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Pecher AC, Günaydin B, Finke H, Henes J. Evaluation of oral health in 148 patients with systemic sclerosis-data from a prospective interdisciplinary monocentric cohort. Rheumatol Int 2024; 44:1567-1573. [PMID: 38874787 PMCID: PMC11222211 DOI: 10.1007/s00296-024-05635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Abstract
In daily rheumatology practice, systemic sclerosis is primarily regarded as a potentially life-threatening disease characterized by fibrosis of various organs. Therefore, other manifestations, such as orofacial involvement, are often not of primary concern. Furthermore, due to its rarity, the disease might not be well known by dentists, which contrasts with the increased risk of various problems in the oral cavity. Periodontitis in particular is a known risk factor for morbidity and mortality and is associated with various systemic diseases. The risk of periodontitis appears to be increased in patients with systemic sclerosis, but little is known about the gender-specific differences. This study aims to elucidate the health-conscious behaviour of patients, their dental care and the risk of periodontitis with regard to gender-specific differences. This descriptive study of the Interdisciplinary Centre of Rheumatic Diseases (INDIRA) in collaboration with the Department of Orthodontics at the University Hospital of Tuebingen, Germany, examined the data of 148 patients with systemic sclerosis with regard to their oral health using a questionnaire and evaluating the risk of periodontitis with the DG Paro self-assessment score in this cohort. Among the participating patients, 90% reported regular visits to the dentist and good dental care. Nevertheless, more than half of the patients had missing teeth and problems opening their mouths. Sicca symptoms in the oral cavity were also common (40%). The risk of periodontitis among female participants was high (around 60%), and even higher among male study participants (around 80%). Gingival bleeding as a surrogate parameter for periodontitis was associated with salivary flow and the modified Rodnan skin score (mRSS). Despite a high awareness of dental health, we observed a high risk of periodontitis, especially in male patients with systemic sclerosis. In addition, the association between xerostomia and missing teeth as well as gingival bleeding and mRSS may indicate an increased risk in patients with a more progressive disease. We would therefore recommend regular dental consultations and careful oral hygiene for patients with systemic sclerosis in addition to the-more organ-focused-regular examinations of patients.
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Affiliation(s)
- Ann-Christin Pecher
- Interdisciplinary Center of Rheumatic Diseases (INDIRA), University Hospital Tuebingen, Tuebingen, Germany
| | - Bahar Günaydin
- Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Hannah Finke
- Department of Orthodontics, University Hospital Tuebingen, Osianderstr. 2-8, 72076, Tuebingen, Germany.
| | - Jörg Henes
- Interdisciplinary Center of Rheumatic Diseases (INDIRA), University Hospital Tuebingen, Tuebingen, Germany
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Han C, Wu D, Yu F, Wang Q, Yang Y, Li Y, Qin R, Chen Y, Xu L, He D. No genetic causal association between periodontitis and ankylosing spondylitis: a bidirectional two-sample mendelian randomization analysis. BMC Med Genomics 2024; 17:118. [PMID: 38698441 PMCID: PMC11067206 DOI: 10.1186/s12920-024-01845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 03/04/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Observational studies that reveal an association between periodontitis (PD) and ankylosing spondylitis (AS) exist. However, observational research is prone to reverse causality and confounding factors, which make it challenging to infer cause-and-effect relationships. We conducted a two-sample Mendelian randomization (MR) study to examine the causal relationship between the genetic prediction of PD and AS. METHODS In our study, single-nucleotide polymorphisms (SNPs) were defined as instrumental variables (IVs). The genetic association with PD came from the Gene-Lifestyle Interactions and Dental Endpoints (GLIDE) consortium, wherein 17353 cases of European ancestry and 28210 controls of European ancestry were included in this study. The genetic association with AS from the Neale Laboratory Consortium included 337,159 individuals from the United Kingdom, with 968 cases and 336,191 controls. MR analysis was mainly performed using the inverse-variance weighted (IVW) method. In addition, the robustness of the study findings was assessed using sensitivity, pleiotropy, and heterogeneity analyses. RESULTS Eighteen independent SNPs with P-values significantly smaller than 1 × 10- 5 were used as IV SNPs for PD, while 39 independent SNPs with P-values significantly smaller than 1 × 10- 5 were used as IV SNPs for AS. The results of the IVW method revealed no causal association between PD and AS (odds ratio = 1.00, 95% confidence interval: 0.99953 to 1.00067, P = 0.72). The MR-Egger method did not support the causal association between PD and AS. It is unlikely that horizontal pleiotropy distorts causal estimates based on sensitivity analysis. No significant heterogeneity was observed in the Q test. The ''leave-one-out'' analysis demonstrated that the robustness of our results was unaffected by eliminating any of the IVs. Likewise, no significant causative effect for AS on PD was observed in the inverse MR analysis. CONCLUSIONS The study results do not support shared heritability or a causal association between PD and AS.
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Affiliation(s)
- Chong Han
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Dongchao Wu
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Feiyan Yu
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Qianqian Wang
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Yang Yang
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Yi Li
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Rao Qin
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Yue Chen
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Linkun Xu
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China
| | - Dongning He
- Shanxi Medical University School and Hospital of Stomatology, Taiyuan, China.
- Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, China.
- Department of Implantology, Shanxi Medical University School and Hospital of Stomatology, No. 63, New South Road, Yingze District, 030001, Taiyuan, Shanxi, P.R. China.
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Ciurea A, Rednic NV, Soancă A, Micu IC, Stanomir A, Oneț D, Șurlin P, Filipescu I, Roman A, Stratul ȘI, Pamfil C. Current Perspectives on Periodontitis in Systemic Sclerosis: Associative Relationships, Pathogenic Links, and Best Practices. Diagnostics (Basel) 2023; 13:diagnostics13050841. [PMID: 36899985 PMCID: PMC10000920 DOI: 10.3390/diagnostics13050841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Systemic sclerosis is a chronic, autoimmune, multisystemic disease characterized by aberrant extracellular matrix protein deposition and extreme progressive microvasculopathy. These processes lead to damage within the skin, lungs, or gastrointestinal tract, but also to facial changes with physiognomic and functional alterations, and dental and periodontal lesions. Orofacial manifestations are common in SSc but are frequently overshadowed by systemic complications. In clinical practice, oral manifestations of SSc are suboptimally addressed, while their management is not included in the general treatment recommendations. Periodontitis is associated with autoimmune-mediated systemic diseases, including systemic sclerosis. In periodontitis, the microbial subgingival biofilm induces host-mediated inflammation with subsequent tissue damage, periodontal attachment, and bone loss. When these diseases coexist, patients experience additive damage, increasing malnutrition, and morbidity. The present review discusses the links between SSc and periodontitis, and provides a clinical guide for preventive and therapeutical approaches in the management of these patients.
