Does periodontal treatment influence clinical and biochemical measures for rheumatoid arthritis? 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.

Chronic periodontitis and risk of cerebro-cardiovascular diseases among older Koreans

BACKGROUND AND OBJECTIVE

There is a relative lack of evidence from observational studies of older populations investigating the association between chronic periodontitis and cerebro-cardiovascular diseases. Accordingly, we investigated the risk of cerebro-cardiovascular diseases according to the severity of chronic periodontitis among older adults.

METHODS

Data on older adults with chronic periodontitis were extracted from the Korea National Health Insurance Service-Senior Cohort Database using diagnosis codes and dental procedures. Participants were divided into two exposure groups. Among 46 737 participants eligible for inclusion, 21 905 (46.9%) had newly diagnosed mild chronic periodontitis, and 24 832 (53.1%) had newly diagnosed severe chronic periodontitis. To determine the risk of cerebro-cardiovascular diseases, including ischemic stroke, haemorrhagic stroke, and myocardial infarction, multivariable-adjusted Cox proportional hazards modelling was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) in this retrospective follow-up study.

RESULTS

A total of 3453 (7.4%) outcomes were identified during a mean follow-up of 6.1 years. Kaplan-Meier analysis revealed that disease-free probability was lower in the severe group than in the mild group (log-rank P < .001). In the multivariable-adjusted model, the HR for cerebro-cardiovascular diseases in the severe group (relative to the mild group) was 1.16 (95% CI: 1.09-1.25). In individual outcome analysis, ischemic stroke and myocardial infarction were associated with chronic periodontitis severity, but haemorrhagic stroke was not.

CONCLUSION

The severity of chronic periodontitis could be associated with the risk of cerebro-cardiovascular diseases in older adults.

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.

Integrative non-pharmacological care for individuals at risk of rheumatoid arthritis

There is increasing knowledge in the recognition of individuals at risk for progression to rheumatoid arthritis (RA) before the clinical manifestation of the disease. This prodromal phase preceding the manifestation of RA may represent a "window of opportunity" for preventive interventions that may transform the clinical approach to this disease. However, limited evidence exists in support of effective interventions to delay the onset or even halt the manifestation of RA. Given the multifactorial nature of RA development and disease progression, the latest guidelines for established RA stress the use of integrative interventions and multidisciplinary care strategies, combining pharmacologic treatment with non-pharmacological approaches. Accordingly, individuals at risk of RA could be offered an integrative, multifactorial intervention approach. Current data point toward pharmacological intervention reverting the subclinical inflammation and delay in the disease onset. In addition, targeting life style modifiable factors (smoking cessation, dental health, physical activity, and diet) may presumably improve RA prognosis in individuals at risk, mainly by changes in epigenetics, autoantibodies, cytokines profiles, and microbiome. Nonetheless, the benefits of multidisciplinary interventions to halt the manifestation of RA in at-risk individuals remain unknown. As there is a growing knowledge of possible pharmacological intervention in the preclinical phase, this narrative review aims to provide a comprehensive overview of non-pharmacological treatments in individuals at risk of RA. Considering the mechanisms preceding the clinical manifestation of RA we explored all aspects that would be worth modifying and that would represent an integrative non-pharmacological care for individuals at risk of RA.

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.

Effects of periodontitis on cancer outcomes in the era of immunotherapy

Periodontitis results from dysbiosis of the oral microbiome and affects up to 70% of US adults aged 65 years and older. More than 50 systemic inflammatory disorders and comorbidities are associated with periodontitis, many of which overlap with immunotherapy-associated toxicities. Despite the increasing use of immunotherapy for the treatment of cancer, uncertainty remains as to whether the microbial shift associated with periodontal disease can influence response rates and tolerance to cancer immunotherapy. We herein review the pathophysiology of periodontitis and the local and systemic inflammatory conditions related to oral dysbiosis, and discuss the overlapping adverse profiles of periodontitis and immunotherapy. The effects of the presence of Porphyromonas gingivalis, a key pathogen in periodontitis, highlight how the oral microbiome can affect the hosts' systemic immune responses, and further research into the local and systemic influence of other microorganisms causing periodontal disease is necessary. Addressing periodontitis in an ageing population of people with cancer could have potential implications for the clinical response to (and tolerability of) immunotherapy and warrants further investigation.

Influence of periodontitis on levels of autoantibodies in rheumatoid arthritis patients: A systematic review

BACKGROUND AND OBJECTIVE

Periodontitis (PD) is a dysbiotic disease of tooth-supporting structures that has been associated with various systemic diseases including rheumatoid arthritis (RA). To date, evidence demonstrated increased prevalence of RA among PD patients and postulated PD to have a role in the development of autoantibodies in RA patients. Therefore, a systematic review was conducted to assess the available evidence to ascertain the effect of PD on levels of autoantibodies in the serum, saliva and gingival crevicular fluid (GCF) of RA patients.

MATERIAL AND METHODS

The systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Relevant literature was searched from PubMed, Web of Science, Scopus and Ebscohost databases from inception until 31 August 2020. The risk of bias in each study was determined based on the Newcastle-Ottawa Scale tool. Results from random-effect meta-analyses were presented as summary estimates of odds ratios (ORs) for seropositivity and standardised mean difference (SMD) of autoantibody levels with 95% confidence intervals. Sensitivity tests and meta-regression were performed to assess the robustness of the results and potential cause of heterogeneity.

RESULTS

The electronic and manual searches gathered 932 articles. Following screening and full-text assessment, a total of 29 studies were included in the analysis. Twenty-eight published observational studies were included in the quantitative analysis in the form of random-effect meta-analysis which revealed that PD was associated with anti-citrullinated proteins autoantibodies (ACPAs) and Rheumatoid Factor (RF) seropositive RA patients (OR for ACPA seropositivity: 1.82; 95% CI: 1.13-2.93) (OR for RF seropositivity: 1.53; 95% CI: 1.05-2.24). Also, RA patients with PD had increased serum levels of ACPA and RF. However, high heterogeneity among studies' results, partially ascribed to the unstandardised case definition of PD and laboratory testing of autoantibodies. Apart from ACPA and RF in serum, studies which reported on other RA-related autoantibodies, as well as autoantibody levels in saliva and GCF were scarce.

CONCLUSION

RA patients with PD tend to have greater ACPA and RF levels in their serum when compared with the RA patients without PD supporting the plausible role of PD in the development of systemic autoimmunity in RA patients.

