7

MUSCULOSKELETAL
DISEASES
Chris Sproat

Rheumatoid arthritis (RA)

This is a common systemic disease that predominantly affects
the joints, resulting in a severely disabling and symmetrical
polyarthritis.

Epidemiology
RA affects about 1% of the UK population, with a femaleto-male ratio of 3 to 1. In a quarter of patients the temporomandibular joint (TMJ) is affected but this is often
asymptomatic. The cervical spine involvement occurs in
40% of patients.

Aetiology
RA is a chronic inammatory disease with a genetic predisposition the cause of which remains unknown.

Clinical features
These can be divided into two groups:
1. Intra-articular (within the synovial joints) where
there is inammation of the synovium, destruction
of the joint cartilage, soft tissues and adjacent bone.
This leads to impaired movement, deformity (Fig. 7.1),
pain and swelling. The hands and wrists are most
commonly affected. The atlanto-axial joint of the
cervical spine is often affected, which may make
the neck vulnerable to damage during dental
treatment.
2. Extra-articular (systemic features) which includes
rheumatoid nodules, secondary Sjgrens syndrome,
vasculitis, pulmonary brosis, pericarditis and carpal
tunnel syndrome.

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Musculoskeletal diseases

Fig. 7.1 Deformity as a result of RA affecting the hands. Note the

ulnar deviation of the wrist and deformity of the ngers.

Diagnosis
This is made by the presence of at least four out of seven
of the criteria of the American Rhematology Society:
1. Morning stiffness
2. Arthritis in > 3 joint areas
3. Arthritis of the hands
4. Symmetric arthritis
5. Presence of rheumatoid nodules
6. Positive rheumatoid factor
7. Radiographic changes in the hand.

Treatment
The treatment of RA involves a multidisciplinary team
approach involving education, support, medical and
surgical treatment.
Two groups of drugs are used:
1. Anti-inammatory drugs, which give symptomatic
relief, i.e. aspirin, non-steroidal anti-inammatory
drugs (NSAIDs), and COX-2 inhibitors.
2. Disease-modifying anti-rheumatic drugs (DMARDs),
which modify the fundamental pathological process,
i.e. steroids, tumour necrosis factor inhibitors and
immune suppressants.

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Dental treatment patients with RA pose a number of problems for the dental surgeon which are best thought of in
terms of their physical, social and psychological aspects.

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Ankylosing spondylitis

DENTAL RELEVANCE OF RHEUMATOID

ARTHRITIS

Physical
Arthritis-related
Is the neck stable for treatment?
Is the TMJ symptomatically involved?
Haematological
The associated anaemia may lead to glossitis, burning mouth
and angular chelitis
Altered liver function may affect drug metabolism
Drugs
NSAIDs are often prescribed at high doses
Immune suppressants may increase the risk of infection
Aphthous ulceration may occur
Social
Mobility
Access to treatment may be restricted
Domiciliary visits may be required
Disabled facilities may be required
The patient may not be able to hold a conventional
toothbrush
Psychological
Pain, lack of mobility, dry eyes and mouth associated with
Sjgrens syndrome may lead to depression

Other musculoskeletal conditions

Ankylosing spondylitis
This is a form of arthritis in which the sacroiliac joints and
spine become ossied (bamboo spine). It usually manifests in the early twenties and rarely after the age of 35. Its
origin is multifactorial with an increased risk in those
people who are HLA-B27 positive. There is often back pain
and progressive restriction of movement. In about 20% of
cases complete rigidity of the spine and pelvis occurs,
affecting the patients ability to walk and move.

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DENTAL RELEVANCE OF ANKYLOSING

SPONDYLITIS

Spinal deformity may make access for treatment difcult.

Patients may be prescribed NSAIDs for symptomatic relief.

