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A D A J ✷ ✷ N CON IO T T A N I U C IN U G ED ARTICLE 3 RHEUMATOID ARTHRITIS: A REVIEW AND SUGGESTED DENTAL CARE CONSIDERATIONS NATHANIEL TREISTER, B.A.; MICHAEL GLICK, D.M.D. A B S T R A C T Background. Rheumatoid arthritis, or RA, identified, as well as complications due to treat- is a chronic multisystem disease of presumed autoim- ment modalities and various related oral manifes- mune etiology. It is estimated that arthritis and other tations and conditions. rheumatic conditions affect 42.7 million Americans. Conclusions. Medical complications due Medical complications due to RA and its treatment to RA and its treatment can affect oral health care. may affect the provision of oral health care. Oral health care providers need to recognize and Methods. The authors undertook an extensive identify modifications of dental care based on the review of the English literature relating to RA and medical status of patients with RA. Furthermore, dental care. They used primarily MEDLINE search- oral health care providers play an important role in es, which included such key words as “rheumatoid the overall care of these patients as it relates to arthritis” and “dental care” and subsequent appro- early recognition, as well as control of the disease. priate subheadings. While the MEDLINE search Clinical Implications. In most spanned the years from 1975 to the present, the most patients with RA, the condition will necessitate few recent literature was prioritized. Appropriate medical or no changes in routine dental care. However, con- and dental textbooks were also used. The authors ex- siderations include the patient’s ability to maintain trapolated information from selected texts based adequate oral hygiene, xerostomia and its related on its relevance to dentistry, oral health and the role complications, the patient’s susceptibility to infec- of the dental provider in the overall treatment of tions, impaired hemostasis, and untoward drug RA patients. actions and interactions. Patients with RA may re- Results. The authors reviewed nearly 200 arti- quire antibiotic prophylaxis owing to joint replace- cles and seven textbooks. Their determination of the ment and/or immune suppression, glucocortico- texts’ relevance to oral health care was based on con- steroid replacement therapy and modifications in tent, significance, quality, journal in which articles oral hygiene procedures. Intra- and extraoral con- were published and year of publication. Major fea- ditions such as ulcerations, gingival overgrowth, tures of RA—including its diagnosis, pathophysiolo- disease-associated periodontitis and temporo- gy, clinical features and medical treatment—were mandibular pathology also need to be recognized. Rheumatoid arthritis, or RA, was first de- likely a group of diseases in which chronic scribed clinically in a 1800 doctoral thesis by polysynovitis is a major manifestation.2 Landre-Beauvais, a French medical student, who Arthritis and other rheumatic conditions in- called the condition “primary aesthenic gout.” Sir volving chronic joint symptoms affect 42.7 million Alfred Garrod established the distinction between Americans, costing $65 billion per year.3,4 Nearly RA and gout in 1859 and gave the condition its three million Americans have the specific diagno- present name.1 Still today, however, many sis of RA. Interestingly, approximately 40 percent rheumatologists have suggested that RA is more of people with chronic joint symptoms have not JADA, Vol. 130, May 1999 689 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE contacted a physician for a diag- counseling, patient education provoked synovitis depends on nosis.5 Women are about three and surgical intervention. the local accumulation and acti- times more likely to be affected vation of cytokine-releasing PATHOPHYSIOLOGY than men, and 80 percent of cells, which appear to regulate people with RA develop signs The cause of RA is not known, the growth, differentiation and and symptoms of the disease although its etiology appears to activity of other cells involved between the ages of 35 and be multifactorial and may in- in inflammatory and immuno- 50 years.6,7 The classic charac- volve infectious, genetic, en- logical reactions in the rheuma- teristics of this disease are bi- docrine and immune