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Affiliation(s)
- Andreea Ciurea
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
| | - Nicolae Voicu Rednic
- Department of Gastroenterology, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor St., No. 19, 400394 Cluj-Napoca, Romania
| | - Andrada Soancă
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
| | - Iulia Cristina Micu
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
| | - Alina Stanomir
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
| | - Diana Oneț
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
| | - Petra Șurlin
- Department of Periodontology, University of Medicine and Pharmacy Craiova, Petru Rareș St., No. 2, 200349 Craiova, Romania
| | - Ileana Filipescu
- Department of Rheumatology, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Clinicilor St., No. 2, 400000 Cluj-Napoca, Romania
| | - Alexandra Roman
- Department of Periodontology, Faculty of Dental Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Victor Babeș St., No. 15, 400012 Cluj-Napoca, Romania
- Correspondence: ; Tel.: +40-722-627-488
| | - Ștefan Ioan Stratul
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, Victor Babeș University of Medicine and Pharmacy Timișoara, Revoluției from 1989 St., No. 9, 300041 Timișoara, Romania
| | - Cristina Pamfil
- Department of Rheumatology, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Clinicilor St., No. 2, 400000 Cluj-Napoca, Romania
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Evaluating the relationship between ankylosing spondylitis and periodontal disease: a case-control study. Clin Oral Investig 2023; 27:411-420. [PMID: 36394610 DOI: 10.1007/s00784-022-04776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/06/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study aimed to determine the possible relationship between periodontal disease and ankylosing spondylitis (AS) by evaluating clinical periodontal measurements and gingival crevicular fluid (GCF) levels of sclerostin, interleukin-1β (IL-1ß), and matrix metalloproteinase-8 (MMP-8) levels. MATERIALS AND METHODS Twenty-eight patients with AS (AS group) and 28 systemically healthy controls (C group) were enrolled in this study. Full-mouth periodontal measurements: plaque index, bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) measurements were obtained from all patients. AS-related parameters were included in the data analyses. An enzyme-linked immunosorbent assay determined GCF IL-1β, MMP-8, and sclerostin levels. RESULTS There were no significant differences in the clinical periodontal measurements between the two groups (p > 0.05). Interestingly, patients with AS had significantly lower GCF sclerostin levels than the C group (p < 0.05). But there were no statistical differences in the GCF levels of IL-1ß and MMP-8 between the two groups (p > 0.05). Serum C-reactive protein (CRP) levels strongly correlated with both BOP (r = 0.497, p < 0.05) and PPD (r = 0.570, p < 0.05) in the AS group. Bath AS Metrology Index (BASMI) also positively correlated with both BOP (r = 0.530, p < 0.05) and CAL (r = 0.568, p < 0.05). Similarly, Maastrıcht Ankylosing Spondylitis Enthesis Score (MASES) strongly correlated with both BOP (r = 0.487, p < 0.05) and CAL (r = 0.522, p < 0.05). CONCLUSION These results suggest that the patient's systemic condition may influence local sclerostin levels in GCF, and the strong correlations between periodontal measurements and AS-related parameters may indicate an interrelationship between inflammatory periodontal disease and AS. CLINICAL RELEVANCE The present study provides important information concerning the relationship between periodontal disease and ankylosing spondylitis. TRIAL REGISTRATION Thai Clinical Trials.gov (TCTR20200908001) (08. September 2020).
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Relationship between periodontal status and disease activity in patients with ankylosing spondylitis. Reumatologia 2021; 59:35-40. [PMID: 33707794 PMCID: PMC7944957 DOI: 10.5114/reum.2021.103643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/02/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Ankylosing spondylitis (AS) is a chronic inflammatory disease mainly affecting the spine and sacroiliac joints, characterized by enthesitis. Recent studies have investigated the relationship between AS and periodontitis. The aim of this study was to evaluate the periodontal status of patients with AS and to determine the factors affecting this. Material and methods The study included 200 AS patients, of which 129 were taking anti-tumour necrosis factor (TNF) drugs and 71 were taking non-steroid anti-inflammatory drugs (NSAID). Patients did not change their medication during the study. Disease activity was evaluated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), mobility with the Bath Ankylosing Spondylitis Metrology Index (BASMI), functional status with the Bath Ankylosing Spondylitis Functional Index (BASFI), enthesitis with the integrated Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and quality of life with the Ankylosing Spondylitis Quality of Life (ASQoL) scale. Data related to erythrocyte sedimentation rate, and C-reactive protein were recorded from the hospital information system. The plaque index (PI), gingival index (GI), pocket depth (PD), attachment level (CAL) measurements, and bleeding index (BOP) were measured. Results The results showed that 35.5% of the AS patients had periodontitis, at a lower rate in the anti-TNF group than in the NSAID group, but the difference was not statistically significant. Periodontitis-related factors were found to be age, BASFI and BASMI. A significant relationship was found between MASES and BOP and GI. Conclusions This suggests that periodontitis may be an enthesis in AS. Nevertheless, further studies are needed to explain the mechanism of periodontitis in AS patients.
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Öğrendik M. Treatment of ankylosing spondylitis with co-amoxiclav. Clin Exp Pharmacol Physiol 2019; 45:742-744. [PMID: 29676028 DOI: 10.1111/1440-1681.12952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 01/06/2023]
Abstract
This article presents the efficacy of co-amoxiclav in two patients with ankylosing spondylitis. Both patients were administered oral co-amoxiclav for 7 days. The primary efficacy variable was the ankylosing spondylitis activity index. Secondary outcome measures were the ankylosing spondylitis functional index and spinal mobility. We detected a marked improvement in all symptoms and physical examination parameters. Co-amoxiclav has been shown to be effective against ankylosing spondylitis.
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Affiliation(s)
- Mesut Öğrendik
- Department of Physical Medicine and Rehabilitation, Seyfi Demirsoy State Hospital, Buca, Izmir, Turkey
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Abbood HM, Pathan E, Cherukara GP. The link between ankylosing spondylitis and oral health conditions: two nested case-control studies using data of the UK Biobank. J Appl Oral Sci 2018; 27:e20180207. [PMID: 30427476 PMCID: PMC6223783 DOI: 10.1590/1678-7757-2018-0207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/27/2018] [Indexed: 12/17/2022] Open
Abstract
Ankylosing Spondylitis (AS) is an inflammatory rheumatic disease that affects the axial skeleton and the sacroiliac joints. Recent studies investigated the link between AS and oral diseases, particularly periodontitis. Others suggested that periodontitis may have a role in the pathogenesis of rheumatic diseases. Objective: The aim of this study is to investigate the association between AS and oral conditions. Material and Methods: This research was conducted using the UK Biobank Resource under Application Number 26307. The UK Biobank recruited around 500000 participants throughout Great Britain. Clinical records were available for 2734 participants. Two case-control studies were conducted based on whether AS was self-reported or clinically diagnosed. Oral conditions were identified using self-reported reports of oral ulcers, painful gums, bleeding gums, loose teeth, toothache, and dentures. The association between AS and oral conditions was assessed using logistic regression adjusted for age, gender, educational level, smoking status, alcohol consumption, and body mass index. Results: A total of 1307 cases and 491503 control participants were eligible for the self-reported AS study. The mean age was 58 years for the cases [7.5 standard deviation (SD)] and 57 years for the control groups (8.1 SD). Also, 37.1% of the cases and 54.2% of the control participants were females. Among the oral conditions, only oral ulcers were strongly associated with AS [1.57 adjusted odds ratio (OR); 95% confidence interval (CI) 1.31 to 1.88]. For the study of clinically diagnosed AS, 153 cases and 490351 control participants were identified. The mean age for both cases and control groups was 57 years; 7.6 SD for the cases and 8.1 for the control group. Females corresponded to 26.1% of the cases, and 54.2% of the control participants. Clinically diagnosed AS was associated with self-reported oral ulcers (2.17 adjusted OR; 95% CI 1.33 to 3.53). Conclusion: Self-reported and clinically diagnosed AS populations have increased risk of reporting oral ulcers. Further investigations are required to assess the link between a specific type of oral condition and AS.
