Rheumatoid arthritis

Definition
Rheumatoid Arthritis (RA) is an autoimmune disease that causes inflammation of the
synovial joints, eventually resulting in destruction of cartilage and bone.[58]
It is a chronic painful condition involving almost all joints, causing erosion of the
joints and the presentation is usually symmetric. It usually involves peripheral joints.
[59]
RA can also affect the temporomandibular joint (TMJ).
The prevalence of TMJ involvement in patients with RA has been reported to range
between 19% and 86%.[60][61]
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. [62]
Patients with RA also demonstrate more alveolar bone loss compared to non-RA
controls .[63]
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.[64]

Signs and symptoms

In the early stages, people with RA may not see redness or swelling in the joints, but
they may experience tenderness and pain.
These symptoms are clues to RA:
 Joint pain, tenderness, swelling or stiffness that lasts for six weeks or longer.
 Morning stiffness that lasts for 30 minutes or longer.
 More than one joint is affected.
 Small joints (wrists, certain joints in the hands and feet) are typically affected
first.
 The same joints on both sides of the body are affected.
Many people with RA get very tired (fatigue) and some may have a low-grade fever.
[65]
Causes
Rheumatoid arthritis is an autoimmune disease.  Normally, the immune system helps
protect the body from infection and disease.  When you have rheumatoid arthritis,
your immune system attacks the healthy tissues in your joints.  This condition can
also cause medical problems with the heart, lungs, nerves, eyes, and skin.

Doctors don't know what triggers this process, but the likely cause seems to be a
genetic component.  Although genes don't actually cause rheumatoid arthritis, they
can make you more likely to respond to environmental factors — such as infection
with certain viruses and bacteria — that may cause the disease.[65]
Risk factors
Factors that may increase your risk of developing rheumatoid arthritis include:

1_Sex :Women are more likely than men to develop rheumatoid arthritis.

2_ age.:Rheumatoid arthritis occurs at any age, but it is common starting in middle

age.

3_Family medical history:  The risk of developing rheumatoid arthritis increases if

someone in your family has it.

4_smoking:Cigarette smoking increases your risk of developing rheumatoid arthritis,

especially if you are genetically predisposed to developing the disease.  Smoking also
appears to be associated with an increased severity of the disease.

5_Overweight:Overweight people appear to be at increased risk of developing

rheumatoid arthritis.[65
Investigations
1. Routine blood investigation
2. Erythrocyte sedimentation rate(ESR),C_Reactive protein(CRP) 3_Rheumatoid
factor
4. ANA is a frequent finding in RA patients
5. Citrulline Antibody tests (done in dreadful cases)
6. Orthopantomogram(OPG)
7. Magnetic resonance imaging(MRI)
8. Computed tomography (CT) scan
9. TMJ Tomogram
10. Arthrography
11. Cone beam computed tomography (CBCT)
Regarding rheumatoid arthritis, there won’t be any
changes in early stage of disease. The findings may vary from
19 - 86 %. In chronic stage or in severe stage there will be
flattening of condylar head, erosion of the joint, reduced joint
space, spiked or pencil head deformity of condyle and in some
cases sub cortical cysts.]66

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.[67]
Diagnosis
Doctors diagnose RA by:
1_Taking a medical history.
2_Performing a physical exam.
3_Ordering laboratory tests.
4_Ordering imaging studies, such as x-rays or ultrasound.
Medical history. The doctor will ask about joint symptoms (pain, tenderness,
stiffness, difficulty moving), when they started, if they come and go, how severe they
are, what actions make them better or worse and whether family members have RA
or another autoimmune disease. 
Physical examination.  The doctor will look for joint tenderness, swelling, warmth
and painful or limited movement, bumps under the skin or a low-grade fever. 
Blood tests. The blood tests look for inflammation and blood proteins (antibodies)
that are linked to RA:
 Erythrocyte sedimentation rate (ESR, or “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.[68]
Differential Diagnosis
Rheumatoid arthritis diagnosis does not depend on specific diagnostic criteria, but
rather in presentation with sufficient history and examination. Usually, a patient with
rheumatoid arthritis will present with swollen, tender joints along with morning
stiffness. Initial investigations will show elevation of ESR and CRP levels, although
this is not specific enough to make a diagnosis. in this phase, other differential
diagnoses can include osteoarthritis, infectious arthritis, reactive arthritis, Lyme
disease, connective tissue diseases, and other possible causes. Differential diagnosis
will further depend on the presence of other signs and symptoms like alopecia, Sicca
syndrome, rash, positive antinuclear antibodies, Raynaud's
phenomenon, elevated muscle enzymes, and/or mouth ulcers. [69]
In 2010, new criteria for diagnosing rheumatoid arthritis were proposed to replace the
American College of Rheumatology (ACR) criteria. These criteria provide more
reliable measures of chronicity and prognosis. It was developed after analyzing the
results of large cohort studies, and requires the presence of at least single joint with
swelling. Thereafter, joints involvement extent will be assessed
by MRI or ultrasound and subsequently classified as active or clinically swollen
joints. RF, ACPA, and other serological markers, duration of symptoms, and the
presence of systemic inflammation manifestations, all also have an effect. This score
is associated with a sensitivity that is 21% higher than the previous one
although less specific [70]
Classification of Rheumatoid Arthritis:
Classification is based on radiographic changes. Larsen classified into 6 grades
1. Normal
2. Slight narrowing of joint space
3. Early abnormality, slight narrowing of joint space, slight erosion
4. Moderate disturbance, joint space eroded and reduced
5. Destruction is severe. Eroded, reduced joint space, deformity is seen
6. Mutilating, disappearance of joint space, bony deformity. [ [71]
Treatment
1_ Medical therapy : The first aim of management is to relieve pain, initially using
conservative measures, which will resolve symptoms in over 80% patients[72]
. These include reassurance; jaw rest with a soft diet; avoidance of wide mouth
opening; physiotherapy; non-steroidal anti-inflammatory drugs (NSAIDs), which can
be prescribed topically; and soft occlusal splints made by the dentist[73].Effective
management of the disease activity with disease-modifying antirheumatic drugs
(DMARDs) and biologics appropriate to the underlying disease is vital.

2_Local anesthetic and steroid injections : Pain emanating from the TMJ can be
confirmed, and temporarily relieved, by infiltration of local anesthetic (lignocaine 1%
or 2%) into the joint space. Resolution of the pain after 10 min establishes an intra-
articular etiology rather than a muscular source. The site of injection is 10 mm along
and 2 mm inferior to a straight line from the tragus to the lateral canthus of the eye .
[74]
Anatomical location of the TMJ joint space for the injection of local anesthetic or steroid (red
circle)

3_Open joint surgery : Prior to the widespread use of arthroscopy and

arthrocentesis, the management of TMJ problems unresponsive to simple treatments
was done using open surgery. Synovectomy is a high-risk procedure due to the close
proximity of the medial joint capsule to the trigeminal nerve branches, terminal
carotid vessels, and internal jugular vein, which complicates complete synovial
removal. In a series of patients from over 20 years ago, it was found that it
successfully treated pain and restricted opening in patients with RA, PA, and AS
affecting the TMJ, but was normally combined with discectomy that probably
accounted for the majority of symptomatic relief[75_77]
4_Total temporomandibular joint replacement surgery : When symptoms return
despite conservative and minimally invasive treatments, the final common pathway
for all destructive, degenerative, and ankylotic TMJ disease is total joint replacement.
[78]
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