Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis

Systemic Factors Affecting Prognosis and Outcomes in Periodontal Disease

This review delves into the effects of autoimmune conditions like rheumatoid arthritis, inflammatory disorders such as irritable bowel syndrome, cardiovascular disease, diabetes, infectious ailments like human immunodeficiency virus, and their medications on periodontal therapy outcomes. It also explores the influence of hormones. Understanding these systemic factors is crucial for optimizing periodontal health and treatment efficacy. The review underscores the necessity of considering these variables in periodontal care. Other vital systemic factors are addressed elsewhere in this special edition.

Correlation between rheumatoid arthritis and chronic periodontitis: a systematic review and meta-analysis

INTRODUCTION

The aim of this article is to summarize, compare, and assess possible association in individuals with or without rheumatoid arthritis (RA) for periodontitis.

EVIDENCE ACQUISITION

Three study repositories were searched for quantitative studies examining the relationship between periodontal disease and rheumatoid arthritis between 2000 and December 2022. Quality was evaluated using the Newcastle Ottawa Scale (NOS). The standardized mean difference (SMD), with a random effect model and a P value of 0.05 as the significance level, was utilized as a summary statistic measure.

EVIDENCE SYNTHESIS

Fourteen papers were included in the descriptive synthesis. Thirteen were qualified for meta-analysis. Our findings suggest a link between the two conditions in terms of clinical attachment levels (CAL), tooth loss, Plaque Index, and probing depth. The estimated SMD for CAL was found to be 0.68 (95% CI: 0.15-1.21) (P<0.01). For tooth loss, the forest plot analysis revealed an SMD of 1.62 (95% CI: 0.48-2.76) (P=0.005). Similarly, for pocket depth, the SMD was 0.53; CI: 0.07-0.99 (P>0.05). The pooled estimates for plaque index were 0.29; CI: 0.03-0.61 (P>0.05). The funnel plot showed a symmetric distribution with the absence of systematic heterogeneity.

CONCLUSIONS

Although our data suggest a link between periodontal disease and rheumatoid arthritis, larger population-based investigations are needed to validate this connection. Case-control studies must pave the way to more rigorous investigations with well-defined populations and clinical outcomes as primary outcome measures.

The relationship between periodontal disease and cancer: Insights from a Systematic Literature Network Analysis

This paper investigates the relationship between periodontal disease and various cancer types. It provides a comprehensive overview of the existing knowledge about the interaction between periodontal disease and carcinogenesis, explores the underlying biological mechanisms of this connection, and consider the impact of these findings on healthcare practices and future research directions. Utilizing Systematic Literature Network Analysis, which combines bibliometric analysis with Systematic Literature Review, this study analyzes 164 documents from 2000 to 2023. Focus is placed on the 38 most globally cited papers, enabling a targeted and comprehensive analysis of the predominant research within this scope. This review highlights that colorectal, oral, pancreatic, lung, and gastrointestinal cancers have consistent associations with periodontal disease. On the other hand, hematological, breast and prostate cancers show associations with periodontal disease, but these links are less pronounced and more variable, indicating the need for targeted research in these domains. These insights emphasize the necessity for a multidisciplinary healthcare approach, recognizing the systemic implications of periodontal disease.

Impact of treatment of rheumatoid arthritis on periodontal disease: A review

BACKGROUND

Numerous studies support a bidirectional association between rheumatoid arthritis (RA), a chronic autoimmune degenerative inflammatory joint disease, and periodontitis, a chronic inflammatory disease caused by the immune reaction to bacteria organized in biofilms. RA and periodontitis are both multifactorial chronic inflammatory diseases that share common modifiable and non-modifiable risk factors. There is no cure for RA; treatment is based on lifestyle modifications and a variety of medications: nonsteroidal anti-inflammatory drugs (NSAID), glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs, e.g., conventional synthetic DMARDs [csDMARDs]; biological DMARDs [bDMARD] and targeted synthetic DMARDs). There are molecular pathways of inflammation that are common to both RA and periodontitis. Thus, there is a potential effect of RA treatments on periodontitis. This systematic review aims to assess the impact of antirheumatic agents on periodontal conditions of patients suffering from both RA and periodontitis.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase online databases were systematically explored, and a manual search was performed to identify relevant studies published until January 2023. This review is registered in the PROSPERO database (CRD42023409006).

RESULTS

A total of 2827 articles were identified, and 35 fulfilled the inclusion criteria. The included studies generally show a consensus that, at normal dosage, NSAID and corticosteroids have negligible impact on periodontium. Similarly, csDMARD alone or in combination with other csDMARD demonstrated no adverse effect on periodontium. Monotherapy with bDMARD had a positive effect on periodontal pocket depths and gingival inflammation in the longitudinal studies up to 6 months but showed negligible effect on the periodontium in interventional studies with a longer follow-up (9 months and 15.1 months). However, the combination of tumor necrosis factor (TNF)-α inhibitors + methotrexate (MTX) was associated with a rise in gingival inflammation. Due to the considerable heterogeneity of the study designs, a meta-analysis could not reasonably be performed.

CONCLUSION

Within the limitations of the available studies, there is evidence to suggest that bDMARD monotherapy may improve the periodontal condition of RA patients with periodontal disease to a certain extent; the concomitant medication of TNF inhibitor + MTX could worsen gingival inflammation. More data are required to understand the impact of RA therapies on periodontal health.

Periodontal host-modulation therapy with avocado/soybean unsaponifiables in rats with arthritis

BACKGROUND

The aim of this study was to evaluate the effect of the avocado/soybean unsaponifiables (ASU) in the treatment of induced periodontitis in rats with experimental arthritis.

METHODS

Sixty rats were randomly assigned to 4 groups according to the type of treatment and the systemic condition of the animals: CTR-S: healthy animals in which saline solution (SS) was administered; ASU-S: healthy animals in which ASU (0.6 mg/kg) was administered; AR/ASU-S: animals with induced arthritis in which ASU was administered; AR-S: animals with induced arthritis in which SS was administered. Periodontitis was induced by ligatures, maintained for 15 days. Subsequently, the treatment was performed by scaling with hand instruments. The SS and ASU were administered daily by gavage until euthanasia of the animals that occurred at 7, 15 or 30 days after the scaling procedure (N.=5 animals/group). Bone resorption, inflammatory infiltrate composition, and osteoclastogenesis were assessed.

RESULTS

The AR-S group had greater bone loss, smaller amounts of fibroblasts and larger amounts of inflammatory cells than all other groups. In addition, the AR-S group had greater osteoclastogenesis in relation to the healthy animal groups.

CONCLUSIONS

The use of ASU improved the healing pattern after treatment for experimental periodontitis in animals with arthritis reducing the periodontal bone loss.

Gut microbial dysbiosis and inflammation: Impact on periodontal health

Periodontitis is widely acknowledged as the most prevalent type of oral inflammation, arising from the dynamic interplay between oral pathogens and the host's immune responses. It is also recognized as a contributing factor to various systemic diseases. Dysbiosis of the oral microbiota can significantly alter the composition and diversity of the gut microbiota. Researchers have delved into the links between periodontitis and systemic diseases through the "oral-gut" axis. However, whether the associations between periodontitis and the gut microbiota are simply correlative or driven by causative mechanistic interactions remains uncertain. This review investigates how dysbiosis of the gut microbiota impacts periodontitis, drawing on existing preclinical and clinical data. This study highlights potential mechanisms of this interaction, including alterations in subgingival microbiota, oral mucosal barrier function, neutrophil activity, and abnormal T-cell recycling, and offers new perspectives for managing periodontitis, especially in cases linked to systemic diseases.

Exploring the Bidirectional Relationship Between Periodontitis and Rheumatoid Arthritis in a Large Danish Cohort

OBJECTIVE

We investigated the bidirectional relationship between rheumatoid arthritis (RA) and periodontitis and their cross-sectional association using national administrative health care data.

METHODS

The sample included 3,308,903 individuals aged 20 to 79 years who resided in Denmark in 2000 and had remained free of RA and periodontitis in the previous 10 years. RA and periodontitis were defined using diagnosis and treatment codes. Marginal structural survival models were employed to estimate the effects of RA on periodontitis incidence and vice versa from 2000 to 2017. Using a cross-sectional sample of 2,574,536 individuals from 2017, the association of periodontitis with RA was investigated using regression analyses and probabilistic quantitative bias analyses, simulating RA and periodontitis misclassification and unmeasured confounding of smoking.

RESULTS

Between 2000 and 2017, 20,348 individuals developed RA and 740,799 developed periodontitis. The estimated hazard ratio (HR) for the effect of periodontitis on incident RA was 1.05 (95% confidence interval [CI] 0.88-1.25), resulting in a restricted mean survival time difference of one day. The HR for the effect of RA on incident periodontitis was 0.84 (95% CI 0.80-0.88), corresponding to a restricted mean survival time difference of 151 days. Cross-sectionally, the unadjusted prevalence ratio for the association was 1.15 (95% CI 1.11-1.19), whereas the estimate adjusted for measured and simulated confounding was practically null (0.99, 95% simulation interval 0.93-1.04).

CONCLUSION

These findings challenge previously reported bidirectional relationships between periodontitis and RA, pointing to potential residual confounding as an important link and prompting reconsideration of the biologic plausibility and clinical significance of these associations.

