Rheumatoid Arthritis and Periodontal Disease
Does gum disease have anything to do with Rheumatoid Arthritis?
Some of the popular studies presented at the ACR meeting last November examined the relationship between periodontal disease and Rheumatoid Arthritis. Is there a relationship? And what is it?
Over the last few years, it has been shown that RA patients are more likely to have gum inflammation. That makes sense: we can have eye inflammation, joint inflammation, inflamed organs and veins… But when we notice correlation, we want to know which comes first – the chicken or the egg?
You have probably seen one of the articles flying around the web over the last few months touting the association between Rheumatoid Arthritis and periodontal disease so I’ve wanted to bring the story to you. Various studies claim that either one leads to the other. One claimed that treating gum disease relieves RA symptoms. I’ve been trying to figure out exactly what the explanation is so that I could give you the facts. I don’t think it’s perfectly clear yet, but here is a fascinating theory.
Prominent rheumatologist says periodontal disease may trigger Rheumatoid Arthritis
According to Dr. Gerald Weissmann, who spoke at ACR, the connection between Rheumatoid Arthritis and periodontal disease may be thus: “Perhaps the humoral response to oral bacteria provides a stimulus for the development of Rheumatoid Arthritis. How might that happen? …namely citrullinated proteins.” He continues: “Autoimmunity to specific citrullinated proteins gives the first clues to the etiology of Rheumatoid Arthritis.”
Weissmann outlines the recent wave of clues regarding periodontal disease as a trigger for Rheumatoid Arthritis:
- “Antibodies to citrullinated alpha-enolase peptide 1 are specific for Rheumatoid Arthritis and cross-react with porphyromonas gingivalis enolase.” Lundberg K., Kinloch A., Fisher, B.A., et al. Arthritis Rheum. 58: 3009-19 2008.
- “Associations of P. gingivalis titers with RF, antiCP suggests that infection with this organism plays a role in disease risk and progression in RA.” Mukuls TR, Payne, J.B., Reinhardt, R. A. et al Int. Immunopharmacol. 9:38-42 2009.
- “Antibodies to Porphyromonas gingivalis are Associated with Anticitrullinated Protein Antibodies in patients with Rheumatoid Arthritis and their Relatives.” Hitchon et al J Rheumatol 37:1105-1112 2010.
Note: You can read abstracts from the ACR meeting which discuss Rheumatoid Arthritis and periodontal disease at this link on the ACR site. There are a few relevant abstracts there. It is a searchable PDF, so you can search “periodontal” to find every mention.
RA patients at risk for periodontal disease because of our fingers too
Some of us find daily gum care very difficult. We might need special tools to help with flossing and brushing. A water-pic type tool is a good idea.
Here’s what WebMD says about gum disease and Rheumatoid Arthritis: “People with rheumatoid arthritis (RA) are eight times more likely to have gum disease than people without this autoimmune disease. Inflammation may be the common denominator between the two. Making matters worse: people with RA can have trouble brushing and flossing because of damage to finger joints. The good news is that treating existing gum inflammation and infection can also reduce joint pain and inflammation.”
Bottom line on periodontal disease and Rheumatoid Arthritis
Something triggers RA – possibly more than one thing. Smokers are more likely to get RA. Maybe that makes sense if smoking increases oral bacteria or weakens something else in the mouth. Sjogren’s is also associated with RA and dry mouth also leads to more gum disease. And yet, there are RA patients with healthy gums and many who have gum disease who do not develop RA. It’s obviously not simple – especially when we consider that infants without teeth develop forms of this disease.
Recommended reading:
- The Rheumatoid Arthritis Commercial Saga
- The Future: Predicting Rheumatoid Arthritis Severity
- Rheumatoid Arthritis and Pregnancy
Goodmorning Kelly..Some great new things your sending our way! A big Thank You!! My thoughts on the gum disease…I believe its all related to our bodies. Yrs ago when mine came out of remission,my teeth were going bad! I had to act fast to save them! But i did! My dentist worked with me on different things and i was able to get rid of the disease! Our bodies are one! So what plays on one part affects the whole body..Very important to have healthy pink gums! Doctors are now associating gum disease with heart trouble..Its all connected! One Body! So floss those pearly whites Folks…
The problem existing because we can’t use our hands, makes a lot of sense to me. I remember, almost 5 yrs ago, asking my husband to please buy me a “spinning” toothbrush because I could no longer use a regular one and brush my teeth. I also think those of us on MTX have a problem with it as well, because of the side effects of MTX. (I could be wrong.)
