Rheumatoid arthritis

Definition

Rheumatoid arthritis (RA) :is a chronic autoimmune inflammatory  disease with bilateral symmetric
polyarthritis as its most common  feature. In addition, other tissues may be damaged.

The disease starts as a vasculitis of the synovial membrane. It progresses to chronic

inflammation marked by an intense round cell infiltrate & subsequent granulation tissue
formation.
The cells infiltrate then spreads from the articular surfaces to cause an erosion of the
underlying bone.
The TMJ involvement in patient with RA ranges from 40% to 80%

. In the oral cavity, RA can be related to temporomandibular joint disorder (TMJD), which is
the most common orofacial mani- festation, secondary SS, and perhaps periodontal disease
The connection between periodontal disease and RA is not yet fully explained. However, this
elevated periodontal risk may be linked to increased dental plaque, which may occur as a
result of difficulty in brushing the teeth due to disease-related changes in the joints. On the
other hand, both of these can be a consequence of a reduced quantity of salivary secretion
in patients with RA. Periodontal disease is more prevalent in patients with rheumatoid
arthritis and 80–85% of patients with RA suffer from periodontitis, compared with 40% of
non-RA control patients. Patients with RA also demonstrate more alveolar bone loss
compared to non-RA controls.
Pathogenesis
Pathogenesis involves multiple factors, including both genetic and environmental
influences. • Immune cells and soluble inflammatory mediators play a crucial role in
the pathogenesis, although the relative contribution of individual components remains
uncertain. • Proliferation of cells in the synovial layer of the joint, together with
infiltration by various cell populations, as orchestrated by cytokines, chemokines,
growth factors, and hormones, produces a locally invasive pannus that is capable of
invading and ultimately destroying cartilage, bone, and surrounding soft tissues.

Clinical features
1. The TMJ are usually involved bilaterally in RA.
2. limitation of mandibular opening & joint pain. The pain is usually
associated with early, acute phases but is not a common complaint
in later stages.
3. morning stiffness, joint sounds, tenderness, & swelling over the
joint area.
 4. The same symptoms on both sides of the body (such as in both
hands or both knees)
5. Weight loss
6. Fatigue or tiredness
7. Weakness,fever.
Causes
Rheumatoid arthritis is an autoimmune disease. Normally, your
immune system helps protect your body from infection and
disease. In rheumatoid arthritis, your immune system attacks
healthy tissue in your joints. It can also cause medical problems
with your heart, lungs, nerves, eyes and skin.
Risk factors
Factors that may increase your risk of rheumatoid arthritis
include:
1. Your sex:Women are more likely than men to develop
rheumatoid arthritis.
2. Age:Rheumatoid arthritis can occur at any age, but it most
commonly begins in middle age.
3. Family history: If a member of your family has rheumatoid
arthritis, you may have an increased risk of the disease.
4. Smoking:Cigarette smoking increases your risk of
developing rheumatoid arthritis, particularly if you have a
genetic predisposition for developing the disease. Smoking
also appears to be associated with greater disease severity.
5. Excess weight: People who are overweight appear to be at
a somewhat higher risk of developing rheumatoid arthritis.
Investigations
1. Radiographic changes include :narrow joint space
2. Magnetic resonance imaging(MRI) and ultrasound may help
diagnose rheumatoid arthritis in the early stages of the disease.
3. Computerized tomography(CT) scan : show erosions of the
condyle and glenoid fossa that cannot be seen in radiography.
Epidemiology

Prevalence varies from 0.5% to 1.5% of the population and RA affects more women
than men (ratio 3:1)and The age of onset is between 30 and 55 years& RA results in
progressive disability, with nearly half of all patients experiencing significant
functional impairment within 10 years& RA shortens life expectancy by a number of
years in both men and women.