Exploring the causal relationships between rheumatoid arthritis and oral phenotypes: a genetic correlation and Mendelian randomization study

Background

Rheumatoid arthritis (RA) frequently presents with oral manifestations, including gingival inflammation, loose teeth, and mouth ulcers; however, the causal connections between these conditions remain unclear. This study aims to explore the genetic correlations and causal relationships between RA and prevalent oral phenotypes.

Methods

Using summary data from genome-wide association studies of European populations, a cross-trait linkage disequilibrium score regression was conducted to estimate the genetic correlations between RA and six oral phenotypes. Subsequently, a two-sample Mendelian randomization (MR) approach was employed to assess the causal relationships, corroborated by various sensitivity analyses. Heterogeneity was addressed through the RadialMR method, while potential covariates were corrected using the multivariable MR approach.

Results

A significant negative genetic correlation was detected between RA and denture usage (rg = -0.192, p = 4.88 × 10-8). Meanwhile, a heterogenous causal relationship between RA and mouth ulcers was observed (OR = 1.027 [1.005-1.05], p = 0.016, P heterogeneity = 4.69 × 10-8), which remained robust across sensitivity analyses. After excluding outlier variants, the results demonstrated robustly consistent (OR = 1.021 [1.008-1.035], p = 1.99 × 10-3, P heterogeneity = 0.044). However, upon adjusting for covariates such as smoking, alcohol consumption, body mass index, and obesity, the significance diminished, revealing no evidence to support independent genetic associations.

Conclusion

Genetically predicted RA increases the risk of mouth ulcers, and a negative genetic correlation is identified between RA and denture use. The observed heterogeneity suggests that shared immunological mechanisms and environmental factors may play significant roles. These findings highlight the importance of targeted dental management strategies for RA patients. Further clinical guidelines are required to improve oral health among vulnerable RA patients.

Relationship between C-reactive protein level and periodontitis and systemic diseases

BACKGROUND

Periodontitis affects systemic disease risk, although the relationship thereof in the context of different C-reactive protein (CRP) levels is not clear. This study investigated the association of periodontitis with systemic diseases according to high-sensitivity CRP (hs-CRP) level and sought to identify the risk of systemic diseases in patients with periodontitis.

METHODS

We used data from the seventh (2016-2018) Korea National Health and Nutrition Examination Survey. In a total of 16,489 subjects, the hs-CRP group was classified into the hs-CRP low-risk group and the hs-CRP high-risk group. Propensity score matching (PSM) is used for 1:1 matching of confounding variables (e.g., age, gender, income, and education) between hs-CRP low-risk and hs-CRP at-risk groups to analyze the final 5316 subjects. The association between general characteristics and prevalence of systemic diseases was analyzed using descriptive statistics and the chi-squared test. The associations between hs-CRP level and systemic and periodontitis were analyzed using logistic regression analyses.

RESULTS

Within the hs-CRP group, the presence of periodontitis was associated with a significantly increased prevalence of hypertension, diabetes mellitus, and stroke. In the hs-CRP risk group, periodontitis significantly increased the risk of hypertension and diabetes mellitus by 2.1 and 2.4 times, respectively.

CONCLUSIONS

The presence of periodontitis significantly increases the prevalence of systemic diseases and more so in individuals with higher hs-CRP levels. This indicates the significance of maintaining oral health in reducing the risk of systemic diseases.

The Association of Chronic Periodontitis as a Potential Risk Factor with Rheumatoid Arthritis: A Nested Case-Control Study Using a Korean National Health Screening Cohort

Growing research has proposed that rheumatoid arthritis (RA) and chronic periodontitis (CP) share similar pathophysiological mechanisms involving inflammation and tissue destruction. However, the potential correlation of CP as a contributing factor for the occurrence of RA warrants validation in the Korean population, where both diseases are prevalent, especially considering the increasingly aging demographic in Korea. This study examined 5139 RA cases and 509,727 matched controls from a Korean national cohort dataset (2002-2019) by carefully employing propensity score matching to ensure comparability between groups. Baseline characteristics were compared using standardized differences, and logistic regression was employed to estimate the impact of CP history on RA likelihood while controlling for covariates. We fully examined medical records documenting CP occurrences within the two-year period leading up to the index date, conducting comprehensive subgroup analyses. While a 1-year history of CP did not show a significant association with likelihood of RA, a 2-year history of CP increased RA likelihood by 12%, particularly among older adults, females, rural residents, and those with certain comorbidities such as hypercholesterolemia. Interestingly, this association persisted even among individuals with non-smoking habits, normal weight, and infrequent alcohol consumption. These findings suggest that chronic CP exposure for at least 2 years may independently elevate RA risk in Korean adults. The association in certain subgroups appears to suggest a predisposition toward genetic susceptibilities over lifestyle and environmental factors. Predicting RA in CP patients may be challenging, emphasizing the importance of regular RA screening, especially in high-risk subgroups.

Patient awareness of the association between periodontal and systemic diseases in an academic setting

BACKGROUND

Periodontal diseases (PD) have been increasingly associated with several systemic conditions such as cardiovascular disease (CVD), diabetes mellitus (DM), rheumatoid arthritis (RA), and Alzheimer's disease (AD). This study aimed to gain insight into patients' awareness of the association between PD and systemic diseases.

METHODS

A survey was developed to analyze patient awareness of the association between PD and systemic diseases. Descriptive and categorical variables were summarized with counts and percentages. Chi-squared tests were used to evaluate differences between variables. A linear logistical regression model was used to assess the simultaneous, independent association between each variable.

RESULTS

Data from 161 completed surveys were analyzed. The majority of the participants (61.49%) reported awareness of symptoms of PD, but only 36.36% identified all its major symptoms. Individuals reporting awareness of the association between PD and systemic diseases was 48.4%, 31.7%, 14.9%, and 9.9% for CVD, DM, RA, and AD, respectively. Patients aged ≥51 years and males were more aware of the association between PD and CVD. Increased awareness of an association between PD and DM was observed among patients who had a higher frequency of dental visits and those with a self-reported history of DM.

CONCLUSIONS

This study provides insight that, even with the vast amount of scientific knowledge on the inter-relationships that exist between PD and systemic diseases, most patients are still unaware of these associations. This research identified that improvement of health literacy surrounding PD, their symptoms, and their association with systemic diseases may be warranted.

Effect of blood lead levels on periodontitis in American adults: a cross-sectional analysis from the national health and nutrition examination survey

BACKGROUND

The primary objective of this study was to assess the impact of blood lead levels on the development and progression of periodontitis.

METHODS

This study included 8600 participants from the National Nutrition and Health Examination Survey conducted the United States between 2009 and 2014. The exposure variable was the blood lead level, while the outcome variable was periodontitis. To evaluate the relationship between the blood lead level and periodontitis, a multivariate logistic regression model was used.

RESULTS

A positive association was observed between blood lead levels and the risk of periodontitis in Model 1 (OR = 7.04, 95% CI = 5.95-8.31). After adjusting for age (continuous), sex, ethnicity, and BMI (continuous) in Model 2, the significant association between blood lead levels and periodontitis risk remained evident (OR = 3.06, 95% CI: 2.54-3.70). Consequently, even after comprehensive adjustment for potential confounding factors in Model 3, the robust association between blood lead levels and periodontitis risk persisted (OR = 2.08, 95% CI = 1.67-2.60). When considering the serum lead concentration as a categorical variable and after adjusting for potential confounders in Model 3, we observed that the odds ratios (ORs) of periodontitis in the T2 (0.94 µg/dL-1.60 µg/dL) and T3 (lead ≥ 1.60 µg/dL) groups increased from 1.27 (OR = 1.27, 95% CI: 1.11-1.44) to 1.57 (OR = 1.57, 95% CI: 1.36-1.81) compared to T1 group. Subgroup analysis revealed no effect modifiers.

CONCLUSIONS

Our main findings suggest that there is no safe range of blood lead levels regarding periodontitis risk and that increasing blood lead levels can significantly increase the prevalence of periodontitis.

Genetic causal association between rheumatoid arthritis and periodontitis: a bidirectional two-sample Mendelian randomization analysis

BACKGROUND

A link between rheumatoid arthritis (RA) and periodontitis (PD) has been established. However, their causal relationship remains unclear and the effect of different serotypes of RA on the PD development has not been investigated. This study aims to elucidate the causal association between PD and different serotypes of RA using Mendelian randomization (MR).

METHODS

A bidirectional two-sample MR analysis was performed using available large-scale genome-wide association studies statistics. The inverse-variance weighted (IVW) or multiplicative random-effects IVW was used to determine causality, depending on the heterogeneity of instrumental variables. Additional sensitivity analyses were also performed.

RESULTS

The forward MR analysis identified that seropositive RA (odds ratio (OR), 1.26; 95% confidence interval (CI), 1.07-1.44; p = 0.0018), but not seronegative RA (OR, 1.01; 95% CI, 0.95-1.06; p = 0.9098), was associated with an increased risk of PD. The reverse MR analysis did not show any significant causal effect of PD on RA, independent of the serotypes. The sensitivity tests (p > 0.05) confirmed the robustness and accuracy of these findings.