Ugh I just wrote a whole response and it got deleted!
I’m too tired to rewrite the whole thing, this was my point:
I just wanted to thank you for posting this and especially for including the underlying information that leads to the potential conclusions for RA patients. I don’t have RA but have diseases in the same general family, and because of the information you included I can consider 1) can I do something to reduce my chances of developing RA and 2) might periodontal disease have similar implications for the activity in my own diagnoses. One of my conditions is Sjogren’s Syndrome, which has caused me extensive dental and oral problems already, so this is really something I think I should spend some time considering. Thanks!!
YES!! Its about time someone picked up on this! I swear my RA was triggered by an abcessed tooth! Has anyone here ever read anything about “toxic tooth”? It was mentioned to me by a friend, so I googled it and was blown away! Really makes you think.
Thank you for this informative post, Kelly.
In my own case, my dentist first noticed periodontal disease about a year after I developed RA. I have visited the dentist twice per year for my entire life, and have always practiced excellent oral hygiene. Imagine my surprise during a recent visit for a cleaning when my dentist proclaimed that I had developed deep pockets in many of my gumline areas. I am now forced to undergo a deep root scaling/cleaning procedure, which makes me cringe at the mere mention.
In my own experience, the theory of periodontal disease being caused by reduced ability to perform dental hygiene is not the case, since my hands are one of my least painful areas (in comparison to my feet, hips and SI joints). I typically do not have difficulty holding objects, opening jars, etc. Thankfully, my dental hygiene practices never suffered as a result of RA. I know that I am lucky in this regard and that others struggle greatly with this.
I guess its the “chicken or the egg” debate, isn’t it? Does RA cause periodontal disease or vice versa? In my experience, the inflammation from RA is systemic and has caused strange manifestations in many seemingly unrelated areas. If I had to make a semi-educated guess, I would say that RA leads to periodontal disease, not the other way around. I’m definitely interested in reading the research on this important topic.
Thanks again Kelly!
Thanks for the article Kelly! I personally believe that RA causes periodontal disease. I had been known all my life for my smile, so I always made sure that it stayed healthy. I was diagnosed a little over a year ago with RA but the docs believe I’ve had it for many years. I think I went into a major flare which enabled me to get my diagnosis. I say “major” only to differentiate from the previous 10 years of constant pain. In April of last year, after trying Plaquenil and then Methotrexate, I was having horrendous gum inflammation. Imagine how I felt when one day while sitting at the computer, 3 of my teeth just fell out! In the next few days, 6 more. By the end of April I had lost all my teeth and had to get dentures!. It has been a horrible struggle for me adjusting to them since I continue to have really bad inflammation and gum sores. None of my doctors agreed with the correlation between the RA and the loss of my teeth! Still today, I constantly fight with the docs to help me ease the inflammation. They insist on prescribing “magic mouthwash”, which in itself is nice for about 10 minutes, so long as I don’t put the dentures in. The chemicals in the mouthwash change the consistency of the denture glue and cause it to crystalize, and therefore, it doesn’t hold. Plus the crystalization sticks to my gums and causes more inflammation. UGH!!! I was taken off Methotrexate and moved on to Arava briefly. Thursday I took my fourth injection of Enbrel, which by the way also has the side effect of gum inflammation and mouth sores. So far no good results from the Enbrel and I’m still fighting with the docs for some remedy for the gum inflammation.
I realize that I’ve rambled off slightly from the original topic but, I feel that my personal experience may help others to know they are not alone, if they have similar problems.
It does seem that the chicken or the egg may be the culprit. but I’m hoping more doctors begin to understand the correlation in either direction! I will look forward to more study results on this topic.
Thanks a million Kelly!
There are dental Periodontists who treat periodontal disease. It may be worth visiting one if you have the money. Some specialize in a newer treatment where they place or inject antibiotics directly into the gums I believe. This might be something you need Trish. Also, can you get those new dentures that are held in place by metal posts put into the jaw? You might need bone implantation for that but it may also be a possibility.
