Oral health and orofacial function in patients with rheumatoid arthritis

Clinical periodontal diagnosis

Periodontal diseases include pathological conditions elicited by the presence of bacterial biofilms leading to a host response. In the diagnostic process, clinical signs such as bleeding on probing, development of periodontal pockets and gingival recessions, furcation involvement and presence of radiographic bone loss should be assessed prior to periodontal therapy, following active therapy, and during long-term supportive care. In addition, patient-reported outcomes such as increased tooth mobility, migration, and tilting should also be considered. More important to the patient, however, is the fact that assessment of signs of periodontal diseases must be followed by an appropriate treatment plan. Furthermore, it should be realized that clinical and radiographic periodontal diagnosis is based on signs which may not reflect the presence of active disease but rather represent the sequelae of a previous bacterial challenge. Hence, the aim of the present review is to provide a summary of clinical and radiographic diagnostic criteria required to classify patients with periodontal health or disease.

Dental Caries in Adult Patients with Rheumatoid Arthritis-A Systematic Review

Patients suffering from rheumatoid arthritis (RA) are repeatedly affected by oral diseases or complaints, including xerostomia, periodontitis and dental caries. The aim of this systematic review was the evaluation of caries prevalence and/or incidence in patients with RA. Within this review, there is a systematic search of the literature based on PubMed, Web of Science and Scopus. Two independent researchers performed the search in February 2023. The search terms were "dental caries" AND "rheumatoid arthritis". Additionally, a manual search completed the review process. Studies on adult patients (age ≥ 18 years) only suffering from RA were included. Studies had to explicitly report on the prevalence or incidence of dental caries. The respective studies were checked regarding suitability and, if they were eligible, analyzed qualitatively. A quality appraisal was performed for all of the analyzed studies. A total of 336 studies were detected, of which 16 studies met the in- and exclusion criteria. The sample sizes of the clinical investigations ranged between 13 and 1337 participants. Twelve studies evaluated a healthy control group. In 8/12 studies, a significant difference in the prevalence/incidence of caries was found between RA patients and controls. The majority of the studies applied the decayed (DT), missing and filled teeth index (DMFT) for the diagnosis of caries. On average (mean value), 0.8 to 5.79 carious teeth per patient were reported across the studies. There was no information on the stadium, activity or location of caries (e.g., root caries) in any study. Quality appraisal revealed a moderate quality for most studies. In conclusion, caries prevalence was heterogeneous across studies, while a higher caries prevalence was repeatedly reported in RA patients against controls. Further research regarding dental caries in RA appears recommendable; multidisciplinary, patient-centered dental care for patients with RA should be fostered to improve patients' dental health status.

Cranial structure and condylar asymmetry of adult patients with rheumatoid arthritis

OBJECTIVE

The aim of this prospective cross sectional study was to evaluate the cranial structure and condylar asymmetry of adult patients with rheumatoid arthritis (RA) diagnosed after 25 years of age compared to a healthy adult control group.

METHODS

Eighteen adult patients (57.4 ± 11.4 years) with RA were compared with a control group. Cephalometric analysis and the Habets method for the calculation of the condylar asymmetry were used. The main cephalometric data investigated were focused on the diagnosis of hyperdivergent cranial structure (NSL/ML, NL/ML), backwards rotation of the mandible (Fh/ML), short vertical ramus (Ar:Go), steep mandibular plane (ML/Oc).

RESULTS

The cephalometric data considered were not significantly different in the RA vs controls except for the steepness of the occlusal plane (NL/Oc), which was steeper in the patients group (P < 0.02) and the ramus of the mandible which was greater in patients. The asymmetry of the condyles was significant (P < 0.003) and different from the control group, but that of the ramus was not.

CONCLUSIONS

In this study, RA patients diagnosed after 25 years of age did not show a different pattern of growth with respect to the control group. As expected, the condyles showed a difference being asymmetrical in RA patients due to the high turnover of this joint reacting to severe systemic inflammation in conditions of continuous functional work, load and forces. This study follows a previous study with the same research plan conducted on young JIA patients who showed a different pattern of growth of the skull leading to a severe hyperdivergent cranial structure with backward rotation of the mandible; this is mainly due to the insufficient growth of the condylar site exposed to the inflammatory process during development. Unlike JIA patients, this study showed that RA patients follow an individual growth pattern not affected by inflammation, even if they show joint asymmetry.

Association between Rheumatoid Arthritis and Poor Self-Perceived Oral Health in Korean Adults

Background and objective: Rheumatoid arthritis (RA) and oral health problems have been reported as specific disease units; however, this study was conducted to evaluate the association between RA and comprehensive oral health status. Therefore, this study aimed to assess the association between RA and oral health using self-perceived oral health (SPOH) variables that can determine the oral health status in Korean adults using representative national data. Methods: Data from 40,186 selected participants were collected from the Korea National Health and Nutrition Examination Survey (KNHANES) between 2007 and 2018. The prevalence relative risk (PRR) was estimated using Poisson regression analysis to obtain the risk ratio of the SPOH according to RA. Results: The risk of SPOH depending on the RA status was statistically significant (odds ratio [OR] = 1.108, 95% confidence interval [CI] 1.005–1.222). In addition, the risk of SPOH depending on the RA status was higher in the group with diabetes mellitus (DM) (OR = 1.205, 95% CI 0.966–1.503) than in the group without DM (OR = 1.088, 95% CI 0.976–1.214). Conclusions: In this study, a significant association was identified between RA and SPOH. Oral health experts should identify the factors affecting the oral health of patients with RA and provide correct oral health care; however, additional research is needed.

