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Observe, record, tabulate, communicate.

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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Observe, record, tabulate, communicate.

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  1. We should endeavor to determine what type of patient has a disease, instead of just what disease the patient has . Observe, record, tabulate, communicate.

  2. RHEUMATIC DISEASES • over 100 different arthritic diseases • > 40 million Americans • > 8 million disabled • > $ 20 billion annually

  3. RHEUMATIC DISEASES • modern : >1800 • not equivalent to “arthritis” • chronic degenerative joint diseases • Female = 2.5 x Male • genetic : HLA-DR4 • socioeconomic, education, psychosocial stress

  4. RHEUMATIC DISEASES • general characteristics( signs & symptoms) • PAIN • INFLAMMATION • musculoskeletal stiffness • musculoskeletal swelling • musculoskeletal aches • musculoskeletal limitations • disability • deformity

  5. RHEUMATIC DISEASES • Laboratory tests • increased RF ~80%; 1:1280; non-Dx • higher = RA; poorer Px • increased ESR • increased ANA ~50% • LE • IgG • SSA/SSB

  6. Rheumatic Fever and Rheumatic Heart Disease • 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.

  7. RHEUMATOID ARTHRITIS • chronic, inflammatory, destructive joint disease • wide range of severity • ankles, cervical spine, elbows; hips, knees, • proximal interphalangeal joints • shoulders, tarsals, TMJ, wrists

  8. RHEUMATOID ARTHRITIS • MANAGEMENT • COMPREHENSIVE • MULTIDISCIPLINARY • CORTICOSTERIODS • SYSTEMIC ; LOCAL INJECTIONS • PREDNISONE, PREDNISOLONE • GOLD, ANTI-MALARIAL, PENICILLAMINE • SULFASALAZINE • BIOLOGICS- TNFa- antagonists • IMMUNOSUPPRESSIVES • IMMURAN, METHOTREXATE

  9. RHEUMATOID ARTHRITIS • TMD • pain, tenderness, stiffness, crepitus, • swelling, limited mandibular opening • fibrosis, ankylosis • bleeding, infection • neutropenia , thrombocytopenia, anemia • adrenal suppression

  10. Osteoarthritis of the TMJ • degenerative joint disease • most common intracapsular disorder • 40% > 40 y.o. who were ASx • osteophytes • steroids ( intra-articular) • surgery

  11. Sjögren’s syndrome

  12. ocular symptoms(1:3) 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 *

  13. oral symptoms (1:3) 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 *

  14. labial histology* focus score / 4mm >50 mononuclear cells Autoantibodies* anti-SS-Ro or anti-SS-La Diagnostic criteria for SS (EC) 4:6 *

  15. 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.

  16. SLE • renal disease 5-22 % • cardiac valvular disease 18-74 % • anemia 70 % • thrombocytopenia 25 % • leukopenia 45 % • arthritis 90 % • TMD 60 %

  17. SLE • systemic complications : • lab tests: CBC, platelets, BUN, creatinine • leukopenia, steriods, etc. = prone to infection • need for antibiotics ( IE ?) • adrenal suppression • bleeding

  18. Paget’s, Osteomyelitis,Osteoporosis, Fibrous dysplasia • osteolytic/osteoblastic • bleeding • bone deformities & tooth loss • infection • radiographs • lab tests: • CBC, Ca, P, alkaline phosphatase • bone biopsy

  19. Scleroderma

  20. SCLERODERMA • tightened, hard skin: face, hands, fingers • internal organ involvement • microstomia • tightened perioral skin • SGD • periodontal disease • painful RAS-type ulcerations CREST

  21. TREATMENT • CORTICOSTEROIDS • topical • systemic • intralesional • IMMUNOSUPPRESIVE agents • topical • systemic • intralesional

  22. Corticosteroid use: routine dental procedures • 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.

  23. Corticosteroid use: 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.

  24. Dental management • diagnosis; severity • systemic complications • musculoskeletal limitations • pain • medications; anti-inflammatory agents • oral manifestations • neutropenia ; thrombocytopenia; anemia • Infections(LPJI)

  25. Prevention of late Prosthetic joint infections Joint ADA/AAOS guidelines 1997

  26. Late ProstheticJoint Infection

  27. Late Prosthetic Joint Infections • 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.

  28. Late Prosthetic Joint Infections • 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

  29. Prevention of late Prosthetic joint infections: 1997 changes • 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

  30. Prevention of late Prosthetic joint infections: 1997 changes • Immunocompromised patients • IDDM • chronic CTD: RA, SLE, etc. • immunosuppressive drugs or irradiation • hemophilia or other blood dyscrasias • malnourishment • HIV

  31. Late Prosthetic Joint Infections • 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 !

  32. Prevention of late Prosthetic joint infections: 1997 changes • Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op • Cephazolin; 1 g; IM/IV; 1 hr. pre-op • Clindamycin; 600mg.; po; 1 hr. pre-op

  33. Thanks!!

  34. QUIZfold 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

  35. QUIZfold sheet and put your name on back • I liked the format of this course. • A. true • B. false

  36. QUIZ 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

  37. QUIZ fold sheet and put your name on back • I learned more from working on my group’s presentation. • A. true • B. false

  38. QUIZ fold sheet and put your name on back • The book was very helpful. • A. true • B. false

  39. QUIZ fold sheet and put your name on back • The group presentations were much better than straight lectures. • A. true • B. false

  40. QUIZ • Please RANK the top three presentations. • 1 • 2 • 3

  41. Cases • Problem-solving process GUIDES- when and where to get information (look it up !) Competencies……

  42. Exam • 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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