Dental Management of Rheumatoid and

Osteoarthritic Patients

Steven Karpas, DMDGeriatric Dentistry FellowBoston University School of Medicine/ Dept. of GeriatricsBoston University Henry M. GoldmanSchool of Dental Medicine

Paula K. Friedman, DDS, MSD, MPHDirector of Geriatric Dentistry FellowshipBoston University Henry M. GoldmanSchool of Dental Medicine

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

Disclosure

1. Public Health of Chronic conditions2. Highlights of Arthritis:

a.Rheumatoid Arthritis and b.Osteoarthritis

3. Dental Implications of Rheumatoid Arthritis and Osteoarthritis

4. Summary5. Recommendations

Outlines

Common Medical Conditions in Older Adults

ArthritisCancerCOPDDiabetesHeart DiseaseHypertensionMental Health ConditionsOsteoporosisParkinson DiseaseStroke

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

Multiple Chronic Conditions Among Medicare Fee-For-Service

Beneficiaries, 2010

• 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

Arthritis

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

[CDC. Prevalence of disabilities and associated health conditions among adults – United States, 1999. MMWR 2001; 50: 120 – 5.]

Arthritis

• 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

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)

Arthritis

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 men

40 in a 100,00 for women• Lifelong disease

Predisposing Factors

• Sex hormones• Socioeconomic status• Education• Psychosocial stress

• Systemic autoimmune disease• Synovial inflammation /cartilage erosion• Pain• Swelling• Morning stiffness• Symmetrical presentation• Typically affects the peripheral joints

What is RA?

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

Rheumatoid Arthritis

Joints AffectedDigits, wrists, feet, and knees

Involvement of the shoulders, hips and TMJ

Involvement of the cervical spine and sacroiliac joint is rare

Criteria for the

Diagnosis of Rheumatoid

Arthritis

• At least four must be present for a diagnosis of rheumatic arthritisAletaha D, Neogl T, Silman AJ, 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.]

Signs and Symptoms:

Morning stiffness

Arthritis of three or more joint areas

Arthritis of hand joints

Symmetric arthritis

Rheumatoid nodules

Positive Serum rheumatoid factor

Radiographic changes

Diagram of Knee Joint

Normal Knee Joint Knee Joint with Inflammation

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

Constitutional symptoms include the following:• Fatigue• Loss of appetite• Loss of weight• Low-grade fever• Morning stiffness

Signs and Symptoms of Rheumatoid Arthritis

Unknown Causes

Genetics

Infectious Agent

Autoimmunity

Vitamins

Foods

Rheumatoid Arthritis

Etiology

Dermatolog

ic

•Rheumatoid nodulesCardio

vascular

•Carditis•Pericarditis

Pulmonary

•Pleuritis

•Intrapulmonary nodules

•Interstitial fibrosis

Neurologic

•Peripheral neuropathy•Entrapment neuropathies

Hematologi

c

•Anemia •Thrombocytosis

Musculoskeletal

•Skeletal muscle weakness•Osteoporosis

• 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

Complications

Palliative treatment – No cure existsTreatment 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

Rheumatoid ArthritisMedical Management

A basic early treatment program• Patient education• Rest• Exercise• Physical therapy• Drugs-aspirin or NSAIDS

Rheumatoid ArthritisMedical Management

• Early intervention before joint damage• Exercise and mobility emphasis

Swimming Avoid joint stress

• Patient education• Appropriate diet and avoid excessive

body weight

Non-Pharmacologic Treatment

What is role of

medication for

RA?

• Maintain function

• Decrease inflammation

• Facilitate healing

• Pain reduction

• Anti-inflammatory Drugs• DMARDS

What Drugs are used?

Pharmacologic Treatment

Anti-inflammatory medications

DMARDs

Salicylates (aspirin) /NSAIDS

Gold- rarelyAzathioprine- rarelyMethotrexate SulasalazineLeflunomide

COX-2 inhibitors (Celebrex)

HydroxychloroquinePenicillamineTofacitinib

Corticosteroids TNF-alpha blocking agents (etanercept, infliximab and adalimumab)

• 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

ASA or NSAIDs

• Have decreased upper GI side effects and nephrotoxicity

• Has an increased risk of potentially fatal cardiovascular events

Cox 2 Inhibitors (Celebrex)

• 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

Corticosteroids

Side Effects• Nausea/vomiting• Rash • Sore throat• Nasal congestion• Oral ulcerations• Stomatitis

• Tender/swollen gums• Muscle aches,

reduces folic acid levels

• Infections• Dizziness• Bleeding

Disease Modifying Antirheumatic Drugs (DMARDs)

• 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

Rheumatoid ArthritisMedical Management

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

Osteoarthritis

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

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

Osteoarthritis

• Prosthetic Joints• Hip• Knee• Shoulder• Elbow• Wrist• Ankle• Guidelines for antibiotic prophylaxis

Chronic  Joint Destruction

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

Diagram of Knee Joint

Normal Knee Joint Knee Joint with Osteoarthritis

Osteoarthritis

• Repeat impact load• Unexpected load• High velocity load

Joint Damage

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

OsteoarthritisRisk Factors

Aging

Mechanical and

molecular joint

changesSingle or repeated

injury

Abnormal motion

Metabolic

disorders

Obesity

Joint infection

OsteoarthritisFinger nodules

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

Osteoarthritis

Medical Management• There is no cure for OA• Management focuses on relieving symptoms and

improving function

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

Osteoarthritis

Treatment of OA

Pharmacologic• Acetaminophen• NSAIDS• Topical Capsaicin• Intra-articular

glucocorticoids• Narcotic analgesics

Non-Pharmacologic• Bracing• Orthotics• Strength training• Weight loss• Joint replacement

