Hand to Mouth: A Systematic Review and Meta-Analysis of the Association between Rheumatoid Arthritis and Periodontitis

Correlation between rheumatoid arthritis and chronic periodontitis: a systematic review and meta-analysis

INTRODUCTION

The aim of this article is to summarize, compare, and assess possible association in individuals with or without rheumatoid arthritis (RA) for periodontitis.

EVIDENCE ACQUISITION

Three study repositories were searched for quantitative studies examining the relationship between periodontal disease and rheumatoid arthritis between 2000 and December 2022. Quality was evaluated using the Newcastle Ottawa Scale (NOS). The standardized mean difference (SMD), with a random effect model and a P value of 0.05 as the significance level, was utilized as a summary statistic measure.

EVIDENCE SYNTHESIS

Fourteen papers were included in the descriptive synthesis. Thirteen were qualified for meta-analysis. Our findings suggest a link between the two conditions in terms of clinical attachment levels (CAL), tooth loss, Plaque Index, and probing depth. The estimated SMD for CAL was found to be 0.68 (95% CI: 0.15-1.21) (P<0.01). For tooth loss, the forest plot analysis revealed an SMD of 1.62 (95% CI: 0.48-2.76) (P=0.005). Similarly, for pocket depth, the SMD was 0.53; CI: 0.07-0.99 (P>0.05). The pooled estimates for plaque index were 0.29; CI: 0.03-0.61 (P>0.05). The funnel plot showed a symmetric distribution with the absence of systematic heterogeneity.

CONCLUSIONS

Although our data suggest a link between periodontal disease and rheumatoid arthritis, larger population-based investigations are needed to validate this connection. Case-control studies must pave the way to more rigorous investigations with well-defined populations and clinical outcomes as primary outcome measures.

Toward Digital Periodontal Health: Recent Advances and Future Perspectives

Periodontal diseases, ranging from gingivitis to periodontitis, are prevalent oral diseases affecting over 50% of the global population. These diseases arise from infections and inflammation of the gums and supporting bones, significantly impacting oral health. The established link between periodontal diseases and systemic diseases, such as cardiovascular diseases, underscores their importance as a public health concern. Consequently, the early detection and prevention of periodontal diseases have become critical objectives in healthcare, particularly through the integration of advanced artificial intelligence (AI) technologies. This paper aims to bridge the gap between clinical practices and cutting-edge technologies by providing a comprehensive review of current research. We examine the identification of causative factors, disease progression, and the role of AI in enhancing early detection and treatment. Our goal is to underscore the importance of early intervention in improving patient outcomes and to stimulate further interest among researchers, bioengineers, and AI specialists in the ongoing exploration of AI applications in periodontal disease diagnosis.

Exploring the Bidirectional Relationship Between Periodontitis and Rheumatoid Arthritis in a Large Danish Cohort

OBJECTIVE

We investigated the bidirectional relationship between rheumatoid arthritis (RA) and periodontitis and their cross-sectional association using national administrative health care data.

METHODS

The sample included 3,308,903 individuals aged 20 to 79 years who resided in Denmark in 2000 and had remained free of RA and periodontitis in the previous 10 years. RA and periodontitis were defined using diagnosis and treatment codes. Marginal structural survival models were employed to estimate the effects of RA on periodontitis incidence and vice versa from 2000 to 2017. Using a cross-sectional sample of 2,574,536 individuals from 2017, the association of periodontitis with RA was investigated using regression analyses and probabilistic quantitative bias analyses, simulating RA and periodontitis misclassification and unmeasured confounding of smoking.

RESULTS

Between 2000 and 2017, 20,348 individuals developed RA and 740,799 developed periodontitis. The estimated hazard ratio (HR) for the effect of periodontitis on incident RA was 1.05 (95% confidence interval [CI] 0.88-1.25), resulting in a restricted mean survival time difference of one day. The HR for the effect of RA on incident periodontitis was 0.84 (95% CI 0.80-0.88), corresponding to a restricted mean survival time difference of 151 days. Cross-sectionally, the unadjusted prevalence ratio for the association was 1.15 (95% CI 1.11-1.19), whereas the estimate adjusted for measured and simulated confounding was practically null (0.99, 95% simulation interval 0.93-1.04).

CONCLUSION

These findings challenge previously reported bidirectional relationships between periodontitis and RA, pointing to potential residual confounding as an important link and prompting reconsideration of the biologic plausibility and clinical significance of these associations.

Prevention of Rheumatoid Arthritis in At-Risk Individuals: Current Status and Future Prospects

Early intervention has been the cornerstone of improving outcomes in patients with rheumatoid arthritis. Over the past decade, the boundaries have been pushed in an attempt to achieve effective prevention strategies in those who are at high risk of developing rheumatoid arthritis. Core risk factors including the presence of serum anti-citrullinated protein antibodies, arthralgia and subclinical inflammation on imaging are highly predictive of arthritis development. The influence of air pollution, diet and the role of microbiome on disease progression are less clear. In turn, therapeutic focus has shifted to an earlier pre-arthritis phase of the disease continuum where the clinically apparent arthritis may potentially be intercepted. Seven proof-of-concept interventional trials in at-risk individuals have been conducted so far. Whether true prevention of rheumatoid arthritis is possible remains elusive. Promising signals towards permanent disease modulation and improvement in symptom burden were seen with some immunomodulatory therapies, whilst others were unsuccessful. Long-term follow-up is required to ascertain a true effect. Looking forward, a better understanding of the natural history and underlying biological mechanisms of arthritis development and more accurate, validated risk stratification is needed.

The peculiar features, diversity and impact of citrulline-reactive autoantibodies

Since entering the stage 25 years ago as a highly specific serological biomarker for rheumatoid arthritis, anti-citrullinated protein antibodies (ACPAs) have been a topic of extensive research. This hallmark B cell response arises years before disease onset, displays interpatient autoantigen variability, and is associated with poor clinical outcomes. Technological and scientific advances have revealed broad clonal diversity and intriguing features including high levels of somatic hypermutation, variable-domain N-linked glycosylation, hapten-like peptide interactions, and clone-specific multireactivity to citrullinated, carbamylated and acetylated epitopes. ACPAs have been found in different isotypes and subclasses, in both circulation and tissue, and are secreted by both plasmablasts and long-lived plasma cells. Notably, although some disease-promoting features have been reported, results now demonstrate that certain monoclonal ACPAs therapeutically block arthritis and inflammation in mouse models. A wealth of functional studies using patient-derived polyclonal and monoclonal antibodies have provided evidence for pathogenic and protective effects of ACPAs in the context of arthritis. To understand the roles of ACPAs, one needs to consider their immunological properties by incorporating different facets such as rheumatoid arthritis B cell biology, environmental triggers and chronic antigen exposure. The emerging picture points to a complex role of citrulline-reactive autoantibodies, in which the diversity and dynamics of antibody clones could determine clinical progression and manifestations.

The Association of Chronic Periodontitis as a Potential Risk Factor with Rheumatoid Arthritis: A Nested Case-Control Study Using a Korean National Health Screening Cohort

Growing research has proposed that rheumatoid arthritis (RA) and chronic periodontitis (CP) share similar pathophysiological mechanisms involving inflammation and tissue destruction. However, the potential correlation of CP as a contributing factor for the occurrence of RA warrants validation in the Korean population, where both diseases are prevalent, especially considering the increasingly aging demographic in Korea. This study examined 5139 RA cases and 509,727 matched controls from a Korean national cohort dataset (2002-2019) by carefully employing propensity score matching to ensure comparability between groups. Baseline characteristics were compared using standardized differences, and logistic regression was employed to estimate the impact of CP history on RA likelihood while controlling for covariates. We fully examined medical records documenting CP occurrences within the two-year period leading up to the index date, conducting comprehensive subgroup analyses. While a 1-year history of CP did not show a significant association with likelihood of RA, a 2-year history of CP increased RA likelihood by 12%, particularly among older adults, females, rural residents, and those with certain comorbidities such as hypercholesterolemia. Interestingly, this association persisted even among individuals with non-smoking habits, normal weight, and infrequent alcohol consumption. These findings suggest that chronic CP exposure for at least 2 years may independently elevate RA risk in Korean adults. The association in certain subgroups appears to suggest a predisposition toward genetic susceptibilities over lifestyle and environmental factors. Predicting RA in CP patients may be challenging, emphasizing the importance of regular RA screening, especially in high-risk subgroups.

