Influence of anti-rheumatic agents on the periodontal condition of patients with rheumatoid arthritis and periodontitis: A systematic review and meta-analysis

Does non-surgical periodontal treatment contribute to rheumatoid arthritis amelioration? Evidence based on an overview and meta-analysis

The aim of the present study was to provide an overview evaluating the effects of non-surgical periodontal treatment in rheumatoid arthritis, focusing on 28-joint Disease Activity Score (DAS28), C-reactive protein, and erythrocyte sedimentation rate. Systematic reviews, with and without meta-analyses, comparing individuals who had undergone non-surgical periodontal treatment with those who had not, and assessing parameters before and after treatment, were included. Electronic searches were conducted in August 2023 and updated in August 2024 across four databases (PubMed, Scopus, Embase, and Web of Science) and gray literature, with no restriction on language or publication date. The study followed the 2020 PRISMA statement, and a protocol was registered in PROSPERO (CRD42023414714). A total of 10 systematic reviews were included: six with meta-analyses and four without meta-analyses. The number of articles included ranged from three to 31 studies. Non-surgical periodontal treatment resulted in a significant decrease in C-reactive protein, erythrocyte sedimentation rate, and DAS28. The follow-up period after treatment ranged from six to 24 weeks. A meta-analysis was conducted, incorporating data from 18 primary studies identified in the systematic reviews and comparing the difference in DAS28 at baseline (n = 454) and up to three months (n = 449) after the non-surgical periodontal treatment. A significant reduction in DAS28 was observed (MD = - 0.76; 95% CI = - 1.07 to - 0.44). Despite the heterogeneity of data related to rheumatoid arthritis and periodontitis status, non-surgical periodontal treatment can result in a decrease in the concentration of circulating inflammatory mediators and, consequently, in a reduction in DAS28 in rheumatoid arthritis.

Periodontal Molecular Diagnostics: State of Knowledge and Future Prospects for Clinical Application

Periodontitis leads to immunologically mediated loss of periodontium and, if untreated, can result in tooth loss. Periodontal diseases are the most prevalent in the world and have a very strong impact on patients' well-being and general health. Their treatment generates enormous costs. Given the above, precise, prompt, and predictive diagnosis of periodontal disease is of paramount importance for clinicians. The aim of the study was to summarize the state-of-the-art knowledge of molecular periodontal diagnostics and the utility of its clinical application. There is a great need to have diagnostic tests that not only describe the periodontal destruction that has occurred in the tissues but also allow clinicians to detect disease at a subclinical level before the changes occur. A test that would enable clinicians to follow the course of the disease and detect areas prone to exacerbation could be used to evaluate the effectiveness of ongoing periodontal therapies. Unfortunately, there is no such diagnostic method yet. A hopeful prospect is molecular diagnostics. There are numerous studies on biomarkers of periodontal disease. Point-of-care tests are also emerging. There are possibilities for processing large biological datasets (omics data). However, all of the above have a minor role in the overall single-patient diagnostics process. Despite advances in microbiological, molecular, and genetic research, the basis of periodontal diagnosis is still clinical examination enriched by the evaluation of radiological images.

Effects of green tea based oral health strategies on disease activity in rheumatoid arthritis

Aim

In this study, we aimed to evaluate oral health strategies in rheumatoid arthritis (RA) patients with periodontitis.

Methods

We enrolled 110 RA patients with periodontitis who were diagnosed in a Grade A tertiary hospital into an oral health strategies program. The control and test groups comprised 55 cases each. The management effect was evaluated by self-care ability, oral health-related quality of life, RA-related clinical indicators, and the DAS28 score. The control group received routine nursing, whereas the test group was in a self-health management program for 3 months.

Results

After the intervention, compared to the control group, the test group showed better self-care ability, oral health-related quality of life score, RA-related clinical indicators, and DAS28 score (P < 0.05).

Conclusion

Our oral health strategies program slowed down the progression of the disease and can be popularized in patients.

Most meta-analyses in oral health do not have conclusive and robust results

OBJECTIVES

In meta-analyses with few studies, between-study heterogeneity is poorly estimated. The Hartung and Knapp (HK) correction and the prediction intervals can account for the uncertainty in estimating heterogeneity and the range of effect sizes we may encounter in future trials, respectively. The aim of this study was to assess the reported use of the HK correction in oral health meta-analyses and to compare the published reported results and interpretation i) to those calculated using eight heterogeneity estimators and the HK adjustment ii) and to the prediction intervals (PIs).

