We should endeavor to determine what type of patient has a disease, instead of just what disease the patient has .

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We should endeavor to determine what type of
patient has a disease, instead of just what
disease the patient has .

• Observe, record, tabulate, communicate.

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RHEUMATIC DISEASES

• over 100 different arthritic diseases
• gt 40 million Americans
• gt 8 million disabled
• gt 20 billion annually

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RHEUMATIC DISEASES

• modern gt1800
• not equivalent to arthritis
• chronic degenerative joint diseases
• Female 2.5 x Male
• genetic HLA-DR4
• socioeconomic, education, psychosocial stress

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RHEUMATIC DISEASES

• general characteristics( signs symptoms)
• PAIN
• INFLAMMATION
• musculoskeletal stiffness
• musculoskeletal swelling
• musculoskeletal aches
• musculoskeletal limitations
• disability
• deformity

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RHEUMATIC DISEASES

• Laboratory tests
• increased RF 80 11280 non-Dx
• higher RA poorer Px
• increased ESR
• increased ANA 50
• LE
• IgG
• SSA/SSB

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Rheumatic Fever and Rheumatic Heart Disease

• acute inflammatory condition
• following group A streptococci infection
• autoimmune reaction
• arthralgia
• gt 75 lt 20 y.o.
• 95 of all heart disease in children
• third world 30-40 of all CVD all ages
• U.S. 100,000 cases 6500 deaths per yr.

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RHEUMATOID ARTHRITIS

• chronic, inflammatory, destructive joint disease
• wide range of severity
• ankles, cervical spine, elbows hips, knees,
• proximal interphalangeal joints
• shoulders, tarsals, TMJ, wrists

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RHEUMATOID ARTHRITIS

• MANAGEMENT
• COMPREHENSIVE
• MULTIDISCIPLINARY
• CORTICOSTERIODS
• SYSTEMIC LOCAL INJECTIONS
• PREDNISONE, PREDNISOLONE
• GOLD, ANTI-MALARIAL, PENICILLAMINE
• SULFASALAZINE
• BIOLOGICS- TNFa- antagonists
• IMMUNOSUPPRESSIVES
• IMMURAN, METHOTREXATE

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RHEUMATOID ARTHRITIS

• TMD
• pain, tenderness, stiffness, crepitus,
• swelling, limited mandibular opening
• fibrosis, ankylosis
• bleeding, infection
• neutropenia , thrombocytopenia, anemia
• adrenal suppression

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Osteoarthritis of the TMJ

• degenerative joint disease
• most common intracapsular disorder
• 40 gt 40 y.o. who were ASx
• osteophytes
• steroids ( intra-articular)
• surgery

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Sjögrens syndrome
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Diagnostic criteria for SS(EC)46

• ocular symptoms(13)
• daily dry eye gt3mos
• sand or gravel sens.
• tear substitutes gttid

• ocular signs (12)
• Shirmers test
• (lt5mm/5min)
• Rose Bengal score
• (gt4 - vBs)

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Diagnostic criteria for SS (EC) 46

• oral symptoms (13)
• daily dry gt3 mos.
• swollen glands
• must drink liquids to swallow food

• salivary function (13)
• scintigraphy
• sialography
• WUSF lt1.5ml/15 min. (0.1ml/min.)

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Diagnostic criteria for SS (EC) 46

• labial histology
• focus score / 4mm
• gt50 mononuclear cells

• Autoantibodies
• anti-SS-Ro or
• anti-SS-La

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• Sjögrens syndrome (SS) on a histopathological
  level is a benign lymphosialadenopathy which
  includes autoimmune lymphocytic infiltration of
  the salivary glands. Oral clinical manifestations
  of SS typically include hyposalivation,
  glossitis, mucositis, angular cheilosis, and
  increased caries rate.

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SLE

• renal disease 5-22
• cardiac valvular disease 18-74
• anemia 70
• thrombocytopenia 25
• leukopenia 45
• arthritis 90
• TMD 60

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SLE

• systemic complications
• lab tests CBC, platelets, BUN, creatinine
• leukopenia, steriods, etc. prone to infection
• need for antibiotics ( IE ?)
• adrenal suppression
• bleeding

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Pagets, Osteomyelitis,Osteoporosis, Fibrous
dysplasia

• osteolytic/osteoblastic
• bleeding
• bone deformities tooth loss
• infection
• radiographs
• lab tests
• CBC, Ca, P, alkaline phosphatase
• bone biopsy

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Scleroderma
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SCLERODERMA

• tightened, hard skin face, hands, fingers
• internal organ involvement
• microstomia
• tightened perioral skin
• SGD
• periodontal disease
• painful RAS-type ulcerations

CREST
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TREATMENT

• CORTICOSTEROIDS
• topical
• systemic
• intralesional
• IMMUNOSUPPRESIVE agents
• topical
• systemic
• intralesional

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Corticosteroid use routine dental procedures

• Rxgt2 wks. d/c w/i 30 days Rx previous
• d/c Rx gt 30 days ago none
• topical none
• current Rx( any dose) none
• alt. day Rx tx on that day
• Monitor BP, good anesthesia, post-op analgesia,
  etc.