CONCLUSION

This study revealed that there was a genetic causal effect of seropositive RA on PD, suggesting that this subtype of RA patients may require specific clinical attention to prevent the development of PD.

The Effects of Periodontal Treatment on Rheumatoid Arthritis and of Anti-Rheumatic Drugs on Periodontitis: A Systematic Review

Rheumatoid arthritis (RA) and periodontitis are chronic inflammatory diseases that widely spread and share the same patterns of pro-inflammatory cytokines. This systematic review aims to evaluate the effects of non-surgical periodontal treatment (NSPT) on RA and, conversely, the impact of disease-modifying anti-rheumatic drugs (DMARDs) on periodontitis. PubMed, Embase, and Web of Science were searched using the MESH terms "periodontitis" and "rheumatoid arthritis" from January 2012 to September 2023. A total of 49 articles was included in the final analysis, 10 of which were randomized controlled trials. A total of 31 records concerns the effect of NSPT on parameters of RA disease activity, including a 28-joint disease activity score, anti-citrullinated protein antibodies, rheumatoid factor, C reactive protein, erythrocyte sedimentation rate, pro-inflammatory cytokines and acute phase proteins in serum, saliva, gingival crevicular fluid, and synovial fluid. A total of 18 articles investigated the effect of DMARDs on periodontal indexes and on specific cytokine levels. A quality assessment and risk-of-bias of the studies were also performed. Despite some conflicting results, there is evidence that RA patients and periodontitis patients benefit from NSPT and DMARDs, respectively. The limitations of the studies examined are the small samples and the short follow-up (usually 6 months). Further research is mandatory to evaluate if screening and treatment of periodontitis should be performed systematically in RA patients, and if the administration of DMARDs is useful in reducing the production of cytokines in the periodontium.

Improving Patient Well-Being as a Broader Perspective in Dentistry

Patient well-being encompasses the physical, mental, psychological, and social health of an individual. To adequately treat an individual and increase their quality of life, whole-person, patient-centred care needs to be utilised. This review aims to concisely summarise ways to improve patients' well-being through and in dentistry. Oral health is tied to one's quality of life through oral function, overall health, self-perception, social acceptance, and social interaction. These relationships demonstrate the importance of utilising oral health to increase patient quality of life, unify health professions in patient treatment, use preventative medicine, and empower patients about their health. To do so, the dental profession can increase the scope of practice to provide preventative health screening and education on general health, have more open communication, collaborate with other health care professionals, and have broader consultations. This will allow for better continuity of care and shift the focus of treatment to the whole person instead of a symptom. Whilst there are barriers that need to be resolved and cost feasibility requires more exploration, the potential benefit to patients is apparent.

Periodontitis and periodontopathic bacteria as risk factors for rheumatoid arthritis: A review of the last 10 years

Rheumatoid arthritis (RA) is characterized by chronic inflammatory destruction of joint tissue and is caused by an abnormal autoimmune response triggered by interactions between genetics, environmental factors, and epigenetic and posttranslational modifications. RA has been suggested to be interrelated with periodontitis, a serious form or stage of chronic inflammatory periodontal disease associated with periodontopathic bacterial infections, genetic predisposition, environmental factors, and epigenetic influences. Over the last decade, a number of animal and clinical studies have been conducted to assess whether or not periodontitis and associated periodontopathic bacteria constitute risk factors for RA. The present review introduces recent accumulating evidence to support the associations of periodontitis and periodontopathic bacteria with the risk of RA or the outcome of RA pharmacological treatment with disease-modifying antirheumatic drugs. In addition, the results from intervention studies have suggested an improvement in RA clinical parameters after nonsurgical periodontal treatment. Furthermore, the potential causal mechanisms underlying the link between periodontitis and periodontopathic bacteria and RA are summarized.

The association of work physical activity and recreational physical activity with periodontitis in the NHANES (2009-2014)

BACKGROUND

The aim of this study was to investigate the association between different types and intensity of physical activities (PA) and periodontitis in a nationally representative sample of adults in the United States.

METHODS

The data of periodontal condition and PA of 10,714 individuals were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014 and the Global Physical Activity Questionnaire (GPAQ). The association between the prevalence of periodontitis and two PAs (work PA and recreational PA) was respectively analyzed and adjusted by uni- and multi-variable logistic regression models. The odd ratios (ORs), adjusted odd ratios (ORad ), and 95% confidence interval (95% CI) were calculated as the main outcome indicators.

RESULTS

After adjusted by age, sex, race, poverty-income ratio (PIR), diabetes, smoking status, alcohol use, and floss frequency, moderate and vigorous work PAs were significantly correlated with higher odds of periodontitis (ORad  = 1.22, 95% CI = 1.02-1.46; ORad  = 1.40, 95% CI = 1.04-1.89, respectively) while moderate and vigorous recreational PAs were correlated with lower odds of periodontitis (ORad  = 0.81, 95% CI = 0.69-0.95; ORad  = 0.55, 95% CI = 0.43-0.71, respectively).

CONCLUSIONS

Work PAs and recreational PAs have opposite associations on the prevalence of developing periodontitis and their aggravating or protective associations enhance with the increase of intensity.

Periodontitis and risk of immune-mediated systemic conditions: A systematic review and meta-analysis

INTRODUCTION

The aim of this review is to examine and quantify the long-term risk of immune-mediated systemic conditions in people with periodontitis compared to people without periodontitis.

METHODS

Medline, EMBASE and Cochrane databases were searched up to June 2022 using keywords and MeSH headings. The 'Risk of Bias in Non-Randomised Studies of Interventions' tool was used to assess bias. Cohort studies comparing incident metabolic/autoimmune/inflammatory diseases in periodontitis to healthy controls were included. Meta-analysis and meta-regression quantified risks and showed impact of periodontitis diagnosis type and severity.

RESULTS

The search retrieved 3354 studies; 166 studies were eligible for full-text screening, and 30 studies were included for review. Twenty-seven studies were eligible for meta-analysis. The risks of diabetes, rheumatoid arthritis (RA) and osteoporosis were increased in people with periodontitis compared to without periodontitis (diabetes-relative risk [RR]: 1.22, 95% CI: 1.13-1.33; RA-RR: 1.27, 95% CI: 1.07-1.52; osteoporosis-RR: 1.40, 95% CI: 1.12-1.75). Risk of diabetes showed gradient increase by periodontitis severity (moderate-RR = 1.20, 95% CI = 1.11-1.31; severe-RR = 1.34, 95% CI = 1.10-1.63).

CONCLUSION

People with moderate-to-severe cases of periodontitis have the highest risk of developing diabetes, while the effect of periodontal severity on risk of other immune-mediated systemic conditions requires further investigation. More homologous evidence is required to form robust conclusions regarding periodontitis-multimorbidity associations.

Appraising causal risk and protective factors for rheumatoid arthritis

Aims

Mendelian randomization (MR) is considered to overcome the bias of observational studies, but there is no current meta-analysis of MR studies on rheumatoid arthritis (RA). The purpose of this study was to summarize the relationship between potential pathogenic factors and RA risk based on existing MR studies.

Methods

PubMed, Web of Science, and Embase were searched for MR studies on influencing factors in relation to RA up to October 2022. Meta-analyses of MR studies assessing correlations between various potential pathogenic factors and RA were conducted. Random-effect and fixed-effect models were used to synthesize the odds ratios of various pathogenic factors and RA. The quality of the study was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization (STROBE-MR) guidelines.

Results

A total of 517 potentially relevant articles were screened, 35 studies were included in the systematic review, and 19 studies were eligible to be included in the meta-analysis. Pooled estimates of 19 included studies (causality between 15 different risk factors and RA) revealed that obesity, smoking, coffee intake, lower education attainment, and Graves' disease (GD) were related to the increased risk of RA. In contrast, the causality contribution from serum mineral levels (calcium, iron, copper, zinc, magnesium, selenium), alcohol intake, and chronic periodontitis to RA is not significant.

Conclusion

Obesity, smoking, education attainment, and GD have real causal effects on the occurrence and development of RA. These results may provide insights into the genetic susceptibility and potential biological pathways of RA.

PRMT5 inhibition ameliorates inflammation and promotes the osteogenic differentiation of LPS‑induced periodontal stem cells via STAT3/NF‑κB signaling

It has been reported that protein arginine methyltransferase 5 (PRMT5) serves a significant role in osteogenic differentiation and inflammatory response. Nevertheless, its role in periodontitis as well as its underlying mechanism remain to be elucidated. The aim of the present study was to explore the role of PRMT5 in periodontitis and whether PRMT5 could reduce liposaccharide (LPS)-induced inflammation of human periodontal ligament stem cells (hPDLSCs) and promote osteogenic differentiation through STAT3/NF-κB signaling. In the current study, the expression levels of PRMT5 were determined in LPS-induced hPDLSCs by reverse transcription-quantitative PCR and western blot analysis. ELISA and western blot analysis were employed to assess the secretion and expression levels of inflammatory factors, respectively. The osteogenic differentiation and mineralization potential of hPDLSCs were evaluated using alkaline phosphatase (ALP) activity assay, Alizarin red staining and western blot analysis. Additionally, western blot analysis was applied to determine the expression levels of the STAT3/NF-κB signaling pathway-related proteins. The results showed that the expression levels of PRMT5 were significantly enhanced in LPS-induced hPDLSCs. Additionally, PRMT5 knockdown reduced the contents of IL-1β, IL-6, TNF-α, inducible nitric oxide synthase and cyclooxygenase-2. PRMT5 depletion also enhanced ALP activity, improved the mineralization ability and upregulated bone morphogenetic protein 2, osteocalcin and runt-related transcription factor 2 in LPS-induced hPDLSCs. Furthermore, PRMT5 knockdown inhibited inflammation and promoted the osteogenic differentiation of hPDLSCs via blocking the activation of the STAT3/NF-κB signaling pathway. In conclusion, PRMT5 inhibition suppressed LPS-induced inflammation and accelerated osteogenic differentiation in hPDLSCs via regulating STAT3/NF-κB signaling, thus providing a potential targeted therapy for the improvement of periodontitis.

