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

Association Studies Between Periodontal Disease and Rheumatoid Arthritis

A number of large epidemiological studies[19,20,21] and smaller case–control and cohort studies have been published showing associations between rheumatoid arthritis and periodontal disease, and have been extensively reviewed. Most have reported positive associations with periodontal disease, comparing rheumatoid arthritis patients with controls. Periodontal parameters have not been uniformly reported, nor have newer periodontal disease case definitions been applied. Studies that used patient report data[22] or included partial dental examinations (e.g. NHANES-I and NHANES-III) with reported associations between certain periodontal parameters and rheumatoid arthritis[3,23] may have underestimated periodontal disease prevalence.[17,18] A recent report in Taiwanese rheumatoid arthritis patients confirmed earlier association studies.[24] Even with their limitations, including their cross-sectional nature, variability in the dental endpoints reported, periodontal disease case definitions, extent of oral exams, limited information on rheumatoid arthritis disease characteristics or analysis of confounders, including steroid, and immunomodulatory drug use, the existing studies provide an overwhelming body of evidence to demonstrate that periodontal parameters including bleeding, gingivitis, and depth of tooth pockets are worse in rheumatoid arthritis patients.[25] An important confounder that has been variably reported is smoking status. Although smoking is a well recognized shared risk for rheumatoid arthritis and periodontal disease, Potikuri et al.[26] recently reported that the associations are present in nonsmoking rheumatoid arthritis patients.

Some studies[27,28] have reported that periodontal disease severity tracks with rheumatoid arthritis disease activity. Other studies[29–32] have suggested that nonsurgical periodontal therapy improves rheumatoid arthritis parameters, including a recent study showing reductions in erythrocyte sedimentation rate/C-reactive protein, tumor necrosis factor (TNF) levels, and Disease Activity Score. Though not designed to address a periodontal hypothesis, a rheumatoid arthritis treatment study[33] with doxycycline with methotrexate (MTX) showed that 20 mg/day doxycycline (the dose typically used to treat periodontal disease) had similar ACR50 responses as a 100-mg dose; both doses were superior to placebo–MTX. The net effects of TNF inhibition on periodontal disease parameters remain an open question but are of interest given the increased TNF levels in gingival crevicular fluid and inflamed periodontium. A recent small study[34] suggested that rheumatoid arthritis patients with periodontal disease had less improvement in rheumatoid arthritis disease activity with TNF inhibitors; others[30,35,36] have reported that rheumatoid arthritis patients treated with TNF inhibitors had improvement in some, but not all, periodontal disease parameters. Clinical studies[37] have also shown that alveolar bone loss in rheumatoid arthritis patients with periodontal disease parallels rheumatoid arthritis erosions at other sites.