METHODS

We sourced systematic reviews (SRs) published between 2021 and 2023 in eighteen leading specialty and general dental journals. We extracted study characteristics at the SR and meta-analysis level and re-analyzed the selected meta-analyses via the random-effects model and eight heterogeneity estimators, with and without the HK correction. For each meta-analysis, we re-calculated the overall estimate, the P-value, the 95 % confidence interval (CI) and the PI.

RESULTS

We analysed 292 meta-analyses. The median number of primary studies included in meta-analysis was 8 (interquartile range [IQR] = [5.75-15] range: 3-121). Only 3/292 meta-analyses used the HK adjustment and 12/292 reported PIs. The percentage of statistically significant results that became non-significant varied across the heterogeneity estimators (7.45 %- 16.59 %). Based on the PIs, >60 % of meta-analyses with statistically significant results are likely to change in the future and >40 % of the PIs included the opposite pooled effect.

CONCLUSIONS

The precision and statistical significance of the pooled estimates from meta-analyses with at least three studies is sensitive to the HK correction, the heterogeneity variance estimator, and the PIs.

CLINICAL SIGNIFICANCE

Uncertainty in meta-analyses estimates should be considered especially when a small number of trials is available or vary notably in their precision. Misinterpretation of the summary results can lead to ineffective interventions being applied in clinical practice.

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.

Higher odds of periodontitis in systemic lupus erythematosus compared to controls and rheumatoid arthritis: a systematic review, meta-analysis and network meta-analysis

Introduction

Periodontitis as a comorbidity in systemic lupus erythematosus (SLE) is still not well recognized in the dental and rheumatology communities. A meta-analysis and network meta-analysis were thus performed to compare the (i) prevalence of periodontitis in SLE patients compared to those with rheumatoid arthritis (RA) and (ii) odds of developing periodontitis in controls, RA, and SLE.

Methods

Pooled prevalence of and odds ratio (OR) for periodontitis were compared using meta-analysis and network meta-analysis (NMA).

Results

Forty-three observational studies involving 7,800 SLE patients, 49,388 RA patients, and 766,323 controls were included in this meta-analysis. The pooled prevalence of periodontitis in SLE patients (67.0%, 95% confidence interval [CI] 57.0-77.0%) was comparable to that of RA (65%, 95% CI 55.0-75.0%) (p>0.05). Compared to controls, patients with SLE (OR=2.64, 95% CI 1.24-5.62, p<0.01) and RA (OR=1.81, 95% CI 1.25-2.64, p<0.01) were more likely to have periodontitis. Indirect comparisons through the NMA demonstrated that the odds of having periodontitis in SLE was 1.49 times higher compared to RA (OR=1.49, 95% CI 1.09-2.05, p<0.05).

Discussion

Given that RA is the autoimmune disease classically associated with periodontal disease, the higher odds of having periodontitis in SLE are striking. These results highlight the importance of addressing the dental health needs of patients with SLE.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/ identifier CRD42021272876.

Methotrexate and Non-Surgical Periodontal Treatment Change the Oral-Gut Microbiota in Rheumatoid Arthritis: A Prospective Cohort Study

This study evaluated the changes in the composition of oral-gut microbiota in patients with rheumatoid arthritis (RA) caused by methotrexate (MTX) and non-surgical periodontal treatment (NSPT). Assessments were performed at baseline (T0), 6 months after MTX treatment (T1), and 45 days after NSPT (T2). The composition of the oral and gut microbiota was assessed by amplifying the V4 region of the 16S gene from subgingival plaques and stools. The results of the analysis of continuous variables were presented descriptively and non-parametric tests and Spearman's correlation were adopted. A total of 37 patients (27 with periodontitis) were evaluated at T0; 32 patients (24 with periodontitis) at T1; and 28 patients (17 with periodontitis) at T2. MTX tended to reduce the alpha diversity of the oral-gut microbiota, while NSPT appeared to increase the number of different species of oral microbiota. MTX and NSPT influenced beta diversity in the oral microbiota. The relative abundance of oral microbiota was directly influenced by periodontal status. MTX did not affect the periodontal condition but modified the correlations that varied from weak to moderate (p < 0.05) between clinical parameters and the microbiota. MTX and NSPT directly affected the composition and richness of the oral-gut microbiota. However, MTX did not influence periodontal parameters.

