Docstoc

RHEUMATOID ARTHRITIS A REVIEW AND SUGGESTED

Document Sample
RHEUMATOID ARTHRITIS A REVIEW AND SUGGESTED Powered By Docstoc
					                                                                                                                                      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. Rheumatoid arthritis: pathogen-
patient with RA because of re-                                                        esis and early recognition. Am J Med
                                       Mr. Treister is a third-year dental student,   1996;100(2A):3S-9S.
duced manual dexterity. To en-        University of Pennsylvania School of Dental       18. Yelin E, Henke C, Epstein W. The work
hance traditional dental hy-          Medicine, Philadelphia.                         dynamics of the person with rheumatoid
                                                                                      arthritis. Arthritis Rheum 1987;30:507-12.
giene practices, floss holders,        Dr. Glick is director, Programs for              19. Gridley G, Klippel JH, Hoover RN,
electric toothbrushes, irrigating     Medically Complex Patients, Department of       Fraumeni JF. Incidence of cancer among men



                                                                                            JADA, Vol. 130, May 1999            697
                            Copyright ©1998-2001 American Dental Association. All rights reserved.
DENTISTRY AND MEDICINE

with the Felty syndrome. Ann Intern Med           1992;21(suppl 3):2-15.                           Temporomandibular degenerative joint dis-
1994;120:35-9.                                      29. Iannuzzi L, Dawson N, Zein N. Does         ease I: Anatomy, pathophysiology, and clini-
  20. Rosenstein ED, Kramer N. Felty’s and        drug therapy slow radiographic deterioration     cal desciption. Oral Surg Oral Med Oral
pseudo-Felty’s syndromes. Semin Arthritis         in rheumatoid arthritis? N Engl J Med            Pathol 1975;40:165-9.
Rheum 1991;21:129-42.                             1983;309:1023-8.                                   39. Goupille P, Fouquet B, Goga D, Cotty P,
  21. Fox RI. Pathogenesis and treatment of         30. American College of Rheumatology Ad        Valat J. The temporomandibular joint in
Sjögren’s syndrome. Curr Opin Rheumatol           Hoc Committee on Clinical Guidelines.            rheumatoid arthritis: correlations between
1997;9:393-9.                                     Guidelines for monitoring drug therapy in        clinical and tomographic features. J Dent
  22. Dugowson CE, Nelson JL, Koepsell TD.        rheumatoid arthritis. Arthritis Rheum            1993;21:141-6.
Evaluation of the 1987 revised criteria for       1996;39:723-31.                                    40. Redlund-Johnell L. Upper airway ob-
rheumatoid arthritis in a cohort of newly di-       31. Kremer JM. The changing face of thera-     struction in patients with rheumatoid arthri-
agnosed female patients. Arthritis Rheum          py for rheumatoid arthritis. Rheum Dis Clin      tis and temporomandibular joint destruction.
1990;33:1042-6.                                   North Am 1995;21:845-52.                         Scand Rheumatol 1988;17:273-9.
  23. Arnett FC, Edworthy SM, Bloch DA, et          32. Morgan SL, Baggott JE, Vaughn WH, et         41. Kaber UR, Gleissner C, Dehne F, Michel
al. The American Rheumatism Association           al. Supplementation with folic acid during       A, Willershausen-Zonnchen B, Bolten WW.
1987 revised criteria for the classification of   methotrexate therapy for rheumatoid arthri-      Risk for periodontal disease in patients with
rheumatoid arthritis. Arthritis Rheum             tis: a double-blind placebo-controlled trial.    longstanding rheumatoid arthritis. Arthritis
1988;31:315-24.                                   Ann Intern Med 1994;121:833-41.                  Rheum 1997;40:2248-51.
  24. Montagna GL, Tirri R, Baruffo A, Preti        33. Weinblatt ME, Kaplan H, Germain BF,          42. Tolo K, Jorkjend L. Serum antibodies
B, Viaggi S. Clinical pattern of pain in          et al. Methotrexate in rheumatoid arthritis: a   and loss of periodontal bone in patients with
rheumatoid arthritis. Clin Exp Rheumatol          five-year prospective multicenter study.         rheumatoid arthritis. J Clin Periodontol
1997;15:481-5.                                    Arthritis Rheum 1994;37:1492-8.                  1990;17:288-91.
  25. Schiff M. Emerging treatments for             34. Wolfe R, Hawley DJ, Cathey MA.               43. Snyderman R, McCarty GA. Analogous
rheumatoid arthritis. Am J Med                    Termination of slow-acting antirheumatic         mechanism of tissue destruction in rheuma-
1997;102(suppl 1A):11S-15S.                       therapy in rheumatoid arthritis: a 14 year       toid arthritis and periodontal research. In:
  26. Blackburn WD. Management of os-             prospective evaluation of 1017 consecutive       Genco RJ, Mergenhagen SE, eds. Host-para-
teoarthritis and rheumatoid arthritis:            starts. J Rheumatol 1990;17:994-1002.            site interaction in periodontal disease.
prospects and possibilities. Am J Med               35. Felson DT, Anderson JJ, Meenan RF.         Washington, D.C.: American Society for
1996;100(suppl 2A):24S-30S.                       The efficacy and toxicity of combination ther-   Microbiology; 1982:354-62.
  27. American College of Rheumatology Ad         apy in rheumatoid arthritis: a meta-analysis.      44. Yavuzyilmaz E, Yamalik N, Calguner M,
Hoc Committee on Clinical Guidelines.             Arthritis Rheum 1994;37:1484-91.                 Ersoy F, Baykara M, Yeniay I. Clinical and
Guidelines for the management of rheuma-            36. Henderson B. Therapeutic modification      immunological characteristics of patients with
toid arthritis. Arthritis Rheum 1996;39:713-      of cytokines. Ann Rheum Dis 1995;54:519-23.      rheumatoid arthritis and periodontal disease.
22.                                                 37. Iacopino AM, Wathen WF.                    J Nihon Univ Sch Dent 1992;34:89-95.
