Rheumatoid Arthritis

Evidence Favoring Periodontal Treatment in Patients With Rheumatoid Arthritis Available, But of Low Quality

Bradley van Paridon
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Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of antiresorptive treatments for osteoporosis. It is characterized as an area of exposed necrotic jawbone that persists >8 weeks in someone with bisphosphonate or denosumab exposure.20 Less than 0.1% of patients with osteoporosis using a bisphosphonate or denosumab develop MRONJ.20 A similar condition has been observed in patients receiving anticancer drugs, glucocorticoids, methotrexate, adalimumab, etanercept, or rituximab.21 The cause of MRONJ is unclear, but may relate to the osteoclastic effects of antiresorptive agents and the antiangiogenic or immunosuppressive effects of other drugs.22 MRONJ in patients with osteoporosis is usually preceded by invasive dental procedures, and antibiotic prophylaxis can reduce risk.20 Periodontal disease, oral infection or trauma, and longer osteoporosis treatment also increase risk.1,20 Limited data suggest patients with RA have a greater risk for MRONJ, possibly because of RA's skeletal effects.1,22 Severe MRONJ may require surgery, whereas early disease is managed conservatively.20

Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of antiresorptive treatments for osteoporosis. It is characterized as an area of exposed necrotic jawbone that persists >8 weeks in someone with bisphosphonate or denosumab exposure.20 Less than 0.1% of patients with osteoporosis using a bisphosphonate or denosumab develop MRONJ.20 A similar condition has been observed in patients receiving anticancer drugs, glucocorticoids, methotrexate, adalimumab, etanercept, or rituximab.21

The cause of MRONJ is unclear, but may relate to the osteoclastic effects of antiresorptive agents and the antiangiogenic or immunosuppressive effects of other drugs.22 MRONJ in patients with osteoporosis is usually preceded by invasive dental procedures, and antibiotic prophylaxis can reduce risk.20 Periodontal disease, oral infection or trauma, and longer osteoporosis treatment also increase risk.1,20 Limited data suggest patients with RA have a greater risk for MRONJ, possibly because of RA’s skeletal effects.1,22 Severe MRONJ may require surgery, whereas early disease is managed conservatively.20

Researchers of a systematic review assessed the evidence of the effect of periodontal therapy on measures of disease activity and inflammatory burden in patients with rheumatoid arthritis.

Well-designed prospective cohort studies and randomized control trials (RCTs) of patients with rheumatoid arthritis (RA) and periodontitis are urgently needed, according to the researchers of a systematic review and meta-analysis published in Arthritis Care & Research.

For the review (PROSPERO Number: CRD42018103359), the researchers searched PubMed, Cochrane Library (CENTRAL), Embase, ClinicalTrials.gov, and WHO-ICTRP portal for RCTs that included data from patients with RA and periodontitis.

Of the 1909 studies identified, 9 studies with 10 comparisons were eligible for quantitative analysis, which included 388 participants. Study durations ranged from 6 to 24 weeks. The majority of studies included comparisons of nonsurgical periodontal treatment plus oral hygiene instructions and oral hygiene instructions only or the absence of treatment; some studies included the addition of antibiotics to the treatment group. 

A total of 13 studies had data on disease activity, of which 7 were included in the current analysis. Researchers observed a reduction in disease activity scores in 6 studies with 7 comparisons, and these findings were statistically significant in 5 of the comparisons. On pooling the results of all studies that reported reductions in disease activity, a statistically significant standardized mean difference of -0.88 (95% CI, -1.38 to -0.38) was observed. The high heterogeneity of results (I2=74%) indicated different treatment effects across studies.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to qualify evidence from RCTs and quasi-randomized studies. Researchers found that very low quality evidence favored treatment to reduce disease activity, systemic inflammation, and life impact compared with no treatment, standard care, and placebo. Analyses of covariates reducing variation across studies indicated stability in RA medication, selection, and reporting bias as sources of heterogeneity across studies.

Researchers identified several factors limiting the available evidence for periodontal treatment including small samples sizes, selection bias, lack of standardized case-definitions and clear descriptions, and the design of the periodontal treatments.

They concluded, “There is an urgent need for a well-designed prospective cohort study (preferably an RCT) of patients with RA and periodontitis using rigorous protocols, [standardized] diagnostic criteria, data collection, and adequate duration of follow-up.”

Reference

Silva DS, Costa F, Baptista IP, et al. Evidence-based research on effectiveness of periodontal treatment in rheumatoid arthritis patients: a systematic review and meta-analysis. Arthritis Care Res. Published online May 10, 2021. doi:10.1002/acr.24622

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