The role of bacterial infections in rheumatoid arthritis development and novel therapeutic interventions: Focus on oral infections

BACKGROUND

Rheumatoid arthritis (RA) represents a primary public health challenge, which is a major source of pain, disability, and socioeconomic effects worldwide. Several factors contribute to its pathogenesis. Infections are an important concern in RA patients, which play a key role in mortality risk. Despite major advances in the clinical treatment of RA, long-term use of disease-modifying anti-rheumatic drugs can cause serious adverse effects. Therefore, effective strategies for developing novel prevention and RA-modifying therapeutic interventions are sorely needed.

OBJECTIVE

This review investigates the available evidence on the interplay between various bacterial infections, particularly oral infections and RA, and focuses on some potential interventions such as probiotics, photodynamic therapy, nanotechnology, and siRNA that can have therapeutic effects.

New insights into inflammatory osteoclast precursors as therapeutic targets for rheumatoid arthritis and periodontitis

Rheumatoid arthritis (RA) and periodontitis are chronic inflammatory diseases leading to increased bone resorption. Preventing this inflammatory bone resorption is a major health challenge. Both diseases share immunopathogenic similarities and a common inflammatory environment. The autoimmune response or periodontal infection stimulates certain immune actors, leading in both cases to chronic inflammation that perpetuates bone resorption. Moreover, RA and periodontitis have a strong epidemiological association that could be explained by periodontal microbial dysbiosis. This dysbiosis is believed to be involved in the initiation of RA via three mechanisms. (i) The dissemination of periodontal pathogens triggers systemic inflammation. (ii) Periodontal pathogens can induce the generation of citrullinated neoepitopes, leading to the generation of anti-citrullinated peptide autoantibodies. (iii) Intracellular danger-associated molecular patterns accelerate local and systemic inflammation. Therefore, periodontal dysbiosis could promote or sustain bone resorption in distant inflamed joints. Interestingly, in inflammatory conditions, the existence of osteoclasts distinct from "classical osteoclasts" has recently been reported. They have proinflammatory origins and functions. Several populations of osteoclast precursors have been described in RA, such as classical monocytes, a dendritic cell subtype, and arthritis-associated osteoclastogenic macrophages. The aim of this review is to synthesize knowledge on osteoclasts and their precursors in inflammatory conditions, especially in RA and periodontitis. Special attention will be given to recent data related to RA that could be of potential value in periodontitis due to the immunopathogenic similarities between the two diseases. Improving our understanding of these pathogenic mechanisms should lead to the identification of new therapeutic targets involved in the pathological inflammatory bone resorption associated with these diseases.

The Interaction Effect of Anti-RgpA and Anti-PPAD Antibody Titers: An Indicator for Rheumatoid Arthritis Diagnosis

Porphyromonas gingivalis secretes virulence factors like Arg-gingipains and peptidyl arginine deiminase (PPAD), that are associated with rheumatoid arthritis (RA) pathogenesis. However, there is no information regarding the antibody titers for these bacterial enzymes as systemic indicators or biomarkers in RA. In this cross-sectional study, 255 individuals were evaluated: 143 were diagnosed with RA, and 112 were without RA. Logistic regression models adjusted for age, sex, basal metabolic index, smoking, and periodontitis severity were used to evaluate the association of RA with rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPAs), erythrocyte sedimentation rate, high sensitivity C-reactive protein, anti-RgpA, anti-PPAD, and double positive anti-RgpA/anti-PPAD. It was found that RF (odds ratio [OR] 10.6; 95% confidence interval [CI] 4.4-25), ACPAs (OR 13.7; 95% CI 5.1-35), and anti-RgpA/anti-PPAD double positivity (OR 6.63; 95% CI 1.61-27) were associated with RA diagnoses. Anti-RgpA was also associated with RA (OR 4.09; 95% CI 1.2-13.9). The combination of anti-RgpA/anti-PPAD showed a high specificity of 93.7% and 82.5% PPV in identifying individuals with RA. RgpA antibodies were associated with the periodontal inflammatory index in RA individuals (p < 0.05). The double positivity of the anti-RgpA/anti-PPAD antibodies enhanced the diagnosis of RA. Therefore, RgpA antibodies and anti-RgpA/anti-PPAD may be biomarkers for RA.

Extracellular Release of Citrullinated Vimentin Directly Acts on Osteoclasts to Promote Bone Resorption in a Mouse Model of Periodontitis

Elevated osteoclast (OC)-mediated bone resorption, a common pathological feature between periodontitis and rheumatoid arthritis (RA), implicates a possible mutually shared pathogenesis. The autoantibody to citrullinated vimentin (CV), a representative biomarker of RA, is reported to promote osteoclastogenesis (OC-genesis). However, its effect on OC-genesis in the context of periodontitis remains to be elucidated. In an in vitro experiment, the addition of exogenous CV upregulated the development of Tartrate-resistant acid phosphatase (TRAP)-positive multinuclear OCs from mouse bone marrow cells and increased the formation of resorption pits. However, Cl-amidine, an irreversible pan-peptidyl arginine deiminase (PAD) inhibitor, suppressed the production and secretion of CV from RANKL-stimulated OC precursors, suggesting that the citrullination of vimentin occurs in OC precursors. On the other hand, the anti-vimentin neutralizing antibody suppressed in vitro Receptor activator of nuclear factor kappa-Β ligand (RANKL)-induced OC-genesis. The CV-induced upregulation of OC-genesis was abrogated by the Protein kinase C (PKC)-δ inhibitor Rottlerin, accompanied by the downmodulation of OC-genesis-related genes, including Osteoclast stimulatory transmembrane protein (OC-STAMP), TRAP and Matrix Metallopeptidase 9 (MMP9) as well as extracellular signal-regulated kinase (ERK) mitogen-activated protein (MAP)-kinase phosphorylation. Elevated levels of soluble CV and vimentin-bearing mononuclear cells were found in the bone resorption lesions of periodontitis induced in mice in the absence of an anti-CV antibody. Finally, local injection of anti-vimentin neutralizing antibody suppressed the periodontal bone loss induced in mice. Collectively, these results indicated that the extracellular release of CV promoted OC-genesis and bone resorption in periodontitis.

Serum antibodies to periodontal pathogens prior to rheumatoid arthritis diagnosis: A case-control study

OBJECTIVES

1) To quantify the association between anti-Porphyromonas gingivalis serum antibody concentrations and the risk of developing rheumatoid arthritis (RA), and 2) to quantify the associations among RA cases between anti-P. gingivalis serum antibody concentrations and RA-specific autoantibodies. Additional anti-bacterial antibodies evaluated included anti-Fusobacterium nucleatum and anti-Prevotella intermedia.

METHODS

Serum samples were acquired pre- and post- RA diagnosis from the U.S. Department of Defense Serum Repository (n = 214 cases, 210 matched controls). Using separate mixed-models, the timing of elevations of anti-P. gingivalis, anti-P. intermedia, and anti-F. nucleatum antibody concentrations relative to RA diagnosis were compared in RA cases versus controls. Associations were determined between serum anti-CCP2, ACPA fine specificities (vimentin, histone, and alpha-enolase), and IgA, IgG, and IgM RF in pre-RA diagnosis samples and anti-bacterial antibodies using mixed-effects linear regression models.

RESULTS

No compelling evidence of case-control divergence in serum anti-P. gingivalis, anti-F. nucleatum, and anti-P. intermedia was observed. Among RA cases, including all pre-diagnosis serum samples, anti-P. intermedia was significantly positively associated with anti-CCP2, ACPA fine specificities targeting vimentin, histone, alpha-enolase, and IgA RF (p<0.001), IgG RF (p = 0.049), and IgM RF (p = 0.004), while anti-P. gingivalis and anti-F. nucleatum were not.

CONCLUSIONS

No longitudinal elevations of anti-bacterial serum antibody concentrations were observed in RA patients prior to RA diagnosis compared to controls. However, anti-P. intermedia displayed significant associations with RA autoantibody concentrations prior to RA diagnosis, suggesting a potential role of this organism in progression towards clinically-detectable RA.

Differential associations of rheumatoid arthritis and periodontitis or tooth loss: A cross-sectional study

AIM

To study the association between periodontitis, tooth loss, and rheumatoid arthritis (RA) by using a large national dataset.

