Periodontal conditions in adults with rheumatoid arthritis- a pilot study

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Rheumatoid Arthritis (RA) is a chronic destructive inflammatory disease characterized by the accumulation and persistence of an inflammatory infiltrate in the synovial membrane that leads to synovitis and destruction of the joint architecture. RA occurs worldwide and affects approximately 1% of the world population in a female/male ratio of 3:1and has a peak incidence of onset in women in the fourth and fifth decades of life1.

Periodontitis is an infection initiated by bacteria present in the dental biofilm, which is characterized by a chronic inflammation and is associated with destruction of both connective tissue and alveolar bone2. Periodontal disease (PD) and its mechanism of inflammatory reactions results in the destruction of tissue and bone in a pattern similar to that which mediate destruction of soft tissue and erosion of bone in rheumatoid arthritis (RA)3.

Moreover, both periodontitis and RA present an imbalance between pro-inflammatory and anti-inflammatory cytokines, which is deemed responsible for the tissue damage. In this sense, both conditions are associated with destruction of bone, mediated by inflammatory cytokines such as interleukin-1, tumoral necrosis factor and prostaglandin E22. The conditions share common environmental, epidemiologic, genetic risk factors. Many patients with RA become more or less manually disabled leading to inadequate oral hygiene maintenance.

A bidirectional relationship of RA and periodontitis may involve RA affecting the pathogenesis of periodontitis and vice-versa2. Whether or not RA is positively, negatively, or not associated at all with the progression of existing inflammatory conditions elsewhere in the body, such as periodontitis, is still controversial. Although several studies have reported contradicting results regarding a relationship between RA and periodontitis, recent studies have reported a significant association between RA and periodontal disease1. Recently one study reported 3.95 % of incidence of RA in patients suffering from periodontitis. The literature correlating the severity of RA and periodontal status is scant3.

Comprehension of a possible association between PD and RA can be relevant for the proper medical and dental care of RA patients. So the need was felt to study the association of periodontal condition among diagnosed RA patients and compare them with those of non rheumatic patients (NRA).


A study was done to investigate the association between PD and RA which included 39 RA patients diagnosed in accordance with the Revised Criteria of the American College of Rheumatology and 22 healthy individuals. Questionnaires on general and oral health were applied and they assessed visible plaque index (VPI), gingival bleeding index (GBI) and attachment loss (AL). The number of teeth present in the oral cavity was determined. RA patients had fewer teeth, higher prevalence of sites presenting dental plaque and higher frequency of sites with advanced attachment loss. Based on these results, they concluded that there is an association between PD and RA2.

A study was planned to evaluate clinical effect of periodontal treatment on biochemical markers of disease severity in RA patients with periodontal disease, which included 42 patients which were divided into two groups. G1group with 16 patients were submitted to oral hygiene instructions and professional supragingival tooth cleaning. G2 group with 26 patients were submitted to full mouth scaling and root planning [SRP]. Clinical periodontal measurements and RA markers like Rheumatoid factor (RF), ESR & drug therapy were obtained at baseline and 3 months after periodontal treatment. Post therapy clinical periodontal measurements indicated a significant clinical improvement in both groups except attachment loss and probing pocket depth of > 6mm for G1.G2 group had a significant reduction in ESR levels. The data suggest that periodontal treatment with SRP might have an effect on ESR reduction3.

161 RA patients [119 females (F) and 42 males (M) , with mean duration of 10 yrs. of disease ] and 122 control group of NRA patients [80 F and 42 M ] were studied to describe periodontal conditions and compare in both groups . All patients were intermittently taking various kinds of non –steroid anti-inflammatory drugs [NSAIDS] for longer periods. Whereas at the time of examination, 86% of RA patients were taking NSAIDS. Number of teeth, dental plaque, gingival inflammation, calculus, probing depth, alveolar bone level were recorded. The RA patients had less plaque [38% ], calculus [supra gingival (65%) and sub gingival (52%) ], gingival inflammation (34%) than the NRA group ie., 47%, 75%, 58%, 47% scores respectively but probing depth of more than 4mm were found in 81% of RA patients. Authors attributed the difference seen in periodontal status of RA with NRA group to long term administration of NSAIDS. However, they cautioned the clinicians while excluding RA patients from a group of individuals at risk of developing progressive periodontal disease. They further proposed for the specially designed dental care programs to counter act negative effect of their immunopathological disease on periodontal health4.

65 patients were observed to determine the extent of periodontal disease and correlate with the various indicators of RA. Probing depths, attachment loss, bleeding scores, plaque scores and radiographic bone loss score were measured. RA measures included tender joint analysis, swollen joint analysis, pain index, physician’s global assessment on a visual analogue scale, health assessment questionnaire, levels of C- reactive protein (CRP) and ESR. RA patients had more missing teeth 11.6(±6.5), deep periodontal pockets than NRA group. RA patients had more than twice as likely to have moderate to severe bone loss (69.2%) than NRA patients (33.8%). Mean ESR levels of RA patients with zero to mild periodontitis was low as compared with RA patients with moderate to severe periodontitis. Severity of periodontal bone loss correlated with CRP level in RA patients. They concluded that individuals who have moderate to severe RA are very likely to suffer moderate to severe PD. They hypothesized that the relation of PD and RA does represent an underlying dysregulation of the molecular pathways in the inflammatory response and this could have significant management implications in the future as new host modifying medications are being developed5.

