الطب الباطني في طب الاسنان

1. Dental manifestations of
Rheumatoid Arthritis.
‫د‬.‫سليم‬ ‫جار‬ ‫هللا‬
‫حمدي‬
‫عبدهللا‬
‫سيف‬
‫محمد‬

2. Joint
Disorder
Degenerative
Disorder
O.A
Inflammatory
Disorder
Rheumatoid arthritis
Connective tissue disorder
Spondarthritis
Autoimmune
Disorder
Crystal
Arthropathy
Infection
Pathological Classification of Rheumatic Disorders
Gouty Arthritis
Pseudogout (CPPA)
Septic Arthritis

3. Introduction..
 Is it Arthritis or Arthralgia?
 Is it Monoarthritis or Polyarthritis ?
 Is it Musculoskeletal emergencies ?

4. RED FLAG CONDITIONS
 FRACTURE
 SEPTIC ARTHRITIS
 GOUT/PSEUDOGOUT
 NERVE OR VESSEL PROBLEMS
 Fever or unexplained weight loss
 History of carcinoma
 Immuno-supression
 Ill health or presence of other medical illness
 Night pain
 Progressive pain

5. Sorting it Out
INFLAMMATORY
DEGENERATIVE
CHRONIC PAIN

6. What are the Symptoms?
Unusual
Unusual
Possibly
Weight Loss
Never
Never
Possibly
Fever
Rapid
Slow
Rapid
Loss of Function
Severe
Mild
New and Severe
Fatigue
> 1 hour
15-20 minutes
> 1 hour
Morning Stiffness
No
No
Yes
Joint Redness
No
Yes
Yes
Joint Swelling
No
Yes
Yes
Joint Pain
Chronic Pain
Degenerative
Inflammatory

7. Arthralgia..
 Fibromyalgia
 Bursitis
 Tendinitis
 Hypothyroidism
 Neuropathic pain
 Metabolic bone disease
 Depression

8. Monoarthritis..
 Trauma
 Infection:
 ± Skin lesion.
 Nongonococcal bacterial infections: large joints.
 Mycobacterial and fungal infection.
 Crystal induced arthritis
 Monosodium Urate crystals (MPJ) - Gout
 Calcium pyrophosphate dihydrate crystals (knee) - Pseudog
out
 Systemic Rheumatoid diseases:
 Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthrit
is, Inflammatory BD..)
 RA
 Osteoarthritis

9. Polyarthritis..
 Rheumatoid Arthritis
 Systemic lupus Erythrematosus
 Viral arthritis
 Reiter’s disease
 Psoriatic arthritis
 Reactive arthritis

10. Migratory Arthritis..
 Differential diagnosis:
 Rheumatic fever
 Gonococcemia
 Meningococcemia
 Viral Arthritis
 SLE
 Acute Leukemia

11. Rheumatic Fever..
 Majer Criteria:
1- Carditis 2- Polyarthritis 3- Chorea
4- Erythema Marginatum 5- Subcutaneous nodules
● Minor criteria:
1- Arthralgia 2- Ferver 3- Acute phase reactant
(ESR, CRP).
4- Prolong PR interval 5- Evidence of group A streotoc
occal infection (AST, Throat culture…)

12. History.. Age & Sex
 <30= SLE, Ankylosis spodylitis, Reactive Arthritis.
 30-50= RA, Systemic sclerosis, Gout.
 >50= OA, Pseudogout, PMR
 Any Age group= Psoriatic arthritis, Enteropathic arthritis
 >Female:
SLE, RA, OA, Systemic sclerosis, PMR.
 Male=Female:
Psoriatic arthritis, Enteropathic arthritis Pseudogout, .
 >Male:
Gout, Reactive Arthritis, Ankylosis spodylitis,

13. History.. Symptoms
 Site:
 Symmetrical= RA, SLE, Systemic sclerosis
 Asymmetrical=OA
 Large joints= OA
 DIP= OA, Psoriatic arthritis
 MCP, PIP= RA, SLE
 1st MTP= Gout, OA
 Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthr
itis
 Shoulder= PMR

