Nonsurgical periodontal therapy to extinguish inflammation seen in rheumatoid arthritis

Tanya Cervantes, BS, RDH
Brooke Reed, BS, RDH
Sarah Moeller, BS, RDH
Emily Holt,  MHA, RDH, CDA, EFDA

There are many beautiful aspects of growing older, whether it’s the wisdom that comes from life experience or the joys of having a family. These pleasures can be dampened by chronic pain associated with rheumatoid arthritis (RA) or difficulty enjoying favorite foods due to tooth loss from periodontitis. RA is an autoimmune and inflammatory disease that commonly affects joints in the hands, wrists, and knees and is associated with bone changes.¹ Similar to periodontitis, RA has a systemic effect on the body beyond the joints. In addition to problems in the lungs, heart, and eyes, individuals with RA have a higher incidence of bleeding on probing and more clinical attachment loss compared to disease-lacking controls.^1,2 A meta-analysis and systemic review found compelling evidence that the likelihood of developing periodontitis is elevated when RA is present compared to the disease-lacking controls.²

The connection between periodontitis and RA can be further explained through results of a small study based on the level of tumor necrosis factor-alpha (TNF-a) in the serum of patients. TNF-a is a protagonist of bone resorption, which occurs in both periodontitis and RA.³ Not only is TNF-a found at the site of inflammation, but it also circulates throughout the vascular system and can generate systemic inflammation.³ This study reported statistically higher TNF-a levels when the participants had both periodontitis and RA, followed by those only with RA, then the periodontitis only group.³ The TNF-a imbalance may be capable of creating a cascade of inflammatory events in both RA and periodontitis, which may lead to tissue destruction.³ This study proposed that increases in periodontal inflammation in RA patients are due to elevated levels of TNF-a in both oral and systemic circulations.³  Since elevated levels of TNF-a in a patient with RA may lead to periodontal inflammation, the researchers suggest that rheumatologists should refer patients with RA to a periodontist for early intervention of periodontitis and to limit disease progression.³

Research suggests that periodontitis may be a key initiator in the formation of RA.⁴ The exact mechanism for the initiation and development remains unknown. The prevalence of periodontitis in individuals with RA is higher compared to those without RA.⁴ Porphyromonas gingivalis, a microorganism associated with periodontitis, could influence the development of RA because its presence generates citrullinated proteins that trigger inflammation.⁵ Citrullinated proteins are generated by everyone, but higher levels form in the presence of RA.⁶ The body responds by producing antibodies which trigger inflammation and tissue degradation, both in RA and periodontitis.⁶ The presence of citrullinated protein antibodies is accepted as the most accurate sign of RA or risk factor for development of RA.⁴ While the connection of RA to the progression of periodontitis has been researched, the impact of treating periodontitis to relieve symptoms of RA is less common. The aim of this literature review is to determine if nonsurgical periodontal therapy should be included in the course of treatment for RA.

The impact of nonsurgical periodontal therapy on rheumatoid arthritis

The usual course of treatment for RA includes medications and self-management strategies.¹ Disease-modifying antirheumatic drugs (DMARDS) slow the disease and prevent deformity within the joints.¹ Self-management strategies are used to reduce pain and disability.  These include getting at least 150 minutes of moderate physical activity each week, maintaining a healthy weight, and avoiding repetitive joint motion and injury.⁷

The impact of nonsurgical periodontal therapy on RA has been studied over a few decades. Much of the research has been completed through small-scale studies with few systematic reviews in print.  One systematic review of the literature found that reduction of Porphyromonas gingivalis has been shown to suppress inflammation systemically, including control of RA.⁸ Symptoms in patients with RA improved or were totally alleviated when periodontal bacteria were removed through scaling and root planing (SRP).⁸ A small study with 40 participants was published in 2009 in the Journal of Periodontology and supports the results of the systematic review.⁹ All participants in the study had both severe periodontitis as well as moderate or severe RA. Half of the participants received SRP while the others did not. Those who received SRP showed a significant decrease in RA markers, including disease activity score (DAS), erythrocyte sedimentation rate (ESR), and serum TNF-a levels.⁹ This study validated that nonsurgical periodontal therapy provided a beneficial effect for managing RA while leaving periodontitis untreated made no impact.⁹

Another small-scale study saw similar results when SRP was performed on patients with RA.⁵ Anti-cyclic citrulline peptide antibody (ACPA) and Disease Activity Score 28 (DAS28) are commonly used to identify the severity of RA. Prior to the study intervention, ACPA was significantly increased in study participants with periodontitis, raising the evidence that periodontitis may be a strong risk factor for the progression of RA.⁵ Within a month after receiving SRP, DAS28 scores decreased, indicating that nonsurgical periodontal therapy has the ability to control systemic inflammatory markers found in RA.⁵