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Affiliation(s)
| | - Ejaz Pathan
- Toronto Western Hospital, University Health Network, Spondylitis Program, Toronto, Canada
| | - George P Cherukara
- University of Aberdeen, School of Medicine, Medical Sciences & Nutrition, Institute of Dentistry, Foresterhill Campus, Foresterhill, Scotland, United Kingdom
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Increased risk of periodontitis among patients with Crohn's disease: a population-based matched-cohort study. Int J Colorectal Dis 2018; 33:1437-1444. [PMID: 30003361 DOI: 10.1007/s00384-018-3117-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Periodontitis is a frequently cited extraintestinal manifestation of Crohn's disease (CD). Despite a plethora of investigations and a recent meta-analysis linking CD and periodontitis, no study has estimated the risk of periodontitis among CD patients with respect to a comparison group nor has any investigation analyzed the effect of CD-specific medications on the risk of periodontitis. The present cohort study compared CD patients and matched subjects without a history of inflammatory bowel disease (IBD) to estimate the effect of CD and CD-specific pharmaceutical prescriptions on the risk of developing periodontitis by leveraging a population-based dataset in Taiwan. METHODS We sourced 6657 CD patients and 26,628 comparison subjects without a history of IBD from the Taiwan National Health Insurance Database. Cox proportional hazards regressions were used to estimate the risk of subsequent periodontitis by CD status and pharmaceutical prescription during the follow-up period. RESULTS After adjusting for socioeconomic status (SES), urbanicity, selected medical co-morbidities, and CD-specific pharmaceutical prescriptions, the hazard ratio (HR) for subsequent periodontitis among patients with CD was 1.36 (95% CI = 1.25-1.48) that of comparison subjects. There was not a significant difference in risk between genders or across ages. Steroids (95% CI = 0.66-0.77) appeared to confer a protective effect and Aspirin, Plavix, and Licodin were marginally protective (95% CI = 0.76-0.95). CONCLUSION This is the first study to report an increased HR for subsequent periodontitis among CD patients when compared to matched comparison subjects without IBD. The protective effect of some pharmaceuticals may suggest that treatment of CD protects against periodontitis.
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Ziebolz D, Douglas D, Douglas D, Schmickler J, Patschan D, Müller GA, Haak R, Schmidt J, Schmalz G, Patschan S. Periodontal condition is associated with disease duration and motoric disabilities in patients with ankylosing spondylitis: results of a cross-sectional study. Rheumatol Int 2018; 38:855-863. [PMID: 29557489 DOI: 10.1007/s00296-018-4012-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/15/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Recent literature reveals worse periodontal health condition in ankylosing spondylitis (AS). However, roles of AS-related parameters, periodontal condition, and their association appear unclear. This cross-sectional study aimed at investigating dental and periodontal health as well as potentially periodontal pathogenic bacteria in patients with AS compared to healthy control subjects (HC). METHODS Dental examination comprised dental findings (DMF-T), periodontal probing depth (PPD), bleeding on probing, clinical attachment loss (CAL), papillary bleeding index, and microbiological analysis based on polymerase chain reaction of selected potentially periodontal pathogenic bacteria. Classification of periodontitis severity was based on PPD and/or CAL and divided into no/mild, moderate, and severe periodontitis. RESULTS 52 participants with AS and 52 HC were included. 96% of the AS group and 75% of HC had moderate to severe periodontitis (moderate: AS = 26, HC = 34; severe: AS = 23, HC = 5; p < 0.01). Furthermore, a higher number of decayed teeth (D-T) were found in AS compared to HC (p = 0.02). A significant difference between AS und HC was detected for the prevalences of Parvimonas micra (AS = 92%, HC = 71%; p = 0.01), Eubacterium nodatum (AS = 35%, HC = 17%; p = 0.05), and Eikenella corrodens (AS = 96%, HC = 77%; p = 0.01). Bath Ankylosing Spondylitis Metrology Index (BASMI) and disease duration showed significant associations to PPD and CAL (p < 0.01). CONCLUSION Patients with AS show worse dental and periodontal conditions compared to HC. Thereby, prevalence of bacteria related to insufficient oral hygiene was higher in AS. BASMI and duration of AS affect periodontal burden. Accordingly, particular attention considering dental care and oral hygiene in AS patients seems to be reasonable.
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Affiliation(s)
- Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany.
| | - David Douglas
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Donya Douglas
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Jan Schmickler
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Daniel Patschan
- Department of Cardiology, Pulmology, Angiology and Nephrology, Brandenburg Medical School, University Hospital Brandenburg, Brandenburg, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Goettingen, Germany
| | - Rainer Haak
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Jana Schmidt
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Susann Patschan
- Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Goettingen, Germany
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Schmalz G, Douglas D, Douglas D, Patschan S, Patschan D, Müller GA, Haak R, Schmickler J, Ziebolz D. Oral health-related quality of life is associated with disease specific parameters in patients with ankylosing spondylitis. Clin Oral Investig 2018. [PMID: 29541915 DOI: 10.1007/s00784-018-2375-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this cross-sectional study was to investigate oral health-related quality of life (OHRQoL) in patients with ankylosing spondylitis (AS) and its association to oral health as well as AS specific parameters. METHODS Patients with AS and a healthy control group (HC) were included and examined. The oral examination included decayed-, missing-, and filled-teeth index (DMF-T) as well as assessment of periodontal probing depth and clinical attachment loss to classify patients into healthy/mild, moderate, or severe periodontitis. Furthermore, the German short form of the oral health impact profile (OHIP G14) was used. RESULTS A total of 50 patients each group (age: AS, 47.18 ± 15.67; HC, 55.82 ± 10.56; p < 0.01, gender male: AS, 52%; HC, 46%; p = 0.69) was included. AS patients showed worse D-T (p < 0.01) and periodontal condition (p = 0.01). The OHIP G14 score was clinically relevant and statistically significant higher in AS compared to HC (AS, 6.2 [2; 0-10.75]; HC, 1.7 [0; 0-2.0]; < 0.01). Only in HC, an association of OHIP G14 to DMF-T (p = 0.01) and M-T (p = 0.01) was found, while the OHIP G14 in AS group was not associated to oral health parameters. Within the AS group, the majority of investigated AS specific parameters were statistically significant and clinically relevant associated to OHIP G14 scores (pi < 0.05). CONCLUSION Patients with AS show worse OHRQoL compared to HC, irrespective of oral status. The high general disease burden might affect OHRQoL, making an increased attention of these patients in dental care, especially considering psychological aspects, necessary. CLINICAL RELEVANCE Increased consideration of psychosocial and disease related aspects in dental care of AS patients appear recommendable.
