Anti–TNF-α Immunotherapy Is Associated With Increased Gingival Inflammation Without Clinical Attachment Loss in Subjects With Rheumatoid Arthritis

Periodontal disease as a model to study chronic inflammation in aging

Periodontal disease is a chronic inflammatory condition that results in the destruction of the teeth supporting tissues, eventually leading to the loss of teeth and reduced quality of life. In severe cases, periodontal disease can limit proper nutritional intake, cause acute pain and infection, and cause a withdrawal from social situations due to esthetic and phonetic concerns. Similar to other chronic inflammatory conditions, periodontal disease increases in prevalence with age. Research into what drives periodontal disease pathogenesis in older adults is contributing to our general understanding of age-related chronic inflammation. This review will present periodontal disease as an age-related chronic inflammatory disease and as an effective geroscience model to study mechanisms of age-related inflammatory dysregulation. The current understanding of the cellular and molecular mechanisms that drive inflammatory dysregulation as a function of age will be discussed with a focus on the major pathogenic immune cells in periodontal disease, which include neutrophils, macrophages, and T cells. Research in the aging biology field has shown that the age-related changes in these immune cells result in the cells becoming less effective in the clearance of microbial pathogens, expansion of pathogenic subpopulations, or an increase in pro-inflammatory cytokine secretions. Such changes can be pathogenic and contribute to inflammatory dysregulation that is associated with a myriad of age-related disease including periodontal disease. An improved understanding is needed to develop better interventions that target the molecules or pathways that are perturbed with age in order to improve treatment of chronic inflammatory conditions, including periodontal disease, in older adult populations.

Impact of treatment of rheumatoid arthritis on periodontal disease: A review

BACKGROUND

Numerous studies support a bidirectional association between rheumatoid arthritis (RA), a chronic autoimmune degenerative inflammatory joint disease, and periodontitis, a chronic inflammatory disease caused by the immune reaction to bacteria organized in biofilms. RA and periodontitis are both multifactorial chronic inflammatory diseases that share common modifiable and non-modifiable risk factors. There is no cure for RA; treatment is based on lifestyle modifications and a variety of medications: nonsteroidal anti-inflammatory drugs (NSAID), glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs, e.g., conventional synthetic DMARDs [csDMARDs]; biological DMARDs [bDMARD] and targeted synthetic DMARDs). There are molecular pathways of inflammation that are common to both RA and periodontitis. Thus, there is a potential effect of RA treatments on periodontitis. This systematic review aims to assess the impact of antirheumatic agents on periodontal conditions of patients suffering from both RA and periodontitis.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase online databases were systematically explored, and a manual search was performed to identify relevant studies published until January 2023. This review is registered in the PROSPERO database (CRD42023409006).

RESULTS

A total of 2827 articles were identified, and 35 fulfilled the inclusion criteria. The included studies generally show a consensus that, at normal dosage, NSAID and corticosteroids have negligible impact on periodontium. Similarly, csDMARD alone or in combination with other csDMARD demonstrated no adverse effect on periodontium. Monotherapy with bDMARD had a positive effect on periodontal pocket depths and gingival inflammation in the longitudinal studies up to 6 months but showed negligible effect on the periodontium in interventional studies with a longer follow-up (9 months and 15.1 months). However, the combination of tumor necrosis factor (TNF)-α inhibitors + methotrexate (MTX) was associated with a rise in gingival inflammation. Due to the considerable heterogeneity of the study designs, a meta-analysis could not reasonably be performed.

CONCLUSION

Within the limitations of the available studies, there is evidence to suggest that bDMARD monotherapy may improve the periodontal condition of RA patients with periodontal disease to a certain extent; the concomitant medication of TNF inhibitor + MTX could worsen gingival inflammation. More data are required to understand the impact of RA therapies on periodontal health.

Immune dysregulation and macrophage polarization in peri-implantitis

The term "peri-implantitis" (peri-implantitis) refers to an inflammatory lesion of the mucosa surrounding an endosseous implant and a progressive loss of the peri-implant bone that supports the implant. Recently, it has been suggested that the increased sensitivity of implants to infection and the quick elimination of supporting tissue after infection may be caused by a dysregulated peri-implant mucosal immune response. Macrophages are polarized in response to environmental signals and play multiple roles in peri-implantitis. In peri-implantitis lesion samples, recent investigations have discovered a considerable increase in M1 type macrophages, with M1 type macrophages contributing to the pro-inflammatory response brought on by bacteria, whereas M2 type macrophages contribute to inflammation remission and tissue repair. In an effort to better understand the pathogenesis of peri-implantitis and suggest potential immunomodulatory treatments for peri-implantitis in the direction of macrophage polarization patterns, this review summarizes the research findings related to macrophage polarization in peri-implantitis and compares them with periodontitis.

Genetic causal association between rheumatoid arthritis and periodontitis: a bidirectional two-sample Mendelian randomization analysis

BACKGROUND

A link between rheumatoid arthritis (RA) and periodontitis (PD) has been established. However, their causal relationship remains unclear and the effect of different serotypes of RA on the PD development has not been investigated. This study aims to elucidate the causal association between PD and different serotypes of RA using Mendelian randomization (MR).

METHODS

A bidirectional two-sample MR analysis was performed using available large-scale genome-wide association studies statistics. The inverse-variance weighted (IVW) or multiplicative random-effects IVW was used to determine causality, depending on the heterogeneity of instrumental variables. Additional sensitivity analyses were also performed.

RESULTS

The forward MR analysis identified that seropositive RA (odds ratio (OR), 1.26; 95% confidence interval (CI), 1.07-1.44; p = 0.0018), but not seronegative RA (OR, 1.01; 95% CI, 0.95-1.06; p = 0.9098), was associated with an increased risk of PD. The reverse MR analysis did not show any significant causal effect of PD on RA, independent of the serotypes. The sensitivity tests (p > 0.05) confirmed the robustness and accuracy of these findings.

CONCLUSION

This study revealed that there was a genetic causal effect of seropositive RA on PD, suggesting that this subtype of RA patients may require specific clinical attention to prevent the development of PD.

