See a Dentist to control your Rheumatoid Arthritis!

You must be wondering from the title as to what a Dentist has got to do with control of Rheumatoid Arthritis (RA)! In fact, he has a lot to contribute & this is known since the ancient times. Hippocrates had stated that removal of bad teeth cures arthritis. In 1818, Benjamin Rush stated that rheumatism can be cured by removal of infected tooth.
Edward C Rosenhow went a step further & showed that injection of apical granuloma from extracted teeth causes arthritis in rabbits.

Mark Bartold, a periodontist and the director of the Colgate Dental Research Centre at the University of Adelaide recently presented his group’s study of mice with preexisting periodontitis & RA at the annual European Congress of Rheumatology. His experiments showed that mice with coexisting periodontitis and RA exhibited more severe joint inflammation than did the mice with just RA. The progress of RA in mice with both conditions followed a more rapid course than it did in mice with just RA or just periodontitis.

What is periodontal disease? The word periodontal literally means ‘around the teeth’. Periodontal disease means infection involving the tissues around the teeth i.e. gums & bone around the teeth. Bacteria in the plaque cause infection of the gums. The bacteria settle down in the space between the tooth & the gum forming a pocket & even destroy the underlying bone.

Recent studies & research has shown that the bacteria involved in the periodontal infection can give rise to anti CCP antibodies & may trigger/ worsen rheumatoid arthritis. Mark Bartold’s work on mice is just one of the studies. Those with gum disease have been found to have a 2.2-fold greater risk of RA than did the general population. Gersuk, V. H. & colleagues studied 6616 subjects from the Olmsted County, MN. They were assessed for periodontal disease, RA & anti CCP antibodies. The study clearly showed that mild to moderate periodontitis is a risk factor developing RA. Periodontitis & smoking were found to be associated with anti CCP antibodies.

So then, how would periodontal infection cause anti CCP antibodies or joint inflammation? Porphyromonas gingivalis is a bacterium associated with a dental infection known as periodontitis. This bacterium produces an enzyme called Peptidyl arginine deiminase (PAD). It is hypothesized that this enzyme produced by the bacteria in the oral cavity diffuses into the blood & reaches the joints. It acts on various proteins & citrullinates them. Once in the joints, it may lead to increased citrullination of proteins in the joint. The body recognizes these ‘citrullinated proteins’ as ‘non-self’ & launches an immune attack. Immune cells produce antibodies to these citrullinated proteins i.e. anti-CCP antibody.

Now, would that mean taking care of periodontal infection takes care of RA as well? Yes, indeed. That must have been the reason why Hippocrates & Benjamin Rush stated that taking care of dental infections cures rheumatism. The ameliorating effect of minocycline on RA could be due to its antibacterial effect on the dental bacteria.

Dr. Nabil F. Bissada carried out an elegant study in RA patients on DMARDs & anti TNF biologics. A group of patients was treated for periodontal infection & was compared with the group that was not treated for the same. Non-surgical periodontal therapy was found to have a beneficial effect on the signs and symptoms of RA, regardless of the medications used to treat this condition.

Thus, if you have RA-
Brush your teeth and floss on a regular basis.
See a dental professional twice a year.
If gum disease develops, consult a Periodontist.
If you have a close relative with RA, oral hygiene & dental care is extremely important as dental infection may increase your risk of developing RA in future.

References:
1.Edward C Rosenhow J Dental Res 1919;1;205-265
2.Pre-existing periodontitis exacerbates experimental arthritis in a mouse model. Cantley D M, Haynes d R, marino V, P. Mark Bartold. Journal of Clinical Periodontology Volume 38, Issue 6, pages 532–541, June 2011
3.Molitor et al. Moderate to Severe Adult Periodontitis Increases Risk of Rheumatoid Arthritis in Non-Smokers and Is Associated with Elevated ACPA Titers: The ARIC Study” ACR 2009 abstract #1160
4.Periodontal Therapy Reduces the Severity of Active Rheumatoid Arthritis in Patients Treated With or Without Tumor Necrosis Factor Inhibitors. Bissada NF et al Journal of Periodontology. April 2009, Vol. 80, No. 4, Pages 535-540

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23 Responses to See a Dentist to control your Rheumatoid Arthritis!

  1. Rachel says:

    interesting…….

  2. Thanks, Dr. Akerkar,
    for this fine posting. I always enjoy reading your articles!

    “Periodontitis & smoking were found to be associated with anti CCP antibodies.” – Yes, that’s absolutely correct. And it is a very interesing fact that the RA pathomechanism in both “RA caused by periodontitis” and “RA caused by smoking” obviously can be put down to citrullination of native proteins, as you wrote in your recent blog post, Dr. Akerkar.

