Rheumatoid arthritis (RA) is known to affect joints, connective tissue, internal organs, and the cardiovascular system, but did you know that RA can also affect oral health?
People who have RA can experience any of a number of oral problems including dry mouth (xerostomia), methotrexate-induced mouth ulcers, temporomandibular disorders such as TMJ, infection, and periodontal disease (gingivitis and periodontitis).
What is periodontal disease
Bacteria in our mouths combine with mucus and other particles to form sticky plaque on teeth that may be removed with daily brushing and flossing. When plaque hardens, it becomes tartar, which must be removed by professional dental cleaning. Plaque and tartar buildup lead to gingivitis, characterized by red, swollen gums that can bleed easily. This is generally reversible with proper treatment and improved dental hygiene.
Periodontal disease happens when gingivitis progresses to a chronic inflammatory process that affects the tissue surrounding and securing teeth, the ligaments providing support, and the bone into which teeth are anchored. Symptoms of periodontal disease include bleeding gums, receding gum-line, deepening pockets around the tooth, tooth loosening, and eventual bone erosion and tooth loss.
Causes of periodontal disease
Approximately 10-15 percent of people with RA develop Sjogren’s Syndrome which is associated with dry mouth caused by inflammation. Dry mouth can cause an increase in dental decay (cavities), gingivitis, and thrush (oral yeast infection). Some people who have Sjogren’s may also experience painful swelling in the saliva glands.
Dry mouth can be relieved by drinking water, chewing gum, or using saliva substitutes, such as Biotene. Some people benefit from using prescription medications that stimulate saliva flow, such as pilocarpine (Salagen), or cevimuline (Evoxac). If your dry mouth causes you to develop a yeast infection, it can be relieved by antifungal medication.
Some people who take methotrexate may develop mucositis (inflammation of mucous membrane) leading to oral ulcerations, however the risk of mouth ulcers does depend on your dose. Supplementing with folic acid helps to reduce the risk of mucositis. You should be aware that certain medications, such as aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and penicillin, may increase levels of methotrexate in the blood. Nitrous oxide, commonly used as an inhaled sedative, also increases the anti-folate effects of methotrexate and should be avoided.
Periodontal disease and RA
Studies indicate that compared to the general population, people with periodontal disease have an increased prevalence of RA, and periodontal disease is at least two times more prevalent in RA patients. Researchers have found that the bacteria porphyromonas gingivalis, which is responsible for periodontal disease, worsens RA by leading to earlier onset, faster progression, and greater severity of disease, including increased bone and cartilage destruction.
Clinical studies have shown that alveolar bone loss (jawbone) in RA patients with periodontal disease parallels RA-associated bone erosions in other joints and that the severity of periodontal disease in RA patients tracks with the severity of RA disease activity.
A recent small study suggested that people with RA who also had periodontal disease showed less improvement in rheumatoid arthritis disease activity with tumor necrosis factor (TNF) inhibitors; other studies have reported that RA patients treated with TNF inhibitors had improvement in some, but not all, periodontal disease parameters. Additional studies have suggested that nonsurgical periodontal therapy can reduce disease activity score, tumor necrosis factor levels, and inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein in people with RA.
What can I do?
Because RA places you at increased risk of periodontal disease, it’s important to do everything you can to protect your oral health. Following a regular routine for dental care will help protect you against oral disease, and perhaps even improve your RA symptoms as well.
- Brush with a soft-bristle toothbrush for two minutes, twice each day, and replace your toothbrush every three months. Try an electric toothbrush to make brushing more efficient and easier on your joints.
- Floss daily to remove plaque and food particles located where brushing cannot reach, such as below the gumline.
- Rinse each day with an antimicrobial mouthwash to reduce bacteria and help prevent gingivitis.
- Visit your dentist or dental hygienist every six months for professional cleaning and a routine checkup.
- If you notice signs of gum disease, such as bleeding or swollen gums, see your dentist as soon as possible.
Updated by Lene Andersen.