Clinical Scenario

A 59‐year‐old woman presents for an urgent consultation because she is unable to open her mouth and has associated pain. She is accompanied to her appointment by her husband who reports that his wife’s jaw ‘locked open when she was eating lunch’. He reports that this has happened several times in the past but this time the jaw will not go back into place.

Structured Learning

1. Further examination confirms that the patient’s mandible is locked in a protruded position and she has an associated anterior open bite. The temporomandibular joint (TMJ) is tender on palpation. What is the most likely cause of these symptoms?
   • TMJ involvement is found ~50% of patients with RA
   • There may be associated pain, swelling, movement impairment and crepitation
     

     

   • Dislocation of the TMJ resulting in malocclusion of the teeth and an anterior open bite may occur in advanced stages of RA, such as this patient
   • Masticatory effort, particularly with hard, chewy foods, can trigger a TMJ dislocation

2. What are the options to try reposition the patient’s TMJ?
   • Intraoral reduction using the wrist pivot method
   • Intraoral Hippocratic method of reduction (Nélaton manoeuvre)
   • Extraoral reduction
   • If the above are unsuccessful, muscle relaxants, analgesics or even general anaesthesia may be required
   • Aftercare includes initial immobilisation, soft food, analgesics and physiotherapy
3. The patient presents for a further appointment a week later, complaining of intense localised pain in the left canine fossa region, which has prevented her from sleeping all night. Clinical and radiographic findings confirm a diagnosis of acute periapical periodontitis of #22. What treatment option do you consider to be the most appropriate: endodontic treatment or dental extraction?
   • Dental extraction of #22 is advisable
   • The reasons for this are:
     • #22: extensive caries and poor restorability; loss of supporting alvelolar bone
     • Mouth opening is limited and painful
     • Endodontic treatment typically requires longer/more frequent appointment (increasing the risk of TMJ pain/dislocation)
     • The patient cannot tolerate long treatment sessions (fatigue)
     • There are numerous lost teeth, with the imminent loss of others; removable prosthetic rehabilitation may be advisable in the long term
4. Before planning the dental extraction, what laboratory test results would you request and why?
   • A recent full blood count with differential would be useful
   • Anaemia of chronic disease is commonly found in patients with RA
   • Neutropenia and thrombocytopenia may be present as adverse effects of synthetic disease‐modifying antirheumatic drugs (DMARDs) such as methotrexate
5. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Lack of motivation as she only visits the dentist for acute episodes
     • Chronic fatigue and joint pain (may result in irregular attendance and reduced tolerance for dental procedures)
   • Medical
     • RA‐related positional limitations/discomfort on transfer to the dental chair
     • Adverse effects of methotrexate including nausea/vomiting, hepatotoxicity and severe leucopenia (see Chapter 12.2)
     • Adverse effects of corticosteroids (deflazacort) include adrenal insufficiency risk, delayed wound healing or increased susceptibility to infections (see Chapter 12.1)
     • Visual impairment (due to steroid‐induced cataracts and macular degeneration); impaired non‐verbal communication; inability to read and sign consent forms
   • Dental
     • Poor oral health, requiring urgent treatment
     • Limited and painful mouth opening
     • Previous failed dental treatments
     • Prone to periodontal disease
     • Hyposalivation
     • Impaired oral hygiene

6. Why is this patient at increased risk of infection postoperatively?
   • Drug‐induced moderate to severe neutropenia (e.g. methotrexate)
   • If the patient routinely receives corticosteroid doses equivalent to more than 10 mg of prednisone (6 mg deflazacort is equivalent to 5 mg prednisone)
7. What analgesic would you prescribe after the dental extraction?
   • At first, none (only as rescue medication if necessary)
   • The patient already regularly takes tramadol/paracetamol (tramadol is a centrally acting analgesic, included in the second step of the WHO analgesic ladder)
   • The patient is also taking deflazacort, which has an anti‐inflammatory effect
   • The risk of methotrexate’s adverse haematological effects increases with non‐steroidal anti‐inflammatory drugs
     

     

8. What difficulties may be affecting this patient’s ability to maintain her oral hygiene?
   • Limited mouth opening
   • Pain on maximum opening
   • Visual impairment
   • Difficultly holding the toothbrush (RA affecting her hands)
   • Limited manual mobility
   • Hyposalivation