participa- toid joint. The hypertrophied, lateral and symmetric chronic tion.6,7 Rheumatoid arthritis is inflamed synovial tissue that inflammation of the synovium, believed to be a T lymphocyte– covers and extends into the car- a condition known as synovitis. driven disease in which a sud- tilaginous areas of the joint This inflammatory response den influx of T cells into the af- with fingerlike processes is de- particularly affects small joints fected joint(s) is followed by an fined as the pannus. Cytokines of the upper and lower extremi- increased number of macro- increase the permeability of ties, and it often leads to the de- phages and fibroblasts, drawn blood vessel walls, facilitating terioration and eventual de- by the release of cytokines, par- the migration of white blood struction of articular cartilage cells into joint spaces that then and juxta-articular bone, as Fifty percent of peo- become sites of inflammation. well as to an inflammatory pro- Cytokine release also leads to cess surrounding tendons, all of ple with rheumatoid the proliferation of fibroblasts, which frequently result in de- arthritis become un- synovial cells, increased formities of the affected joints. able to work within prostaglandin and matrix- In addition to the typical degrading protease activity and, pattern of inflammation, pa- the decade after the ultimately, the resorption of tients with RA may experience onset of disease. bone. IL-1, a cytokine secreted systemic manifestations such primarily by macrophages, is as fatigue, loss of appetite, ticularly interleukin-1, or IL-1, one of the key mediators of local weakness and vague muscu- and tumor necrosis factor- inflammation, tissue damage, loskeletal pain. Recent studies alpha, or TNF-α. This cytokine immunologic reactions and bone have established a connection release and subsequent migra- resorption.11 Additionally, it is between RA and an increased tion of cells is thought to be re- implicated in many of the sys- risk of premature mortality sponsible for the chronic inflam- temic manifestations of RA, due to infections, hematopoiet- mation, and characteristic particularly malaise, fever, ane- ic malignancies, cardiovascular destructive changes in rheuma- mia and elevated serum acute- diseases, renal diseases and/or toid joints.6,10 The cause of the phase reactants.12 TNF-α, an- complications from treatment.8 initial T-cell influx is not other key cytokine that often While patients with RA appear known, but several infectious acts synergistically with IL-1, to die as a result of the same agents—including both bacteria also promotes the cartilage and causes affecting the general such as streptococci and my- bone erosion that leads to RA- population, the increased mor- coplasma as well as viruses characteristic pathological joint tality in people with RA is pro- such as parvovirus, Epstein- alteration.13 portional to the severity of the Barr virus and retroviruses— Joint pathology is pervasive course of their disease.9 have been suggested. in patients with RA. The great- Successful management of Synovial joints are composed est rate of joint damage occurs this condition requires a multi- of articular cartilage, synovial in the first two years of the dis- faceted and multidisciplinary fluid and a synovial membrane. ease, when more than 50 per- approach to treatment. Treat- The synovial membrane is the cent of patients have radio- ment modalities include sys- area of the joint infiltrated by graphic evidence of joint temically administered drugs, the T cells in a rheumatoid at- damage. Within three years, local injections of corticoster- tack and is the site of the subse- nearly 70 percent of affected oids, physical therapy, occupa- quent immune response. The people will exhibit radiographic tional therapy, psychological severity and progression of RA- damage.14,15 Somewhat less than 690 JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE 10 percent of patients report TABLE 1 single, nonrecurrent episodes of RA, or mild but recurring cases, while two-thirds of patients ex- 1987 REVISED CRITERIA FOR THE CLASSIFICATION OF hibit a clinical pattern of wax- ing and waning disease over RHEUMATOID ARTHRITIS.