Correlation of anti-TNF-a biological therapy with periodontal conditions and osteonecrosis in autoimmune patients: A systematic review

Objectives

This systematic review aims to investigate the impact of tumor necrotic factor alpha inhibitors in suppressing bone resorption in periodontitis, and its potential to cause osteonecrosis. Extensive electronic research was conducted following the PRISMA guidelines, which connected various aspects of anti-TNF-a (anti-tumor necrosis factor-a) to periodontitis and osteonecrosis patients.

Background

TNF-a inhibitors are broadly indicated in the treatment of autoimmune patients with possible joint resorption and increased inflammatory processes such as rheumatoid arthritis and inflammatory bowel disease, where they reduce bone loss and certain mediators. As rheumatoid arthritis and periodontitis share many characteristics, these medications may also be helpful in the treatment of coexisting periodontitis. However, besides medical benefits, anti-TNF-a also exhibits several adverse effects, ranging from dizziness to tuberculosis. Osteonecrosis is considered a recent adverse impact.

Methods

An extensive electronic systematic review following the PRISMA guidelines was performed for English-language papers using the following databases as sources of information: PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Library Genesis, Worldwide Science, National Rheumatoid Arthritis Society (NRAS), and other related articles. This systematic review is registered on the PROSPERO platform under registration number CRD42022341753.

Results

Twenty articles were identified after the exclusion criteria were applied. These include systematic reviews, case reports, retrospective cohort studies, case report series, meta-analyses, clinical trials, randomised clinical trials, cross-sectional and longitudinal analyses, longitudinal observational studies, and prospective clinical trials. All these were included in the quantitative and qualitative analyses.

Conclusions

Anti-TNF-a drugs show promising results in treating patients with rheumatoid arthritis and periodontitis but could be considered a risk factor for osteonecrosis. Hence, patients receiving such medications should be closely monitored by the dentist and physician before, during, and after administration.

Inhibition of tumor necrosis factor receptor 1 and the risk of periodontitis

Aim

To investigate the effect of genetically proxied inhibition of tumor necrosis factor receptor 1 (TNFR1) on the risk of periodontitis.

Materials and methods

Genetic instruments were selected from the vicinity of TNFR superfamily member 1A (TNFRSF1A) gene (chromosome 12; base pairs 6,437,923-6,451,280 as per GRCh37 assembly) based on their association with C-reactive protein (N= 575,531). Summary statistics of these variants were obtained from a genome-wide association study (GWAS) of 17,353 periodontitis cases and 28,210 controls to estimate the effect of TNFR1 inhibition on periodontitis using a fixed-effects inverse method.

Results

Considering rs1800693 as an instrument, we found no effect of TNFR1 inhibition on periodontitis risk (Odds ratio (OR) scaled per standard deviation increment in CRP: 1.57, 95% confidence interval (CI): 0.38;6.46). Similar results were derived from a secondary analysis that used three variants (rs767455, rs4149570, and rs4149577) to index TNFR1 inhibition.

Conclusions

We found no evidence of a potential efficacy of TNFR1 inhibition on periodontitis risk.

Influence of Oral Microbiota on the Presence of IgA Anti-Citrullinated Protein Antibodies in Gingival Crevicular Fluid

Introduction

The relation between rheumatoid arthritis (RA) and periodontitis (PD) has been investigated ever since the discovery of the citrullinating enzyme peptidyl arginine deaminase presents in the oral bacterium Porphyromonas gingivalis. Recently, we demonstrated the presence of RA autoantibodies, especially of IgA anti-citrullinated protein antibody (ACPA), in gingival crevicular fluid (GCF) of Indonesian patients with and without RA or PD which might indicate the local formation of RA antibodies in the periodontium.

Aim

The purpose of this study was to assess whether the subgingival microbiome is related to the presence of IgA ACPA in the GCF of healthy individuals with or without PD.