Identification of a new genetic variant (G231N, E232T, N235D) of peptidylarginine deiminase from P. gingivalis in advanced periodontitis

Chronic periodontitis (CP), an inflammatory disease of periodontal tissues driven by a dysbiotic subgingival bacterial biofilm, is also associated with several systemic diseases, including rheumatoid arthritis (RA). Porphyromonas gingivalis, one of the bacterial species implicated in CP as a keystone pathogen produces peptidyl arginine deiminase (PPAD) that citrullinates C-terminal arginine residues in proteins and peptides. Autoimmunity to citrullinated epitopes is crucial in RA, hence PPAD activity is considered a possible mechanistic link between CP and RA. Here we determined the PPAD enzymatic activity produced by clinical isolates of P. gingivalis, sequenced the ppad gene, and correlated the results with clinical determinants of CP in patients from whom the bacteria were isolated. The analysis revealed variations in PPAD activity and genetic diversity of the ppad gene in clinical P. gingivalis isolates. Interestingly, the severity of CP was correlated with a higher level of PPAD activity that was associated with the presence of a triple mutation (G231N, E232T, N235D) in PPAD in comparison to W83 and ATCC 33277 type strains. The relation between mutations and enhanced activity was verified by directed mutagenesis which showed that all three amino acid residue substitutions must be introduced into PPAD expressed by the type strains to obtain the super-active enzyme. Cumulatively, these results may lead to the development of novel prognostic tools to assess the progress of CP in the context of associated RA by analyzing the ppad genotype in CP patients infected with P. gingivalis.

The role of microbiota on rheumatoid arthritis onset

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation and pain, which can lead to the loss of normal joint function. Although the exact cause of the disease is not yet fully understood, both environmental factors and genetics may play a role in its development. Moreover, research suggests microbiota contributes to the onset and progression of RA. People with RA show higher quantities of bacteria such as Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella copri, Proteus mirabilis, and Lactobacillus salivarius compared to healthy individuals. Conversely, studies propose that Lactobacillus casei, a probiotic bacterium with immunomodulatory properties, has beneficial effects for RA in murine and human models. Therefore, this work reviews the potential role of the gut microbiota in the development of RA and explores the feasibility of using probiotic bacteria as a supplementary treatment for this disease.

Quantification of Porphyromonas gingivalis using real-time polymerase chain reaction in subjects suffering from chronic periodontitis with and without rheumatoid arthritis

Background

Porphyromonas gingivalis, highly virulent bacteria, is said to play an important role in the pathogenesis of periodontal disease and rheumatoid arthritis (RA). Chronic periodontitis (CP) is a microbial-induced inflammatory disease leading to tooth loss if undetected and untreated. RA is a systemic inflammatory disease affecting the joints with subsequent morbidity and mortality. These two diseases share a common pathobiology. Although the presence of P. gingivalis has been investigated as a bridging link between these two diseases, its quantification has not been fully elicited. Hence, this case-control study primarily aimed at quantifying P. gingivalis using real-time quantitative polymerase chain reaction (qPCR) and secondarily assess the influence of age and gender on the clinical and biochemical parameters of these two diseases.

Materials and Methods

The study population consisted of 51 patients divided into two age groups, i.e., 35-55 and 55-76 years. Twenty-five patients belonged to the test group (RA with CP) and 26 to the control group (CP without RA). Both the groups were analyzed for quantification of P. gingivalis using the qPCR technique along with periodontal and biochemical parameters. The study also analyzed the influence of age and gender on clinical characteristics.

Results

P. gingivalis count was exponentially raised in younger females having CP with RA. Age had no effect on clinical variables in CP patients with and without RA. However, gender comparison revealed RA factor and erythrocyte sedimentation rate to be more sensitive for females with significant relationship.

Conclusion

P. gingivalis count increased exponentially in CP patients with RA compared to those without RA. Younger females harbored more P. gingivalis.

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.

Periodontal health status, Porphyromonas gingivalis and anti-cyclic citrullinated peptide antibodies among rheumatoid arthritis patients

Porphyromonas gingivalis (P. gingivalis) is the primary periodontal pathogen involved in protein citrullination, which triggers the production of anti-cyclic citrullinated peptide (anti-CCP) antibodies, exacerbating rheumatoid arthritis (RA). This study aims to evaluate the amount of P. gingivalis and its association with anti-CCP antibodies in RA patients with periodontitis. This cross-sectional study involves 100 RA patients with a mean age of 52.36 (SD 13.90) years. Smokers and patients with other uncontrolled systemic diseases were excluded. Disease Activity Score-28 (DAS-28) was used to determine RA disease severity. Periodontal parameters were examined to determine periodontal status. Subsequently, plaque samples were collected from the subgingival periodontal pocket for assessment of P. gingivalis bacterial load using the loop-mediated isothermal amplification method. Blood samples (5 ml) were obtained from all participants to analyse anti-CCP antibody levels. Data was analysed by using SPSS version 24.0. Most participants were female (85.0%) and had low RA disease severity (62%). The mean RA disease duration was 7.77 (SD 6.3) years, with a mean DAS-28 of 3.17 (SD 1.0). Forty-seven per cent of participants had periodontitis, but all periodontal parameters were not associated with RA disease activity (P = 0.38). P. gingivalis bacterial load ranged from 10 to 109 copies/μl. Fifty-five per cent of the collected samples showed positive anti-CCP antibody levels, but no significant association was observed with the P. gingivalis bacterial load (P = 0.58). Considering the study's limitations, although periodontitis is prevalent among RA patients, there is a lack of association between P. gingivalis bacterial load and anti-CCP antibody levels, which should be investigated further.

Oral Dysbiosis and Systemic Diseases: A Two-Way Relationship?

The human body consists of its own cells, but also of microorganisms that are found both inside and outside the human body [...].

Evaluating the potential of matrix metalloproteinase as a diagnostic biomarker in rheumatoid arthritis and periodontitis: A systematic review and meta-analysis

BACKGROUND

Matrix metalloproteinases (MMPs) play a crucial role in the pathogenesis of several chronic diseases including rheumatoid arthritis (RA) and periodontitis (PD). RA patients with periodontitis (RA-PD) are associated with elevated inflammatory burden due to increased production of proinflammatory cytokines. Controlling upregulated MMPs activity in these patients may have potential therapeutic effects. Therefore, aim of this study is to address the focused question: "Do RA subjects with concurrent PD have different levels of MMPs in comparison to RA alone, PD alone and HC subjects?"

METHODS

The systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search from 4 electronic databases (EMBASE, Medline, Web of Science, and Cochrane library) and manual search was performed from inception to July 2023. Quality assessment of each article was done using Newcastle-Ottawa Scale. Meta-analyses derived results were summarized as standardized mean difference (SMD) with 95% confidence intervals.

RESULTS

A total of 879 articles were extracted. Following screening and full text assessment, 9 studies were included. MMP-1, MMP-3, MMP-8, MMP-9, and MMP-13 were consistently elevated in RA-PD subjects. MMP-8 levels were found to be higher in RA-PD subjects compared with RA alone, PD alone, and HC in 3 studies reporting GCF levels (SMD = 1.2; Z = 2.07; P = .04) and 2 studies reporting serum levels (SMD = 0.87; Z = 4.53; P < .00001).

CONCLUSION

RA-PD group showed significantly higher MMP levels in their serum and GCF compared with HC, RA, and PD alone individuals. MMP-8 may serve as a reliable biomarker in the diagnosis and management of RA-PD subjects.

Periodontitis in patients with primary Sjögren's syndrome: A nation-wide register study

The aim of this study was to compare the occurrence of periodontitis in patients with primary Sjögren's syndrome (pSS) and a non-Sjögren's patient group during a 7-year period from 2011 through 2017. In this population-based study, the patients were identified based on the International Classification of Diseases-10 (ICD-10) codes registered in the Norwegian Patient Registry (NPR), which contains information on diagnosis and time of admission for all hospitalized patients in Norway. The pSS group comprised patients with ≥4 registrations with ICD-10 code M35.0 (Sjögren's syndrome) as the main diagnosis. The dependent variable was periodontitis, defined by procedure codes registered in the Norwegian Control and Payment of Health Reimbursement (KUHR). Logistic regression analyses estimated the odds ratio for periodontitis in pSS patients relative to non-pSS patients, adjusted for relevant covariates. Lastly, regression analyses were performed separately for each of the 6 age categories. In total, 760 (7.5%) patients in the pSS group and 22,178 (7.1%) in the non-pSS group had periodontitis. When adjusting for covariates, the presence of pSS had no association with periodontitis (OR = 1.06, 95% CI: 0.98-1.14).