Total, free, and bioavailable 25-hydroxyvitamin D levels in patients with periodontitis (stage III): a case-control study

OBJECTIVE

The aim of this study was to investigate the relationship between total, free and bioavailable 25-hydroxyvitamin D levels, and periodontitis.

MATERIALS AND METHODS

Thirty-nine patients with periodontitis diagnosis and 44 healthy participants were included in this study. 25-Hydroxyvitamin D, vitamin D-binding protein, procalcitonin, and albumin levels were measured from the serum samples obtained. Free and bioavailable 25-hydroxyvitamin D levels were calculated. Total, free, and bioavailable 25-hydroxyvitamin D levels were compared between the healthy control and periodontitis groups. The association of total 25 (OH)D levels with periodontitis was tested through univariate analysis and multivariate logistic regression.

RESULTS

Total 25-hydroxyvitamin D, bioavailable 25-hydroxyvitamin D, and free 25-hydroxyvitamin D levels were significantly lower in the periodontitis group than in the healthy control group (p < 0.001). In the logistic regression analysis, a significant correlation was observed between total 25-hydroxyvitamin D and periodontitis (p<0.001).

CONCLUSION

Our study shows that there is a relationship between total, free and bioavailable 25-hydroxyvitamin D levels and periodontitis. In addition, it has been shown that the determination of free and bioavailable 25-hydroxyvitamin D levels does not provide additional advantages in terms of the relationship between periodontitis and vitamin D.

CLINICAL RELEVANCE

In this case-control study, we examined the relationship between total, free and bioavailable 25-hydroxyvitamin D and periodontitis. We found lower total, free, and bioavailable 25-hydroxyvitamin D levels in periodontitis patients. It was also found that vitamin D-binding protein may be an important biomarker in the identification of various forms of periodontal disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05343273.

Periodontitis is a potential risk factor for transient ischemic attack and minor ischemic stroke in young adults: A nationwide population-based cohort study

BACKGROUND

This study aims to determine whether periodontitis is a risk factor for transient ischemic attack (TIA) in young adults.

METHODS

The National Health Insurance (NHI) Research Database in Taiwan was the source of the data used in this retrospective cohort study. Individuals aged 20 to 53 years with periodontitis in 2001 and 2002 (n = 792,426) and an age- and sex-matched control group (n = 792,426) were selected. All participants were followed up until TIA diagnosis, 55 years of age, removal from the NHI program, death, or December 31, 2016. The incidence density and hazard ratio (HR) of new-onset TIA were compared between individuals with periodontitis and controls. Periodontitis was defined by dentists according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 523.3-5 with concurrent antibiotic prescription or periodontal treatment excluding scaling performed by certified dentists. TIA was defined according to the ICD-9-CM code 435.x at hospital discharge.

RESULTS

After adjustment for confounding factors, the risk of developing TIA/minor ischemic stroke was calculated to be higher in participants with periodontitis (HR, 1.24; 95% confidence interval, 1.15-1.32; P <0.001) than in those without. The HR was slightly higher among people aged 20 to 40 years than among those aged 40 to 53 years.

CONCLUSION

Periodontitis is associated with an increased risk of developing TIA/minor ischemic stroke. Periodontitis might be a modifiable risk factor for stroke in young adults. Clinicians must devote greater attention to this potential association to develop new preventive and therapeutic strategies for stroke in young adults.

Treatment resistance of rheumatoid arthritis relates to infection of periodontal pathogenic bacteria: a case-control cross-sectional study

Recent studies have shown that periodontitis is associated with rheumatoid arthritis (RA) and periodontal bacteria, such as Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) are involved in the pathogenesis of RA via citrullinated proteins. Smoking has also been shown to be involved in the pathogenesis of RA; however, the extent of this involvement is still poorly understood. In addition, RA and polymyalgia rheumatica (PMR) are sometimes difficult to differentiate; however, the relationship between PMR and the factors from smoking and periodontal bacteria is unclear. The aim of this study was to clarify the relationship between periodontal pathogenic bacterial infections and smoking in patients with RA or PMR. This case–control study included 142 patients with untreated RA or PMR. This study evaluated the serum antibody titers against periodontal pathogenic bacterial antigens and an anti-citrullinated peptide antibody (ACPA). In patients with RA, the relationship between antibody titers and disease activity of RA and response after 3 months of treatment was also investigated. Additionally, the effects of smoking were evaluated. Although there was no significant difference in serum antibody titer against periodontal pathogenic bacteria between the ACPA-positive RA group and the ACPA-negative PMR group, we found an association between the elevated antibody titer against Pg and the degree of ACPA value, especially between negative group and high-value positive group (≥ 100 U/mL). The antibody titers against Aa and Pg did not differ depending on disease activity score 28 (DAS28) at baseline; however, patients with high antibody titers had poor RA therapeutic response as judged by DAS28 after 3 months. We could not find any association between smoking and any of these parameters. Periodontal pathogenic bacteria, especially Pg, are associated with elevated ACPA levels. Our findings suggest that Pg and Aa infections interfere with the therapeutic response of RA.

Periodontal Treatment for Chronic Periodontitis With Rheumatoid Arthritis

BACKGROUND

History of rheumatoid arthritis (RA) increases risk of periodontal diseases. A pro-inflammatory condition noted in periodontitis is considered a trigger for RA. Thus, periodontal treatment aimed at attenuating the pro-inflammatory state could aid in potentially reducing the risk of RA.

AIMS

The objective of this research was to assess the effect of periodontal therapy on rheumatoid factor, Disease Activity Score-28, anti-citrullinated protein antibody, and C-reactive protein levels in patients with chronic periodontitis (CP) and RA.

MATERIALS AND METHODS

The sample consisted of 28 patients with CP and RA. The study was designed to be a double-blind, randomised controlled clinical study. The samples were randomly categorised to either the treatment group (n = 13) or the control group (n = 15). CP status (plaque index, bleeding on probing, probing pocket depth, clinical attachment loss), clinical rheumatologic status (Disease Activity Score), and biochemical status (C-reactive protein, anti-citrullinated protein antibody, and rheumatoid factor) were assessed at baseline and at follow-up at 8 to 12 weeks.

RESULTS

The treatment group showed a highly statistically significant reduction in bleeding on probing (P < .005), probing pocket depth (P < .001), plaque index (P < .001), and C-reactive protein (P < .001); a gain in the clinical attachment loss (P < .001) and an improvement in Disease Activity Score-28 (P = .001) were observed at reassessment following nonsurgical periodontal treatment as compared to the control group. However, blood serum anti-citrullinated protein antibody (P = .002) and rheumatoid factor levels (P = .351) were found to increase from baseline to 8 to 12 weeks following subgingival scaling and root planing.

