General oral status in adults with rheumatoid arthritis

Systemic Factors Affecting Prognosis in Restorative and Prosthetic Dentistry: A Review

The field of restorative and prosthetic dentistry focuses on restoring lost tooth structures and replacing missing teeth and lost tissue to restore or improve esthetics and oral health. Many systemic factors such as metabolic, bone, autoimmune, cardiovascular, and endocrine disorders can affect healing procedures, and bone density and impact oral health. Hence patients suffering from systemic disease when treated for prosthodontic rehabilitation can have negative prognostic outcomes. The commonest prosthodontic treatments that can be affected include dental implants, fixed prostheses, and removable prostheses. Understanding and managing these systemic factors play a key role in the success of prosthodontic treatment.

Stomatognathic system involvement in rheumatoid arthritis patients

AIMS

Temporomandibular joint (TMJ) and stomatognathic system involvement are usually observed during the course of rheumatoid arthritis.

METHODOLOGY

This article presents the findings during examination of 190 TMJs from rheumatoid arthritis (RA) patients, and 44 TMJs from controls without RA, including a description of signs and symptoms related to the stomatognathic system, radiological findings in hands-, and TMJ, erythrocyte sedimentation rate (ESR) values, and scores obtained in the Disease Activity Score (Das 28) and the Health Assessment Questionnaire (HAQ).

RESULTS

The sample included 57.89% TMJs associated with spontaneous pain, 87.89% with signs of destruction in radiological images, and 58.94% with 20 teeth or less. Restricted mouth opening was detected in 42.1% of RA patients, from which 71% had blocked opening; headache was present in 58%, and pain in the masticatory muscles was found in 57%. TMJ erosions had a significant association with Larsen scores (r=0.62), but not with the Das 28, HAQ, and ESR values.

CONCLUSIONS

The early evaluation of this joint and the collaborative work of odontologists and rheumatologists are both necessary for a better management of TMJ pathologies.

Association between chronic periodontitis and rheumatoid arthritis: a hospital-based case-control study

Rheumatoid arthritis (RA) and chronic periodontitis are the most common chronic inflammatory diseases with remarkable pathological and clinical similarities. A lot of similarities exist between RA and periodontitis at cellular and molecular levels. The relationship between these two chronic inflammatory diseases is still unclear. This case-control study was undertaken to determine the possible association between chronic inflammatory diseases like RA and periodontitis. The case group consisted of 100 patients attending the Rheumatology clinic who have rheumatoid arthritis (RA group). Age- and gender-matched 112 patients without RA attending the Outpatient wing of Department of General Medicine formed the control group (NRA group). The number of missing teeth, gingival index (GI), oral hygiene index-simplified (OHI-S), probing pocket depth (PPD) and clinical attachment levels (CAL) were evaluated in both the groups. Rheumatoid disease activity was assessed by DAS-28 score system. Systemic markers of inflammation like erythrocytic sedimentation rate (ESR) and serum levels of C-reactive protein (CRP) were assessed. There was a statistically significant difference in GI, OHI-S, PPD, CAL, ESR and CRP levels between cases (RA group) and controls (NRA group) (P < 0.05). Among subjects with RA, there was no association between the rheumatoid disease activity and the severity of periodontal disease. The occurrence and severity of periodontitis was found to be higher in RA subjects as compared to subjects without RA, suggesting a positive relation between these two chronic inflammatory diseases.

Edentulism and comorbid factors

INTRODUCTION

Complete edentulism is the terminal outcome of a multifactorial process involving biological factors and patient-related factors. It continues to represent a tremendous global health care burden, and will for the foreseeable future. The purpose of this review is to determine what comorbid factors exist for the completely edentulous patient.

METHODS

This literature review evaluated articles obtained via the National Library of Medicine's PubMed Website, using keywords of edentulism with various combinations of the terms comorbidity, incidence, health, nutrition, cancer, cardiovascular health, diabetes, osteoporosis, smoking, asthma, dementia, and rheumatoid arthritis. Abstracts were selected and screened, and selected full-text articles were reviewed. Articles were limited to those with adequate patient cohorts and a minimum of 2-year follow-up data.

RESULTS

Edentulism was found to be a global issue, with estimates for an increasing demand for complete denture prostheses in the future. Completely edentulous patients were found to be at higher risk for poor nutrition, coronary artery plaque formation (odds ratio 2.32), to be smokers (odds ratio 2.42), to be asthmatic and edentulous in the maxillary arch (odds ratio 10.52), to being diabetic (odds ratio 1.82), to having rheumatoid arthritis (odds ratio 2.27), and to having certain cancers (odds ratios varying from 1.54 to 2.85, depending on the type of cancer). Chronic residual ridge resorption continues to be the primary intraoral complication of edentulation, and there appear to be few opportunities to reduce bone loss in the edentulous patient.

CONCLUSIONS

While the completely edentulous patient seems to be at risk for multiple systemic disorders, whether development of these disorders is causal or casual has not been determined. To minimize the loss of residual alveolar ridges, exemplary complete denture therapy, along with the establishment of routine recall systems, should be the ultimate goal of treatment of this patient cohort.

