Dental Management of Patients with Autoimmune Disorders

1
Dental Management of Patients with Autoimmune
Disorders

• Adrienne J. Yoon, D.D.S.
• November 18, 2004

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Autoimmune Disorders

• Hashimotos Disease
• Rheumatoid Arthritis
• Sjogrens Syndrome
• Systemic Lupus Erythematosus

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Hashimotos Disease

• A chronic inflammatory disease of the thyroid

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Incidence

• Most common cause of primary thyroid deficiencies
  (thyroid burns out)
• Common in women and adolescents
• Familial predisposition

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Laboratory Values

• Assay the free thyroxine (T4) level
• Primary thyroid disease TSH levels are elevated
• Secondary thyroid disease caused by pituitary
  dysfunction and TSH level is normal or borderline

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Medical Management

• Thyroid hormone replacement once in the
  hypothyroid phase

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Dental Management

• Aggressively treat infections
• Avoid thyrotoxic crisis
• Closely monitor vitals
• Stress management

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Rheumatoid Arthritis

• A chronic nonsuppurative inflammatory destruction
  of the joints

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Incidence

• 3 of general population
• Genetic predisposition
• Female to male ratio 31
• Average age of onset of 40 years

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Pathogenesis

• Synovium is transformed into hyperplastic
  chronically inflammed tissue
• Intimal lining increases in size due to local
  proliferation of fibroblast-like cells and
  macrophage-like synoviocytes
• Prominent angiogenesis
• Rheumatoid factor is synthesized in the synovium
  and detected in synovial fluid

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Signs and Symptoms

• Polyarthritis sometimes associated with fever and
  weight loss
• Joint pain
• Generalized fatigue
• Gelling phenomenon
• morning stiffness difficult to
  resume motion

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Extra-Articular Manifestations

• 20 of patients have rheumatoid nodules
• Carpel tunnel sydrome
• Synovial cysts
• Pleuropulmonary disease
• Systemic rheumatoid vasculitis

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Laboratory Values

• High elevation of rheumatoid factor (RF)
• Antinuclear antibody (ANA) detected in about 50
  of patients
• Active phase patients have elevated erythrocyte
  sedimentation rate (ESR)
• Some affected patients have mild anemia

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Medical Management

• NSAIDs
• Glucocorticoids
• Immunosuppression

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Dental Management

• AHA Guidelines
• Short dental appointments
• Assess if aspirin or NSAIDs are affecting
  platelet function

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Sjogrens Syndrome

• Inflammation of the lacrimal and salivary glands

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Incidence

• 0.2-3.0 of population
• More common in females
• 15 of patients with rheumatoid arthritis
• 30 of patients with SLE

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Signs and Symptoms

• Dry mouth, skin, eyes, nose and vagina
• Tongue becomes fissured and exhibits atrophy of
  the papillae
• Oral mucosa red and tender
• Parotid enlargement

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Extra-glandular Signs and Symptoms

• Lymphadenopathy
• Vasculitis
• Interstitial nephritis
• Interstitial lung fibrosis
• Primary biliary cirrhosis (PBC)

• Raynauds phenomenon
• Peripheral neuropathies
• Scleroderma

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Laboratory Values

• High erythrocyte sedimentation rate and serum
  immunoglobulin levels (IgG)
• 75 of patients have RF regardless of rheumatoid
  arthritis
• Antinuclear antibodies (ANA) also present

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Medical Management

• Local manifestations can be treated
  symptomatically

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Dental Management

• Prevention of caries
• daily use of fluoride, frequent recalls
• Enhance salivary output
• sugarless gum/candy, saliva substitutes
  (salivart, biotene, oral balance, mouth kote,
  glandosane, prescription medication (salagen,
  evoxac)
• Treatment of oral candidiasis
• antifungals
• Pain control for enlarged salivary glands

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Systemic Lupus Erythematosus

• A chronic multisystem disease of unknown origin
  that exhibits wide variations in its clinical
  expression and disease course

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Incidence

• Females are affected 8-10 times more than men
• Average age is 31 years

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Signs and Symptoms

• Fever, weight loss, arthritis, fatigue, and
  general malaise
• Butterfly rash on the malar area and nose
• 40-50 of patients have affected kidneys

• Cardiac involvement
• -Libman-sacks endocarditis found in 50 of
  patients upon autopsy
• -pericarditis, myocarditis, endocarditis, CAD
• Oral lesions
• -5-25 of patients have affected palate, buccal
  mucosa, and gingiva

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Laboratory Values

• 95 of patients have elevated ANA
• 70 of patient have antibodies directed against
  double-stranded DNA

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Medical Management

• Avoid excessive exposure to sunlight
• NSAIDS for mild active disease with antimalarial
  drugs
• Topical corticosteroids

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Dental Management

• AHA Guidelines
• Assess adrenal function for possible suppression
• Consult with physician regarding systemic
  manifestation
• Assess if NSAIDS are affecting platelet function