Rheumatoid Arthritis and Oral Health

4 min


It is an autoimmune disease causing chronic inflammation and pain in the bone joints of the body.

The symptoms can vary from mild to severe. It usually affects the joints on both sides simultaneously. Early diagnosis helps in management throughout life.

One can walk in for a consultation with the physician when they face the following symptoms & signs:

SIGNS & SYMPTOMS OF RHEUMATOID ARTHRITIS:

  • Joint pain.
  • Joint swelling.
  • Stiffness of the joints.
  • Reduction in the range of the movement.
  • Tenderness of the muscles surrounding the joint.

It is more frequently reported for occurring in women with no preference to age.

Though it is not a hereditary disease it can run in families due to genetic or environmental triggers.

Bacterial infections associated with periodontal diseases & Epstein Barr virus is also considered as a risk factor.

Any fracture or trauma of bone will cause delayed healing, dislocation of bone or damage of joint.

Lifestyle habits like smoking and obesity have a certain influence on the occurrence of rheumatoid arthritis.

The management of the disease is mostly based on reducing the pain and inflammation thereby limiting the exacerbation of the disease progression.

RHEUMATOID ARTHRITIS & ORAL HEALTH:

Rheumatoid arthritis works on the mechanism of accumulation and infiltration of the pro-inflammatory cells in the synovial membrane (the inner surface lining of a synovial joint of the bone) causing inflammation and impairment of the joint.

In a severe stage of RA, it has some effect on the temporomandibular joint. The impairment of the jaw, hands & feet joints might affect oral hygiene causing the following oral manifestation.

ORAL MANIFESTATIONS OF RHEUMATOID ARTHRITIS:

  • Loss of gum attached to the teeth.
  • Periodontal diseases.
  • Loss of teeth.
  • Loss of alveolar bone.
  • Bilateral flat Condyles.
  • Temporomandibular joint involvement.
  • Decreased salivary flow.

Periodontal diseases:

The stiffness and immobility of the joints lead to difficulty in brushing causing a poor oral hygiene status.

This causes plaque accumulation and increased inflammatory cell response on the gum tissue. This leads to bone loss with attachment loss.

In severe cases, infections and swelling of the gums are evidenced. The increase in plaque accumulation leads to increased bacterial activity and shifts if the oral environment into acidic causing erosion of the teeth and tooth decay.

Temporomandibular joint (TMJ) involvement:

In the due course of the disease, it affects the temporomandibular joint also causing a granulomatous structure (it is composed of the immune cells) to cover the joint causing the destruction of the underlying bone.

The involvement of the TMJ is characterized by the following changes in the joint:

  • Erosion of the bone joint.
  • Flattened bilateral Condyles.
  • Sclerosis of the joint (abnormal stiffening of the body tissues).
  • Cyst formation in the TMJ joint capsule.
  • Osteoporosis (brittle bone).

These signs are usually accompanied by upper respiratory tract obstruction.

Salivary impairment:

The decreased salivary flow is a feature identified in half the population affected by rheumatoid arthritis. This is can lead to the following possible outcomes:

  • The shift in the oral microbial environment.
  • Inability to speech.
  • Soreness & burning sensation of the mouth.
  • Increased tooth decay.
  • Difficulty in chewing & swallowing.
  • Denture instability.

MANAGEMENT OF RHEUMATOID ARTHRITIS:

The main goal in treating rheumatoid arthritis is to reduce the inflammation and pain in the joint. They are followed by prescribing & suggesting the following:

  • Pain relievers and anti-inflammatory drugs.
  • Corticosteroids act as both Pain relievers and anti-inflammatory.
  • Anti-rheumatic drugs. (DMARD’s).
  • Antioxidants intake, a diet rich in omega 3 fatty acids & fibers.
  • Exercises to restore mobility and function.

For the management of oral health in RA one should adhere to the following:

  • Frequent dental visit.
  • Update the general health status to the dentist.
  • Evaluation of oral health before treatment planning.

PRE-TREATMENT INTERVENTION:

It is best to evaluate the medication status of the individual before planning a surgical intervention.

As they are under corticosteroid therapy achieving hemostasis is quite difficult. Replacement therapy is necessary to swap the steroids.

Prophylactic antibiotic therapy is indicated before a surgical intervention to avoid exacerbations.

ORAL HEALTH MANAGEMENT:

American dental association (ADA) suggests the replacement of the TMJ joint in severe RA after considering the corticosteroid intake and infections.

A prophylactic dose of antibiotics is always suggested before the extraction and surgical replacement of the joints in rheumatoid arthritis.

They are maintained under frequent evaluation for any cross-reactions of the drugs. The regimen is evaluated for effectiveness & side effects. They are advised to maintain good oral hygiene.

RHEUMATOID ARTHRITIS & DENTAL IMPLANTS:

Rheumatoid arthritis is not a contraindication for dental implants if the dentist can achieve the following in them during and after the placement of a dental implant.

  • The RA must not be associated with connective tissue diseases.
  • Must not be under long-term corticosteroid therapy.
  • Poor oral hygiene.

Dental implants in RA have a good survival rate with proper hygiene maintenance and frequent follow up.

In rheumatoid arthritis associated with connective tissue disease, there is marked bone loss causing increased chances of peri-implantitis after the dental implant placement.

Long-term intake of steroid therapy makes it difficult for attaining hemostasis and healing of the tissue causing failure of the dental implants.

Poor oral hygiene is an indicator of a lack of compliance from the patient or increased oral microbial activity. Hence is considered as a relative contraindication to dental implants if the dentist cannot achieve the above.

REFERENCE:

  1. Pischon, N., Pischon, T., Kröger, J., Gülmez, E., Kleber, B.‐M., Bernimoulin, J.‐P., Landau, H., Brinkmann, P.‐G., Schlattmann, P., Zernicke, J., Buttgereit, F. and Detert, J. (2008), Association Among Rheumatoid Arthritis, Oral Hygiene, and Periodontitis. Journal of Periodontology, 79: 979-986
  2. RHEUMATOID ARTHRITIS: A REVIEW AND SUGGESTED DENTAL CARE CONSIDERATIONS, TREISTER, NATHANIEL et al.The Journal of the American Dental Association, Volume 130, Issue 5, 689 – 698
  3. Krennmair, G., Seemann, R. and Piehslinger, E. (2010), Dental implants in patients with rheumatoid arthritis: clinical outcome and peri‐implant findings. Journal of Clinical Periodontology, 37: 928-936

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Dr Arun

Dr. Arun is a practicing dentist with more than 11 years of experience. Loves to blog and in constant search of new knowledge in dentistry and health niche.

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