Rheumatoid arthritis (RA) and periodontitis share a key characteristic: chronic inflammation. Previous studies have identified an association between the two diseases. Individuals with RA have a higher prevalence of periodontitis, and conversely, individuals with periodontitis have a greater risk of developing RA.1
A recently published systematic review aimed to “evaluate the effects of non-surgical periodontal treatment (NSPT) on RA and, conversely, the impact of disease-modifying anti-rheumatic drugs (DMARDs) on periodontitis.”1
The Review
RA and periodontitis share an imbalance of cytokines associated with disease onset and progression. Additionally, it has been proposed that RA starts at mucosal sites such as the oral cavity. The combination of mucosal inflammation and local bacterial dysbiosis has been proposed as the mechanism responsible for triggering the autoimmune response of RA.1
Based on this information, it can be postulated that the management of either disease would affect disease progression and management of the other, either through NSPT or DMARDs.1
A total of 49 studies were reviewed for this systematic review. Of those, ten were randomized controlled trials.1
The Results
In general, the review found that the severity of RA and periodontitis was directly proportional. All periodontal indexes were worse in RA patients.1
When evaluating the effect of NSPT on RA, multiple studies included in the review found that NSPT significantly reduced the disease activity score for RA in those patients. Additionally, in all studies reviewed, the reduction in disease activity score for RA correlated with improvement of periodontal parameters with six-month follow-up.1
However, when longer follow-up times were employed, the studies found that NSPT did not affect the reduction in disease activity scores in RA patients, though it did reduce the prevalence of red complex bacteria. Nonetheless, NSPT and follow-up care seemed to positively affect quality of life and self-reported health indicators.1
DMARDs work by slowing down joint damage progression via modulating cytokine levels, ultimately reducing chronic inflammation. The effects of DMARDs on periodontal parameters were mixed in the included studies. This could be because there are multiple treatment protocols and different medications used for DMARDs.1
Several studies found improvement in bleeding on probing, periodontal probing depths, and clinical attachment loss. However, those that reported no improvement mainly were in patients taking immune-suppressing medications as part of their DMARD treatment protocol.1
The authors reported a greater risk of developing infections, including periodontitis, in these cases. However, it is important to note that the authors found no changes, meaning patients with periodontitis do not experience worsening of their disease.1
This review reported multiple limitations, including small sample sizes, the variability of the follow-up (usually six months), the heterogeneity of the periodontal parameters examined, and the small number of randomized controlled trials.1
Conclusion
Periodontitis is recognized as a modifiable risk factor for RA, playing a role in both triggering and sustaining immune-driven inflammation. NSPT, a simple and cost-effective treatment, has the potential to reduce inflammation and may help minimize the reliance on systemic medications for RA, thereby reducing the risk of serious complications, particularly cardiovascular events.1
The findings suggest that while NSPT positively impacts clinical disease activity indices in RA, it has a lesser effect on systemic inflammatory markers, which are likely influenced by other factors, such as infections that are more prevalent in RA patients, particularly those undergoing glucocorticoid and immunosuppressive therapy. These observations suggest regular periodontal assessments should be incorporated into RA treatment guidelines to identify and manage periodontitis early.1
Additionally, this review highlights the reciprocal relationship between periodontitis and RA, with both conditions influencing each other through cytokine production and immune system activation.1
Although the literature on the subject presents some inconsistencies, many studies have shown that DMARDs can benefit both the clinical and immunological aspects of periodontal health, supporting the theory of a bidirectional connection between RA and periodontitis. Further research is needed to assess the cost-effectiveness of using biologic DMARDs in treating periodontitis. However, given the potential risks, such as infections and cancer, and the high costs associated with these therapies, these therapies may not be sustainable for managing periodontitis alone.1
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Reference
1. Inchingolo, F., Inchingolo, A.M., Avantario, P., et al. The Effects of Periodontal Treatment on Rheumatoid Arthritis and of Anti-Rheumatic Drugs on Periodontitis: A Systematic Review. Int J Mol Sci. 2023; 24(24): 17228. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10743440/