* many years.16,17 The general pro- GUIDELINES gression of RA leads to an in- creasing disability and loss of dFour of seven criteria must be functional capacity; 50 percent satisfied for a diagnosis. of people with RA become un- dCriteria 1 through 4 must be present for at least six weeks. able to work within the decade dCriteria 2 through 5 must be after the onset of disease.18 observed by a physician. There are extra-articular dDesignation as classic, definite or manifestations of RA as well, in- probable rheumatoid arthritis, or RA, is not to be made. cluding rheumatoid nodules, rheumatoid vasculitis, intersti- Criteria Definition tial lung disease, pericardial dis- ease, episcleritis and scleritis, 1. Morning Stiffness Stiffness in and around the Felty’s syndrome and Sjögren’s joints, lasting at least one syndrome. Felty’s syndrome, a hour before maximal im- provement rare condition affecting 1 to 2 percent of people with RA, is 2. Arthritis of Three or Soft-tissue swelling or fluid More Joint Areas (but not just bony over- characterized by chronic RA, growth) in at least three splenomegaly, neutropenia and joint areas simultaneously (the 14 possible joint areas sometimes anemia or thrombo- are right or left proximal cytopenia.19 These patients can interphalangeal, or PIP; metacarpophalangeal, or have neutrophil counts of less MCP; wrist; elbow; knee; than 1,000 cells per microliter as ankle; and metatarsopha- langeal, or MTP, joints) well as defective neutrophil function.20 Sjögren’s syndrome is 3. Arthritis of Hand Joints At least one area swollen (as defined in criterion 2) in a chronic autoimmune disease a wrist, MCP or PIP joint characterized by lymphocytic in- 4. Symmetric Arthritis Simultaneous involvement filtration of the exocrine glands of the same joint areas (as resulting in xerostomia, dry eyes defined in criterion 2) on both sides of the body and joint pain. When observed in association with RA, it is 5. Rheumatoid Nodules Subcutaneous nodules over bony prominences, extensor called “secondary Sjögren’s surfaces or juxta-articular syndrome.”7,21 regions 6. Amount of Serum Demonstration of abnormal DIAGNOSIS Rheumatoid Factor amounts of serum rheuma- toid factor by any method In 1987, the American for which the result has been positive in less than 5 Rheumatism Association (now percent of normal control the American College of subjects Rheumatology, or ACR) revised 7. Radiographic Changes Changes typical of RA on the criteria it had set in 1958 to posteroanterior hand and wrist radiographs, which create a better model for the di- must include erosions or agnosis of RA (Table 1).22,23 There unequivocal bony decalcifi- cation localized in or most are no specific laboratory tests to marked adjacent to the in- diagnose RA. Rheumatoid fac- volved joints tors—immunoglobulin M, or IgM, antibodies directed against * Adapted from Arnett and colleagues. 23 other immunoglobulins—are JADA, Vol. 130, May 1999 691 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE TABLE 2 to restore or at least maintain quality of life by relieving pain, TOXICITIES OF ANTIRHEUMATIC DRUGS.* reducing joint inflammation and preventing joint destruction DRUG TOXICITIES and deformity.25 The challenge for physicians in treating RA is Methotrexate Gastrointestinal symptoms, preventing early stages of the stomatitis, rash, alopecia, infrequent myelosuppres- disease from progressing to sion, hepatotoxicity, rare stages of severe erosion and but potentially life-threat- ening pulmonary toxicity joint deformity.26 Currently available antirheumatic drugs Injectable Gold Salts Rash, stomatitis, myelosup- pression, thrombocytope- control established RA only par- nia, proteinuria tially. They rarely induce long- Oral Gold Salts Same as those of injectable term remission and seldom af- form but less frequent; fect the progression of joint frequent diarrhea destruction.27 Additionally, D-penicillamine Rash, stomatitis, dysgeu- many of these drugs have seri- sia, proteinuria, myelosup- pression, infrequent but se- ous side effects that contraindi- rious autoimmune disease cate their use for early-stage Cyclosporine Renal impairment, hyper- RA and interfere with long-term tension, gingival over- therapeutic use for more severe growth RA cases28,29 (Table 2). Physical Nonsteroidal Anti- Gastrointestinal symptoms, therapy, exercise, use of orthot- inflammatory Drugs including indigestion, ulceration, hemorrhage, ic devices and, in severe cases, small-bowel