Rheumatoid arthritis is known to affect joints, connective tissue, internal organs, and cardiovascular system, but did you know that RA can also affect oral health? RA patients 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).
Approximately 10-15% of the RA population 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 patients with Sjogren’s may also experience painful swelling in the saliva glands around the face. Dry mouth can be relieved by drinking water, chewing gum, or using saliva substitutes. Some patients benefit from using prescription medications that stimulate saliva flow, such as pilocarpine (Salagen) or cevimuline (Evoxac). If patients develop yeast infections, these can be relieved by anti-fungal therapies.
Patients taking methotrexate may develop mucositis (inflammation of mucous membrane) leading to oral ulcerations, however the risk of mouth ulcers is dose-dependent. Folic acid supplementation helps to reduce the risk of mucositis. Patients should be aware that drugs, 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 sedation, 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.
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, which is generally reversible with proper treatment and improved dental hygiene.
Periodontal disease is characterized by disease progression beyond gingivitis 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. 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 RA patients with periodontal disease had less improvement in rheumatoid arthritis disease activity with 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 RA patients.
What can I do?
During a rheumatology appointment today, my doctor shared that in the early 1900’s, it was common practice to pull the teeth of people living with RA. Dental care was not nearly as sophisticated as it is today; many people had "bad" teeth to begin with and the risk of infection was great. Fortunately, in modern times, we try to keep our teeth for as long as possible and do not have to go to such extremes to treat RA. But knowing that RA patients are at increased risk of periodontal disease, we should do everything we can to protect our oral health.
Following a regular routine for dental care will help protect you against oral disease, and perhaps improve your RA symptoms as well.
- Brush with a soft bristle toothbrush for two minutes, twice each day, and replace your toothbrush every 3 months. Try an electric toothbrush to make brushing more efficient.
- Floss daily to remove plaque and food particles located where brushing cannot reach, such as below the gumline.
- Rinse each day with an anti-microbial mouthwash to reduce bacteria and help prevent gingivitis.
- Visit your dentist or dental hygienist every 6 months for professional cleaning and routine checkup. If you notice signs of gum disease, such as bleeding or swollen gums, see your dentist as soon as possible and follow the recommended treatment plan.
Bingham CO, Moni M. Periodontal Disease and Rheumatoid Arthritis: The Evidence Accumulates for Complex Pathobiologic Interactions. Curr Opin Rheumatol. 2013;25(3):345-353.
Deeming GM, Collingwood J, Pemberton MN. Methotrexate and oral ulceration. Br Dent J. 2005 Jan 22;198(2):83-5. doi:10.1038/sj.bdj.4811972
Detert J, Pischon N, Burmester GR, Buttgereit F. The association between rheumatoid arthritis and periodontal disease. Arthritis Research & Therapy 2010, 12:218 doi:10.1186/ar3106
Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic Disease Caused by Oral Infection. Clin Microbiol Rev. 2000 October; 13(4): 547-558.
Maresz KJ, Hellvard A, Sroka A, et al. Porphyromonas gingivalis Facilitates the Development and Progression of Destructive Arthritis through Its Unique Bacterial Peptidylarginine Deiminase (PAD). PLoS Pathog 2013; 9(9): e1003627. doi:10.1371/journal.ppat.1003627.
Savioli C, Ribeiro AC, Fabri GM, et al. Persistent periodontal disease hampers antitumor necrosis factor treatment response in rheumatoid arthritis. J Clin Rheumatol. 2012 Jun; 18(4):180-4. doi: 10.1097/RHU.0b013e31825828be.
Treister N, Glick M. Rheumatoid arthritis: a review and suggested dental care considerations. J Am Dent Assoc. 1999 May;130(5):689-98.
University of Louisville School of Dentistry (September 12, 2013). Bacteria responsible for gum disease facilitates development and progression of rheumatoid arthritis [Press release].
National Institute of Dental and Craniofacial Research (NIDCR). Periodontal (Gum) Disease: Causes, Symptoms, and Treatments. Accessed February 4, 2014.