Essay: Association between rheumatoid arthritis and periodontal disease

Introduction
Recently, the association between rheumatoid arthritis (RA) and periodontal disease has been investigated. Reports have shown an increase in prevalence and association between the two when compared to clinically healthy patients. Inflammation is the primary feature that both of these diseases share. There are clinical features of periodontal disease in those with RA, differences in serum antibody levels, and cytokines (Bjorn et. al., 2014)
Clinical similarities between Periodontal Disease and Rheumatoid Arthritis
Patients with RA have a higher prevalence of periodontal disease than patients who do not (Huang, 2017). According to Oral Status and Rheumatoid Arthritis (OSARA), “94% of RA patients also have periodontal disease with 46% of those patients having severe periodontal disease.” Recent studies have shown that periodontal disease can happen before the development of RA, in the earlier stages or even chronic RA. It is significant to acknowledge that periodontal disease can happen at any stage of RA. Therefore, patients should be properly notified about the risk of periodontal disease as well as be educated about how periodontal disease and RA can exacerbate each other.
Periodontal disease and RA have multiple similarities including the influence of pathogens, host response, and immune response (Li, 2017). Both periodontal disease and RA are characterized by chronic inflammation, but they differ in the fact that the etiology of periodontal disease is well established, and the etiology of RA is not well understood. Both diseases result in the destruction of healthy tissue, which in the case this discussion is the synovial membrane of joints for RA and the periodontium for periodontal disease (Billings et. al, 2017). Generally, male patients with RA will likely have higher prevalence to periodontal disease than females. On the other hand, older patients with RA will have a decreased rate with periodontal disease (Huang, 2017). In a clinical aspect, patients who have RA will likely have larger loss of periodontal attachment when compared to a healthy patient. The probing depths in patients with RA were increasingly deeper (Bjorn et. al., 2014).
According to Bartold, P.M., “clinical attachment loss and tooth loss is common finding of patients with RA compared to non-immunocompromised subjects.” Conversely, it was found that patients with RA have been unaffected by particular biologic markers that suppress the inflammatory system (Bjorn et. al., 2014).
There are certain factors that have been studied in an attempt to determine causes for the development of RA. Amongst the factors studied which includes genetic, hormonal, infectious, and environmental, smoking has been linked as a risk factor in the development of RA, as well as periodontitis (Smit et al., 2015).
Pathogenicity
Investigators have discovered additional similarities in the fluid circulation of both diseases. The gingival crevicular fluid circulation was analyzed in recent studies focused on periodontitis. The analysis concluded that there was extensive protein circulation in this fluid, similar to that found in RA. Additional studies elaborate on this idea to describe that the pathogens found in persons afflicted with RA are strongly associated to the bacterial species of those with periodontitis (Billings et. al, 2017). The primary bacteria associated with RA and periodontal disease are P. gingivalis and A. actinomycetemcomitans. Each of these pathogens have strong connections to etiology in periodontal disease, but current research brought to light that these bacteria may contribute to the favorable conditions that allow for the development of RA. Billings and associates state: “P. gingivalis affects citrullination and produces autoantibodies” which in return “has an impact on the development, progression and chronicity of RA” (Billings et. al, 2017). There is a causative relationship with P. gingivalis and periodontitis associated with RA. Anti-citrullinated protein/peptide antibodies (ACPA), are known to be present before RA ever becomes symptomatic (Smit et al., 2015).
P. gingivalis positive patients with periodontal disease have also demonstrated an exacerbated response when compared to healthy patients. In recent studies, it is shown that patients with RA and periodontal disease have immune response to P. gingivalis (Li, 2017). In addition, A. actinomycetemcomitans (A.a) could potentially be the primary oral pathogen with the ability to trigger autoimmunity in RA. A.a has been found to be the “only pathogen able to reproduce the same characteristics of citrullinated antigens in the RA joint and is a potent inducer of cellular hypercitrullination” (Billings et. al, 2017). One of the first important biomarkers that aid in diagnosing RA is the presence of Rheumatoid Factor (RF). RF is an antibody or protein triggered by the involvement of systemic inflammatory diseases and infectious challenges in the body, such as periodontitis (Smit et al., 2015).
Cytokines in Rheumatoid Arthritis and Periodontal Disease
The c-reactive protein (CRP) is a protein found in elevated levels in conditions of inflammation. Studies have determined that it is a marker for inflammation associated with RA and in elevated concentrations of patients with periodontal disease. The rheumatoid factor is an antibody that aids in the diagnosis of RA but has also been found at elevated levels in patients with periodontitis. Another inflammatory cytokine that plays roles in both RA and periodontitis is the tumor necrosis factor (TNF). ‘Interleukin 1B (IL-1B) is the most notable cytokine found in cases of chronic inflammation, such as RA and periodontitis. Research has found a strong correlation of this cytokine between both RA and periodontitis (Bartold et. al, 2013). Neutrophils are the first response to injury or infection in the body. Therefore, when periodontitis is present, there are elevated neutrophil counts in an attempt to fight off infection. They recruit helper T cells like that of T-helper 17 (Th17) cells via chemotaxis. These Th17 cells produce cytokine interleukin-17 (IL-17) which is a proinflammatory. When there is uncontrolled activity from the Th17 cells, this causes obdurate joint inflammation as well as the breakdown of bone in RA (Smit et al., 2015).
Treatment Options for Periodontitis Patients with RA
The generalized aches and pains RA patients deal with during daily life often influences treatment plans and home care routines. Patients with Rheumatoid Arthritis (RA) will need intensified dental care. This will help to decrease the amount of inflammation (Bjorn et. al., 2014), Immunodeficient patients, such as those with rheumatoid arthritis, often exhibit multiple periodontal issues. Treatment is often more complicated and personalized for these patients due to this fact (Holmstrup and Glick, 2002). Pharmaceutical therapies can be used to ease pain, protect joints and ultimately improve the functioning of patients with RA. Medications such as disease-modifying anti-rheumatic drugs (DMARDS) may be administered to reduce pain, swelling and damage to the joints. In addition to these therapies, nonsurgical periodontal therapy may be beneficial for RA patients in order to reduce systemic inflammation. This dental intervention has been found to decrease RA activity through “reducing the amount of inflammatory products, endotoxins, and bacteria in the bloodstream” (Billings et. al, 2017).
Significantly, patients that undergo periodontal treatment will reduce the severity of rheumatoid arthritis (Huang, 2017). Patients with RA will benefit from individualized treatment plans and specific oral hygiene instructions. Patients who are given adequate home care instruction and education were better able to control their RA condition by improving their oral health (Billings et. al, 2017). Along with periodontal therapy, the use of antibiotics like sulfasalazine, tetracycline, minocycline, and levofloxacin will help reduce the amount of periodontal pathogens in patients. These antibiotics were studied and shown to be effective for patients diagnosis with RA that have not shown any effect to anti-rheumatic medication (Li, 2017).
Summary
Understanding the similarities and connections of RA and periodontal disease are important when considering treatment of patients afflicted by both diseases. Research has drawn connections between these diseases through analyzing clinical symptoms, etiology, contributing factors, associated pathogens and therapies. A majority of studies have drawn the conclusion that the presence of periodontal disease may exacerbate rheumatoid arthritis and vise versa. Therefore, patients who have both RA and periodontal disease would benefit greatly from the collaboration of medical professionals and personalized treatment plans.
2019-2-10-1549836334