. Hashimoto’s Disease A chronic inflammatory disease of the thyroid

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

    5. 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

    6. Medical Management • Thyroid hormone replacement once in the hypothyroid phase

    7. Dental Management • Aggressively treat infections • Avoid thyrotoxic crisis • Closely monitor vitals • Stress management

    8. Rheumatoid Arthritis A chronic nonsuppurative inflammatory destruction of the joints

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

    10. 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

    11. Signs and Symptoms • Polyarthritis sometimes associated with fever and weight loss • Joint pain • Generalized fatigue • “Gelling” phenomenon morning stiffness; difficult to resume motion

    12. Extra-Articular Manifestations • 20% of patients have rheumatoid nodules • Carpel tunnel sydrome • Synovial cysts • Pleuropulmonary disease • Systemic rheumatoid vasculitis

    13. 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

    14. Medical Management • NSAIDs • Glucocorticoids • Immunosuppression

    15. Dental Management • AHA Guidelines • Short dental appointments • Assess if aspirin or NSAIDs are affecting platelet function

    16. Sjogren’s Syndrome Inflammation of the lacrimal and salivary glands

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

    18. 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

    19. Lymphadenopathy Vasculitis Interstitial nephritis Interstitial lung fibrosis Primary biliary cirrhosis (PBC) Raynaud’s phenomenon Peripheral neuropathies Scleroderma Extra-glandular Signs and Symptoms

    20. 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

    21. Medical Management • Local manifestations can be treated symptomatically

    22. 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

    23. Systemic Lupus Erythematosus A chronic multisystem disease of unknown origin that exhibits wide variations in its clinical expression and disease course

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

    25. 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

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

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

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