MATERIALS AND METHODS

An observational cross-sectional study was performed using the National Health and Nutrition Examination Survey cycles (2009-2014). RA status was detected using a questionnaire. Periodontal status was assigned on the basis of the clinical attachment level and periodontal pocket depth. Dentition status was assessed by the number of permanent teeth observed. We examined the association between RA as exposure and moderate/severe periodontitis and non-functional dentition as outcomes. We progressively adjusted our models for different sets of potential confounders.

RESULTS

Moderate/severe periodontitis was more prevalent in participants reporting RA (53% vs. 41.5%, p = .0003). Non-functional dentition was more prevalent in participants with RA (41% vs. 15.5%, p = .0001). The fully adjusted model showed that participants with RA had higher odds of having non-functional dentition (odds ratio 1.8, 95% confidence interval [CI] 1.3-2.3, p = .0001) but no association with moderate/severe periodontitis (prevalence ratio 1.01, 95% CI 0.9-1.1, p = .9).

CONCLUSION

RA was associated with a higher likelihood of having non-functional dentition but did not show any association with periodontitis after adjusting for the risk factors to control their confounding effect.

Effect of osteoarthritis on alveolar bone loss in experimental periodontitis in rats

BACKGROUND

There is scarce information about the relationship between periodontal disease and osteoarthritis. This study investigated the effect of surgically induced osteoarthritis on alveolar bone loss in experimental periodontitis in rats.

METHODS

12 rats were divided into test and control groups. On day 1, the animals were anaesthetized, and silk ligatures were ligated around 6 maxillary posterior teeth in each animal from both groups. Surgical induction of osteoarthritis was performed on the left knees in the test group. No knee surgeries were performed in the control group. The ligatures were kept in place for 30 days, at which time the animals were euthanatized, and the maxillae and knee joints were harvested and processed for histological analysis. The alveolar bone loss was assessed using a zoom stereomicroscope.

RESULTS

The knee joint histologic sections of the control group showed normal joint features, whereas in the test group there were substantial changes typical of osteoarthritis, including wide joint spaces, prominent monocytic infiltration of the synovium, invasion of periarticular bone, and decreased chondrocyte density. Comparison of the bone height between the groups showed a significantly higher bone loss in the test than in the control group The marginal mean bone height, adjusted for covariates and the intraclass correlation between sites, was 1.19 and 0.78 mm in the test and control groups, respectively (p < .0001).

CONCLUSIONS

Surgically induced osteoarthritis leads to greater alveolar bone loss in the experimental periodontitis model in rats.

Novel Herbal Therapeutic YH23537 Improves Clinical Parameters in Ligature-Induced Periodontal Disease Model in Beagle Dogs

Currently, available medicine does not satisfy the clinical unmet needs of periodontal disease. Therefore, novel drugs with improved efficacy profiles are needed. We previously demonstrated that YH14642, water extracts of Notoginseng Radix and Rehmanniae Radix Preparata, improved probing depths in double-blind phase II clinical trial. However, it still has hurdles for commercialization due to the low efficiency of active compound extraction. To resolve this issue, we developed YH23537 through process optimization to extract active compounds efficiently while still achieving the chemical profile of YH14642. In this study, we investigated the therapeutic effects of YH23537 compared with YH14642 using a canine model of ligature-induced periodontitis. Human gingival fibroblast (hGF) cells were treated with various concentrations of YH23537 or YH14642 with lipopolysaccharide (LPS) for 24 hr. IL-6 and IL-8 levels in the conditioned media were determined using Luminex. Sixteen 3-year-old male beagle dogs had their teeth scaled and polished using a piezo-type ultrasonic scaler under general anesthesia and brushed once daily for the following 2 weeks. Two weeks after the scaling procedure, the left upper second premolar (PM2), third premolar (PM3), and fourth premolar (PM4) as well as the left lower PM3, PM4, and first molar (M1) were ligated with silk-wire twisted ligatures. The dogs were fed with soft moistened food to induce periodontitis for 8 weeks, and the ligatures were then removed. YH23537 and YH14642 were administered for 4 weeks, and clinical periodontal parameters such as plaque index (PI), gingival index (GI), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BoP) were determined before and 1, 2, 3, and 4 weeks after treatment. YH23537 inhibited IL-6 and IL-8 secretion in a dose-dependent manner in hGF cells stimulated with LPS. The IC₅₀ values for YH23537 were 43 and 54 μg/ml for IL-6 and IL-8, respectively, while the values for YH14642 were 104 and 117 μg/ml, respectively. In the animal study, clinical parameters including GI, PD, CAL, and BoP were significantly increased after 8 weeks of ligature-induced periodontitis. The YH23537 300 and YH23537 900 mg groups had significant improvements in CAL from 1 to 4 weeks after treatment in comparison to the placebo group. GR values in the YH23537 900 mg group were decreased throughout the treatment period. GI values were also reduced significantly after 4-week treatment with 300 and 900 mg of YH23537. YH23537 at 300 mg doses showed comparable efficacy for CAL and GR with 1,000 mg of YH14642. YH23537 showed therapeutic efficacy against periodontitis in dogs, mediated by anti-inflammatory effects. These findings indicate that YH23537 has the potential for further development as a new drug for patients suffering from periodontal disease.

The exposome in rheumatoid arthritis

The exposome integrates the variety and accumulation of exposures (external and internal) to which an individual is submitted to from conception to death. Exposome may therefore be a useful tool for understanding the diversity of these factors and their role in the pathophysiology of rheumatoid arthritis (RA). Life is perceived as a continuum of cumulative changes, with key periods of disruption (e.g. birth, adolescence, pregnancy, prolonged treatment). The combination of these changes and the external signals that cause them constitute an individual's exposome, which is constantly changing and expanding throughout life. Thus, measuring the exposome requires specific tools and approaches as well as a global perspective. RA, a complex, heterogeneous, pro-inflammatory autoimmune disease with a genetic component and for which a large number of environmental factors have already been incriminated is an appropriate field of application for the exposome. The aim of this review is to define the exposome concept, outline the different analytic tools available for its study and finally apply them to the field of RA.

Prevalence of Periodontal Disease among Patients at the Outpatient Clinic of Internal Medicine in an Academic Hospital in The Netherlands: A Cross-Sectional Pilot Study

There is a worldwide increase in individuals suffering ≥2 chronic diseases (multimorbidity), and the cause of combinations of conditions remains largely unclear. This pilot study analysed the prevalence of periodontal disease (PD) among (multi)-morbid patients at the outpatient clinic of internal medicine. PD is an inflammatory disease of the tooth supporting tissues and has a negative impact on the overall health. Data were obtained from 345 patients, on demographics, systemic conditions and presence of PD. The possible differences in the distribution of PD status among patients with/without multimorbidity and Medical Subject Headings (MeSH) disease chapters were explored. In total, 180 (52.2%) patients suffered from multimorbidity. The prevalence of severe PD was 16.2%, while the prevalence of mild and severe PD combined (Total PD) was 53.6%. Patients with disease chapter cardiovascular diseases (CVD) had a significantly higher prevalence of severe PD (odds ratio (OR) 2.33; 95% confidence interval (CI) 1.25, 4.33) and Total PD (OR 1.61; 95% CI 1.04, 2.50) than patients without CVD. After subsequent analyses, myocardial infarction was significantly associated with severe PD (OR: 4.68 (95% CI; 1.27 to 17.25)). Those suffering from multimorbidity showed to have a non-significant increased risk for severe (OR 1.27; 95% CI 0.69, 2.34) or Total PD (OR 1.23; 95% CI 0.81, 1.88). In conclusion, PD is highly prevalent in multimorbidity patients. Furthermore, PD was significantly prevalent in patients with CVD. However, larger epidemiological studies are necessary to confirm that the prevalence of PD is significantly increased among multimorbid patients.

Periodontal disease and systemic health: An update for medical practitioners

INTRODUCTION

Chronic periodontal disease is a highly prevalent dental condition affecting tooth-supporting tissues. Scientific evidence is accumulating on links between periodontal disease and various systemic conditions. This narrative review provides a holistic yet succinct overview that would assist medical practitioners to deliver integrated care for better clinical outcomes.

METHOD

Scientific evidence on associations between periodontal disease and systemic conditions was synthesised and critically appraised. Key findings of latest prospective cohort studies, randomised clinical trials, and meta-analysis were closely assessed and compiled.

RESULTS

A bidirectional relationship has been established, indicating that diabetes and periodontal disease are closely linked and amplify one another, if not successfully controlled. Existing evidence also supports the associations of periodontal disease with cardiovascular diseases and adverse pregnancy outcomes. Successful treatment of periodontal disease and dental prophylaxis has been shown to improve clinical outcomes in these systemic conditions. Other systemic conditions associated with periodontal disease include respiratory diseases, Alzheimer's disease, rheumatoid arthritis and chronic kidney disease. Although the underlying mechanisms remain to be fully elucidated, it is generally accepted that the inflammatory burden of chronic periodontal disease has an important systemic impact.

CONCLUSION

Oral-systemic links are multifaceted and complex. While evidence linking periodontal disease with a variety of systemic conditions is still emerging, the nature of the relationship is becoming clearer. The updated understanding of these associations warrants the attention of medical experts and policymakers for a concerted effort to develop a patient-centric, integrated model for the treatment of comorbid dental and medical conditions.

