Identification of rheumatoid factor in periodontal disease

Periodontitis severity affects the clinical response to biological disease-modifying antirheumatic drugs in rheumatoid arthritis: A 1-year follow-up study

OBJECTIVES

To assess whether periodontitis severity affects the clinical response to biological disease-modifying antirheumatic drugs (bDMARDs) for 1 year in rheumatoid arthritis (RA) patients.

METHODS

Data were collected from 50 RA patients who had received corticosteroids, conventional synthetic DMARDs, or non-steroidal anti-inflammatory drugs before (baseline) and after 1 year of bDMARD therapy in a retrospective study. Rheumatologic conditions were compared between the two periodontitis severity groups according to the periodontal inflamed surface area (PISA) or Centers for Disease Control and Prevention (CDC)/American Academy of Periodontology (AAP) case definitions.

RESULTS

Twenty-eight patients with no or mild periodontitis showed significantly greater decreases in changes in Clinical Disease Activity Index (CDAI) and tender and swollen joint count in comparison to 22 patients with moderate and severe periodontitis (p = .02, p = .01, and p = .03). Both bivariate and multivariate analyses revealed a significantly positive association between the baseline CDC/AAP definitions and CDAI changes (p = .005 and p = .0038). However, rheumatologic conditions were comparable between 25 patients each in the low and high PISA groups.

CONCLUSIONS

Baseline periodontitis severity according to the CDC/AAP definitions is associated with the clinical response to bDMARDs for 1 year in RA patients.

Differential effects of periodontal microbiome on the rheumatoid factor induction during rheumatoid arthritis pathogenesis

Association between exposure to periodontal bacteria and development of autoantibodies related to rheumatoid arthritis (RA) has been widely accepted; however, direct causal relationship between periodontal bacteria and rheumatoid factor (RF) is currently not fully understood. We investigated whether periodontal bacteria could affect RF status. Patients with preclinical, new-onset, or chronic RA underwent periodontal examination, and investigation of subgingival microbiome via 16S rRNA sequencing. Degree of arthritis and RF induction was examined in collagen-induced arthritis (CIA) mice that were orally inoculated with different periodontal bacteria species. Subsequently, single-cell RNA sequencing analysis of the mouse spleen cells was performed. Patients with preclinical RA showed an increased abundance of the Porphyromonadacae family in the subgingival microbiome compared to those with new-onset or chronic RA, despite comparable periodontitis severity among them. Notably, a distinct subgingival microbial community was found between patients with high-positive RF and those with negative or low-positive RF (p=0.022). Oral infections with the periodontal pathogens P. gingivalis and Treponema denticola in CIA mice similarly enhanced arthritis score, but resulted in different levels of RF induction. Genes related to B cell receptor signaling, B cell proliferation, activation, and differentiation, and CD4⁺ T cell costimulation and cytokine production were involved in the differential induction of RF in mice exposed to different bacteria. In summary, periodontal microbiome might shape RF status by affecting the humoral immune response during RA pathogenesis.

Host and bacterial factors linking periodontitis and rheumatoid arthritis

Observations from numerous clinical, epidemiological and serological studies link periodontitis with severity and progression of rheumatoid arthritis. The strong association is observed despite totally different aetiology of these two diseases, periodontitis being driven by dysbiotic microbial flora on the tooth surface below the gum line, while rheumatoid arthritis being the autoimmune disease powered by anti-citrullinated protein antibodies (ACPAs). Here we discuss genetic and environmental risk factors underlying development of both diseases with special emphasis on bacteria implicated in pathogenicity of periodontitis. Individual periodontal pathogens and their virulence factors are argued as potentially contributing to putative causative link between periodontal infection and initiation of a chain of events leading to breakdown of immunotolerance and development of ACPAs. In this respect peptidylarginine deiminase, an enzyme unique among prokaryotes for Porphyromonas gingivalis, is elaborated as a potential mechanistic link between this major periodontal pathogen and initiation of rheumatoid arthritis development.

Pros and cons of causative association between periodontitis and rheumatoid arthritis

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

Rheumatoid arthritis serotype and synthetic disease-modifying anti-rheumatic drugs in patients with periodontitis: A case-control study

Patients with rheumatoid arthritis (RA) experience a higher prevalence of periodontitis. This study aimed to examine the variation of periodontitis experienced with different serotypes suffered by RA patients and to examine the relationship between the different medications taken for RA that may influence this relationship. Two hundred and sixty RA and control participants underwent standardized periodontal examinations. Medical, serological and radiological (Sharp/van der Heijde) records were assessed. Functional status was assessed using the administered Health Assessment Questionnaire. Moreover, disease parameters, including disease activity (DAS28-ESR) and anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF) seropositivity were evaluated. Periodontitis was higher in RA (71.54%) compared with controls (54.62%). The stage of periodontitis experienced by ACPA-positive participants were higher than APCA-negative participants. The probing pocket depth and recession experienced by RF-positive participants were higher than those who were RF-negative. RA participants on methotrexate had lower clinical attachment loss and lower periodontal probing depth compared with participants on a combination methotrexate and other disease-modifying antirheumatic drugs. Participants taking corticosteroids had lower gingival index scores. The association between seropositivity and the type of medications taken with periodontal health parameters in this group of patients suggests that both seropositivity and medications taken are important modifiers in the relationship between periodontitis and RA.

