Rheumatology - Overview

• The notes covers various diseases, drugs, treatments, and tests related to rheumatology and their impact on oral health.

Osteoarthritis

• Degenerative joint disease caused by age-related cartilage degradation, mechanical stress, and joint overuse.
• Treatment includes pain management (analgesics), physiotherapy, and lifestyle modifications (weight management, exercise).
• Dental involvement is minimal unless the temporomandibular joint (TMJ) is affected.
• Prevention involves maintaining a healthy weight, staying active, and avoiding repetitive joint stress.

Gout

• Inflammatory arthritis characterized by sudden, severe joint pain, often in the big toe but can affect other joints.
• Caused by elevated uric acid levels leading to crystal deposits in joints.
• Treatment includes anti-inflammatory medications (NSAIDs, colchicine) and lifestyle modifications, such as reducing intake of high-purine foods and alcohol.
• Prevention includes adequate hydration, dietary measures, and medications to control uric acid levels (where indicated).

Rheumatoid Arthritis (RA)

• Chronic autoimmune disease causing joint inflammation, pain, and deformities.
• The immune system attacks the synovium, with genetic and environmental factors involved.
• Treatment involves disease-modifying antirheumatic drugs (DMARDs), biologic agents, and physiotherapy.
• Good oral care is crucial, as RA can worsen periodontal disease.
• Early diagnosis and DMARD therapy can prevent joint damage progression, though guaranteed prevention is not possible.

Systemic Lupus Erythematosus (SLE / Lupus)

• Systemic autoimmune disease where the immune system attacks multiple organs and tissues.
• Caused by a combination of genetic, environmental, and hormonal factors.
• Treatment involves immunosuppressants, corticosteroids, and monitoring for organ involvement.
• Mouth ulcers are common and may require topical treatments.
• No definitive prevention exists, but avoiding triggers like excessive sun exposure, smoking cessation, and adhering to treatment plans can reduce flare severity.

Osteoporosis

• Metabolic disease leading to decreased bone density and increased fracture risk (including jawbones).
• Caused by an imbalance between bone resorption and formation, with risk factors including age, hormonal changes, and certain medications.
• Treatment involves anti-resorptive drugs, adequate calcium and vitamin D intake, and weight-bearing exercise.
• Prevention includes a healthy diet, regular exercise, and avoiding smoking and excessive alcohol.

Medication-Related Osteonecrosis of the Jaw (ONJ)

• Exposure and death of jawbone tissue, often when gum tissue no longer covers the underlying bone.
• Caused by reduced blood supply to the jawbone, linked to anti-resorptive or anti-angiogenic cancer therapies, or dental procedures.
• Can happen spontaneously or after dental procedures
• Treatment involves stopping or modifying causative medications, managing infection or necrotic bone, and maintaining good oral hygiene.
• Prevention includes dental check-ups, completing invasive dental work before starting high-risk medications, and optimizing oral health to reduce procedures that expose bone.

Giant Cell Arteritis (GCA)

• Inflammation of medium and large arteries, predominantly in older adults.
• Trigger is unclear, possibly an immune-mediated process, with genetic predisposition and possible infectious triggers.
• Treatment involves high-dose corticosteroids to prevent permanent vision loss.
• Urgent referral is needed if visual symptoms occur.
• Not specifically preventable; early recognition and treatment are key to preventing complications like sight loss.

Sjogren’s Syndrome

• Systemic autoimmune disease targeting exocrine glands, causing dryness of eyes and mouth.
• Caused by lymphocytic infiltration and damage to salivary and lacrimal glands, either primary or secondary to other autoimmune diseases.
• Treatment involves artificial tears, saliva substitutes, and immunosuppressive treatments for systemic involvement.
• Good dental care is essential to avoid caries and oral infections.
• No direct prevention; early detection, meticulous oral hygiene, and hydration help reduce complications.

Periodontal Disease

• Inflammation and infection of the gums and periodontal tissues.
• Caused by bacterial plaque and poor oral hygiene, exacerbated by autoimmune conditions or reduced saliva flow.
• Treatment involves professional dental cleaning, improved oral hygiene, and possible antibiotic or antiseptic mouthwashes.
• Prevention includes regular brushing, flossing, dental check-ups, and controlling underlying autoimmune diseases.

