RHEUMATOID ARTHRITIS; AUTO IMMUNE DISEASE, MOST COMMON, JOINT PAINS, ETIOLOGY, PATHOGENESIS, FACTORS, CLINICAL SIGN, ORAL MANIFESTATION, LAB EVALUATION, DIAGNOSIS,MANAGEMENT. DENTAL MANAGEMENT, TYPES, CLASSIFICATION, SYNDROMES, TREATMENT,

1. 1

2.  It is a disease characterised
by symmetrical, inflammatory
arthritis of small and large
joints
2

3. 3

4. One of the most common
autoimmune diseases
Affects upto 2% of population in
US over the age of 60 years
Higher prevalance in women
In contrast to osteoarthritis, RA
is a systemic disease with
constitutional symptoms
4

5. 5

6.  Unknown etiology
 Substantial evidence of complex genetic disease
1. GENETIC FACTORS
 According to twin studies only 16 % of monozygotic
twins with RA suggests – environment plays
significant role in etiology of the disease
 Triggering factors – smoking, infection and diet
 Specifically HLA-DRB 1 genotypes have more
susceptibility to seropositive RA and greater risk
with smoking
 More common in women due to harmonal
influence 6

7. 2. Immune factors
Target organ of RA – synovial tissue and cartilage
of joint
Inflammtory cell (t cell)
infiltrate the synovium
Causing expansion of the
tissue
Formation of the pannus
that overlays the articular
surface of the cartilage
and invades the bone 7

8. Mediator of
inflammation
(cytokine ,TNF-
α)released
Destruction of
cartilage and bone
B cell also found
(participate in
pathophysiology of
RA ) 8

9. 9

10. Most common autoantibody in RA is
RF – reactive against antigenic
determinants on the Fc fragment
of IGg molecule
80% of RA patients have circulating
RF
Typically IgM RF or IgA RF found in
circulation
Both severity and activity of RA
depends on RF levels
10

11. 3. INFECTIOUS AGENTS
Parvovirus
Rubella virus
Epstein- barr virus
Borrelia burgdorferi
11

12.  Symmetric arthritis involving the proximal
interphalangeal joints of fingers and
metacarpophalangeal joints of the hands, wrists,
elbows, knees and ankles.
 All joints may also be involved like
TMJ,cricoarytenoid joint of larynx.
 Redness, swelling, warmth with eventual atrophy of
muscle around the involved area
 Patients with progressive active disease develop
joint destruction & deformity with time, including
subcutaneous nodules & swan-neck deformities .
12

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14. 14

15. 15

16.  Cervical spine disease may cause C1-C2
subluxation & spinal cord compression
 Rheumatoid nodules may develop in the
lungs, pleura, pericardium, sclera & rarely
the heart, eyes or the brain
 Can decrease life expectancy by as much as
5-10 years
 One long term explanation- increase in
cardiovascular disease
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19.  Long term use of methotrexate & other
antirheumatic agents such as NSAIDS can
cause stomatitis with oral ulcerations.
 Minocycline may cause hyperpigmentation
intraorally
 Prednisone or TNF-α blocking therapy may
develop opportunistic infections.
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20. 20

21.  Cohort studies suggest an increased
prevalence of aggressive periodontitis with
RA
 Exhibit inflammatory bone loss, tooth loss,
increased caries
 Uncontrolled plaque index
 Sjogren’s syndrome
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22.  TMJ can also be affected
 Radiographic changes may be detected, but
patients may be asymptomatic
 Treatment reserved for those with pain or
dysfunction
 when TMJ arthritis is symptomatic
pain on palpation
limited opening
deviation of mandible
ankylosis of joint
facial asymmetry
Treatment -
 Surgical Reconstruction
 Orthognathic Surgery
22

23.  Initial diagnosis – observe clinical features
 Number of joint involvement
 Serology
 RA antibodies – present in 48.5% of patients
 Patients show positive test for RF and anti-
CCP antibodies
 ↑ RF titers – more destructive disease and
worse prognosis
 Other findings - ↑ ESR, ↑ Normochromic
Normocytic Anaemia
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24. 24

25. (A) Initial therapy – Methotrexate
initial dose – 7.5mg once a week
maximum dose – 25mg in adults
 Used for symmetric polyarthritis involving three
or more joints
 ↓ disease activity
 ↓ joint erosion
 Long term reduction in mortality
(B) Patients with severe disease
 Combination therapy given
 Prednisone – 10mg/day
25

26. (C) Biological agents (Antibodies, block receptors
or mediators of inflammation)
 Etanercept- 50 mg weekly
block the action of TNF
 Inflixima- 3mg/kg at 0 ,2 and 6 weeks
 Leflunomide – 25mg daily
inhibits: (a) pyrimidine synthesis; (b) T cell
activation
Also causes:
 Diarrhoea
 Abdominal Pain
 Allergic Reaction
 ↑ serum transaminases
26

27.  NSAIDs cause gastric ulceration and affect kidney
function
 Asprin – inhibits platelet function
 Cause stomatitis, nephrotic syndrome
 Azothiaprine –50 -150mg once daily
causes bone marrow separation, hepatitis,
pancreatitis
 D-Penicillamine – 125-250mg/day
cause bone marrow seperation, renal toxicity,
hepatotoxicity
 Patient with curvical spine disease – C1-C2
subluxation and spinal cord compression
(hyperextention avoided)
 Prolonged morning stiffness is common
 Later morning appointments given
27

28.  Prophylatic antibiotic therapy given before
dental procedures
 Instructions for oral care and dietary
modifications
 Tropical flouride given
 More frequent recall visit
 Patients with sjogren’s syndrome are given
salivary stimulants – Pilocarpine (5-10mg
thrice daily)
 In felty’s syndrome – CBC done before
treatment to rule out neutropenia and
thrombocytopenia.
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29. JUVENILE ARTHRITIS: Arthritis in children
Juvenile idiopathic arthritis : ( Juvenile
rheumatoid arthritis )
 Children with chronic arthritis
 SYMPTOMS : Joint pain, swelling, tenderness,
warmth and stiffness for atleast 6 weeks
 Severe joint and organ damage
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30. 30

31. Systemic arthritis –
Oligoarthritis
Polyarthritis - RF negative
Polyarthritis – RF positive
Psoriatic arthritis
Enthesitis related arthritis
Undifferentiated arthritis
31

32. Systemic arthritis –
autoinflammatory disease
causes swelling in the joints
can help kids get diagnosed and
treated sooner
32

33. Oligoarthritis -
involving fewer than five joints
Constituting approx 50% of cases
33

34. Polyarthritis - RF negative
Closely resembles adult
rheumatoid arthritis
More severe disease
about 25% cases have the
polyarticular form
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35. Polyarthritis – RF positive
bears a close genetic
resemblance to adult
rheumatoid arthritis
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36. Psoriatic arthritis -
range widely in presentation and
severity
cutaneous psoriasis is not always
present
extent of articular involvement may
vary
36

37.  Enthesitis related arthritis -
Produces swelling and pain
Location – where tendons and ligaments
attach to bone
 Undifferentiated arthritis – form that
does not fulfil any category or has criteria
for more than one category
37

38. Characterised by Neutropenia
and Splenomegaly in
conjunction with RA
Susceptibility to bacterial
infection if neutropenia is
severe
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