A case report at the outpatient Immuno-Rheumatology Clinic in Italy also had similar findings. This report studied a full and lengthy RA recovery following periodontal therapy in a male patient with both periodontitis and RA. The individual exhibited successful treatment outcomes for periodontitis and also displayed progressive improvement of RA clinical manifestations and a gradual resolution of arthritic symptoms.¹⁰ Also, the case report reviewed proceedings from six studies in which the treatment of periodontal infection reduced the severity of active RA.¹⁰ Therefore, it is possible to hypothesize that in selected early RA cases, prompt treatment of periodontitis may prevent the development of a chronic and progressive RA.¹⁰ This is one of the first cases of periodontitis-associated RA healing, through periodontal treatment only, without the use of DMARDs and/or TNF inhibitors.¹⁰

Similar findings are the basis for why the Arthritis Foundation supports nonsurgical periodontal therapy for periodontitis, as it cites a research study performed at Case Western Reserve University where SRP was performed on a small group of individuals with RA.¹¹ The control group did not receive SRP, but they did receive instructions for oral care. The study reports that less than a month after treatment, the group who received SRP reported less rigidity and aching in the mornings and joints were not as sore or bloated.¹¹ The study also found that the amount of TNF-a was decreased through nonsurgical periodontal therapy.¹¹ Researchers concluded that the elimination of inflammation and infection in the oral cavity through nonsurgical periodontal therapy has the ability to suppress inflammation in the joints of RA patients.¹¹

There are other studies that demonstrate beneficial results of SRP, but the studies lacked a control group. One study with 54 participants reviewed the effect of SRP on rheumatologic parameters.¹² Each participant had both RA and periodontitis and received SRP. The DAS was used to determine the severity of RA one month after SRP. The results showed significant improvement in C-reactive protein, ACPA, ESR, and DAS28.¹² The results showed that periodontal therapy was highly effective at improving rheumatologic parameters.¹² Yet another study lacking a control group utilized 31 participants diagnosed with both RA and periodontitis.¹³ Each participant received SRP to treat periodontitis then researchers examined its impact on ACPA and TNF-a markers. SRP once again proved it was capable of lowering RA-related inflammatory markers ACPA and TNF-a and the serum levels were also reduced.¹³

A new spin on the field was reviewed when researchers studied if providing SRP to patients with periodontitis and RA increased patient responsiveness to biological therapy. Biological therapy is an RA treatment that disrupts the signals of the immune response that leads to destruction of joints.¹⁴ TNF inhibitor therapy is one example of this. RA response to biological therapy was measured with the DAS score. Periodontitis affected 83 of the 111 participants with RA, 37 of which were treated with SRP during the 3-month study. The study found that participants with periodontitis who received SRP were more likely to respond to their biological therapy compared to those who did not receive SRP.¹⁴

Conclusion

While lacking robust studies to support a conclusion, the unified results from numerous smaller scale studies confirm that providing nonsurgical periodontal therapy to patients with both periodontitis and RA reduces inflammatory markers consistent with RA. Since this result is replicated through each of the eight above-mentioned studies, it seems that it would be wise to perform more robust studies to solidify this theory. By doing so, it is possible that nonsurgical periodontal therapy could eventually be included in the course of treatment for patients with comorbidities of periodontitis and RA.

Integration into dental hygiene practice

Since RA affects 1.3 million Americans, dental hygienists are likely to treat patients affected by this condition.¹⁵ Dental hygienists should be prepared to explain connections between periodontitis and RA to patients with the comorbidities. In the studies mentioned, patients with periodontitis and RA had significantly higher levels of rheumatologic parameters compared with those who did not have periodontitis, suggesting that the existence of periodontitis greatly promoted the progression of RA. Due to these findings, it is strongly recommended that patients with RA and periodontitis undergo nonsurgical periodontal therapy and routine periodontal maintenance. Nonsurgical periodontal therapy can effectively reduce systemic inflammation. Due to the morning joint stiffness experienced in RA, patients with RA will likely have more joint mobility if appointments are scheduled in late morning or in the afternoon.¹⁵ Joint stiffness usually lasts between 1-2 hours and improves with movement.¹⁵

Reviewing oral care should be an important part of the appointment when treating a patient with periodontitis and RA. RA could make oral care more challenging, but dental hygienists should recommend modifications so thorough biofilm removal is completed. Powered toothbrushes could be suggested for those with limited ability to grip and remove biofilm. Placing a towel around the toothbrush handle or placing a tennis ball on the end of the handle are other ways to enable effective biofilm removal. Modifications for interdental care could include using a powered oral irrigator or floss holder. Oral care may be easier to complete in the afternoon compared to the morning due to joint stiffness.¹⁵ Individualizing care for patients with the comorbidity of periodontitis and RA can be rewarding and a positive way to connect with patients.

References

1.    Rheumatoid Arthritis (RA). Centers for Disease Control and Prevention. https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html. Reviewed March 5, 2019. Accessed April 29, 2020.

2.     Fuggle NR, Smith TO, Kaul A, Sofat N. Dental Association or Incidental Finding? A Meta- Analysis and Systematic Review of the Relationship Between Rheumatoid Arthritis and Periodontitis. Ann Rheum Dis. 2016; 75:468. https://doi:10.1136/annrheumdis-2016-eular.1787.