Ulcerative colitis and periodontitis - a cross-sectional pilot study from a Norwegian cohort

BACKGROUND

Inflammatory bowel disease, which includes ulcerative colitis (UC), is an inflammatory disorder with potential impact on periodontal disease, but evidence to date for this association is limited. The primary aim of this study was to investigate the prevalence of periodontitis according to the 2017-classification in a cohort of subjects with UC. The secondary aim was to assess a potential correlation of periodontal status with previous UC disease parameters and to assess oral health-related quality-of-life.

METHOD

A cohort from a community hospital in Norway with confirmed extensive UC was comprehensively examined. Periodontal parameters, OHIP-14 and demographic variables were collected. Previous UC data including colon activity index (CAI), Mayo score and years of UC diagnosis was used to explore a potential correlation with periodontal status.

RESULTS

A total of 50 out of 63 invited patients participated. According to the 2017-classification, 74% of the patients presented periodontitis. No correlation was found between periodontitis (stage, grade, bleeding on probing or probing pocket depth ≥6mm) and CAI, Mayo score, or years with UC diagnosis.

CONCLUSIONS

Within the limitations of this study, the prevalence of periodontitis among patients with mild UC for more than 12 years was in line with that reported from a Norwegian general population. No correlation between periodontitis and UC disease indices or years with UC diagnosis was observed. The study suggests that the susceptibility to periodontitis may be limited in patients with well treated or mild UD who regularly attend the dental office, despite a considerable UC disease duration.

Periodontitis and risk of immune-mediated systemic conditions: A systematic review and meta-analysis

INTRODUCTION

The aim of this review is to examine and quantify the long-term risk of immune-mediated systemic conditions in people with periodontitis compared to people without periodontitis.

METHODS

Medline, EMBASE and Cochrane databases were searched up to June 2022 using keywords and MeSH headings. The 'Risk of Bias in Non-Randomised Studies of Interventions' tool was used to assess bias. Cohort studies comparing incident metabolic/autoimmune/inflammatory diseases in periodontitis to healthy controls were included. Meta-analysis and meta-regression quantified risks and showed impact of periodontitis diagnosis type and severity.

RESULTS

The search retrieved 3354 studies; 166 studies were eligible for full-text screening, and 30 studies were included for review. Twenty-seven studies were eligible for meta-analysis. The risks of diabetes, rheumatoid arthritis (RA) and osteoporosis were increased in people with periodontitis compared to without periodontitis (diabetes-relative risk [RR]: 1.22, 95% CI: 1.13-1.33; RA-RR: 1.27, 95% CI: 1.07-1.52; osteoporosis-RR: 1.40, 95% CI: 1.12-1.75). Risk of diabetes showed gradient increase by periodontitis severity (moderate-RR = 1.20, 95% CI = 1.11-1.31; severe-RR = 1.34, 95% CI = 1.10-1.63).

CONCLUSION

People with moderate-to-severe cases of periodontitis have the highest risk of developing diabetes, while the effect of periodontal severity on risk of other immune-mediated systemic conditions requires further investigation. More homologous evidence is required to form robust conclusions regarding periodontitis-multimorbidity associations.

Modifiable risk factors linked to the development of rheumatoid arthritis: evidence, immunological mechanisms and prevention

Rheumatoid Arthritis (RA) is a common autoimmune disease that targets the synovial joints leading to arthritis. Although the etiology of RA remains largely unknown, it is clear that numerous modifiable risk factors confer increased risk to developing RA. Of these risk factors, cigarette smoking, nutrition, obesity, occupational exposures and periodontal disease all incrementally increase RA risk. However, the precise immunological mechanisms by which these risk factors lead to RA are not well understood. Basic and translational studies have provided key insights into the relationship between inflammation, antibody production and the influence in other key cellular events such as T cell polarization in RA risk. Improving our general understanding of the mechanisms which lead to RA will help identify targets for prevention trials, which are underway in at-risk populations. Herein, we review the modifiable risk factors that are linked to RA development and describe immune mechanisms that may be involved. We highlight the few studies that have sought to understand if modification of these risk factors reduces RA risk. Finally, we speculate that modification of risk factors may be an appealing avenue for prevention for some at-risk individuals, specifically those who prefer lifestyle interventions due to safety and economic reasons.

The Immunomodulatory Role of Microbiota in Rheumatic Heart Disease: What Do We Know and What Can We Learn from Other Rheumatic Diseases?

Rheumatic heart disease (RHD) represents a serious cardiac sequela of acute rheumatic fever, occurring in 30-45% of patients. RHD is multifactorial, with a strong familial predisposition and known environmental risk factors that drive loss of immunological tolerance. The gut and oral microbiome have recently been implicated in the pathogenesis of RHD. Disruption of the delicate balance of the microbiome, or dysbiosis, is thought to lead to autoimmune responses through several different mechanisms including molecular mimicry, epitope spreading, and bystander activation. However, data on the microbiomes of RHD patients are scarce. Therefore, in this comprehensive review, we explore the various dimensions of the intricate relationship between the microbiome and the immune system in RHD and other rheumatic diseases to explore the potential effect of microbiota on RHD and opportunities for diagnosis and treatment.

Increased risk of periodontitis in patients with rheumatoid arthritis: A nationwide register study in Norway

AIM

To investigate the risk of periodontitis in rheumatoid arthritis (RA) patients in a nationwide register-based study.

MATERIALS AND METHODS

Patients and controls were defined using ICD-10 codes registered in the Norwegian Patient Registry (NPR), from 2011 to 2017. The 324,232 included subjects had at least one registered diagnostic code for RA (33,040 patients) or diagnostic codes for non-osteoporotic fractures or hip or knee replacement due to osteoarthritis (controls). The outcome was periodontitis, defined by codes for periodontal treatment from the Norwegian Control and Payment of Health Reimbursements Database (KUHR). Hazard ratios (HRs) were calculated for periodontitis in RA patients compared to controls. Generalized additive model in Cox regressions was estimated to visualize periodontitis occurrences as a function of number of RA visits.

RESULTS

The risk of periodontitis increased with increasing number of RA visits. RA patients having 10 or more visits during the 7-year period had a 50% increased risk of periodontitis compared to controls (HR = 1.48, 95% confidence interval [CI]: 1.39-1.59); also, in patients with assumed new RA, an even higher risk estimate was seen (HR = 1.82, 95% CI: 1.53-2.17).

CONCLUSIONS

In this register-based study in which periodontal treatment was used as a surrogate marker for periodontitis, we found an increased risk of periodontitis in RA patients, particularly those with active disease and new RA.

Dental Caries in Adult Patients with Rheumatoid Arthritis-A Systematic Review

Patients suffering from rheumatoid arthritis (RA) are repeatedly affected by oral diseases or complaints, including xerostomia, periodontitis and dental caries. The aim of this systematic review was the evaluation of caries prevalence and/or incidence in patients with RA. Within this review, there is a systematic search of the literature based on PubMed, Web of Science and Scopus. Two independent researchers performed the search in February 2023. The search terms were "dental caries" AND "rheumatoid arthritis". Additionally, a manual search completed the review process. Studies on adult patients (age ≥ 18 years) only suffering from RA were included. Studies had to explicitly report on the prevalence or incidence of dental caries. The respective studies were checked regarding suitability and, if they were eligible, analyzed qualitatively. A quality appraisal was performed for all of the analyzed studies. A total of 336 studies were detected, of which 16 studies met the in- and exclusion criteria. The sample sizes of the clinical investigations ranged between 13 and 1337 participants. Twelve studies evaluated a healthy control group. In 8/12 studies, a significant difference in the prevalence/incidence of caries was found between RA patients and controls. The majority of the studies applied the decayed (DT), missing and filled teeth index (DMFT) for the diagnosis of caries. On average (mean value), 0.8 to 5.79 carious teeth per patient were reported across the studies. There was no information on the stadium, activity or location of caries (e.g., root caries) in any study. Quality appraisal revealed a moderate quality for most studies. In conclusion, caries prevalence was heterogeneous across studies, while a higher caries prevalence was repeatedly reported in RA patients against controls. Further research regarding dental caries in RA appears recommendable; multidisciplinary, patient-centered dental care for patients with RA should be fostered to improve patients' dental health status.

