RA Therapies and the Effect on Oral Health and Periodontal Disease

Both disease modifying anti-rheumetic drugs (DMARDs) and anti-tumor necrosis factor alpha (TNF-α) have anti-inflammatory effects and are used to treat RA, although their effects on local periodontal inflammatory mediators have demonstrated inconsistent results.72 A recent study has demonstrated patients with chronic periodontitis demonstrated significantly less improvement in rheumatoid clinical parameters including DAS, erythrocyte sedementation rates (ESR), and C-reactive proteint (CRP) levels than periodontally healthy patients with RA when treated with anti-TNF-α blockers.75 It is postulated the increased systemic inflammation due to periodontitis may dampen the effects of this therapy.76 Patients with a history of periodontal disease who were initially treated with a TNF-α blocker were also more likely to discontinue the drug than those without periodontal disease.77

RA symptoms may also be treated with steroid and non-steroidal anti-inflammatory drugs (NSAIDs). NSAID anti-inflammatory medications have shown an adjunctive benefit in reducing overall signs of periodontal inflammation in patients with periodontitis.78-81 Of particular interest, smokers and other subjects with increased inflammatory burden demonstrated improved treatment outcomes.82 Chronic corticosteroid stimulation, conversely, has been linked to an increased susceptibility to periodontitis.83,84 In patients with RA who are taking these medications for treatment of their arthritis symptoms, consultation with their rheumatologist or treating physician is critical to achieve optimal and safe results from therapy.

The use of many anti-rheumatic medications also poses a risk to patients undergoing treatment, as some patients may experience decreased immune response and higher infection rates.85 Furthermore, the effectiveness of some DMARD and anti-rheumatic drugs may change based upon RA disease activity and patient age.86,87 As these may affect the ability of the patients to undergo invasive periodontal therapy, consultation with each patient’s rheumatologist or treating physician and careful assessment of the risks and benefits to treatment should be performed.