3.     Thilagar S, Theyagarajan R, Sudhakar U, Suresh S, Saketharaman P, Ahamed N. Comparison of serum tumor necrosis factor-α levels in rheumatoid arthritis individuals with and without chronic periodontitis: A biochemical study. J Indian Soc Periodontol. 2018; 22:116-21. https://doi:10.4103/jisp.jisp_362_17.

4.     Loutan L, Alpizar-Rodriguez D, Courvoisier DS, Finckh, A, Mombelli A, Giannopoulou C. Periodontal status correlates with anti‐citrullinated protein antibodies in first‐degree relatives of individuals with rheumatoid arthritis. J Clin Periodontol. 2019;46(7):690-698. https://doi.org/10.1111/jcpe.13117.

5.     Zhao X, Liu Z, Shu D, et al. Association of periodontitis with rheumatoid arthritis and the effect of non-surgical periodontal treatment on disease activity in patients with rheumatoid arthritis. Med Sci Monit. 2018; 24:5802–5810. https://doi.org/10.12659.

6.     Billings S, Libbert S, Hawthorne P. Periodontal Disease: Impact on Periodontitis. Access. 2017; 31(10):13-16.

7.     Arthritis: Key Public Health Messages. Centers for Disease Control and Prevention. https://www.cdc.gov/arthritis/about/key-messages.htm. Reviewed February 5, 2019. Accessed April 29, 2020.

8.     Gleiznys A, Gleiznys D, Januzis G, Kriauciunas A. The Influence of Porphyromonas Gingivalis Bacterium Causing Periodontal Disease on the Pathogenesis of Rheumatoid Arthritis: Systematic Review of Literature. Cureus. 2019;11(5). https://doi.org/10.7759/cureus4775.   

9.     Ortiz P, Bissada NF, Palomo L, et al. Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor necrosis factor inhibitors. J Periodontol. 2009;80(4):535–540. https://doi:10.1902/jop.2009.080447.

10.  Argento G, Biondo M, Fiorentino C, Salemi S. Could Early Rheumatoid Arthritis Resolve After Periodontitis Treatment Only? Medicine. 2014 Dec; 93(27):195. https://doi.org/10.1097/MD.0000000000000195.

11.  Goodman B. Treat Gum Disease to Relieve RA Pain and Stiffness. Arthritis Pain Management Managing Arthritis Pain. https://www.arthritis.org/living-with-arthritis/comorbidities/gum-disease/dental-care-relieves-ra-pain.php/. Published 2017. Accessed September 25, 2019.   

12.  Guo B, He M, Liu Z, Shu D, Si S. Association of Periodontitis with Rheumatoid Arthritis and the Effect of Non-Surgical Periodontal Treatment on Disease Activity in Patients with Rheumatoid Arthritis. Med Sci Monit. 2018; 24: 5802-5810. https://doi:10.12659/MSM.909117.

13.  Yang Ning-Ya , Wang Chen-Ying, Chyuan I-Tsu, et al. Significant association of rheumatoid arthritis-related inflammatory markers with nonsurgical periodontal therapy. Journal of the Formosan Medical Association. 2018;(117):1003-1010. https://doi.org/10.1016/j.jfma.2017.11.006.

14.  Chen HH, Chen HY, Huang LG. THU0691 Association between Periodontitis and Clinical Response in Rheumatoid Arthritis Patients Under Biological Treatment. Ann Rheum Dis. 2018; 77: 539. https://doi:10.1136/annrheumdis-2018-eular.1104.

15.  Rheumatoid Arthritis: Fast Facts. American College of Rheumatology. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis. Updated March 2019. Accessed April 29, 2020.

Tanya Cervantes, BS, RDH, recently graduated from the University of Southern Indiana with a Bachelor of Science degree in Dental Hygiene. Ms. Cervantes plans to practice dental hygiene in Frankfort, Indiana.

Brooke Reed, BS, RDH, is a recent graduate from the University of Southern Indiana with her Bachelor of Science degree in Dental Hygiene. Ms. Reed plans to practice dental hygiene in Bloomington, Indiana.

Sarah Moeller, BS, RDH, is a 2020 graduate from the University of Southern Indiana. Ms. Moeller graduated with a Bachelor of Science degree in Dental Hygiene. Ms. Moeller plans to practice dental hygiene in Indianapolis, Indiana.

Emily Holt,  MHA, RDH, CDA, EFDA, is a clinical associate professor of dental hygiene at the University of Southern Indiana in Evansville, Indiana with 20 years of experience in the field of dental hygiene. Mrs. Holt is a member of the American Dental Education Association and currently serves as secretary for the Dental Hygiene Clinical Coordinator special interest group.  Mrs. Holt has been a consultant member of the Commission on Dental Competency Assessments since 2008 and is a peer reviewer for professional journals.