• No.

Is medical consult advised?  

• No, assuming patient/client is already under medical care for osteoarthritis.
• No, assuming patient/client does not have significant temporomandibular joint involvement.

• No, in the absence of possible treatment-related contraindications.

Is medical consult advised? 

• See above.

Is medical clearance required? 

• No, in most circumstances.
• Yes, if clinically significant increased risk of bleeding from the use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) is suspected, which would be unusual.
• Possibly, if patient/client is being treated with medications associated with immunosuppression (i.e., systemic corticosteroids).¹

Is antibiotic prophylaxis required?  

• No, although extended use of systemic corticosteroids may warrant consideration of antibiotic prophylaxis.

Is postponing treatment advised?

• No, assuming ability to open mouth is not excessively compromised by temporomandibular joint involvement.

• Because patients/clients may have multiple joint involvement (e.g., hips and knees) with associated pain, stiffness, and immobility, dental hygiene appointments should be kept as short as possible. The patient/client should be allowed to make frequent position changes as required. The semi-supine chair position may be more comfortable than the supine position. Physical aids, such as a rolled towel or pillow, may be used to provide support for involved joints (including cervical spine) and limbs.   
• Patients/clients with OA often take aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) for pain control, which can increase the risk of bleeding with scaling and root planing. However, the prolonged bleeding is usually not of clinical significance.
• OA in the hands can reduce a patient/client’s ability to perform oral self-care measures, resulting in accumulation of plaque and calculus and increasing risk of periodontal disease and caries.  
• Brushing can be made easier for patients/clients by using an electric toothbrush (which has a larger handle and requires fewer motor skills), enlarging the handle of a standard toothbrush with a bike handlebar grip or tennis ball, or by using large-handled toothbrushes.
• Flossing can be made easier for patients/clients by using floss holders (e.g., U-shaped flossers) as an alternative to dental string.
• In patients/clients with temporomandibular (TMJ) osteoarthritis which results in restricted range of motion and inflammation, dental hygienists should not open the mouth too wide or for too long a period of time, according to the patient’s level of tolerance.
• Treatment of OA of the TMJ includes acetaminophen, aspirin, NSAIDs, muscle relaxants, physical therapy (i.e., heat, ice, ultrasound, controlled exercise), approaches to limit jaw motion, and occlusal splints to reduce joint loading. Rarely, TMJ surgery may be necessary to reduce pain and dysfunction.
• A potential long-term consequence of osteoarthritis is the destruction of joint structures to the extent that joint replacement with synthetic materials may be indicated. Patients/clients with prosthetic joints (most commonly hip and knee in the case of OA) commonly present in dental practice; antibiotic prophylaxis is not routinely indicated to prevent infection of the prosthesis.²

• The temporomandibular joint (TMJ) may be affected by osteoarthritis. While most persons aged older than 40 years show some radiographic and histologic change in the TMJ, most have no symptoms. Occasionally, there may be associated pain.  Typically, this pain is insidious in onset, unilateral and pre-auricular in location, aching in character, and associated with stiffness after a period of inactivity, which then decreases with mild activity. Severe pain may occur with wide opening of the mouth, and such pain occurs with normal function and worsens as the day progresses. There may be adjacent muscle splinting and spasm, in addition to crepitus (i.e., popping or crackling sounds), clicking, or snapping in the TMJ.  
• In most cases, OA pain in the TMJ resolves within a year of onset. X-rays may show decreased joint space, sclerosis, remodelling, and osteophytes. No correlation exists between TMJ symptoms and histologic or radiographic findings. Since the TMJ is not a weight-bearing joint, changes here may be insignificant even though arthropathy may be present in other joints; changes that do occur may result from a disturbed balance of the joint due to loss of teeth or to external injury.
• TMJ disk displacement is associated with OA. About half of such affected patients/clients have reducing anterior disk displacement, which will not progress. The other half is at risk of progression to nonreducing disk displacement or dislocation (i.e., closed lock). These latter patients/clients may experience variable pain and dysfunction, which tend to be self-limiting.  Most patients with TMJ disk displacement, whether reducing or non-reducing, are treated successfully with conservative, reversible therapies.

• Osteoarthritis, the most common form of arthritis, is a localized disease characterized by degeneration of cartilage and underlying bone within a joint, in addition to bony overgrowth. Classically thought of as normal “wear and tear” on joints over time, factors such as pre-existing joint abnormalities, metabolic conditions, genetic predisposition, obesity, intrinsic aging, and macrotrauma or microtrauma are also considered causative or contributory factors to OA.
  