Six-Month Follow-Up of Periodontal Condition in Rheumatoid Arthritis and Ankylosing Spondylitis Arthritis Patients Undergoing Anti-Tumour Necrosis Factor-α Therapy

In our present study, we aimed to assess the effects of anti-TNF therapy on periodontal condition in a mixed cohort of patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Moreover, we wished to determine whether the baseline dental condition of these patients would affect response to biological therapy. A cohort of 24 arthritis patients was consecutively recruited before starting anti-TNFα therapy. After the dropout of six patients, we evaluated the dental status of 18 subjects at baseline and after 6 months of biological therapy. Clinical responder (R) and non-responder (NR) status was determined after 6 months of anti-TNF treatment. Plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing pocket depth (PPD), PPDmax, clinical attachment loss (CAL), and CALmax were determined. During the 6-month treatment period, six patients (3 RA and 3 AS) terminated the study prematurely as they did not respond to treatment (NR). Therefore, 18 patients were included in the full analysis. There were no major differences in PI, BOP, PPD, PPD max, CAL, and CALmax, among R and NR patients. TNF inhibition resulted in increased GI (0.65 ± 0.34 vs. 0.88 ± 0.30; p < 0.05), as well as decreased PPDmax (4 ± 1.94 vs. 2.72 ± 1.36; p < 0.05) and CALmax (5.22 ± 2.56 vs. 2.72 ± 1.36; p < 0.05) after 6 months. Eight patients had incomplete canal fillings or dead pulps and/or apical periodontitis; six in the R and two in the NR group. In our present study, anti-TNF therapy seemed to worsen the extent of gingival inflammation (GI); however our results also do not support the reduction of mean CPD and CAL as reported by others.

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

Objectives

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Aim

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

Materials and methods

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

Results

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

Conclusions

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

World Workshop on Oral Medicine VII: Oral adverse effects to biologic agents in patients with inflammatory disorders. A scoping review

BACKGROUND

Biologic agents are rapidly emerging as an effective therapy to treat autoimmune and other chronic diseases. The use of these agents is poorly characterized, resulting in a lack of guidance for dental practitioners. Case reports of oral adverse events have begun to emerge. However, their scope and frequency have not been summarized and analysed to date. The objective of this review was to characterize the literature on oral adverse effects associated with biological therapy when used for autoimmune and inflammatory disorders.

METHODS

This review was developed in accordance with scoping review recommendations. Search strategies were developed and employed for six databases. Studies were selected using a systematic search process but with broad inclusion of study types given the paucity of information available. Reports of oral adverse events were analysed descriptively according to agent, mechanism of action, underlying disease, and oral adverse effect observed.

RESULTS

Our search returned 2080 articles and 51 met our inclusion criteria, of which most were case reports. The most frequent adverse effects included angioedema, oral lichenoid lesions, osteonecrosis of the jaw, and oral infections. There were also cases of oral malignancies associated with use of biologic agents. Less common effects such as pigmentation were also described.

CONCLUSIONS

Oral adverse events have been reported in patients on biologic therapy, albeit in small numbers to date. This limits the generalizability of these results, which should not be used to generate a clinical guideline as they are based primarily on case reports. However, this study presents the first review characterizing the adverse effects observed. Large multi-center studies will be necessary to further define the oral and dental complications caused by biologic agents.

Application of Nano-Inspired Scaffolds-Based Biopolymer Hydrogel for Bone and Periodontal Tissue Regeneration

This review’s objectives are to provide an overview of the various kinds of biopolymer hydrogels that are currently used for bone tissue and periodontal tissue regeneration, to list the advantages and disadvantages of using them, to assess how well they might be used for nanoscale fabrication and biofunctionalization, and to describe their production processes and processes for functionalization with active biomolecules. They are applied in conjunction with other materials (such as microparticles (MPs) and nanoparticles (NPs)) and other novel techniques to replicate physiological bone generation more faithfully. Enhancing the biocompatibility of hydrogels created from blends of natural and synthetic biopolymers can result in the creation of the best scaffold match to the extracellular matrix (ECM) for bone and periodontal tissue regeneration. Additionally, adding various nanoparticles can increase the scaffold hydrogel stability and provide a number of biological effects. In this review, the research study of polysaccharide hydrogel as a scaffold will be critical in creating valuable materials for effective bone tissue regeneration, with a future impact predicted in repairing bone defects.

Immunomodulation—What to Modulate and Why? Potential Immune Targets

Despite over 50 years of research into the immunology of periodontal disease, the precise mechanisms and the role of many cell types remains an enigma. Progress has been limited by the inability to determine disease activity clinically. Understanding the immunopathogenesis of periodontal disease however is fundamental if immunomodulation is to be used as a therapeutic strategy. It is important for the clinician to understand what could be modulated and why. In this context, potential targets include different immune cell populations and their subsets, as well as various cytokines. The aim of this review is to examine the role of the principal immune cell populations and their cytokines in the pathogenesis of periodontal disease and their potential as possible therapeutic targets.

Modulating the Immune Response in Periodontitis

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

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

Objective

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

Material and methods

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

Results

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

Conclusions

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

The Effect of Acknowledged and Novel Anti-Rheumatic Therapies on Periodontal Tissues-A Narrative Review

Rheumatoid arthritis (RA) and periodontal disease (PD) are chronic complex inflammatory diseases with several common susceptibility factors, especially genetic and environmental risk factors. Although both disorders involve a perturbation of the immune–inflammatory response at multiple levels, one major difference between the two is the different locations in which they develop. RA is triggered by an exaggerated autoimmune response that targets joints, while periodontal disease occurs as a consequence of the subgingival periodontopathogenic microbiota. Current treatment models in both pathologies involve the stratification of patients to allow therapeutic individualization according to disease stage, complexity, progression, lifestyle, risk factors, and additional systemic diseases. Therapeutic guidelines for RA comprise of five main classes of drugs: non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, glucocorticoids, and disease-modifying anti-rheumatic drugs (DMARDs): biologic and non-biologic. Although various treatment options are available, a definitive treatment remains elusive, therefore research is ongoing in this area. Several alternatives are currently being tested, such as matrix metalloproteinases (MMP) inhibitors, toll-like receptors (TLR) blockers, pro-resolution mediators, anti-hypoxia inducing factors, stem cell therapy, NLRP3 inhibitors and even natural derived compounds. Although the link between PD and rheumatoid arthritis has been investigated by multiple microbiology and immunology studies, the precise influence and causality is still debated in the literature. Furthermore, the immunomodulatory effect of anti-rheumatic drugs on the periodontium is still largely unknown. In this narrative review, we explore the mechanisms of interaction and the potential influence that anti-rheumatoid medication, including novel treatment options, has on periodontal tissues and whether periodontal health status and treatment can improve the prognosis of an RA patient.