Reactive Arthritis Resulting From Postoperative Complications of Third Molar Extraction: A Case Report

The role of bacterial infections as potential triggers for chronic rheumatic diseases is well-documented. Oral infections such as periodontitis may play a particularly important role in the development of autoimmune diseases, with the oral cavity serving as a reservoir for pathogenic bacteria. These bacteria may trigger dysregulatory immune responses through mechanisms like molecular mimicry, whereby bacterial peptides resemble self-peptides. Genetic factors may also predispose individuals to specific autoimmune diseases, most notably human leukocyte antigen B27 (HLA-B27) in the case of ankylosing spondylitis as well as other rheumatic diseases.

We present a case of a 23-year-old woman with reactive arthritis resulting from a postoperative infection. The patient presented with bilateral shoulder pain, decreased range of motion, worsening lower back pain, and mandibular pain at the site of a recent third molar extraction. Though initially diagnosed with rheumatoid arthritis, the patient experienced rapid and dramatic improvements following surgical treatment of the unresolved infection, demonstrating a causative or temporally related association between oral infections and chronic systemic autoimmune disease.

This case provides useful evidence regarding causal mechanisms for the connections between chronic autoimmune diseases and oral bacterial infection, illustrating how oral infection may serve as a causative factor for reactive arthritis. We suggest that this implicates bacteria normally present in oral microflora as a potential source of the antigens involved in triggering systemic inflammation, especially those already associated with other autoimmune diseases, such as Klebsiella pneumoniae in the case of ankylosing spondylitis. Based on prior publications linking self-peptides with homologies in such bacteria, we speculate on mechanisms underlying this connection, with particular attention to molecular mimicry. Clinicians should be aware of the close connection between certain rheumatic diseases (such as reactive arthritis) and bacterial infection, particularly of the oral cavity; such awareness should inform strategies for treatment and prevention of arthritic disease.

Pros and cons of causative association between periodontitis and rheumatoid arthritis

Research in recent decades has brought significant advancements in understanding of the molecular basis of the etiology of autoimmune diseases, including rheumatoid arthritis, a common systemic disease in which an inappropriate or inadequate immune response to environmental challenges leads to joint destruction. Recent studies have indicated that the classical viewpoint of the immunological processes underpinning the pathobiology of rheumatoid arthritis is restricted and needs to be expanded to include a more holistic and interdisciplinary approach incorporating bacteria-induced inflammatory reactions as an important pathway in rheumatoid arthritis etiology. Here, we discuss in detail data showing the clinical and molecular association of rheumatoid arthritis development with periodontal diseases. We also describe the unique role of periopathogens, which have been proposed to be crucial in the initiation and progression of this autoimmune pathological disorder.

Association between periodontitis and chronic kidney disease

Periodontitis and chronic kidney disease are chronic conditions with high community prevalence across the world. Patients with chronic kidney disease have been noted to have a high burden of periodontitis, and several shared risk factors have been associated with the prevalence and severity of both conditions. However, the precise relationship between the two conditions, and the extent to which each may contribute to the development of the other, remains a matter of debate. The goals of the present work were to: (a) provide the most current and relevant literature overview of the association between periodontitis and chronic kidney disease; (b) explore mechanisms underlying this association; and (c) determine if evidence exists for an independent association between these conditions. We also assessed whether improved oral hygiene and periodontal treatment could reduce the risk of developing chronic kidney disease and, if so, what protocols these strategies involve. Finally, we aimed to reveal gaps in our current knowledge to delineate the directions of future research. Although the exact relationship between these two conditions has not yet been defined, we highlight the importance of the interprofessional interaction between dental practitioners and the nephrology team and the importance of oral health assessment in the management of chronic kidney disease.

The Effect of Periodontal Treatment on Clinical and Biological Indicators, Quality of Life, and Oral Health in Rheumatoid Arthritis Patients: A Quasi-Experimental Study

Non-surgical periodontal therapy (NSPT) has been shown to have systemic effects. It has been suggested that, similar to rheumatoid arthritis (RA), periodontitis (PD) has an impact on general health, in terms of psychological, physical, and social aspects. This study determines the effect of periodontal treatment in RA activity, health-related quality of life, and oral health self-perception before and after periodontal treatment in RA patients. A quasi-experimental, prospective, non-randomized study was conducted, and 52 patients were included in the study. Periodontal parameters and the instruments disease activity score-28 (DAS-28), SF-36, and OHIP-14 were measured at baseline and at 3 months after NSPT. All differences were statistically assessed. The study protocol was registered in Clinical Trials (NCT04658615). No statistically significant differences were found in the scores of DAS-28 before and after the intervention in the group with PD and reduced periodontium. When the effect of periodontal treatment was analyzed in the group of 29 patients who were followed up, it was found that there were statistically significant differences before and after in variables such as psychological distress, emotional role, and mental health, which indicates an improvement in the scores of these variables. NSPT influenced the health-related quality of life measured with SF-36 and OHIP-14 in patients with RA. In conclusion, NSPT has an effect on self-reported quality of life and health indicators more than the RA activity as measured with DAS-28. However, the clinical effect of periodontal treatment in RA patients provides important data to support periodontal care in patients.

Propolis and Diet Rich in Polyphenols as Cariostatic Agents Reducing Accumulation of Dental Plaque

Conducted studies indicate the relationship between oral health and systemic diseases. Moreover, the latest research indicated that cariogenic bacteria may severely influence the course of SARS-CoV-2 infection and increase risk of COVID-19 complications. This article aims to review various applications of propolis and pay attention to a healthy diet rich in polyphenols, which may allow the reduction of dental plaque accumulation. A literature review has been conducted from June until November 2021. It showed that propolis could be a useful agent in decreasing the accumulation of dental plaque. Moreover, a diet rich in polyphenols prevents cariogenic bacteria and reduces the accumulation of dental plaque. A reduction of a dental plaque may influence the risk of a severe course of COVID-19. Therefore, propolis and a diet rich in polyphenols may play an important role in prophylaxis of systemic diseases. Recently, it has been proven that oral infection may affect cardiovascular system, musculoskeletal system, respiratory system, nervous system, as well as may be a risk factor for diabetes mellitus. These aspects should stimulate clinicians to further research about polyphenols.

Association between rheumatoid arthritis and thyroid dysfunction: A meta-analysis and systematic review

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disorder. Multiple studies have investigated the risk of thyroid dysfunction in patients with RA but have reached conflicting conclusions. This systematic review aimed to determine whether patients with RA are at higher risk of thyroid dysfunction.

METHODS

We comprehensively reviewed online literature databases, including PubMed, Scopus, Embase, and the Cochrane Library, from their respective inception dates to March 25, 2022. Studies that provided data on at least one case of thyroid dysfunction in RA patients and their controls were included. Based on these data, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) for thyroid dysfunction in RA and non-RA patients.

RESULTS

Twenty-nine studies met the inclusion criteria, involving a total of 35,708 patients with RA. The meta-analysis showed that, compared with non-RA patients, RA patients had an increased risk of developing thyroid dysfunction, particularly hypothyroidism (OR 2.25, 95% CI 1.78-2.84). Subgroup analysis suggested that study type and sample source of control group were the source of heterogeneity.

CONCLUSIONS

Patients with RA are at increased risk of developing thyroid dysfunction, especially hypothyroidism. Routine biochemical examination of thyroid function in RA patients should be strengthened. Larger prospective studies are needed to explore the causal relationship between RA and thyroid dysfunction, and to investigate the impact of thyroid dysfunction on RA disease activity, drug efficacy, and medication safety.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42022331142.

Effect of periodontal treatment on serum inflammatory parameters and disease activity in patients with systemic lupus erythematosus: A randomized controlled trial

Background

Several descriptive studies have shown an association between periodontitis and systemic lupus erythematosus (SLE), but clinical trials evaluating the effect of periodontal treatment on serological inflammatory parameters or disease activity in SLE patients are very limited. The aim of this study was to see how periodontal treatment affects the status of SLE patients.

Materials and Methods

Ninety patients with active SLE and periodontitis were randomly assigned to one of two groups: case (oral hygiene instructions + scaling and root planning) or control (oral hygiene instructions only). Periodontal parameters, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) and SLE Disease Activity Index (SLEDAI) levels were monitored at baseline and 3 months later.

Results

Periodontal parameters in the case group were significantly reduced both statistically and clinically after 3 months. However, in the control group, these indices decreased statistically (P < 0.05) but not clinically. The score of SLEDAI in both the groups showed a significant downward trend (P < 0.05) from the start of the study, but the differences in this index between the two groups were not statistically significant (P = 0.894). Although there was a significant decrease in CRP and ESR (P = 0.001) after 3 months in the case group, indicating a positive effect of periodontal treatment on inflammation reduction, there was no significant decrease in CRP and ESR in the control group.

Conclusion

According to our findings, it appears to be no statistically significant association between periodontal treatment and SLEDAI level. However, this treatment seems to be effective in reducing acute phase biomarkers such as CRP and ESR.

