TMJ or Temporomandibular Joint Pain

Tags

Arthritis, disc, displacement, jaw, JCA, JRA, osteoarthritis, psoriatic, rheumatoid arthritis

Key points to remember here are:

1. The first step here is to make sure there is no dental issues causing the TMJ such as the mandible not lining up with maxilla. It is not unusual for this to develop after dental work.

2. MRI often provide the details needed to make proper diagnosis as to what is causing the pain in TMJ.

3. The causes here vary from trauma with damage to the joint structures to various forms of arthritis including:

– Disc displacement
– Meniscal tear
– Juvenile Idiopathic Arthritis (Juvenile rheumatoid arthritis)
– Rheumatoid arthritis
– Psoriatic arthritis
– Traumatic arthropathy
– Gout

4. Treatment obviously depends on the cause. Early treatment of the underlying disease is the key to avoid damage to TMJ.

5. Aggressive and early treatment of Rheumatoid, Psoriatic, and JIA with new biologics treatments such as Enbrel and Humira has resulted in significant decline of TMJ problems in these patients.

6. Oral Surgeons often deal with TMJ when medical therapy is exhausted.

C-reactive Protein

Tags

Arthritis, ESR, infection, inflammation, Rheumatic

Points to remember here are:

1. High CPR concentration should raise the suspicion for possible infection.

2. CRP, unlike ESR, can change rapidly as condition evolves.

3. Although CPR is very sensitive, it is not very specific. Therefore physical examination of patient is very important.

4. Common uses of CRP are: Infections, Polymyalgia Rheumatica, Rheumatoid Arthritis, Temporal Arteritis, malignancy, vasculitis,

5. Combination of ESR and CRP as well as history and physical examination will enhance the sensitivity and specificity of these tests.

6. Ultimately patients should be treated based on history and physical examination. These tests are not always reliable.

7. Obtaining both ESR and CRP from the beginning and following them serially will help you decide on which one to use for monitoring the disease activity.

Metal-on-metal hip implants

Tags

chromium, cobalt, Diabetes, Hip replacement, immune suppression, metal ion, nickel, obesity, steroids

The seven points to remember about metal-on-metal implants:

1. There are now FDA guidelines regarding these implants.

2. MoM hip systems should not be implanted in those with kidney failure, metal sensitivity to cobalt, chromium, nickel, immune suppressed patients, those on high dose steroids, and women of childbearing age.

3. Potential risks with with metal-on-metal hip implants according to FDA include:
Infection
Loosening
Dislocation
Osteolysis
Bone or device fracture
Elevated metal ion levels in the joint and blood
Transplacental transport of metal ions
Development of local inflammatory reactions and lesions including soft tissue masses and tissue necrosis
Development of potential systemic events related to elevated metal ion levels
Revision surgery
Femoral neck fracture (for hip resurfacing)

4. Those patients at risk for problems with metal-on-metal hip implants according to FDA
include:
Patients with bilateral implants
Patients with resurfacing systems with small femoral heads (44mm or smaller)
Female patients
Patients receiving high doses of corticosteroids
Patients with evidence of renal insufficiency
Patients with suppressed immune systems
Patients with suboptimal alignment of device components
Patients with suspected metal sensitivity (e.g. cobalt, chromium, nickel)
Patients who are severely overweight
Patients with high levels of physical activity.

5. Local symptoms related to MoM implants is as a result of metal particles being released to tissue surrounding the hip implant causing pain, bone and soft tissue damage. As a result patients may develop pain or swelling at or near the hip, a change in walking ability, or a noise from the hip. Other local reaction include:
Hypersensitivity (allergic type reaction)
Loosening
Infection
Osteolysis (bone loss)
Aseptic lymphocytic vasculitis-associated lesions (ALVAL) (histologic reaction in surrounding tissue)
Soft tissue mass (fluid-filled or solid soft tissue mass around the replaced joint that is diagnosed radiologically)
Femoral neck fracture (for resurfacing systems)

6. Systemic reactions to MoM implants has to do with metal ions that were release are moving via blood stream to other organs causing systemic symptoms. These systemic symptoms include:

General hypersensitivity reaction (skin rash)
Cardiomyopathy
Neurological changes including sensory changes (auditory, or visual impairments)
Psychological status change (including depression or cognitive impairment)
Renal function impairment
Thyroid dysfunction (including neck discomfort, fatigue, weight gain or feeling cold).

7. Proper patient selection, correct placement, and implantation are most important in order to avoid problems with metal-on-metal implants.

M. Rezaian, MD

Baclofen

Tags

cerebral palsy, multiple sclerosis, Muscle relaxant, spasm

Seven points to remember about Baclofen.

1. It is used primarily as a muscle relaxant for patients with severe spasm as a result of Multiple Sclerosis, Cerebral Palsy, Dystonia, and Trigeminal Neuralgia.

2. It should not be stopped suddenly as it can cause serious spasms, seizures, hallucination, muscle damage and even death.