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

OBJECTIVE

To evaluate the influence of diverse anti-rheumatic agents on the periodontal condition and to provide clinical medication guidance for patients with rheumatoid arthritis (RA) and periodontitis.

BACKGROUND

In recent years, the correlation between RA and periodontitis has become a hot research topic, but no medication recommendations for patients with RA and periodontitis are available at present.

METHODS

The protocol of this review was registered in advance with PROSPERO (CRD42021248827). Electronic search and manual searches up to March 20, 2021 were conducted. The inclusion criteria for the studies were as follows: included patients diagnosed with periodontitis and RA submitted to anti-rheumatic agent therapy; with a control group receiving no anti-rheumatic agent therapy; with outcomes including at least one periodontal parameter. Probing depth (PD) and clinical attachment loss (CAL) were pooled using weighted mean difference (WMD) and 95% confidence intervals (CI) while gingival index (GI)/modified gingival index (MGI) was analyzed by standardized mean difference (SMD) and 95% CI.

RESULTS

One thousand four hundred and seventy-eight studies potentially related to the aim of this review were screened, but only 463 patients from 14 studies were included in the qualitative analysis, and 146 patients from 4 studies were included in the meta-analysis. Statistically significant reductions were observed among the subjects who received anti-rheumatic agents for PD [WMD = -0.20; 95% CI (-0.33, -0.07); effect p = .003; I²  = 50%; p = .11], CAL [WMD = -0.4; 95% CI (-0.66, -0.15); effect p = .002; I²  = 57%; p = .07] and GI/MGI [SMD = -0.61;95% CI (-0.94, -0.27; effect p = .0004; I²  = 26%; p = .25]. Consistent with the above results, this systematic review produced promising results that PD, CAL, GI/MGI, and bleeding on probing (BOP) decreased when patients with RA and periodontitis were treated with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), anti-B lymphocyte agents, anti-IL-6R agents, or JAK inhibitors. PD and CAL declined after the administration of anti-TNF-α agents; most studies reported decreased GI/MGI and BOP, while 2 studies reported increased GI/MGI and BOP.

CONCLUSIONS

These results revealed that csDMARDs, anti-B lymphocyte agents, anti-IL-6R agents, anti-TNF-α agents, and JAK inhibitors had potential positive effects in improving the periodontal condition of patients with RA and periodontitis. However, future research is needed to elucidate whether anti-TNF-α agents have a side effect of increased gingival inflammation.

Periodontitis and rheumatoid arthritis: What have we learned about their connection and their treatment?

Rheumatoid arthritis and periodontitis are chronic inflammatory diseases defined respectively by the destruction of the articular cartilage and tooth-supporting periodontal tissues. Although the epidemiologic evidence for an association between these two diseases is still scarce, there is emerging scientific information linking specific bacterial periodontal pathogens, such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, in the citrullination process, leading to autoantibody formation and compromised immunotolerance of the susceptible patient to rheumatoid arthritis. In this review, we update the existing information on the evidence, not only regarding the epidemiologic association, but also the biologic mechanisms linking these two diseases. Finally, we review information emerging from intervention studies evaluating whether periodontal treatment could influence the initiation and progression of rheumatoid arthritis.

Periodontal and dental health in inflammatory bowel diseases: a systematic review

Introduction: An increased risk of dental caries and periodontal diseases has been reported for inflammatory bowel disease (IBD) patients and are challenging conditions to manage.Areas covered: The authors searched international databases to find all studies assessing dental/periodontal outcomes in patients with IBD and other immune-mediated inflammatory disease (IMID), as well as the association between IMID medications and dental/periodontal status.Expert opinion: IBD are associated with a higher risk of both periodontitis and caries. Some evidence from rheumatoid arthritis suggests that periodontitis may be associated with a lower response to anti-TNF. There is no reliable evidence that IBD patients may be at greater risk of complications during routine dental care. On the basis of current data, guidelines can be proposed for the dental management focusing on the detection and eradication of infectious foci prior to the implementation of immunosuppressants/biologics and modified dental treatment protocol for invasive dental procedures that includes antibiotic prophylaxis.

Selective Antimicrobial Therapies for Periodontitis: Win the "Battle and the War"

Traditional antimicrobial therapies for periodontitis (PD) have long focused on non-selective and direct approaches. Professional cleaning of the subgingival biofilm by instrumentation of dental root surfaces, known as scaling and root planning (SRP), is the mainstay of periodontal therapy and is indisputably effective. Non-physical approaches used as adjuncts to SRP, such as chemical and biological agents, will be the focus of this review. In this regard, traditional agents such as oral antiseptics and antibiotics, delivered either locally or systemically, were briefly reviewed as a backdrop. While generally effective in winning the “battle” against PD in the short term, by reducing its signs and symptoms, patients receiving such therapies are more susceptible to recurrence of PD. Moreover, the long-term consequences of such therapies are still in question. In particular, concern about chronic use of systemic antibiotics and their influence on the oral and gut microbiota is warranted, considering antibiotic resistance plasmids, and potential transfer between oral and non-oral microbes. In the interest of winning the “battle and the war”, new more selective and targeted antimicrobials and biologics for PD are being studied. These are principally indirect, blocking pathways involved in bacterial colonization, nutrient acquisition, inflammation or cellular invasion without directly killing the pathogens. This review will focus on current and prospective antimicrobial therapies for PD, emphasizing therapies that act indirectly on the microbiota, with clearly defined cellular and molecular targets.

Association Between the Extent of Periodontal Inflammation and the Severity of Rheumatoid Arthritis in Japanese Patients With Rheumatoid Arthritis

Objective

Periodontal inflammation can affect the progression of rheumatoid arthritis (RA), and RA drugs may influence the periodontal condition of patients with RA. We examined whether the association between periodontal inflammation and the severity of RA is influenced by RA medication.

