Periodontal Disease and Rheumatoid Arthritis

The Evidence Accumulates for Complex Pathobiologic Interactions

Clifton O. Bingham III; Malini Moni


Curr Opin Rheumatol. 2013;25(3):345-353. 

In This Article

Abstract and Introduction


Purpose of review This review was conducted to focus on the recent clinical and translational research related to the associations between periodontal disease and rheumatoid arthritis.

Recent findings There is a growing interest in the associations between oral health and autoimmune and inflammatory diseases. A number of epidemiologic studies have described associations between rheumatoid arthritis and periodontal disease. Recent clinical studies continue to support these reports, and are increasingly linked with biological assessments to better understand the nature of these relationships. A number of recent studies have evaluated the periopathogenic roles of Porphyromonas gingivalis, the oral microbiome, and mechanisms of site-specific and substrate-specific citrullination. These are helping to further elucidate the interactions between these two inflammatory disease processes.

Summary Studies of clinical oral health parameters, the gingival microenvironment, autoantibodies and biomarkers, and rheumatoid arthritis disease activity measures are providing a better understanding of the potential mechanisms responsible for rheumatoid arthritis and periodontal disease associations. The cumulative results and ongoing studies have the promise to identify novel mechanisms and interventional strategies to improve patient outcomes for both conditions.


In the past few years, increasing attention has been given to aspects of oral health in patients with rheumatoid arthritis, especially related to associations with periodontal disease. The numbers of publications are on the rise, driven in part by interest in the role of citrullination and attendant autoantibody responses as a disease-defining feature of rheumatoid arthritis, and the recognition that oral bacteria and inflammation may play important roles.

Observations related to oral conditions and inflammatory arthritis extend back for centuries, with Hippocrates suggesting that pulling teeth could cure arthritis. Common oral manifestations in rheumatoid arthritis include Sjogren's syndrome and temporomandibular joint disease (TMD), and studies have suggested associations with periodontal disease in patients with rheumatoid arthritis. Although a number of hypothesized interactions between the diseases were proposed, cross-sectional association studies could not discern temporal relationships. Initial conceptualizations for the nature of the relationship involved shared inflammatory disease pathways, shared risk factors such as smoking, oral hygiene difficulties from TMD and/or peripheral joint dysfunction, effects of nonsteroidal antiinflammatory drugs, steroids, and immunosuppressants, and xerostomia from Sjogren's.

As the importance of peptide citrullination as an etiopathologic event in rheumatoid arthritis has been elucidated, studies have focused on the expression and function of the peptidylarginine deiminase (PAD) enzymes that can lead to posttranslational modification, neoepitope generation, with subsequent development of anticitrullinated peptide antibodies (ACPA). A seminal discovery that a major bacterial species involved in the development and propagation of periodontal disease, Porphyromonas gingivalis (Pg), has a PAD capable of citrullination[1] fuelled interest and additional investigation of citrullination as a mechanistic link between the two conditions. Moreover, additional studies of the periodontal microenvironment and immunological mechanisms in periodontal disease have provided additional insights.

This review focuses on recently published studies that are adding to the knowledge base and broadening understanding of clinical and biological links between rheumatoid arthritis and periodontal disease, with references to major historical studies and topical reviews.