    That enzymatic modification of proteins actually leads to a change in the structure of the protein. This forms so called “neo epitopes”, which are falsely recognized as foreign by the immune systems of RA patients, and are attacked (“auto-immunity”!!!). These persons start to form antibodies against the altered proteins, which leads to the onset of the autoimmune disease called rheumatoid arthritis. Incidentally, these pathological autoantibodies are exactly the antibodies recommended as ACPA for the diagnosis of rheumatoid arthritis (the acronym ACPA stands for antibodies against citrullinated protein/peptide antibodies, or: anti-citrullinated protein/peptide antibodies). Regarding “ACPA as RA biomarkers”, see the The 2010 ACR-EULAR classification criteria for rheumatoid arthritis, part “B. serology”: http://www.rheumatology.org/practice/clinical/classification/ra/ra_2010.asp

    As these ACPA (anti-CCP, anti-MCV, anti-Fibrinogen …) can appear years before the onset of rheumatoid arthritis, some of these autoantibodies can be utilized in effective biomarker systems and as high-performance diagnostic tools for early (!) RA diagnosis as well as for diagnosing established rheumatoid arthritis – effective test assays provided, that goes without saying.

    On the other hand, this early ACPA detection years before disease’s onset demonstrates that the autoimmune disease is often in full swing by the time the first clinical symptoms appear. By this time, the disease is probably being sustained by completely differently processes and factors instead of citrullination. It is thus not certain whether “rheumatism can be cured by removal of infected tooth”, as Benjamin Rush reportedly stated in 1818. RA symptoms may improve by stopping cigarette smoking and by periodontal treatment – but it won’t be cured; at best, this debilitating disorder may be controlled. Despite all the immense progress in knowledge on this autoimmune disease, rheumatoid arthritis still is an incurable systemic illness and a chronic ailment.

    Best regards
    Tobias Stolzenberg

  3. Akil vohra says:

    hello sir
    i am 23 old guy and i also suffring from same disase i.e. R.A
    AND SAME MEDICINE GIVEN TO ME
    AND I FEEL WELL IN JUST 3 MONTH,
    BT NOW AFTER 3 MONTH I STOP TO TAKE MEDICINE
    AND I FEEL SMALL PAIN IN JOINTS IS CAME BACK AGAIN….
    WHAT SHOULD I DO???
    I AM REALLY SCARED….

    AKIL VAHORA,

  4. vishal says:

    What are the non-surgical used for periodontitis? I would like to take precautions right away!

  5. Gregory says:

    Hi, Very Impressive article. But i want to know some more details of Peptidyl arginine deiminase. If you have this please give the response for this comment.

    Gregory Moore
    benefits of l arginine

  6. Lorianna McARthur says:

    Hi, I woke on Sept 8th with pain in right wrist, it kept getting worse and moved to other hand. Went to dr and within two weeks was dx with RA.. My blood test showed RF above 500 and CCP antibodies of 180. There is now history of RA in my family anywhere. In fact most my family didn’t know what it was as I didn’t.

    However, there were two things that happened around this same time concurrently that I truly believe triggered my RA. The first being I quit smoking in on July 15th, 2011 after smoking for 20 years, just two months prior to dx. When I quit my bowels just seemed to forget how to work. I had major bloating and constipation. I did research and discovered that nicotine is a stimulant to the bowels and adrenalin gland. Thus I think explains why I had IBS symptoms. I also believe that there is a connection with RA and the IBS.

    Second, when dx I had a severe abscess tooth. I knew the tooth was bad, it had already had a root canal done and a temp filling in it. The temp filling fell out and I was waiting for dental insurance before I got it fixed so I knew I had a hole in a tooth that could get infected and ignored it. Well, it tooth z-pac antibiotics to kill the infection and I’ve since had the tooth pulled. At the same time there was another tooth hurting that was already root canal-ed. I had that re treated and in the process of getting a crown on it. For now no mouth pain.

    Anyway, I just had a hunch that the tooth infection was connected to my RA dx. In fact, I was hoping that once the infection was under control the RA symptoms would disappear. So far hat has not happened. I have not gotten blood work done since the infection has gone though either. My rheumy wants me on mtx immediately because he says from my blood work I have an aggressive form of RA and need to hit it hard. I can’t say I’m in total agreement with him. I think that yes I have it but because of the tooth infection at the time my RF and CCP factors were off the charts, therefore a lesser treatment might just work. I talked him into letting me try minocycline first before mtx. I will start minocycline in a few days.

    In the meantime my rheumy prescribed prednisone to relieve the inflammation and lessen my pain. He started me at 30mg and I’ve been weaning down since. I’m currently at 10mg in the am and 5 mg before bed and I woke this morning with very little pain. I was able to do aerobic exercise yesterday on my bike which I believe has helped with my RA pain also. I believe I’ve been progressively getting better. I know I’m taking the prednisone but I’ve been able to wean down. My rheumy says he wants me on mtx, he keeps reminding me that the prednisone is only masking the pain…lol.