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Affiliation(s)
- Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Donya Douglas
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - David Douglas
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Susann Patschan
- Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Goettingen, Germany
| | - Daniel Patschan
- Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Goettingen, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Goettingen, Germany
| | - Rainer Haak
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Jan Schmickler
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany.
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Bautista-Molano W, van der Heijde D, Landewé R, Lafaurie GI, de Ávila J, Valle-Oñate R, Romero-Sanchez C. Is there a relationship between spondyloarthritis and periodontitis? A case-control study. RMD Open 2017; 3:e000547. [PMID: 29299339 PMCID: PMC5729302 DOI: 10.1136/rmdopen-2017-000547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 01/21/2023] Open
Abstract
Objective To compare the frequency and severity of periodontitis in patients with spondyloarthritis (SpA) with healthy control individuals, through the evaluation of clinical, serological and microbiological periodontal condition. Methods Patients with a diagnosis of SpA (n=78) and biological disease-modifying antirheumatic drug (bDMARD) naive fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria as well as 156 healthy controls matched for age/gender were included. Two trained and calibrated periodontologists performed the periodontal clinical assessment. The presence of periodontitis and its severity were determined according to the criteria established by the Centers for Disease Control and Prevention-American Academy of Periodontology. The clinical periodontal variables, IgG1/IgG2 antibodies against Porphyromonas gingivalis andperiodontopathic bacterial identification, were also established. Comparisons of periodontal characteristics between the patients with SpA and the control group were performed using univariable analyses. A logistic regression analyses was performed to calculate the OR (95% CI) for diagnosis of periodontitis in patients with SpA and matched controls. Results A diagnosis of periodontitis was established in 56% in patients with SpA versus 69% of healthy controls (P≤ 0.01). Severe periodontitis was found in 3% versus 12% in SpA versus healthy controls, respectively (P≤ 0.01). There was no significant increase of frequency of any periodontal variable, IgG1/IgG2 antibodies against P. gingivalis or the presence of periodontopathic bacteria between patients with SpA and control group. Periodontitis was not positively associated with a diagnosis of SpA (OR: 0.57, 95% CI 0.32 to 1.00, P=0.05) in the logistic regression analyses. Conclusions We found a lower rather than a higher frequency and severity of periodontitis in patients with SpA in comparison with healthy control individuals. Our findings suggest that there is no positive association between SpA and periodontitis in Colombian patients.
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Affiliation(s)
- Wilson Bautista-Molano
- Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology Department, School of Medicine, Universidad Militar Nueva Granada and Hospital Militar, Bogota, Colombia.,Unit of Oral Basic Investigation, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
| | | | - Robert Landewé
- Amsterdam Rheumatology & Clinical Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center Heerlen, Heerlen, The Netherlands
| | - Gloria I Lafaurie
- Unit of Oral Basic Investigation, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
| | - Juliette de Ávila
- Unit of Oral Basic Investigation, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
| | - Rafael Valle-Oñate
- Rheumatology Department, School of Medicine, Universidad Militar Nueva Granada and Hospital Militar, Bogota, Colombia
| | - Consuelo Romero-Sanchez
- Rheumatology Department, School of Medicine, Universidad Militar Nueva Granada and Hospital Militar, Bogota, Colombia.,Unit of Oral Basic Investigation, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
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12
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Öğrendik M. Oral Anaerobic Bacteria in the Etiology of Ankylosing Spondylitis. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2017. [PMID: 28638241 PMCID: PMC5470850 DOI: 10.1177/1179544117712992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Ankylosing spondylitis (AS) is associated with periodontitis. Anti-Porphyromonas gingivalis and anti-Prevotella intermedia antibody titers were higher in patients with spondyloarthritis than in healthy people. Sulfasalazine is an effective antibiotic treatment for AS. Moxifloxacin and rifamycin were also found to be significantly effective. The etiology hypothesis suggests that oral anaerobic bacteria such as Porphyromonas spp and Prevotella spp contribute to the disease. These bacteria have been identified in AS, and we will discuss their pathogenic properties with respect to our knowledge of the disease. Periodontal pathogens are likely to be responsible for the development of AS in genetically susceptible individuals. This finding should guide the development of more comprehensive and efficacious treatment strategies for AS.
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Affiliation(s)
- Mesut Öğrendik
- Department of Physical Medicine and Rehabilitation, Uzunköprü State Hospital, Edirne, Turkey
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13
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Rothschild B. Correlation of Periodontal Disease With Inflammatory Arthritis in the Time Before Modern Medical Intervention. J Periodontol 2016; 88:266-272. [PMID: 27834119 DOI: 10.1902/jop.2016.160422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Controversy exists regarding possible correlation of periodontal disease with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Confounding factors may relate to stringency of inflammatory disease diagnosis and the effect of therapeutic intervention for RA on periodontal disease. These factors are investigated in this study. METHODS Forty-five individuals with documented RA (n = 15), spondyloarthropathy (n = 15), and calcium pyrophosphate deposition disease (CPPD) (n = 15), from the Hamann-Todd collection of human skeletons compiled from 1912 to 1938, and 15 individuals contemporarily incorporated in the collection were examined for tooth loss, cavity occurrence, average and maximum lingual and buccal depth of space between tooth and bone, periosteal reaction, serpentine bone resorption, abscess formation, and root penetration of the bone surface and analyzed by analysis of variance. RESULTS Tooth loss was common, but actual number of teeth lost, cavity occurrence, average and maximum lingual and buccal depth of space between tooth and bone, periosteal reaction, serpentine grooving surrounding teeth (considered a sign of inflammation), abscess formation, and root exposure (penetration of bone surface) were indistinguishable among controls and individuals with RA, spondyloarthropathy, and CPPD. CONCLUSIONS Although many factors can affect periodontal disease, presence of inflammatory arthritis does not appear to be one of them. The implication is that dental disease was common in the general population and not necessarily associated with arthritis, at least before the advent of modern rheumatologic medications. As specific diagnosis did not affect prevalence, perhaps current prevalence controversy may relate to current intervention, a subject for further study.