Methods

This cross-sectional study recruited 98 Japanese patients with RA from an orthopaedic clinic. We assessed the severity of RA using the Steinbrocker class and stage. The periodontal inflamed surface area (PISA) was used as an indicator of periodontal status. We obtained data on RA medications from medical records. We examined the associations among periodontal tissue inflammation, RA medications, and RA severity using multinomial logistic regression analyses.

Results

In univariate multinomial logistic regression analyses, no significant association between PISA score and RA severity was observed. There was no significant association between PISA score and RA severity in multivariate analyses not including variables about RA drugs as independent variables. However, in multivariate analyses adjusted for RA drugs and other confounding variables, patients with a PISA >550 mm² had significantly higher odds ratios (ORs) for Steinbrocker class III-IV and stage III-IV (OR, 20.24; 95% confidence interval [CI], 1.78-229.85 and OR, 12.42; 95% CI, 1.79-86.49, respectively) compared to patients with PISA score ≤550 mm².

Conclusion

The extent of periodontal inflammation is associated with the severity of RA independent of RA medications.

Host Modulation and Treatment of Periodontal Disease

Periodontitis is the sixth-most prevalent disease in the world and the first cause for tooth loss in adults. With focus shifted to the inflammatory/immune response in the pathogenesis of periodontitis, there is a critical need to evaluate host modulatory agents. Synthetic and biological disease-modifying antirheumatic drugs are a cornerstone for the treatment of inflammatory diseases. Recent prospective cohort studies showed that synthetic disease-modifying antirheumatic drugs improved periodontal clinical parameters following nonsurgical periodontal treatment in patients with rheumatoid arthritis. Treatment with recombinant humanized monoclonal antibodies against CD20 (rituximab) and IL-6 receptor (tocilizumab), the latter also in clinical trials for the treatment of COVID-19 pneumonia, resulted in decreased periodontal inflammation and improved periodontal status. Studies on the effect of TNF-α inhibitors in patients with periodontitis yielded inconsistent results. Recent data suggest that probiotics provide anti-inflammatory clinical benefit, as do nutritional supplements, such as n-3 fatty acids, when combined with periodontal therapy. Probiotics reduce the production of proinflammatory cytokines/chemokines by suppressing NF-κB pathways and promote the accumulation of T regulatory cells. Statins, like aspirin, have been shown to exhibit anti-inflammatory and bone-preserving actions by upregulating production of Specialized Proresolving Mediators (SPMs). Currently, there is insufficient scientific support for the topical delivery of statins or bisphosphonates as adjuncts to periodontal therapy. Here, we present a critical review of the most recent host modulatory agents applied in humans and the key immune pathways that they target. Emerging evidence from novel drug candidates, including SPMs and complement inhibitors as previously studied in animal models and currently in human clinical trials, suggests future availability of adjunctive therapeutic strategies for the management of periodontitis.

Salivary Glands and Periodontal Changes in a Population of Sjögren's and Sicca Syndrome Treated by Pilocarpine: A Pilot Study

Introduction

Oral administration of pilocarpine enhances salivary flow in sicca patients but its effect upstream on ultrasound (US) of salivary glands (SG) and downstream on periodontium remain unknown.

Methods

Sicca patients were prospectively included. Echostructural and vascularization of SG were assessed using B mode and pulsed Doppler (USPD). Vascularization of SG was measured using resistive index (RI) before and after stimulation by lemon juice. Echostructure (measure of glandular length in cm², evaluation of parotid and submandibular glands parenchymal abnormalities) was assessed at baseline (M0) and after 3 months (M3) of treatment with pilocarpine. A dental consultation was performed at M0 and M3 to evaluate changes in unstimulated salivary flow (USSF), stimulated salivary flow (SSF), and periodontal parameters such as modified gingival index (Lobene), plaque index (Silness), bleeding index, pocket depth, and pH.

Results

Nineteen patients were included but only 11 received pilocarpine treatment for 3 months, as six stopped pilocarpine due to side effects and two were excluded for other causes. Among the 11 patients who completed the 3-month follow-up, five had primary Sjögren’s syndrome according to the American-European’s classification criteria. As expected, statistical differences were found concerning SSF (p = 0.018) and USSF (p = 0.027) between M0 and M3 while no statistical change in both SG echostructure and vascularization or periodontal evaluation was shown.

Conclusions

Pilocarpine improved SSF and USSF measurements in sicca syndrome but no ultrasonography of major salivary glands (SGUS) structural and vascular changes were detected as well as periodontal evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-020-00263-y.

Use of TNF Inhibitors in Rheumatoid Arthritis and Implications for the Periodontal Status: For the Benefit of Both?

The inflammatory diseases rheumatoid arthritis (RA) and periodontitis show similarities in misbalances of cytokine levels, such as tumor necrosis factor-α (TNF-α). RA has been treated for two decades with TNF inhibitors which are effective by blocking TNF's destructive action. Since RA and periodontitis show similarities in high levels of TNF, the periodontal status of RA patients may improve with the use of anti-TNF therapy. To assess this, a systematic review with special emphasis on duration of therapy was performed to evaluate the effect of anti-TNF-α treatment on the periodontal status of RA patients. Overall, studies showed an improvement in periodontal health with anti-TNF therapy. When analyzed over time (6 weeks to 9 months), it became apparent that initial improvements concerned bleeding on probing (BOP) and gingival index (GI) after therapy duration of 6 weeks. Periodontitis parameters that improved after prolonged treatment were: probing pocket depth (PPD) after 3 months and clinical attachment level (CAL) after 6 months. In conclusion, this systematic review reveals that anti-TNF treatment is therefore not only beneficial for rheumatic joints but also for the gums of rheumatoid arthritis patients. We propose that the sequential tissue recovery due to anti-TNF therapy progresses as follows: 1. block of diapedesis by lowering vessel permeability, 2 fewer leukocytes in the inflamed tissue, and 3. reduced proteolytic activity and subsequent repair of collagen fiber functionality and normalization of osteoclast activity. Clinically, this could lead to a decrease in bleeding on probing and ultimately in an improved clinical attachment level.

