Serum antibodies and loss of periodontal bone in patients with rheumatoid arthritis

The oral cavity as a reservoir of bacterial pathogens for focal infections

Dental procedures, but more importantly, oral infections and poor oral health can provoke the introduction of oral microorganisms into the bloodstream or the lymphatic system. The subsequent attachment and multiplication of these bacteria on tissues or organs can lead to focal oral infections. Pathogenic agents may also remain at their primary oral site but the toxins liberated can reach an organ or tissue via the bloodstream and cause metastatic injury. Finally, metastatic inflammation may result from an immunological injury caused by oral bacteria or their soluble products that enter the bloodstream and react with circulating specific antibodies to form macromolecular complexes.

Root canal treatment and general health: a review of the literature

REVIEW

The focal infection theory was prominent in the medical literature during the early 1900s and curtailed the progress of endodontics. This theory proposed that microorganisms, or their toxins, arising from a focus of circumscribed infection within a tissue could disseminate systemically, resulting in the initiation or exacerbation of systemic illness or the damage of a distant tissue site. For example, during the focal infection era rheumatoid arthritis (RA) was identified as having a close relationship with dental health. The theory was eventually discredited because there was only anecdotal evidence to support its claims and few scientifically controlled studies. There has been a renewed interest in the influence that foci of infection within the oral tissues may have on general health. Some current research suggests a possible relationship between dental health and cardiovascular disease and published case reports have cited dental sources as causes for several systemic illnesses. Improved laboratory procedures employing sophisticated molecular biological techniques and enhanced culturing techniques have allowed researchers to confirm that bacteria recovered from the peripheral blood during root canal treatment originated in the root canal. It has been suggested that the bacteraemia, or the associated bacterial endotoxins, subsequent to root canal treatment, may cause potential systemic complications. Further research is required, however, using current sampling and laboratory methods from scientifically controlled population groups to determine if a significant relationship between general health and periradicular infection exists.

Generalized periodontal involvement in a young patient with systemic lupus erythematosus

Inflammation is considered to be a leading cause of morbidity in systemic lupus erythematosus (SLE), yet inflammatory periodontal involvement is rarely encountered. A young lady suffering from active SLE accompanied by severe periodontal loss, manifested by gingival recession of all her teeth, was referred to our clinic for treatment. The association between periodontal involvement and connective tissue diseases is unclear, and the literature dealing with periodontal involvement in patients suffering from Sjogren's syndrome and rheumatoid arthritis is comprised of studies showing both normal and pathological periodontal status. We discuss the possible underlying mechanisms.

Rheumatoid arthritis: a review and suggested dental care considerations

BACKGROUND

Rheumatoid arthritis, or RA, is a chronic multisystem disease of presumed autoimmune etiology. It is estimated that arthritis and other rheumatic conditions affect 42.7 million Americans. Medical complications due to RA and its treatment may affect the provision of oral health care.

METHODS

The authors undertook an extensive review of the English literature relating to RA and dental care. They used primarily MEDLINE searches, which included such key words as "rheumatoid arthritis" and "dental care" and subsequent appropriate subheadings. While the MEDLINE search spanned the years from 1975 to the present, the most recent literature was prioritized. Appropriate medical and dental textbooks were also used. The authors extrapolated information from selected texts based on its relevance to dentistry, oral health and the role of the dental provider in the overall treatment of RA patients.

RESULTS

The authors reviewed nearly 200 articles and seven textbooks. Their determination of the texts' relevance to oral health care was based on content, significance, quality, journal in which articles were published and year of publication. Major features of RA--including its diagnosis, pathophysiology, clinical features and medical treatment--were identified, as well as complications due to treatment modalities and various related oral manifestations and conditions.

CONCLUSIONS

Medical complications due to RA and its treatment can affect oral health care. Oral health care providers need to recognize and identify modifications of dental care based on the medical status of patients with RA. Furthermore, oral health care providers play an important role in the overall care of these patients as it release to early recognition, as well as control of the disease.

CLINICAL IMPLICATIONS

In most patients with RA, the condition will necessitate few or no changes in routine dental care. However, considerations include the patient's ability to maintain adequate oral hygiene, xerostomia and its related complications, the patient's susceptibility to infections, impaired hemostasis, and untoward drug actions and interactions. Patients with RA may require antibiotic prophylaxis owing to joint replacement and/or immune suppression, glucocorticosteroid replacement therapy and modifications in oral hygiene procedures. Intra- and extraoral conditions such as ulcerations, gingival overgrowth, disease-associated periodontitis and temporomandibular pathology also need to be recognized.