    I’m going to share the references you quoted with my rheumy because so far he seems a great doctor and seems willing to try different things I want as long as if there is some kind of study done to back it up.

    I would appreciate any further information you have on the connection with tooth infection and RA. There does not seem to be enough information out there and my gut says there is a link.

    I would love to hear what you and/or Tobias think of my story because I truly think my instincts were right and if so that more people need to be made aware of this.

    Glad I found this thread.

    Thanks,
    Lori

    • Dear Lori,

      There is a definite link between smoking, tooth infection & RA.

      Your RA definitely seems to be aggressive given the high levels of anti CCP & the fact that it has involved both the hands in a span of 6 weeks. I am happy that it has been diagnosed really early.

      Diagnosing RA early is only half the battle won. It has to be treated with DMARDs in time. Your Rheumie is absolutely correct in suggesting methotrexate. Don’t give it a second thought. You should be on Methotrexate asap. You may like to read this blogpost to know what a difference it would mean. Minocycline & steroids are good, but not the mainstay of therapy.

      Please consult your Rheumie asap & go ahead with Methotrexate. All the best!

  7. Thank you for your quick reply, it just confirmed what I already knew I must do, get on mtx immediately.

    The only reason I’ve stalled is because mtx scares me, and I’ve heard it has such bad side effects. It seems such a harsh drug. However, I don’t know much about it and therefore need to do more research. I had a holistic doctor tell me that mtx ingredients are not man made is that correct? Also, what has been your experience with people on mtx and side effects are they as bad as I’ve read?

    • Despite all the developments & biologics, Methotrexate still remains the best drug for RA. Since its introduction, it has changed the prognosis of RAers & become the mainstay of therapy.

      It is definitely a safe drug in experienced hands. You may go through blogposts Focus on Methotrexate & Methotrexate: does it harm the liver? for information.

      Methotrexate is man made (but hoes does that matter??) You should go in for methotrexate asap. All the time wasted presently in decision making may haunt you later in the form persistent inflammation/ deformities.

      • Thank you, I actually called my doctor today and my husband picked it up. I will begin taking it Sunday morning. He has started me on 12.5 mg dose. I’m really scared to start even though I know I’m going to. The side effects page of the pamphlet is scary to read.

      • Great! All the very best! I sincerely wish that you conquer your RA.

  8. Shuvra Dey says:

    Dear Lori,
    It’s good that you’ve started methotrexate.I’m myself diagnosed with RA n have been taking methotrexate (15 mg) every week for the past one year.I’ve had no side effects so far whatsoever.I had been badly affected on my wrists.The pain n swelling has subsided tremendously.So I guess you shouldn’t have any second thoughts on taking mtx.My best wishes to you.

  9. Hi Shuvra, thank you for your post. I just took my first dose today and your post helped to quite my fears tremendously.

    doctorakerkar, I thank you also for all your information and references and for you spending your time to answer our questions. God Bless…it has helped so much.

    I will post to let you know how it goes.

  10. Juan Grez says:

    Great information, Dr. Akerkar, dental health related to RA (very new to me).

  11. Juan Grez says:

    Is it possible to translate some of your articles to spanish for the blog I keep?, with no modificatios in content and link to original post will be given.

  12. lmwillgetbetter says:

    Hi all, wanted to update and have a new question. I started MTX it did help but also my liver enzymes went up..my rhuemy made me stop and started me on Enbrel. I’m week 5 with Enbrel and so far its amazing. Still have some pain but it’s very tolerable mostly. However, I don’t know if this is just a bad allergy season or if the Enbrel is causing sinus issues. No infection yet but definitely issues. I’ve started doing sinus rinses every morning to help. Enbrel seems like it will work so I hate to quit because of the sinus issues…any suggestions besides the rinses I’ve already started.

  13. colin says:

    hi ive just ended up in hospital for three days because my shoulders became that painfull I had to go to ae where my temp went very high and I collapsed and ended up in the ward with drips etc
    doctor has referred me to rheumatoid doctor
    I have had problems with a tooth crown for about two years getting antibiotics where tooth inflammation would go away so hence just kept thinking that was me okay
    now since this has happened even tho my tooth was not painfull I went to dentist and said it was
    the dentist then started root canal treatment and the found pus inside the tooth which she said was dead, went back after a week for more treatment and in the final cavity she found more pus
    I said to her how is there poison inside my tooth even after all the antibiotics I had in hospital she said the only way it could get out was through the bone
    I know this isn’t very scientific but im pretty certain that this is the cause of my problem ie after all the time this tooth was like thisi think my immune system had just had enough
    hope this can help anybody doing research rather than just saying they don’t know the cause of RA

  14. Dollie says:

    Thank you, I have just been looking for info about this topic for ages and yours
    is the greatest I have discovered till now.

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