ulceration, surgery all are factors in treat- stomatitis; renal abnormal- ities; neurological abnor- ment planning.7 malities; pulmonary abnor- To prevent erosive damage malities; dermatologic abnormalities; hematologic by progressive RA, the condi- abnormalities; hepatic ab- tion must be diagnosed early normalities; displacement of protein-bound drugs; and therapy begun promptly, possible systemic complica- ideally within two months of tions disease onset.6 Nonsteroidal * Adapted from American College of Rheumatology Ad Hoc Committee on Clinical anti-inflammatory drugs, or Guidelines27 and Lehmann and colleagues.50 NSAIDs, are the current main- stream “first-line” treatment, although this protocol is now found in more than two-thirds of patients who already had been criticized by many physicians adult patients with RA, but they diagnosed with RA and had a who are arguing for more ag- are not specific to RA and are median disease duration of 7.7 gressive early treatment of RA. found in patients with a number years.22 Therefore, they are However, while NSAIDs often of other conditions. Additionally, more helpful in evaluating are effective in controlling 5 percent of otherwise healthy those with well-established symptoms of RA, they do not people have circulating rheuma- symptoms, and often are diffi- alter the course of the disease. toid factors.7 While the presence cult to apply to people in early Corticosteroids, another option, of rheumatoid factor is not use- stages of the disease.22 have both anti-inflammatory ful as a screening test, high lev- Evaluations of specific patterns and immunosuppressive effects. els in combination with a sug- of pain in suspected cases have This type of drug can provide ef- gestive clinical presentation of been able to predict RA with a fective relief by decreasing cir- RA are prognostic for more se- 70 percent probability at early culating monocytes, reducing vere disease with extra-articular stages of the disease.24 macrophage phagocytosis and manifestations. IL-1 secretion, inhibiting colla- TREATMENT The latest set of criteria was genase and lysosomal enzyme developed through the study of The objective of RA therapies is release, and slowing 692 JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE TABLE 3 RHEUMATOID ARTHRITIS AGENTS.* AGENT DOSING COST PER MONTH IN DOLLARS† Auranofin 3 milligrams per mouth, or PO, twice 79 daily Aurothioglucose 50 mg intramuscularly once every two 28 weeks Azathioprine 150 mg PO once daily 105 Celecoxib 100 mg PO twice daily 86 Cyclophosphamide 150 mg PO daily 300 Cyclosporine 2 mg/kilogram PO twice daily 475 D-penicillamine 750 mg PO once daily 86 Etanercept 25 mg subcutaneously twice weekly 1,100 Gold Sodium Thiomalate 50 mg once every two weeks 18 Hydrochloroquine 200 mg PO twice daily 64 Leflunomide 20 mg PO once daily 245 Methotrexate 15 mg PO once daily 75 Sulfasalazine 1,000 mg PO three times daily 52 57 * Adapted from Dunn and Small. † Based on average wholesale price in December 1998. prostaglandin and leukotriene glucocorticoids treat primarily frequent patient monitoring synthesis. However, cortico- symptoms, DMARDs have the and ultimately limits their ther- steroid therapy is limited in its potential to reduce disease ac- apeutic value, as many patients usefulness because of its severe are able to tolerate the drugs side effects, which may include The primary goal of for only one or two years before osteoporosis, muscle weakness, they are forced to discontinue glucose intolerance, cataracts the latest treatment the treatment.17,30 and sex hormone imbalances.7 protocols has been Methotrexate has become a In cases of long-term use of glu- aggressive early con- popular treatment choice re- cocorticosteroids, the drugs usu- cently because of its immuno- ally are given only every other trol of inflammation, suppressive and anti-inflamma- day to reduce potential side based largely on the tory effects.31 This drug has effects. finding that signifi- been proven effective. Also, it is “Second-line” or disease-mod- tolerable as a long-term treat- ifying antirheumatic drugs, or cant joint damage ment, particularly as folic acid DMARDs, whose mechanisms of does occur in the supplements can be used to action as a group are predomi- early stages of ameliorate many of its toxic nantly unknown, include gold, side