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Affiliation(s)
- Bruce Rothschild
- Northeast Ohio Medical University, Rootstown, OH.,Vertebrate Paleontology, Carnegie Museum of Natural History, Pittsburgh, PA
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14
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Gossec L, Baillet A, Dadoun S, Daien C, Berenbaum F, Dernis E, Fayet F, Hudry C, Mezieres M, Pouplin S, Richez C, Saraux A, Savel C, Senbel E, Soubrier M, Sparsa L, Wendling D, Dougados M. Collection and management of selected comorbidities and their risk factors in chronic inflammatory rheumatic diseases in daily practice in France. Joint Bone Spine 2016; 83:501-9. [DOI: 10.1016/j.jbspin.2016.05.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/18/2016] [Indexed: 12/15/2022]
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15
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Abstract
BACKGROUND Recently, it has been demonstrated that patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA) have a higher risk of periodontitis; however, the effect of anti-TNF therapy in periodontal status of patients with AS and particularly in dental attachment is not known. OBJECTIVE To evaluate longitudinally the local periodontal effect of TNF-antagonist in AS and compare to patients with RA. METHODS Fifteen patients with AS and 15 RA control patients were prospectively evaluated at baseline and after 6 months (6 M) of anti-TNF therapy. Periodontal assessment included: probing pocket depth (PPD), clinical attachment level (CAL), gingival bleeding index, and plaque index. Rheumatologic clinical and laboratory evaluations were the following: Bath AS Disease Activity Index, Bath AS Metrology Index, Bath AS Functional Index, C-reactive protein and erythrocyte sedimentation rate for AS and Disease Activity Score 28 joints, and C-reactive protein and erythrocyte sedimentation rate for patients with RA. RESULTS At baseline, periodontal parameters were alike in AS and RA (P > 0.05). After 6 M of anti-TNF therapy, clinical and laboratory parameters of rheumatic diseases decreased significantly in the patients with AS and RA (P < 0.05). A significant improvement in periodontal attachment measurements were observed in the patients with AS (PPD, 2.18 vs 1.94 mm; P = 0.02; CAL, 2.29 vs.2.02 mm; P = 0.03), but not in RA (PPD, 1.92 vs 2.06 mm; P = 0.06; CAL, 2.14 vs 2.28 mm; P = 0.27). Oral hygiene and gingival inflammation remained unchanged from baseline to 6-M evaluation in AS and RA (P > 0.05). CONCLUSION Patients with AS under anti-TNF improved periodontal attachment. The mechanism for this effect needs further studies.
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16
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Pischon N, Hoedke D, Kurth S, Lee P, Dommisch H, Steinbrecher A, Pischon T, Burmester GR, Buttgereit F, Detert J, Riemekasten G. Increased Periodontal Attachment Loss in Patients With Systemic Sclerosis. J Periodontol 2016; 87:763-71. [DOI: 10.1902/jop.2016.150475] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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17
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Bisanz JE, Suppiah P, Thomson WM, Milne T, Yeoh N, Nolan A, Ettinger G, Reid G, Gloor GB, Burton JP, Cullinan MP, Stebbings SM. The oral microbiome of patients with axial spondyloarthritis compared to healthy individuals. PeerJ 2016; 4:e2095. [PMID: 27330858 PMCID: PMC4906644 DOI: 10.7717/peerj.2095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/09/2016] [Indexed: 12/20/2022] Open
Abstract
Background. A loss of mucosal tolerance to the resident microbiome has been postulated in the aetiopathogenesis of spondyloarthritis, thus the purpose of these studies was to investigate microbial communities that colonise the oral cavity of patients with axial spondyloarthritis (AxSpA) and to compare these with microbial profiles of a matched healthy population. Methods. Thirty-nine participants, 17 patients with AxSpA and 22 age and gender-matched disease-free controls were recruited to the study. For patients with AxSpA, disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). All participants underwent a detailed dental examination to assess oral health, including the presence of periodontal disease assessed using probing pocket depth (PPD). Plaque samples were obtained and their bacterial populations were profiled using Ion Torrent sequencing of the V6 region of the 16S rRNA gene. Results.Patients with AxSpA had active disease (BASDAI 4.1 ± 2.1 [mean ± SD]), and a significantly greater prevalence of periodontitis (PPD ≥ 4 mm at ≥4 sites) than controls. Bacterial communities did not differ between the two groups with multiple metrics of α and β diversity considered. Analysis of operational taxonomic units (OTUs) and higher levels of taxonomic assignment did not provide strong evidence of any single taxa associated with AxSpA in the subgingival plaque. Discussion. Although 16S rRNA gene sequencing did not identify specific bacterial profiles associated with AxSpA, there remains the potential for the microbiota to exert functional and metabolic influences in the oral cavity which could be involved in the pathogenesis of AxSpA.
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Affiliation(s)
- Jordan E Bisanz
- Department of Microbiology and Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, Lawson Health Research Institute, London, Ontario, Canada
| | - Praema Suppiah
- School of Dentistry, University of Otago , Dunedin , New Zealand
| | - W Murray Thomson
- School of Dentistry, University of Otago , Dunedin , New Zealand
| | - Trudy Milne
- School of Dentistry, University of Otago, Dunedin, New Zealand; Sir John Walsh Research Institute, University of Otago, Dunedin, Otago, New Zealand
| | - Nigel Yeoh
- Dunedin School of Medicine, University of Otago , Dunedin , New Zealand
| | - Anita Nolan
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Oral Health, AUT, Auckland, New Zealand
| | - Grace Ettinger
- Department of Microbiology and Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, Lawson Health Research Institute, London, Ontario, Canada
| | - Gregor Reid
- Department of Microbiology and Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, Lawson Health Research Institute, London, Ontario, Canada; Division of Urology, Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Gregory B Gloor
- Canadian Centre for Human Microbiome and Probiotic Research, Lawson Health Research Institute, London, Ontario, Canada; Department of Biochemistry, University of Western Ontario, London, Ontario, Canada
| | - Jeremy P Burton
- Department of Microbiology and Immunology, Western University, London, Ontario, Canada; Canadian Centre for Human Microbiome and Probiotic Research, Lawson Health Research Institute, London, Ontario, Canada; Division of Urology, Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mary P Cullinan
- School of Dentistry, University of Otago, Dunedin, New Zealand; Sir John Walsh Research Institute, University of Otago, Dunedin, Otago, New Zealand
| | - Simon M Stebbings
- Dunedin School of Medicine, University of Otago , Dunedin , New Zealand
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18
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Ramesh Kumar SG, Aswath Narayanan MB, Jayanthi D. Comparative assessment of the prevalence of periodontal disease in subjects with and without systemic autoimmune diseases: A case-control study. Contemp Clin Dent 2016; 7:170-5. [PMID: 27307662 PMCID: PMC4906858 DOI: 10.4103/0976-237x.183069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Immune mechanism shares a common pathway both for systemic autoimmune diseases and periodontal diseases. Scientific exploration of literature revealed limited studies on the association between systemic autoimmune diseases and periodontal diseases in India. AIM The aim of the study is to find whether the presence of systemic autoimmune diseases in an individual is a risk factor for the development of periodontal disease. SETTINGS AND DESIGN This was a hospital-based case-control study. MATERIALS AND METHODS A sample of 253 patients with systemic autoimmune diseases, attending the Rheumatology Department of Government General Hospital, Chennai-3, and 262 patients without systemic autoimmune diseases, attending the outpatient department of the Tamil Nadu Government Dental College and Hospital, Chennai-3, constituted the case and control groups, respectively. Age, gender, and oral hygiene status matching was done. Oral hygiene status was assessed using oral hygiene index (OHI) and periodontal status was assessed using community periodontal index (CPI) and loss of attachment (LOA) index. STATISTICAL ANALYSIS Statistical analysis was done using SPSS version 15 (SPSS Inc, 2006, Chicago). RESULTS Results showed 99.2% and 73.9% prevalence of gingivitis and periodontitis, respectively, in the case group as compared to 85.5% and 14.9%, respectively, in the control group. There is no linear relationship between OHI scores and prevalence of periodontitis (CPI and LOA scores) in the case group. Patients suffering from systemic autoimmune diseases showed more prevalence of periodontal diseases irrespective of oral hygiene scores. CONCLUSION It is postulated that the presence of systemic autoimmune diseases may pose a risk for the development of periodontal diseases.