Identification of Cross-Talk and Pyroptosis-Related Genes Linking Periodontitis and Rheumatoid Arthritis Revealed by Transcriptomic Analysis

BACKGROUND

The current study is aimed at identifying the cross-talk genes between periodontitis (PD) and rheumatoid arthritis (RA), as well as the potential relationship between cross-talk genes and pyroptosis-related genes.

METHODS

Datasets for the PD (GSE106090, GSE10334, GSE16134) and RA (GSE55235, GSE55457, GSE77298, and GSE1919) were downloaded from the GEO database. After batch correction and normalization of datasets, differential expression analysis was performed to identify the differentially expressed genes (DEGs). The cross-talk genes linking PD and RA were obtained by overlapping the DEGs dysregulated in PD and DEGs dysregulated in RA. Genes involved in pyroptosis were summarized by reviewing literatures, and the correlation between pyroptosis genes and cross-talk genes was investigated by Pearson correlation coefficient. Furthermore, the weighted gene coexpression network analysis (WGCNA) was carried out to identify the significant modules which contained both cross-talk genes and pyroptosis genes in both PD data and RA data. Thus, the core cross-talk genes were identified from the significant modules. Receiver-operating characteristic (ROC) curve analysis was performed to identify the predictive accuracy of these core cross-talk genes in diagnosing PD and RA. Based on the core cross-talk genes, the experimentally validated protein-protein interaction (PPI) and gene-pathway network were constructed.

RESULTS

A total of 40 cross-talk genes were obtained. Most of the pyroptosis genes were not differentially expressed in disease and normal samples. By selecting the modules containing both cross-talk genes or pyroptosis genes, the blue module was identified to be significant module. Three genes, i.e., cross-talk genes (TIMP1, LGALS1) and pyroptosis gene-GPX4, existed in the blue module of PD network, while two genes (i.e., cross-talk gene-VOPP1 and pyroptosis gene-AIM2) existed in the blue module of RA network. ROC curve analysis showed that three genes (TIMP1, VOPP1, and AIM2) had better predictive accuracy in diagnosing disease compared with the other two genes (LGALS1 and GPX4).

CONCLUSIONS

This study revealed shared mechanisms between RA and PD based on cross-talk and pyroptosis genes, supporting the relationship between the two diseases. Thereby, five modular genes (TIMP1, LGALS1, GPX4, VOPP1, and AIM2) could be of relevance and might serve as potential biomarkers. These findings are a basis for future research in the field.

Impact of photodynamic therapy as an adjunct to non-surgical periodontal treatment on clinical and biochemical parameters among patients having mild rheumatoid arthritis with periodontitis

PURPOSE

To evaluate the efficacy of photodynamic therapy (PDT) as an adjunct to non-surgical periodontal therapy on the clinical periodontal and biochemical parameters among patients with rheumatoid arthritis (RA) having periodontitis.

METHODS

A total of 50 RA patients with periodontitis were included. The subjects were equally divided into two groups: Group A - scaling and root planning (SRP) + PDT; Group B - SRP only, respectively. Plaque score (PS), bleeding on probing (BOP), and pocket depth (PD) were estimated. The biochemical parameters included the assessment of interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and rheumatoid factors (RFs).

RESULTS

Plaque scores and BOP significantly reduced in both the groups at both 6 and 12 weeks with significant difference between both the groups at 6 weeks follow up (p<0.05). On inter-group comparison, there was a statistically significant reduction seen for BOP in Group A at 12 weeks (p<0.001). PD significantly reduced in both the groups at both time points; however, significant reduction was noted for Group A compared to Group B (p<0.01). IL-6 and TNF-α significantly reduced in both the groups at 6 and 12 weeks follow up. However, the proinflammatory cytokine levels significantly reduced in group A as compared to group B at both 6 and 12 weeks (p<0.05). GCF levels of RF did not show any change in either of the groups at either time point or between the groups (p>0.05).

CONCLUSION

PDT significantly reduced the proinflammatory burden in terms of periodontal attachment level and bleeding on probing within the periodontal inflammatory pockets in patients having RA.

The Effect of Acknowledged and Novel Anti-Rheumatic Therapies on Periodontal Tissues-A Narrative Review

Rheumatoid arthritis (RA) and periodontal disease (PD) are chronic complex inflammatory diseases with several common susceptibility factors, especially genetic and environmental risk factors. Although both disorders involve a perturbation of the immune-inflammatory response at multiple levels, one major difference between the two is the different locations in which they develop. RA is triggered by an exaggerated autoimmune response that targets joints, while periodontal disease occurs as a consequence of the subgingival periodontopathogenic microbiota. Current treatment models in both pathologies involve the stratification of patients to allow therapeutic individualization according to disease stage, complexity, progression, lifestyle, risk factors, and additional systemic diseases. Therapeutic guidelines for RA comprise of five main classes of drugs: non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, glucocorticoids, and disease-modifying anti-rheumatic drugs (DMARDs): biologic and non-biologic. Although various treatment options are available, a definitive treatment remains elusive, therefore research is ongoing in this area. Several alternatives are currently being tested, such as matrix metalloproteinases (MMP) inhibitors, toll-like receptors (TLR) blockers, pro-resolution mediators, anti-hypoxia inducing factors, stem cell therapy, NLRP3 inhibitors and even natural derived compounds. Although the link between PD and rheumatoid arthritis has been investigated by multiple microbiology and immunology studies, the precise influence and causality is still debated in the literature. Furthermore, the immunomodulatory effect of anti-rheumatic drugs on the periodontium is still largely unknown. In this narrative review, we explore the mechanisms of interaction and the potential influence that anti-rheumatoid medication, including novel treatment options, has on periodontal tissues and whether periodontal health status and treatment can improve the prognosis of an RA patient.

Causal risk and protective factors in rheumatoid arthritis: A genetic update

The characterization of risk and protective factors in complex diseases such as rheumatoid arthritis (RA) has evolved from epidemiological studies, which test association, to the use of Mendelian randomization approaches, which test direct relationships. Indeed, direct associations with the mucosal origin of RA are retrieved with periodontal disease (Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans predominantly), interstitial lung involvement, tobacco smoking and air pollutants. Next, factors directly associated with an acquired immune response include genetic factors (HLA DRB1, PTPN22), capacity to produce anti-modified protein antibodies (AMPA), and relatives with a history of autoimmune diseases. Finally, factors can be also classified according to their direct capacity to interfere with the IL-6/CRP/sIL-IL6R proinflammatory pathway as risk factor (body fat, cardiometabolic factors, type 2 diabetes, depressive syndrome) or either as protective factors by controlling of sIL-6R levels (higher education level, and intelligence). Although some co-founders have been characterized (e.g. vitamin D, physical activity, cancer) the direct association with sex-discrepancy, pregnancy, and infections among other factors remains to be better explored.

Common Medical and Dental Problems of Older Adults: A Narrative Review

The advancement of medicine has reduced the rate of mortality and older adult population is increasing. Among the 7,700,000,000 world population in 2019, 1 in 11 people were at the age of 65 or more. The population is expected to increase to 1 in 6 people by 2050. Older adults have degenerative changes that become more severe with age. This study used the World Health Organization’s websites and PubMed and Google Scholar databases to review current global oral and systemic health issues. Studies generally reported that many older adults have no regular dental checkup. Common oral diseases such as dental caries particularly root caries and periodontal disease are highly prevalent among them. These oral diseases are often interrelated with their systemic problems. A meta-analysis reported diabetes increases the incidence and progression of periodontitis by 86%. A decrease in salivary output is common among older adults having polypharmacy. A review reported the caries risk in older adults increases by 60% with low resting pH and low stimulated salivary flow rate. Many older adults suffer from dementia and depression which complicates the delivery of dental treatment. Proper oral hygiene practice and dental care at supine position are often difficult to be carried out if they have rheumatoid arthritis. With the increasing need of elderly dental care, dentists and other dental personnel should understand interlaced oral and general health in order to provide a successful dental care plan for older adults. The aim of this study is to give an overview of the common medical conditions and dental problems and their impacts on older adults.

Effects of non-surgical periodontal therapy on periodontal clinical data in periodontitis patients with rheumatoid arthritis: a meta-analysis

Backgrounds

To date, there is still no consensus about the clinical efficacy of non-surgical periodontal therapy in rheumatoid arthritis (RA) patients with periodontitis. Therefore, the aim of this study was to summarize clinical data regarding the efficacy of scaling and root planing (SRP) in patients with RA and periodontitis compared to non-RA periodontitis patients.

Methods

We selected randomized controlled trials (RCTs) that compared periodontal clinical data in RA as compared to non-RA periodontitis patients by searching Embase, PubMed and Cochrane Central Register of Controlled Trials and by manually retrieving from the earliest records to March 8, 2021. The overall effect size of plaque index (PI), gingival index (GI), attachment loss (AL), probing depth (PD) and bleeding on probing (BOP) were calculated by either a fixed or random-effect model, and subgroup analyses were conducted according to the different time points of follow-up. Two investigators extracted the data and assess the accuracy of the obtained results with 95% of Confidence Intervals (CI). Cochrane Collaboration's tool was responsible for the evaluation of the literature quality and the inter-study heterogeneity was evaluated by Q test and I² statistic. Sensitivity analyses were applied for results with heterogeneity. Publication bias was determined by Begg's test, Egger's test and the trim-and-fill method.

