Rheumatoid Arthritis 1
Rheumatoid Arthritis
Priscilla Garcia, Jennifer Klocki, Reina Ligeralde, and Dorinda Thomas
Riverside Community College
Rheumatoid Arthritis 2
Abstract
A clinician will encounter medically compromised patients on a regular basis. The importance of
medical and dental management must be taken into consideration. Patients that present with
rheumatoid arthritis need to be evaluated and assessed to accommodate their specific oral health
care needs. This paper will address in detail the medically compromised rheumatoid arthritis
patient and the dental and medical management along with treatment planning considerations.
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Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an autoimmune disease of unknown origin that is
characterized by symmetric inflammation of the joints, especially of the hands, feet, and knees
(Little, Falace, Miller, & Rhodus, 2008). The overall understanding of the mechanisms of RA is
constantly evolving through research. The incidence and prevalence, etiology, signs and
symptoms, dental and medical management of the patient, and treatment planning considerations
and modifications will be addressed.
Incidence and Prevalence
The estimates of prevalence range from 1-2% of the population (Little et al., 2008).
Disease onset usually occurs from ages 35-50 years old (Little et al.). Treister and Glick (1999)
stated that fifty percent of people with RA become unable to work within the decade after the
onset of disease. The long-term prognosis for people with an abrupt onset of disease is similar to
that for people with a gradual disease onset (Little et al.). The course and severity of RA is
unpredictable, but the disorder is characterized by remissions and exacerbations (Little et al.).
Etiology
The etiology of RA is unknown, although evidence seems to implicate an
interrelationship of infectious agents, genetics, and autoimmunity (Little et al, 2008.). Women
are affected approximately three times more than men (Little et al.). This implies the
involvement of sex hormones in the sensitivity of the disease. Other possible predisposing
factors include psychosocial stress, education, and socioeconomic status (Little et al.).
Signs and Symptoms
A patient will first experience fatigue and weakness with joint muscle aches, followed by
painful joint swelling of the hands and feet, which begins with several joints and then progresses
Rheumatoid Arthritis 4
to others symmetrically (Little et al., 2008). Joint involvement gradually progresses to
immobility, contractures, subluxation, deviation, and other deformities (Little et al.).
Characteristic features include pain aggravated by movement, generalized stiffness after
inactivity, and morning stiffness lasting longer than one hour (Little et al.). The joints that are
most commonly affected include the fingers, wrists, feet, ankles, knees, elbows, and TMJ in up
to 75% of patients (Little et al.). Extra-articular manifestations may include rheumatoid nodules,
vasculitis, skin ulcers, Sjögren’s syndrome, interstitial lung disease, pericarditis, C-spine
instability, entrapment neuropathies, and ischemic neuropathies (Little et al.).
Dental and Medical Management of Patient
The importance of proper diagnosis, particularly in the early stages, can prevent lifelong
complications (Little et al., 2008). Treatment is palliative as there is no cure for the disease
(Little et al.). Treatment goals are to reduce joint inflammation and swelling, relieve pain and
stiffness, and encourage normal function (Little et al.). This is accomplished by patient
education, rest, exercise, physical therapy, NSAIDs, and other drugs (Little et al.).
Drugs for management of RA have been divided into those used primarily for control of
joint pain and swelling, and those intended to limit joint damage and improve long-term outcome
(Little et al., 2008). NSAIDs inhibit proinflammatory prostaglandins and are used to treat pain,
swelling, and stiffness but have no effect on the disease course or the risk of joint damage (Little
et al.). Aspirin is the most effective and safest drug for patients (Little et al.). Disease-modifying
antirheumatic drugs (DMARDs) are used to control disease and limit joint damage (Little et al.).
Gold compounds, antimalarials used with aspirin or corticosteroids, and immunosuppressive
therapy may be necessary (Little et al.). Surgical management such as arthroplasty,
reconstruction, synovectomy, and total joint replacement is often required (Little et al.).
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The dental hygienist must understand the complications associated with the drugs taken
for RA. Aspirin taken with corticosteroids will prolong bleeding so the hygienist will want to
obtain a bleeding time (Hupp, Williams, & Firriolo, 2006). Patients taking DMARDS will need
white and red blood cell counts because DMARDS suppress bone marrow (Hupp et al.). The
patient taking corticosteroids over an extended period will have immunosuppression (Hupp et
al.). Knowledge of these drugs allows the hygienist to be aware of the patient's needs.
During treatment, the dental hygienist should make an effort to provide comfort for the
patient. Pillows or rolled towels can help support the patient’s limbs (Little et al., 2008). In cases
of TMJ arthritis, a bite block may be helpful. The patient should be allowed to frequently change
positions during the short appointment to aid in comfort (Little et al.).
Treatment Planning Considerations and Modifications
The RA patient has a difficult time doing daily tasks that may seem simple to non-RA
patients. The dental hygienist must customize oral hygiene instruction to correspond with patient
needs. Altering toothbrush handles and oral hygiene aids improves the patient’s oral home-care
and enhances the patient's oral prognosis. Bicycle handle sleeves can be used to improve the RA
patient's reduced grip strength on the toothbrush (Montandon, Pinelli, & Fais, 2006).
Conclusion
RA is a debilitating disease that affects many arenas of the patient's life, including the
patient's oral health care. As a result, the clinician should be aware of medical and dental
modifications necessary to alleviate the difficulties faced by the RA patient. Through evervigilant research into new and innovative techniques, the clinician can better address the needs of
a large and growing segment of the population.
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References
Hupp, J. R., Williams, T. P., & Firriolo, F. J. (2006). Dental Clinical Advisor. St. Louis, MO:
Mosby Elsevier.
Little, J. W., Falace, D. A., Miller, C. S., & Rhodus, N. L. (2008). Dental Management of the
Medically Compromised Patient (7th ed.). St. Louis, MO: Mosby Elsevier.
Montandon, A. A. B., Pinelli, L. A. P., & Fais, L. M. G. (2006, December). Quality of life and
oral hygiene in older people with manual functional limitations. Journal of Dental
Education, 70(12), 1261-1262.
Treister, N., & Glick, M. (1999, May). Rheumatoid arthritis: A review and suggested dental care
considerations. The Journal of the American Dental Association, 130(5), 689-698.