Risk for periodontal disease in patients with longstanding rheumatoid arthritis

OBJECTIVE

To quantify periodontal disease in rheumatoid arthritis (RA) patients and controls, and to correlate the degree of destruction from periodontal disease and from RA.

METHODS

Fifty RA patients were matched for age, sex, smoking status, and oral hygiene with 101 controls. Correlations between indices of chronic destruction in periodontal disease (gingival attachment loss) and in RA (Larsen radiographic score) were determined.

RESULTS

Patients with longstanding active RA (mean +/- SD 13 +/- 8 years) who were receiving treatment with disease-modifying antirheumatic drugs (n = 46), corticosteroids (n = 38), or nonsteroidal antiinflammatory drugs (n = 43) had a higher rate of gingival bleeding (increased by 50%), greater probing depth (increased by 26%), greater attachment loss (increased by 173%), and higher number of missing teeth (increased by 29%) compared with controls. No correlation was found between the Larsen radiographic score and gingival attachment.

CONCLUSION

Patients with longstanding active RA have a substantially increased frequency of periodontal disease, including loss of teeth, compared with controls. Antiinflammatory treatment interferes with periodontal disease and might have masked a possible correlation between the indices of chronic destruction in RA and periodontal disease.

Prevalence of periodontal disease in patients with Sjögren's syndrome

The periodontal status of 25 patients with Sjögren's syndrome was compared with that of an age-, sex-, and race-matched healthy controls. Clinical evaluation included determination of number of teeth, decayed/missing/filled surfaces, probing pocket depth, clinical attachment level, plaque index, gingival index, bleeding on probing, and measurement of alveolar bone level (examined with radiography). Results of the study suggest that patients with Sjögren's syndrome have a significantly higher plaque index score (p < 0.005), higher decayed/missing/filled surfaces scores (p < 0.05), increased alveolar bone loss (p < 0.05), deeper clinical attachment level (p < 0.05), and increased cementoenamel junction-alveolar bone crest distance (p < 0.005). Although no significant difference was found in the number of cases of "established periodontitis" between the Sjögren's syndrome and controls, odds ratio analysis suggests that patients with Sjögren's syndrome are at 2.2 times higher risk of having adult periodontitis than healthy controls.

[Oral manifestations in patients with systemic lupus erythematosus]

Forty-six patients with systemic lupus erythematosus underwent thorough dental examination to determine the frequency and severity of oral lesions and periodontal diseases. According to clinical criteria, disease was classified as severe (n = 26) or less severe (n = 20). The overall rate of mucosal involvement in the studied patients was 48%-from 54% in patients with severe disease, 40% in those with less severe disease. Patients with severe disease were found to have a higher rate of tooth loss and an increased rate of gingival inflammation. The severity of periodontal lesions correlated with alterations in the immunoglobulin pattern, particularly with an increase in gamma-immunoglobulins. Thus it is suspected that complex immunodysregulation in combination with immunosuppressive therapy is responsible for the high rate of oral and periodontal lesions in patients with systemic lupus erythematosus.

Periodontal regeneration around natural teeth

1. Evidence is conclusive (Table 2) that periodontal regeneration in humans is possible following the use of bone grafts, guided tissue regeneration procedures, both without and in combination with bone grafts, and root demineralization procedures. 2. Clinically guided tissue regeneration procedures have demonstrated significant positive clinical change beyond that achieved with debridement alone in treating mandibular and maxillary (buccal only) Class II furcations. Similar data exist for intraosseous defects. Evidence suggests that the use of bone grafts or GTR procedures produce equal clinical benefit in treating intraosseous defects. Further research is necessary to evaluate GTR procedures compared to, or combined with, bone grafts in treating intraosseous defects. 3. Although there are some data suggesting hopeful results in Class II furcations, the clinical advantage of procedures combining present regenerative techniques remains to be demonstrated. Additional randomized controlled trials with sufficient power are needed to demonstrate the potential usefulness of these techniques. 4. Outcomes following regenerative attempts remain somewhat variable with differences in results between studies and individual subjects. Some of this variability is likely patient related in terms of compliance with plaque control and maintenance procedures, as well as personal habits; e.g., smoking. Variations in the defects selected for study may also affect predictability of outcomes along with other factors. 5. There is evidence to suggest that present regenerative techniques lead to significant amounts of regeneration at localized sites on specific teeth. However, if complete regeneration is to become a reality, additional stimuli to enhance the regenerative process are likely needed. Perhaps this will be accomplished in the future, with combined procedures that include appropriate polypeptide growth factors or tissue factors to provide additional stimulus.