• More than 4 million Canadians live with this progressive, incurable condition, and about 220,000 persons are newly diagnosed annually in Canada.³ Disease onset is gradual and usually begins after 40 years of age, with 70% of people over age 65 years being affected. However, nearly 1/3 of persons with OA report being diagnosed before the age of 45.
• Pain or aching, swelling, stiffness⁴, and decreased range of motion (or flexibility) eventually result from the breakdown of joint tissues. Less frequently, a grating sensation may be felt by the patient/client in the affected joint with movement, and crepitus may be heard.
• OA usually affects weight-bearing joints such as the hips, knees, feet, and spine, (particularly lower back and neck), as well as the hands (particularly ends of fingers and base and ends of thumbs⁵). In contrast to symmetrical (bilateral), polyarticular rheumatoid arthritis, OA, at least in its initial manifestations, is often asymmetrical (unilateral) and monoarticular or pauciarticular.
• Joint pain and disability can lead to poor sleep and fatigue, as well as anxiety and depression.
• Compared with rheumatoid arthritis, OA has a more favourable prognosis and less serious complications, depending on the specific joint(s) involved.⁶
• While most OA is considered primarily non-inflammatory in nature⁷, there is an exception. Inflammatory osteoarthritis typically occurs suddenly in middle-aged women, affecting the distal and proximal interphalangeal joints of the hand.⁸ Its signs/symptoms may mimic those of rheumatoid arthritis of the hand.

• Estee MM, Cicuttini FM, Page MJ et al. Efficacy of corticosteroids for hand osteoarthritis – a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2022;23:665.
  https://doi.org/10.1186/s12891-022-05619-9
• Government of Canada
  https://www.canada.ca/en/public-health/services/publications/diseases-conditions/osteoarthritis.html
• Arthritis Society
  https://arthritis.ca/about-arthritis/arthritis-types-(a-z)/types/osteoarthritis   https://arthritis.ca/about-arthritis/what-is-arthritis/arthritis-facts-and-figures
• Canadian Dental Association Oasis Discussion
  http://oasisdiscussions.ca/2016/01/28/oa-2/ (Osteoarthritis — Implications for Dentistry)
• Canadian Dental Association
  https://www.cda-adc.ca/en/about/position_statements/jointreplacement/
• Canadian Orthopaedic Association
  https://coa-aco.org/wp-content/uploads/2023/03/Consensus_Statement_2016_Patients_with_Total_Joint_Replacements_having_Dental_Procedures-1.pdf
• Centers for Disease Control and Prevention
  https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
• National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health
  http://www.niams.nih.gov/Health_Info/Arthritis/default.asp
• Arthritis Foundation
  https://www.arthritis.org/diseases/osteoarthritis
  https://www.arthritis.org/diseases/more-about/what-is-inflammatory-osteoarthritis
• American College of Rheumatology
  https://rheumatology.org/osteoarthritis-guideline
• Mayo Clinic
  https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925
• The Sports Medicine Review
  https://www.sportsmedreview.com/blog/oral-corticosteroids-for-osteoarthritis/
• Today’s RDH
  https://www.todaysrdh.com/osteo-conditions-overview-and-oral-health-implications/
• Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9^th edition). St. Louis: Elsevier; 2018.
• Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5^th edition). St. Louis: Elsevier; 2020.
• Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8^th edition). St. Louis: Elsevier; 2023.

¹ Oral corticosteroids (as distinct from intra-articular corticosteroid injections) are sometimes used in the management of OA (particularly OA with inflammatory features).
² Most patients/clients with prosthetic joints do not require antibiotic prophylaxis for invasive dental hygiene procedures, as per the 2016 Canadian Orthopaedic Association/Canadian Dental Association/Association of Medical Microbiology and Infectious Disease Canada Consensus Statement.
³ OA is diagnosed via a review of symptoms, signs on physical examination, X-rays of joints, and lab tests (to rule out other causes of arthritis).
⁴ In OA, joint stiffness typically occurs in the morning or after a period of rest, and it usually lasts 30 minutes or less.
⁵ Bony outgrowths on the medial and lateral aspects of the proximal interphalangeal joints of the fingers are called Heberden nodes. When the outgrowths occur on the distal interphalangeal joints, they are called Bouchard nodes.
⁶ OA is usually managed with a combination of therapies, including: increasing physical activity (including low impact exercise); weight loss; physiotherapy to strengthen muscles; medications to decrease pain; supportive devices (e.g., canes, crutches, braces, and orthotics); and surgery (i.e., joint replacement).
⁷ The scientific literature is evolving regarding the pathogenesis and progression of OA. Inflammation is increasingly recognized as playing a role in OA in general.
⁸ Inflammatory osteoarthritis is managed differently than typical OA and rheumatoid arthritis. While usually treated with NSAIDs, inflammatory OA may also, rarely, be treated with corticosteroid injections directly into the affected joints or with oral corticosteroids.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.