effects, which may still in- sulfasalazine, hydroxychloro- rheumatoid arthritis. clude gastrointestinal distress, quine, D-penicillamine, azathio- stomatitis, thrombocytopenia, prine and a recently approved tivity and/or prevent joint dam- bone marrow suppression, drug, leflunomide (Arava, age.27 These second-line agents pneumonitis and/or pulmonary Hoechst Marion Roussel Inc.) can have considerable toxicity. lesions, hepatic fibrosis/cirrho- (Table 3). While NSAIDs and Therefore, their use requires sis and renal toxicity. Well more JADA, Vol. 130, May 1999 693 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE cantly greater than that of sin- INDICATIONS FOR ANTIBIOTIC PROPHYLAXIS FOR gle agents. Combinations of methotrexate and cyclosporine DENTAL PATIENTS WITH RHEUMATOID ARTHRITIS have shown some promise.2 Moreover, there is little evi- dence supporting the effective- AND TOTAL JOINT REPLACEMENTS.* ness of aggressive drug therapy in altering the long-term conse- DENTAL PROCEDURES FOR WHICH ANTIBIOTIC PROPHYLAXIS quences of RA.35 IS INDICATED One of the latest and more dDental extractions novel approaches to treatment is dPeriodontal procedures cytokine therapy, which could dDental implant placement and reimplantation of involve the inhibition of cytokine avulsed teeth synthesis, inhibition of cytokine dEndodontic instrumentation or surgery only beyond the release, inhibition of cytokine apex action and/or inhibition of cyto- dInitial placement of orthodontic bands (not brackets) kine intracellular signaling dIntraligamentary local anesthetic injections pathways. While some of these dProphylactic cleaning of teeth or implants when bleed- ing is anticipated modalities are showing promis- ing clinical success, it remains SUGGESTED ANTIBIOTIC PROPHYLAXIS REGIMENS uncertain how effective blocking Note: No second doses are recommended for any of these single cytokines can be in in- regimens. hibiting the complex cytokine- dPatients not allergic to penicillin: cephalexin, cephra- induced pathology of RA.36 dine or amoxicillin, 2 grams orally, one hour before dental procedure Surgical intervention is used dPatients not allergic to penicillin and unable to take in cases of unacceptable pain oral medications: cefazolin (1 g) or ampicillin (2 g) in- and limitation or loss of func- tramuscularly or intravenously, one hour before dental procedure tion due to severe joint damage. dPatients allergic to penicillin: clindamycin, 600 mil- The most successful procedures ligrams orally, one hour before dental procedure include arthroplasties and total dPatients allergic to penicillin and unable to take oral joint replacements involving the medications: clindamycin, 600 mg intravenously, one hour before dental procedure hips, knees and shoulders.7,27 * Adapted from American Dental Association and American Academy of Orthopaedic ORAL MANIFESTATIONS Surgeons.53 AND CONDITIONS As mentioned above, long-term than one-half—64 percent—of early control of inflammation, use of methotrexate and other people who use methotrexate based largely on the finding antirheumatic agents such as are able to continue its use for that significant joint damage gold, D-penicillamine and five years or more.32,33 does occur in the early stages of NSAIDs can cause stomatitis. Signs and symptoms of RA RA, particularly in the first two Cyclosporine may cause gingival typically recur when second-line years of the disease.15,27 New overgrowth. Additionally, most drug therapies are discontin- treatment strategies have patients with RA will exhibit ued. Because most second-line sought to maximize long-term some temporomandibular joint, therapy (with the exception of efficacy of second-line drugs by or TMJ, involvement during the methotrexate therapy) must be introducing them earlier and course of the disease. Involve- discontinued after less than two giving them in combinations.35 ment of the TMJ results from years owing to toxicity or loss of In controlled trials, however, granulomatous involvement of efficacy, recurrence and long- multiple-agent treatments have the articular surface of the syn- term control of RA is a failed to demonstrate greater ef- ovial membrane, which leads to problem.34 The primary goal of ficacy than single agents, and destruction of the underlying the latest treatment protocols, the toxicity of some combina- bone. Symptoms are character- however, has been aggressive tions has proven to be signifi- istic of TMJ dysfunction.37 694 JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE Radiographic findings include TABLE 4 narrowed joint spaces, flattened condyles, erosions, subchondral GUIDELINES FOR CARIES PREVENTION FOR PATIENTS WITH SJÖGREN’S sclerosis, cysts and osteo- porosis.38,39 Severe arthritic dete- SYNDROME AND/OR REDUCED SALIVARY FLOW.