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We should endeavor to determine what type of patient has a disease, instead of just what disease the patient has. Observe, record, tabulate, communicate. RHEUMATIC DISEASES. over 100 different arthritic diseases > 40 million Americans > 8 million disabled > $ 20 billion annually.

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We should endeavor to determine what type of patient has a disease, instead of just what disease the patient has .

Observe, record, tabulate, communicate.


Rheumatic diseases
RHEUMATIC DISEASES disease, instead of just what disease the patient has .

  • over 100 different arthritic diseases

  • > 40 million Americans

  • > 8 million disabled

  • > $ 20 billion annually


Rheumatic diseases1
RHEUMATIC DISEASES disease, instead of just what disease the patient has .

  • modern : >1800

  • not equivalent to “arthritis”

  • chronic degenerative joint diseases

  • Female = 2.5 x Male

  • genetic : HLA-DR4

  • socioeconomic, education, psychosocial stress


Rheumatic diseases2
RHEUMATIC DISEASES disease, instead of just what disease the patient has .

  • general characteristics( signs & symptoms)

    • PAIN

    • INFLAMMATION

    • musculoskeletal stiffness

    • musculoskeletal swelling

    • musculoskeletal aches

    • musculoskeletal limitations

    • disability

    • deformity


Rheumatic diseases3
RHEUMATIC DISEASES disease, instead of just what disease the patient has .

  • Laboratory tests

    • increased RF ~80%; 1:1280; non-Dx

    • higher = RA; poorer Px

    • increased ESR

    • increased ANA ~50%

    • LE

    • IgG

    • SSA/SSB


Rheumatic fever and rheumatic heart disease
Rheumatic Fever and Rheumatic Heart Disease disease, instead of just what disease the patient has .

  • acute inflammatory condition

  • following group A streptococci infection

  • autoimmune reaction

  • arthralgia

  • > 75% < 20 y.o.

  • ~95% of all heart disease in children

  • third world = 30-40 % of all CVD all ages

  • U.S. 100,000 cases; 6500 deaths per yr.


Rheumatoid arthritis
RHEUMATOID ARTHRITIS disease, instead of just what disease the patient has .

  • chronic, inflammatory, destructive joint disease

  • wide range of severity

  • ankles, cervical spine, elbows; hips, knees,

  • proximal interphalangeal joints

  • shoulders, tarsals, TMJ, wrists


Rheumatoid arthritis1
RHEUMATOID ARTHRITIS disease, instead of just what disease the patient has .

  • MANAGEMENT

    • COMPREHENSIVE

    • MULTIDISCIPLINARY

    • CORTICOSTERIODS

      • SYSTEMIC ; LOCAL INJECTIONS

      • PREDNISONE, PREDNISOLONE

    • GOLD, ANTI-MALARIAL, PENICILLAMINE

    • SULFASALAZINE

    • BIOLOGICS- TNFa- antagonists

    • IMMUNOSUPPRESSIVES

      • IMMURAN, METHOTREXATE


Rheumatoid arthritis2
RHEUMATOID ARTHRITIS disease, instead of just what disease the patient has .

  • TMD

    • pain, tenderness, stiffness, crepitus,

    • swelling, limited mandibular opening

    • fibrosis, ankylosis

    • bleeding, infection

    • neutropenia , thrombocytopenia, anemia

    • adrenal suppression


Osteoarthritis of the tmj
Osteoarthritis of the TMJ disease, instead of just what disease the patient has .

  • degenerative joint disease

  • most common intracapsular disorder

  • 40% > 40 y.o. who were ASx

  • osteophytes

  • steroids ( intra-articular)

  • surgery


Sj gren s syndrome
Sjögren’s syndrome disease, instead of just what disease the patient has .


Diagnostic criteria for ss ec 4 6

ocular symptoms(1:3) disease, instead of just what disease the patient has .

daily dry eye >3mos

sand or gravel sens.

tear substitutes >tid

ocular signs (1:2)

Shirmer’s test

(<5mm/5min)

Rose Bengal score

(>4 - vBs)

Diagnostic criteria for SS(EC)4:6 *


Diagnostic criteria for ss ec 4 61

oral symptoms (1:3) disease, instead of just what disease the patient has .

daily dry >3 mos.

swollen glands

must drink liquids to swallow food

salivary function (1:3)

+ scintigraphy

+ sialography

WUSF <1.5ml/15 min. (0.1ml/min.)

Diagnostic criteria for SS (EC) 4:6 *


Diagnostic criteria for ss ec 4 62

labial histology* disease, instead of just what disease the patient has .

focus score / 4mm

>50 mononuclear cells

Autoantibodies*

anti-SS-Ro or

anti-SS-La

Diagnostic criteria for SS (EC) 4:6 *


  • Sjögren’s syndrome (SS) on a histopathological level is a benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : hyposalivation, glossitis, mucositis, angular cheilosis, and increased caries rate.


SLE benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

  • renal disease 5-22 %

  • cardiac valvular disease 18-74 %

  • anemia 70 %

  • thrombocytopenia 25 %

  • leukopenia 45 %

  • arthritis 90 %

  • TMD 60 %


SLE benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

  • systemic complications :

    • lab tests: CBC, platelets, BUN, creatinine

    • leukopenia, steriods, etc. = prone to infection

    • need for antibiotics ( IE ?)