Novel and known periodontal pathogens residing in gingival crevicular fluid are associated with rheumatoid arthritis

Background

Periodontitis is a suspected environmental risk factor for the development of rheumatoid arthritis (RA). However, correlation mechanisms between the two pathologies remain elusive. This study examined potential correlations between detached subgingival bacteria collected in gingival crevicular fluid (GCF) and RA parameters.

Methods

RA patients (n = 52, F:M = 40:12), patients with Behcet's disease (BD, n = 40, F:M = 29:11) as another systemic inflammatory disease were studied along with a systemically healthy control group (HC, n = 57, F:M = 40:17). All participants were non‐smokers. Full mouth periodontal parameters were recorded. RA activity was assessed using the 28‐joint Disease Activity Score (DAS‐28). Rheumatoid factors (RFs)‐IgM and ‐IgA were measured by ELISA. GCF samples were investigated by means of fluorescent in situ hybridization for 10 different bacterial taxa.

Results

The taxa TM7, Synergistetes cluster B, Leptotrichia, Megasphaera, Anaeroglobus geminatus, and Tannerella forsythia displayed significantly differential abundances between the groups. Whereas abundances of Megasphaera and A. geminatus were significantly increased in the RA group, only Porphyromonas gingivalis displayed significant correlations with plaque scores, bleeding on probing, and RF‐IgA. RA patients displaying RF‐IgA levels >75 IU/mL exhibited five‐fold more abundant P. gingivalis levels than patients below the threshold. This association with RF‐IgA levels appeared even more pronounced, by six‐fold more P. gingivalis (P = 0.025), in patients with a DAS‐28 score >3.2, indicative of moderate/very active RA.

Conclusions

Unattached GCF bacteria may mediate the association between periodontitis and RA, and monitoring the bacterial composition of GCF might inform on RA activity. The role of newly identified bacterial taxa in RA warrants further investigations.

Increased IgA anti-citrullinated protein antibodies in the periodontal inflammatory exudate of healthy individuals compared to rheumatoid arthritis patients

Aim

To assess rheumatoid arthritis (RA)‐associated autoantibodies in the gingivocrevicular fluid (GCF) of RA patients and healthy controls with or without periodontal disease, as chronic mucosal inflammation in periodontal disease is hypothesized to contribute to the formation of these autoantibodies.

Materials and methods

Anti‐citrullinated protein antibodies (ACPA), rheumatoid factor (RF), and their IgA isotypes were assessed in the serum and GCF of RA patients (n = 72) and healthy controls (HC, n = 151). The presence and levels of these antibodies were studied in relation to interleukin (IL)‐8 and periodontal disease.

Results

In contrast to the HC, the levels of ACPA and RF in the serum and GCF of the RA patients were strongly correlated (p < .0001). The HC with high levels of IgA‐ACPA (n = 27) also had significantly higher levels of total IgG, total IgA, and IL‐8 in the GCF than the HC with low levels of IgA‐ACPA in the GCF (n = 124). Periodontal inflammation and smoking were seen more frequently in the group with high levels of IgA‐ACPA compared to the group with low IgA‐ACPA.

Conclusion

The IgA‐ACPA in the GCF of HC may be associated with periodontal inflammation and smoking, and could be involved in the progression to RA.

The Impact of Cigarette Smoking on Risk of Rheumatoid Arthritis: A Narrative Review

Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation and subsequent proliferation of synovial tissues, which eventually leads to cartilage and bone destruction without effective treatments. Anti-citrullinated cyclic peptide/protein antibody (ACPA) and rheumatoid factor (RF) are two main characteristic autoantibodies found in RA patients and are associated with unfavorable disease outcomes. Although etiologies and causes of the disease have not been fully clarified yet, it is likely that interactive contributions of genetic and environmental factors play a main role in RA pathology. Previous works have demonstrated several genetic and environmental factors as risks of RA development and/or autoantibody productions. Among these, cigarette smoking and HLA-DRB1 are the well-established environmental and genetic risks, respectively. In this narrative review, we provide a recent update on genetic contributions to RA and the environmental risks of RA with a special focus on cigarette smoking and its impacts on RA pathology. We also describe gene–environmental interaction in RA pathogenesis with an emphasis on cigarette smoking and HLA-DRB1.