Let’s also add to that narcotic pain meds can dry the mouth, changing the biology of the mouth, making it more prone to gum disease and cavities. The worst 5 dental years of my life were when I was off NSAIDs due to an internal bleed and on heavy narcotics for pain. I ended up with multiple root canals, crowns, cavities, and gum issues.
Also, fatigue is my issue with dental care. I’m exhausted a lot and the thought of getting up after resting in bed for awhile and sticking that buzzing Sonicare in my mouth is always a struggle.
Kelly, please read this press release from the ACR: http://www.rheumatology.org/about/newsroom/2010/2010_the_body_against_itself.asp
“THE BODY AGAINST ITSELF: BACTERIA INSIDE ONE’S OWN BODY LINKED TO RHEUMATOID ARTHRITIS AND OTHER AUTOIMMUNE DISEASES ”
It addresses both oral and intestinal bacteria, so studies in this area will hopefully help babies as well as adults.
Here is the clinical trial:
http://clinicaltrials.gov/ct2/show/NCT01198509?term=Rheumatoid+Arthritis&rank=1
“Role of Oral and Intestinal Microbiota in Rheumatoid Arthritis (RA)”
Thanks, Suzanne. I was at that press conference! 🙂 How cool is that?
This was the first opportunity I’ve had to go back to Dr. Weissmann’s talk & transcribe what he said about how the bacteria of periodontal disease may be an RA trigger. I’ve gotten a lot of good feedback on this post since it’s a hot topic. I guess maybe it gives people hope that it could lead to answers.
I know that it gives me hope! Imagine if they could test you for the oral and/or gut bacteria, and if you were positive, treat you appropriately – that is what has happened with stomach ulcers and h. pylori.
EEK!
This really reminds me that I need to go to the dentist LOL
Thanks for the info….
Heather Moran
Eventually, I will get to the link between gums and RA – honestly.
I first developed RA 23 years ago in my early 30s. My symptoms were bad enough to stop me playing sport (badminton). It took about a two years to get medication to stem the pain and stiffness and after about 8/9 years i weaned myself off medication completely. I was well. I had not visited the dentist from age 14 when I had a crown fitted. I had an abcess above the crown at about age 28 which was cleaned out and packed. In all, over the next 15 years the abcess returned twice more. My remission lasted until I was 50 and I was aware of the signs so immediately went back to my rheumatologist to try some early intervention. It didn’t work and I got worse and worse over the next 18 months. During this period I was taking the same meds (Salazopyrin) as before hoping the same remission pattern might follow – but no. The stiffness, swelling and pain was kept at bay with Kenalog injections every 4 months or so. Those of you who have had these injections may know well the feeling of of euphoria when the drug kicks in. Without a word of a lie, I had the same result on two occasions from using an interdental stick. It only lasted a day on the first occasion and 4 or 5 hours the second time – but I could actually feel the swelling reduce in my hands over a 30 minute period. I think each time I burst a little abcess between two of my teeth – causing a little bleeding. My oral hygiene isn’t perfect and I can’t repeat this effect at will – but there must be some kind of link. My mum told me of a lady who’s RA symptoms stopped when she had all her teeth removed. I know it’s a ramble but may be of interest. My rheumatologist does not believe there is a link.
As a dentist, the relationship between periodontal disease and RA is, like other relationships between periodontal disease and other health issues, in the very early stages of research. We have known the relationship between periodontal disease and cardiovascular disease is real and significant.
As I have just recently been diagnosed with RA, these topics interest me greatly.
It is my opinion that RA is triggered by one or several events that initiate the inflammatory response in our bodies. As I have read the stories of others and review my own history, I can see the very early symptoms of RA expressing itself intermittently following periods of stress (physical or emotional). The bodies response to the trauma of stress triggers an inflammatory response to heal that trauma. What I have experienced is that the inflammatory response is the trigger for expression (flareup) of RA. When a certain threshold is reached (everyone has a different threshold) the RA becomes permanently expressed. Like flipping a switch. Once turned on completely it becomes like a dimmer switch, which can only be increased or decreased, but not turned off. Why it cannot be turned off at this point in time, is for future research.
