Dental Care and Arthritis

Dr.Meheriar Chopra (M.D.S), Conservative Dentistry & Endodontics, Diploma in Lasers (Vienna)

Dr.Arvind Chopra (M.D), Director & Chief Rheumatologist, Center for Rheumatic Diseases, Pune.

Teeth must never be considered as just being part of the oral cavity but an integral component of the body as a whole. In recent years tremendous amount of research and public education has emphasised on the finding that various medical conditions can first manifest in the mouth. Diabetes, Hypertension and Arthritis have all been shown to have various levels of connection with the oral cavity and hygiene. Regular Dental check-ups must hold an equal importance to a Doctor’s check-up.

According to Anderson et al gum disease and tooth loss are more prevalent in patients of Rheumatoid Arthritis. Arthritis can affect the TMJ (Temporomandibular Joint), inflammation along the muscles of the jaw can make it painful and difficult to open the mouth. Immunosuppressants can cause bacterial and fungal infections such as Candida or Oral Thrush. Oral ulcers can be painful and with other underlying medical conditions eg Diabetes can cause delayed healing following Dental Treatment. Another syndrome that is known to hinder oral health is Sjogren’s Syndrome.

Periodontitis and Arthritis

Periodontitis is an oral inflammatory disease affecting the teeth supporting tissues. It has been associated with increased prevalence of systemic diseases such as cardiovascular disease, diabetes, rheumatoid arthritis, preterm birth and inflammatory bowel disease. Patients with longstanding active RA have a substantially increased frequency of periodontal disease. (Potempa.J et al, National Rev Rheumatol, 2017 Oct;13(10):606-620 ,Kasser UR et al, Arthritis Rheum, 1997 Dec;40 (12):2248-51)

Oral Bacteria and Arthritis: A Two-Way Street

According to Walter Koenig (Dept of Oral Pathology and Microbiology, University of Georgia) certain oral micro-organisms may act as a trigger factor for Arthritis. P.gingivalis, Actinomyces species , S.Mutans and Lactobacilli species have been identified at different levels of involvement in Arthritis patients. The major studies have quoted P.gingivalis (Porphyromonas) which causes Periodontal disease as a silent culprit in the genesis/progress of Arthritis. P.gingivalis has been shown to induce elevated systemic and local immune responses in subjects with various forms of periodontitis (Scott & Ferris 1964)

Sjogren’s Syndrome

Sjögren’s syndrome an autoimmune disorder can cause inflammation damaging the glands that secrete fluids such as salivary glands. Xerostomia(Dry Mouth) causes burning sensation in the mucosa and increases prevalence of dental caries. Thick and sticky saliva makes chewing and swallowing food difficult. Can occur Primary (Sicca) or Secondary to other autoimmune diseases (Lupus, Rheumatoid Arthritis, Scleroderma). Common treatment options include the use of artificial saliva in the form of gels or sprays.

Important Role of Saliva

Saliva is the “blood stream” of the oral cavity. It plays many roles from moistening the mucosa, removing and preventing build-up of plaque and food debris, enzymes which help in digestion of food and make swallowing food easy. A very important and often overlooked role is the strong immune properties of saliva which help in defending the hard and soft tissues of the oral cavity from micro-organisms. Hence in many cases of dry mouth there is an increased prevalence of tooth decay and gingival problems.

Salivary IgA:- The Secret Role it Plays

Salivary IgA has a very important role to play in the defence against tooth decay and gingival problems. It has a strong effect against many bacteria which are responsible for tooth decay and periodontal disease. A study done by Arvind Chopra, Meheriar Chopra and Anuradha Venugopalan at CRD Pune, revealed that individuals who have rarely suffered from tooth decay or gingival disease have naturally high levels of IgA. Also, patients of Arthritis had a much lower level of IgA which might weaken the protective ability of saliva.

CPP-ACP: - A Novel Treatment Option

CPP-ACP (Casein Phosphoprotein- Amorphous Calcium Phosphate) is a combination of milk protein and a strong form of biological calcium. It has many roles in protection of teeth against cavities, reducing tooth sensitivity and maintaining healthy gums. It is available in paste form and needs to be massaged onto the teeth and gums two times a day for 2-3 minutes. Studies have shown that regular application of CPP-ACP helps to increase the levels of Salivary IgA boosting the oral immunity.

TMJ Disorders

Swelling of the joint and muscle pain makes chewing food difficult. Cannot keep mouth open for long making oral hygiene and dental treatment difficult. “Clicking” and “Grating” in the joint is felt on opening and closing the mouth. Diffuse and aching pain in and around the ear. An easy home care method is by carrying out regular TMJ massage and exercises to relax and strengthen the joint.

Candida / Oral Thrush

An infection in which the fungus Candia Albicans accumulates in the mouth. Patients on immunosuppressants and steroids (Methotrexate, Dexamethasone). Oral Thrush causes white lesions, white coat on the tongue and mucosa of the cheek. Redness, Irritation and pain under dentures (Denture Stomatitis).

Smoking/Tobacco and its Negative Impact on Oral Health

Smoking has an impact on gingival health and leads to inflammation of the gums and periodontitis. There are numerous studies that have shown a direct connection to smoking and slow healing of the oral mucosa. It leads to deep staining of the enamel of the teeth which can be difficult to remove. There is overall dryness of the mouth and bad breath. Chewing Tobacco/Mishri causes abrasion of the enamel of the teeth leading to increases tooth sensitivity and also loss of gum attachment with loose teeth. Dental Treatment becomes difficult to perform and has a lower success rate. Both these habits must be avoided in order to maintain a healthy oral environment.

Common Questions asked by Patients

Is Dental Treatment Painful?