CONCLUSIONS

Reduction of inflammation in the periodontium by nonsurgical periodontal therapy did not reduce anti-citrullinated protein antibody and rheumatoid factor levels. However, it has shown improvement in periodontal conditions, and remarkable changes were observed in the clinical Disease Activity Score and C-reactive protein levels of individuals with RA.

Managing the Systemic Impact of Periodontitis

Periodontitis is a microbially driven host-mediated disease that leads to loss of periodontal attachment and bone. It is associated with elevation of systemic inflammatory markers and with the presence of systemic co-morbidities. Furthermore, periodontal treatment leads to a 24-48 h-long acute local and systemic inflammatory response. This systemic response might increase the burden of patients with compromised medical history and/or uncontrolled systemic diseases. The correlation between periodontitis and systemic diseases, the impact of periodontitis on the quality of life and public health, the effects of periodontal treatment on systemic health and disease, and the available methods to manage systemic inflammation after periodontal therapy are discussed. The main focus then shifts to a description of the existing evidence regarding the impact of periodontitis and periodontal treatment on systemic health and to the identification of approaches aiming to reduce the effect of periodontitis on systemic inflammation.

Maladaptive trained immunity and clonal hematopoiesis as potential mechanistic links between periodontitis and inflammatory comorbidities

Periodontitis is bidirectionally associated with systemic inflammatory disorders. The prevalence and severity of this oral disease and linked comorbidities increases with aging. Here, we review two newly emerged concepts, trained innate immunity (TII) and clonal hematopoiesis of indeterminate potential (CHIP), which together support a potential hypothesis on how periodontitis affects and is affected by comorbidities and why the susceptibility to periodontitis and comorbidities increases with aging. Given that chronic diseases are largely triggered by the action of inflammatory immune cells, modulation of their bone marrow precursors, the hematopoietic stem and progenitor cells (HSPCs), may affect multiple disorders that emerge as comorbidities. Such alterations in HSPCs can be mediated by TII and/or CHIP, two non-mutually exclusive processes sharing a bias for enhanced myelopoiesis and production of innate immune cells with heightened proinflammatory potential. TII is a state of elevated immune responsiveness based on innate immune (epigenetic) memory. Systemic inflammation can initiate TII in the bone marrow via sustained rewiring of HSPCs, which thereby display a skewing toward the myeloid lineage, resulting in generation of hyper-reactive or "trained" myeloid cells. CHIP arises from aging-related somatic mutations in HSPCs, which confer a survival and proliferation advantage to the mutant HSPCs and give rise to an outsized fraction of hyper-inflammatory mutant myeloid cells in the circulation and tissues. This review discusses emerging evidence that supports the notion that TII and CHIP may underlie a causal and age-related association between periodontitis and comorbidities. A holistic mechanistic understanding of the periodontitis-systemic disease connection may offer novel diagnostic and therapeutic targets for treating inflammatory comorbidities.

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.

Does non-surgical periodontal treatment influence on rheumatoid arthritis? A systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review was to evaluate the efficacy of non-surgical periodontal therapy on rheumatoid arthritis activity.

MATERIAL AND METHODS

Articles published until April 2019 were electronically searched and screened using PubMed / MEDLINE, Scopus, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). This study was recorded in the international PROSPERO database (CRD42019132205). The PICO question (population, intervention, comparison, results) was: in adult patients with rheumatoid arthritis and periodontitis (P), does non-surgical periodontal treatment (I), as compared to no treatment (C), provides better outcomes in rheumatoid arthritis activity (O).

RESULTS

After searching the databases, seven articles were selected for qualitative and five for quantitative analysis. The total number of participants included was 292, with an average age of 50.5 years. All patients had rheumatoid arthritis and periodontal disease. Non-surgical periodontal treatment significantly reduced Disease Activity Score 28 (P = 0.004; I2 = 92%) and erythrocyte sedimentation rate (P = 0.01; I2 = 78%), but with no significant effect on C-reactive protein (P = 0.34; I2 = 92%).

CONCLUSIONS

It can be concluded that non-surgical periodontal treatment can benefit patients with rheumatoid arthritis.

Association Between Rheumatoid Arthritis Disease Activity and Periodontitis Defined by Tooth Loss: Longitudinal and Cross-Sectional Data From Two Observational Studies

OBJECTIVE

To analyze the effect of tooth loss/periodontitis on disease activity in early and established rheumatoid arthritis (RA).

METHODS

Participants of the Course And Prognosis of Early Arthritis (CAPEA) early arthritis cohort reported their number of teeth at baseline. The number of teeth had been validated as a predictor of periodontitis. Clinical end points, including disease activity score (Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [ESR]), swollen joint count (SJC), ESR, and C-reactive protein level were collected at baseline, 3, 6, 12, 18, and 24 months. We used linear mixed regression models to estimate the association between tooth loss and clinical end points over time in early arthritis. For established RA, we analyzed cross-sectional data from the German National Database (NDB). All models accounted for age, sex, smoking, seropositivity, education level, and disease duration (only NDB).

RESULTS

Among 1,124 CAPEA participants with early arthritis, those with higher tooth loss were older, more often male, smokers, and seropositive, and they had higher disease activity and inflammation markers at baseline. Tooth loss was associated with higher disease activity and ESR values over time. Inflammatory markers decreased comparably across tooth loss categories. Glucocorticoid use was higher among those with more tooth loss, whereas dose reduction was similar across tooth loss categories. Among 7,179 NDB participants with longstanding RA, disease activity and inflammation markers but not SJC were significantly higher in patients with more tooth loss.

CONCLUSION

Although we observed an association between tooth loss and disease activity scores and inflammation markers in early and established RA, longitudinal results suggest that tooth loss does not hamper treatment response.

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.

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.