Results

Seven RCTs including 212 patients eventually met the inclusion criteria for the study. As the primary results, the change of PD was not statistically significant and in the secondary results changes of PI, GI, AL and BOP were also not statistically significant in RA patients with periodontitis compared to non-RA periodontitis patients. In subgroup analysis, a larger BOP reduction at 3 months, PI and AL reduction at 6 months were observed in patients with RA and periodontitis group. The results of sensitivity analyses had no significant effect. No evidence of potential publication bias was tested. There were some limitations due to the small number of eligible RCTs.

Conclusions

SRP is equally effective in RA as compared to non-RA periodontitis patients. It suggests RA does not affect the clinical efficacy of non-surgical periodontal therapy. These results could serve evidence-based practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01695-w.

Effect of Anti-Rheumatic Treatment on the Periodontal Condition of Rheumatoid Arthritis Patients

Periodontitis, a bacterial-induced infection of the supporting soft and hard tissues of the teeth (the periodontium), is common in patients with rheumatoid arthritis (RA). As RA and periodontitis underlie common inflammatory pathways, targeting the progression of RA might mediate both periodontitis and RA. On the other hand, patients with RA on immunosuppressive medication have an increased risk of infection. Therefore, the objective of this longitudinal observation study was to assess the effect of methotrexate (MTX) and anti-tumor necrosis factor-α (anti-TNF, etanercept) treatment on the periodontal condition of RA patients. Overall, 14 dentate treatment-naive RA patients starting with MTX and 12 dentate RA patients starting with anti-TNF therapy in addition to MTX were included. Follow-up was scheduled matching the routine protocol for the respective treatments. Prior to the anti-rheumatic treatment with MTX or the anti-TNF therapy in addition to MTX, and during follow-up, i.e., 2 months for MTX, and 3 and 6 months for the anti-TNF therapy in addition to MTX, the periodontal inflamed surface area (PISA) was measured. The efficacy of the anti-rheumatic treatment was assessed by determining the change in RA disease activity (DAS28-ESR). Furthermore, the erythrocyte sedimentation rates were determined and the levels of C-reactive protein, IgM-rheumatoid factor, anti-cyclic citrullinated protein antibodies, and antibodies to the periodontal pathogen Porphyromonas gingivalis, were measured. Subgingival sampling and microbiological characterization of the subgingival microflora was done at baseline. MTX or anti-TNF treatment did not result in an improvement of the periodontal condition, while both treatments significantly improved DAS28 scores (both p < 0.01), and reduced C-reactive protein levels and erythrocyte sedimentation rates (both p < 0.05). It is concluded that anti-rheumatic treatment (MTX and anti-TNF) has negligible influence on the periodontal condition of RA patients.

Investigating the relationship between the severity of periodontitis and rheumatoid arthritis: a cross-sectional study

OBJECTIVES

This paper evaluates the prevalence and severity of periodontitis (PD) in patients with rheumatoid arthritis (RA), focusing on the link between the severity of PD with RA disease activity/disability scores, the influence of RA treatment on PD, and levels of vitamin D.

METHODS

A total of 93 RA patients were enrolled in the cross-sectional study and analyzed accordingly as RA-PD (N = 63, 67.8%) and RA-only (N = 30, 32.2%) groups. A number of associations between rheumatological clinical data, i.e., Disease Activity Score (DAS28 CRP), health assessment questionnaires, and PD severity (measured by periodontal outcome parameters) with regard to serum levels of vitamin D were assessed. The outcome variables were compared by parametric and non-parametric tests.

RESULTS

A total of 29% of RA patients were diagnosed with severe PD. The RA-PD group presented a higher mean DAS28 CRP score in moderate-severe PD compared to periodontally healthy-initial stage PD subjects (4.49 ± 1.22 vs. 3.86 ± 1.58, p = 0.033). RA patients treated with biologic disease-modifying antirheumatic drugs (bDMARDs) were less likely to be diagnosed with PD (p = 0.022) and revealed significantly lower PD outcome parameters, i.e., bleeding on probing (%) and bone loss (%) (p < 0.05). Vitamin D concentration was significantly lower in RA-PD group with diagnosed advanced severe PD (IV stage) compared to moderate PD (II stage) (39.61 ± 17.12 vs. 52.07 ± 18.23 nmol/l, p = 0.031).

CONCLUSIONS

The study revealed a high prevalence of severe PD in RA patients, being significantly associated with higher RA disease activity and lower vitamin D level in RA-PD group, while bDMARD treatment was related to lower PD outcome parameters. Key Points • Severe PD is prevalent amongst RA patients and is associated with RA disease activity. The higher RA DAS28 CRP score is associated with moderate-severe PD compared to periodontally healthy-initial stage PD in RA patients. • Biologic DMARDs treatment used for RA is linked to lower PD rates and PD outcome parameters. • Significantly lower vitamin D level is found in advanced severe PD compared to moderate PD stage in RA-PD subjects.

Exploring the Role of Interleukin-6 Receptor Inhibitor Tocilizumab in Patients with Active Rheumatoid Arthritis and Periodontal Disease

BACKGROUND

The aim of our study was to explore the influence of weekly subcutaneous administration of interleukin-6 (IL-6) receptor inhibitor tocilizumab (TCZ) on periodontal status in a local longitudinal study of patients with rheumatoid arthritis (RA) and periodontal disease (PD).

METHODS

We performed a 6-month prospective study in 51 patients with chronic periodontitis and moderate-to-severe RA starting TCZ in accordance with local recommendations. Extensive rheumatologic (clinical activity, inflammatory, serological biomarkers) and periodontal (visible plaque index, gingival index, bleeding on probing, probing pocket depth, clinical attachment loss) assessments were done. Changes in RA activity and periodontal status were reassessed after 3 and 6 months.

RESULTS

We demonstrated significant correlations between periodontal status, disease activity, and serologic biomarkers (p < 0.05). Tocilizumab significantly improved the gingival index scores and decreased the number of sites with bleeding on probing after only 3 months (p < 0.05), while the probing pocket depth significantly decreased after 6 months; overall, clinical attachment loss presented only slight changes without any statistical significance as well as teeth count and plaque levels (p > 0.05).

CONCLUSION

IL-6 inhibition is able to improve periodontal outcomes in patients with RA and concomitant PD, which is essentially related to a dramatic decrease in serum inflammatory mediators.

Is implant surgery a risk factor for osteonecrosis of the jaw in older adult patients with osteoporosis? A national cohort propensity score-matched study

OBJECTIVES

This study aimed to investigate the association between dental implant therapy and osteonecrosis of the jaw (ONJ) in osteoporotic patients and the relationship between tooth extraction, dental implantation, and ONJ.

MATERIAL AND METHODS

This retrospective cohort study used the Customized Health Information Data from the National Health Insurance Corporation in South Korea. The study population included patients older than 70 years with a history of osteoporosis; the cases included patients who had undergone dental implant surgery between July 2014 and July 2016 with specific procedure codes. The case and control cohorts were stratified by tooth extraction because it was the strongest risk factor to consider in this study. Each group of patients was matched using the propensity score. To investigate the relationship between dental implants and ONJ, a Cox proportional hazard model was applied to socio-economic factors, comorbidities, and bisphosphonates (BPs). All analyses were conducted using SAS statistical software.

RESULTS

Based on the fully adjusted model, the propensity score-matched osteoporosis patients with dental implants had a 0.51 times hazard ratio of osteonecrosis. On the contrary, tooth extraction was associated with a higher risk of ONJ (HR = 5.89). The patients with rheumatoid arthritis (RA) and those using BPs had a higher HR, respectively, 6.80 and 4.09 HR (p < .001).

CONCLUSIONS

Dental implantation was not a risk factor and patients with implants show rather lower ratios. However, older osteoporotic Korean patients who had undergone tooth extraction had higher risks of ONJ. A significantly higher risk of ONJ was associated with RA and BPs as well.

Biosensor and Lab-on-a-chip Biomarker-identifying Technologies for Oral and Periodontal Diseases

Periodontitis is a complex multifactorial disease that can lead to destruction of tooth supporting tissues and subsequent tooth loss. The most recent global burden of disease studies highlight that severe periodontitis is one of the most prevalent chronic inflammatory conditions affecting humans. Periodontitis risk is attributed to genetics, host-microbiome and environmental factors. Empirical diagnostic and prognostic systems have yet to be validated in the field of periodontics. Early diagnosis and intervention prevents periodontitis progression in most patients. Increased susceptibility and suboptimal control of modifiable risk factors can result in poor response to therapy, and relapse. The chronic immune-inflammatory response to microbial biofilms at the tooth or dental implant surface is associated with systemic conditions such as cardiovascular disease, diabetes or gastrointestinal diseases. Oral fluid-based biomarkers have demonstrated easy accessibility and potential as diagnostics for oral and systemic diseases, including the identification of SARS-CoV-2 in saliva. Advances in biotechnology have led to innovations in lab-on-a-chip and biosensors to interface with oral-based biomarker assessment. This review highlights new developments in oral biomarker discovery and their validation for clinical application to advance precision oral medicine through improved diagnosis, prognosis and patient stratification. Their potential to improve clinical outcomes of periodontitis and associated chronic conditions will benefit the dental and overall public health.