Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation, primarily affecting the joints. While RA is often associated with joint pain and stiffness in the hands and feet, its systemic nature means the inflammation is not confined, linking it closely to oral health issues. Shared inflammatory pathways and physical challenges posed by RA significantly increase the risk for dental complications. Poor oral health can also influence the severity of RA symptoms.
Systemic Inflammation and Periodontal Disease
The most direct link between RA and oral health is the shared inflammatory burden connecting RA to periodontal disease, or gum disease. Periodontal disease starts as gingivitis, characterized by red, swollen, and easily bleeding gums, and can progress to periodontitis, destroying the bone and tissues supporting the teeth. Pro-inflammatory proteins, or cytokines, such as Tumor Necrosis Factor-alpha (TNF-α) and Interleukin-6 (IL-6), drive joint destruction in RA and travel through the bloodstream to exacerbate gum inflammation.
Individuals with RA have a higher prevalence and more severe periodontitis compared to the general population, sometimes being up to four times more likely to have gum disease. The inflammation from periodontitis can worsen RA activity; treating gum disease often leads to a measurable improvement in RA disease activity scores. A specific bacterium common in periodontitis, Porphyromonas gingivalis, produces an enzyme that may trigger the production of autoantibodies central to RA, suggesting gum infection could play a role in initiating the autoimmune disease.
Secondary Oral Health Complications
Rheumatoid arthritis creates several secondary problems impacting oral health beyond the inflammatory link to periodontitis. The temporomandibular joint (TMJ), which connects the jaw to the skull, is a synovial joint susceptible to RA inflammation. Inflammation in the TMJ causes pain, limits jaw motion, and makes actions like chewing or opening the mouth for a dental exam difficult. Chronic TMJ involvement can eventually damage cartilage and bone, potentially changing bite alignment.
Xerostomia, or chronic dry mouth, is another common complication, often resulting from secondary Sjögren’s syndrome, an autoimmune condition frequently accompanying RA. Sjögren’s syndrome attacks moisture-producing glands, severely decreasing saliva and tear production. Saliva is a natural defense, washing away food particles and neutralizing bacterial acids. Without adequate saliva, the risk of dental cavities and oral fungal infections, such as oral candidiasis, increases significantly.
Physical limitations stemming from RA also pose a challenge. Pain and stiffness in the finger, wrist, and elbow joints can make gripping a toothbrush or manipulating dental floss nearly impossible. This reduced dexterity leads to inadequate plaque removal, contributing directly to gum disease and tooth decay. Furthermore, some RA medications, such as immunosuppressants, can increase susceptibility to oral infections or cause side effects like mouth ulcers.
Integrated Dental Care Strategies
Managing oral health with RA requires a collaborative approach between the rheumatologist and the dentist, focusing on systemic and local care. Patients should inform their dental team about their RA diagnosis, symptom severity, and all current medications. Due to the elevated risk of periodontal disease and decay, more frequent dental cleanings and check-ups, often every three or four months instead of the standard six, are typically recommended.
To compensate for reduced manual dexterity, simple adjustments to the oral hygiene routine are helpful. Using an electric toothbrush requires less physical manipulation and is highly effective for many patients. For those who struggle to grip a standard handle, specialized tools with larger, ergonomic handles or modifications like attaching a bicycle grip can provide better control. Interdental cleaning can be maintained using aids like water flossers or specialized floss picks, which are easier to maneuver than traditional floss.
Managing Dry Mouth and TMJ
Strategies for managing dry mouth are crucial for preventing cavities and infection. Patients can use over-the-counter saliva substitutes and specialized moisturizing, often alcohol-free, mouthwashes to keep oral tissues hydrated. Applying topical fluoride rinses or gels daily helps remineralize tooth enamel and protects against decay. For jaw joint discomfort, a dentist may recommend soft diet modifications, warm compresses, or a custom nightguard to alleviate TMJ symptoms.