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.

Electroacupuncture Reduces Inflammation but Not Bone Loss on Periodontitis in Arthritic Rats

Periodontitis and rheumatoid arthritis (RA) are inflammatory diseases characterized by chronic inflammation and bone erosion. Electroacupuncture (EA) shows anti-inflammatory and anti-resorptive effects in experimental periodontitis (EP) and in RA. It is important to investigate whether EA shows these effects in periodontal tissues in the presence of these two inflammatory diseases or not. For this, Wistar rats were divided into six groups: control (C); experimental rheumatoid arthritis (RA; bovine type II collagen-induced (CII)); experimental periodontitis (EP); RA/EP (RA + EP); EP/EA (EP treated with EA); RA/EP/EA (RA + EP treated with EA). EP was induced 21 days after RA induction and EA was performed previously and during the EP induction period, every 3 days until the 36th experimental day. The rats were euthanized on day 39. RA was evaluated by edema and the withdrawal threshold of hind paws. The maxillae were removed, and alveolar bone loss (ABL) and bone radiographic density (BRD) were evaluated. Immunohistochemical analyses for interleukins (IL)-6 and -17 and nuclear factor (NF)-κB were performed. Our results showed that EA reduced only the pain intensity in arthritic rats. Histomorphometric, macroscopic, and radiographic analyses did not show differences between the control and EP/EA groups. EA caused a reduction in ABL and BRD only in the presence of EP. EA caused a reduction in IL-6 and -17 in all groups, but NF-κB was only reduced in the arthritic rats with EP. In conclusion, EA reduced the inflammation related to periodontitis in arthritic rats but did not prevent ABL.

Does periodontitis affect the treatment response of biologics in the treatment of rheumatoid arthritis?

BACKGROUND

Rheumatoid arthritis (RA) and periodontitis (PD) have been suggested to share many clinical and pathological features. However, few reports have investigated the relationship between the degree of PD and the treatment response to RA. This study aimed to examine the relationship between the extent of PD and the treatment response to biologics in RA patients using FDG-PET/CT.

METHODS

Sixty RA patients (male, n = 14; female, n = 46; average age, 58.3 years) treated with biologic agents were included in this study. FDG-PET/CT was performed at baseline and 6 months after the initiation of biological therapy. The maximum standardized uptake value (SUVmax) was used as a representative value for the assessment of the FDG uptake in periodontal tissue and joints including the bilateral shoulders, elbows, wrists, hip, knees, and ankle joints. The Disease Activity Score (DAS) 28-CRP and the following clinical parameters were assessed: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), anti-cyclic citrullinated peptide antibody (ACPA), rheumatoid factor (RF), and matrix metalloproteinase 3 (MMP-3). The relationship between the treatment response of RA and the baseline SUVmax of the periodontal tissue was evaluated.

RESULTS

The baseline periodontal SUVmax was related to patient age (r = 0.302, p = 0.009) and the ACPA level (r = 0.265, p = 0.025). The DAS28-CRP, CRP, ESR, MMP-3, and joint SUVmax values were significantly decreased after 6 months of biological therapy. However, the mean periodontal SUVmax, ACPA, and RF showed no significant changes after treatment. There was a significantly negative correlation between the baseline periodontal SUVmax and the treatment response of DAS28-CRP (r = - 0.369, p = 0.004).

CONCLUSION

There was a negative correlation between the extent of PD at baseline and the treatment response of RA patients who received biological therapy. The evaluation of the periodontal condition is considered to be an essential part for the management of RA.

Progranulin promotes osteogenic differentiation of human periodontal ligament stem cells via tumor necrosis factor receptors to inhibit TNF-α sensitized NF-kB and activate ERK/JNK signaling

OBJECTIVE

To investigate the molecular mechanism of Progranulin (PGRN) in promoting osteogenic differentiation of human periodontal ligament stem cells (hPDLSCs) in inflammatory environment.

BACKGROUND

Progranulin is an antagonist of tumor necrosis factor (TNF) receptors (TNFRs) and is known to promote inflammatory periodontal bone defect regeneration.

METHODS

TNFR1- and TNFR2-silenced hPDLSCs designed as hPDLSCs-sh-TNFR1 and hPDLSCs-sh-TNFR2 were cultured with osteoinductive medium containing TNF-α and (or) PGRN. Immunofluorescence, quantitative real-time PCR, and western blot were used to, respectively, detect expressions of TNFR1\TNFR2 and osteogenic differentiation markers as well as phosphorylation level in NF-κB\MAPK-related pathways.

RESULTS

Immunofluorescence and real-time PCR showed that TNFR1 and TNFR2 positively expressed in hPDLSCs. TNF-α stimulation could significantly decrease the expressions of ALP and RUNX2 in hPDLSCs, whereas PGRN treatment could significantly enhance their expressions, and reverse TNF-α-mediated expression suppression of ALP and RUNX2 in hPDLSCs. In hPDLSCs-sh-TNFR1, TNF-α mediated osteogenic inhibition decreased, but both TNF-α + PGRN and alone PGRN significantly promoted expression of ALP and RUNX2. PGRN significantly enhanced expression of P-ERK1/2 and P-JNK, while corresponding inhibitors eliminated PGRN-stimulated osteogenic differentiation. In hPDLSCs-sh-TNFR2, no significant difference existed in osteogenic markers and P-JNK expression between the PGRN group and the control group. However, PGRN still activated P-ERK1/2 expression. Besides, PGRN antagonized TNF-α-enhanced NF-κB P65 expression.

CONCLUSION

Progranulin promotes osteogenic differentiation of hPDLSCs via TNFR1 to inhibit TNF-α-sensitized NF-κB and via TNFR2 to activate JNK signaling. The mechanism by which PGRN activates ERK signaling remains to be explored.