Gut Microbiota and Cardiovascular Disease: Evidence on the Metabolic and Inflammatory Background of a Complex Relationship

Several studies in recent years have demonstrated that gut microbiota-host interactions play an important role in human health and disease, including inflammatory and cardiovascular diseases. Dysbiosis has been linked to not only well-known inflammatory diseases, such as inflammatory bowel diseases, rheumatoid arthritis, and systemic lupus erythematous, but also to cardiovascular risk factors, such as atherosclerosis, hypertension, heart failure, chronic kidney disease, obesity, and type 2 diabetes mellitus. The ways the microbiota is involved in modulating cardiovascular risk are multiple and not only related to inflammatory mechanisms. Indeed, human and the gut microbiome cooperate as a metabolically active superorganism, and this affects host physiology through metabolic pathways. In turn, congestion of the splanchnic circulation associated with heart failure, edema of the intestinal wall, and altered function and permeability of the intestinal barrier result in the translocation of bacteria and their products into the systemic circulation, further enhancing the pro-inflammatory conditions underlying cardiovascular disorders. The aim of the present review is to describe the complex interplay between gut microbiota, its metabolites, and the development and evolution of cardiovascular diseases. We also discuss the possible interventions intended to modulate the gut microbiota to reduce cardiovascular risk.

Impacts of Porphyromonas gingivalis periodontitis on rheumatoid arthritis autoimmunity

In RA patients' synovial sites, citrullinated RA-related antigens such as type II collagens, fibrin (ogen), vimentin, and α-enolase could be targeted by ACCPAs. Since ACCPA production can be initiated a long time before RA sign appearance, primary auto-immunization against these citrullinated proteins can be originated from extra-articular sites. It has been shown that there is a significant association between P. gingivalis periodontitis, anti- P. gingivalis antibodies, and RA. P. gingivalis gingipains (Rgp, Kgp) can degrade proteins such as fibrin and α-enolase into some peptides in the form of Arg in the C-terminal which is converted to citrulline by PPAD. Also, PPAD can citrullinate type II collagen and vimentins (SA antigen). P. gingivalis induces inflammation and chemoattraction of immune cells such as neutrophils and macrophages through the increase of C5a (gingipain C5 convertase-like activity) and SCFA secretion. Besides, this microorganism stimulates anoikis, a special type of apoptosis, and NETosis, an antimicrobial form of neutrophil death, leading to the release of PAD1-4, α-enolase, and vimentin from apoptotic cells into the periodontal site. In addition, gingipains can degrade macrophages CD14 and decrease their ability in apoptotic cell removal. Gingipains also can cleave IgGs in the Fc region and transform them into rheumatoid factor (RF) antigens. In the present study, the effects of P. gingivalis on rheumatoid arthritis autoimmune response have been reviewed, which could attract practical insight both in bench and clinic.

Current knowledge on the association between cardiovascular and periodontal disease: an umbrella review

INTRODUCTION

Periodontal disease (PD) and cardiovascular diseases (CVD) are among the most common pathologies in the world and their relationship has long been studied. Both conditions lead to a chronic inflammatory process with degenerative characteristics and their biunivocal correlation is now well established. The aim of this umbrella review on cardiovascular and periodontal disease was to evaluate the real degree of association between these two pathological conditions.

EVIDENCE ACQUISITION

We conducted a comprehensive literature search on PubMed/Medline and in the Cochrane Library for systematic reviews focused on clinical evidence regarding the relationship between PD and CVD. The internal validity of systematic reviews and meta-analyses was formally analyzed using the Overview Quality Assessment Questionnaire (OQAQ) Tool. The umbrella review was planned in accordance with current international recommendations and was described as specified by the PRISMA Guidelines.

EVIDENCE SYNTHESIS

Thirty-one systematic reviews, including 8 meta-analyses for a total of 507 clinical studies and over 3,549,966 patients were included. PD resulted to be associated with a higher risk of developing CVD (acute coronary syndrome, acute myocardial infarction) and cerebrovascular diseases (ischemic stroke); however, if the treatment of periodontitis reduces the risk of CVD events related is yet to be investigated.

CONCLUSIONS

To date, the relationship between CVD and PD provides heterogeneous data. There is an association between PD and CVD, but a causal relationship cannot be established. Further research with properly designed long-term follow-up studies are needed in order to examine various physiopathological aspects of their association.

Association between sleep-disordered breathing and periodontitis: a meta-analysis

BACKGROUND

Systemic inflammation is a feature of sleep-disordered breathing (SDB) as well as periodontitis. The association between SDB and periodontitis, however, has been inconsistent in previous studies. In order to fully evaluate the above association, we conducted a meta-analysis.

MATERIAL AND METHODS

Observational studies related to the aim of the meta-analysis were identified by search of PubMed, Embase, Web of Science, Wanfang, and CNKI databases. Only studies with SDB diagnosed with the objective polysomnography examination were included. The results were analyzed using a random-effects model that incorporated potential heterogeneity between studies.

RESULTS

Ten cross-sectional or case-control studies with 43,296 participants contributed to the meta-analysis. Pooled results showed that SDB was significantly associated with periodontitis (odds ratio [OR]: 1.83, 95% confidence interval [CI]: 1.52 to 2.20, I2 = 40%, p < 0.001). Sensitivity analysis showed consistent association for severe periodontitis (OR: 1.39, 95% CI: 1.20 to 1.61, I2 = 0%, p < 0.001). Subgroup analyses showed consistent results in patients with mild (OR: 1.66, p < 0.001), moderate (OR: 2.23, p = 0.009), and severe SDB (OR: 2.66, p < 0.001). Moreover, the association between SDB and periodontitis was consistent in Asian and non-Asian studies, in cross-sectional and case-control studies, in studies with univariate and multivariate regression models, and in studies with different quality scores (p for subgroup effects all < 0.05).

CONCLUSIONS

Polysomnography confirmed diagnosis of SDB is associated with periodontitis in adult population.

Lack of association between periodontitis and rheumatoid arthritis

BACKGROUND AND OBJECTIVE

Periodontitis and rheumatoid arthritis (RA) have been associated in a bidirectional way. The objective of this study was to determine the association between clinical parameters of periodontitis and RA.

MATERIALS AND METHODS

Seventy-five (75) participants distributed in 3 groups (21 patients with periodontitis without RA, 33 patients with periodontitis with RA and 21 patients with reduced periodontium with RA) were included in this cross-sectional study. A full periodontal and medical examination was performed in each patient. Additionally, subgingival plaque samples for the detection of Porphyromonas gingivalis (P. gingivalis) and blood samples for biochemical markers of RA were also taken. Logistic regression analysis adjusted for confounding variables, Spearman's rank correlation coefficient and a linear multivariate regression were used to analyze the data.

RESULTS

Patients with RA presented less severity of periodontal parameters. The highest levels of anti-citrullinated protein antibodies were detected in non-periodontitis patients with RA. Covariates such as age, P. gingivalis, diabetes, smoking, osteoporosis and use of medication were not associated with RA. All periodontal variables and P. gingivalis expressed a negative correlation with biochemical markers of RA (P<0.05).

CONCLUSIONS

Periodontitis was not associated with RA. Furthermore, there was no correlation between periodontal clinical parameters and biochemical markers of RA.

Association of Oral Health with Risk of Rheumatoid Arthritis: A Nationwide Cohort Study

Periodontitis and rheumatoid arthritis (RA) are inflammatory diseases that share many similarities. We aimed to investigate the associations of periodontitis and oral hygiene status and behaviors with RA in a nationwide general population cohort. Participants from the National Health Screening cohort database of Korea who underwent oral health screening by dentists between 2003 and 2004 were included. The occurrence of RA was analyzed according to the presence of periodontitis, oral health examination findings, and behaviors. Overall, 2,239,586 participants were included. During a median of 16.7 years, RA occurred in 27,029 (1.2%) participants. The risk for incident RA was higher when participants had periodontitis (hazard ratio (HR) 1.2, 95% confidence interval (CI), 1.08-1.24) and an increased number of missing teeth (HR 1.5, 95% CI, 1.38-1.69). In contrast, better oral hygiene behaviors, such as a higher frequency of daily tooth brushing (HR 0.76, 95% CI 0.73-0.79, p for trend <0.001) and a recent history of dental scaling (HR 0.96, 95% CI 0.94-0.99), were associated with a lower occurrence of RA. Periodontitis and increased missing teeth were associated with an increased risk of RA. Maintaining good oral hygiene through frequent tooth brushing and regular dental scaling may reduce the risk of RA occurrence.