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Affiliation(s)
- S. G. Ramesh Kumar
- Department of Public Health Dentistry, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
| | - M. B. Aswath Narayanan
- Department of Public Health Dentistry, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
| | - D. Jayanthi
- Department of Public Health Dentistry, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
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19
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Agrawal N, Agarwal K, Varshney A, Agrawal N, Dubey A. Is there a common pathogenesis in aggressive periodontitis & ankylosing spondylitis in HLA-B27 patient? Med Hypotheses 2016; 90:63-5. [PMID: 27063088 DOI: 10.1016/j.mehy.2016.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/06/2016] [Indexed: 10/22/2022]
Abstract
HLA-B27 is having strong association to ankylosing spondylitis (AS) and other inflammatory diseases collectively known as seronegative spondyloarthropathy. In literature, although the evidence for association between AS and periodontitis as well as AS and HLA-B27 are there but the association of aggressive periodontitis in HLA-B27 positive patient with AS are not there. We hypothesize that there may be a common pathogenesis in aggressive periodontitis and ankylosing spondylitis in HLA-B27 patient. A 27-years-old female presented with the features of generalized aggressive periodontitis and difficulty in walking. On complete medical examination, ankylosing spondylitis was diagnosed with further positive HLA-B27 phenotype and negative rheumatic factor. This report may open up a new link to explore in the pathogenesis of aggressive periodontitis.
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Affiliation(s)
- Neeraj Agrawal
- Department of Periodontology, People's Dental Academy, Bhopal, India.
| | - Kavita Agarwal
- Department of Oral Medicine & Radiology, People's College of Dental Sciences, Bhopal, India
| | - Atul Varshney
- Department of Orthopedics, People's College of Medical Sciences, Bhopal, India
| | - Navneet Agrawal
- Department of Pedodontics, Rau Institute of Dental Sciences, Indore, India
| | - Ashutosh Dubey
- Department of Periodontology, People's Dental Academy, Bhopal, India
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20
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Kang EH, Lee JT, Lee HJ, Lee JY, Chang SH, Cho HJ, Choi BY, Ha YJ, Park KU, Song YW, Van Dyke TE, Lee YJ. Chronic Periodontitis Is Associated With Spinal Dysmobility in Patients With Ankylosing Spondylitis. J Periodontol 2015; 86:1303-13. [PMID: 26291296 DOI: 10.1902/jop.2015.150202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although microbes have been suggested to play a role in the pathogenesis of ankylosing spondylitis (AS), several studies present contradictory results regarding the association between AS and chronic periodontitis (CP). METHODS Clinical, laboratory, and medication data were collected from 84 patients with AS and 84 age- and sex-matched controls. Periodontal measurements, including probing depths (PDs), clinical attachment loss (AL), serum anti-Porphyromonas gingivalis titers, and the detection of P. gingivalis DNA in gingival crevicular fluid, were recorded. All participants with periodontitis with PD ≥4 to <7 mm received scaling and root planing and were re-evaluated at 12 weeks; those still exhibiting periodontitis with PD of ≥4 to <7 mm at 12 weeks were followed at 24 weeks. RESULTS The prevalence of moderate-to-severe CP was not different between patients with AS and controls (70.2% versus 66.6%). The P. gingivalis detection rate was not different between patients with AS and controls or between patients with AS receiving and not receiving anti-tumor necrosis factor (TNF)-α agents. However, CP was positively associated with impaired spinal mobility of patients with AS in multivariate analyses. After periodontal treatment, PD and AL levels were improved in both groups, but the change was significantly greater in patients with AS than in controls. Patients with AS receiving anti-TNF-α agents exhibited a greater improvement in PD and AL than those who did not. CONCLUSIONS Although AS was not associated with the presence of CP, CP was associated positively with the severity of spinal dysmobility in Korean patients with AS. These results suggest that periodontitis can have a negative effect on axial movement in AS.
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Affiliation(s)
- Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Tae Lee
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital
| | - Hyo-Jung Lee
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital
| | - Joo Youn Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Hae Chang
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyon Joung Cho
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byoong Yong Choi
- Department of Internal Medicine, Seoul Medical Center Public Corporation, Seoul, Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital
| | - Yeong Wook Song
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Thomas E Van Dyke
- Department of Applied Oral Sciences, Forsyth Institute, Cambridge, MA
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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21
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Ogrendik M. Periodontal Pathogens are Likely to be Responsible for the Development of Ankylosing Spondylitis. Curr Rheumatol Rev 2015; 11:47-49. [PMID: 26002454 PMCID: PMC4997922 DOI: 10.2174/1573397111666150522094821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 01/06/2023]
Abstract
The role of oral bacteria in the etiology of ankylosing spondylitis (AS) is examined in this review. Periodontitis is related to AS to a significant degree, and periodontitis is significantly more prevalent in patients with AS. Anti-Pophyromonas gingivalis and anti-Prevotella intermedia antibodies titers are higher in AS patients than in healthy subjects. Eight randomized controlled trials that used sulfasalazine were reviewed. Moxifloxacin and rifamycin are significantly effective in the treatment of AS. Periodontal pathogens are likely to be responsible for the development of AS in genetically susceptible individuals. These results will guide more comprehensive and efficacious treatment strategies for AS.
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Affiliation(s)
- Mesut Ogrendik
- Kozagac District, 253 Street, Park Apt house No:45-47, D:4, Buca-IZMIR, Turkey
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22
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Ratz T, Dean LE, Atzeni F, Reeks C, Macfarlane GJ, Macfarlane TV. A possible link between ankylosing spondylitis and periodontitis: a systematic review and meta-analysis. Rheumatology (Oxford) 2014; 54:500-10. [PMID: 25213130 DOI: 10.1093/rheumatology/keu356] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine the link between AS and periodontitis. METHODS Medline, Embase, AMED, CINAHL, Web of Science and Google Scholar were searched to identify eligible studies that were selected and reviewed independently by at least two authors. RESULTS Six case-control studies were included in the review. Study size ranged from 90 to 40 926 participants. The prevalence of periodontitis ranged from 38% to 88% in AS patients and from 26% to 71% in controls. As there was low-level heterogeneity (I(2) = 13%), using fixed effects analysis the overall pooled estimate of the odds ratios for periodontitis was 1.85 (95% CI 1.72, 1.98). There was no evidence of publication bias. CONCLUSION The results led to the need for a further large study with sufficient statistical power to detect the desired effect size, taking into account potential confounding factors and using validated measures of AS and periodontitis.