* rioration of the TMJ may be ac- THERAPY GUIDELINES companied by a high incidence Treatment Planning Four-month recall visits; fre- of upper-airway obstruction.40 quent, high-quality bitewing radiographs; conservative Patients with longstanding restorations based on pa- active RA may have an in- tient hygiene, compliance with fluoride use and caries creased incidence of periodontal susceptibility disease, including loss of alveo- Personal Oral Hygiene Brush at least twice daily lar bone and teeth.41,42 This has Instruction with a fluoride dentifrice; been a neglected feature of RA. floss or, space permitting, use an interproximal brush Similarities in host immune re- sponse between RA and perio- Treatment of Xerostomia Water, artificial saliva, sugarless gum or mints, dontal disease have been re- 5 milligrams of pilocarpine ported, involving reduced hydrochloride 3 to 4 times a day (note that adverse cellular and enhanced humoral reactions to pilocarpine activity.43,44 While a protective hydrochloride include in- creased sweating in 40 influence of NSAIDs on gingivi- percent of patients) tis and periodontitis has been Dietary Instruction Limit between-meal inges- reported because of their reduc- tion of fermentable carbohy- tion of inflammation and, there- drates and encourage use of noncariogenic sweetening fore, of subsequent loss of bone, agents such as acesulfame there is little knowledge regard- K, aspartame, saccharin, sorbitol or xylitol ing the impact of second-line agents on periodontal disease.45 Office Fluoride Treatment 1.23 percent fluoride acidu- lated phosphate fluoride, or It does not appear that inade- APF, gel for four minutes in quate oral hygiene resulting a tray; or a 2.25 percent fluo- ride varnish applied directly from functional impairment is a to the teeth, four times a year primary factor in periodontal Office Chlorhexidine Application of a 1 percent disease.41 Treatment chlorhexidine gel for five Patients with secondary minutes or a high-concentra- tion chlorhexidine varnish Sjögren’s syndrome have chron- applied directly to the teeth ic xerostomia. A recent study of (neither yet available in the United States) 604 people with RA indicated a decrease in salivary flow in 43 Home Fluoride Treatment Daily five-minute applica- tion of 1.1 percent sodium percent of patients.46 Further- fluoride, or NaF, or of APF more, the risk of developing re- gel in a custom tray; or daily 0.05 percent NaF rinse for duced salivary flow increased one minute is an alternative with severity of the disease. for patients unable to toler- ate the gel owing to gagging This leads to multiple oral prob- or nausea; use of extremely- lems, including difficulty in high-fluoride-content tooth- paste once daily swallowing food, difficulty in speaking, oral soreness and If on three-month recall, the Home Chlorhexidine Streptococcus mutans count burning (which may be due to Treatment exceeds 1 × 10 colony-form- oral candidiasis), intolerance to ing units per milliliter of saliva, institute a 30-second spicy foods, problems in wear- rinse twice daily with 0.12 ing dentures and an increase in percent chlorhexidine glu- conate for two weeks caries.7,21,47,48 Caries in these pa- tients may progress despite ex- 47 48 49 55 * Adapted from Newbrun, Atkinson and Fox, Atkinson and Wu, Fox and colleagues. cellent regular home oral care, JADA, Vol. 130, May 1999 695 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE and eliminated in large part in SUMMARY: DENTAL MANAGEMENT OF THE the urine by active secretion in the proximal tubules of the kid- RHEUMATOID ARTHRITIS PATIENT. neys.51 Although it is somewhat inconclusive, there is evidence BEFORE TREATMENT for a greater possibility of infec- dAdminister antibiotic prophylaxis because of joint tions in patients using replacement when indicated methotrexate owing to immuno- dAdminister antibiotic prophylaxis