Influence of periodontitis on levels of autoantibodies in rheumatoid arthritis patients: A systematic review

BACKGROUND AND OBJECTIVE

Periodontitis (PD) is a dysbiotic disease of tooth-supporting structures that has been associated with various systemic diseases including rheumatoid arthritis (RA). To date, evidence demonstrated increased prevalence of RA among PD patients and postulated PD to have a role in the development of autoantibodies in RA patients. Therefore, a systematic review was conducted to assess the available evidence to ascertain the effect of PD on levels of autoantibodies in the serum, saliva and gingival crevicular fluid (GCF) of RA patients.

MATERIAL AND METHODS

The systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Relevant literature was searched from PubMed, Web of Science, Scopus and Ebscohost databases from inception until 31 August 2020. The risk of bias in each study was determined based on the Newcastle-Ottawa Scale tool. Results from random-effect meta-analyses were presented as summary estimates of odds ratios (ORs) for seropositivity and standardised mean difference (SMD) of autoantibody levels with 95% confidence intervals. Sensitivity tests and meta-regression were performed to assess the robustness of the results and potential cause of heterogeneity.

RESULTS

The electronic and manual searches gathered 932 articles. Following screening and full-text assessment, a total of 29 studies were included in the analysis. Twenty-eight published observational studies were included in the quantitative analysis in the form of random-effect meta-analysis which revealed that PD was associated with anti-citrullinated proteins autoantibodies (ACPAs) and Rheumatoid Factor (RF) seropositive RA patients (OR for ACPA seropositivity: 1.82; 95% CI: 1.13-2.93) (OR for RF seropositivity: 1.53; 95% CI: 1.05-2.24). Also, RA patients with PD had increased serum levels of ACPA and RF. However, high heterogeneity among studies' results, partially ascribed to the unstandardised case definition of PD and laboratory testing of autoantibodies. Apart from ACPA and RF in serum, studies which reported on other RA-related autoantibodies, as well as autoantibody levels in saliva and GCF were scarce.

CONCLUSION

RA patients with PD tend to have greater ACPA and RF levels in their serum when compared with the RA patients without PD supporting the plausible role of PD in the development of systemic autoimmunity in RA patients.

Immune dysregulation and pathogenic pathways mediated by common infections in rheumatoid arthritis

Rheumatoid arthritis (RA) is one of the world's most prevalent inflammatory autoimmune diseases, affecting between 0.4 and 1.3% of the population. The susceptibility to RA appears to be influenced by a complex interaction between a favorable genetic background and the existence of a specific immune reaction against a wide range of environmental variables. Among the known environmental variables, infections are believed to have a significant role in promoting the formation of autoimmune disorders, which are frequently caused by specific microorganisms. Infections have been linked to RA in recent medical studies. In this study, we selected the most prevalent infections associated with RA from the literature and described the data confirming their pathogenic role in RA. Our investigation included Mycobacterium, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Proteus mirabilis, Epstein-Barr virus, parvovirus, and Prevotella copri.

The Role of the Microbiome in Connective-Tissue-Associated Interstitial Lung Disease and Pulmonary Vasculitis

The microbiome can trigger and maintain immune-mediated diseases and is associated with the severity and prognosis of idiopathic pulmonary fibrosis, which is the prototype of interstitial lung diseases (ILDs). The latter can be a major cause of morbidity and mortality in patients with connective-tissue diseases (CTD). In the present review, we discuss the current evidence regarding microbiome in CTD-ILD and pulmonary vasculitis. In patients with rheumatoid arthritis (RA) the BAL microbiota is significantly less diverse and abundant, compared to healthy controls. These changes are associated with disease severity. In systemic sclerosis (SSc), gastrointestinal (GI)-dysbiosis is associated with ILD. Butyrate acid administration as a means of restoration of GI-microbiota has reduced the degree of lung fibrosis in animal models. Although related studies are scarce for SLE and Sjögren's syndrome, studies of the gut, oral and ocular microbiome provide insights into the pathogenesis of these diseases. In ANCA-associated vasculitis, disease severity and relapses have been associated with disturbed nasal mucosa microbiota, with immunosuppressive treatment restoring the microbiome changes. The results of these studies suggest however no causal relation. More studies of the lung microbiome in CTD-ILDs are urgently needed, to provide a better understanding of the pathogenesis of these diseases.

Severe Periodontitis Is a Major Contributory Factor to Unmet Dental Healthcare Needs among Rheumatoid Arthritis Patients in Hong Kong

Objective

This study aimed to examine the frequency and predictive factors of adverse oral and dental outcomes in patients with rheumatoid arthritis (RA) with the goal to address their unmet dental healthcare needs in the metropolitan city of Hong Kong.

Methods

238 RA patients followed up at local public hospitals were recruited in this cross-sectional study. A full dental examination was performed. Data were compared with the retrospective data collected from age-matched control groups in the community conducted in a territory-wide oral health survey in 2011. Predictive factors for severe periodontitis including various demographic and disease-specific factors were examined by multiple logistic regression analysis.

Results

Loose teeth and gum bleeding were frequent dental complaints. Only 85.0% of RA patients had >20 natural teeth. Total edentulism was observed in 3.8% of patients, which was higher among adult (22-64 years) and elderly (>65 years old) RA patients than their respective age-matched community control groups. RA patients had a higher decayed, missing, and filled tooth score. Adult RA patients had a 5.3-fold increase in risk of severe periodontitis than their community counterparts. The plaque index was the main predisposing factor for severe periodontitis (odds ratio 17.5, p=0.001), which was worse among the 22-34 age group of patients. More RA patients required tooth extraction compared to dental filling for their community controls.

Conclusion

Severe periodontitis is a major cause of unmet dental healthcare needs among RA patients in Hong Kong. It is recommended that dental care plans for RA patients be commenced early among newly diagnosed patients.

Association between Porphyromonas Gingivalis and systemic diseases: Focus on T cells-mediated adaptive immunity

The association between periodontal disease and systemic disease has become a research hotspot. Porphyromonas gingivalis (P. gingivalis), a crucial periodontal pathogen, affects the development of systemic diseases. The pathogenicity of P. gingivalis is largely linked to interference with the host's immunity. This review aims to discover the role of P. gingivalis in the modulation of the host's adaptive immune system through a large number of virulence factors and the manipulation of cellular immunological responses (mainly mediated by T cells). These factors may affect the cause of large numbers of systemic diseases, such as atherosclerosis, hypertension, adverse pregnancy outcomes, inflammatory bowel disease, diabetes mellitus, non-alcoholic fatty liver disease, rheumatoid arthritis, and Alzheimer's disease. The point of view of adaptive immunity may provide a new idea for treating periodontitis and related systemic diseases.

Inhalant and Additional Mucosal-Related Environmental Risks for Rheumatoid Arthritis

Rheumatoid arthritis (RA) occurs as the result of a complex interplay of environmental factors in a genetically susceptible individual. There is considerable evidence that the lungs may serve as an initial site of tolerance loss in the generation of RA-related autoimmunity, and several environmental inhalant exposures and lung diseases have been associated with RA risk. There is additional evidence that immune and microbial dysregulation of other mucosal sites, including the oral and gastrointestinal mucosa, may contribute to the development of RA. Epidemiologic evidence linking mucosal exposures to various environmental insults as risk determinants in RA will be reviewed.

Peptidylarginine Deiminase 2 Gene Polymorphisms in Subjects with Periodontitis Predispose to Rheumatoid Arthritis

Epidemiologic studies have shown associations between periodontitis and rheumatoid arthritis (RA), but a causal relationship has not been established. Citrullination of gingival proteins by human peptidylarginine deiminases (PADs) or PAD from Porphyromonas gingivalis has been proposed to generate autoantigens in anti-CCP-positive RA. This study investigated whether the association between periodontitis and RA is influenced by single nucleotide polymorphisms (SNPs) in the genes encoding PAD2 and PAD4 that catalyze aberrant citrullination in RA and often are overexpressed in inflamed gingival connective tissue in subjects with periodontitis. The study included 137 RA patients and 161 controls with self-reported periodontitis. Periodontitis onset preceded RA onset by 13 years on average and was not associated with any of the SNPs investigated. In subjects with periodontitis, carriage of the minor alleles of rs2057094 and rs2235912 in PADI2 significantly increased the risk of RA (odds ratios 1.42 [p = 0.03] and 1.48 [p = 0.02], respectively), and this effect was driven by the anti-CCP-negative RA patients. The minor alleles of these SNPs only increased risk of anti-CCP-positive RA in individuals with periodontitis and a history of smoking. These data suggest that individuals with periodontitis carrying the minor alleles of SNPs rs2057094, rs2076616 and rs2235912 in PADI2 may be at increased risk of RA.

