Dental Management o f Rheumatoid and Osteoarthritic Patients

1. Dental Management of Rheumatoid and Osteoarthritic Patients Paula K. Friedman, DDS, MSD, MPH Director of Geriatric Dentistry Fellowship Boston University Henry M. Goldman School of Dental Medicine Steven Karpas, DMD Geriatric Dentistry Fellow Boston University School of Medicine/ Dept. of Geriatrics Boston University Henry M. Goldman School of Dental Medicine

2. Disclosure Neither authors have no actual or potential conflict of interest in relation to this presentation discuss today.

3. Outlines Public Health of Chronic conditions Highlights of Arthritis: Rheumatoid Arthritis and Osteoarthritis Dental Implications of Rheumatoid Arthritis and Osteoarthritis Summary Recommendations

4. Scully, S. and Ettinger, R. (2007) The Influence of systemic diseases on oral health care in older adults. JADA;138(9 supplement):7S-14S.

5. Multiple Chronic Conditions Among Medicare Fee-For-Service Beneficiaries, 2010

7. Arthritis • In 2002, 51% of adults 75 years and over • Arthritis increases with age • Arthritis annually results in: • 36 million ambulatory care visits • 744,000 hospitalizations • 9,367 death • 19 million people with activity limitations Heimick, C., et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, Arthritis & Rheumatism, 58(1), 15-25, 2008

8. Term used to describe more than 100 different conditions that affect joints as well asother parts of the body • Most prevalent chronic health problems and one ofthe nation’s most common causes of disability in the elderly population • Inflammatory or degenerative process involving joints • Today’s presentation will focus on Rheumatoid Arthritis and Osteoarthritis Arthritis [CDC. Prevalence of disabilities and associated health conditions among adults – United States, 1999. MMWR 2001; 50: 120 – 5.]

9. Arthritis Etiology • The most cause of inflammatory arthritis in older patients • Rheumatoid Arthritis • The most common cause of non-inflammatory arthritis in older patients • Osteoarthritis (degenerative joint disease--DJD)

10. Rheumatoid Arthritis Incidence + Prevalence • Prevalence estimates 1%- 2% U.S. population/increasing each decade • Disease onset between 35-50 years • Females > males 3:1 • Incidence varies with age • 20 in a 100,00 for men40 in a 100,00 for women • Lifelong disease Predisposing Factors • Sex hormones • Socioeconomic status • Education • Psychosocial stress

11. What is RA? • Systemic autoimmune disease • Synovial inflammation /cartilage erosion • Pain • Swelling • Morning stiffness • Symmetrical presentation • Typically affects the peripheral joints

12. Rheumatoid Arthritis Lab work • Rheumatoid factor • 50% positive in early disease • 80% of patients will develop a positive rheumatoid factor during the disease • Increased sedimentation rate • C-reactive protein • Anti-CCP (cyclic citrullinated peptide) • CBC-thrombocytopenia and anemia

17. Criteria for the Diagnosis of Rheumatoid Arthritis • At least four must be present for a diagnosis of rheumatic arthritis Aletaha D, Neogl T, SilmanAJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative [Ann Rheum Dis. 2010; 69(9): 1583.]

18. Diagram of Knee Joint Normal Knee Joint Knee Joint with Inflammation

19. Frontal images of both the right and left wrists show advanced changes of rheumatoid arthritis with soft tissue swelling (yellow arrows), narrowing of the radiocarpal joint space (blue arrow). erosions (red arrows), and destruction of the ulnar styloid (green arrow). The intercarpal joints are destroyed as re all of the carpal-metacarpal joints of both hands. Note the symmetric appearance of the disease

20. Signs and Symptoms of Rheumatoid Arthritis Constitutional symptoms include the following: • Fatigue • Loss of appetite • Loss of weight • Low-grade fever • Morning stiffness

21. Rheumatoid Arthritis Etiology

23. Complications • Disability secondary to joint deformity • Toxic effect of drug therapy • Intracardiac rheumatoid nodule causing valvular and/or conduction abnormalities • Pleural, subpleural disease, interstitial fibrosis • Median nerve entrapment • Systemic amyloidosis and vasculitis • Sjogren’s Syndrome

24. Rheumatoid ArthritisMedical Management Palliative treatment – No cure exists Treatment goals: • Reduce joint inflammation and swelling • Relieve pain and stiffness • Encourage normal function • Stop joint damage • Prevent disability and disease-related morbidity • Behavioral health management