Periodontitis in systemic rheumatic diseases

Periodontitis is a chronic inflammatory disease that is characterized by loss of the periodontal ligament and alveolar bone, and is a major cause of tooth loss. Results from clinical and epidemiologic studies have suggested that periodontitis and tooth loss are more prevalent in individuals with rheumatoid arthritis (RA). However, the strength and temporality of the association are uncertain. Several biologically plausible causal and noncausal mechanisms might account for this association between periodontitis and RA. There is evidence to suggest that periodontitis could indeed be a causal factor in the initiation and maintenance of the autoimmune inflammatory response that occurs in RA. If proven, chronic periodontitis might represent an important modifiable risk factor for RA. In addition, patients with RA might show an increased risk of developing periodontitis and tooth loss through various mechanisms. Moreover, exposure to common genetic, environmental or behavioral factors might contribute to a noncausal association between both conditions.

Periodontal and hematological characteristics associated with aggressive periodontitis, juvenile idiopathic arthritis, and rheumatoid arthritis

BACKGROUND

Periodontitis shares several clinical and pathogenic characteristics with chronic arthritis, and there is some degree of coexistence. The aims of this study were to elucidate whether patients with localized aggressive periodontitis (LAgP), generalized aggressive periodontitis (GAgP), juvenile idiopathic arthritis (JIA), and rheumatoid arthritis (RA) share periodontal and hematological characteristics distinguishing them from individuals free of diseases.

METHODS

The study population consisted of white adults (<or=35 years old) with LAgP (N=18), GAgP (N=27), JIA (N=10), RA (N=23), and healthy controls (N=25). All individuals underwent a standardized interview, blood sampling, and an intraoral examination, including registration of plaque, bleeding on probing, probing depth (PD), clinical attachment loss (CAL), and alveolar bone loss (ABL) on radiographs. Blood samples were analyzed for erythrocyte fraction, leukocytes and differential counts, erythrocyte sedimentation rate, C-reactive protein (CRP), immunoglobulin (Ig) M and IgA rheumatoid factors (RFs), and antibodies to cyclic citrullinated peptides.

RESULTS

RA patients had a higher percentage of sites with PD>or=4 mm, CAL>or=2 mm, and ABL>or=2 mm compared to controls. The percentage of sites with CAL>or=2 mm significantly correlated with the levels of IgM-RF and IgA-RF. Missing teeth in JIA and RA patients were not lost due to periodontitis. Patients with GAgP showed higher levels of leukocytes, including neutrophils, and CRP compared to controls. In part, JIA and RA patients showed similar results.

CONCLUSIONS

Young adults with RA may develop periodontal destruction, and these patients require professional attention. Both differences and similarities in periodontal and hematological variables were seen in individuals with periodontitis, JIA, and RA.

The long-term effect of anti TNF-α treatment on temporomandibular joints, oral mucosa, and salivary flow in patients with active rheumatoid arthritis: A pilot study

OBJECTIVE

The objective of this study was to evaluate the long-term effects of anti-TNF-alpha treatment on temporomandibular joints (TMJs), oral mucosa, and salivary flow in RA.

STUDY DESIGN

Seventeen patients received infusions of TNF-alpha blocking agents after 0, 2, and 6 weeks, and then every 8 weeks until week 54 (follow-up). Clinical dysfunction index (Di) for the TMJ system, salivary flow, disease activity score (DAS28), and other medical assessments were calculated at weeks 0 and 54.

RESULTS

Median Di was 5.0 (range 0-21) at baseline and 1.0 (range 0-6) (P = .001) at follow-up. Mean salivary flow was 3.2 mL/15 minutes at baseline and 4.6 at follow-up (P = .055). Two (11.7%) of the patients developed oral candidiasis during the period of treatment. The median DAS28 was 6.2 (range, 4.7-7.7) at baseline and 4.1 (range, 1.6-6.8) at follow-up (P = .001).

CONCLUSION

We conclude that anti-TNF-alpha blocking treatments have beneficial effects on oral as well as general manifestations of RA.

Periodontal infection as a possible severity factor for rheumatoid arthritis

OBJECTIVE

Clinical effects of periodontal treatment on biochemical and clinical markers of disease severity in rheumatoid arthritis (RA) patients with periodontal disease were evaluated.

METHODS

Forty-two patients were assigned to two groups, G1 (n=16) and G2 (n=26). G1 patients were submitted to oral hygiene instruction and professional tooth cleaning and G2 patients additionally had full-mouth scaling and root planing (SRP). Clinical periodontal measurements were obtained at baseline and 3 months after periodontal treatment. A Health Assessment Questionnaire (HAQ) was used to evaluate their performance on daily living. Rheumatoid factor (RF), erythrocyte sedimentation rate (ESR) and drug therapy were assessed.

RESULTS

Both groups presented a full-mouth improvement in all periodontal clinical parameters (p<0.05), with the exception of clinical attachment level (CAL) and probing pocket depth (PPD) >6 mm for G1. G2 showed greater mean reductions on PPD >4 mm than G1 (p<0.001). HAQ analyses showed a reduction on the degree of disability of G2, but not statistically significant. ESR was significantly reduced for G2 after SRP although RF did not show statistical reductions.