Periodontal disease, as we understand it, is episodic in nature. This means it will be quiet for months or years, then take a turn and cause bone and tissue damage quite rapidly over a very short period of time. In this way, it is like RA with periods of flareup and remission with the bone damage occurring most rapidly during the flareup periods. I would suspect that it is during the aggressive periods that periodontal inflammation could be of sufficient quantity to trigger the immune response required to “flip the RA switch”. Once the switch has been flipped, the RA responds to the periodontal inflammation and makes it worse inherently, and also makes it difficult physically to take proper care of the periodonium to prevent more inflammation. For those patient who have both RA and periodontal disease, the dental health professionals are an important part of the healing process. More frequent recall visits, improved home care using a variety of tools (floss aids, proxy brushes, ultrasonic tooth brushes, oral rinses such as peridex or gum tonic, tooth picks, etc.) are all part of the regimen to help people who have difficulty with manipulating dental home care aids. I am not a big fan of the water pik as it does not significantly remove plaque which has attached to the tooth or root surfaces. Mechanical disruption of the plaque is necessary for its removal.
Good luck to all of you with a diagnosis of RA. This is just one more reason to have a good dentist and dental team who are aggressive in diagnosing and treating periodontal disease.
Warm regards,
David H. Roholt, DDS
I have just finished spending 4,000.00 Dollars on my red swollen gums. Now l must go as often as every 3 months for check-ups. I have had RA for 15 years but have never been told what kind I intend to find out because of your blog. Thanks for relating all the things you know Kelly, it has changed my life. Can you comment on The Mayo in Florida for a Rheumatologist. I am a Green Cove Boater for 6 months.
I’ve seen mixed reviews, but you can see where they are on this list here.
A friend forward me this blog.
I am an APer so, of course, I see everything from the microbial point of view.
I am somebody who has always said that my PRA/RA started with dental work because the dentist left something in there. I even went back to him and told him that but was told I was ‘wrong’ and that ‘dry socket’ infection I got was over and not the start of my Road to RA.
Most people are looking for a single causative factor in the onsets of these diseases. Not possible. Microbes work together and ‘swap spit’ as need be. This is why we see both viruses and bacteria linked to the onsets. What happens is that when they happen at the same time the resulting ‘disease’ is more virulent. Hence ‘systemic’ disease.
This is an example study on dendritic cells – antigen presenting cells. I’ve seen similar studies for RA and just about any other AI disease you can think of.
http://www.biomedcentral.com/1471-2334/11/201/abstract
I also don’t think there is any difference between people who have RA, and those with Lupus, or those with Crohns. It’s not a different disease…it’s a different MANIFESTATION of the SAME disease…in this case intracellular infection. Genes aren’t all that.
So, why the hubbub about these new ACR studies?
Because they’re thinking this may be the ‘magic bullet’ and maybe we can cure this disease. But over the next few years they’re going to find people without p. gingivalis and say, ‘darn, we were so close’.
Because like most researchers, they are not looking ‘whole body’ but are instead searching one ‘neighborhood’. In this case, the mouth. Not realizing the GI tract has a greater chance of producing the cure.
Remember, a few months back, they proved that there are only 3 types of gut systems. And those 3 types use different B vitamins. So, like Suzanne said, if your culprit CWD bacteria is p. acnes (not p. gingivalis) and they can readjust your gut bacteria (taking into account the HPA axis/stress somebody mentioned) than in theory it is quite possible to cure these diseases.
Those interested should research Cell Wall Deficient Bacteria and/or mycoplasma in RA.
That being said, I’m am currently recuperating from major dental surgery. About a 1 1/2 years ago, using CAM, I managed to bring those ‘toxic pockets’ of bacterial waste to life. Unfortunately, I had to delay dealing with the surgery because my husband was hospitalized. By the time he was better, I began to lose my 4 1/2 year RA remission. Mostly it was my jaw.
I developed pain in my bones and was diagnosed with osteonecrosis. Which really is awful because I wasn’t any where near biphosphonates and wouldn’t have touched them for the world.
By X-ray, there was nothing wrong with me. Every DDS I’d ever seen said there was nothing wrong with me. But I knew there was something in there and it was following that nerve into the body and it burned.
I had ‘alternative x-rays'(Pana and Cavitat) which alternative DDS’s said showed pockets and which Traditional DDS’s said ‘showed nothing’.
I researched, chose one of those wacky alternative dentists and had the surgery. Why? Because I was tired of all these supposed experts telling me there wasn’t something in there when I could feel it.