Polymyalgia rheumatica and giant

cell arteritis
These conditions represent the opposite ends of the
spectrum of the same disease, involving granulomatous
inammation. Polymyalgia rheumatica (PMR) commonly
affects the musculature of the pelvic and shoulder girdles,
causing stiffness and pain. In giant cell arteritis there is
granulomatous inammation within the arteries of the
head and neck (Fig. 7.2), leading to headache and scalp
tenderness, most commonly in the temporal region.
Both conditions are more common in the over-60 age
group and there are often systemic features of tiredness,
weight loss and fever. In both conditions the erythrocyte
sedimentation rate (ESR) is often raised.
Headache/stroke
Temporal artery
visible
tender
pulseless

Blindness if
untreated

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Tenderness over
temporal area

Jaw
claudication

Fig. 7.2 Signs and symptoms of giant cell arteritis in the head
and neck.

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Osteoporosis

DENTAL RELEVANCE OF GIANT

CELL ARTERITIS

If untreated giant cell arteritis can lead to irreversible

blindness.
Jaw claudication may indicate the presence of giant cell
arteritis.
Patients with PMR have an increased risk of giant cell
arteritis.

If giant cell arteritis is suspected the patient should be

referred urgently to their general medical practitioner
for investigation and treatment to avoid irreversible
blindness.

Osteoporosis
Osteoporosis is a common condition affecting one in three
women and one in 12 men over the age of 50. There is a
decrease in mineral density of normally mineralised bone
(Fig. 7.3). The whole skeleton is affected with signicant
weakening of the structure leading to fractures of the hip
and wrist. Fractures of the vertebral bodies lead to collapse
of the spine and deformity. Osteoporosis is classied as
primary if no predisposing or causative disease can be
(A)

(B)

Fig. 7.3 Comparison between normal bone (A) and osteoporotic

bone (B). There is decreased bone density in osteoporosis.

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DENTAL RELEVANCE OF OSTEOPOROSIS

There are no signicant dental implications of primary

osteoporosis.
Dental implants may take longer to integrate in osteoporotic
bone.

found or secondary if there is an identiable cause, e.g.

steroid therapy or renal disease. Post-menopausal women
are at the greatest risk and some protection can be offered
by hormone replacement therapy.

Osteoarthritis
This is the most common form of arthritis and is due to
degenerative destruction of the joint cartilage and underlying bone (Fig. 7.4). Unlike rheumatoid arthritis it is
limited to the joints and does not affect other tissues. The
large weight-bearing joints hips and knees are most commonly affected but the hands, feet and spine may also be
involved. Pain after repetitive use is the main symptom
with decreased range of movement in severe cases. In
primary osteoarthritis there is no detectable cause and this
is usually age-related. In secondary osteoarthritis a cause
can be found, e.g. trauma, surgery or obesity.
The main aim of treatment is to reduce pain and restore
function. This often requires regular analgesia and joint
replacement.

DENTAL RELEVANCE OF OSTEOARTHRITIS

Patients may be taking regular NSAIDs so avoid overdose.

Antibiotic prophylaxis for invasive dental procedures in those
with prosthetic joint replacement is controversial.

Pagets disease

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Pagets disease is chronic disease of bone in which there

is disorganised breakdown and reformation of bone
leading to deformity and altered function (Fig. 7.5). The
cause is unknown but may be related to a slow virus infection. About 3% of the population are affected, males and
females are at equal risk and it is rarely diagnosed under

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Pagets disease

Loss of joint
space and
articular
(A)

(B)

Fig. 7.4 Diagrams and radiographs showing the differences

between a normal joint (A) and an osteoarthritic joint (B). Note the
destruction of the joint cartilage and reduced joint space in the
case of osteoarthritis.

the age of 40. There are random phases of bone resorption

and deposition leading to disorganised bone structure.
The affected bones become weakened and susceptible to
fracture. Bony foraminae become narrowed, putting
pressure on the underlying nerves.

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Fig. 7.5 Skull X-ray

showing the classical
features of Pagets
disease with cotton
wool appearance of
the bone.

Symptoms:
Deformity
Bone pain
Headaches
Hearing loss.
Treatment includes calcium supplementation, drugs to
reduce the rate of bone turnover, i.e. bisphosphonates, and
occasionally surgery.

DENTAL RELEVANCE OF PAGETS DISEASE

If the jaw bones are affected there may be:

mobility of the teeth
occlusal derangement
difcult tooth extraction
hypercementosis
osteomyelitis
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increased incidence of facial pain.

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