Although compelling data exist to support a link between periodontal disease (PD) and the development of rheumatoid arthritis (RA), cementing the association will require extensive investigative work.1 However, in reviewing the literature of the past 10 years, Elliot D. Rosenstein, MD, director, Institute for Rheumatic and Autoimmune Diseases at Overlook Medical Center, Summit, N.J., and colleagues were able to draw some conclusions.
It has long been known that patients with active RA demonstrate significantly increased frequency and severity of PD, as well as tooth and alveolar bone loss. “Several recent studies have substantiated that PD may be present in patients with RA early in the course of disease,” Dr. Rosenstein says.2,3 “The presence of PD or, at least the organism responsible for it and the development of antibodies to that organism, have been linked with more severe RA.”
Dr. Rosenstein has surmised that properly treating PD would have a favorable impact on RA, diminishing the intensity of joint inflammation and making patients more responsive to employed therapies.
“This is supported by the fact that nonsurgical periodontal treatment of patients with moderate to severe PD can reduce levels of several inflammatory mediators that contribute to the activity of RA,” Dr. Rosenstein says. “Meanwhile, the response of RA to treatment with anti-tumor necrosis factor therapy (anti-TNF) (e.g., medications, such as etanercept, infliximab) can be blunted by the presence of PD, whereas those patients who had been treated showed better responses.”
In addition, patients destined to develop RA can often now be identified by their antibody profile and other laboratory parameters. “The connection between gum disease and RA offers the potential to not only identify these patients early in their disease, but to offer potentially therapeutic interventions at a time that an impact can likely be had on its ultimate course,” Dr. Rosenstein says.
Recommendations in 4 Areas
Based on this evidence, Dr. Rosenstein and colleagues would advise rheumatologists to make practical recommendations to patients with RA in each of the following areas.
Take fatty acid supplements: Supplementation with borage seed oil as a source of gamma-linolenic acid and fish oil for eicosapentaenoic acid and docosahexaenoic acid has been shown to improve outcomes in RA patients by decreasing the need for anti-TNF use, improving the response to standard therapy, and achieving a higher rate of clinical remission. Similar benefits have also been shown in the treatment of PD.4