Rheumatoid Arthritis-Associated Mechanisms of Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans

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

Does periodontitis represent a risk factor for rheumatoid arthritis? A systematic review and meta-analysis

Periodontitis is an inflammatory disease of dental supporting tissues (gingiva, periodontal ligament, and bone) and it has been suggested as a possible etiology for rheumatoid arthritis (RA). In this systematic review, we aim to verify if periodontitis represents a risk factor for RA. Electronic databases were consulted until March 2018 considering eligibility criteria focusing on: (P, participants) adults; (E, exposure) with periodontitis; (C, comparison) without periodontitis; and (O, outcome) development of RA. Quality assessment of studies and risk-of-bias evaluation were also performed. To undertake a quantitative analysis, the number of persons with RA and a total number of participants for the case group (with periodontitis) and control group (without periodontitis) were used to calculate the odds ratio (OR) with a 95% confidence interval (CI). A total of 3888 articles were identified, and nine studies were considered eligible. Seven of 9 articles suggested an association among diseases by the common pro-inflammatory profiles. The pooled analysis of 3 articles showed a higher RA prevalence for persons with periodontitis (n = 1177) than controls (n = 254) (OR 1.97; CI 1.68–2.31; p < 0.00001). However, considerable heterogeneity among studies was verified (I² = 96%, p < 0.00001). Periodontitis may represent a risk factor for RA by heredity, bacterial infection, and the pro-inflammatory profile shared between both diseases. Although most of the elective studies report an association between periodontitis and RA, the quantitative analysis showed a high heterogeneity, leading to the need for further studies.

Relationship between autoantibody associated with rheumatoid arthritis and tooth loss

INTRODUCTION

This study evaluated the relationship between serum Rheumatoid Factor (RF) levels and tooth loss in a community-dwelling elderly Japanese women. It was hypothesised that women with high baseline RF levels would experience greater tooth loss over 10 years than age-matched women with lower baseline serum RF levels.

MATERIALS AND METHODS

The study population consisted of 197 women aged 70 years with ≥12 teeth at baseline. One hundred and twenty-four participants completed a 10-year follow-up and were divided into 2 groups according to their baseline serum RF levels as follows: RF negative (<15 U/mL; n = 114) and RF positive (>15 U/mL; n = 10). Negative binomial regression was used to investigate the relationship between baseline RFs and tooth lost over the 10-year period. RF and its interaction with the baseline number of teeth were independent variables, with 9 other adjustment covariates.

RESULTS

Baseline RFs were significantly associated with tooth loss (P = .035). In addition, a statistical interaction between baseline RFs and baseline number of teeth was identified (P = .023), modifying the association between RFs and tooth loss. The adjusted incidence rate ratio (IRR) for RF-positive participants with 21 baseline teeth was 1.88 (95% confidence interval (95% CI): 0.76, 4.65). IRRs obtained for participants who had 25 baseline teeth (3.02; 95% CI: 1.03, 8.83) or 30 baseline teeth (5.47; 95% CI: 1.29, 23.13) suggested that RF-positive participants with a high number of baseline teeth would exhibit greater tooth loss than RF-negative participants.

CONCLUSION

High serum RF levels were associated with a greater IRR for future tooth loss in elderly Japanese women.

Autoimmunity of the lung and oral mucosa in a multisystem inflammatory disease: The spark that lights the fire in rheumatoid arthritis?

There is a growing body of evidence to suggest that autoimmunity in patients with rheumatoid arthritis (RA) is initiated outside the joint. This is supported by the observation that circulating autoantibodies, including both rheumatoid factor and anti-citrullinated protein antibody, can be detected in many subjects years before the development of initial joint symptoms leading to an RA diagnosis. Of the potential extra-articular sites implicated in disease initiation, mucosal tissues have garnered increasing attention. Several lines of investigation have separately implicated mucosal tissues from varying anatomic locations as possible initiating sites for RA, including those from the lung and oral cavity. In this review we summarize recent reports incriminating these mucosal tissues as the initial site of autoantibody generation and inflammation in patients with RA.

Does periodontal treatment influence clinical and biochemical measures for rheumatoid arthritis? A systematic review and meta-analysis

OBJECTIVE

Periodontitis is a potential risk factor for rheumatoid arthritis (RA). This systematic review considers the evidence for whether non-surgical treatment of periodontitis in RA patients has any effect on the clinical markers of RA disease activity.

METHODS

MEDLINE/PubMed, CINAHL, DOSS, Embase, Scopus, Web of Knowledge, MedNar, Lilacs and ProQuest Theses and Dissertations were searched till September 2013 for quantitative studies examining the effect of non-surgical periodontal treatment on disease activity of RA. The following were the inclusion criteria: (1) patients diagnosed with both RA and chronic periodontitis, aged 30 years or older; (2) no antibiotics in the past 3 months or periodontal treatment in the past 6 months; (3) non-surgical periodontal therapy; (4) age- and gender-matched control group; (5) measures of RA activity and (6) published in English.