because of immune suppression. While stomatitis is suppression when indicated considered a relatively minor dAdminister glucocorticosteroid replacement therapy adverse effect of methotrexate when indicated use, folic acid may help reduce its severity.51 dAssess potential impairment of hemostasis With long-term glucocortico- DURING TREATMENT steroid use, secondary adrenal dRecognize and address ulcerations and gingival insufficiency is a potential prob- overgrowth due to medications lem. Replacement therapy for adrenally suppressed people dRecognize and address xerostomia-associated may be necessary to prevent complications cardiovascular collapse, as their dRecognize and address disease-associated periodontitis response to surgical stress may AFTER TREATMENT include a precipitous drop in blood pressure. In such cases, dAvoid untoward drug actions and interactions when an intramuscular or intra- choosing postoperative medications venous injection of hydrocorti- dImprove and modify oral hygiene instruction sone may be necessary. Long- lasting local anesthetics (such as bupivacaine) and postopera- tive pain medications should be use of fluoride and avoidance of impairment or peptic ulcers.50 used with these patients, as cariogenic foods. Unexplained GI-protective agents such as the well as mild sedatives in more dental caries, especially in root prostaglandin analog misopros- apprehensive patients.52 and incisal sites, may be the tol may help alleviate these side According to the guidelines first apparent clinical sign in recently published by the Sjögren’s syndrome.49 It is essential that the American Dental Association and the American Association of DENTAL MANAGEMENT dentist keep himself Orthopaedic Surgeons, 53 it is It is essential that the dentist or herself updated as recommended that patients keep himself or herself updated to the drugs the pa- with severe RA who have had as to the drugs the patient with joints surgically replaced with RA is currently receiving, their tient with RA is cur- prosthetic joints may require possible side effects and interac- rently receiving, their prophylactic antibiotic therapy tions with other drugs. The possible side effects before invasive dental proce- most common adverse effects dures (Box, “Indications for involved with NSAIDs include and interactions with Antibiotic Prophylaxis for the gastrointestinal and renal other drugs. Dental Patients With systems, and both are dose- Rheumatoid Arthritis and Total related. Before prescribing addi- effects.27 NSAIDs are known to Joint Replacements”). Patients tional NSAIDs, the clinician displace protein-bound drugs as with RA who have upper-air- must assess the RA patient’s well as impair renal function, way obstruction resulting from current medication schedule to both of which can increase free TMJ dysfunction may pose diffi- avoid toxic levels, especially in levels of methotrexate, which is culty in intubation.37 In addi- patients with a history of renal 50 to 60 percent albumin-bound tion, depending on the severity 696 JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved. DENTISTRY AND MEDICINE of the TMJ dysfunction, the pa- devices, and chlorhexidine and Oral Medicine, University of Pennsylvania School of Dental Medicine, 4001 Spruce St., tient may require a soft diet re- fluoride rinses all can be helpful Philadelphia, Pa. 19104. Address reprint re- striction. These patients may to RA patients experiencing quests to Dr. Glick. derive long-term benefits from symptoms in the hands and 1. Short CL. The antiquity of rheumatoid local physical therapy of the wrists.56,57 Specially designed arthritis. Arthritis Rheum 1974;17:193-205. 2. Kushner I, Dawson NV. Aggressive ther- stomatognathic system.54 toothbrushes are also available apy does not substantially alter the long-term Patients with Felty’s syn- for patients with RA. course of rheumatoid arthritis: so what else is new? Rheum Dis Clin North Am 1993;19:163- drome are at an increased risk 72. CONCLUSION of developing infection owing to 3. Centers for Disease Control and Prevention. Prevalence of disabilities and as- their neutropenia and impaired For most patients with RA, few sociated health conditions—United States, hemostasis owing to their or no changes will be required 1991-1992. MMWR 1994;43:730-1, 737-9. 