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Affiliation(s)
- Tiara Ratz
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK. Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK
| | - Linda E Dean
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK
| | - Fabiola Atzeni
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK. Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK
| | - Christopher Reeks
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK
| | - Gary J Macfarlane
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK
| | - Tatiana V Macfarlane
- Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK, Department of Public Health, University of Bremen, Bremen, Germany, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy and University of Aberdeen Dental School and Hospital, Aberdeen, UK.
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23
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Wendling D, Prati C. Spondyloarthritis and smoking: towards a new insight into the disease. Expert Rev Clin Immunol 2014; 9:511-6. [DOI: 10.1586/eci.13.35] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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24
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Increased risk of stroke among patients with ankylosing spondylitis: a population-based matched-cohort study. Rheumatol Int 2013; 34:255-63. [DOI: 10.1007/s00296-013-2912-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 11/26/2013] [Indexed: 01/17/2023]
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25
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Abstract
BACKGROUND The oral cavity is frequently affected in patients with inflammatory bowel disease (IBD), especially in patients with Crohn's disease (CD). Periodontitis is thought to influence systemic autoimmune or inflammatory diseases. We aimed to analyze the relationship of periodontitis and gingivitis markers with specific disease characteristics in patients with IBD and to compare these data with healthy controls. METHODS In a prospective 8-month study, systematic oral examinations were performed in 113 patients with IBD, including 69 patients with CD and 44 patients with ulcerative colitis. For all patients, a structured personal history was taken. One hundred thirteen healthy volunteers served as a control group. Oral examination focussed on established oral health markers for periodontitis (bleeding on probing, loss of attachment, and periodontal pocket depth) and gingivitis (papilla bleeding index). Additionally, visible oral lesions were documented. RESULTS Both gingivitis and periodontitis markers were higher in patients with IBD than in healthy control. In univariate analysis and logistic regression analysis, perianal disease was a risk factor for periodontitis. Nonsmoking decreased the risk of having periodontitis. No clear association was found between clinical activity and periodontitis in IBD. In only the CD subgroup, high clinical activity (Harvey-Bradshaw index > 10) was associated with 1 periodontitis marker, the loss of attachment at sites of maximal periodontal pocket depth. Oral lesions besides periodontitis and gingivitis were not common, but nevertheless observed in about 10% of patients with IBD. CONCLUSIONS IBD, and especially perianal disease in CD, is associated with periodontitis. Optimal therapeutic strategies should probably focus on treating both local oral and systemic inflammation.
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26
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Keller JJ, Wu CS, Lin HC. Chronic rhinosinusitis increased the risk of chronic periodontitis. Laryngoscope 2013; 123:1323-7. [DOI: 10.1002/lary.23720] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 07/22/2012] [Accepted: 08/13/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Joseph J. Keller
- School of Public Health; Taipei Medical University Hospital; Taipei
| | - Chuan-Song Wu
- Department of Otolaryngology; Taipei City Hospital; Taipei; Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration, and the Sleep Research Center; Taipei Medical University Hospital; Taipei
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27
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Keller JJ, Kang JH, Lin HC. Association between ankylosing spondylitis and chronic periodontitis: A population-based study. ACTA ACUST UNITED AC 2012; 65:167-73. [DOI: 10.1002/art.37746] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/04/2012] [Indexed: 11/07/2022]
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Keller JJ, Lin HC. The effects of chronic periodontitis and its treatment on the subsequent risk of psoriasis. Br J Dermatol 2012; 167:1338-44. [PMID: 22755552 DOI: 10.1111/j.1365-2133.2012.11126.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although psoriasis and chronic periodontitis (CP) may share an underlying immune dysregulation as part of their pathologies, to date only one small-scale cross-sectional pilot study has investigated the potential association between CP and psoriasis. OBJECTIVES This study aimed to investigate the subsequent risk for psoriasis following a diagnosis of CP by utilizing a cohort study design and population-based dataset in Taiwan. METHODS In total, 115 365 patients with CP were included in the study cohort and 115 365 patients without CP were included in the comparison cohort. We individually tracked each patient for a 5-year period to identify those who had subsequently received a diagnosis of psoriasis. A Cox proportional hazards regression was performed to compute the 5-year risk of subsequent psoriasis following a diagnosis of CP. RESULTS We found that the incidence rate of psoriasis during the 5-year follow-up period was 1·88 [95% confidence interval (CI) 1·77-1·99] per 1000 person-years in patients with CP and 1·22 (95% CI 1·14-1·32) per 1000 person-years in comparison patients. After censoring those who died during the follow-up period, and adjusting for monthly income and geographical region, compared with comparison patients, the hazard ratio (HR) of psoriasis for patients with CP was 1·52 (95% CI 1·38-1·70). Furthermore, the study subjects who had undergone a gingivectomy or periodontal flap operation had only a slightly higher adjusted risk of psoriasis than comparison patients (HR 1·26). CONCLUSIONS This study detected an increased risk for psoriasis among patients with CP. Treatment for CP attenuated, but did not nullify, the risk for subsequent psoriasis.
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Affiliation(s)
- J J Keller
- School of Public Health, Taipei Medical University, Taipei, Taiwan
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29
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Röhner E, Hoff P, Matziolis G, Perka C, Riep B, Nichols FC, Kielbassa AM, Detert J, Burmester GR, Buttgereit F, Zahlten J, Pischon N. The impact of Porphyromonas gingivalis lipids on apoptosis of primary human chondrocytes. Connect Tissue Res 2012; 53:327-33. [PMID: 22260531 DOI: 10.3109/03008207.2012.657308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The role of oral bacterial infections including periodontal disease in the pathogenesis of rheumatoid arthritis (RA) has gained increasing interest. Among the major periodontal pathogens, Porphyromonas gingivalis has been mostly associated with RA pathogenesis. The aim of this study was to analyze the effect of P. gingivalis total lipid (TL) fraction and dihydroceramides, as potent virulence factors, on human primary chondrocytes. Primary chondrocyte cultures were incubated with P. gingivalis phosphoglycerol dihydroceramide (PG DHC) lipids, the TL fraction or phosphoethanolamine dihydroceramide. Cell morphology changes were determined by phase contrast light microscopy. Early and late apoptosis cell analysis was performed by Annexin-V, active caspases, and 7-Aminoactinomycin D staining, and examined by flow cytometry, and cell necrosis was evaluated by lactate dehydrogenase release. Procaspase-3 activation was determined by Western blot analysis. Microscopic analysis showed altered cell morphology and cell shrinkage following incubation with P. gingivalis TLs and PG DHC lipids. Flow cytometry demonstrated an increase of Annexin-V positive and active caspases positive chondrocytes after incubation with TL and PG DHC fractions but not after phosphoethanolamine dihydroceramide (control lipid) treatment or in untreated control cells. Furthermore, Western blot analysis showed an early cleavage of procaspase-3 after 1 hr. Significant lactate dehydrogenase release following incubation with P. gingivalis lipids was demonstrated. The present data demonstrate that P. gingivalis lipids promote apoptosis in primary human chondrocytes, and thereby may contribute to the joint damage seen in the pathogenesis of RA.