Serum rheumatoid factor induced by intraperitoneal administration of periodontopathic bacterial lipopolysaccharide in mice

Serum rheumatoid factor (RF) level and peritoneal and splenic CD5+B (B-1) cells in mice were examined after intraperitoneal administration of purified lipopoly-saccharides (LPS) from oral periodontopathic bacteria; Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum and Capnocytophaga ochracea. F. nucleatum and C. ochracea LPS induced higher levels of serum IgM- and IgG-RF, while P. gingivalis LPS showed the least induction. In addition, wet weights of spleen and serum IgM and IgG concentration were markedly increased in F. nucleatum LPS injected group. On the other hand, the proportion of CD5+ B cells to lymphocytes in the peritoneal cavity and spleen did not increase. The reason for this was not clear but conventional B cells (CD5- B cells) might increase more rapidly with splenic enlargement than CD5+ B cells. These results suggested that RF induced by bacterial LPS may modulate immune responses against bacteria and plays an important role for defence and destruction of periodontal tissue.

The significance of bone in periodontal disease

Although the connective tissue attachment represents the key issue in periodontal health or disease and in periodontal therapy, the assessment of alveolar bone changes renders valuable indirect evidence for periodontal stability, progression of disease, or repair mechanisms. In periodontal disease bacterial products trigger host cells to release mediators, which may imbalance the steady state between resorption of bone and apposition of osteoid. Modulation of the hosts prostaglandin or interleukin-I synthesis by drug therapy could support the antimicrobial concept of periodontal therapy. Cross-sectional and long-term assessments of alveolar bone have been used to estimate the progression rate of periodontal disease. Inherent limitations of bone assessments in radiographs have to be considered when drawing conclusions from measurements that represent remodeling in periodontal lesions after therapy. Both bone quantity and quality seem to be of secondary importance with respect to the progression of disease, as well as response to therapy. Other risk factors that affect the microbial ecology and/or the hosts immune system seem to be the primary determinants for the periodontal health status.

Gingival and periodontal health in systemic lupus erythematosus

This study compared the periodontal health of patients with SLE with that of healthy controls. Patients with systemic lupus erythematosus had significantly lower periodontal probing depths compared with healthy controls. It is possible that systemic drugs such as corticosteroids and NSAIDS may be responsible for these reduced probing depths but this study did not reveal a statistically significant effect of drugs. There is thus no evidence for a predisposition to increased periodontal disease in SLE.

Remaining teeth, oral dryness and dental health habits in middle-aged Norwegian rheumatoid arthritis patients

The aim of the study was to assess the effect of rheumatoid arthritis (RA) upon dental health. A questionnaire was mailed to all seropositive rheumatoid arthritis (RA) patients aged 44-56 yr in the files of the two main departments of rheumatology in South Eastern Norway. Data were obtained from 125 patients, constituting 91% of the target group. The number of remaining teeth in these patients was not related to disease duration or physical dysfunction, whereas a relationship to prolonged use of medication for pain relief was indicated. Factors known to affect tooth loss in the general population, such as smoking habits, dental attendance, interdental cleaning habits, previous dental disease, and place of residence were found to be important in RA patients as well. The RA patients from Oslo had a mean number of 25 remaining teeth, which is the same as reported for the general Oslo population at this age. Oral dryness was reported by more than 50% of the RA patients, but was not related to the number of teeth. The conclusion is that serious and long lasting rheumatoid arthritis had little influence on the number of remaining teeth in this middle-aged group of Norwegians.

Immunochemical and structural characterization of the antigenic polysaccharide from Eubacterium saburreum T18

An antigenic surface polysaccharide produced by Eubacterium saburreum strain T18, isolated from human dental plaque, was purified from formamide extract of whole cells. Methylation analysis, Smith degradation, optical rotation data and nuclear magnetic resonance spectra demonstrated that the purified antigen was a homopolysaccharide composed of D-glycero-D-galacto-heptose (Hep.) residues. The structure of the repeating unit in the polysaccharide was: -[----6)-[alpha-Hep.furanosyl-(1----4)]-beta-Hep.pyranosyl- (1----6)-[alpha-Hep.furanosyl-(1----2), alpha-Hep.furanosyl-(1----4)]-beta- Hep.pyranosyl-(1-)4----6)-beta-Hep.pyranosyl-(1----. No heptose residues were acetylated. Immunodiffusion reactions in agar gel suggested that the immunodeterminant of the antigenic polysaccharide was D-glycero-D-galacto-heptofuranosyl residues as branched nonreducing terminals.