4. Yelin E, Callahan LF. The economic cost thrombocytopenia.20 Patients in standard dental treatment and social and psychological impact of muscu- with Sjögren’s syndrome may (Box, “Summary: Dental loskeletal conditions. Arthritis Rheum 1995;38:1351-62. require additional personal oral Management of the Rheumatoid 5. Centers for Disease Control and care instruction, dietary in- Arthritis Patient”). However, it Prevention. Prevalence and impact of chronic joint symptoms—seven states, 1996. MMWR struction and modifications, is important to assess the sta- 1998;47:345-51. home/clinical fluoride therapy, tus of the patient’s condition 6. Harris ED Jr. Rheumatoid arthritis: pathophysiology and implications for therapy. home/clinical chlorhexidine carefully, as even mild cases of N Engl J Med 1990;322:1277-89. therapy, treatment for their xe- RA may adversely affect the pa- 7. Lipsky PE. Rheumatoid arthritis. In: Wilson JD, Braunwald E, Isselbacher KJ, et rostomia, more frequent recall tient’s ability to maintain good al., eds. Harrison’s principles of internal visits and radiographs and oral hygiene, especially in pa- medicine. 14th ed. New York: McGraw-Hill; 1998:1880-8. more conservative treatment tients with xerostomia. 8. Myllykangas-Luosujarvi RA, Aho K, plans48 (Table 4). Pilocarpine Associated syndromes may con- Isomaki HA. Mortality in rheumatoid arthri- tis. Semin Arthritis Rheum 1995;25:193-202. hydrochloride (Salagen, MGI tribute to a patient’s suscepti- 9. Pincus T, Brooks RH, Callahan LF. Pharma Inc.) was recently ap- bility to infections and impaired Prediction of long-term mortality in patients with rheumatoid arthritis according to simple proved in the United States for hemostasis. A proper review of questionnaire and joint count measures. Ann treatment of Sjögren’s syn- the patient’s medication history Intern Med 1994;120:26-34. 10. van Leeuwen MA, Westra J, Limburg drome in patients who are expe- will allow for more accurate dif- PC, van Riel PL, van Rijswijk MH. riencing hyposalivation and ferential diagnoses of oral le- Interleukin-6 in relation to other proinflam- matory cytokines, chemotactic activity and have remaining functional sali- sions and will minimize compli- neutrophil activation in rheumatoid synovial vary tissue.55 cations with drug interactions fluid. Ann Rheum Dis 1995;54:33-8. 11. Lorenzo JA. The role of cytokines in the Additional concerns when or overdoses. Practitioners regulation of local bone resorption. Crit Rev treating dental patients with specifically need to be aware of Immunol 1991;11:195-213. 12. Dinarello CA. Biology of interleukin-1. RA are patient comfort and pa- potential adrenal insufficiency FASEB J 1988;2:108-15. tient education. According to in patients receiving long-term 13. Stashenko P, Dewhirst FE, Peros WJ, Kent RL, Ago JM. Synergistic interactions be- the severity of the patient’s RA, glucocorticosteroid therapy. A tween interleukin-1, tumor necrosis factor, certain considerations should be further concern is patients who and lymphotoxin in bone resorption. J Immunol 1987;138:1464-8. addressed. The dentist should have had joint replacement, for 14. Fuchs HA, Kaye JJ, Callahan LF, be conscious of the patient’s whom antibiotic prophylaxis is Nance EP, Pincus T. Evidence of significant radiographic damage in rheumatoid arthritis physical comfort level in the indicated. within the first 2 years of disease. J dental chair: altering the chair’s As with many other chronic Rheumatol 1989;16:585-91. 15. van der Heijde D, van Leeuwen MA, van position, allowing the patient to conditions, early intervention Riel P, van de Putte L. Radiographic progres- shift positions, using pillows can reduce the severity of the sion of radiographs on hands and feet during the first 3 years of rheumatoid arthritis mea- and other such aids, and disease. Thus, dental health- sured according to Sharp’s method (van der scheduling shorter appoint- care workers play an important Heijde modification). J Rheumatol 1995;22:1792-6. ments all should be considered. role in recognizing signs and 16. Pincus T, Callahan LF. What is the nat- Home oral hygiene procedures symptoms of RA and in advising ural history of rheumatoid arthritis? Rheum Dis Clin North Am 1993;19:123-51. may present a challenge to the patients to seek medical care. s 17. Pope R. 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