Rheumatoid Arthritis Multiple symmetric joint

involvementSignificant joint inflammation

Morning joint stiffness for longer than 1 hour

Systemic manifestations (fatigue, weakness, malaise)

Symmetric swelling of proximal interphalangeal joints

Osteoarthritis

Usually one or two joints involved

Joint pain usually without inflammation

Joint stiffness < 30 min/ worsens during the day

Non symmetrical swelling of the distal interphalangeal

joints

Mobility Limitations• Arthritis in the hand, finger(s), elbow, shoulder,

and/or neck can affect one’s ability to provide good daily oral care

• Modified manual toothbrush handles or electric toothbrushes (wide handle) can help to accommodate for lost mobility

• Interdental cleaners/brushes can assist when flossing is not possible

• Increase frequency of oral prophylaxes and examinations

Osteoarthritis and Rheumatoid Arthritis

• No specific findings• Dental caries and gingivitis can develop

due to poor oral hygiene caused by dexterity limitation

Implications for Oral Care• Total joint replacement patients may need

prophylactic antibiotics

OsteoarthritisOral Clinical Findings

• Floss holders• Toothpicks• Irrigation devices• Mechanical toothbrushes

Patients with Severe Disease May Need

Suggested Toothbrush Modifications

From the Dental Care Every Day: A Caregiver’s Guide. NIH Publication No. 11-5191. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/DentalCareEveryDay.htm.

Suggested Toothbrush Modifications

Velcro strap modified to hold brush Wide elastic or rubber band to hold brush

Handle enlargement by cutting slit in tennis ball

Handle enlargement  by attaching a bicycle grip to the handle

From the Dental Care Every Day: A Caregiver’s Guide. NIH Publication No. 11-5191. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities/DentalCareEveryDay.htm.

• Temporo-mandibular joint disease (TMD) may be present

• Limitation of mouth opening secondary to TMD

• Dental caries and gingivitis can develop • Poor oral hygiene caused by dexterity

limitation• Xerostomia (medications)

Rheumatoid ArthritisOral Clinical Findings

• Patient at risk for poor oral hygiene• TMJ: Pain, occlusal changes, limited oral intake,

decreased nutritional intake, mastication and oral hygiene

• Decreased mobility may affect access to care• Anterior open bite, limited intraoral opening,

and possible joint ankylosis• Neutropenia, thrombocytopenia due to

medications

Dental Significance

• Arthritis medications may prolong bleeding tendency, immune suppression and increase susceptibility for oral bacterial, fungal and viral infections

• Total joint replacement patients may need prophylactic antibiotics

• Medications such as methrotrexate, D-peniciliamine, gold salts, DMARDs and/or corticosteroids may develop abnormal liver function, CBC values or platelet count

Rheumatoid ArthritisImplications for Oral Care

• Steroids may cause adrenal suppression• More frequent recall/hygiene appointments

may be needed• Modified oral health aids may be indicated• Consider fluoride/Peridex supplementation

Rheumatoid ArthritisImplications for Oral Care

• Oral hygiene neglect secondary to impaired dexterity

• Patients may need assistance in/out of dental chair

• Severe RA limits neck hyperextension

Rheumatoid ArthritisImplications for Oral Care

• Schedule short appointments and consider patient ‘s ideal time of the day

• Ensure physical comfort• Drug considerations:• ASA, NSAID: impaired hemostasis• DMARDs: get CBC with platelets• Corticosteroid: risk of adrenal suppression

• Prosthetic Joints: may require abx guidelines

Specific Management Consideration

DentistPhysical therapist

Dental Hygienist

Physician

Where Do We Go From Here?

Arthritis Summary

• Serious systemic disease• Painful• Patient Fatigue• Leads to significant disability• Difficulty with oral care• Drugs can affect risk of infection + bleeding• Tailor dental treatment plan to the individual, their

degree of disability, their comorbid conditions, age, and their drugs

• Contact physician for questions

Arthritis Summary

• Determine the type of rheumatic disease affecting your patient.

• Determine spine involvement and mobility status.• Provide TMD care if TMJ involvement.• Have patient move neck themselves when positional

changes needed• Do not rotate neck yourself (negatively affects patient,

upper extremity nerve pains)• Inquire on cervical spine instability• Transfer assistance to dental chair• Consider short appointments

• Utilize lumbar pillow, lambswool chair cover• Know patients current medications• Confirm any steroid use for two weeks or longer

in the past two years.• Follow “the rule of twos” prior to major surgery• Consult physician• All infection should be aggressively treated• Xerostomia….saliva substitutes, frequent recalls,

oral candidiasis

Arthritis Summary

Daily Oral Care Recommendations

• Brush with a soft bristle toothbrush for two minutes, twice each day, and replace your toothbrush every 3 months.  Try an electric toothbrush to make brushing more efficient.

• Floss daily to remove plaque and food particles located where brushing cannot reach, such as below the gumline.  

• Rinse each day with an anti-microbial mouthwash to reduce bacteria and help prevent gingivitis. 

• Visit your dentist or dental hygienist every 6 months for professional cleaning and routine checkup.  If you notice signs of gum disease, such as bleeding or swollen gums, see your dentist as soon as possible and follow the recommended treatment plan.