Disease mechanisms in preclinical rheumatoid arthritis: A narrative review

In the last decades, the concept of preclinical rheumatoid arthritis (RA) has become established. In fact, the discovery that disease mechanisms start years before the onset of clinical RA has been one of the major recent insights in the understanding of RA pathogenesis. In accordance with the complex nature of the disease, preclinical events extend over several sequential phases. In a genetically predisposed host, environmental factors will further increase susceptibility for incident RA. In the initial steps of preclinical disease, immune disturbance mechanisms take place outside the joint compartment, namely in mucosal surfaces, such as the lung, gums or gut. Herein, the persistent immunologic response to altered antigens will lead to breach of tolerance and trigger autoimmunity. In a second phase, the immune response matures and is amplified at a systemic level, with epitope spreading and widening of the autoantibody repertoire. Finally, the synovial and bone compartment are targeted by specific autoantibodies against modified antigens, initiating a local inflammatory response that will eventually culminate in clinically evident synovitis. In this review, we discuss the elaborate disease mechanisms in place during preclinical RA, providing a broad perspective in the light of current evidence.

Oral Microbiota Profile in Patients with Anti-Neutrophil Cytoplasmic Antibody–Associated Vasculitis

Microbiota has been associated with autoimmune diseases, with nasal Staphylococcus aureus being implicated in the pathogenesis of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). Little is known about the role of oral microbiota in AAV. In this study, levels of IgG antibodies to 53 oral bacterial species/subspecies were screened using immunoblotting in plasma/serum in pre-symptomatic AAV-individuals (n = 85), matched controls, and established AAV-patients (n = 78). Saliva microbiota from acute-AAV and controls was sequenced from 16s rDNA amplicons. Information on dental status was extracted from a national register. IgG levels against oral bacteria were lower in established AAV versus pre-AAV and controls. Specifically, pre-AAV samples had, compared to controls, a higher abundance of periodontitis-associated species paralleling more signs of periodontitis in established AAV-patients than controls. Saliva microbiota in acute-AAV showed higher within-sample diversity but fewer detectable amplicon-sequence variants and taxa in their core microbiota than controls. Acute-AAV was not associated with increased abundance of periodontal bacteria but species in, e.g., Arthrospira, Staphylococcus, Lactobacillus, and Scardovia. In conclusion, the IgG profiles against oral bacteria differed between pre-AAV, established AAV, and controls, and microbiota profiles between acute AAV and controls. The IgG shift from a pre-symptomatic stage to established disease cooccurred with treatment of immunosuppression and/or antibiotics.

Treatment resistance of rheumatoid arthritis relates to infection of periodontal pathogenic bacteria: a case-control cross-sectional study

Recent studies have shown that periodontitis is associated with rheumatoid arthritis (RA) and periodontal bacteria, such as Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) are involved in the pathogenesis of RA via citrullinated proteins. Smoking has also been shown to be involved in the pathogenesis of RA; however, the extent of this involvement is still poorly understood. In addition, RA and polymyalgia rheumatica (PMR) are sometimes difficult to differentiate; however, the relationship between PMR and the factors from smoking and periodontal bacteria is unclear. The aim of this study was to clarify the relationship between periodontal pathogenic bacterial infections and smoking in patients with RA or PMR. This case–control study included 142 patients with untreated RA or PMR. This study evaluated the serum antibody titers against periodontal pathogenic bacterial antigens and an anti-citrullinated peptide antibody (ACPA). In patients with RA, the relationship between antibody titers and disease activity of RA and response after 3 months of treatment was also investigated. Additionally, the effects of smoking were evaluated. Although there was no significant difference in serum antibody titer against periodontal pathogenic bacteria between the ACPA-positive RA group and the ACPA-negative PMR group, we found an association between the elevated antibody titer against Pg and the degree of ACPA value, especially between negative group and high-value positive group (≥ 100 U/mL). The antibody titers against Aa and Pg did not differ depending on disease activity score 28 (DAS28) at baseline; however, patients with high antibody titers had poor RA therapeutic response as judged by DAS28 after 3 months. We could not find any association between smoking and any of these parameters. Periodontal pathogenic bacteria, especially Pg, are associated with elevated ACPA levels. Our findings suggest that Pg and Aa infections interfere with the therapeutic response of RA.

Maladaptive innate immune training of myelopoiesis links inflammatory comorbidities

Bone marrow (BM)-mediated trained innate immunity (TII) is a state of heightened immune responsiveness of hematopoietic stem and progenitor cells (HSPC) and their myeloid progeny. We show here that maladaptive BM-mediated TII underlies inflammatory comorbidities, as exemplified by the periodontitis-arthritis axis. Experimental-periodontitis-related systemic inflammation in mice induced epigenetic rewiring of HSPC and led to sustained enhancement of production of myeloid cells with increased inflammatory preparedness. The periodontitis-induced trained phenotype was transmissible by BM transplantation to naive recipients, which exhibited increased inflammatory responsiveness and disease severity when subjected to inflammatory arthritis. IL-1 signaling in HSPC was essential for their maladaptive training by periodontitis. Therefore, maladaptive innate immune training of myelopoiesis underlies inflammatory comorbidities and may be pharmacologically targeted to treat them via a holistic approach.

Antibodies to a Citrullinated Porphyromonas gingivalis Epitope Are Increased in Early Rheumatoid Arthritis, and Can Be Produced by Gingival Tissue B Cells: Implications for a Bacterial Origin in RA Etiology

Based on the epidemiological link between periodontitis and rheumatoid arthritis (RA), and the unique feature of the periodontal bacterium Porphyromonas gingivalis to citrullinate proteins, it has been suggested that production of anti-citrullinated protein antibodies (ACPA), which are present in a majority of RA patients, may be triggered in the gum mucosa. To address this hypothesis, we investigated the antibody response to a citrullinated P. gingivalis peptide in relation to the autoimmune ACPA response in early RA, and examined citrulline-reactivity in monoclonal antibodies derived from human gingival B cells. Antibodies to a citrullinated peptide derived from P. gingivalis (denoted CPP3) and human citrullinated peptides were analyzed by multiplex array in 2,807 RA patients and 372 controls; associations with RA risk factors and clinical features were examined. B cells from inflamed gingival tissue were single-cell sorted, and immunoglobulin (Ig) genes were amplified, sequenced, cloned and expressed (n=63) as recombinant monoclonal antibodies, and assayed for citrulline-reactivities by enzyme-linked immunosorbent assay. Additionally, affinity-purified polyclonal anti-cyclic-citrullinated peptide (CCP2) IgG, and monoclonal antibodies derived from RA blood and synovial fluid B cells (n=175), were screened for CPP3-reactivity. Elevated anti-CPP3 antibody levels were detected in RA (11%), mainly CCP2+ RA, compared to controls (2%), p<0.0001, with a significant association to HLA-DRB1 shared epitope alleles, smoking and baseline pain, but with low correlation to autoimmune ACPA fine-specificities. Monoclonal antibodies derived from gingival B cells showed cross-reactivity between P. gingivalis CPP3 and human citrullinated peptides, and a CPP3+/CCP2+ clone, derived from an RA blood memory B cell, was identified. Our data support the possibility that immunity to P. gingivalis derived citrullinated antigens, triggered in the inflamed gum mucosa, may contribute to the presence of ACPA in RA patients, through mechanisms of molecular mimicry.

Salivary Microbiota and Host-Inflammatory Responses in Periodontitis Affected Individuals With and Without Rheumatoid Arthritis

Objectives

Periodontitis and rheumatoid arthritis (RA) are two widespread chronic inflammatory diseases with a previously suggested association. The objective of the current study was to compare the oral microbial composition and host´s inflammatory mediator profile of saliva samples obtained from subjects with periodontitis, with and without RA, as well as to predict biomarkers, of bacterial pathogens and/or inflammatory mediators, for classification of samples associated with periodontitis and RA.