Radiographic changes in the temporomandibular joint related to medication in rheumatic diseases

OBJECTIVES

The purpose of this study was to assess radiographical changes on temporomandibular joint (TMJ) in relation the autoimmune rheumatic diseases and the medicines that treat this diseases with cone beam computed tomography(CBCT).

METHODS

65 people with rheumatoid diseases were included in the study and divided into five subgroups according to drugs they used. Condyle height (CH), anteroposterior dimension (APD), mesiolateral dimension (MLD) and superior joint space (SJS) were measured in order to evaluate mandibular condyle dimensions. Further, were evaluated in terms of osteoarthritic changes such as erosion, flattening, osteophyte and subchondral cyst in the mandibular condyle. TMJ measurements were compared between study-control groups and subgroups by using Student's t-test, Mann-Whitney-U test, one-way analysis of variance (ANOVA) and Kruskal-Wallis test. The association between osteoarthritic features, rheumatoid status was tested by using χ2 test. Observers were blinded to all groups. Cohen κ values (0853-0945) and Spearman's correlation coefficient (0.959-0.997) indicated high interexaminer reliability.

RESULTS

Condylar dimentions were significantly lower in CH and SJS in rheumatic diseases group (p < 0.001), however APD (p = 0,681) and MLD (p = 0,757) was not different significantly. Osteoarthritic changes such as erosion (p < 0.001), flattening (p = 0.005), osteophyte (p = 0.001) and subchondral cyst (p = 0.001) were significantly higher in the patient group. None of the parameters were different significantly according to subgroups determined according to drugs used(p > 0.05).

CONCLUSIONS

Degenerative changes may cause decrease in condyle size and changes in condyle position. It is a process that can continue despite the use of antirheumatic or immunosuppressive drugs. All of these can become the source of possible TMJ problems.

Anti-inflammatory and Hepatoprotective Effects of Quercetin in an Experimental Model of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by inflammation in the joints. Although methotrexate (MX) is the first-line treatment, side effects are common. This study aimed to investigate the effects of quercetin (QT) and/or MX on inflammation and systemic toxicity in a rat model of RA. Male Wistar rats were divided into control (C), RA, QT, MX, and QT + MX groups (n=6). The RA induction consisted of three intra-articular injections of methylated bovine serum albumin (1×/week) in the temporomandibular joint (TMJ). QT (25 mg/kg) and/or MX (0.75 mg) administration occurred by oral gavage daily. We performed mechanical hyperalgesia in TMJ, leukocyte recruitment in synovial fluid, histopathology, and immunohistochemistry (TNF-α, IL-17, and IL-10) in synovial membrane and toxicity parameters. The RA showed a reduction in the nociceptive threshold (p<0.001), increase in leukocyte recruitment in synovial fluid (p<0.001), intense inflammatory infiltrate (p<0.001), and intense immunoexpression of TNF-α, IL-17, and IL-10 in the synovial membrane (p<0.001) compared to C (p<0.001). QT and/or MX therapy reduced inflammatory parameters (p<0.001). However, downregulation of IL-10 was observed only in the groups that received MX (p<0.001). Leukocytosis was seen in RA (p<0.05), but QT and/or MX reversed it (p<0.05). MX was associated with pathological changes in the liver and higher levels of transaminases when compared to the other groups (p<0.05). QT co-administered with MX reversed this hepatotoxicity (p<0.05). There were no alterations in the kidney between the groups (p>0.05). QT has potential to support MX therapy, showing anti-inflammatory and hepatoprotective effects in this model.

Increased Risk of Temporomandibular Joint Disorder in Patients with Rheumatoid Arthritis: A Longitudinal Follow-Up Study

We evaluated the incidence of temporomandibular disorder (TMD) in patients with rheumatoid arthritis (RA) and examined the association between TMD and RA, through longitudinal follow-up. Population data from the Korean National Health Insurance Service-Health Screening Cohort from 2002 to 2015 was used. From 514,866 subjects, 3122 with RA were matched with 12,488 controls in a 1:4 ratio. The crude and adjusted models (for obesity, smoking, alcohol consumption, blood pressure, blood glucose, total cholesterol, and Charlson Comorbidity Index scores) were calculated. Chi-square tests, Kaplan-Meier (KM) analysis, and two-tailed analyses were used for statistical analysis. Stratified Cox proportional hazard models were used to assess the hazard ratios (HR) and 95% confidence intervals (CI) for TMD in the RA group, compared to those in the control group. The adjusted HR for TMD in RA was 2.52 (95% CI = 1.70–3.74), compared to the control group. The results were consistent with the subgroup analyses, according to age and sex, except in men older than 60 years of age. KM analysis showed similar results. Hence, we found that patients with RA have a higher risk of TMD, and should be observed for symptoms of the initial stage of TMD to prevent the risk of aggravation.