Study conducted by John Hopkins University between healthy patients and arthritis patients revealed that arthritis patients often complained of 10-20% increased dental pain as compared to the healthy patients with dental pain. Measuring the level of pain however is often challenging and subjective. Most dental pain is often diffuse and localising it to a specific tooth is sometimes difficult. 60-70% individuals avoid visiting the dentist due to fear of pain. However, with the introduction of new methods of anaesthesia including computerised local anaesthesia and gas based conscious sedation has enabled virtually painless dental treatment. Also, Dental lasers are now being used for a variety of treatment options resulting in faster healing and minimal post treatment pain.

How Best should I Clean my Teeth?

The three important steps to maintaining good oral hygiene are:

1.IDA certified toothpaste containing fluoride and using Soft Bristle tooth brush.

2.Rinsing with a non-alcoholic mouthwash. Always dilute 1 bottle cap in a glass of water.

3. Flossing with a Single non braided floss. Preferably must be waxed

The Time spent for carrying out each step is 2minutes of brushing and 2min of flossing followed by 1min of mouth wash. These 3 steps totalling 5min must be carried out once in the morning before breakfast and once at night before bedtime. This simple daily 10min routine will greatly help in maintaining a healthy oral environment.

Challenges of Maintaining Oral Hygiene in Arthritis

Weak grip/ inability to hold tooth brush properly. Unable to maintain constant brushing motion. Cannot keep the mouth open for long, weak TMJ and muscles. Sensitive gingiva and tongue, dryness of mouth (Sjogren’s Syndrome) makes using mouth wash uncomfortable. In such cases it is recommended to use an electric tooth brush which reduces strain and is easy to hold. A water pick which uses a stream of water can be used for flossing. Regular visits to the dentist for in office teeth cleaning are also recommended.

Why are my Teeth Sensitive and Loose?

Jameson et al concluded that patients of RA have a 30-40% increased amount of generalised tooth sensitivity. Sensitivity to cold is more common than heat. Most cases are mild and reversible with good oral hygiene maintenance and professional teeth cleaning. Loosening of teeth due to loss of surrounding alveolar bone is more difficult to treat as conventional treatment response is poor in RA cases.

PRF (Platelet Rich Fibrin) in Periodontal Regeneration

A very promising technique with a high success rate. Uses no artificial grafting and instead the patient’s own blood is used. Has been carried out in patients with systemic conditions (Diabetes, Arthritis) with good healing of the periodontium. Is less invasive and faster post-operative healing as compared to conventional periodontal surgical procedures.

Why my Dentures get Loose and Uncomfortable?

Chronic bone loss and receding(shrinking) gums can cause dentures to get loose over time. This has been more frequently observed in arthritis patients. Xerostomia (Dry mouth) as discussed previously causes the denture to not hold well to the gums and over a period of time causes gingival ulcers. Denture Stomatitis occurs in candida infections causing redness and erosion of the mucosal surface.

What are Dental Implants?

Dental implants are fast becoming a preferred alternative over removable dentures. They consist of screws which are surgically placed in the alveolar bone and the artificial tooth replacement is fixed over them. These fixed teeth don’t need to be removed like dentures, are quite strong and have a very good long term success rate. Studies of placing dental implants in RA patients have shown success rates of over 90% for a period of over 15 years. Newer implant systems need minimal surgery with no stitches and can have teeth fixed over them on the same day.

Is it Better to Extract or Save a Tooth?

The benefits of maintaining a vital tooth have always been preferred over extracting a tooth. No artificial replacement can ever come as close to the strength, dexterity and adaptability of a real tooth. However not in all cases can a tooth be saved and this is especially challenging in patients having medical history, poor or unable to maintain oral hygiene and socio-economic factors. A wise point of guidance is this “A saved tooth can always be replaced by an artificial tooth but an artificial tooth can only be replaced by another artificial tooth”

Are Dental X-rays Safe and Needed?

X-Rays play a very important role in the diagnosis and treatment of dental conditions. Earlier X-Rays required a larger amount of exposure radiation and only a limited number of images per patient. Conventional X-Rays have a disadvantage of being only 2Dimensional images while a tooth is a complex 3Dimensional object. The newer Digital X-Rays (RVG) however have minimal radiation exposure, are fast to take, have excellent image clarity and can safely be taken as many number of times per patient as required.

Conclusion

Dental Care and maintaining Good Oral Hygiene is of paramount importance for the overall prime health of the individual. In Arthritis especially though there are musculoskeletal difficulties all attempts must be made at carrying out the best Dental Care and Oral Hygiene Programmes as possible. A very important though not much discussed question is “How much does treatment cost?” this is especially important in the Indian Context and treatment costs must be kept as reasonable as possible without compromising on treatment quality. A good and increased communication channel between the Medical Specialist (Rheumatologist) and the Dental Surgeon is a great way to provide a well discussed mutual and confident treatment plan for the patient.

References:

1.Potempa.J et al, National Rev Rheumatol, 2017 Oct;13(10):606-620

2.Kasser UR et al, Arthritis Rheum, 1997 Dec;40 (12):2248-51)

3.Walter Koenig (Journal of O Path, Dept of Oral Pathology and Microbiology, University of Georgia)

4.Scott & Ferris 1964, Journal of Oral Microbiology 1964

5.CPP-ACP Study by Meheriar Chopra, Arvind Chopra and Anuradha Venugopalan, CRD Pune.

6.John Hopkins University, Dept of Community Dentistry Patient Statistics Data

7.Soben P (2004) Epidemiology etiology and prevention of dental caries. In: Soben P (ed) Essentials of preventive and community dentistry, 2nd edn. Arya, New Delhi, pp 241–278