25. Rheumatoid ArthritisMedical Management A basic early treatment program • Patient education • Rest • Exercise • Physical therapy • Drugs-aspirin or NSAIDS

26. Non-Pharmacologic Treatment • Early intervention before joint damage • Exercise and mobility emphasis • Swimming • Avoid joint stress • Patient education • Appropriate diet and avoid excessive body weight

28. What Drugs are used? • Anti-inflammatory Drugs • DMARDS

29. Pharmacologic Treatment

30. ASA or NSAIDs • Relieve pain and inflammation • Increased risk of upper GI ulcerations—encourage increased water intake • Increased risk of hepatotoxicity and nephrotoxicity • Most common sign aspirin toxicity-tinnitus

31. Cox 2 Inhibitors (Celebrex) • Have decreased upper GI side effects and nephrotoxicity • Has an increased risk of potentially fatal cardiovascular events

32. Corticosteroids • Used in severe disease • Short-term use • Long-term effects: • Hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, depression, psychosis, adrenal suppression and an increased risk of infection

33. Disease Modifying Antirheumatic Drugs (DMARDs) Side Effects • Nausea/vomiting • Rash • Sore throat • Nasal congestion • Oral ulcerations • Stomatitis • Tender/swollen gums • Muscle aches, reduces folic acid levels • Infections • Dizziness • Bleeding

34. Rheumatoid ArthritisMedical Management • Rest, controlled exercise, splint • Anti-inflammatory medications, COX-2 inhibitors (Celebrex), salicylates (aspirin), corticosteroids and NSAIDS • Disease-Modifying Anti-Rheumatic Drugs (DMARDS) • Surgery –maximize function, minimize deformity *Removal inflamed joint lining *Joint replacement *Joint fusions

35. Osteoarthritis

36. Osteoarthritis • Most common type of arthritis • Disease onset is gradual • Degenerative joint disease--DJD • Progressive pathological change of the hyaline cartilage + bony joints • Vertebrae, hips, knees, and distal interphalangeal joints of fingers

37. Osteoarthritis • Chronic joint failure • Degradation of cartilage/bone • Minimal inflammation • Immobility • Pain on rotation • Negligible morning stiffness • Bony enlargements, specially affecting hands

38. Osteoarthritis Symptoms • Joint pain which gets worse with use • No association with prolonged morning stiffness • Joint pain <30 min • Joint stiffness • Joint noises or crepitus • Loss of function • Swelling not usually seen • Unilateral joint involvement

39. Chronic  Joint Destruction • Prosthetic Joints • Hip • Knee • Shoulder • Elbow • Wrist • Ankle • Guidelines for antibiotic prophylaxis

40. Osteoarthritis Prevalence • 14% of adults > 25 years • 34% of adults > 65 years • Affects almost all adults by age 80 Gender • Before age 55, occurs equally in both genders • After age 55, more common in females • 80% of people over age 50 have radiographic OA • 80% of people over age 75 have symptomatic OA

41. Diagram of Knee Joint Knee Joint with Osteoarthritis Normal Knee Joint

42. Osteoarthritis Joint Damage • Repeat impact load • Unexpected load • High velocity load

43. Osteoarthritis Changes Loss of cartilage Sclerosis of bone Bone cysts Osteophyte formation Stretch of joint capsule Joint instability Joint space narrowing And/or bony sclerosis

44. OsteoarthritisRisk Factors

45. Osteoarthritis Finger nodules

46. Osteoarthritis Signs • Bony enlargement • Heberden’s nodes • Bouchard’s nodes • With or without non-inflammatory joint effusions • Crepitus with range of motion • Restricted range of motion

47. Osteoarthritis Medical Management • There is no cure for OA • Management focuses on relieving symptoms and improving function

48. Osteoarthritis Treatment Goals • Patient education • Physical therapy • Weight control • Exercise – can sometimes stop or reverse OA of hip and knee • Orthotics • Bracing • Modify ADLs -bathing, dressing, transferring, toileting, eating • Medications (Acetaminophen, Aspirin, NSAIDS) • Surgery

49. Treatment of OA Pharmacologic • Acetaminophen • NSAIDS • Topical Capsaicin • Intra-articular glucocorticoids • Narcotic analgesics Non-Pharmacologic • Bracing • Orthotics • Strength training • Weight loss • Joint replacement