People with rheumatoid arthritis may be at increased risk for periodontal disease, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in San Francisco, Calif.

Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

Some studies have shown links between RA and periodontal disease, a gum disease characterized by inflammation that leads to separation of the teeth from the gums, loss of bony support, and possible tooth loss; however, many of these studies have lacked RA-specific information.

Researchers recently evaluated the prevalence of periodontal disease—and other aspects of oral health—in 153 patients with RA who were already enrolled in a cardiovascular disease study. Sixty-six percent of the patients were female, ranged in age from 45 to 84 years, were primarily Caucasian, and had—on average—suffered from RA for 11 years.

Researchers administered oral health questionnaires that assessed their dental histories, oral hygiene practices, tooth loss, mouth dryness, and periodontal disease status of each patient. Periodontal-specific questions included past diagnosis and treatment of periodontal disease, as well as self-reported gum recession due to gingivitis and bleeding and swelling of the gums.

By using established RA criteria, researchers looked at the associations between the disease and periodontal symptoms and estimated the prevalence of periodontal disease in the patients taking into consideration socio-demographic factors, lifestyle, and oral hygiene, as well as the presence of other diseases.

Eighty-two percent of the patients reported periodontal symptoms, including a history of the disease, gum recession, swollen gums and gum bleeding. In further analysis, researchers found that the presence of periodontal disease was significantly associated with a patient’s RA disease activity score, or DAS as it is commonly called, and with rheumatoid nodules – leading researchers to believe that periodontal disease is independently associated with RA disease activity.

“These findings, along with prior studies and our additional preliminary data showing a high prevalence of moderate to severe periodontal disease in RA patients based on comprehensive oral examinations, strongly suggest an association between these two inflammatory diseases. We are now conducting a number of additional studies to better understand the pathobiologic mechanisms that may explain these associations,” notes Clifton O. Bingham III, MD a rheumatologist from the Johns Hopkins University School of Medicine and lead investigator in the study. “It is notable that treatment of periodontal disease leads to improvement of other systemic conditions including diabetes, and may even lower cardiovascular risk. Thus it is possible that increased attention to oral health and treatment of periodontal disease may improve outcomes for patients with RA.”

Patients should talk to their rheumatologists to determine their best course of treatment.

The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases. For more information on the ACR’s annual meeting, see http://www.rheumatology.org/annual.

Editor’s Notes: Dr. Bingham will present this research during the ACR Annual Scientific Meeting at the Moscone Center from 3:00 – 3:15 PM on Tuesday, October 28, in Room 135.
Presentation Number: 1937

Periodontal Disease Symptoms are Independently Associated with Rheumatoid Arthritis Disease Activity

Clifton O. Bingham, III, Susan J. Bartlett, Marissa Hildebrant, Michelle Jones, Malini Moni, Marilyn C. Towns, Joan M. Bathon, Jon T. Giles. Johns Hopkins, Baltimore, MD

Purpose: Recent epidemiological reports have suggested an increased prevalence of periodontal (perio) disease (PD) in patients with rheumatoid arthritis (RA), but these reports have lacked information on RA disease-specific parameters. Both conditions are driven by similar inflammatory mediators and have been linked to cardiovascular disease (CVD). We evaluated the prevalence of PD and other aspects of oral health in a well-characterized cohort of RA patients participating in an observational study.

Methods: Men and women with RA aged 45-84 yrs enrolled in a cohort study of subclinical CVD were administered an oral health questionnaire assessing dental history, oral hygiene practices, tooth loss, oral dryness, and PD status. Perio questions included past diagnosis or treatment for PD and self-report of gingival recession, bleeding, and swelling. The associations of perio symptoms with RA disease characteristics (duration, RF, anti-CCP, Ro, La, HLA-DRBI “shared epitope”, DAS28-CRP, HAQ, Sharp score, and rheumatoid nodules) were modeled using Poisson regression with robust variance estimation. Prevalence ratios (PR) were calculated in simple and multivariable (MV) models adjusting for socio-demographic, lifestyle, oral hygiene, and co-morbid disease variables.

Results: 153 RA patients [66% female; mean age (±SD) 61±8 yrs; 88% white; median RA duration (IQR) 11(6 - 19) yrs; mean DAS28 3.4 ± 1.2] were studied. The overall prevalence of self-reported periodontal symptoms was 82%(perio history 24%, gum recession 40%, swollen gums 19%, gum bleeding 69%). In bivariate analyses, the only RA characteristics significantly associated with presence of any perio symptoms, swollen gums, and bleeding gums were DAS28 and nodules. DAS28 remained significantly associated with specific perio symptoms after MV adjustments (Table) in which associations with highest levels of DAS28 were observed. Similar associations were observed in subgroups by gender and number of missing teeth.

Conclusion: In this sample of RA patients, symptoms of periodontal disease were common in patients with higher levels of RA disease activity. More careful attention to oral health and PD in RA is warranted to identify and treat this potentially under recognized comorbidity. Additional studies are underway to validate self-reported PD with detailed examination of the periodontium and gingiva and to evaluate pathophysiologic interactions between PD and RA.

Funding: NIH/NIDCR R03-DE018094 (COB), NIH/NIAMS R01-AR050026 (JMB), NIH/NIAMS K23-AR054112 (JTG), Maryland Chapter Arthritis Foundation Institutional Grant (COB)

Disclosure Block: C.O. Bingham, None; S.J. Bartlett, None; M. Hildebrant, None; M. Jones, None; M. Moni, None; M.C. Towns, None; J.M. Bathon, None; J.T. Giles, None.

Source: American College of Rheumatology (ACR)