The Dilemma

“Mommy, would you come here?” calls my son.

As I trudge into his room, as I seem to do every night after he’s been tucked into bed, I speculate.  If I were a gambler, I’d bet that a joint hurts.  Which will it be tonight?

Sure enough, when I arrive in his room, I hear him declare, “My knee hurts.”  I turn on the light, examine the joint in question, and ask the usual questions:  When did it start hurting? Do you know the cause? Does anything make it better? Does anything make it worse? Does anything else hurt?

Tonight we’re lucky. It’s only one knee.  Nothing out of the ordinary hurts, just the usual stuff.  “The usual stuff” being his ankles and a headache, plus he doesn’t feel good.  Sometimes it’s his back, often it’s both wrists or his heels.  This kid has more aches and pains than his grandmothers.

It’s not stalling tactics; he isn’t trying to stay up later.  It’s almost as if he can keep things in the background while he’s up and running around, but once he settles into bed, the pain starts screaming for attention.

Dejected, I wonder what to do.  Is there really any point in taking him to see our family physician?  I anticipate x-rays of the joint-du-joir, an expense that would yield no diagnosis of the problem.  Next, a blood draw that might or might not show any abnormalities.  Then, I expect some deliberating… is this nothing, or is this ERA… and eventually a referral to a pediatric rheumatologist.  More poking and prodding and time spent.  Eventually we’d get an NSAID prescription.  I’m inclined to skip all the expensive, time-consuming diagnostic process and just give the kid OTC children’s ibuprofen.

Sometimes doctors give a medicine to see if it will help. I can certainly do that on my own without spending a couple thousand dollars.  If the ibu works, problem solved.  If it doesn’t help, then at least that provides more data for when I eventually do take him to the doctor.

Medrol Dosepak

Medrol (methylprednisolone) is a glucocorticoid similar to prednisone.  Available in 2mg, 4mg, 8mg, 16mg, and 32mg tablets, this steroid can be used to treat bursitis, rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, and a variety of other conditions.

A fast-taper methylprednisolone dosepak contains 4mg pills conveniently arranged for easy dosing:  6 pills the first day, 5 pills the second day, and so on, decreasing one pill per day.

medrol pack

At my pharmacy, the cash price for these twenty-one pills is $33 ($1.57 per pill); the cost is obviously in the packaging. The cash price for a bottle of seventy 5mg prednisone pills is only $10 (14 cents per pill).  4mg Medrol equals approximately 5mg prednisone, so this is a fair comparison.

Of course, buying a bottle of pills would require you to be able to count to six so you get the right number of pills the first day. It would also require keeping track of which day you’re on. That’s easier said than done, because any condition that would call for that dose of steroid probably puts clear-thinking on hold.  Nonetheless, a simple piece of paper kept on the kitchen counter with the pill bottle would suffice.  Another option would be to put a portion of the money saved toward a pill box (if you don’t already own one).  If you don’t want a bunch of prednisone left for future tapers, you’d still save money buying prednisone instead of Medrol, and just throw the unused medicine in the trash.

Cost is not the only drawback I find.  It amazes me that something marketed for people who might be having difficulty using their hands is so incredibly difficult to open.  Be aware that if you use this medicine, you might need assistance getting at your pills.

If your doctor ever recommends a Medrol dosepak for a quick steroid taper, it might be worth discussing a more economical and easy to use medicine.

RA and Your Mouth

Imagine a beautiful weekend morning.  The weather is sunny and warm, and with no commitments to go anywhere until after noon, you can stay home and tackle all those outdoor projects that you’ve been wanting to do.  You might change the oil in the car, mow the lawn, weed the garden, or prune the hedge.  After a few hours, your tummy starts growling and you head inside for lunch.

Do you head straight for the refrigerator?  I hope not!  Most of us would wash our hands before touching food.  Even though we’re busy and it takes extra time, we know how important it is to clean our hands first.

Just as it’s important to clean our hands before eating, it’s important to clean our teeth after eating.  The fact that we’re busy is irrelevant.  If we have time to eat, we have time to brush our teeth afterward.  It’s especially important if you have RA.

There have been many studies published about a possible link between RA and gum disease.  The results are by no means conclusive.  Some studies suggest that people with gum disease have a greater likelihood of developing RA.  Other say that those with RA are more likely to develop gum disease.  Peridontists reject the idea that there is a link, claiming selection bias and other errors in the studies that suggest a link between the two.  One alternate-med site goes so far as to claim that RA is caused by dental infection, particularly dental work (root canals, fillings, etc.) that got infected but was never treated.  I would scoff, except that the timeline between my first crown and the onset of my RA symptoms makes me wonder.  It would certainly explain why some people respond so well to antibiotic therapy.

Regardless of how you view the evidence, the consensus seems to be that there are at least two factors involved:

  • RA is a systemic disease, and the immune malfunction that causes joints and organs to be inflamed also causes gum inflammation.
  • People with RA are sometimes in too much pain to properly clean their teeth, which can quickly lead to/worsen gum disease.

People with RA need to be particularly vigilant about dental care.  We need to take three important steps.

Floss at least twice a day.  If swollen, painful hands can’t grasp dental floss or a holder, consider a waterpik.  If flossing hurts and causes your gums to bleed, it is especially important to floss.  Two weeks of careful flossing should eliminate bleeding gums (which does not imply that it’s okay to stop flossing!) — if not, dentists recommend a checkup.

Brush after eating. Every time.  No excuses.  If you have time to eat, you have time to brush.  Brushing right before bedtime is also recommended — especially if you’ve snacked after supper.

When uncontrolled RA makes the toothbrush difficult to hold, it’s possible to pad the handle of a “normal” toothbrush to make it easier to grasp:

  • Slip a bicycle hand grip over the toothbrush handle
  • Stab a hole in a tennis ball, then put it on the end of the toothbrush
  • Shove the toothbrush handle into a wrist- or thumb brace

Another good option is an electric toothbrush; they have larger handles and also brush more effectively.  If you’re no more willing to spend $130 for a toothbrush than I am, there are other options than the pricey model recommended by dentists.  The toothpaste aisle in the grocery store now carries a variety of battery-powered toothbrushes.  Most of them oscillate (not what my dentist recommends), but I found one for $30 that has a rotating head and does not hurt the mouth.

toothbrushesAs you can see from this picture, the handle of this electric toothbrush is significantly larger than the handle of a standard toothbrush.  It is very easy to hold.

Finally, use mouthwash every night.  There are many different kinds.  Some dentists recommend an antibacterial mouthwash.  Also, some dentists recommend that the mouthwash also contain flouride, calcium, and phosphate to help repair tooth enamel.

Sometimes we’re tired and sore, but following these three simple steps is important.  We’d all like to have pearly-white teeth.  There is a bonus.  Many people discover that keeping their teeth scrupulously clean leads to an improvement in RA symptoms.

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Protect Your Dental Health From Symptoms of Rheumatoid Arthritis

Associations between Periodontitis and Systemic Inflammatory Diseases: Response to Treatment.

Don’t Let Disability Keep the Dentist Away

Inter-relationship Between Rheumatoid Arthritis and Periodontitis

Periodontal Systemic Associations: Review of the Evidence