Periodontal disease and influence of periodontal treatment on disease activity in patients with rheumatoid arthritis and spondyloarthritis

The aim of this study was to assess the prevalence of periodontal disease and the effect of periodontal treatment in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Forty-four RA patients, thirty SpA patients and thirty-nine healthy volunteers were recruited to the study. Periodontal examination included the approximal plaque index (API), bleeding on probing (BoP), probing depth (PD) and number of teeth. Samples from the deepest periodontal pockets were taken for the detection of Porphyromonas gingivalis DNA with the use of the polymerase chain reaction. All subjects with periodontitis, who completed the study, received periodontal treatment consisting of scaling/root planing and oral hygiene instructions. Disease activity scores, clinical and laboratory parameters were assessed before and 4-6 weeks after periodontal treatment. No significant difference in the prevalence of periodontal disease and the presence of P. gingivalis DNA were found in RA and SpA patients compared to healthy controls. Significantly higher API (80% vs 63%; p = 0.01) and a lower number of teeth (20 vs 25, p = 0.001) were found in RA patients. BoP was significantly elevated in SpA patients (51% vs 33%, p = 0.02). Disease activity measured by the DAS28(CRP) was significantly reduced in RA patients after periodontal treatment (p = 0.002). Clinical and biochemical parameters were not improved in SpA patients. Nonsurgical periodontal treatment had an impact on the decrease in RA activity. Periodontal examination is necessary in patients with RA to detect and treat periodontitis at an early stage.

The cytokine network involved in the host immune response to periodontitis

Periodontitis is an inflammatory disease involving the destruction of both soft and hard tissue in the periodontal region. Although dysbiosis of the local microbial community initiates local inflammation, over-activation of the host immune response directly activates osteoclastic activity and alveolar bone loss. Many studies have reported on the cytokine network involved in periodontitis and its crucial and pleiotropic effect on the recruitment of specific immunocytes, control of pathobionts and induction or suppression of osteoclastic activity. Nonetheless, particularities in the stimulation of pathogens in the oral cavity that lead to the specific and complex periodontal cytokine network are far from clarified. Thus, in this review, we begin with an up-to-date aetiological hypothesis of periodontal disease and summarize the roles of cytokines in the host immune response. In addition, we also summarize the latest cytokine-related therapeutic measures for periodontal disease.

Gums and joints: is there a connection? Part two: the biological link

Rheumatoid arthritis (RA) and periodontitis (PD) are inflammatory diseases characterised by an exacerbated immune-inflammatory reaction that leads to the destruction of bone and other connective tissues that share numerous similarities. Although a significant and independent association between these two conditions has been described, the pathophysiological processes that may explain this relationship remain unknown and multiple theories have been proposed. This review presents the most important theories currently proposed to explain the biological link between RA and PD.

Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions

The association between rheumatoid arthritis (RA) and periodontal disease (PD) has been the focus of numerous investigations driven by their common pathological features. RA is an autoimmune disease characterized by chronic inflammation, the production of anti-citrullinated proteins antibodies (ACPA) leading to synovial joint inflammation and destruction. PD is a chronic inflammatory condition associated with a dysbiotic microbial biofilm affecting the supporting tissues around the teeth leading to the destruction of mineralized and non-mineralized connective tissues. Chronic inflammation associated with both RA and PD is similar in the predominant adaptive immune phenotype, in the imbalance between pro- and anti-inflammatory cytokines and in the role of smoking and genetic background as risk factors. Structural damage that occurs in consequence of chronic inflammation is the ultimate cause of loss of function and disability observed with the progression of RA and PD. Interestingly, the periodontal pathogen Porphyromonas gingivalis has been implicated in the generation of ACPA in RA patients, suggesting a direct biological intersection between PD and RA. However, more studies are warranted to confirm this link, elucidate potential mechanisms involved, and ascertain temporal associations between RA and PD. This review is mainly focused on recent clinical and translational research intends to discuss and provide an overview of the relationship between RA and PD, exploring the similarities in the immune-pathological aspects and the possible mechanisms linking the development and progression of both diseases. In addition, the current available treatments targeting both RA and PD were revised.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Periodontal complications of prescription and recreational drugs

Drug use for both therapeutic and recreational purposes is very widespread in most societies. The range of drugs used, the variations in response to these drugs and other health and behavioral confounders mean that drug use may be an important contributor to individualized periodontal diagnoses. In this narrative review, we review the main reported effects of drugs on the periodontal tissues and periodontal disease processes. Although some of the more common adverse drug reactions on periodontal tissues are well described, in many other cases the evidence for these drug effects is quite limited and based on small case series or isolated reports. Prescription drugs are responsible for a range of effects, including drug-induced gingival overgrowth and increased gingival bleeding, and influence periodontal inflammation and periodontal breakdown. The effects of recreational drugs on the periodontal tissues is less well researched, perhaps for the obvious reason that assembling large cohorts of recreational drug users presents particular challenges. Use of nearly all of these substances is associated with poorer periodontal and dental health, although there is almost certainly a large degree of behavioral confounding in these findings. Overall, further studies of adverse drug reactions on the periodontal tissues are required as this continues to be an important and increasing factor in periodontal health determination.

Interaction of biologic therapy with apical periodontitis and periodontitis: a systematic review

Biologic medications (BMs) are increasingly used for the management of systemic chronic inflammatory diseases. These diseases are often associated with a higher prevalence of apical periodontitis (AP) and periodontitis (P). The purpose of this systematic review was to ascertain the interactions between AP and/or P and BMs. The review was registered in the PROSPERO database (CRD42017054756). Electronic searches were performed on Pubmed Medline, Scopus and The Web of Science from their inception through to 20 March 2018. The references of the articles selected were checked. The keywords were chosen based on a pilot search, which aimed to find the most frequently prescribed BMs. The included studies were appraised qualitatively using appropriate tools. Thirty-five articles met the inclusion criteria, comprising 16 non-randomized clinical studies, 12 in vivo animal studies and 7 case reports. Quality of information was assessed as high in 18 articles, moderate in 16 articles and low in 1 article. BMs in patients suffering from chronic inflammatory diseases seems to inhibit the progression of AP and P, and to enhance the healing response to periodontal and endodontic treatment. A healthier condition of the periodontal tissues seems to be associated with a better response of the patient to BMs therapy.

