Hussain, Syed Basit; (2024) Association between Periodontitis and Rheumatic Diseases. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

BACKGROUND: Periodontitis (PD) is a chronic disease defined by the loss of the teeth supporting tissues including bone and periodontal ligament and it is a major cause behind tooth loss. Several studies suggested that PD is more prevalent in patients with Rheumatic Diseases (RD) but inconclusive evidence on a direct association has been reported. Specific plausible biological mechanisms have been proposed as a basis for the association between PD and RD. The aim of this research programme was to explore the nature of the association between PD and RD. METHODS: The research programme methodology included, critical appraisal, observational and experimental evidence generated from the following studies: (1) Study I: A systematic review aimed at exploring the prevalence of PD in SLE patients (both sex and females only). Differences in periodontal clinical parameters including probing pocket depth (PPD), clinical attachment level (CAL), SLE disease activity index (SLEDAI) scores of SLE in patients with or without PD were also examined. 2) Study II: A systematic review of the association between PD and Rheumatoid Arthritis (RA). The bidirectional nature of their association was assessed with both qualitative and quantitative methodology. 3) Study III: A critical review and observational questionnaire survey linking self-reported PD and Rheumatic Diseases (SLE and RA) with particular emphasis on describing the plausible common mechanistic pathways. 4) Study IV: A secondary analysis of a representative sample of the US population (n= 13,677, NHANES III, 1988-1994) to define the potential association between PD (exposure) and self-reported SLE (outcome) using multivariate linear and logistic regression models. Case-definition, clinical periodontal parameters and periodontal pathogen serum antibodies were used as specific measure of exposure. 5) Study V: A synopsis and protocols for the pilot study with the aim of assessing the impact of Intensive periodontal treatment (IPT) compared to control (CPT) on measures of vascular function in patients with moderate to severe PD and SLE. RESULTS: Study I systematic review data demonstrated that SLE diagnosis was associated with greater odds of PD (OR = 1.33, 95% Confidence Interval [CI]: 1.20–1.48). Patients with SLE exhibited no differences in PPD (SMD: −0.09 mm, 95%CI: −0.45–0.27) and CAL (SMD: 0.05 mm, 95%CI: −0.30–0.40) when compared with systemically healthy controls. PD diagnosis was, however, associated with higher SLEDAI scores in patients suffering from SLE (SMD: 0.68, 95% CI: 0.03–1.32). Study II systematic review data confirmed no substantial effect of RA on PPD and CAL levels of patients with PD when compared to controls, but high degree of study heterogeneity was found. Diagnosis of PD was associated with worse RA disease activity as assessed by an increased DAS28 score of 0.74 (0.25-1.24, 95%CI, p < 0.001). Study III critical review and a questionnaire survey data confirmed that there was no statistically significant difference in the prevalence of self-reported PD in two patients’ cohorts (SLE and RA). Self-reported PD had increased CRP levels compared to controls (p = 0.033) in patients with SLE whilst in RA patients PD was associated with higher ESR (p = 0.022). Study IV The NHANES data demonstrated that the participants with PD were more likely to have self-reported SLE (OR 2.6 [95%CI 1.1, 6.0]) compared to those without PD. The association was stronger in those with moderate PD diagnosis (OR 6.3 [95%CI 1.4, 28.7]). Participants with higher serum antibody levels of Mm (OR 1.6 [95%CI 1.0, 2.4]) and lower antibody levels of Pg (OR 0.8 [95%CI 0.6, 1.0]) reported higher prevalence of SLE. CONCLUSION: The evidence identified and produced by this study confirmed that PD is closely linked to Rheumatic Diseases such as SLE and RA. Further studies should explore the impact of treatment of PD on the management of Rheumatic Diseases. A pilot RCT as future work will also explore and observe the bi-directional association between the two conditions. Oral health should be promoted in patients suffering from Rheumatic Diseases.

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