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Corticosteroid use complex dental procedures

• Rxgt2 wks. d/c w/i 30 days Rx previous
• Rx d/c gt 30 days ago none
• topical none
• current Rx( any dose) double
• alt. day Rx double tx on that day
• Monitor BP, good anesthesia, post-op Rx
  analgesia, etc.

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Dental management

• diagnosis severity
• systemic complications
• musculoskeletal limitations
• pain
• medications anti-inflammatory agents
• oral manifestations
• neutropenia thrombocytopenia anemia
• Infections(LPJI)

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Prevention of late Prosthetic joint infections

• Joint ADA/AAOS guidelines
• 1997

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Late ProstheticJoint Infection
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Late Prosthetic Joint Infections

• Wahls myths
• 1 There are similarities between IE (PVE)
  and LPJI. NO.
• 2 Dental treatment is a probable cause
• of LPJI. NO.
• 3 Animal experiments document dental
  bacteremias as cause of LPJI.
• NO.
• 4 To protect patients DDS should always
  cover patients with PJ.
• NO.

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Late Prosthetic Joint Infections

• infection rate gt 1
• gt70 staph Pallusch
• gt1000 PJ pts., 6 yrs. - no prophylaxis 0
  LPJIs Ainscow
• 4 cases of LPJI cultured no oral
  pathogen Batzokas
• other prosthetic- synthetic implants

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Prevention of late Prosthetic joint infections
1997 changes

• ADA/AAOS advisory statement
• medical consultation with Orthopod
• No prophylaxis for pins, rods, screws, plates,
  wires, implants, etc.
• healthy patient lt 2 yrs. after TJR
• chronic RA or other infection of TJR
• immunocompromised patients

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Prevention of late Prosthetic joint infections
1997 changes

• Immunocompromised patients
• IDDM
• chronic CTD RA, SLE, etc.
• immunosuppressive drugs or irradiation
• hemophilia or other blood dyscrasias
• malnourishment
• HIV

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Late Prosthetic Joint Infections

• Benefits of prophylaxis DO NOT
• necessarily outweigh potential
• risks especially considering
• antimicrobial resistance, costs,
• risk of anaphylaxis, etc.
• Little, Rhodus, et.al. JADA 1991
• . Orthopedic surgeons 90
• recommend antibiotic prophylaxis for dental Tx
• SOBE CAREFUL WHAT YOU ASK FOR !

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Prevention of late Prosthetic joint infections
1997 changes

• Cephalexin ( Keflex) 2g po 1 hr. pre-op
• Cephazolin 1 g IM/IV 1 hr. pre-op
• Clindamycin 600mg. po 1 hr. pre-op

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Thanks!!
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QUIZfold sheet and put your name on back

• I know you do another course evaluation, but this
  is more for my own information in order to
  improve learning
• I will respect your confidentiality and my
  secretary will record your name and after the
  course is complete and the grade submitted, Ill
  review your responses

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QUIZfold sheet and put your name on back

• I liked the format of this course.
• A. true
• B. false

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QUIZ fold sheet and put your name on back

• I learned as much ( or MORE) from the peer
  presentations as I would have from the instructor
• A. true
• B. false

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QUIZ fold sheet and put your name on back

• I learned more from working on my groups
• presentation.
• A. true
• B. false

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QUIZ fold sheet and put your name on back

• The book was very helpful.
• A. true
• B. false

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QUIZ fold sheet and put your name on back

• The group presentations were much better than
  straight lectures.
• A. true
• B. false

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QUIZ

• Please RANK the top three presentations.
• 1
• 2
• 3

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Cases

• Problem-solving process
• GUIDES- when and where to get information
• (look it up !)
• Competencies

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Exam

• 40 objective( MC- TF ?s) form Midterm
• Allergies(5-6), Bleeding (5-6), Thyroid
  (3-4),blood dyscrasias(5-6), pregnancy (4-5),
  Neurological(4-5), HIV(4-5), Behavioral (2-3)
• Open book casejust like those in class
• Do the obj. first then youll get the case
• Friday, Dec. 7 at 730 am
• 130 ONLY !!