Diagnosis
Doctors diagnose RA by:
 Taking a medical history.
 Performing a physical exam.
 Ordering laboratory tests.
 Ordering imaging studies, such as x-rays or ultrasound.
It can be difficult to diagnose rheumatoid arthritis when it is in the early stages
because:
 The disease develops over time, and only a few symptoms may be present in
the early stages.
 There is no single test for the disease.
 Symptoms differ from person to person.
 Symptoms can be similar to those of other types of arthritis and joint
conditions.
As a result, doctors use a variety of tools to diagnose the disease and to rule out
other conditions.
 “sed rate”) and C-reactive protein (CRP) levels are markers for inflammation.
A high ESR or CRP combined with other clues to RA helps make the diagnosis. 
 Rheumatoid factor (RF) is an antibody found (eventually) in about 80 percent
of people with RA. Antibodies to cyclic citrullinated peptide (CCP) are found
in 60 to 70 percent of people with RA. However, they are also found in
people without RA. 
Imaging tests. RA can cause the ends of the bones within a joint to wear down
(erosions). An X-ray, ultrasound, or MRI (magnetic resonance imaging) scan can look
for erosions. But if they don’t show up on the first tests that could mean RA is in an
early stage and hasn’t damaged bone yet. Imaging results can also show how well
treatment is working.
Treatment :
1 _Conservtive treatment include : A_nonsteroidal anti-inflammatory
drugs can alleviate pain but have no effect on disease progression, soft
diet.
B_Intra articular steroid used in sever symptoms.
2_Conventional disease-modifying or biological antirheumatic drugs are
recommended, ideally within the
first 3 months of diagnosis; therapy should include methotrexate and at
least one other disease-modifying
agent, plus short-term glucocorticoids.
3_A surgical opinion should be sought early on if the patient does not
respond to nonsurgical therapy.

References
1_Allen A, Carville S, McKenna F. Guideline Development Group.
Diagnosis and management of rheumatoid arthritis in adults: sum-
mary of updated NICE guidance. BMJ. 2018;362:k3015. https://
doi.org/10.1136/BMJ.K3015.
2_American College of Rheumatology ad hoc Committee on Clinical Guidelines. Guidelines
for the management of
rheumatoid arthritis. Arthritis Rheum 2002;46:328–46.
3_Äyräväinen L, Leirisalo-Repo M, Kuuliala A, et al. Periodontitis in
early and chronic rheumatoid arthritis: a prospective follow-up
study in Finnish population. BMJ Open. 2017;7:e011916. https://
doi.org/10.1136/bmjopen-2016-011916 Accessed august 8, 2018.
A study demonstarting that periodontitis is more prevelant in
patients with rheumatoid arthritis.
4_Detert J, Pischon N, Burmester GR, Buttgereit F. The association
between rheumatoid arthritis and periodontal disease. Arthritis Res
Ther. 2010;12(5):218. https://doi.org/10.1186/ar3106.
5_Deighton C, O’Mahoney R, Tosh J, Turner C, Rudolf M; Guideline Development Group.
Management of rheumatoid
arthritis: summary of NICE guidance. BMJ 2009;338:710–2.
6_Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van Zeben D, Kerstens PJ,
Hazes JM, Zwinderman AH,
Ronday HK, Han KH, Westedt ML, et al. Clinical and radiographic outcomes of four
different treatment strategies in
patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial.
Arthritis Rheum 2005;52:3381–90.
7_https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html.
8_Mayo Clinic researchers use AI, biomarkers to personalize rheumatoid arthritis treatment.
9_Rheumatoid arthritis finding may lead to new inflammation blockers.
10_Mayo researchers link gut microbiome to rheumatoid arthritis prognosis.
11_https://newsnetwork.mayoclinic.org/?p=327664.
12_Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA,
Kaplan SR, Liang MH, Luthra HS, et
al. The American Rheumatism Association 1987 revised criteria for the classification of
rheumatoid arthritis. Arthritis
Rheum 1988;31:315–24.
13_Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP,
Hirsch R, Hochberg MC, Hunder
GG, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in
the United States. Arthritis
Rheum 1998;41:778–99.
14_https://www.niams.nih.gov/health-topics/rheumatoid-arthritis/diagnosis-treatment-and-
steps-to-take.
15_https://www.arthritis.org/diseases/rheumatoid-arthritis.
16_Sluka KA. Osteoarthritis and rheumatoid arthritis. In: Sluka KA, editor. Mechanisms and
management of pain for the
physical therapist. Seattle: IASP Press; 2009. p. 349–360.
17_Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan
MC, et al. 2015 American College of Rheumatology guideline for the
treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68:1–26.
18_Silman AJ, Hochberg MC. Epidemiol-ogy of the rheumatic diseases. 2 nd ed. Oxford,
England: Oxford Univ. Press; 2001:31-71.