RESULTS

Five studies met the inclusion criteria. Non-surgical periodontal treatment was associated with significant reductions in erythrocyte sedimentation rate and a trend towards a reduction in TNF-α titres and DAS scores. There was no evidence of an effect on RF, C-reactive protein, anti-cyclic citrullinated protein antibodies and IL-6.

CONCLUSIONS

Based on clinical and biochemical markers, non-surgical periodontal treatment in individuals with periodontitis and RA could lead to improvements in markers of disease activity in RA. All studies had low subject numbers with the periods of intervention no longer than 6 months. Larger studies are required to explore the effect of non-surgical periodontal treatment on clinical indicators of RA, using more rigorous biochemical and clinical outcome measures as well as giving consideration to potential confounding factors of co-morbidity.

Periodontal treatment decreases levels of antibodies to Porphyromonas gingivalis and citrulline in patients with rheumatoid arthritis and periodontitis

BACKGROUND

Porphyromonas gingivalis has been implicated as an etiologic agent of rheumatoid arthritis (RA) because of the expression of peptidylarginine deiminase. The present study evaluates whether periodontal treatment may affect serum antibodies to P. gingivalis and citrulline levels in relation to disease activity of RA.

METHODS

Fifty-five patients with RA were randomly assigned to receive oral hygiene instruction and supragingival scaling (treatment group, n = 26) or no periodontal treatment (control group, n = 29). Periodontal and rheumatologic parameters and serum levels of cytokine and inflammatory markers citrulline and immunoglobulin (Ig)G to P. gingivalis were examined at baseline and 8 weeks later.

RESULTS

Both groups did not differ statistically in any parameters except percentage of sites with probing depth and clinical attachment level ≥ 4 mm at baseline. The treatment group exhibited a significantly greater decrease in disease activity score including 28 joints using C-reactive protein (DAS28-CRP) (P = 0.02), serum levels of IgG to P. gingivalis hemin binding protein (HBP)35 (P = 0.04), and citrulline (P = 0.02) than the control group. Serum levels of IgG to P. gingivalis HBP35 were significantly correlated positively with those of anti-cyclic citrullinated peptide antibodies (P = 0.0002). The same correlation was obtained between serum levels of IgG to P. gingivalis-sonicated extracts and those of rheumatoid factor (P = 0.02).

CONCLUSIONS

These results suggest that supragingival scaling decreases DAS28-CRP and serum levels of IgG to P. gingivalis HBP35 and citrulline in patients with RA. These observations may reflect a role of P. gingivalis in the protein citrullination, which is related to the pathogenesis of RA.

Rheumatoid arthritis in the elderly and its relationship with periodontitis: a review

Periodontitis and rheumatoid arthritis are chronic inflammatory diseases commonly seen in the elderly. It has been proposed that the two conditions are interrelated and influence the severity of each other. Recently, the role of Porphyromonas gingivalis, a periodontopathogen, has been explained in the pathogenesis and progression of rheumatoid arthritis. It can be inferred from the present review that the two conditions share a common pathobiology, genetics and environmental risk factors. Furthermore, a thorough understanding of the aforementioned mechanisms might enable the development of conjoint treatment modalities beneficial in treating the geriatric population afflicted by both the disorders.

Porphyromonas gingivalis and disease-related autoantibodies in individuals at increased risk of rheumatoid arthritis

OBJECTIVE

To examine the relationship of Porphyromonas gingivalis to the presence of autoantibodies in individuals at risk of rheumatoid arthritis (RA).

METHODS

Study participants included the following: 1) a cohort enriched in subjects with HLA-DR4 and 2) subjects at risk of RA by virtue of having a first-degree relative with RA. None of the study subjects satisfied the American College of Rheumatology 1987 classification criteria for RA. Autoantibodies measured included anti-citrullinated protein antibody (ACPA; by second-generation anti-cyclic citrullinated peptide antibody enzyme-linked immunosorbent assay [ELISA]) and rheumatoid factor (RF; by nephelometry or ELISA for IgA, IgM, or IgG isotype). Individuals were considered autoantibody positive (n = 113) if they had ≥1 RA-related autoantibody; individuals were further categorized as high risk (n = 38) if they had ACPA or positive findings ≥2 assays for RF. Autoantibody-negative individuals (n = 171) served as a comparator group. Antibody to P gingivalis, P intermedia, and F nucleatum were measured. Associations of bacterial antibodies with group status were examined using logistic regression.

RESULTS

Anti-P gingivalis concentrations were higher in high-risk (P = 0.011) and autoantibody positive group (P = 0.010) than in the autoantibody negative group. There were no group differences in anti-P intermedia or anti-F nucleatum concentrations. After multivariable adjustment, anti-P gingivalis concentrations (but not anti-P intermedia or anti-F nucleatum) were significantly associated with autoantibody-positive and high-risk status (P < 0.05).

