For more on this topic, go to www.dentaleconomics.com and search using the following key words: periodontal disease, oral-systemic, rheumatoid arthritis, Richard H. Nagelberg, DDS.Recent research has indicated an association between two chronic, noncurable diseases - periodontal disease and rheumatoid arthritis. Rheumatoid arthritis is a debilitating, autoimmune, joint destroying, chronic inflammatory condition of unknown etiology. It affects about 1% of the adult population. Anyone who has experienced rheumatoid arthritis (RA) firsthand, or in a family member or friend, understands how life-changing it can be.
Evidence for the link between periodontal disease and rheumatoid arthritis comes from the commonality of their pathogenesis and clinical presentation. The immunological and pathological processes occurring in periodontitis and RA are nearly identical. Both conditions are characterized by chronic inflammation in a soft-tissue site adjacent to bone. In both diseases, the inflammatory mediators released include IL-1, IL-6, and TNF-alpha, among others. Furthermore, antibodies to the same bacterial species are found in periodontal tissues and synovial tissues in individuals with RA. There is also a strong genetic association between the two diseases.
The clinical manifestations occurring in both periodontitis and RA are also remarkably similar - pain, swelling, and tenderness. If left untreated, the chronic inflammatory processes ultimately lead to bone destruction.
Several recent studies have demonstrated the link between periodontitis and RA. A 2009 study (Ogrendik M. Mod Rheumatol. 2009 Jun 24. [Epub ahead of print]) reported the presence of high levels of antibodies to oral bacteria in the serum and synovial fluid in RA patients with perio disease. Furthermore, the study found the presence of virulent perio pathogens, including P. gingivalis, T. forsythia, and P. intermedia, in the RA synovial fluid. The authors concluded that the perio pathogens were directly associated with the development of rheumatoid arthritis.
Another 2009 study (Smolik I, et al. Compendium of Continuing Education in Dentistry. 2009 May; 30(4):188-197) had fascinating results. In this study, the authors indicate that a specific perio pathogen, Porphyromonas gingivalis (Pg), is the only microbe known to produce an enzyme capable of modifying specific proteins. The bacterial enzymes catalyze a protein-folding reaction. The body recognizes this folded protein as a foreign entity. The body mobilizes an autoimmune response to these proteins, which culminates clinically in the joint destruction typically seen in RA-susceptible individuals. The authors conclude that if further research affirms the initiation of rheumatoid arthritis by Pg, periodontal disease prevention and treatment may lead to the prevention of RA in susceptible individuals. If this association between these two diseases is confirmed, it will be among the biggest developments in dentistry or medicine.
Rheumatoid arthritis is a debilitating disease. It usually begins gradually, commonly presenting with morning stiffness, weakness, and widespread muscle aches. Eventually joint pain appears. Joints can become warm, tender, and stiff. When joint inflammation sets in, the joints become swollen. Affected areas include the fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, and neck.
Additional symptoms include fever, hand and feet deformities, lung inflammation, numbness, and tingling, among others. Joint destruction may appear within one to two years of the appearance of the disease. Lifelong treatment is required, as there is no cure, nor is the cause currently understood. Treatment usually consists of a combination of medications, physical therapy, exercise, and surgery when indicated.
Some other similarities between RA and perio disease bear consideration. Both conditions require a lifetime of disease management. Early detection and aggressive management of RA can delay tissue destruction in some cases. The same is true for perio disease; however, prevention is possible as well if gingivitis is identified and adequately managed.
Some research has shown improvement in RA symptoms following successful perio treatment. This is likely due to the reduction in the oral contribution to the total inflammatory burden, following the favorable perio treatment outcome.
We should perhaps view our patients with RA and perio disease as an opportunity to impact their health in a very real way. These patients will likely be unaware that perio treatment may result in improvement in their RA symptoms. When this happens, it will be very gratifying for both the dental professional and the patient. We are always treating people, not oral cavities.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].