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«Rheumatoid arthritis (RA), the most common long-term, inflammatory disease of the joints, affects about 1% of the population. This chronic disease ...»

Megan Woodman DH2

Special Needs Patient

4/14/2015

Rheumatoid Arthritis

Rheumatoid arthritis (RA), the most common long-term, inflammatory disease of

the joints, affects about 1% of the population. This chronic disease can lead to severe

damage of the joints and other organs in the body, which is completely irreversible

(Emery and Symmons). This disease affects the synovial joints in the fingers, hands,

feet and sometimes the larger joints like the knee and shoulder. This disease can occur in multiple joints but is not always symmetrical (Hughes). RA is usually triggered by a certain environmental condition, but is also attributed to genetics. RA is classified as an autoimmune disorder, and in patients suffering from autoimmune deficiencies such as this, the immune system triggers irregular inflammation in the membrane that lines the joints (Emery and Symmons). The symptoms of RA can present as fatigue, pain, warm, swollen, reddish joints and long periods of joint stiffness (“Rheumatoid Arthritis”).

In the majority of patients, the onset of RA is surreptitious and typically infects the smaller joints of the hands and feet before spreading to larger joints. With this, there are four commonly seen manifestations (Bukhari et al.). Polymyalgic onset is seen in pa- tients who are elderly and present stiff joints, mostly around the shoulders and pelvic girdle (Suresh). Palindromic onset is found in patients suffering from relentless episodes of pain, joint swelling and redness in one or multiple joints simultaneously (Suresh).

Systematic onset is seen in patients with non-focal symptoms such as weight loss, de- pression or fever, and articular symptoms are not immediately present (Suresh). Finally, persistent monoarthritis is displayed in patients who have initial persistent arthritis found 1 in one large joint like the ankle or shoulder (Suresh). Ideally, textbook symptoms are fa- vored for early diagnoses of the disease. However, this is not always the case seeing that each patient varies.

There have been many different techniques and treatments developed, but be- cause RA acts differently in each and every patient, it becomes difficult to test the validi- ty of these treatments (Suresh et al.). In order to properly manage the disease in its ear- ly stages, its activity must be closely observed, treatments must be applied accordingly, and the proper target must be established. The importance of recognizing RA in its early stages is twofold, the primary reason being that the disease can be worse in the future if it is not properly treated and handled in the beginning (ACR). The initial evaluation of an early RA patient should include documentation of the disease activity, the patient’s func- tional status, joint pain and functioning, and the presence of radiographic damage (ACR). This assessment should also include laboratory evaluations, such as a total blood cell count, a rheumatoid factor measurement, and measurement of ESR (erythrocyte sedimentation rate) or CRP (c-reactive protein) (ACR).

A common treatment for patients with RA is the use of disease-modifying drugs (DMARDS), which was first tested in the 1930’s. This classic treatment was the injection of gold into the body of the patient, which is no longer used today. Commonly used DMARDS are sulfasalazine (SSZ), methotrexate (MTX), and leflunomide hydroxychloroquine (HCQ) (Sizova). The initiation of DMARD treatment is supported in patients that are at a risk of developing persistent, erosive arthritis, or patients who have been showing symptoms but have not yet been diagnosed. This treatment is highly effective and may be as short as 3-4 months, but is most effective when the patient starts within

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vealing RA symptoms choose to begin treatment before diagnosis, it can potentially prevent severe joint damage and will most likely change the course of the disease drastically.

In the early 1900s, Swedish physician Henrik Sjorgen described a group of women with chronic arthritis that were also presenting with dry eyes and dry mouth.