Methods

Salivary samples were obtained from 53 patients with periodontitis and RA and 48 non-RA with chronic periodontitis. The microbial composition was identified using 16S rRNA gene sequencing and compared across periodontitis patients with and without RA. Levels of inflammatory mediators were determined using a multiplex bead assay, compared between the groups and correlated to the microbial profile. The achieved data was analysed using PCoA, DESeq2 and two machine learning algorithms, OPLS-DA and sPLS-DA.

Results

Differential abundance DESeq2 analyses showed that the four most highly enriched (log2 FC >20) amplicon sequence variants (ASVs) in the non-RA periodontitis group included Alloprevotella sp., Prevotella sp., Haemophilus sp., and Actinomyces sp. whereas Granulicatella sp., Veillonella sp., Megasphaera sp., and Fusobacterium nucleatum were the most highly enriched ASVs (log2 FC >20) in the RA group. OPLS-DA with log2 FC analyses demonstrated that the top ASVs with the highest importance included Vampirovibrio sp. having a positive correlation with non-RA group, and seven ASVs belonging to Sphingomonas insulae, Sphingobium sp., Novosphingobium aromaticivorans, Delftia acidovorans, Aquabacterium spp. and Sphingomonas echinoides with a positive correlation with RA group. Among the detected inflammatory mediators in saliva samples, TWEAK/TNFSF12, IL-35, IFN-α2, pentraxin-3, gp130/sIL6Rb, sIL-6Ra, IL-19 and sTNF-R1 were found to be significantly increased in patients with periodontitis and RA compared to non-RA group with periodontitis. Moreover, correlations between ASVs and inflammatory mediators using sPLS-DA analysis revealed that TWEAK/TNFSF12, pentraxin-3 and IL-19 were positively correlated with the ASVs Sphingobium sp., Acidovorax delafieldii, Novosphingobium sp., and Aquabacterium sp.

Conclusion

Our results suggest that the combination of microbes and host inflammatory mediators could be more efficient to be used as a predictable biomarker associated with periodontitis and RA, as compared to microbes and inflammatory mediators alone.

Maladaptive trained immunity and clonal hematopoiesis as potential mechanistic links between periodontitis and inflammatory comorbidities

Periodontitis is bidirectionally associated with systemic inflammatory disorders. The prevalence and severity of this oral disease and linked comorbidities increases with aging. Here, we review two newly emerged concepts, trained innate immunity (TII) and clonal hematopoiesis of indeterminate potential (CHIP), which together support a potential hypothesis on how periodontitis affects and is affected by comorbidities and why the susceptibility to periodontitis and comorbidities increases with aging. Given that chronic diseases are largely triggered by the action of inflammatory immune cells, modulation of their bone marrow precursors, the hematopoietic stem and progenitor cells (HSPCs), may affect multiple disorders that emerge as comorbidities. Such alterations in HSPCs can be mediated by TII and/or CHIP, two non-mutually exclusive processes sharing a bias for enhanced myelopoiesis and production of innate immune cells with heightened proinflammatory potential. TII is a state of elevated immune responsiveness based on innate immune (epigenetic) memory. Systemic inflammation can initiate TII in the bone marrow via sustained rewiring of HSPCs, which thereby display a skewing toward the myeloid lineage, resulting in generation of hyper-reactive or "trained" myeloid cells. CHIP arises from aging-related somatic mutations in HSPCs, which confer a survival and proliferation advantage to the mutant HSPCs and give rise to an outsized fraction of hyper-inflammatory mutant myeloid cells in the circulation and tissues. This review discusses emerging evidence that supports the notion that TII and CHIP may underlie a causal and age-related association between periodontitis and comorbidities. A holistic mechanistic understanding of the periodontitis-systemic disease connection may offer novel diagnostic and therapeutic targets for treating inflammatory comorbidities.

No Genetic Causal Association Between Periodontitis and Arthritis: A Bidirectional Two-Sample Mendelian Randomization Analysis

Objectives

Periodontitis (PD) has been linked to arthritis in previous epidemiological observational studies; however, the results are inconclusive. It remains unclear whether the association between PD and arthritis is causal. The purpose of this study was to investigate the causal association of PD with arthritis, including rheumatoid arthritis (RA) and osteoarthritis (OA).

Methods

We performed a two-sample bidirectional Mendelian randomization (MR) analysis using publicly released genome-wide association studies (GWAS) statistics. The inverse-variance weighted (IVW) method was used as the primary analysis. We applied four complementary methods, including weighted median, weighted mode, MR-Egger regression and MR pleiotropy residual sum and outlier (MR-PRESSO) to detect and correct for the effect of horizontal pleiotropy.

Results

Genetically determined PD did not have a causal effect on OA (OR = 1.06, 95% CI: 0.99-1.15, P = 0.09) and RA (OR = 0.99, 95% CI: 0.87-1.13, P = 0.89). Furthermore, we did not find a significant causal effect of arthritis on PD in the reverse MR analysis. The results of MR-Egger regression, Weighted Median, and Weighted Mode methods were consistent with those of the IVW method. Horizontal pleiotropy was unlikely to distort the causal estimates according to the sensitivity analysis.

Conclusions

Our MR analysis reveals non-causal association of PD with arthritis, despite observational studies reporting an association between PD and arthritis.

Antibodies to Porphyromonas gingivalis Are Increased in Patients with Severe Periodontitis, and Associate with Presence of Specific Autoantibodies and Myocardial Infarction

There is accumulating data suggesting that periodontitis is associated with increased risk of systemic and autoimmune diseases, including cardiovascular disease, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), and there is an unmet need to identify these individuals early. With the periodontal bacteria Porphyromonas gingivalis (Pg) as one of the key drivers of periodontitis, we set out to investigate whether antibodies to Pg virulence factor arginine gingipain (Rgp) could serve as a biomarker for periodontitis patients at increased risk of autoimmunity and systemic disease. We measured serum anti-Rgp IgG in three study populations: PAROKRANK (779 individuals with myocardial infarction (MI); 719 controls), where 557 had periodontitis, and 312 were positive for autoantibodies associated with RA/SLE; the PerioGene North pilot (41 periodontitis; 39 controls); and an SLE case/control study (101 SLE; 100 controls). Anti-Rgp IgG levels were increased in severe periodontitis compared to controls (p < 0.0001), in individuals positive for anti-citrullinated protein antibodies (p = 0.04) and anti-dsDNA antibodies (p = 0.035), compared to autoantibody-negative individuals; and in MI patients versus matched controls (p = 0.035). Our data support longitudinal studies addressing the role of anti-Rgp antibodies as biomarkers for periodontitis patients at increased risk of developing autoimmunity linked to RA and SLE, and mechanisms underpinning these associations.

Impact of photodynamic therapy as an adjunct to non-surgical periodontal treatment on clinical and biochemical parameters among patients having mild rheumatoid arthritis with periodontitis

PURPOSE

To evaluate the efficacy of photodynamic therapy (PDT) as an adjunct to non-surgical periodontal therapy on the clinical periodontal and biochemical parameters among patients with rheumatoid arthritis (RA) having periodontitis.

METHODS

A total of 50 RA patients with periodontitis were included. The subjects were equally divided into two groups: Group A - scaling and root planning (SRP) + PDT; Group B - SRP only, respectively. Plaque score (PS), bleeding on probing (BOP), and pocket depth (PD) were estimated. The biochemical parameters included the assessment of interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and rheumatoid factors (RFs).

RESULTS

Plaque scores and BOP significantly reduced in both the groups at both 6 and 12 weeks with significant difference between both the groups at 6 weeks follow up (p<0.05). On inter-group comparison, there was a statistically significant reduction seen for BOP in Group A at 12 weeks (p<0.001). PD significantly reduced in both the groups at both time points; however, significant reduction was noted for Group A compared to Group B (p<0.01). IL-6 and TNF-α significantly reduced in both the groups at 6 and 12 weeks follow up. However, the proinflammatory cytokine levels significantly reduced in group A as compared to group B at both 6 and 12 weeks (p<0.05). GCF levels of RF did not show any change in either of the groups at either time point or between the groups (p>0.05).

CONCLUSION

PDT significantly reduced the proinflammatory burden in terms of periodontal attachment level and bleeding on probing within the periodontal inflammatory pockets in patients having RA.