Behçet’s Disease

• Systemic vasculitis affecting both veins and arteries, with recurrent oral and genital ulcers and eye inflammation.
• Unknown exact cause, but associated with HLA-B51 and thought to have autoimmune and environmental components.
• Treatment involves immunosuppressive agents and topical treatments for oral ulcers.
• No known direct prevention; avoiding triggers like spicy foods can reduce ulcer discomfort.

Systemic Sclerosis (Scleroderma)

• Rare autoimmune condition characterized by excessive collagen deposition in skin and internal organs.
• Caused by autoimmune-driven overproduction of collagen, along with microvascular abnormalities.
• Treatment involves immunosuppression, vascular support, and physiotherapy.
• Oral stretching exercises can help with restricted mouth opening.
• Not preventable in a strict sense; early diagnosis and treatment can limit organ damage and improve quality of life.

TMJ Disease

• Disorders of the temporomandibular joint, including inflammation, joint degeneration, and muscle dysfunction.
• Causes vary, including mechanical stress, arthritis, or direct trauma.
• Treatment involves pain management, physical therapy, splints, and occasionally surgery.
• Prevention includes good oral habits, stress management, and early treatment of underlying rheumatic conditions.

Drugs, Treatments, and Tests

• Bisphosphonates: Used for treating osteoporosis and cancer-related bone issues by reducing bone breakdown.
• Notable risk: Osteonecrosis of the jaw, especially with high doses or prolonged use.
• Denosumab: Used for osteoporosis and some cancers; a monoclonal antibody that prevents osteoclast development, reducing bone resorption.
• Notable risk: Osteonecrosis of the jaw.
• Anti-Angiogenic Drugs: Used for cancer therapy by blocking new blood vessel formation to tumors. Work by inhibiting angiogenesis.
• Notable risk: Osteonecrosis of the jaw due to compromised blood supply.
• Anti-Resorptive Drugs: General term for drugs that reduce bone resorption, suppressing osteoclast activity.
• Methotrexate: Used for rheumatoid arthritis and other autoimmune conditions, interferes with DNA synthesis and immune cell proliferation.
• Risks: Oral mucositis/ulcers if dosing mistakes occur or without adequate folic acid supplementation. Given weekly in RA to control inflammation.
• Folic Acid Supplementation: Reduces methotrexate’s side effects by replenishing folate.
• Chlorhexidine Mouthwash: Antiseptic rinse to reduce oral bacterial load, helpful in oral mucositis or periodontal disease. Broad-spectrum antimicrobial that helps prevent infection in compromised oral tissues.
• Difflam (Benzydamine) Mouthwash: Reduces pain and inflammation in the mouth/throat. Locally acting anti-inflammatory/analgesic mouthwash.
• Viscous Lidocaine: Topical pain relief in oral ulcerations. Local anesthetic effect to numb mucosal surfaces.
• Prednisolone Mouthwash: Treats inflammatory/ulcerative conditions in the mouth. Corticosteroid that reduces local inflammation. Care must be taken to avoid systemic absorption and adrenal suppression.
• Immunomodulatory Drugs: Used for autoimmune diseases, target specific immune pathways to reduce systemic inflammation.
• Diagnostic Tests
• Imaging (X-ray, MRI, Ultrasound): Assess joint/bone changes or suspected osteonecrosis.
• Used for: Assessing joint/bone changes or suspected osteonecrosis
• Biopsy: Confirm inflammatory infiltrates (e.g., in Sjogren’s or suspected vasculitis).
• Autoantibody Measurement: Detect disease-specific antibodies.
• Immunomodulatory Drugs (e.g., Biologic Antibodies): Used for autoimmune diseases (RA, SLE, etc.). Target specific immune pathways (e.g., TNF inhibitors) to reduce systemic inflammation.
• Autoantibody Measurement: Detect disease-specific antibodies (e.g., rheumatoid factor, anti-CCP for RA, ANA for lupus, etc.).