Periodontal disease in patients with rheumatoid arthritis in Sub-Saharan Africa: A case-control study

[Clinical and morphological picture of chronic tonsillitis and its pathogenetic relationship with periodontal diseases: literature review]

The article is devoted to the study of chronic tonsillitis from the point of view of the clinical and morphological picture of the disease, histological changes in the palatine tonsils in various forms of CT. The authors raise the question of studying the assessment of the effect of conservative therapy on the morpho-functional state of the palatine tonsils. The article focuses on the study and influence of extratonsillary oropharyngeal loci of focal infection, such as periodontopathies, on the course of chronic inflammation of the palatine tonsils. The association of periodontitis with CT and various somatic diseases has been demonstrated. The necessity of further study of the cause-and-effect relationships of CT and periodontal diseases, as well as a more in-depth study of the morphological picture in CT using immunohistochemical methods of research, which will allow us to develop new principles for the diagnosis and treatment of this disease, is justified.

Periodontitis and rheumatoid arthritis: What have we learned about their connection and their treatment?

Rheumatoid arthritis and periodontitis are chronic inflammatory diseases defined respectively by the destruction of the articular cartilage and tooth-supporting periodontal tissues. Although the epidemiologic evidence for an association between these two diseases is still scarce, there is emerging scientific information linking specific bacterial periodontal pathogens, such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, in the citrullination process, leading to autoantibody formation and compromised immunotolerance of the susceptible patient to rheumatoid arthritis. In this review, we update the existing information on the evidence, not only regarding the epidemiologic association, but also the biologic mechanisms linking these two diseases. Finally, we review information emerging from intervention studies evaluating whether periodontal treatment could influence the initiation and progression of rheumatoid arthritis.

Rheumatic diseases in Africa

Historically, rheumatic diseases have not received much attention in Africa, particularly in sub-Saharan Africa, possibly owing to a focus on the overwhelming incidence of infectious diseases and the decreased life span of the general population in this region. Global attention and support, together with better health policies and planning, have improved outcomes for many infectious diseases; thus, increasing attention is being turned to chronic non-communicable diseases. Rheumatic diseases were previously considered to be rare among Africans but there is now a growing interest in these conditions, particularly as the number of rheumatologists on the continent increases. This interest has resulted in a growing number of publications from Africa on the more commonly encountered rheumatic diseases, as well as case reports of rare diseases. Despite the limited amount of available data, some aspects of the epidemiology, genetics and clinical and laboratory features of rheumatic diseases in African populations are known, as is some detail on the use of therapeutics. Similarities and differences in these conditions can be seen across the multi-ethnic and genetically diverse African continent, and it is hoped that increased awareness of rheumatic diseases in Africa will lead to earlier diagnosis and better outcomes for patients.

The prevalence of rheumatic diseases is increasing in African countries, leading to an increased need for specialist rheumatologists and disease-modifying drugs. In this Review, the authors outline what is currently known about the state of rheumatic diseases in Africa.

In the past, there has been an emphasis on communicable diseases in Africa, but attention has now shifted towards non-communicable diseases such as rheumatic diseases.

Common rheumatic diseases are seen in Africa and are both comparable and different from presentations seen outside of Africa.

Diverse genetic and environmental factors affect the presentation of common rheumatic diseases among different African nations.

A shortage of appropriately trained staff, laboratory testing capacity and effective medications exists across the whole continent.

Advocacy and research are needed to increase awareness of the risk factors, presentations and management of rheumatic diseases in Africa.

Specialized treatment guidelines are needed for resource-poor countries in Africa.

Non-surgical oral hygiene interventions on disease activity of Rheumatoid arthritis patients with periodontitis: A randomized controlled trial

