L23. Dental Management: Rheumatologic + CT Disorders

Question

Answer

Dental management for arthritis: general approach

Short appointments; frequent position changes; physical supports (rolled towel); sitting/semisupine preferred over supine

Dental tx plan modification: no physical disabilities (arthritis)

No specific modifications needed

Dental tx plan modification: physical disabilities present (arthritis)

Assess pain/immobility/manual dexterity; assess home care ability; avoid complex long procedures; consider removable prosthesis (easy insertion/removal)

TMJ complications of arthritis

Pain/dysfunction; decreased jaw function; crepitus; sudden occlusal changes may = condyle erosion

TMJ management (arthritis)

Soft diet; moist heat/ice; occlusal appliance to reduce joint loading; surgery if pain persists

Adverse drug effects: rheumatoid disorders/SLE (list all classes)

Prolonged bleeding; immunosuppression; adrenal suppression; increased infections; impaired/delayed healing; oral ulcerations/stomatitis; bone marrow suppression

Salicylates (aspirin): dental/oral considerations

Prolonged bleeding — not usually clinically significant (platelet function interference)

NSAIDs (ibuprofen, naproxen, etc.): dental/oral considerations

Prolonged bleeding (not usually clinically significant); oral ulceration/stomatitis

COX-2 inhibitors (celecoxib): dental/oral considerations

None

TNF-α inhibitors (etanercept, infliximab, adalimumab, etc.): dental/oral considerations

None

Systemic glucocorticoids (prednisone, dexamethasone, etc.): dental/oral considerations

Adrenal suppression; masking of oral infection; impaired healing

Injectable glucocorticoids: dental/oral considerations

Adrenal suppression; masking of oral infection; impaired healing

Antimalarial agents (hydroxychloroquine, chloroquine): dental/oral considerations

None

Penicillamine: dental/oral considerations

None

Gold compounds (auranofin, etc.): dental/oral considerations

Bone marrow suppression (rare); increased infections; delayed healing; prolonged bleeding; oral ulcerations

Sulfasalazine: dental/oral considerations

Bone marrow suppression (rare); increased infections; delayed healing; prolonged bleeding; intraoral pigmentation

Immunosuppressives (azathioprine, methotrexate, cyclosporine, etc.): dental/oral considerations

Bone marrow suppression; increased infections; delayed healing; prolonged bleeding; stomatitis

2015 ADA guideline: prosthetic joint prophylaxis

Prophylactic antibiotics NOT recommended prior to dental procedures to prevent prosthetic joint infection (in general)

2015 ADA: why no prophylaxis for prosthetic joints?

Dental procedures not associated with joint infections; antibiotics don't prevent them; risks (anaphylaxis, resistance, C. diff) may outweigh benefits

2015 ADA: exceptions — when to consider prophylaxis for prosthetic joints

Immunocompromised (RA, SLE, drug/radiation immunosuppression); Type 1 DM; prior prosthetic joint infection; malnourishment; hemophilia — consult orthopedic surgeon

Prosthetic joint note: pins, plates, screws NOT in synovial joint

NOT at increased risk for hematogenous seeding → prophylaxis NOT recommended

SLE dental workup: what to assess

MD consult; systemic stability; hematologic profile (CBC, platelets, PT/PTT/bleeding time); medication list

SLE systemic manifestations to know

Renal failure; skin; vasculitis; arthritis; Libman-Sacks endocarditis; lung; brain; eyes

SLE dental tx plan: considerations

Arthritis/myalgia; drug side effects (infection risk, prolonged bleeding, stomatitis, oral ulcers)

SLE: ASA/NSAIDs consideration

Prolonged bleeding — not usually clinically significant

SLE: gold/sulfasalazine/immunosuppressives consideration

Bone marrow suppression → anemia, agranulocytosis, thrombocytopenia → infection risk + prolonged bleeding

SLE: corticosteroids dental consideration

Adrenal suppression? — additional corticosteroids usually NOT needed for routine dentistry/oral surgery

SLE hematologic: leukopenia significance

Common in SLE; NOT associated with increased infection risk unless on corticosteroids or cytotoxic drugs

SLE hematologic: thrombocytopenia threshold

Platelet <50,000/mm³ → severe bleeding risk

SLE hematologic: elevated PTT (lupus anticoagulant)

Does NOT usually cause increased bleeding — surgery OK

SLE oral manifestations

Oral lesions (lips/mucosa) in 5–25%; resemble lichen planus/leukoplakia; erythematous with white spots/radiating lines; painful ulcerations; worsened by sun exposure

SLE oral lesion treatment

Symptomatic; avoid sun exposure

Sjögren syndrome: classic triad/presentation

Eye dryness; hyposalivation; parotid gland enlargement

Sjögren syndrome: secondary oral outcomes

Dental caries (up to 65%); oral candidiasis (>1/3); dysgeusia; angular cheilosis; glossodynia (burning mouth)

Xerostomia vs. salivary hypofunction

Xerostomia = sensation of dryness; salivary hypofunction = decreased flow

Signs of salivary hypofunction (clinical)

White frothy saliva; film; gloves/mirror stick to mucosa

Xerostomia etiology

Sjögren syndrome; medications; chemotherapy; radiation; mouth breathing (desiccation)

Xerostomia main dental risk

Increased root and dentinal caries

Dry mouth screening questions (Fox 1987) — 4 questions

1. Difficulty swallowing dry foods? 2. Mouth feel dry while eating? 3. Sip liquids to aid swallowing? 4. Saliva amount seem too little?

Dry mouth screening: positive findings

Yes to 1–3 + "too little" → associated with salivary hypofunction

Sialometry: unstimulated whole flow — normal

≥1 mL/5 min (drool into container, no chewing)

Sialometry: stimulated whole flow — normal

≥5 mL/5 min (while chewing gum/wax)

Sialometry: Sjögren syndrome unstimulated flow

Salivary hypofunction management: moisture/lubrication

Sip water; sugar-free candy/gum; avoid ethanol, tobacco, caffeine; d/c meds if possible; artificial saliva/moisturizers (esp. at night)

Salivary hypofunction management: soft tissue lesions

Magic mouthwash (Benadryl + Maalox + nystatin); viscous lidocaine 2%; Decadron 0.5mg/5mL elixir; triamcinolone 0.1% in Orabase; Orabase-HCA

Salivary hypofunction management: candidiasis

Mycelex 60-mg troches; Mycolog II ointment (corners of lips)

Salivary hypofunction management: caries/perio prevention

Meticulous hygiene; avoid acidic foods/drinks; regular recalls; sodium bicarb rinses; Biotene toothpaste; neutral NaF 1.0% trays; Peridex (chlorhexidine); fluoride trays; Waterpik

Pilocarpine HCl (Salagen): indications and regimen

Radiation xerostomia + Sjögren syndrome; 5 mg TID

Cevimeline (Evoxac): indications and regimen

Sjögren syndrome; 30 mg TID

Pilocarpine/Cevimeline: contraindications

Uncontrolled asthma; acute iritis; narrow-angle glaucoma

Pilocarpine/Cevimeline: side effects

Salivation, sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, blurred vision, headache, hypo/hypertension, brady/tachycardia