CONCLUSION

Immunity to P gingivalis, but not P intermedia or F nucleatum, is significantly associated with the presence of RA-related autoantibodies in individuals at risk of RA. These results support the hypothesis that infection with P gingivalis may play a central role in the early loss of tolerance to self antigens that occurs in the pathogenesis of RA.

Antibody responses to periodontopathic bacteria in relation to rheumatoid arthritis in Japanese adults

BACKGROUND

Periodontopathic bacteria have been implicated as contributory to the etiology of rheumatoid arthritis (RA). Anticyclic citrullinated peptide (CCP) antibodies and rheumatoid factor (RF) were shown to be associated with RA. This study examines whether serum levels of antibodies to periodontopathic bacteria may affect clinical and laboratory profiles of RA.

METHODS

The study participants consisted of 80 patients with RA, and 38 age-, sex-, smoking status-, and periodontal condition-balanced healthy controls. After periodontal and rheumatologic examination, serum levels of immunoglobulin G (IgG) antibodies to Porphyromonas gingivalis (Pg), Prevotella intermedia, Aggregatibacter actinomycetemcomitans (Aa) (previously Actinobacillus actinomycetemcomitans), and Eikenella corrodens (Ec) and those of anti-CCP antibodies and RF were determined by an enzyme-linked immunosorbent assay.

RESULTS

Patients with RA showed significantly higher levels of anti-Pg and anti-CCP antibodies than controls (P = 0.04 and P <0.0001). In contrast, IgG responses to Aa and Ec in patients with RA were significantly lower than those in controls (P <0.0001 and P = 0.0001). Multiple logistic regression analysis revealed a significant association of anti-Pg and anti-Aa IgG responses with RA, after adjustment for age, sex, and smoking (P = 0.005 and P = 0.02). Anti-Pg titer displayed a significant correlation with RF levels, probing depth, and clinical attachment level (P = 0.03, P = 0.03, and P = 0.02).

CONCLUSION

These results suggest that serum levels of anti-Pg IgG antibodies were associated with RA, and might affect serum levels of RF and periodontal condition in patients with RA.

Rheumatoid arthritis is linked to oral bacteria: etiological association

The purpose of this review is to evaluate the association between rheumatoid arthritis (RA) and periodontopathic bacteria. Clinical studies of RA and periodontal disease have provided evidence for a significant association between the two disorders. Patients with long-standing active RA have a substantially increased frequency of periodontal disease compared with that among healthy subjects. High levels of oral anaerobic bacterial antibodies have been found in the serum and synovial fluid of RA patients. Porphyromonas gingivalis, Tannerella forsythensis, and Prevotella intermedia have been identified in RA synovial fluid. Ornidazole, levofloxacin, and clarithromycin are used in the treatment of infections caused by anaerobic bacteria. These antibiotics have been shown to be effective against RA. The evidence in this review indicates that oral bacteria directly associate with etiopathogenesis of RA.

Antibody responses to Porphyromonas gingivalis (P. gingivalis) in subjects with rheumatoid arthritis and periodontitis

Antibody titers to P. gingivalis are increased in patients with rheumatoid arthritis and are associated with disease-specific autoimmunity.

BACKGROUND

Periodontitis (PD) has been implicated as a risk factor for rheumatoid arthritis (RA). We sought to characterize antibody titers to P. gingivalis (a pathogen in PD) in subjects with RA, PD, and in healthy controls and to examine their relationship with disease autoantibodies.

METHODS

P. gingivalis antibody was measured in subjects with RA (n=78), PD (n=39), and in controls (n=40). Group frequencies of bacterial titer elevations were compared using the Chi-square test and antibody titers were compared using non-parametric tests. Correlations of P. gingivalis titer with C-reactive protein (CRP), antibody to cyclic citrullinated peptide (anti-CCP), and rheumatoid factor (RF) were examined in those with RA while CRP and autoantibody concentrations were compared based on seropositivity to P. gingivalis.

RESULTS

Antibody titers to P. gingivalis were highest in PD, lowest in controls, and intermediate in RA (p=0.0003). Elevations in P. gingivalis (titer> or =800) were more common in RA and PD (67% and 77%, respectively) than in controls (40%) (p=0.002). In RA, there were significant correlations with P. gingivalis titer with CRP, anti-CCP-IgM, and -IgG-2. CRP (p=0.006), anti-CCP-IgM (p=0.01) and -IgG2 (p=0.04) concentrations were higher in RA cases with P. gingivalis titers > or =800 compared to cases with titers <800.

CONCLUSION

Antibodies to P. gingivalis are more common in RA subjects than controls, although lower than that in PD. Associations of P. gingivalis titers with RA-related autoantibody and CRP concentrations suggests that infection with this organism plays a role in disease risk and progression in RA.

Control of periodontal infection reduces the severity of active rheumatoid arthritis

OBJECTIVE

To determine if eliminating periodontal infection and gingival inflammation affects the severity of active rheumatoid arthritis (RA) in patients with chronic inflammatory periodontal disease.