Tooth Loss Is Associated with Disease-Related Parameters in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis-A Cross-Sectional Study

Background: The aim of this cross-sectional study was to investigate potential associations between periodontal inflamed surface area (PISA) and tooth loss with disease-related parameters in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Methods: Patients who attended the Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Germany, were included. The oral examination comprised the detection of the number of remaining teeth and periodontal condition based on staging and grading matrix. Based on periodontal pockets with positive bleeding on probing, the periodontal inflamed surface area (PISA) was determined. Disease related parameters were extracted from the patients’ records. Results: In total, 101 (RA) and 32 participants (AS) were included. Patients with RA had 22.85 ± 4.26 and AS patients 24.34 ± 5.47 remaining teeth (p < 0.01). Periodontitis stage III and IV was present in 91% (RA) and 81.2% (AS) of patients (p = 0.04). Associations between PISA and disease-related parameters were not found in both groups (p > 0.05). In RA, a higher age (p < 0.01), C-reactive protein (p = 0.02), disease activity (p < 0.01) and prednisolone intake (p < 0.01) were associated with fewer remaining teeth. In AS, a higher age (p = 0.02) and increased Bath Ankylosing Spondylitis Metrology Index (p = 0.02) were associated with a lower number of remaining teeth. Conclusions: Tooth loss is associated with disease activity, especially in RA individuals. Dental care to prevent tooth loss might be recommendable to positively influence oral health condition and disease activity in RA and SA patients.

Effects of nonsurgical periodontal therapy in patients with rheumatoid arthritis: a prospective before and after study

Background

periodontal therapy has been suggested to have systemic effects. However, studies of periodontal therapy in rheumatoid arthritis patients have produced controversial results.

Aim

To compare the effects of nonsurgical periodontal therapy on biochemical markers of rheumatoid arthritis and periodontal parameters in patients with and without rheumatoid arthritis.

Methods

a prospective before-and-after study was conducted that included 21 participants without and 29 participants with rheumatoid arthritis. Periodontal parameters, Porphyromonas gingivalis detection, C-reactive protein, rheumatoid factor and anti-citrullinated protein antibodies were measured at baseline and three months after nonsurgical periodontal therapy and the changes were statistically assessed.

Results

In general, both groups presented statistically significant improvement in periodontal parameters (p<0.05). There was an increase in the counts of P. gingivalis in both groups at three months. In addition, there was a reduction in levels of anti-citrullinated protein antibodies and rheumatoid factor in participants with rheumatoid arthritis. In contrast, C-reactive protein levels increased in both groups but were higher in the rheumatoid arthritis group. Periodontal parameters in rheumatoid arthritis participants under disease-modifying antirheumatic drugs presented a slightly higher improvement (p <0.05).

Conclusions

Nonsurgical periodontal therapy has similar improvements in periodontal parameters in patients with and without rheumatoid arthritis. In addition, nonsurgical periodontal therapy may benefit serum levels of anti-citrullinated protein antibodies and rheumatoid factors in patients with rheumatoid arthritis. NCT04658615.

Evidence-based research on effectiveness of periodontal treatment in rheumatoid arthritis patients: a systematic review and meta-analysis

OBJECTIVES

To gauge the evidence of periodontal therapy's impact on measures of disease activity and systemic inflammatory burden in individuals with rheumatoid arthritis (RA).

METHODS

A search for randomised trials and controlled cohort studies of RA patients with Periodontitis was conducted on 7 April 2019, with an update on 17 December 2020, in PubMed, Cochrane Library (CENTRAL), Embase, http://clinicaltrials.gov/, and WHO-ICTRP portal (PROSPERO: CRD42018103359). Two reviewers screened titles/abstracts and selected papers for full-text review. We used OMERACT-endorsed outcome domains for RA trials and summarised continuous outcomes using standardised mean differences (SMDs) with 95% confidence intervals (95% CIs). We evaluated inconsistency using the I² statistic and combined SMDs using random-effects models for the meta-analyses; fixed-effect meta-analyses were used for sensitivity analysis. To explore heterogeneity, we added stratified/meta-regression analyses, expressed in T² .

RESULTS

Of the 1909 studies identified, 9 (incl. 10 comparisons) were eligible for quantitative synthesis (n = 388). Evidence suggested a favourable effect of periodontal treatment on disease activity (SMD -0.88[95% CI,-1.38 to -0.38], n=311). The GRADE approach was used to judge the estimates' certainty; evidence rated as having 'low' or 'very low-certainty' indicated that any possible effect of periodontal treatment in RA is likely to change as more evidence is provided. Selection bias and RA medication stability were highlighted as sources of heterogeneity between studies.

CONCLUSIONS

There is an urgent need for a well-designed prospective cohort study (preferably an RCT) of patients with RA and Periodontitis using rigorous protocols, standardised diagnostic criteria, data collection, and adequate duration of follow-up.

Non-surgical periodontal treatment improves rheumatoid arthritis disease activity: a meta-analysis

OBJECTIVES

The aim of the meta-analysis was to clarify the efficacy of non-surgical periodontal treatment (NSPT) in improving rheumatoid arthritis (RA) disease activity.

METHODS

A systematic literature search was conducted using the PubMed, Embase, and Cochrane databases up to October 2020. A total of nine studies were included for the comparison of RA-related indicator changes between the NSPT group and no treatment (NT) group. Mean differences (MD) and 95% confidence intervals (CI) were calculated for disease activity score (DAS28), erythrocyte sedimentation rate (ESR), tender joint counts (TJC), swollen joint counts (SJC), visual analogical scale (VAS), morning stiffness (MS), rheumatoid factor (RF), C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin-6 (IL-6).

RESULTS

NSPT induced significant reductions of DAS28 (MD: 0.61, 95% CI: 0.37, 0.85, P < 0.001), TJC (MD: 0.65, 95% CI: 0.37, 0.93, P < 0.001), SJC (MD: 0.67, 95% CI: 0.18, 1.17, P = 0.008), VAS (MD: 0.48, 95% CI: 0.08, 0.88, P = 0.02), and CRP (MD: 0.34, 95% CI: 0.07, 0.64, P = 0.01) in RA patients with periodontitis. Other parameters showed a trend toward reduction, but results were not statistically significant.

CONCLUSIONS

This meta-analysis indicates that NSPT could improve RA activity as assessed by DAS28, TJC, SJC, VAS, and CRP.

CLINICAL RELEVANCE

The results emphasize the effectiveness and need for periodontal diagnosis and periodontal therapy in rheumatoid arthritis patients to reduce disease activity.