Talk to your gut: the oral-gut microbiome axis and its immunomodulatory role in the etiology of rheumatoid arthritis

Microbial communities inhabiting the human body, collectively called the microbiome, are critical modulators of immunity. This notion is underpinned by associations between changes in the microbiome and particular autoimmune disorders. Specifically, in rheumatoid arthritis, one of the most frequently occurring autoimmune disorders worldwide, changes in the oral and gut microbiomes have been implicated in the loss of tolerance against self-antigens and in increased inflammatory events promoting the damage of joints. In the present review, we highlight recently gained insights in the roles of microbes in the etiology of rheumatoid arthritis. In addition, we address important immunomodulatory processes, including biofilm formation and neutrophil function, which have been implicated in host-microbe interactions relevant for rheumatoid arthritis. Lastly, we present recent advances in the development and evaluation of emerging microbiome-based therapeutic approaches. Altogether, we conclude that the key to uncovering the etiopathogenesis of rheumatoid arthritis will lie in the immunomodulatory functions of the oral and gut microbiomes.

Association between severity of periodontitis and clinical activity in rheumatoid arthritis patients: a case-control study

Background

A high prevalence of periodontitis has been reported in rheumatoid arthritis (RA) patients, although the strength of this association, its temporal link and the possible relationship between the severity of periodontitis and RA disease activity remain unclear. The objective of this work was to investigate whether periodontitis is associated with RA and whether periodontitis severity is linked to RA disease activity.

Methods

This case–control study included 187 patients diagnosed with RA and 157 control patients without inflammatory joint disease. RA disease activity and severity were evaluated by the Disease Activity Score 28, the Simplified Disease Activity Index, the Clinical Disease Activity Index, rheumatoid factor, anti-citrullinated protein antibody titers, the erythrocyte sedimentation rate, C-reactive protein, presence of extra-articular manifestations and type of RA therapy. Exposure severity was assessed by the following periodontal parameters: plaque index, bleeding on probing, probing pocket depth and clinical attachment levels. Sociodemographic variables and comorbidities were evaluated as confounding variables. Outcome and exposure variables were compared by both parametric and nonparametric tests, and possible associations were assessed through regression analysis with a calculation for the adjusted odds ratio (OR).

Results

A significant association was demonstrated between periodontitis and RA with an adjusted OR of 20.57 (95% CI 6.02–70.27, p < 0.001). Compared with controls, all parameters related to periodontal status (plaque index, bleeding on probing, probing pocket depth and clinical attachment levels) were significantly worse in RA patients (p < 0.001). Periodontitis severity was significantly associated with RA disease activity (p < 0.001), showing in an ordinal logistic regression model an association between periodontal severity and disease activity with an adjusted OR of 2.66 (95% CI 1.24–5.74, p = 0.012).

Conclusion

A significant association was demonstrated between periodontitis and RA, independent of other confounders. This association was more evident in patients with pronounced periodontal disease and higher RA disease activity.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1808-z) contains supplementary material, which is available to authorized users.

Association of different immunosuppressive medications with periodontal condition in patients with rheumatoid arthritis: Results from a cross-sectional study

BACKGROUND

The aim of this cross-sectional study was to investigate clinical periodontal findings as well as prevalence of selected potentially periodontal pathogenic bacteria in patients with rheumatoid arthritis (RA) treated with different immunosuppressive rheumatic medications.

METHODS

One hundred sixty-eight patients with RA undergoing different immunosuppressive medications were included and divided into subgroups according to their medication, which was taken in the past 6 months, in detail, 1) non-steroidal anti-inflammatory drugs (NSAID) and glucocorticoids combined, and the following different disease modifying anti-rheumatic drugs (DMARDs): 2) methotrexate (MTX), 3) leflunomide, 4) MTX and TNF-α antagonists combined, 5) interleukin-6 (IL-6) antagonist, 6) MTX and rituximab combined, and 7) combination therapies of > 2 of these DMARDs. Periodontal examination consisted of papilla bleeding index (PBI), periodontal status with periodontal probing depth (PD), bleeding on probing (BOP), and clinical attachment loss (AL). Periodontitis was classified as none/mild, moderate, or severe. Samples obtained from gingival crevicular fluid were analyzed for presence of 11 periodontal pathogenic bacteria.

RESULTS

Patients with MTX + TNF-α antagonists therapy showed higher PBI and BOP values compared with leflunomide (P < 0.01) and higher BOP than MTX + rituximab (P = 0.02). Porphyromonas gingivalis (P < 0.01), Treponema denticola (P < 0.01), Fusobacterium nodatum (P = 0.02) and Capnocytophaga species (P = 0.05) was associated with medication subgroup, whereby post hoc testing confirmed singular differences for several medication subgroups.

CONCLUSIONS

RA medication is associated with periodontal inflammation, without differences in periodontal disease severity. Thereby, combination of MTX + TNF-α shows an increased potential to periodontal inflammation. Additionally, several differences in prevalence of selected bacteria were detected.

Effects of Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Response to Periodontal Treatment in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) and periodontitis are common chronic inflammatory diseases and periodontitis is known to be more common and more severe in patients with RA. Based on a paucity of studies about the relationship between common conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and periodontitis, this prospective study aimed to evaluate the adjunctive effect of csDMARDs on response to nonsurgical periodontal treatment in patients with RA. Thirty-two patients with RA (RA group) and 32 systemically healthy patients (control group) with periodontitis were included in this study. The RA group patients were treated with csDMARDs, such as methotrexate, hydroxychloroquine, and sulfasalazine. Conventional nonsurgical periodontal treatment with scaling and root planing was performed in both groups. The extent and severity of periodontitis were evaluated by plaque index (PI), gingival index (GI), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) at baseline and 4 weeks after periodontal treatment. There was no statistically significant difference of periodontal parameters between the RA and control groups at baseline. Four weeks after scaling and root planing, PD reduction, and CAL gain were higher in the RA group treated with csDMARDs compared to the control group, and the difference was statistically significant (P = 0.006 and 0.003, respectively). A post hoc analysis of the RA group showed no statistically significant difference on the response to nonsurgical periodontal treatment in multiple csDMARDs therapy and addition of NSAIDs and/or steroids to csDMARDs. In patients with RA, csDMARDs showed beneficial effect on periodontal clinical parameters following the nonsurgical periodontal treatment.

