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Relationship Between Periodontitis and

Rheumatoid Arthritis

P. Mark Bartold

Colgate Australian Clinical Dental Research Centre

University of Adelaide

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ENVIRONMENT

HOSTRESPONSES

GENETICS

AETIOLOGY

PERIODONTAL DISEASES

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PERIODONTAL DISEASES

ARE

ECO-GENETIC DISEASES

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May 2000, the Surgeon General the United States of America

Oral Health and general

health should notnecessarily be dissociated

as in the past.

In the interests of an

holistic approach to patient

care oral health must be

considered as a critical

issue for general well-being.

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AtherosclerosisAtherosclerosis

MIMI

PTLBWPTLBW

Periodontitis

DiabetesDiabetes

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PERIODONTAL MEDICINE Changing paradigms for Periodontics

Systemic disease modifies periodontitis

Periodontitis may affect systemic

diseases Interrelationships between periodontitis

and other diseases

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Periodontitis Chronic inflammation

Immunoregulation imbalance

Initiating bacterial

peptides/antigens

Macrophage presence

Release of multitude of

cytokines

Genetic/environment

Rheumatoid Arthrit is Chronic inflammation

Immunoregulation imbalanc

Initiating bacterial

peptides/antigens

Macrophage presence

Release of multitude of

cytokines

Genetic/environment

MODEL FOR POSSIBLE INTERRELATIONSHIP OF

RHEUMATOID ARTHRITIS AND PERIODONTITIS

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In fact, adult periodontitis and rheumatoidarthritis have much in common, so much

so, that I have argued that they are really

the same disease.

Greenwald, RA. Adult periodontitis as a modelfor rheumatoid arthritis.

Journal of Rheumatology 26:1650-53; 1999

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What is the incidence of self-reported RA

in normal and periodontitis patients?

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HYPOTHESES

Individuals with Periodontal Disease have ahigher prevalence of RA than those withoutPeriodontitis.

Individuals with RA have a higherprevalence of advanced forms ofPeriodontitis than patients with Periodontitis

but without RA.

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PREVALENCE OF RHEUMATOID ARTHRITIS

1.00%0.66%

3.95%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

RA

Published GeneralPopulation *

General Group

Perio Group

* Arnett et al 1988* Arnett et al 1988

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RELATIVE RISK

RAPeriodontitis

Periodontitis

Relative Ris

= 4.7

Relative Ris

= 1.5

RA

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What is the incidence of periodontitis in

clinically diagnosed RA patients and howdoes this vary between different severity

indices?

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Greater tooth loss and periodontal bone lossin RA patients

Greater pocket depths in RA patients

Periodontal patients had increased incidenceof tender and swollen joints

Periodontal patients had higher HAQ scores

Periodontal patients had elevated serum CRP

levels

SUMMARY OF RESULTS

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Using standard clinical and laboratoryparameters, RA patients appeared to be more

likely to have periodontitis

A particular group of RA patients who hadmoderate to severe RA were also likely to have

severe periodontitis

CONCLUSIONS

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CONCLUSIONS

Does this represent an

underlying dysregulation of

the inflammatory responses

in these individuals?

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COMMON PATHWAYS IN

PERIODONTITIS AND RA

OSTEOCLAST ACTIVATION AND

VASCULAR DAMAGE

ROLE OF TNF-alpha Family?

(OPG, RANKL, TRAIL)

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Normal Gingiva Periodontitis Rheumatoid Arthri

OsteoProtoGerin (OPG)Decreases with increasing inflammation

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Normal Gingiva Periodontitis Rheumatoid Arthri

ReceptorActivator ofNF Kappa L igand B

(RANKL)Increases with increasing inflammation

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Normal Gingiva Periodontitis Rheumatoid Arthr

TNF-RelatedApoptosis Inducing L igand

(TRAIL)Increases in connective tissue with inflammation

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Working Model

OPG decreases leading todecreased vascular protection. With

an increase in RANKL and TRAIL not

only is vascular damage possible butsignificant activation of osteoclasts

may result.

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Of course,

This is only one small piece in thepuzzle, but

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Evidence is accruing to supportthe hypothesis that Periodontitis

and Rheumatoid Arthritis areinterrelated diseases