METHODS

Twenty-nine subjects with confirmed diagnosis of RA and mild-to-moderate chronic periodontitis of at least 3 years' duration were enrolled in the study. The activity of RA was assessed using the disease activity score test (DAS28). Seventeen subjects completing the study received periodontal treatment consisting of scaling/root planing and oral hygiene instruction; 12 subjects completing the study received no treatment. Participants continued their usual disease-modifying medications for RA without any changes in DMARD therapy during the study period. RA measurements, and periodontal indices were recorded at baseline and at 8 weeks for each participant. Mann-Whitney U and chi tests were used to test for significant differences in the severity of RA in the periodontally treated group compared with the untreated groups.

RESULTS

Ten of 17 subjects (58.8%) in the treated group and 2 of 12 subjects (16.7%) in the untreated group showed improvement in RA scores. There was a statistically significant difference in DAS28 (4.3 +/- 1.6 vs. 5.1 +/- 1.2) and erythrocyte sedimentation rate (31.4 +/- 24.3 vs. 42.7 +/- 22) between the treatment and the control groups.

CONCLUSION

Control of periodontal infection and gingival inflammation by scaling/root planing and plaque control in subjects with periodontal disease may reduce the severity of RA. This notion is supported by reported subjective improvement in treated patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hypothesis: the humoral immune response to oral bacteria provides a stimulus for the development of rheumatoid arthritis

Rheumatoid arthritis (RA) and adult periodontitis share common pathogenetic mechanisms and immunologic and pathological findings. One oral pathogen strongly implicated in the pathogenesis of periodontal disease, Porphyromonas gingivalis, possesses a unique microbial enzyme, peptidylarginine deiminase (PAD), the human equivalent of which has been identified as a susceptibility factor for RA. We suggest that individuals predisposed to periodontal infection are exposed to antigens generated by PAD, with de-iminated fibrin as a likely candidate, which become systemic immunogens and lead to intraarticular inflammation. PAD engendered antigens lead to production of rheumatoid factor-containing immune complexes and provoke local inflammation, both in gingiva and synovium via Fc and C5a receptors.

Periodontal infection as a possible severity factor for rheumatoid arthritis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Inter-relationships between rheumatoid arthritis and periodontal disease. A review

This review considers the considerable similarities between periodontal disease and rheumatoid arthritis (RA). While the etiology of these two diseases may differ, the underlying pathogenic mechanisms are remarkably similar and it is possible that individuals manifesting both periodontitis and RA may suffer from a unifying underlying systemic dysregulation of the inflammatory response. In light of these findings, the implications for the use of disease-modifying medications in the management of these two chronic inflammatory conditions is apparent. Further longitudinal studies and medication-based intervention studies are required to determine just how closely these two conditions are allied.

Root canal treatment and general health: a review of the literature

REVIEW

The focal infection theory was prominent in the medical literature during the early 1900s and curtailed the progress of endodontics. This theory proposed that microorganisms, or their toxins, arising from a focus of circumscribed infection within a tissue could disseminate systemically, resulting in the initiation or exacerbation of systemic illness or the damage of a distant tissue site. For example, during the focal infection era rheumatoid arthritis (RA) was identified as having a close relationship with dental health. The theory was eventually discredited because there was only anecdotal evidence to support its claims and few scientifically controlled studies. There has been a renewed interest in the influence that foci of infection within the oral tissues may have on general health. Some current research suggests a possible relationship between dental health and cardiovascular disease and published case reports have cited dental sources as causes for several systemic illnesses. Improved laboratory procedures employing sophisticated molecular biological techniques and enhanced culturing techniques have allowed researchers to confirm that bacteria recovered from the peripheral blood during root canal treatment originated in the root canal. It has been suggested that the bacteraemia, or the associated bacterial endotoxins, subsequent to root canal treatment, may cause potential systemic complications. Further research is required, however, using current sampling and laboratory methods from scientifically controlled population groups to determine if a significant relationship between general health and periradicular infection exists.

Induction of anti-thymocyte/T lymphocyte antibodies in mice injected with lipopolysaccharides from periodontopathic bacteria

We examined the levels of anti-thymocyte/T lymphocyte autoantibody (ATA) in the serum of mice injected intraperitoneally with lipopolysaccharides (LPS) from periodontopathic bacteria; Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum, Capnocytophaga ochracea, and non-oral Escherichia coli. All of the LPS induced IgM-ATA. Among these, LPS from C. ochracea induced the highest level of IgM-ATA, whereas that of P. gingivalis induced the lowest. The peritoneal T lymphocytes of mice injected with LPS were bound by IgM-ATA. Peritoneal B-1 (CD5+B) cells stimulated by each LPS produced much more IgM-ATA than splenic B-2 (CD5-B) cells, suggesting that B-1 cells might be responsible for the production of these antibodies. Serum of mice injected with C. ochracea and F. nucleatum LPS showed cytotoxicity against thymocytes in the presence of rabbit complements. Binding and cytotoxicity were confirmed by IgM purified from serum of the mice injected with C. ochracea LPS. Furthermore, serum of mice treated with C. ochracea, F. nucleatum or A. actinomycetemcomitans LPS inhibited the proliferation of thymocytes. However, purified IgM from the serum of mice treated with C. ochracea LPS failed to produce the same inhibition. Our results suggest that LPS from certain species of periodontopathic bacteria can induce IgM-ATA in the serum and these antibodies may modulate the local immune network in periodontal tissues.