Periodontitis in early and chronic rheumatoid arthritis: a prospective follow-up study in Finnish population

OBJECTIVES

To investigate the association between rheumatoid arthritis (RA) and periodontitis with special emphasis on the role of antirheumatic drugs in periodontal health.

DESIGN

Prospective follow-up study. Patients with early untreated RA and chronic active RA were examined at baseline and 16 months later. Controls were examined once.

SETTINGS AND PARTICIPANTS

The study was conducted in Finland from September 2005 to May 2014 at the Helsinki University Hospital. Overall, 124 participants were recruited for dental and medical examinations: 53 were patients with early disease-modifying antirheumatic drug (DMARD) naїve RA (ERA), 28 were patients with chronic RA (CRA) with insufficient response to conventional DMARDs. After baseline examination, patients with ERA started treatment with synthetic DMARDs and patients with CRA with biological DMARDs. Controls were 43 age-matched, gender-matched and community-matched participants.

OUTCOME MEASURES

Degree of periodontitis (defined according to the Center for Disease Control and Prevention and the American Academy of Periodontology). Prevalence of periodontal bacteria (analysed from plaque samples), clinical rheumatological status by Disease Activity Score, 28-joint count (DAS28), function by Health Assessment Questionnaire (HAQ) and treatment response by European League Against Rheumatism (EULAR) criteria.

RESULTS

Moderate periodontitis was present in 67.3% of patients with ERA, 64.3% of patients with CRA and 39.5% of control participants (p=0.001). Further, patients with RA had significantly more periodontal findings compared with controls, recorded with common periodontal indexes. In the re-examination, patients with RA still showed poor periodontal health in spite of treatment with DMARDs after baseline examination. The prevalence of Porphyromonas gingivalis was higher in patients with ERA with periodontal probing depth ≥4 mm compared with patients with CRA and controls. Antirheumatic medication did not seem to affect the results.

CONCLUSIONS

Moderate periodontitis was more frequent in patients with RA than in controls. Patients with ERA and CRA exhibited poorer periodontal health parameters when compared with controls. There was no association between antirheumatic treatment and periodontal parameters.

Salivary and serum procalcitonin and C-reactive protein as biomarkers of periodontitis in United States veterans with osteoarthritis or rheumatoid arthritis

Serum procalcitonin (ProCT) is elevated in response to bacterial infections, whereas high sensitivity C-reactive protein (hsCRP) is a nonspecific inflammatory marker that is increased by excess adipose tissue. We examined the efficacy of ProCT and hsCRP as biomarkers of periodontitis in the saliva and serum of patients with arthritis, which is characterized by variable levels of systemic inflammation that potentially can confound the interpretation of inflammatory biomarkers. Blood and unstimulated whole saliva were collected from 33 patients with rheumatoid arthritis (RA) and 50 with osteoarthritis (OA). Periodontal status was assessed by full mouth examination and patients were categorized as having no/mild, moderate or severe periodontitis by standard parameters. Salivary and serum ProCT and hsCRP concentrations were compared. BMI, diabetes, anti-inflammatory medications and smoking status were ascertained from the patient records. Differences between OA and RA in proportionate numbers of patients were compared for race, gender, diabetes, adiposity and smoking status. Serum ProCT was significantly higher in arthritis patients with moderate to severe and severe periodontitis compared with no/mild periodontitis patients. There were no significant differences in salivary ProCT or salivary or serum hsCRP in RA patients related to periodontitis category. Most of the OA and RA patients were middle aged or older, 28.9% were diabetic, 78.3% were overweight or obese, and slightly more than half were either current or past smokers. The OA and RA groups differed by race, but not gender; blacks and males were predominant in both groups. The OA and RA groups did not differ in terms of controlled or uncontrolled diabetes, smoking status or BMI. The RA patients had been prescribed more anti-inflammatory medication than the OA patients. Our results demonstrate that circulating ProCT is a more discriminative biomarker for periodontitis than serum hsCRP in patients with underlying arthritis. Any elevation in salivary and serum hsCRP due to periodontitis apparently was overshadowed by differences among these patients in factors that influence CRP, such as the extent of inflammation between RA and OA, the extent of adipose tissue, the use of anti- inflammatory medications and smoking status. Although our study showed no differences in salivary ProCT related to severity of periodontitis, this biomarker also may be useful with further refinement.

Periodontitis Response to Anti-TNF Therapy in Ankylosing Spondylitis

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.

Interleukin-6 receptor inhibitor tocilizumab ameliorates periodontal inflammation in patients with rheumatoid arthritis and periodontitis as well as tumor necrosis factor inhibitors

Interleukin-6 (IL-6) may play a pathological role in rheumatoid arthritis (RA) and periodontitis. Although the efficacy of medication with IL-6 receptor inhibitor, tocilizumab (TCZ), has been demonstrated in the treatment of RA, very little is known about whether TCZ therapy affects periodontitis. The aim of the present study is to compare periodontal condition in patients with RA and periodontitis before and after TCZ therapy. The study participants consisted of 20 patients with RA and periodontitis who were treated with TCZ and 40 patients with RA and periodontitis who received medication with tumor necrosis factor inhibitor (TNFI). Clinical periodontal and rheumatologic assessments and serum biochemical measurements using enzyme-linked immunosorbent assays were performed at baseline and 3 and 6 months later. TCZ and TNFI therapies significantly reduced periodontal inflammation that was determined by gingival index, bleeding on probing, and probing depth (p < 0.017), although plaque levels were comparable before and after the therapies. Both therapies also significantly decreased disease activity score including 28 joints using C-reactive protein (CRP), number of tender and swollen joints, and serum levels of anti-cyclic citrullinated peptide antibodies, rheumatoid factor, CRP, and matrix metalloproteinase-3 (p < 0.017). Additionally, a significant decrease was observed in periodontal clinical attachment level after TCZ therapy (p < 0.017), but not after TNFI therapy. TCZ therapy significantly decreased serum levels of TNF-α, total immunoglobulin G, and serum amyloid A (p < 0.017), although serum levels of IL-6 and soluble IL-6R were significantly increased (p < 0.017). These results suggest a beneficial effect of TCZ therapy on levels of periodontal inflammation in patients with RA and periodontitis, which might be related to decrease in serum inflammatory mediators.