Patients and Methods

Healthy individuals with a known periodontal status and high IgA ACPA (>0.1 U/ml) in GCF (n = 27) were selected and matched for age, gender, periodontal status, and smoking status with 27 healthy individuals without IgA ACPA in their GCF. Taxonomic profiling of the subgingival microbiome was based on bacterial 16S rRNA gene sequencing. Downstream analyses were performed to assess compositional differences between healthy subjects with or without IgA ACPA in GCF and with or without PD.

Results

Between groups with or without PD, or with or without IgA ACPA in GCF, no differences in alpha diversity were seen. Beta diversity was different between groups with or without PD (p < 0.0001), and a trend was seen in subjects with PD between subjects with or without IgA ACPA in GCF (p = 0.084). Linear discriminant analysis effect size (LEfSe) revealed no significant differences in the total population between subjects with IgA ACPA compared to subjects without IgA ACPA in GCF. Although Porphyromonas was not identified by LEfSe, its relative abundance was significantly higher in healthy individuals with high IgA ACPA in GCF compared to individuals without IgA ACPA in GCF (p = 0.0363). Zooming in on the subgroup with PD, LEfSe revealed that species Neisseriaceae, Tannerella, and Haemophilus were more abundant in the subjects with IgA ACPA in GCF compared to subjects without IgA ACPA in GCF.

Conclusion

Periodontitis and certain taxa, including Porphyromonas, seem to be associated with the local presence of ACPA in the periodontium.

Modulating the Immune Response in Periodontitis

Periodontitis is a chronic inflammatory condition initiated by the accumulation of bacterial biofilm. It is highly prevalent and when left untreated can lead to tooth loss. The presence of bacterial biofilm is essential for the initiation of the inflammatory response but is not the sole initiator. Currently it is unknown which mechanisms drive the dysbiosis of the bacterial biofilm leading to the dysregulation of the inflammatory response. Other players in this equation include environmental, systemic, and genetic factors which can play a role in exacerbating the inflammatory response. Treatment of periodontal disease consists of removal of the bacterial biofilm with the goal of resolving the inflammatory response; however, this does not occur in every case. Understanding the way the inflammatory response does not return to a state of homeostasis has led investigators to consider both systemic and local pharmacological interventions. Nonetheless, a better understanding of the impact that genetics and environmental factors may have on the inflammatory response could be key to helping identify how inflammation can be modulated therefore stopping the destruction of the periodontium. In this article, we will explore the current evidence associating the microbial dysbiosis and the dysregulation of the immune response, potential mechanisms or pathways that may be targeted for the modulation of the inflammatory response, and discuss the advantages and drawbacks associated with local and systemic inflammatory modulation in the management of periodontal disease. This information will be valuable for those interested in understanding potential adjunct methods for managing periodontal diseases, but not limited to, dental professionals, clinical researchers and the public at large.

Periodontitis-Related Knowledge and Its Relationship with Oral Health Behavior among Adult Patients Seeking Professional Periodontal Care

Background: Periodontitis is a chronic inflammatory disease that not only damages the stomatognathic system, but may also adversely influence other systems and organs. Patients with low oral health literacy levels are more prone to gingivitis/periodontitis and have a more severe disease course. Methods: A written questionnaire was carried out to assess the knowledge of patients of the Outpatient Clinic of Department of Periodontal and Oral Mucosa Diseases, Medical University of Bialystok, Poland. The questions concerned knowledge regarding the causes of periodontal disease, its risk factors, and the connection between periodontal disease and general health status. To analyze the population, patients were divided according to gender, age and if they were first-time or regular outpatients. Results: Written questionnaires were completed by a total of 302 patients. In the studied population, we noted knowledge deficits, particularly related to weaker periodontal disease risk factors (stress, diabetes, osteoporosis, obesity) and the genetic factor, which is the determinant of periodontitis. The patients’ awareness of the role of plaque bacteria and the effect of smoking on the periodontium was at a relatively high level. The respondents were also aware of the impact of periodontal disease on general health as well as the role of oral hygiene in preventing the disease. At the same time, few of them (26%) used interdental brushes or an irrigator (8%). Conclusions: We demonstrated that patients have an insufficient level of knowledge related to risk factors as well as the prevention of periodontal disease. Awareness of the extent of oral health literacy among patients will help to identify key issues connected with health education interventions

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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