Porphyromonas gingivalis and Its Systemic Impact: Current Status

The relationship between periodontitis and systemic diseases, notably including atherosclerosis and diabetes, has been studied for several years. Porphyromonas gingivalis, a prominent component of oral microorganism communities, is the main pathogen that causes periodontitis. As a result of the extensive analysis of this organism, the evidence of its connection to systemic diseases has become more apparent over the last decade. A significant amount of research has explored the role of Porphyromonas gingivalis in atherosclerosis, Alzheimer's disease, rheumatoid arthritis, diabetes, and adverse pregnancy outcomes, while relatively few studies have examined its contribution to respiratory diseases, nonalcoholic fatty liver disease, and depression. Here, we provide an overview of the current state of knowledge about Porphyromonas gingivalis and its systemic impact in an aim to inform readers of the existing epidemiological evidence and the most recent preclinical studies. Additionally, the possible mechanisms by which Porphyromonas gingivalis is involved in the onset or exacerbation of diseases, together with its effects on systemic health, are covered. Although a few results remain controversial, it is now evident that Porphyromonas gingivalis should be regarded as a modifiable factor for several diseases.

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.

Identification of Small-Molecule Inhibitors Targeting Porphyromonas gingivalis Interspecies Adherence and Determination of Their In Vitro and In Vivo Efficacies

Porphyromonas gingivalis is one of the primary causative agents of periodontal disease and initially colonizes the oral cavity by adhering to commensal streptococci. Adherence requires the interaction of a minor fimbrial protein (Mfa1) of P. gingivalis with streptococcal antigen I/II (AgI/II). Our previous work identified an AgI/II peptide that potently inhibited adherence and significantly reduced P. gingivalis virulence in vivo, suggesting that this interaction represents a potential target for drug discovery.

Porphyromonas gingivalis is one of the primary causative agents of periodontal disease and initially colonizes the oral cavity by adhering to commensal streptococci. Adherence requires the interaction of a minor fimbrial protein (Mfa1) of P. gingivalis with streptococcal antigen I/II (AgI/II). Our previous work identified an AgI/II peptide that potently inhibited adherence and significantly reduced P. gingivalis virulence in vivo, suggesting that this interaction represents a potential target for drug discovery. To develop targeted small-molecule inhibitors of this protein-protein interaction, we performed a virtual screen of the ZINC databases to identify compounds that exhibit structural similarity with the two functional motifs (NITVK and VQDLL) of the AgI/II peptide. Thirty three compounds were tested for in vitro inhibition of P. gingivalis adherence and the three most potent compounds, namely, N7, N17, and V8, were selected for further analysis. The in vivo efficacy of these compounds was evaluated in a murine model of periodontitis. Treatment of mice with each of the compounds significantly reduced maxillary alveolar bone resorption in infected animals. Finally, a series of cytotoxicity tests were performed against human and murine cell lines. Compounds N17 and V8 exhibited no significant cytotoxic activity toward any of the cell lines, whereas compound N7 was cytotoxic at the highest concentrations that were tested (20 and 40 μM). These results identify compounds N17 and V8 as potential lead compounds that will facilitate the design of more potent therapeutic agents that may function to limit or prevent P. gingivalis colonization of the oral cavity.

Microbial Influences of Mucosal Immunity in Rheumatoid Arthritis

PURPOSE OF REVIEW

This review will summarize recent data defining the relationship between rheumatoid arthritis (RA) and the microbiome at mucosal sites throughout the body. It will highlight what is known, what is speculated, and current knowledge gaps regarding the microbiome in RA.

RECENT FINDINGS

An extensive relationship between the microbiome and immune cell function can influence RA-related inflammation and T cell and B cell biology. Studies are beginning to characterize microbial changes in individuals who are at risk for RA, which is a critical element needed to understand the influence of the microbiome on RA pathogenesis. Expanding our understanding of the microbiome in RA beyond the bacteria at the gut and oral mucosae into the lung and urogenital surfaces, including viral and fungal components, and establishing the relationship across mucosal sites will be critical in future work. Importantly, approaches to manipulate the microbiome could lead to novel therapeutic and preventive strategies.

Prevention and management of periodontal diseases and dental caries in the older adults

As a result of aging populations, in the future, dental practitioners will be caring for more older adults than ever before. These older adults, especially in developed countries, will demand a greater number of dental services, driven by increased tooth retention and an expectation of excellent oral healthcare throughout the life course. Further, the global rise in the prevalence and incidence of chronic diseases will increase the risk and/or severity of oral diseases and add a layer of complexity to the management of oral diseases in older adults. More older adults will be at a higher risk of periodontal disease and root caries as a result of reduced tooth loss and edentulism. This article reviews information on periodontitis and root caries, oral diseases which reflect the cumulative risk of the individual, and which are best addressed through prevention. Oral healthcare providers must embrace the concept of lifelong emphasis on prevention, as well as participation as active members of a healthcare team which provides healthcare for older adults in various settings (eg, hospital/clinic-based care, community-based settings, and long-term care facilities). National guidelines that address oral health are being considered by some countries, and if these are implemented they will increase the accessibility to oral health for older adults. In parallel to this, revisions of existing older adult insurance schemes (eg, the inclusion of routine oral healthcare in the US Medicare program) would promote the maintenance of a functional dentition that is pain-free and conducive to general health. The opportunity exists to implement a holistic approach to oral health that will align oral health with general health and emphasize that true health can only be achieved with the inclusion of oral health.

[Protein arginine deiminase of oral microbiome plays a causal role in the polyarthritis rheumatoid initiating]

In the last decade, the association between the periodontitis and rheumatoid arthritis (RA) has been established, suggesting that oral microbiome plays a causal role by initiating this chronic autoimmune inflammatory disease of articulation. Both pathogenesis are similar in term of chronic inflammation, tissue breakdown and bone resorption. Molecular aspects have also revealed that citrullination, a post-translational modification catalyzed by peptidyl-arginine deiminases (PADs), is involved in both diseases. For RA, citrullinated proteins production leads to the synthesis the of anti-citrullinated protein antibodies triggering the loss of immune tolerance. In humans, five PADs have been identified. Recently, studies have found that only Porphyromonas species possess PAD. Thus, a major periodontal pathogen, Porphyromonas gingivalis, is able to generate citrullinated epitopes, and could consequently induce anti-citrullinated protein antibodies. In this review, citrullination process, periodontitis and RA are described to put them in relation with molecular, clinical and epidemiological studies establishing the association between periodontitis and RA.