Etiology and Risk Factors for Rheumatoid Arthritis: A State-of-the-Art Review

Rheumatoid arthritis (RA) is the most common systemic inflammatory rheumatic disease. It is associated with significant burden at the patient and societal level. Extensive efforts have been devoted to identifying a potential cause for the development of RA. Epidemiological studies have thoroughly investigated the association of several factors with the risk and course of RA. Although a precise etiology remains elusive, the current understanding is that RA is a multifactorial disease, wherein complex interactions between host and environmental factors determine the overall risk of disease susceptibility, persistence and severity. Risk factors related to the host that have been associated with RA development may be divided into genetic; epigenetic; hormonal, reproductive and neuroendocrine; and comorbid host factors. In turn, environmental risk factors include smoking and other airborne exposures; microbiota and infectious agents; diet; and socioeconomic factors. In the present narrative review, aimed at clinicians and researchers in the field of RA, we provide a state-of-the-art overview of the current knowledge on this topic, focusing on recent progresses that have improved our comprehension of disease risk and development.

The current status of anti-citrullinated protein antibodies and citrullinated protein-reactive B cells in the pathogenesis of rheumatoid arthritis

Anti-citrullinated protein antibodies are a hallmark of rheumatoid arthritis. It is widely acknowledged that the presence of ACPAs is the result of the interaction of genes, the environment and epigenetic modifications. The mechanism by which the factors, especially citrullination and ACPA glycosylation, affect ACPAs is still unclear. In this article, we review the presence of the ACPAs in RA and their relationship with clinical manifestations. The pathogenicity of ACPAs and B cells in RA was also summarized. A growing body of evidence has shown that ACPA-positive patients have more serious bone erosion and destruction and poor clinical prognosis than ACPA-negative patients. Recently, with the direct study of citrullinated protein-reactive B cells, their role in the development of rheumatoid arthritis has been further understood. It indicates that further understanding of the mechanism of ACPAs and CP-reactive B cells would beneficial in the prevention and treatment of RA.

Association of Serum and Crevicular Fluid Dickkopf-1 Levels with Disease Activity and Periodontitis in Patients with Early Rheumatoid Arthritis

BACKGROUND

The aim of this study was to assess DKK-1 levels, in Gingival Crevicular Fluid (GCF) and serum, as a biomarker for bone loss and disease activity in periodontitis and early RA (eRA).

METHODS

In this cross-sectional study, we obtained serum and GCF from 10 interproximal sites (Distal Buccal I/S, Mesio Buccal I/S, Distal Palatal/Lingual, Mesio Palatal/Lingual) according to the highest degree of inflammation by a patient for 240 sites from eRA patients. Patients received a periodontal assessment, a radiographic evaluation, tomography of interproximal sites, and DKK1 levels were determined by ELISA. Comparisons were performed by the Mann-Whitney U test and analysis by Chi2 test, and a logistic regression model was applied.

RESULTS

The mean age was 46.33 ± 12.0 years, the Disease Activity Score (DAS-28-ESR) was 4.08 ± 1.4. Periodontitis was present in 65.2% of the patients, and 59.6% of these patients had bone loss in interproximal sites. Higher GCF-DKK1 levels were associated with serum-DKK1 (OR:2.41 IC95% 1.14-5.09, p=0.021) and were related with DAS28-ESR (p=0.001), Routine Assessment of Patient Index Data 3 (RAPID 3) (p=0.001), and tender joints (p=0.040). Foot bone erosion and juxta-articular osteopenia were associated with high levels of serum-DKK1 (p=0.009 and 0.001, respectively). Serum-DKK1 were associated with SDAI (OR: 2.38 IC95% 1.03-5.52, p=0.043), RAPID 3 (p=0.001), and rheumatoid factor (p=0.018). The GCF-DKK1 levels were associated with periodontal bone loss (p=0.011), periodontitis (p=0.070) and its severity (OR: 2.58 IC95% 2.28-7.28, p=0.001). Bone loss was more frequent in buccal sites (73.5%) and was associated with increased levels of DKK1 (p=0.033).

CONCLUSION

In the early stages of the eRA disease, serum and GCF-DKK1 could be a biomarker for clinical disease activity and periodontal and articular bone erosion.

Gingival crevicular fluid microRNA associations with periodontitis

PURPOSE

The present study was performed to assess the associations of gingival crevicular fluid (GCF) microRNAs miR-140-3p, miR-145-5p, miR-146a-5p, and miR-195-5p with periodontitis (PD) and to evaluate the possible influence of rheumatoid arthritis (RA) in this context.

METHOD

GCF samples were collected from 134 individuals with PD and 76 periodontally healthy individuals, with or without RA. After miRNA extraction from GCF, the levels of miR-140-3p, miR-145-5p, miR-146a-5p, and miR-195-5p were assessed using RT-qPCR.

RESULTS

MiR-146a-5p levels were significantly lower among the patients with PD than among the healthy individuals (P < 0.001) and negatively correlated with PD severity based on PD stage and periodontal outcome parameters (P < 0.05). Patients with severe PD had higher GCF levels of miR-140-3p and miR-145-5p than did periodontally healthy individuals (P < 0.05). Significant AUC values for diagnosis of severe PD were revealed for miR-140-3p (AUC = 0.614, P = 0.022), miR-145-5p (AUC = 0.621, P = 0.016) and miR-146a-5p (AUC = 0.702, P < 0.001). Combination of the aforementioned miRNAs increased the diagnostic performance (AUC = 0.709, P < 0.001).

CONCLUSION

It was demonstrated that miR-140-3p, miR-145-5p and miR-146a-5p were associated with PD and would be potentially effective for GCF-based non-invasive periodontitis diagnostics in patients with and without RA.

Association of Bitter Taste Receptor T2R38 Polymorphisms, Oral Microbiota, and Rheumatoid Arthritis

The association of taste genetics and the oral microbiome in autoimmune diseases such as rheumatoid arthritis (RA) has not been reported. We explored a novel oral mucosal innate immune pathway involving the bitter taste G protein-coupled receptor T2R38. This case–control study aimed to evaluate whether T2R38 polymorphisms associate with the buccal microbial composition in RA. Genomic DNA was obtained from buccal swabs of 35 RA patients and 64 non-RA controls. TAS2R38 genotypes were determined by Sanger sequencing. The buccal microbiome was assessed by Illumina MiSeq sequencing of the V4-16S rRNA gene. Bacterial community differences were analyzed with alpha and beta diversity measures. Linear discriminant analysis effect size identified taxa discriminating between RA versus non-RA and across TAS2R38 genotypes. TAS2R38 genotype frequency was similar between RA and non-RA controls (PAV/PAV; PAV/AVI; AVI/AVI: RA 42.9%; 45.7%; 11.4% versus controls 32.8%; 48.4%; 18.8%, chi-square (2, N = 99) = 2.1, p = 0.35). The relative abundance of Porphyromonas, among others, differed between RA and non-RA controls. The relative abundance of several bacterial species also differed across TAS2R38 genotypes. These findings suggest an association between T2R38 polymorphisms and RA buccal microbial composition. However, further research is needed to understand the impact of T2R38 in oral health and RA development.

Oral Microbiota Identifies Patients in Early Onset Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common autoimmune inflammatory disease, and single periodontitis-associated bacteria have been suggested in disease manifestation. Here, the oral microbiota was characterized in relation to the early onset of RA (eRA) taking periodontal status into consideration. 16S rRNA gene amplicon sequencing of saliva bacterial DNA from 61 eRA patients without disease-modifying anti-rheumatic drugs and 59 matched controls was performed. Taxonomic classification at 98.5% was conducted against the Human Oral Microbiome Database, microbiota functions were predicted using PICRUSt, and periodontal status linked from the Swedish quality register for clinically assessed caries and periodontitis. The participants were classified into three distinct microbiota-based cluster groups with cluster allocation differences by eRA status. Independently of periodontal status, eRA patients had enriched levels of Prevotella pleuritidis, Treponema denticola, Porphyromonas endodontalis and Filifactor alocis species and in the Porphyromonas and Fusobacterium genera and functions linked to ornithine metabolism, glucosylceramidase, beta-lactamase resistance, biphenyl degradation, fatty acid metabolism and 17-beta-estradiol-17-dehydrogenase metabolism. The results support a deviating oral microbiota composition already in eRA patients compared with healthy controls and highlight a panel of oral bacteria that may be useful in eRA risk assessment in both periodontally healthy and diseased persons.