special patient rheumatologic disorders and transplantations

rheumatoid arthritis

•Autoimmune condition exhibiting inflammation of joints, particularly hands, feet, and knees

•Etiology- Unknown, but may be related to infectious agents, genetics, and autoimmunity

rheumatoid arthritis clinical presentations

•Begins with general fatigue, weakness, joint and muscle aches

•Progresses to painful joints swelling (hands, feet) and then other joints

•Immobility, contractures, subluxation, deviation, other deformities

•Pain aggravated by movement, joints are stiff after inactivity, morning stiffness

•Most commonly affects fingers, wrists, feet, ankles, knees, elbows

rheumatoid arthritis dental management

•Dental Management- Adjust chair based on patient comfort; short appointments, give patient frequent breaks, patient may bring physical supports like pillows, etc. especially for long appointments.

•Medications may affect bleeding (NSAIDs)

•Immunosuppressive agents may result in anemia, agranulocytosis, thrombocytopenia- may require physician consult for lab test results

•Corticosteroid therapy puts patient at risk for adrenal suppression

•Treatment Planning Modifications- Focus on preventive care and oral hygiene aids- may need modification to accommodate disability

rheumatoid arthritis medical management

• Treats symptoms but does not cure

•NSAIDs to reduce pain and inflammation

•Corticosteroids quickly reduce inflammation until NSAIDs kick in

• Disease-modifying antirheumatic drugs modify the course of the disease (Methotrexate, Plaquenil, Azulfidine, Arava, Imuran); can help prevent joint damage

•Biologic agents help slow progression of disease; target specific component of the inflammatory process; IV or injected (no oral); cause pain and rash at injection site

•Janus-Associated Kinase Inhibitor- Xeljanz; reduced inflammation by disrupting inflammatory process

•Prosthetic Joint- necessary when a joint has been destroyed by the disease.*

rheumatoid arthritis oral complications and manifestations

• TMJ may be affected by disease; may affect opening and show up on radiographs before inflammation causes degenerative changes in the joint.

•May result in open bite requiring surgery to repair.

•RA may increase periodontal disease- consider more frequent recare with

•Severe stomatitis from immunosuppressive agents- may indicate drug toxicity (refer to physician)

•Offer mouthrinses for palliative care

osteoarthritis

The most common form of degenerative joint disease that is thought to result from normal wear and tear on joints over a long period of time.

Clinical presentation:

•Dull ache and stiffness localized to affected joints

•Appearance of Heberden nodes and Bouchard nodes

•Incapacitation

•Radiographic narrowing of joint space, articular surface irregularities, bone spurs, sclerosis, remodeling

osteoarthritis medical management

•Medical management- analgesics for palliative care (Acetaminophen, aspirin, NSAIDs) and steroid injections for flare ups.

•Management includes physical therapy, patient education, exercise, weight reduction

•May require surgery or joint replacement to improve function

•Dental management- same as RA

•May affect TMJ and cause unilateral pain/stiffness and muscle spasm

•Severe pain on opening and crepitus

•TMJ disc displacement

systemic lupus erythematosus

Autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage to affected organs. Can also affect joints, skin, brain, lungs, kidneys, and blood vessels.

•Caused by genetically determined immune abnormalities that can be triggered by certain factors inside or outside of the body to include infections, stress, diet, toxins, drugs, and sunlight.

Clinical presentation

•Female with polyarthritis and butterfly-shaped erythematous rash across nose and cheeks

Lupus medical management

Medical Management

•Same medications as used for other rheumatologic disorders coupled with observation for renal, cardiac, and clotting issues

•Avoid sun exposure

Lupus dental management

•Consider physician consult to determine patient needs based on disease status at the time of appointment

•Review oral side effects of medications

•May require antibiotic premedication if taking corticosteroids or cytotoxins and have leukopenia

•Obtain platelet count to determine if thrombocytopenia will result in abnormal bleeding (should be 50,000/mL)

Oral Complications and Manifestations

•Lesions on lips and mucosa- red with white spots; may be painful ulcerations; resemble lichen planus; xerostomia, hyposalivation, dysgeusia, glossodynia

sjogren syndrome

An immune system disorder characterized by dry eyes and dry mouth. The body's immune system attacks its own healthy cells that produce saliva and tears. There is no known cause.

•Keratoconjunctivitis sicca

•Xerostomia

•Connective tissue disease

sjorgren syndrome clinical presentation

•Dry eyes

•Hyposalivation/xerostomia

•Enlarged parotid gland

Sjogren syndrome dental management

Focus on palliative and preventive care- relief of symptoms and normal homeostatic environment

1.Moisture and lubrication

2.Treat conditions resulting from SS- mucositis or candidiasis

3.Prevention- OHI, nutritional counseling, importance of frequent recare

psoriatic arthritis

A form of arthritis that affects some people who have the skin condition psoriasis.

•Flaky skin patches

•Swollen fingers and toes with pain

•Foot pain

•Lower back pain

•Small dents or pits in nails; nails may crumble or separate from the nail bed

•Eye inflammation including eye pain, redness, blurry vision; may lead to vision loss if untreated

giant cell arteritis

Inflammation of the lining of the arteries, usually in the head/temples. 