Correlated characteristics of the jaws: association between torus mandibularis and marginal alveolar bone height

The factor marginal alveolar bone height and torus mandibularis (TM) were studied in 2 groups of dentate patients more than 20 years of age, altogether 571 individuals. Subgroups possessing TM had the higher prevalence of unimpaired bone height as compared with those without the trait (P less than 0.001). Different environmental factors considered, such as food habits, exposure to infection, oral hygiene habits, bruxism, access to professional dental care, and habits as to seeking dental treatment, did not seem to account for or to have any influence on the observed phenotypic correlation between TM and more favorable bone height. It was therefore suggested that TM and marginal bone seem to be influenced by common pleiotropic genes. It is hypothesized that future disclosure of the loci that regulate the capacity to develop TM at the same time may throw some light on the genetic contribution and mechanisms that tend to make the marginal alveolar bone more resistant to destructive agents.

Humoral immunity of older adults with periodontal disease to Porphyromonas gingivalis

The effect of age on the humoral response to Porphyromonas gingivalis was assessed in groups of adults (25 to 54 years and 55 to 74 years) with periodontal disease and compared with that in age-matched healthy controls. To determine whether there was an antibody response against P. gingivalis, we measured serum antibodies against whole cells of P. gingivalis 381, A7A1-28, and W50. In addition, antibody levels against purified P. gingivalis outer membrane proteins (i.e., the 43-kDa fimbrial protein and a 75-kDa protein) were also evaluated. Elderly subjects showed the same response to P. gingivalis as younger subjects. Immunoglobulin G (IgG) antibodies to both purified proteins were also elevated in both diseased groups as compared with the normal groups. Total serum IgG, IgA, and IgM levels were also determined by an enzyme-linked immunosorbent assay for all four groups. Total serum IgG levels were elevated in older adults with periodontitis and total IgA levels were elevated in both groups of older adults compared with the younger groups of similar disease status. Total serum IgM levels were comparable for the four groups. Antinuclear antibody titers were assessed in the two groups of older adults and were also found to be higher for the group with periodontitis. These studies show that older adults as well as younger adults have markedly elevated specific antibodies of the IgG and IgA classes to antigens of P. gingivalis, a putative pathogen in both groups. Furthermore, older adults with periodontitis have significantly elevated levels of total serum IgG which may possibly be related to higher levels of autoantibodies.

Periodontal disease mechanisms in immunocompromised patients

Deficiency in the number and function of phagocytes is associated with gingival inflammation and periodontitis. A hereditary deficiency in membrane glycoproteins involved in granulocyte adherence causes impaired chemotaxis, reduced phagocytosis and periodontal problems. Virus infections of antigen-presenting cells interfere with immune responses and lead to seriously increased susceptibility to infections with bacteria which cause no problems in normal patients. Increased levels of IgG antibodies may limit penetration of antigens in the tissues, but at the cost of local inflammation and tissue injury. Mucosal inflammatory disease with increased local formation of IgG is more frequent in IgA deficient patients. The immunological homeostasis depends on a balance between the respective classes and subclasses of antibodies. Deficiencies in the IgA system may contribute to a disturbed balance of the humoral immune response to critical antigens from oral bacteria. A disproportional increase in IgG1 and IgG3 antibodies may persistently activate complement, stimulate the inflammatory activity and cause tissue injury.

Some predictors of radiographic alveolar bone height reduction over 6 years

The present study was undertaken to 1) develop a model to predict the proportion of sites with alveolar bone height reduction over 6 years by means of a few factors, 2) build a second model to predict the initial values of the dependent variable, and 3) describe the relationship between initial bone loss and the bone loss over 6 yr with age. 142 subjects (18-67 yr) were examined radiographically at baseline and 6 yr later using a standardized method. For each subject, the proportion of sites depicting significant alveolar bone height reduction during the study was assessed. Explanatory variables were: presence of initial bone loss, local plaque retaining factors, age, sex, number of missing teeth at baseline and rheumatoid arthritis. Employing multiple regression analysis, the combined effect of initial bone loss, plaque retaining factors, age and rheumatoid arthritis provided the best model suited to predict the proportion of sites undergoing bone loss over time. However, age, plaque retaining factors and number of missing teeth were the best predictors of initial bone loss. A logistic regression model was then used to study the significance of these predictors at the site level. This model indicated that alveolar bone loss over time at a given site is related mainly to presence of local factors and initial bone loss at that site as compared to the effect of other sites with local factors and initial bone loss in the subject. Age demonstrated a linear relationship with initial bone loss and a curvilinear relationship to periodontal disease progression.(ABSTRACT TRUNCATED AT 250 WORDS)