14. Physical Examination..
 Joint:
 Soft tissue swelling, warm, effusion…= Inflammation.
 Inflammation signs extended= Septic arthritis, crystal i
nduced arthritis, fracture.
 Passive motion (N), active(↓↓)= Bursitis, Tendinitis,
Muscle injury.
 Passive motion (↓↓), active(↓↓)= Synovitis

15. Physical Examination..
 General Examination:
 Parotid enlargement, oral ulceration, heart murmurs, pericardial or
pleural friction rubs, crackle…= systemic disease.
 Fever= Infection, reactive arthritis, RA, SLE, Crystal induced art
hritis…
 Subcutaneous nodules= RA, RHD, Gout (tophi)
 Skin manifestations= Psoriasis, RA, SLE…
 Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, epis
cleritis…)

19. Laboratory & Radiology Studies..
 Can be misleading.
 Basic: CBC, Urinalysis, U&E, LFT.
 Acute phase reactant: ESR, CRP.
 Uric acid concentration= Gout
 Synovial fluid analysis= infection, crystal induced arthritis, inflamm
atory..
 Antibody tests:
 ANA= SLE
 Anti-dsDNA= SLE
 Anti-native DNA, anti-Sm= SLE
 RF= RA
 Anti-CCP antibody=RA
 X-ray:
 MRI:

20. Rheumatoid Arthritis
A chronic nonsuppurative inflammatory destruction of the joints

21. Rheumatoid Arthritis..
 Incidence
 1-3% of general population
 Genetic predisposition
 Female to male ratio 3:1
 Average age of onset of 40 years

22. History..
 Malaise
 Fever
 Fatigue
 Weight loss
 Myalgias
 Difficulty performing activities of daily living

23. Examination..
 Joint affected
 swelling
 tenderness
 warmth
 decreased range of motion
 Atrophy of the interosseous muscles
 deformities

24. ≥ 4 Diagnosis.. ACR Criteria criteria
present > 6 wks
 Morning stiffness > 1 ho
ur
 Arthritis of ≥ 3 joints are
as (PIP, MCP, wrist, elbo
w, knee, ankle, and MTP
)
 Arthritis of hand joints (
wrist, MCP, PIP)
 Symmetric arthritis
 Rheumatoid nodules
 RF+
 Radiographic changes
 Erosions
 Unequivocal periarticular
osteopenia

26. Synovitis

27. RA - hands

28. Deformities..

29. Swan neck and Boutonniere

30. Rheumatoid Arthritis

31. Extra-Articular Manifestations..
 Rheumatoid nodule
 Cardiovascular
 Pulmonary
 GI & Renal
 Hematological
 Skin
 Vasculitis
 Neurological
 Ocular

32. Rheumatoid nodules

33. Vasculitis

34. Ocular
 Sicca symptoms
 Episcleritis
 Scleritis
 Scleromalacia Perforance

35. Head & Neck Manifestations
 Rheumatoid Arthritis may involve the TMJ.
 55% Affected
70% with radiographic evidence of TMJ involvement
Juvenile form may lead to Retrognathia

36. Head and Neck Manifestations
 Cricoarytenoid joint
 Most common cause of cricoarytenoid arthritis
 30% patients hoarse
 Exertional dyspnea, ear pain, globus
 Hoarseness
 Rheumatoid nodules, recurrent nerve involvement
 Stridor
 local/systemic steroids
 Conductive Hearing Loss
 Ossicular chain involvement
 Sensory Neural Hearing Loss
 Unexplained
 Assoc. with rheumatoid nodules
 Cervical spine
 Subluxation

37. Laboratory ..
 Hematologic parameters
 Anaemia
 Thrombocytosis
 ↓ Serum iron & IBC
 ↑ Serum globuline
 ↑ ALP
 ↑ Acute phase reactant ( ESR / CRP )
 Immunological parameters ( RF ) / ANF “50 % )
 Synovial fluid analysis (WBC > 2000/mm3 )

38. Laboratory
 Rheumatoid Factor
 Ig M Antibody against the Fc fragment of Ig G
 Not sensitive
 80% of RA patients
 RF+ patients more likely to have
 More severe disease
 Extraarticular manifestations
 Anti-cyclic citrullinated peptide (Anti-CCP )
 Specificity = 90%
 Sensitivity = 50-80%