Association of cytokine patterns and clinical/laboratory parameters, medication and periodontal burden in patients with rheumatoid arthritis (RA)

To evaluate serum levels of the following cytokines in rheumatoid arthritis subjects with periodontal disease: Interleukin-6, -10, -17, and -23. Patients with rheumatoid arthritis frequently suffer from periodontal disease. Both diseases partly result from a dysregulated immune response. The current study aimed to quantify Interleukin-6, -10, -17, and -23 levels in rheumatoid arthritis. It should be investigated if the periodontal disease would have additional modifying effects. A total of 157 patients were included. Serum levels of IL-6, -10, -17, and -23 were measured by ELISA. Serum IL-10 increased with longer duration of morning stiffness and with higher rheumatoid factor and anti-cyclic citrullinated peptide titres. IL-10 was also elevated with longer duration of prednisolone (< 5 mg daily) and leflunomide therapy. Subjects with lower erythrocyte sedimentation rate/longer leflunomide therapy displayed more missing teeth/more clinical attachment loss. IL-17 was higher in subjects with fewer missing teeth if the following criteria were fulfilled: shorter prednisolone (< 5 mg) and methotrexate therapy, more swollen joints, longer morning stiffness. IL-23 finally was increased in subjects with higher rheumatoid factor and in those with higher periodontal probing depth/clinical attachment loss in the following situations: lower rheumatoid factor and shorter leflunomide therapy. Subjects suffering from dental/periodontal burden show an aberrant systemic cytokine availability of serum IL-6, IL-10, IL-17 and IL-23 related to disease activity and medication. This examination underlines the complexity of potential interactions between disease activity and medication related to periodontal burden.

Is there a bidirectional association between rheumatoid arthritis and periodontitis? A systematic review and meta-analysis

BACKGROUND

Several lines of evidence suggest a bi-directional association between Rheumatoid Arthritis (RA) and Periodontitis (PD). Our aim was to systematically appraise the evidence on the association between RA and PD in terms of clinical and laboratory outcomes.

METHODS

An electronic search of several databases (PubMed, EMBASE, MEDLINE, LILACS, CINHL, Scopus, Web of Science, The Cochrane Library, OpenGrey and Google Scholar) was conducted up to March 2019 (PROSPERO CRD42018107817) by two independent reviewers. Observational studies included in the review were quality-appraised using the Newcastle-Ottawa Scale (NOS) tool. Random effects models were used for quantitative analyses.

RESULTS

A total of 8 case-control studies were identified after the final search of 1491 titles. Following quality assessment, 2 studies were excluded due to the high risk of bias, while the remaining 6 were further analysed. Meta-analyses revealed no substantial effect of RA on the Probing Pocket Depth (PPD) and Clinical Attachment Level (CAL) of patients with PD when compared to controls but high degree of study heterogeneity was found. To the contrary, PD was associated with substantially worse RA disease activity as assessed by an increase in the DAS28 score of 0.74 (0.25-1.24, 95%CI, p < 0.001).

CONCLUSION

There is consistent evidence suggesting that PD is associated with worse RA clinical activity as assessed by DAS28 scores whereas, RA patients do not have worsen PD clinical outcomes.

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.

A review of the influence of periodontal treatment in systemic diseases

The effects and consequences of periodontal diseases might not be confined to the oral cavity. A great body of evidence has arisen supporting the claim demonstrating an association with several systemic conditions and diseases. With different levels of evidence, an association between periodontal disease and cardiovascular disease, diabetes, psoriasis, rheumatoid arthritis, pregnancy outcomes and respiratory diseases has been established. However, the true nature of this association, if it is causal, still remains elusive. For a better understanding of the complex relationships linking different conditions, interventional studies now begin to focus on the possible outcomes of periodontal treatment in relation to the events, symptoms and biomarkers of several systemic disorders, assessing if periodontal treatment has any impact on them, hopefully reducing their severity or prevalence. Therefore, we proceeded to review the recent literature on the subject, attempting to present a brief explanation of the systemic condition or disease, what proposed mechanisms might give biological plausibility to its association with periodontal disease, and finally and more importantly, what data are currently available pertaining to the effects periodontal treatment may have. Raising awareness and discussing the possible benefits of periodontal treatment on overall systemic health is important, in order to change the perception that periodontal diseases are only limited to the oral cavity, and ultimately providing better and comprehensive care to patients.

Inhibition of Ctsk modulates periodontitis with arthritis via downregulation of TLR9 and autophagy

Objectives

The mechanisms underlying the effects of Toll‐like receptor 9 (TLR9) and autophagy on rheumatoid arthritis (RA)‐aggravated periodontitis are unclear. We aimed to explore a novel target, cathepsin K (Ctsk)‐mediated TLR9‐related autophagy, during the progress of periodontitis with RA.

Materials and Methods

DBA/J1 mouse model of periodontitis with RA was created by local colonization of Porphyromonas gingivalis (Pg) and injection of collagen. The expression of Ctsk was inhibited by adeno‐associated virus (AAV). Micro‐CT, immunohistochemistry (IHC), Western blot and quantitative real‐time polymerase chain reaction (qRT‐PCR) were used to detect the expression of TLR9‐related autophagy in periodontitis with RA. Small interfering RNA (siRNA) and CpG oligodeoxynucleotides (CpG ODN) were applied in macrophages. Western blot, immunofluorescence (IF) and qRT‐PCR were used to verify the in vivo results.

Results

RA can promote periodontitis bone destruction in the lesion area, while inhibiting Ctsk could effectively alleviate this effect. The infiltration of macrophages, TLR9, autophagy proteins (TFEB and LC3) and inflammatory cytokines increased in the periodontitis‐with‐RA group and was reduced by the inhibition of Ctsk in the periodontal region. Macrophage stimulation confirmed the in vivo results. With the activation of TLR9 by CpG ODN, inhibition of Ctsk could suppress both TLR9 downstream signalling proteins and autophagy‐related proteins.

Conclusions

This study advanced a novel role for Ctsk in TLR9 and autophagy to explain the interaction between periodontitis and RA.

Predictive factors related to the progression of periodontal disease in patients with early rheumatoid arthritis: a cohort study

Background

Rheumatoid arthritis (RA) and periodontal disease are inter-related conditions. However, factors predictive of periodontal disease progression in patients with early rheumatoid arthritis (eRA) are lacking. The aim of this study was to identify factors associated with the progression of clinical attachment loss (CAL) in interproximal dental sites of eRA patients.

Methods

Twenty-eight eRA patients were evaluated for the progression of CAL at 280 interproximal dental sites at 1 year of follow-up. Markers of RA activity (rheumatoid factor, erythrocyte sedimentation rate, and C-reactive protein), a marker of bone resorption (Dickkopf-related protein 1), Disease Activity Score 28 and Simple Disease Activity Index were included as potential systemic predictive factors. Plaque index, gingival index, pocket depth, clinical attachment level and Dickkopf-related protein 1 in crevicular fluid at baseline were included as potential local predictive factors. Data were analysed in a hierarchical structure using generalised linear mixed models for progression at each site (> 2 mm) during follow-up.

