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1. The Musculoskeletal System
1.1. Monoarticular Arthritis
Pain involving the small joints of the hands and feet can sometimes be more sharply localized than the larger joints. When only one joint is affected, it is referred to as monoarticular arthritis.
1.2. Rheumatic Fever
Rheumatic Fever (RF) is a nonsuppurative acute inflammatory complication of Group A beta hemolytic streptococcal infection. It may manifest itself with any of the following conditions:
- arthritis (swollen, painful, tender joints);
- carditis (inflammation of any of the three layers of the heart-endocardium, myocardium, pericardium);
- chorea (involuntary jerky movements involving any part of the body);
- erythema marginatum (a serpiginous, doughnut-shaped, fast-disappearing rash); or
- subcutaneous nodules (painless nodules on the shins and around joints).
Arthritis, carditis, chorea, erythema marginatum and subcutaneous nodules are referred to as the Major Jones Criteria.
The arthritis in rheumatic fever has a migratory pattern of spread—the pain and inflammation affecting one set of joints and when their inflammation subsides, it results in the migration of the inflammation and pain to another set of joints. Fever, arthralgia, elevated WBC count, increased C-reactive protein, elevated ESR, positive ASLO (anti-streptolysin O titer), EKG changes, etc., constitute the Minor Jones Criteria.
To make a diagnosis of rheumatic fever one has to have two major criteria or one major plus two minor criteria. Patients with a history of RF with RHD need premedication prior to dental treatment.
1.3. Rheumatoid Arthritis
Rheumatoid arthritis (RA) is thought to be an immunologically mediated or connective tissue disease. Joint pain and damage are the most prominent features. Rheumatoid arthritis shows a progressive or additive pattern and is typically symmetrical. The patient frequently complains of bilateral stiffness of the small and large joints on waking up in the morning. Patients also state that the pain decreases as the day progresses. RA affects middle-aged females most frequently. RA is often associated with Raynaud’s phenomenon (white, painful, cold fingers and toes), anemia and a lowered platelet count on CBC. Joint pain and deformity are the most prominent features as the disease progresses.. The knuckles, proximal interphalyngeal joints, TMJ and cervical vertebrae are frequently affected.
Generalized symptoms like fever, chills, anorexia, weight loss, fatigue and weakness are often associated with rheumatoid arthritis and the other inflammatory arthritides.
Gout can also affect the joints. It is an inborn error of metabolism which causes an elevation of serum levels of uric acid and deposition of urates, especially in the joints. Unusually severe and rapidly progressing pain in a swollen joint is suggestive of gouty arthritis. Large toe arthritis is a very common complaint. Males are frequently affected.
1.5. Other Causes of Arthritis
Other causes of arthritis are:
• Systemic lupus erythematosus (SLE)—often associated with a butterfly skin rash on the cheeks; headaches, depression, anemia, thrombocytopenia, etc. Females are frequently affected.
• Osteoarthritis—a degenerative arthritis. Pain, stiffness and progressive deformity of one or more of the larger joints is a typical feature. Often joints are affected unilaterally. Pain is most pronounced at night. Very commonly affects the elderly. Unlike rheumatoid arthritis, there are no systemic symptoms nor any blood picture changes.
1.6. Establish a History
When patients come into the dental office, establish a history of joint pain/stiffness with or without muscle fatigue. Also determine:
- Which joints are affected? (See if joint involvement is unilateral/bilateral)
- Is the pain more in the morning or at night?
- Is there improvement as the day progresses?
- Does the patient have cold, clammy fingers and toes along with the joint pains?
- Rheumatoid arthritis, osteoarthritis, gout, SLE are some of the more common conditions associated with joint involvement.