Prevalence of periodontal disease in patients with Sjögren's syndrome

The periodontal status of 25 patients with Sjögren's syndrome was compared with that of an age-, sex-, and race-matched healthy controls. Clinical evaluation included determination of number of teeth, decayed/missing/filled surfaces, probing pocket depth, clinical attachment level, plaque index, gingival index, bleeding on probing, and measurement of alveolar bone level (examined with radiography). Results of the study suggest that patients with Sjögren's syndrome have a significantly higher plaque index score (p < 0.005), higher decayed/missing/filled surfaces scores (p < 0.05), increased alveolar bone loss (p < 0.05), deeper clinical attachment level (p < 0.05), and increased cementoenamel junction-alveolar bone crest distance (p < 0.005). Although no significant difference was found in the number of cases of "established periodontitis" between the Sjögren's syndrome and controls, odds ratio analysis suggests that patients with Sjögren's syndrome are at 2.2 times higher risk of having adult periodontitis than healthy controls.

Interleukin-10 promotes anti-collagen antibody production in type I diabetic peripheral B lymphocytes

Previous studies have shown that type I diabetes (IDDM) increases the risk of developing periodontitis by 2-3-fold. IDDM patients exhibit destruction of the pancreatic beta cells, most probably caused by an autoimmune reaction. Evidence is accumulating to support the role of the autoimmune response in periodontal pathogenesis. A cytokine, interleukin (IL)-10, has been reported to selectively promote the expansion of a B lymphocyte lineage (CD5/LY1/B1) which has the propensity for secreting high levels of autoantibody. Therefore, the purpose of this project was to evaluate IL-10 production, percentage of CD5 B cells and the frequency of anti-collagen secreting cells in peripheral blood mononuclear cells of age, gender and race matched IDDM patients and controls. IL-10 production was evaluated by an ELISA using the supernatant of adherent peripheral blood cells cultured for 24 h in the presence of Porphyromonas gingivalis lipopolysaccharide (LPS). In 8 of 31 patients, IL-10 levels were significantly increased in IDDM compared to controls and a higher percentage of CD5 B cells was also observed by flow cytometry. In addition, these patients exhibited a higher frequency of anti-collagen secreting cells as elucidated by an ELISPOT. Moreover, treatment with a neutralizing anti-IL-10 antibody diminished the anti-collagen antibody response by 70%. These findings support the concept that a subset of IDDM patients possess an extremely robust IL-10 response following exposure to Gram-negative LPS, which could predispose them to the development of periodontitis through a heightened autoimmune mechanism.

Serum rheumatoid factor induced by intraperitoneal administration of periodontopathic bacterial lipopolysaccharide in mice

Serum rheumatoid factor (RF) level and peritoneal and splenic CD5+B (B-1) cells in mice were examined after intraperitoneal administration of purified lipopoly-saccharides (LPS) from oral periodontopathic bacteria; Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum and Capnocytophaga ochracea. F. nucleatum and C. ochracea LPS induced higher levels of serum IgM- and IgG-RF, while P. gingivalis LPS showed the least induction. In addition, wet weights of spleen and serum IgM and IgG concentration were markedly increased in F. nucleatum LPS injected group. On the other hand, the proportion of CD5+ B cells to lymphocytes in the peritoneal cavity and spleen did not increase. The reason for this was not clear but conventional B cells (CD5- B cells) might increase more rapidly with splenic enlargement than CD5+ B cells. These results suggested that RF induced by bacterial LPS may modulate immune responses against bacteria and plays an important role for defence and destruction of periodontal tissue.

Fc gamma-binding bacteria in periodontal lesions

The proportion of bacteria exhibiting surface Fc gamma-binding proteins was determined in periodontal pockets of 20 patients diagnosed with periodontal disease and in subgingival areas of 20 patients without periodontal lesions. Bacterial smears were examined by fluorescence microscopy based on DNA staining (Hoechst 33256) and staining of Fc gamma-binding proteins by human biotin-labelled Fc gamma and Texas red-conjugated streptavidin. Fc gamma-binding proteins were observed in all smears from the patients diagnosed with periodontitis, and in a majority of the smears high proportions of the bacteria were positive for Fc gamma-binding proteins. In contrast, most smears from patients without periodontal lesions included low or undetectable proportions of bacteria with Fc gamma-binding proteins.