Results

C-reactive protein level was the most important predictive systemic factor for the progression of CAL. The mean CAL and a high degree of gingival inflammation in interproximal sites at baseline were important predictive local factors (p <  0.0001). Patients who received combined treatment with disease-modifying antirheumatic drugs and corticosteroids exhibited less CAL (p <  0.0001). The predictive value of the generalised linear mixed model for progression was 85%.

Conclusions

Systemic factors, including RA disease activity and baseline periodontal condition, were associated with periodontal progression. Pharmacological treatment may affect periodontal progression in patients with early RA.

Periodontitis As A Risk Factor For Stroke: A Systematic Review And Meta-Analysis

This systematic review and meta-analysis investigate the association between periodontitis and stroke. This review followed the methods established by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Searches were conducted in five databases and two sources of grey literature. After the selection of the articles, a risk of bias evaluation was performed. Three meta-analyzes were performed: Assessing the overall association between stroke and periodontitis in case–control studies; Ischemic stroke and periodontitis in case–control studies; The association between stroke and periodontitis in cohort studies. Heterogeneity was assessed using the I² index and the odds ratio was also calculated (p < 0.05). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate the level of evidence. 2193 potentially relevant studies were identified, with 10 studies included in qualitative and quantitative analysis. All the articles were considered with low risk of bias and a low level of certainty. The results demonstrated a positive association between both disorders and increased risk for stroke among cohort studies (RR 1.88 [1.55, 2.29], p<0.00001, I²=0%) and for ischemic stroke events in case–control studies (RR 2.72 [2.00, 3.71], p<0.00001, I²= 4%). Periodontitis may represent a risk factor for stroke, especially in ischemic events. However, new studies with a robust design are necessary for a reliable conclusion.

Association between periodontitis and the risk of inadequate disease control in patients with rheumatoid arthritis under biological treatment

AIM

To assess the association between periodontitis (PD) and inadequate disease control (IDC) in patients with rheumatoid arthritis (RA) receiving biological therapy.

MATERIALS AND METHODS

In total, 111 RA patients receiving biological therapy for at least 3 months were assessed for periodontal disease at baseline. RA disease activity was assessed at baseline and at 3 months of follow-up. A multivariable logistic regression analysis was used to estimate the association between PD and IDC, adjusting for age, sex, smoking, diabetes, and baseline RA disease activity. An additional exploratory model further controlled for disease characteristics and other medications.

RESULTS

Among 111 patients, 84 (75.7%) had PD, of whom 37 (44.0%) received periodontal treatment. Thirty-four (40.5%) of PD patients had IDC; 12 (32.4%) of treated PD patients and 22 (46.8%) of untreated patients had IDC, respectively. The ORs (95% CIs) for IDC were 1.45 (0.50-4.23) in PD patients and 1.84 (0.59-5.76) in untreated PD patients. In the exploratory model, the ORs (95% CIs) for IDC were 5.00 (1.19-21.03) in PD patients and 6.26 (1.34-29.34) in untreated PD patients.

CONCLUSION

This single-centre, prospective study failed to demonstrate a consistently positive correlation between PD and IDC in RA patients receiving biological treatment.

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.

Role of good oral hygiene on clinical evolution of rheumatoid arthritis: a randomized study nested in the ESPOIR cohort

Objective

There is a relationship between RA and periodontal disease. We aimed to investigate if a good oral hygiene could improve activity of RA.

Methods

The patients with RA according to ACR/EULAR 2010 criteria and included in the French early arthritis ESPOIR cohort were included in a randomized nested study into: (i) intervention group: general recommendations of good oral hygiene including teeth brushing, daily antiseptic mouthwash and twice a year scaling; and (ii) control group: no intervention. The primary end point was the delta DAS28-ESR.

Results

Four hundred and seventy-two patients were randomized (238 in intervention and 234 in control). 92/238 from the intervention group accepted the procedure and 81 had a first visit to the dentist. 56% of patients had periodontal disease at baseline. Duration of RA was 9.0±0.7 years. Baseline DAS28-ESR was 2.7±1.3. After a median duration of 24 months, delta DAS28-ESR was −0.17±1.29 and −0.09±1.28 in intervention and control groups, respectively (mean difference (complier average causal effect): −0.37 (95% CI −1.12, 0.37), P = 0.33). In the intervention group, there was a significant decrease of the bacteria involved in the red complex: Porphyromonas gingivalis (P = 0.002), Tannerella forsythia (P = 0.002) and Treponema denticola (P = 0.019). The patients with baseline periodontal disease and those who became negative for one red complex bacterium had a slightly more important decrease of DAS28-ESR.

Conclusion

Oral hygiene instruction together with regular scaling and polishing of the teeth significantly decreased the load of periodontal pathogens but did not decrease RA activity. This intervention should be tested in patients with earlier RA and more active disease.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01831648.

Rheumatoid Arthritis-Associated Mechanisms of Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans

Rheumatoid arthritis (RA) is an autoimmune disease of unknown etiology characterized by immune-mediated damage of synovial joints and antibodies to citrullinated antigens. Periodontal disease, a bacterial-induced inflammatory disease of the periodontium, is commonly observed in RA and has implicated periodontal pathogens as potential triggers of the disease. In particular, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans have gained interest as microbial candidates involved in RA pathogenesis by inducing the production of citrullinated antigens. Here, we will discuss the clinical and mechanistic evidence surrounding the role of these periodontal bacteria in RA pathogenesis, which highlights a key area for the treatment and preventive interventions in RA.

Oral Bacteria and Intestinal Dysbiosis in Colorectal Cancer

The human organism coexists with its microbiota in a symbiotic relationship. These polymicrobial communities are involved in many crucial functions, such as immunity, protection against pathogens, and metabolism of dietary compounds, thus maintaining homeostasis. The oral cavity and the colon, although distant anatomic regions, are both highly colonized by distinct microbiotas. However, studies indicate that oral bacteria are able to disseminate into the colon. This is mostly evident in conditions such as periodontitis, where specific bacteria, namely Fusobacterium nucrelatum and Porphyromonas gingivalis project a pathogenic profile. In the colon these bacteria can alter the composition of the residual microbiota, in the context of complex biofilms, resulting in intestinal dysbiosis. This orally-driven disruption promotes aberrant immune and inflammatory responses, eventually leading to colorectal cancer (CRC) tumorigenesis. Understanding the exact mechanisms of these interactions will yield future opportunities regarding prevention and treatment of CRC.