  28. Pincus T. The paradox of effective thera-   Craniomandibular disorders in the geriatric        45. Howell HT. Blocking periodontal disease
pies but poor long term outcome in rheuma-        patient. J Orofac Pain 1993;7:38-52.             progression with anti-inflammatory agents. J
toid arthritis. Semin Arthritis Rheum               38. Kreutziger KL, Mahan PL.                   Periodontol 1993;64:828-33.
                                                                                                     46. Russel SL, Reisine S. Investigation of
                                                                                                   xerostomia in patients with rheumatoid
                                                                                                   arthritis. JADA 1998;129:733-9.
                                                                                                     47. Newbrun E. Current treatment modali-
                                                                                                   ties of oral problems of patients with
                                                                                                   Sjögren’s syndrome: caries prevention. Adv
                                                                                                   Dent Res 1996;10:29-34.
                                                                                                     48. Atkinson J, Fox P. Sjögren’s syndrome:
                                                                                                   oral and dental considerations. JADA
                                                                                                   1993;124:74-86.
                                                                                                     49. Atkinson J, Wu A. Salivary gland dys-
                                                                                                   function: causes, symptoms, treatment. JADA
                                                                                                   1994;125:409-16.
                                                                                                     50. Lehmann T, Day RO, Brooks PM.
                                                                                                   Toxicity of antirheumatic drugs. Med J Aust
                                                                                                   1997;166:378-83.
                                                                                                     51. Bannwarth B, Labat L, Moride Y,
                                                                                                   Schaeverbeke T. Methotrexate in rheumatoid
                                                                                                   arthritis: an update. Drugs 1994;47:25-50.
                                                                                                     52. Glick M. Glucocorticosteroid replace-
                                                                                                   ment therapy: a literature review and sug-
                                                                                                   gested replacement therapy. Oral Surg Oral
                                                                                                   Med Oral Pathol 1989;67:614-20.
                                                                                                     53. American Dental Association, American
                                                                                                   Academy of Orthopaedic Surgeons. Antibiotic
                                                                                                   prophylaxis for dental patients with total
                                                                                                   joint replacements. JADA 1997;128:1004-8.
                                                                                                     54. Tegelberg A, Kopp S. A 3-year follow-up
                                                                                                   of temporomandibular disorders in rheuma-
                                                                                                   toid arthritis and ankylosing spondylitis. Acta
                                                                                                   Odontol Scand 1996;54:14-8.
                                                                                                     55. Fox P, Brennan M, Pillemer S, Radfar
                                                                                                   L, Yamano S, Baum B. Sjögren’s syndrome: a
                                                                                                   model for dental care in the 21st century.
                                                                                                   JADA 1998;129:719-28.
                                                                                                     56. Risheim H, Kjoerheim V, Arneberg P.
                                                                                                   Improvement of oral hygiene in patients with
                                                                                                   rheumatoid arthritis. Scand J Dent Res
                                                                                                   1992;100:172-5.
                                                                                                     57. Dunn EC, Small RE. Leflunomide: an
                                                                                                   immunomodulatory agent for rheumatoid
                                                                                                   arthritis. Formulary 1999;34:21-31.




                              Copyright ©1998-2001 American Dental Association. All rights reserved.