Clinical and laboratory studies on a patient with early onset periodontitis and her family members. A case report

Extensive clinical, microbiological, hematological, and immunological studies were performed on a patient with early onset periodontitis (EOP) and two other members of the family. The proband, a 27-year-old female, had early onset periodontitis and a high level of serum rheumatoid factors (RF) with no diagnosable medical disease. Her mother had lost all her teeth at the age of 50 because of advanced periodontitis, while her elder sister was unaffected by periodontitis. Neither the proband's periodontally-affected mother nor her unaffected sister exhibited a detectable level of RF. In this study, we examined: 1) serum immunoglobulin G (IgG) antibody titers against putative periodontal pathogenic bacteria; 2) peripheral neutrophil functions; 3) phenotypic analyses of peripheral lymphocyte subpopulations; and 4) peripheral lymphocyte functions (T cell proliferative activity, ability of cytokine [interleukin (IL)-2, tumor necrosis factor-alpha, interferon-gamma, IL-6 and IL-8] and IgG and IgM productivity). High antibody titers to Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Campylobacter rectus were detected in the sera of the proband, as were high serum antibody titers to P. gingivalis in the mother and to C. rectus in the unaffected sister compared to the non-periodontitis affected subjects. The proband also showed enhanced neutrophil chemotaxis; a high percentage of pan-B cells; and high productivity of IL-6, IgG, and IgM compared to individuals who were not periodontally affected. The mother showed slightly low helper/induced T cells (Th/i) suppressor/cytotoxic T cells (Ts/c) ratios due to the elevated count of Ts/c, and high IFN-gamma productivity compared to control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal disease mechanisms in immunocompromised patients

Deficiency in the number and function of phagocytes is associated with gingival inflammation and periodontitis. A hereditary deficiency in membrane glycoproteins involved in granulocyte adherence causes impaired chemotaxis, reduced phagocytosis and periodontal problems. Virus infections of antigen-presenting cells interfere with immune responses and lead to seriously increased susceptibility to infections with bacteria which cause no problems in normal patients. Increased levels of IgG antibodies may limit penetration of antigens in the tissues, but at the cost of local inflammation and tissue injury. Mucosal inflammatory disease with increased local formation of IgG is more frequent in IgA deficient patients. The immunological homeostasis depends on a balance between the respective classes and subclasses of antibodies. Deficiencies in the IgA system may contribute to a disturbed balance of the humoral immune response to critical antigens from oral bacteria. A disproportional increase in IgG1 and IgG3 antibodies may persistently activate complement, stimulate the inflammatory activity and cause tissue injury.

Autoimmunity in periodontal disease

Periodontal disease in characterized by the loss of the normal supporting tissues of the teeth and a humoral and cellular immune response to bacterial antigen of dental plaque which accumulates at the dento-gingival junction. This review considers the evidence for the existence of an autoimmune component of the host immune response, the possible origin of such a response and the way in which such a host response may contribute to the changes observed in the periodontium in the disease.

Serum antibodies and loss of periodontal bone in patients with rheumatoid arthritis

The number of teeth, % of alveolar bone loss, serum IgG, and serum antibodies to Bacteroides gingivalis, Capnocytophaga ochracea and Eubacterium saburreum were recorded in 37 patients diagnosed with rheumatoid arthritis (RA) and in an age- and sex-matched control group of 37 individuals free from RA. The RA group had a significantly increased loss of teeth and loss of alveolar bone compared to the control group. The RA patients also had a significantly increased level of serum IgG. In the total material, 26% of the variation in loss of alveolar bone was accounted for by age, diagnosis of rheumatoid arthritis, and levels of antibodies against B. gingivalis and E. saburreum. In the RA group, 48% of this variation was accounted for by age, total serum IgG and IgG antibodies to B. gingivalis and E. saburreum.

Periodontal conditions in adults with rheumatoid arthritis

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

Local production of IgA- and IgM-rheumatoid factors in adult periodontal disease

The enzyme-linked immunospot assay was used to enumerate both the number and the frequency of spontaneous IgG, IgA, and IgM immunoglobulin-secreting cells and IgA- and IgM-rheumatoid factor (RF)-producing cells present in the gingivae and peripheral blood of adult periodontitis patients. Cells from 29 patients were incubated on plates coated with human IgG, Fc, or F(ab')2 fragments and on plates coated with class-specific anti-human antibodies and secreted antibodies were subsequently visualized by means of an immunoenzymatic procedure. The data indicate that (1) IgA-RF- and IgM-RF-secreting cells are frequently present in the gingiva of adult periodontitis patients; (2) production of RF in gingivae of adult periodontitis patients occurs in the absence of demonstrable RF production by simultaneously obtained peripheral blood mononuclear cells, suggesting that local autoimmune reactions may occur in this disease; and (3) lack of correlation between IgA-RF and IgM-RF production in diseased gingiva suggests that the two RF isotypes are regulated independently of each other.