Infliximab Induced a Dissociated Response of Severe Periodontal Biomarkers in Rheumatoid Arthritis Patients

OBJECTIVE

Rheumatoid arthritis and periodontal disease are associated together, but the effect of therapy provided for one disease to the second one remained under-investigated. This study investigated effect of infliximab therapy used to treat rheumatoid arthritis (RA) on various biomarkers of periodontal disease (PD) severity including serologies of Porphyromonas gingivalis and Prevotella intermedia and matrix metalloproteinase 3.

METHODS

Seventy nine RA patients were enrolled at the time to start infliximab therapy and the 28 joint disease activity score (DAS28), anti-cyclic citrullinated petides 2nd generation (anti-CCP2), anti-P. gingivalis antibody, and Matrix metalloproteinase 3 (MMP-3) were monitored before and at 6 months of infliximab therapy. Joint damage and severe periodontal disease were assessed at baseline. Anti-CCP2, anti-P. gingivalis antibody, and MMP-3 were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

At baseline, anti-CCP2 titers were associated with anti-P. gingivalis lipopolysaccharide (LPS)-specific antibodies titers (p < 0.05). Anti-P. gingivalis antibodies were not significantly correlated with clinical, biological, or destruction parameters of RA disease. At 6 months of infliximab therapy, MMP-3 level decreased (from 119 ± 103 ng/mL to 62.44 ± 52 ng/mL; p < 0.0001), whereas P. gingivalis antibody levels remained at the same level. DAS28 and inflammation markers C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) also decreased significantly during infliximab therapy (p < 0.05) as anti-CCP2 levels (p < 0.001). Only high MMP-3 level at baseline was associated with infliximab efficacy (p < 0.01).

CONCLUSION

MMP-3 level can be a useful marker of the efficacy of infliximab in RA patients. The treatment did not affect anti-P. gingivalis antibodies.

The effect of periodontal treatment on patients with rheumatoid arthritis: The ESPERA randomised controlled trial

OBJECTIVES

To assess the effect of periodontal treatment on clinical and biochemical parameters of rheumatoid arthritis (RA) and quality of life (QoL) in patients with moderately active RA who were diagnosed with periodontitis.

METHODS

In this open-label randomised controlled trial, RA subjects (n = 22) were allocated to "immediate" or "delayed" periodontal treatment (full-mouth non-surgical scaling and root planing, systemic antibiotics, and oral hygiene instructions). The main outcome was the 3-month change on the Disease Activity Score 28 based on the Erythrocyte Sedimentation Rate (DAS28-ESR). The Health Assessment Questionnaire and the General Oral Health Assessment Index were used to assess general and oral health QoL, respectively.

RESULTS

Periodontal health significantly improved after periodontal treatment (P = 0.03). Periodontal treatment appeared to be safe but led to no significant effects on the DAS28-ESR (adjusted mean difference with 95% confidence interval (aMD) of -0.03 [-0.98; 0.92]). There was no evidence of improvement in the general QoL after periodontal treatment and no significant effect was found for the oral health QoL, despite a positive trend in the "psychological impacts" domain (aMD of 0.13 [-0.07; 0.33], P = 0.20).

CONCLUSIONS

Although no clinical effect of periodontal treatment on RA was identified, this trial provides important data to support periodontal care in RA patients. Periodontal treatment is safe and reduces oral inflammation with a possible effect on oral health QoL. Since both periodontitis and RA are complex and multifactorial chronic diseases, it is likely that patient-centred approaches involving both oral health professionals and rheumatologists will contribute to optimal patient care. ISRCTN79186420.

Effect of periodontal therapy on disease activity in patients of rheumatoid arthritis with chronic periodontitis

Background

Evidence have been proposed a positive association between severity of Periodontitis and Rheumatoid arthritis (RA) activity, individuals with advanced RA are more likely to develop periodontal problems compared to their non-RA counterparts, and vice versa. Studies have been suggested that RA manifest as a result of an inflammatory imbalance and autoimmunity. In this perspective, treatment modalities that lead to inhibition of proinflammatory mediators, may prove beneficial for reducing the severity of RA. This study examined the effects of non surgical periodontal therapy (NSPT) on disease activity of RA.

Methods

Diagnosed patients of active rheumatoid arthritis with chronic periodontitis were recruited in this study and divided in to treatment and controls groups, both groups were similar in all demographics assessed. Treatment group (n = 20) and controls group (n = 20) underwent assessment for periodontal clinical parameters (plaque index, gingival index, probing pocket depth, clinical attachment level), Rheumatologic clinical (simplified disease activity index) and biochemical parameters(C-reactive protein, Rheumatoid factor, Anti-cyclic citrullinated protein) at baseline and 8 weeks. Serum levels of biochemical parameters were measured by enzyme-linked immunosorbent assay (ELISA).

Results

The statistically significant (p < 0.001) reduction observed in mean values of PI, GI, PPD, CAL, SDAI in treatment group at 8weeks after NSPT as compare to control group. However serum level of ACCPA, CRP and RF did not show statistically significant (p > 0.05) changes from baseline to reassessment (8 weeks) in both groups.

Conclusions

The improvement in RA disease activity may occurs after non surgical periodontal therapy.

The Biological Efficacy of Natural Products against Acute and Chronic Inflammatory Diseases in the Oral Region

The oral inflammatory diseases are divided into two types: acute and chronic inflammatory diseases. In this review, we summarize the biological efficacy of herbal medicine, natural products, and their active ingredients against acute and chronic inflammatory diseases in the oral region, especially stomatitis and periodontitis. We review the effects of herbal medicines and a biscoclaurin alkaloid preparation, cepharamthin, as a therapy against stomatitis, an acute inflammatory disease. We also summarize the effects of herbal medicines and natural products against periodontitis, a chronic inflammatory disease, and one of its clinical conditions, alveolar bone resorption. Recent studies show that several herbal medicines such as kakkonto and ninjinto reduce LPS-induced PGE2 production by human gingival fibroblasts. Among herbs constituting these herbal medicines, shokyo (Zingiberis Rhizoma) and kankyo (Zingiberis Processum Rhizoma) strongly reduce PGE2 production. Moreover, anti-osteoclast activity has been observed in some natural products with anti-inflammatory effects used against rheumatoid arthritis such as carotenoids, flavonoids, limonoids, and polyphenols. These herbal medicines and natural products could be useful for treating oral inflammatory diseases.