Medical management- glucocorticoid therapy (Prednisone)

Dental management- may cause headaches and tmj pain

lyme disease

Systemic inflammatory disease caused by a tick bite. Method of infection is not clear.

Three phases of clinical manifestations:

•Early localized

•Early disseminated

•Late

fibromyalgia

•Chronic disorder that causes pain and tenderness, fatigue, and trouble sleeping.

•Treated with heterocyclic and selective serotonin  reuptake inhibitor antidepressant drugs, and anticonvulsant medications

•Dental management – consider comfort level of patient and adjust chair accordingly

•May cause TMJ pain which worsens throughout the day so morning appointments may be considered

are not recommended

• in general, prophylactic antibiotics __ __ __ prior to dental procedures

antibiotic prophylaxis should be considered

• For patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures

• Considered after consultation with the patient and orthopedic surgeon

solid organ transplant

•The surgical transplantation of internal organs including, but not limited to, the liver, kidney, pancreas, lungs, or heart.

•Treatment (not cure) for end-stage liver, kidney, pancreas, heart, and lung disease

bone marrow transplant

Cellular infusion of stem cells from the bone marrow

graft rejection

•recipient’s immune system recognizes the donor organ as foreign and tries to eliminate it; does not always result in loss of the transplanted organ.

immunosuppression/ infection

•Immunosuppressants block white blood cells and increase risk for infection.  Recipients learn about prevention prior to surgery to help decrease risk for infection while taking these drugs.

other systemic conditions resulting from immunosuppressive meds

•Kidney disease, tremors, HBP, hyperglycemia, hyperkalemia, hyperuricemia, GI issues, hyperlipidemia, osteoporosis

dental management for patients with organ transplants

•Thorough medical history- indication for transplantation, organ function status, current medications, pertinent laboratory results, transplantation schedule and timeline

•Possible >risk for bleeding due to anticoagulant therapy, liver disease or thrombocytopenia

•Period of profound immunosuppression following the transplant = high risk for infection

•Patients undergo pretransplant dental screening and clearance to reduce the risk of infectious complications.

•Emphasize importance of oral health care maintenance

•Stress basic oral health care- Tb/interdental care/Fluoride dentifrice

•Possible daily chlorhexidine rinse for patient with gingivitis/periodontitis

•Care of removeable prosthesis- clean manually and soak in disinfecting solution overnight.

pretransplant dental care

•Patient may have limited access to dental care due to medical status, complications, costs, disability or unemployment

•Comprehensive dental and oral eval. is necessary as early as possible prior to transplant to identify and eliminate sources of infection from oral cavity.

•Treat all periodontal disease or provide prophylaxis before transplant as indicated

•Extract teeth with poor prognosis and third molars with a history of pericoronitis.

•Complete all necessary dental treatment at least two weeks before transplantation

post-transplant dental care

•Defer care during immediate post transplantation period due to profound immunosuppression and risk for infection (OK to provide emergency care).

•Objective is to reduce infection risk in the immediate post-transplant period when immunosuppression is greatest

•No elective treatment during chronic rejection phase due to significantly higher risk for infection

•During the stable phase (as indicated by physician) provide routine dental care, perio maintenance, treat active pathology

immediate post-transplant period (<6 months)

• Physician consult indicated

• defer routine dental treatment

• continue oral hygiene practices

• provide emergency dental care as needed (eliminate infection)

stable graft period

• physician consult

• Continue oral hygiene procedures

• Initiate active recare program with appointments every 3-6 months

• Monitor BP in patients taking cyclosporine, tacrolimus, or prednisone, and if BP increases, establish a baseline referral for medical evaluation

• treat all new dental diseases

• examine for signs and symptoms of over-immunosuppression or graft rejection

chronic rejection period

• physician consultation

• follow recommendations for stable graft period

• manage odontogenic infections aggressively

• monitor medical status and medication; continually reassess risk

oral manifestations of immunosuppression meds

• Mucositis 7- 10 days after

• •Diffuse, nonspecific erythema and ulcerations of nonkeratinized oral mucosa

  •May compromise oral function and quality of life

  •May affect esophagus- painful swallowing

  •Recommend diet modifications and palliative rinses

medication-relation complications

• gingival overgrowth

• orofacial granulomatosis-like lesions

• oral hairy leukoplakia

gingival overgrowth

edematous, swollen overgrown gingival enlargement

•Interdental areas extending on to crowns of teeth

•Poor oral hygiene increase incidence and severity

•Management- periodontal care, improved oral hygiene, surgical excision by gingivectomy

•Newer medication use has decreased this complication

orofacial granulomatosis-like lesions

•Multiple spherical lesions on tongue, mucosal fissuring, and lip swelling

oral hairy leukoplakia

•Corrugated white plaques on the ventrolateral tongue that cannot be removed

graft vs host disease

•Complication of bone marrow transplant

•Clinical Features

•Oral mucosal lichenoid inflammation

•Typical lichen planus-like changes

•Mouth discomfort and sensitivity

•Salivary gland dysfunction with xerostomia

•Fibrosis of oral and perioral tissues

•Mucoceles- superficial saliva-filled blisters on the hard palate

•Manage by controlling symptoms, application of topical steroids, topical lip ointment, Rx topical fluoride if salivary gland dysfunction is present