Background. Periodontitis and rheumatoid arthritis have similar epidemiology and pathophysiology. Understanding the interaction between these two diseases is vital in our settings. We set out to assess the effect of oral hygiene interventions on disease activity of rheumatoid arthritis patients with periodontitis in Kampala, Uganda. Methods. Fifty-eight patients attending an arthritis clinic with rheumatoid arthritis and periodontitis were randomly assigned to either an intervention group or a control group. Patients diagnosed with rheumatoid arthritis at least two years before, who were on the same medication, dose, or formulation for RA treatment during the preceding three months, were included. The patients were >18 years of age, would be available for all the study visits in the next six months, had at least six natural teeth, had periodontal disease classified as Dutch Periodontal Index (DPSI) >3 and provided written informed consent. Those who had a chronic disorder requiring chronic or intermittent use of antibiotics, were pregnant, were lactating, or had intent to become pregnant were excluded. The primary outcome measure was a change in Disease Activity Score of 28 Joints (DAS28 score) in two 3-month follow-up periods after the intervention. The secondary outcome measure was a change in periodontal status. Results. There was a statistically significant improvement in the DAS-28 score in both the intervention and control arms during the follow-up period (P<0.01). The participants carrying more than one bacterial species had worse DAS-28 scores. Conclusion. Oral hygiene interventions given to RA patients could drastically improve their RA treatment outcomes, especially in resource-limited settings.

Gums and joints: is there a connection? Part one: epidemiological and clinical links

Rheumatoid arthritis (RA) and chronic periodontitis are common chronic inflammatory diseases that share numerous clinical and pathobiological characteristics. Due to their similarities, despite manifesting at anatomically distinct sites, the relationship between these two diseases has been investigated for many years. This review attempts to summarise the state of the field based on evidence published in the last ten years.

Periodontitis and Rheumatoid Arthritis in sub-Saharan Africa, gaps and way forward: a systematic review and meta-analysis

Background

This review identified papers that described periodontitis and rheumatoid arthritis in sub-Saharan Africa. Only English language publications from January 2010 to December 2017 describing original research in sub-Saharan Africa on the association between periodontitis and rheumatoid arthritis were considered for this study.

Methods

Published databases: PubMed, Science direct and Google scholar, were searched using terms "periodontitis", "rheumatoid arthritis" and "Sub-Saharan Africa" to generate a set of putative studies. Articles with data on both rheumatoid arthritis and periodontitis compared to controls were selected. Studies on the association of periodontitis with cardiovascular disease, arthritis or rheumatoid arthritis alone were excluded. Data were extracted, critically appraised, and analyzed using a random-effect Mantel-Haenszel meta-analysis on plaque index, gingival index, pocket depth and clinical attachment loss.

Results

Three publications were selected for the systematic review and 2 for the meta-analysis. Two studies were from Sudan, and one was from Burina Faso. There was a significant increase in pocket depth (mean difference: 0.31; 95% CI: 0.21, 0.41; N= 274; (p ≤ 0.001) and clinical attachment loss (mean difference: 0.47; 95% CI: 0.22, 0.75; N= 274; (p ≤ 0.001) in participants with rheumatoid arthritis compared to normal controls.

Conclusion

Findings from these combined studies show a significant relationship between periodontal disease and rheumatoid arthritis with increased periodontal pocket depth and clinical attachment loss. They also highlight the need for additional work especially in the area of associating rheumatoid arthritis with P. gingivalis, the oral microbiome and treating periodontal diseases to help in the management of rheumatoid arthritis.

Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions

The association between rheumatoid arthritis (RA) and periodontal disease (PD) has been the focus of numerous investigations driven by their common pathological features. RA is an autoimmune disease characterized by chronic inflammation, the production of anti-citrullinated proteins antibodies (ACPA) leading to synovial joint inflammation and destruction. PD is a chronic inflammatory condition associated with a dysbiotic microbial biofilm affecting the supporting tissues around the teeth leading to the destruction of mineralized and non-mineralized connective tissues. Chronic inflammation associated with both RA and PD is similar in the predominant adaptive immune phenotype, in the imbalance between pro- and anti-inflammatory cytokines and in the role of smoking and genetic background as risk factors. Structural damage that occurs in consequence of chronic inflammation is the ultimate cause of loss of function and disability observed with the progression of RA and PD. Interestingly, the periodontal pathogen Porphyromonas gingivalis has been implicated in the generation of ACPA in RA patients, suggesting a direct biological intersection between PD and RA. However, more studies are warranted to confirm this link, elucidate potential mechanisms involved, and ascertain temporal associations between RA and PD. This review is mainly focused on recent clinical and translational research intends to discuss and provide an overview of the relationship between RA and PD, exploring the similarities in the immune-pathological aspects and the possible mechanisms linking the development and progression of both diseases. In addition, the current available treatments targeting both RA and PD were revised.