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Affiliation(s)
- Eric Röhner
- Department of Traumatology and Orthopaedics, Charité-Universitätsmedizin, Berlin, Germany.
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30
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Sezer U, Erciyas K, Pehlivan Y, Ustün K, Tarakçioğlu M, Senyurt SZ, Onat AM. Serum cytokine levels and periodontal parameters in ankylosing spondylitis. J Periodontal Res 2011; 47:396-401. [PMID: 22126620 DOI: 10.1111/j.1600-0765.2011.01448.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Multiple studies support the role of periodontal disease in contributing to the chronic systemic inflammatory burden in a variety of diseases, including ankylosing spondylitis (AS), in the progression which the inflammatory process plays an important role. We assume that patients with AS are more likely to have periodontal disease than healthy individuals. The aim of this study was to determine the possible relationship between inflammatory periodontal diseases and AS by evaluating clinical periodontal parameters and serum cytokine levels. MATERIAL AND METHODS Forty-eight adults with AS (35 women and 13 men; age range 18-56 years; mean age 34.27 years) and 48 age- and sex-matched systemically healthy control subjects participated in the study. The clinical periodontal parameters, venous blood and Bath Ankylosing Spondylitis Disease Activity Score were obtained, and serum C-reactive protein, tumour necrosis factor-α and interleukin-6 (IL-6) levels were evaluated. RESULTS There was statistically no significant difference in the frequency of periodontitis between AS patients and the control group. Furthermore, there was no significant difference in probing depth, clinical attachment level and plaque index, and the only significant clinical difference between groups was in levels of bleeding on probing (p < 0.001). Serum concentrations of IL-6, tumour necrosis factor-α and C-reactive protein in the AS group were significantly higher than those in the control group (p < 0.001). In the AS group, there was a correlation between serum IL-6 levels and clinical attachment level (p < 0.001). CONCLUSION The results of present study suggest that bleeding on probing was the only different periodontal parameter between the AS and the control group, and the periodontal status of patients with AS may be affected by IL-6 levels.
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Affiliation(s)
- U Sezer
- Department of Periodontology, Faculty of Dentistry, Gaziantep University, Gaziantep,Turkey.
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31
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Ziebolz D, Pabel SO, Lange K, Krohn-Grimberghe B, Hornecker E, Mausberg RF. Clinical Periodontal and Microbiologic Parameters in Patients With Rheumatoid Arthritis. J Periodontol 2011; 82:1424-32. [DOI: 10.1902/jop.2011.100481] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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32
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Finzel S, Englbrecht M. [Psoriatic arthritis : a permanent challenge for rheumatologists and patients--Part 1: epidemiology, pathogenesis and clinical course]. Z Rheumatol 2011; 70:685-97. [PMID: 21912984 DOI: 10.1007/s00393-011-0860-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Psoriatic arthritis is still one of the big challenges in rheumatology due to the great variety of symptoms. Treatment frequently requires an interdisciplinary collaboration of general practitioners, dermatologists and rheumatologists who are able to recognize the onset of disease early by means of classification criteria and new imaging techniques followed by the implementation of appropriate antirheumatic treatment. During recent years new immunological pathways have been discovered leading to an increasing number of potential therapies, which increases the chance to find effective individualized treatment. However, tracking back the onset of the disease to specific causes is still a challenge which is made even more complex due to the absence of specific serum parameters.
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Affiliation(s)
- S Finzel
- Medizinische Klinik III (Rheumatologie & Immunologie), Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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Röhner E, Detert J, Kolar P, Hocke A, N'Guessan P, Matziolis G, Kanitz V, Bernimoulin JP, Kielbassa A, Burmester GR, Buttgereit F, Pischon N. Induced apoptosis of chondrocytes by Porphyromonas gingivalis as a possible pathway for cartilage loss in rheumatoid arthritis. Calcif Tissue Int 2010; 87:333-40. [PMID: 20582408 DOI: 10.1007/s00223-010-9389-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
Abstract
The role of bacterial infections in the pathogenesis of rheumatoid arthritis (RA) has gained increasing interest. Patients with RA often exhibit periodontal disease, which is associated with pathogens like Porphyromonas gingivalis. The present study examines the direct effects of P. gingivalis on apoptosis of human chondrocytes (a feature of inflammatory joint diseases) as one can assume an interrelation of pathogenesis of RA and P. gingivalis infections. Primary chondrocytes were infected with P. gingivalis. Early apoptotic and dead cell analysis was performed using Annexin-V, 7AAD, and propidium iodide and examined by flow cytometry and fluorescence microscopy. Caspase activation and DNA fragmentation were determined by western blot analysis and TUNEL reaction. Flow cytometry and fluorescence microscopy demonstrated an increase of Annexin-V-positive early apoptotic chondrocytes after infection. Western blot showed upregulation of activated caspase-3 expression, and TUNEL reaction revealed considerable DNA fragmentation following infection. The data show that P. gingivalis promotes early and later stages of apoptosis of primary human chondrocytes, which might contribute to the joint damage seen in the pathogenesis of RA.
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Affiliation(s)
- E Röhner
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany.
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Detert J, Pischon N, Burmester GR, Buttgereit F. [Pathogenesis of parodontitis in rheumatic diseases]. Z Rheumatol 2010; 69:109-12, 114-6. [PMID: 20107818 DOI: 10.1007/s00393-009-0560-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Inflammatory periodontal disease (PD) is a common disease worldwide that has a primarily bacterial aetiology and is characterized by dysregulation of the host inflammatory response. The degree of inflammation varies among individuals with PD independently of the degree of bacterial infection, suggesting that alteration of the immune function may substantially contribute to its extent. Factors such as smoking, education, and body mass index (BMI) are discussed as potential risk factors for PD. Most PD patients respond to bacterial invaders by mobilizing their defensive cells and releasing cytokines such as interleukin (IL)-1beta, tumour necrosis factor (TNF)-alpha, and IL-6, which ultimately causes tissue destruction by stimulating the production of collagenolytic enzymes, such matrix metalloproteinases. Recently, there has been growing evidence suggesting an association between PD and the increased risk of systemic diseases, such ateriosclerosis, diabetes mellitus, stroke, and rheumatoid arthritis (RA). PD and rheumatologic diseases such as RA share many pathological aspects and immunological findings.
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Affiliation(s)
- J Detert
- Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité-Universitätsmedizin Berlin, Berlin, Deutschland.
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