Rheumatoid arthritis and dental care consideration

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks the joints producing an inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints. Medical complications due to RA and its treatment can affect oral health care also. Furthermore, RA can affect 1 % of populations worldwide. There is female predominance, with peak age-related incidence in the 5th decade of life. RA is a form of autoimmunity, the cause of which is still incompletely known. RA is associated with HLA-DR4. Affected patients have rheumatoid factor (an immunoglobulin M or A antibody directed against self IgG), but it should be noted that the presence of rheumatoid factor does not imply that an individual will necessarily ultimately develop rheumatoid arthritis. It is postulated that immune complex (Antigen-antibody complex) formation may then lead to the activation of complement, inflammation and synovial damage. Clinical features The disease gives rise to a chronic peripheral synovitis that typically affects the small joints of hands and feet that may ultimately give rise to a variety of deformities, the most common being volar (i.e towards palm) subluxation and ulnar (i.e in the direction of the ulna) deviation of the metacarpophalangeal joints. Almost all joints can be affected such as the wrists, elbow, ankles and knees may be involved and the patient becomes disabled. Although involvement of the hip and sacroiliac joints is uncommon. The onset of RA is often insidious, with increasing stiffness of the hands or feet, worse in the morning. In the acute stage there is aching, swelling, redness, tenderness, and limitation of movement of small joints. There is sometimes fever and malaise RA can give rise to a wide spectrum of extra-articular features:

• Subcutaneous nodules, typically of the extensor surface of the forearm
• Normocytic normochromic anaemia
• Ocular disease (e.g episcleritis and scleritis and keratoconjunctivitis secondary to Sjogren’s syndrome)
• Involvement of the lungs, heart, liver, kidneys and bones
• Felty’s syndrome ( a disorder characterized by the combination of rheumatoid arthritis, spleenomegaly and neutropenia

Oral Manifestations Xerostomia as part of secondary Sjogren’s syndrome (table1) is most likely oral consequence of rheumatoid arthritis. The TMJ can be affected, clinically and/or radiographyically, in up to 84% of patients with rheumatoid arthritis, although the TMJs are only rarely the sites of initial clinical presentations. Such involvements may give rise to pain, tenderness and possibly swelling of the pre-auricular area and some limitation of mandibular movement. As with other joint features of rheumatoid arthritis, the symptoms and sign of the TMJ involvement may periodically exacerbate and remit. Disease may cause erosion of the condylar head which, if bilateral may give rise to an anterior open bite. In children, condylar destruction may give rise to loss of mandibular growth,and resultant asymmetric or symmetrical growth retardation, the latter resulting in mandibular retrusion. Ankylosis is a late complication. The oral mucosal consequences of rheumatoid arthritis include oral ulceration, glossitis and angular cheilitis secondary to anaemias ( eg of chronic disease, iron deficiency secondary to NSAIDs use or autoimmune pernicious anaemia) and oral lichen planus (e.g secondary to NSAIDs or penicillamine).As noted previously, Felty’s syndrome may give rise to oral ulceration, angular chelitis and candidal infections secondary to the accompanying neutropenia. Amyloidosis is a rare, but possible,consequence of longstanding rheumatoid arthritis, this giving ries to nodular deposits on the tongue and gingivae, and very rarely labial enlargement and trigeminal neuropathy. Xerostomia Salivary gland swellings Hence possible dysphagia, dysarthria and dysgeusia Secondary to the inflammation of the gland Liability to; Caries Acute suppurative sialadenitis Gingivitis Mucosa-associated lymphoid tumour MALT Candidosis Acute suppurative sialadenitis Halitosis Poor denture retention Sticking of lips together and tongue to the palate Table 1: Oral manifestations of Sjogren’s syndrome Diagnosis The diagnosis of Rheumatoid Arthritis is made if at least four of the features shown in Table 2 are present. Rheumatoid factor in about 70%,is usually IgM and a sensitive marker of RA but is not specific. In so –called seronegative cases the RF may be IgG, and therefore not detected by the routine agglutination tests (Latex and SCAT),which detect only IgM RF.RIA and ELISA detect any class of RF. Antinuclear antibodies are also often found but are usually in low titre. The ESR and C reactive protein are typically high. Radiographic features are soft –tissue swelling, juxtra –articular osteoporosis and widening of the joint space due to accumulation of fluid in the early satges. Later there is narrowing of the joint spaces,cyst like spaces in the bone and subluxation.Ultimately there may be severe bone destruction and deformity,but ankylosis does not follow. Features of Rheumatoid Arthritis (Table 2) Features Definition 1. Morning Stiffness Stiffness in and around joints, lasting for atleast 1 hour before maximal improvement 2 .Arthritis of three or more joint areas Soft-tissue swelling or fluid (but not just bony overgrowth) in at least three joint areas simultaneously (the 14 possible joint areas are right or left proximal interphalangeal, or PIP; metacarpophalangeal, or MCP; wrist; elbow; knee; ankle; and metatarsophalangeal, or MTP, joints) 3. Arthritis of hand joints At least one area swollen (as defined in criterion 2) in a wrist, MCP or PIP joint 4 .Symmertrical arthritis Simultaneous involvement of the same joint areas (as defined in criterion 2) on both sides of the body 5. Rheumatoid nodules Subcutaneous nodules over bony prominences, extensor surfaces or juxta-articular regions 6. Positive Rheumatoid Factor Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in less than 5 percent of normal control subjects 7. Radiological changes consistent with Rheumatoid Arthritis Changes typical of RA on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints Conclusion Many people attending for oral health care have Rheumatoid Arthritis. Aside from the impact that such disease will have upon their impacts to access the dental clinic (eg owing to impaired motor function), some affected individuals will have oral disease which may be the first or principal manifestation of an underlying RA. Dental care professionals have a key role in the management of patients with RA, and can lessen the risk of common oral consequences, recognize oral diseases that warrant specialist investigation or treatment and be able to modify the dental treatment to ensure that patients are not liable to further complications of the RA or its therapy.