3. It can cause significant drowsiness.

4. It does not help patients with stroke.

5. It does not help patients with rheumatic problems.

6. It may help with reflux disease of stomach (GERD).

7. It is being evaluated for treatment of alcohol and drug addiction.

M. Rezaian, MD

MRI examination

Tags

ct scan, imaging, MRI, radiology, X-ray

Seven points to consider about MRI testing:

1. Sixty four percent of patients with no history of back pain had abnormal MRI exam. This simply means just because you see a herniated disc on an MRI, this does not necessarily mean the herniated disc is the cause of the back pain.

2. History and physical exam is the key to decide on the cause of the back pain. Therefore MRI should be interpreted in the context of history and physical exam.

3. A neurological exam by a neurologist not a neurosurgeon would be worthwhile when looking at severe back pain with possibility of surgery.

4. A radiologist who is fellowship trained in MRI would be most qualified to read your MRI exam. Always ask who will be reading your MRI.

5. MRI of hands and feet should be read by a fellowship trained radiologist in MRI as these are difficult to read and requires much experience.

6. X-ray examination should be done before MRI exam as X-rays may reveal enough information that MRI may no longer be necessary.

7. MRI exams are expensive therefore only specialists should be allowed to order these tests.

M. Rezaian, MD

Flexeril

Tags

baclofen, cyclobezaprine, Muscle relaxant, robaxin, skelaxin, soma

7 important points to remember about Flexeril.

1. Start at 1/4 of a pill as it can make you tiered or put you to sleep for a long time at full dose.

2. Take it at supper time so that you will not be tiered when you wake up the next day as Flexeril has a long half life.

3. The dose can be adjusted depending on the tolerance that can develop over time.

4. It is not addictive and goes not cause weight gain.

5. It can be taken to help with sleep in patients with chronic pain. The benefits in these cases are seen over 6 to 12 months. So be patient can give it time.

6. Be careful mixing this with other drugs such as sleeping medications, other muscle relaxants, and pain medications.

7. It can be taken for a long time especially in cases of patients with chronic pain. It does not need monitoring by blood testing.

Humira

Tags

biologics, cimzia, enbrel, orencia, remicade, rituxan, simponi

Seven points to remember about Humira:

1. This should be started early in treatment of inflammatory arthritis as to avoid joint damage.

2. It works significantly better when taken along with Methotrexate.

3. I give my patients antibiotic usually Levaquine or Avalox to keep at home to be taken if they develop an infection. This is to avoid delay in treatment of an infection while on biologics.

4. You should not be taken Humira if you have infection or leg ulcer.

5. You can not have immunization with live vaccines while on Humira.

6. Periodic blood testing is needed as Humira can suppress your white blood cell count or the Platelets.

7. I will choose Humira when there is a history of colitis, psoriasis, or uveitis as Humira can control all these conditions at the same time.

M. Rezaian, MD

Arthroscopy of the knee

Tags

arthroscopy, knee, Meniscal tear, osteoarthritis

Seven points to remember about knee arthroscopy:

1. It is of no value to treat Osteoarthritis and in fact can worsen the arthritis.

2. Meniscal tears are seen in MRI of patients who have no knee pain. Therefore just because one sees a tear on the meniscus in the MRI of the knee does not mean that the tear is actually the cause of the knee pain.

3. You most likely have a tear if your knee has a tendency to give-out. So be very careful not to fall. Hold on to the railings when going up and down the stairs. You may use a knee brace with metal hinges if the knee feels unstable. Cane is used here for stability and help with ambulation.

4. You most likely have a tear if your knee locks frequently. Again be careful and use a cane.

5. If you can tolerate the pain and can get around, there is no need to rush for surgery.

6. I would refer to an orthopedic surgeon if a knee with meniscal tear has recurrent swelling and has to be drained frequently or if the knee locks constantly making it very hard to walk.

7. If in doubt, you can always get a second opinion from a rheumatologist.

Do NSAIDs interfere with antidepressant medications?

Tags

Antidepressant, NSAIDs

A study reported in American journal of psychiatry tries to look at this. Having read the article and the editorial all I can say is this: I do not believe these people know what they are doing. I can not believe how such an article even got published.

Enbrel

Tags

Biologic, cimzia, humira, remicade, simponi

Seven points to remember about Enbrel:

1. This should be started early in treatment of inflammatory arthritis as to avoid joint damage.

2. It works significantly better when taken along with Methotrexate.

3. I give my patients antibiotic usually Levaquine or Avalox to keep at home to be taken if they develop an infection. This is to avoid delay in treatment of an infection while on biologics.

4. You should not be taken Enbrel if you have infection or a leg ulcer. You should call your rheumatologist immediately if you have any sign of infection.

5. You can not have immunization with live vaccines while on Enbrel. You can have flu shot but not the flu mist. You can not have the ” shingles vaccine” because it is a live vaccine

6. Periodic blood testing is needed as Enbrel can suppress your white blood cell count or the Platelets.

7. I ask my patients to increase the interval between their injections if they are doing very well and I do not see evidence for joint damage.

M. Rezaian, MD