    • adrenal suppression

    • bleeding


Paget s osteomyelitis osteoporosis fibrous dysplasia
Paget’s, Osteomyelitis, benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : Osteoporosis, Fibrous dysplasia

  • osteolytic/osteoblastic

  • bleeding

  • bone deformities & tooth loss

  • infection

  • radiographs

  • lab tests:

    • CBC, Ca, P, alkaline phosphatase

    • bone biopsy


Scleroderma benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :


Scleroderma
SCLERODERMA benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

  • tightened, hard skin: face, hands, fingers

  • internal organ involvement

  • microstomia

  • tightened perioral skin

  • SGD

  • periodontal disease

  • painful RAS-type ulcerations

CREST


Treatment
TREATMENT benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

  • CORTICOSTEROIDS

    • topical

    • systemic

    • intralesional

  • IMMUNOSUPPRESIVE agents

    • topical

    • systemic

    • intralesional


  • Corticosteroid use routine dental procedures
    Corticosteroid use: routine dental procedures benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Rx>2 wks. d/c w/i 30 days= Rx previous

    • d/c Rx > 30 days ago = none

    • topical = none

    • current Rx( any dose) = none

    • alt. day Rx = tx on that day

    • Monitor BP, good anesthesia, post-op analgesia, etc.


    Corticosteroid use complex dental procedures
    Corticosteroid use: benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : complex dental procedures

    • Rx>2 wks. d/c w/i 30 days= Rx previous

    • Rx d/c > 30 days ago = none

    • topical = none

    • current Rx( any dose) = double +

    • alt. day Rx = double + tx on that day

    • Monitor BP, good anesthesia, post-op + Rx + analgesia, etc.


    Dental management
    Dental management benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • diagnosis; severity

    • systemic complications

    • musculoskeletal limitations

    • pain

    • medications; anti-inflammatory agents

    • oral manifestations

    • neutropenia ; thrombocytopenia; anemia

    • Infections(LPJI)


    Prevention of late prosthetic joint infections

    Prevention of late Prosthetic joint infections benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    Joint ADA/AAOS guidelines

    1997


    Late ProstheticJoint Infection benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :


    Late prosthetic joint infections
    Late Prosthetic Joint Infections benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Wahl’s myths:

    • #1: There are similarities between IE (PVE) and LPJI. NO.

    • #2: Dental treatment is a probable cause

    • of LPJI. NO.

    • #3: Animal experiments document dental bacteremias as cause of LPJI.

      NO.

    • #4: To protect patients DDS should always cover patients with PJ.

      NO.


    Late prosthetic joint infections1
    Late Prosthetic Joint Infections benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • infection rate > 1%

    • >70% staph Pallusch

    • >1000 PJ pts., 6 yrs. - no prophylaxis= 0 LPJIs Ainscow

    • 4 cases of LPJI cultured= no oral pathogen Batzokas

    • other prosthetic- synthetic implants


    Prevention of late prosthetic joint infections 1997 changes
    Prevention of late Prosthetic joint infections: 1997 changes benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • ADA/AAOS advisory statement

    • medical consultation with Orthopod

    • No prophylaxis for pins, rods, screws, plates, wires, implants, etc.

    • healthy patient: < 2 yrs. after TJR

    • chronic RA or other infection of TJR

    • immunocompromised patients


    Prevention of late prosthetic joint infections 1997 changes1
    Prevention of late Prosthetic joint infections: 1997 changes benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Immunocompromised patients

    • IDDM

    • chronic CTD: RA, SLE, etc.

    • immunosuppressive drugs or irradiation

    • hemophilia or other blood dyscrasias

    • malnourishment

    • HIV


    Late prosthetic joint infections2
    Late Prosthetic Joint Infections benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Benefits of prophylaxis DO NOT

      necessarily outweigh potential

      risks especially considering

      antimicrobial resistance, costs,

      risk of anaphylaxis, etc.

    • Little, Rhodus, et.al.; JADA 1991

      …. Orthopedic surgeons ~ 90 %

      recommend antibiotic prophylaxis for dental Tx

    • SO…BE CAREFUL WHAT YOU ASK FOR !


    Prevention of late prosthetic joint infections 1997 changes2
    Prevention of late Prosthetic joint infections: 1997 changes benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op

    • Cephazolin; 1 g; IM/IV; 1 hr. pre-op

    • Clindamycin; 600mg.; po; 1 hr. pre-op


    Thanks
    Thanks!! benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :


    Quiz fold sheet and put your name on back
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • I know you do another course evaluation, but this is more for my own information in order to improve learning

    • I will respect your confidentiality and my secretary will record your name and after the course is complete and the grade submitted, I’ll review your responses


    Quiz fold sheet and put your name on back1
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • I liked the format of this course.

    • A. true

    • B. false


    Quiz fold sheet and put your name on back2
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • I learned as much ( or MORE) from the peer presentations as I would have from the instructor

    • A. true

    • B. false


    Quiz fold sheet and put your name on back3
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • I learned more from working on my group’s

      presentation.

    • A. true

    • B. false


    Quiz fold sheet and put your name on back4
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • The book was very helpful.

    • A. true

    • B. false


    Quiz fold sheet and put your name on back5
    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include : fold sheet and put your name on back

    • The group presentations were much better than straight lectures.

    • A. true

    • B. false


    QUIZ benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Please RANK the top three presentations.

    • 1

    • 2

    • 3


    Cases
    Cases benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • Problem-solving process

      GUIDES- when and where to get information

      (look it up !)

      Competencies……


    Exam benign lymphosialadenopathy which includes autoimmune lymphocytic infiltration of the salivary glands. Oral clinical manifestations of SS typically include :

    • 40 objective( MC- TF ?s): form Midterm

    • Allergies(5-6), Bleeding (5-6), Thyroid (3-4),blood dyscrasias(5-6), pregnancy (4-5), Neurological(4-5), HIV(4-5), Behavioral (2-3)

    • Open book case…just like those in class

    • Do the obj. first then you’ll get the case

    • Friday, Dec. 7 at 7:30 am

    • 1:30 ONLY !!

    • **


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