39. RF is not specific for RA.
 Other autoimmune disease
 Sjogren’s syndrome , Systemic Lupus
 Chronic infection
 Hep B/C, SBE, Viral, Parasites, TB
 Pulmonary inflammation
 Sarcoid, IPF, Silicosis, Asbestosis
 Malignancy
 Healthy – 4% young; 5-25% > age 60

40. Radiography
 Periarticular osteopenia
 Symmetric joint space loss
 Marginal erosions
 Absence of productive changes
 Best films for diagnosis:
 Bilateral Hand Arthritis Series
 Bilateral Foot Series
 Larger joints may not show erosions early due to thicke
r cartilage.

41. Treatment
 Aggressive Treatment Early!
 Physical therapy, daily exercise, splinting, joint protection
 Salicylates, NSAIDS, DMARDs , hydroxychloroquine, immunosu
ppressive agents , Steroids
 Cyclosporin-A
 Prognosis
 10-15 yrs of disease
 50% fully employed
 10% incapacitated
 10-20% remission
 Persistent active cases more than 1 year likely to lead to joint deformi
ties.
 Periods of activity cases have better prognosis.
 Mortality rate 2.5 times than generalpopulation

42. Dental Management
 Short dental appointments
 Assess if Aspirin or NSAIDs are affecting platelet f
unction

43. Osteoarthritis?
 Most common form of arthritis
 Middle-aged to elderly
 Gradual pain, worse with use
 F= M up to age 55; after 55 F>M
 Obesity, history of trauma
 Cartilage irregularity
 10-20% of these symptomatic
 Only small percentage present for help
 Joints affected
 Hands – DIP, PIP, CMC thumb
 Hips, knees, ankles, great toes
 Cervical and lumbar spine

44. Osteoarthritis
 Mechanical symptoms ( Pain on activity),Stiffness
 Bony swelling, crepitus
 DIP (Heberden)
 PIP (Bouchard)
 1st CMCJ,
 Neck,
 Lower back,
 Hips,
 Knees,
 1st MTP
Clinical subsets
Generalised OA
Primary / nodal OA
Erosive OA

45. Osteoarthritis Radiology
 ( Correlate poorly with symptoms )
 Four cardinal features:
 Joint space narrowing
 Sclerosis
 Subchondral cysts
 Osteophytes

46. OA Management
 Pain Relief
 Simple/compound analgesics, exercises
 Glucosamine sulphate, patellar taping
 Topical capsaicin/NSAID; acupuncture
 Oral NSAIDs – COX2s, gastro-protection
 Injections – peri-articular, intra-articular
 Joint Replacement (Referral guidance hip/knee OA )
 ? Infection – same day
 Rapid deterioration/severe disability (2/52 hip, soon – ‘locally agreed’ knee)
 Symptoms impair QOL – routine
 Giving way despite Rx– soon (knee only)
 Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee only)

48. Gout?
 Disease of Monosodium urate crystal deposition in
tissues of and around joints
 Adult men, peaks in ages 40’s to 50’s
 Urate Overproduction (<10%) vs
 Under Excretion (90%)
 Three stages:
 Asymptomatic hyperuricemia
 Acute intermittent gout
 Chronic tophaceous gout
 Definitive dx by aspiration of fluid

49. Gout?
 Onset before 25 should raise the question of unusual form
of gout , specific enzyme defect
 A single joint involve in 85-90% of first attack
 90% acute attacks in great toe, next in order of frequency
are the ankles, heels, knees, wrists, fingers and elbows
 Acute gouty bursitis-- prepatella, olecranon
 Chronic
 Tophi

50. Septic Arthritis
 Septic arthritis is inflammation of a synovial mem
brane with purulent effusion into the joint capsule,
usually due to bacterial infection.
 It is an emergency- it can destroy a joint extremely
quickly and (v.rarely) lead to sepsis and death
 Frequency:
 2-10 cases per 100,000 in the general population.
 30-70 cases per 100,000 in immunosuppressed/ joint prosth
esis