CONCLUSION

The data suggest that periodontal treatment with SRP might have an effect on the ESR reduction.

Salivary gland and temporomandibular joint involvement in rheumatoid arthritis: relation to disease activity

OBJECTIVES

To study temporomandibular joint (TMJ) involvement, salivary gland dysfunction and oral mucosal lesions in rheumatoid arthritis (RA), and to investigate the relationship to general disease activity.

SUBJECTS AND METHODS

The TMJ dysfunction index (D(i)), mean salivary flow and disease activity score (DAS28), were calculated for 50 RA-patients, and 23 non-RA patients (controls).

RESULTS

Median D(i) was 5.5 (range: 0-21) for the RA-patients compared with 2.0 (range: 0-9) for the controls (P < 0.0001). Pain on movement of the TMJ (P = 0.015), muscular pain (P = 0.006), TMJ pain (P = 0.019) and D(i) as a total (P = 0.009), significantly correlated with DAS28. Mean resting whole saliva (RWS) flow was 2.6 (s.d. 2.4) ml per 15 min for the RA-patients and 4.5 (s.d. 3.0) for the controls (P = 0.003). RWS correlated positively with haemoglobin (P = 0.021) and negatively with Westergren erythrocyte sedimentation rate (ESR) (P = 0.029). No major differences in frequency of oral mucosal lesions were seen between RA-patients and controls.

CONCLUSIONS

Higher frequency of TMJ and salivary gland dysfunction in RA-patients compared with controls has been demonstrated. RA disease activity is associated with hyposalivation and TMJ dysfunction.

Oral infections and systemic diseases

An association between periodontal infection and CVD has been revealed in some epidemiologic studies, whereas other studies were unable to demonstrate such an association. A link between the two diseases may be explained by shared established or nonestablished risk factors. Future studies with extended control of confounding factors and intervention studies may add to the understanding of a possible relationship between the diseases. In some cases, IE is caused by dental plaque bacteria. Several studies are suggestive of oral bacteria causing respiratory infection. The pathogenesis and course of a number of other diseases including DM and rheumatoid arthritis have been associated wish periodontitis, but more research is necessary to elucidate possible pathogenic interactions.

Dentition status and temporomandibular joint disorders in patients with rheumatoid arthritis

We compared dentition status and temporomandibular joint (TMJ) disorders in 142 women with rheumatoid arthritis (RA, ages, 40 to 69 years) and 143 women of similar age without RA. The RA group had significantly fewer remaining teeth than the non-RA group. Number of decayed, missing, and filled (DMF) teeth, number of edentulous subjects, and number of subjects with complete and removable partial dentures were significantly higher in the RA group. Among RA subjects, 1.4% had unprovoked TMJ pain, 4.9% had pain on mouth opening, and 14.8% noted difficulty with opening. In the RA group, TMJ tenderness was elicited in 9.2%, clicking in 12.7%, and crepitus in 35.9%, representing a significant excess occurrence of crepitus. The prevalence of TMJ disorders was 67.6% in the RA group and 32.9% in the non-RA group; degenerative joint disorders were particularly frequent. TMJ disorders correlated with Steinbrocker stage and the duration of RA.

Medical conditions associated with missing teeth and edentulism in the institutionalized elderly

Several studies have reported the prevalence of medical conditions or investigated the relationships between the oral health status and general health conditions in the elderly. However, the relationship between medical conditions and oral health among the elderly is not well-described. Previous studies have not clearly identified a consistent association between medical conditions and oral health, specifically edentulism and tooth loss. The purpose of this study was to investigate the relationships between medical conditions and oral health, as assessed by edentulism and missing teeth, in an institutionalized elderly population. A systematic sample (n = 175), stratified by age and sex, was drawn from nursing home patients treated by the University of low' as Geriatric Mobile Unit (GMU) team. Data were extracted from GMU dental records, regarding history of medical conditions, medications, dental history, dentate status, and tooth-by-tooth conditions. Mean numbers of missing teeth were significantly higher among those who had a history of atherosclerotic vascular disease, heart failure, ischemic heart disease, and joint disease. Subjects who had a history of atherosclerotic vascular disease, heart failure, ischemic heart disease, and joint disease were more likely to be edentulous than subjects who did not have a history of those diseases. The biological basis for these relationships between dentate status and systemic medical conditions is unclear and warrants further study.

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

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

Periodontal conditions in adults with rheumatoid arthritis

Periodontal conditions among an adult population of 161 dentate patients with rheumatoid arthritis (RA) were compared with those of an age and sex-matched random sample of non-rheumatic subjects. The number of teeth and prevalence of dental plaque, calculus, gingivitis, and deepened periodontal pockets were recorded. Alveolar bone breakdown and the distribution of subjects according to severity of periodontal disease were also registered. There was a tendency towards better periodontal conditions among RA-patients, severe periodontal breakdown occurring less frequently among RA-patients (12%) than among the controls (16%). The RA-patients had less plaque and calculus than the control group, a finding which could indicate a difference in periodontal care.