My husband was concerned. We have a lot of expenses because of his hospitalization. He just wanted to be sure I knew what I was doing because while he believed in my research-ability, this was a huge step for something I couldn’t ‘prove’.
Which I also think is pretty funny now that he has RA too and is on AP. LOL
So, I go have the surgery and the wacky alternative doc lets hubby watch.
I wake up and hubby is all excited – you were right, your jaw was crumbling, I saw it!!!”
Too bad a traditional doc couldn’t.
Pip
I have kind of a long story. I am now 57 years old. At about 27 or 28 years old I was diagnoed with periodontal problems. My Dentist and I did everything we could. I went peridonists, had my teeth cleaned every three months for years. It could never be halted. All my teeth dropped out, one by one. One bridge after another. I now have a mouth full of implants, no natural teeth at all. Honestly, with all that dental work I am glad they are gone!! I my thirties I had symptoms of Crohn’s, but was never really treated. It just went away after a while. This year, 2011, I was diagnosed with RA. My theory is that my immune system went haywire in my mid twenties. I do have one Aunt that died of lupus when she was 29 years old.
I’m so thankful for your website. I have had some form of all-over body pain since I was a teenager, but it was tolerable and I thought little of it. In my late twenties a doctor told me (after a lot of tests) that I could very well have fibromyalgia. I thought nothing of that either and would have forgotten it until this year.
This year (I’m 36) I went and got my teeth cleaned for the first time in 10 years (don’t judge.) The dentist used some kind of ultrasonic (??) device to clean the plaque off my teeth and I knew it then that something was wrong. I could taste it going down my throat. Anyway, within the next month I could barely walk. The pain in my feet and ankles was so intense. And then the pain in my knees started. And then I couldn’t even lift the kettle without using both hands. I went for tests and while I haven’t been able to see the rheumatologist yet, the blood work points to RA (high ccp and rf.)
I think the dentist woke up something that was co-existing in my mouth quite happily until something tried to wipe out its habitat. Maybe. At this point I do believe there is a connection.
This is a very interesting read- I had two inflammed root fillings for about 8 years- always being told that they were ok- especially the one that was discharging a blister type infection about once a month! I eventually found a dentist who agreed that they were better taken out, but this was not done as it could have been. Three weeks later I developed Palindromic Rheumatism. Five years later this went to Rheumatoid disease.
I am absolutly positive that these inflammed Root fillings, also affecting the gum, were the cause of my disease.
Patricia NZ
Thank you so much for this article Kelly!! I just wanted to add my experience with periodontal disease. I was diagnosed with RA in April of this year, after I had my first flare in my post partum period, about 4 weeks after my 3rd baby was born. I have had gingivitis since I was pregnant with my first child 9 yrs ago. I was told My by dentist at the time,that I developed periodontal disease due to hormones from pregnancy. (based on what I know now, I’m not 100% sure… Like Kelly said, chicken or the egg??) I have never had a cavity, and always had routine dental care so this was scary and surprising for me! I have been treating it for 8 yrs but can not ever get ahead. During my last cleaning, the dentist commented on my new RA diagnosis and said there is a link between RA and periodontal disease. When I told my Rheumy that I had periodontal disease he said the same thing!! So who knows If one caused the other, either way I’m another prime example of the link between the two.
Thanks for this info Kelly.
In Australia, there is a medicare programme for free dental care for people with chronic disease, as long as your GP signs off on it. Mine wouldn’t sign off without some evidence of a link between RA and the need for dental care – and you’ve given me just what I need.
Cheers
Craig
This is the case with so many aspects of RA disease – doctors and insuring programs are unaware of the fact that “arthritis” is only one symptom and many parts of the body can suffer. Glad this study will help you. This is why we are changing the name of the disease to “disease” instead of “arthritis.”
All I know is a back tooth cracked and had a root canal and the dentist drilled into my sinus, bc some back teeth are in the sinus cavity and he broke all the bone in my sinus…he was a terrible doctor….if I was not so young I would have known better that when you have a root canal you never bleed…a ct scan prior and after the root canal showed the damage he did….therefore, before the tooth I was perfectly healthy…after that tooth the RA and SLE came into play…The tooth had to be pulled 15 years later and the gum was always red around the cap….should have hired an attorney and took a better law class in college!
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