Sjorgen’s syndrome is an inflammatory disease and mostly affects the tear and saliva glands. Dry mouth, swelling of the glands around the neck and face or burning of the eye are symptoms of the condition. “Secondary” Sjorgen’s occurs in people that already have another rheumatological disease. The exact cause of this syndrome is unknown, but it is an autoimmune disease. This suggests that the immune system, which normally functions to protect the body against cancers and infection, is reacting against its own tissue. The decrease in tears and saliva seen in Sjorgen’s syndrome occurs when the glands that produce these fluids are damaged by inflammation. (Wise) Most complications of Sjorgen’s syndrome occurs because of decreased tears and saliva. Patients with dry eyes are at increased risk for infections around the eye and may have damage to the cornea. Dry mouth may cause an increase in dental decay, gingivitis, and oral yeast infections (thrush) that may cause pain and burning. (Wise) Sjorgen’s is normally diagnosed through a combination of bolded tests, physical examination, and sometimes special studies. Special tests may assess any decrease in tear and saliva production. While blood tests can determine the presence of antibodies typical of the disease. Treatment options for dry eyes and dry mouth include; artificial tears, eye drops that reduce inflammation, Restasis to increase tear production, pilo

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Sjorgen’s patients remain healthy, it is important for them to know they are at an increased risk for infections in and around the eyes and an increased risk for dental problems due to long-term decrease in tears in saliva. (Wise) I researched different ways to use everyday oral aids for patients with crippled hands. I found a PowerPoint (Karpas) that shows different ways to accommodate to a patient with severe RA and I was prepared to take extra time in the appointment for oral hygiene instruction.

My special needs patient, Debra, is 62 years-old and has severe rheumatoid arthritis. She also has Sjorgen’s syndrome as a side effect. These conditions have caused her to have severely crippled hands and dry mouth/eyes. She is a Periodontal Case Type II and rated a 1/1.

Debra is currently medicating for her RA. Her medications include; Remicade (IV at a local hospital once a month), Levothyroxine, Lansoprazole, Restasis eye drops, Estradiol, Medroxyprogesterone, Ibuprofen, Methotrexate and Calcium. Remicade is an antibody and it reduces inflammation by blocking tumor necrosis factor alpha (TNF-alpha). (Sheil) None of her medications have significant oral side effects. She walks every day and tries to swim as much as possible to keep her inflammation under control and to prevent stiffening of her joints. She has had her right knee replaced as well. Her hands are affected by RA the most. They are severely crippled and she has a hard time performing fine dexterity tasks like writing, un-zipping her coat, flossing and brushing.

Her neck gets stiff while laying in the dental chair. She had to sit up multiple times during the appointment to stretch. I offered her a pillow multiple times, but she didn’t want

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Using the Cavitron was nice for her since it lubricated her mouth. I recommended that she try to sip on water throughout the day and that she should chew xylitol gum (Spry, Mentos or Ice Breakers) or use the ACT lozenges. I explained to her that the lozenges might be the best for her since the gum may cause TMJ stiffness or inflammation, especially with her condition.

Debra did well with her plaque control considering her severe condition. She is very dedicated to not letting RA take over her life and does her best to floss and brush.

While she enjoys flossing, it is quite the task for her. She does it after every meal, like I said she is very dedicated and strong willed. I had her demonstrate her flossing technique to me. She grips the floss between her thumb and palm more than with her fingers. I honestly don’t know how she holds it as well as she does. I gave her a floss aid to use that has a wide handle and regular floss is used with it. I explained to her that the wide handle might be easier on her hands and help her reach the distal surfaces of her most posterior teeth, where she is missing plaque. I helped her practice wrapping the floss through the aid and then let her practice it for a few minutes to make sure it would work for her. She liked the idea and was open to trying it until her next appointment.

Since most of the manual toothbrushes, which is what Debra is using, have narrow handles, I gave her an Oral B electric toothbrush. Our clinic has a grant through Delta Dental that approves patients 55 and over to qualify for a free Oral B electric toothbrush based on their income. I explained to her that this toothbrush would have a larger handle and be easier to hang on to. I also showed her that the toothbrush would do most of the work for her and that all she would have to do is get the head of the toothbrush

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showed her how to close down half way and make more room for the head of the toothbrush. She was exited to try this and hopeful that it would make her job a little easier. If Debra wouldn’t have qualified for the Oral B toothbrush, I was prepared to show her a technique that involves a rubber band over the hand, securing the toothbrush in the palm. I finished Debra’s cleaning in one appointment and sent her with the electric toothbrush and floss aid.

Debra came back in for an hour long appointment just to assess how her home care was going about a month after her initial appointment. Upon greeting her, I asked her how the electric toothbrush was working out. She replied to me, “I love it!” She was so pleased with how much cleaner her teeth felt from before. When I assessed her mouth, I found that her overall plaque was decreased, especially on her posterior teeth.