A study was conducted to evaluate the prevalence and severity of periodontitis in RA patients which included 69 patients with RA and 35 with Osteo- arthritis(OA) and examined for bleeding on probing (BOP), erythema/ oedema [presence/absence], tooth mobility [Miller mobility index].Digital panoramic radiographs were used to evaluate the presence and severity of periodontitis. Measures of RA disease activity included a multi-dimensional health assessment questionnaire, C- reactive protein(CRP) concentration, and the four- variable disease activity score-28[DAS289(4v)]. RA disease severity was assessed by presence or absence of RF or Anti- cyclic citrullinated peptide (CCP) antibodies and the presence of radiographic erosions on hand or foot films. Periodontitis was more common and severe in patients with RA compared to patients with OA (51% versus 26%; P=0.03). Moderate to severe periodontitis was frequently observed among RA patients who were sero positive for RF (59%) and Anti-CCP antibodies (56%), than who were sero negative for RF (15%) and Anti-CCP antibodies (22%)6.


  1. To study periodontal conditions and determine the extent of severity among patients suffering from Rheumatoid Arthritis

  2. To compare them with those of non Rheumatic subjects.



The study design includes 60 RA patients attending Orthopaedic OPD clinic at S.N. MEDICAL COLLEGE AND HOSPITAL, BAGALKOT and 40 non-RA healthy dental patients attending the OPD of P.M.N.M DENTAL COLLEGE AND HOSPITAL, BAGALKOT for routine dental care like oral prophylaxis and fillings.

  1. Inclusion criteria: -

Inclusion criteria for Group1 and Group 2 are both genders, age between 30-60 yrs with at least 8 teeth in the oral cavity (excluding 3rd molars).

Group1- Consists of 60 RA patients (diagnosed in

accordance with the Revised Criteria of the

American college of Rheumatology)7, with disease

duration more than 3yrs.

Group2- 40 age, sex matched healthy subjects with absence of

RA or any other autoimmune disease.

  1. Exclusion criteria

For both groups includes

  • Smoking

  • Pregnancy and lactating females

  • Significant medical history indicating evidence of known systemic modifiers of periodontal disease and saliva characteristics.

  • Individuals who had undergone periodontal treatment (including prophylaxis) and /or/ on antibiotic therapy over the last 3 months.

  • Individual undergoing orthodontic treatment.

  • Systemic diseases that require prophylactic antibiotic therapy.


Study population will be subjected to dental and medical examination to satisfy the study selection criteria. Standardized questionnaire covering medical history, use of medication, duration, severity and oral hygiene measures will be recorded. Data regarding other essential laboratory findings will be procured from medical files of the patients.

Collection of samples: -


Venous blood samples (5ml) will be collected in vacutainer tubes containing lithium heparin, EDTA or buffered sodium citrate on the day of the intra - oral examination and analysed for C- reactive protiens [ CRP] by a highly sensitive, Latex particle- enhanced immunoassay; ESR by the Wintergren method.


Periodontal examination consists of recording visible plaque, marginal bleeding, probing depth, clinical attachment level, radiographs for bone loss assessment. In addition, the number of teeth present will be registered.

  1. Missing teeth

  2. Supra and sub gingival calculus

  3. Visible plaque index [Silness and Loe]8

  4. Marginal gingival bleeding index [Loe and Silness]9

  5. Probing pocket depth- probing depths will be measured to nearest mm at the mesial, distal, buccal and lingual tooth surfaces with a periodontal probe (William’s probe).

A participant will be considered to have periodontal attachment loss [AL] when an AL of 2mm or more will be detected in proximal sites by probing.

  1. Radiographic examination using standardized Orthopantomography or periapical radiographs (fullmouth) using modified Hugoson and Jordan classification method4.

  2. Categories and criteria for the application of diagnostic data are abbreviated from clinical guidelines published through the American Academy of Periodontology6,10 as follows:

  1. No periodontitis (essentially a healthy periodontium)

  2. Mild periodontitis = < 30% bone loss and minimal or no BOP

  3. Moderate periodontitis = <50% bone loss, BOP, and tooth mobility

< 2

  1. Severe periodontitis = ≥ 50% bone loss, marked BOP, and tooth mobility ≥ 2.

Periodontal grouping will be done according to analysis and interpretation of

parameters and results obtained will be statistically analyzed.






  1. Mercado FB, Marshall RI, Bartold PM: Inter-relationships between rheumatoid arthritis and periodontal disease. J Clin periodontal 2003; 30: 761-772.

  2. Ishi EP, Bertolo MB, Jr CR, Kirkwood KL, Onofre MA. Periodontal condition in patients with rheumatoid arthritis. Braz Oral Res 2008; 22(1):72-7.

  3. Ribeiro J, Leao A, Novaes AB. Periodontal infection as a possible severity factor for rheumatoid arthritis. J Clin periodontal 2005; 32: 412-416.

  4. Sjostrom L, Laurell L, Hugoson A,Hakansson JP. Periodontal conditions in adults with rheumatoid arthritis. Community Dent Oral Epidemiol 1989; 17: 234-6.

  5. Mercado FB, Marshall RI, Klestov AC, Bartold PM. Relationship between rheumatoid arthritis and periodontitis. J Periodontol 2001; 72: 779-787.

  6. Dissick A, Redman RS, Jones M, Rangan BV, Reimold A, Griffiths GR et al. Association of periodontitis with rheumatoid arthritis: A pilot study. J Periodontol 2010; 81: 223-230.

  7. Arnett FC, Edworthy SM, Bloch DA, Mcshane DJ, Fries JF, Cooper NS, et al.The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 315-324.

  8. Sillness J, Loe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal conditions. Acta odontol scand 1964; 22: 121-35.

  9. Loe H, Sillness J. Periodontal disease in pregnancy. Prevalence and severity. Acta odontol scand 1963; 21:533-51.

  10. Armitage GC. Diagnosis of periodontal diseases. J Periodontol 2003; 74: 1237-1247.

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