Dental Management of Patients with Autoimmune Disorders

Dental Management of Patients with Autoimmune Disorders Adrienne J. Yoon, D.D.S. November 18, 2004 Autoimmune Disorders Hashimoto’s Disease  Rheumatoid Arthritis  Sjogrens Syndrome  Systemic Lupus Erythematosus  Hashimoto’s Disease A chronic inflammatory disease of the thyroid Incidence Most common cause of primary thyroid deficiencies (thyroid “burns” out)  Common in women and adolescents  Familial predisposition  Laboratory Values Assay the free thyroxine (T4) level  Primary thyroid disease: TSH levels are elevated  Secondary thyroid disease: caused by pituitary dysfunction and TSH level is normal or borderline  Medical Management  Thyroid hormone replacement once in the hypothyroid phase Dental Management Aggressively treat infections  Avoid thyrotoxic crisis  Closely monitor vitals  Stress management  Rheumatoid Arthritis A chronic nonsuppurative inflammatory destruction of the joints Incidence 3% of general population  Genetic predisposition  Female to male ratio 3:1  Average age of onset of 40 years  Pathogenesis     Synovium is transformed into hyperplastic chronically inflammed tissue Intimal lining increases in size due to local proliferation of fibroblast-like cells and macrophage-like synoviocytes Prominent angiogenesis Rheumatoid factor is synthesized in the synovium and detected in synovial fluid Signs and Symptoms Polyarthritis sometimes associated with fever and weight loss  Joint pain  Generalized fatigue  “Gelling” phenomenon  morning stiffness; difficult to resume motion Extra-Articular Manifestations 20% of patients have rheumatoid nodules  Carpel tunnel sydrome  Synovial cysts  Pleuropulmonary disease  Systemic rheumatoid vasculitis  Laboratory Values High elevation of rheumatoid factor (RF)  Antinuclear antibody (ANA) detected in about 50% of patients  Active phase: patients have elevated erythrocyte sedimentation rate (ESR)  Some affected patients have mild anemia  Medical Management NSAIDs  Glucocorticoids  Immunosuppression  Dental Management AHA Guidelines  Short dental appointments  Assess if aspirin or NSAIDs are affecting platelet function  Sjogren’s Syndrome Inflammation of the lacrimal and salivary glands Incidence 0.2-3.0% of population  More common in females  15% of patients with rheumatoid arthritis  30% of patients with SLE  Signs and Symptoms Dry mouth, skin, eyes, nose and vagina  Tongue becomes fissured and exhibits atrophy of the papillae  Oral mucosa red and tender  Parotid enlargement  Extra-glandular Signs and Symptoms      Lymphadenopathy Vasculitis Interstitial nephritis Interstitial lung fibrosis Primary biliary cirrhosis (PBC)    Raynaud’s phenomenon Peripheral neuropathies Scleroderma Laboratory Values High erythrocyte sedimentation rate and serum immunoglobulin levels (IgG)  75% of patients have RF regardless of rheumatoid arthritis  Antinuclear antibodies (ANA) also present  Medical Management  Local manifestations can be treated symptomatically Dental Management   Prevention of caries daily use of fluoride, frequent recalls Enhance salivary output sugarless gum/candy, saliva substitutes (salivart, biotene, oral balance, mouth kote, glandosane, prescription medication (salagen, ` evoxac)  Treatment of oral candidiasis antifungals  Pain control for enlarged salivary glands Systemic Lupus Erythematosus A chronic multisystem disease of unknown origin that exhibits wide variations in its clinical expression and disease course Incidence Females are affected 8-10 times more than men  Average age is 31 years  Signs and Symptoms    Fever, weight loss, arthritis, fatigue, and general malaise Butterfly rash on the malar area and nose 40-50% of patients have affected kidneys  Cardiac involvement -Libman-sacks endocarditis found in 50% of patients upon autopsy -pericarditis, myocarditis, endocarditis, CAD  Oral lesions -5-25% of patients have affected palate, buccal mucosa, and gingiva Laboratory Values 95% of patients have elevated ANA  70% of patient have antibodies directed against double-stranded DNA  Medical Management Avoid excessive exposure to sunlight  NSAIDS for mild active disease with antimalarial drugs  Topical corticosteroids  Dental Management AHA Guidelines  Assess adrenal function for possible suppression  Consult with physician regarding systemic manifestation  Assess if NSAIDS are affecting platelet function 