I could tell she was able to get the electric toothbrush head all the way to the back of each arch. Her tissue was also closer to normal color and less inflamed than at the initial appointment. I asked her how the floss aid had worked for her and she explained to me that she hadn’t had a chance to use it. She was still missing some interproximal plaque, so I showed her how to use soft picks. I wasn’t sure if she would be able to hold onto the well, but she seemed to manage and told me that she liked using them in-between her teeth. I also asked her if she was using Biotene for her dry mouth and she was. I polished and placed a fluoride varnish at this appointment.

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Debra was a great patient and hit home with me because my little sister was diagnosed with the juvenile form of RA when she was very young. I am familiar with the condition and felt I could relate to Debra’s obstacles and aches and pains after going through a similar situation with my sister. Debra is an inspiration in that she is very dedicated and determined not to let her disease take over her life. I felt like I made a big difference in her life by giving her an electric toothbrush and showing her that there are other ways to get in-between her teeth. She was very concerned about her oral health status when she came to the clinic and was relieved to know that she had been doing a pretty good job. I think that my positive reinforcement about all of the things she was doing right motivated her to try new techniques to improve the little bit that she needed to. Debra benefited from my oral hygiene instruction and my recommendations worked for her. She seemed really excited about her improvements the second time I saw her. I can relate her condition to a lot of elderly patients that I see that may not have RA, but severe arthritis. These patients could have some of the same obstacles that Debra had and now I feel that I will be prepared to assist them in their oral hygiene care.

Extra research:

The Arthritis Foundation posted a research article correlating RA and gum disease. The article explains citrullination, the process of a protein undergoing a molecular change in structure. This causes the immune system to attack the protein as a foreign body by creating anti-cyclic citrullinated (anti-CCP) antibodies. The article doesn’t specify, but explains that there is a periodontitis-causing, oral bacteria that can induce citrullination.

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"Rheumatoid Arthritis." : Symptoms & Treatment. 2015. Web. 7 Apr. 2015. http:// www.arthritis.org/arthritis-facts/disease-center/rheumatoid-arthritis.php.

Hughes, Pam. ”DentalCare.” Crest Oral B. Web. 7 Apr. 2015. http://www.dentalcare.com/en-US/dental-education/continuing-education/ce330/ce330.aspx?

ModuleName=coursecontent&PartID=2&SectionID=0.

Dunkin, Mary Anne. "Related Features." RA and Gum Disease. Web. 7 Apr. 2015.

http://www.arthritistoday.org/about-arthritis/types-of-arthritis/rheumatoid-arthritis/whatto-expect/effects-on-body-and-health/ra-and-gum-disease-2.php.

Sheil, Jr., William C. "Rheumatoid Arthritis: My Doctor Says I Need Remicade." EMedicineHealth. Web. 7 Apr. 2015. http://www.emedicinehealth.com/script/main/art.asp?articlekey=15766.

Karpas, DMD, Steven, and Paula K. Friedman, DDS, MSD, MPH. "Dental Management of Rheumatoid and Osteoarthritis Patients." Web. 7 Apr. 2015.

Suresh, E., Maiden, N.L., Dhillon, V.B., McRorie, E.R. (2004). The impact of the publication of SIGN guideline on management of early rheumatoid arthritis. Rheumatology, 43(2): 138.

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diagnosis. Bailiere’s Clin. Rheumatol., 11: 13-26.

American College of Rheumatology (ACR) Subcommittee on Rheumatoid Arthritis Guidelines.(2002). Guidelines for the management of rheumatoid arthritis. Arthritis & Rheumatism, 46(2): 328-346.

Sizova, L. (2008). Approached to the treatment of early rheumatoid arthritis with disease-modifying antirheumatic drugs. Br. J. Clin. Pharmacol., 66(2): 173-178.

Wise, Chris. "Sjögren's Syndrome | American College of Rheumatology | ACR." Sjögren's Syndrome | American College of Rheumatology | ACR. 1 July 2012. Web. 15 Apr.

2015. http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Sjögren_s_Syndrome/.

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