People who suffer with Rheumatoid Arthritis (RA) live with an array of symptoms that range from mild to debilitating. The obvious effects of RA are on the joints of the the hands, wrists, knees and feet. Less well known are the myriad effects on oral health.
RA is a chronic, systemic disease. RA is a member of a family autoimmune diseases with a high level of rheumatoid factor which gives the condition its name. High rheumatoid factor diseases include lupus erythematosis, scleroderma, and sjorgren’s syndrome. Autoimmune diseases cause the body’s own defenses attack healthy tissue.
RA is characterized by a pattern of swollen tender joints. The joints most often include the small joints of the hands and feet, wrists and knees. RA is not the only disease that causes sore joints. Physicians diagnose RA after interviewing the patient to determine their history of disease, testing the blood for rheumatoid factor and other effects of the disease, physical examination to determine the pattern of inflamed joints, and to look for lumps under the skin (rheumatoid nodules), and imaging exams (x-ray, CAT scan, and others).
As a systemic disease, RA may affect multiple organs including the lungs, kidneys, even the tissue surounding the heart. RA becomes active or flares up and then becomes silent or goes into remission. Many patients have flares and remissions throughout their lives.
There is no cure for RA. Patients primarily take a variety of anti-inflamatory drugs to ease the pain and inflamation of RA. Aspirin is a time-tested non-steroidal anti-inflamatory drug (NSAID). Newer NSAIDs including Ibuprofen and Naproxophen are alternatives. Steroids are very strong inflamation fighters. Prednisone is a good choice to gain control of an especially bad flare. Unfortunately, prednisone carries frequent and serious side effects such as pseudotumor cerebri (increasing pressure of the fluid surrounding the brain), infection, diabetes, and a littany of others. Physicians may inject another steroid, cortisone, to give patients fast relief in key joints.
There are other medications known as disease modifying anti-rheumatic drugs or DMARDs. Gold, methotrexate, and hydroxychloroquine slow the progress of the disease. These medications carry their own serious side effects.
RA effects oral health in a variety of ways.
Part of the reason that RA patients have more serious tooth decay and gum disease is that swollen, inflamed hand and wrist joints make oral hygiene (brushing and flossing) tedious and painful. Oral-B and Sonicaire make popular and effective electric toothbrushes that make home care easier. Electric toothbrushes provide larger, more comfortable handles for patients who loose the ability to grasp the thin handle of standard toothbrushes. RA sufferers may find that they can clean their teeth more effectively with the vibrating brush head of the electric toothbrush than the manual brush.
Obviously, flossing is virtually impossible for many RA sufferers. There are a few useful devices available for interdental cleaning. Butler’s Floss Aid is a popular device that streaches any floss across the ends of a “Y” shaped handle. The Reach Access Flosser (www.Reachaccess.com) is similar to the Floss Aid, except that it uses snap-on bows preloaded with monofilament floss. The problem with both of these devices is that their handles are thin and hard to grasp for people with hands affected by RA. Oral-B (www.OralB.com) and Waterpik (www.Waterpik.com) make inexpensive flossing alternatives, the Humming Bird and the Power Flosser respectively. Both devices have easier to hold handles, and effectively clean between teeth. All of these electric toothbrushes and interdental cleaners are available at pharmacies, and department stores nation wide.
RA often affects salivary glands causing inflamation and dryness. Sjorgren’s syndrome the combination of dry eye (keratoconjunctivitis sicca) and dry mouth (xerostomia) is common in RA. In some cases, medications that increase the effectiveness of the salivary glands such as pilocarpine (brand name Salagen by www.novartis.com). Such medications take weeks or months to bring relief. Artificial saliva products such as Oasis by Glaxo (www.gsk.com), and Salivart by Gebauer (www.salivart.com) provide immediate relief. Use of a gentle toothpaste formulation as Biotene (www.Laclede.com) is a good idea. The simplest treatments for xerostomia include drinking plenty of water and stimulating the salivary glands by chewing sugar free gum or sucking on sugar free hard candies.
Without the cleansing and antibacterial effects of saliva, teeth are much more likely to decay. Fight rampant decay with maximal use of fluoride, impeccable oral hygiene and decreasing sugar consumption.
Thrush, oral yeast infection, frequently accompanies long standing xerostomia. Symptoms of thrush include a burning sensation especially in the tongue and sores in the corners of the mouth. Dentists identify thrush by its characteristic white coating of the lining of the mouth which wipes away leaving red patches. Effective treatment includes presciptions of antifungal tablets, rinses and salves.
An Australian study published in the June 2001 issue of the Journal of Periodontology, by Mercado, et al, reports a strong link between periodontal disease and RA. The authors believe the two diseases result from a poorly regulated immune system. The report does not suggest a treatment for periodontal disease. Therefore, do not expect that the treatment for RA will decrease the effect of periodontal disease.
The temporomandibular joint (jaw joint or TMJ) is the most complicated joint in the human body. Most joints only bend as a hinge, some allow rotation, but the TMJ rotates for the first five degrees or about one inch of opening and then it slides to the full open position. The TMJ allows the jaw to swing from side to side for chewing. This joint is succeptable to RA. As with other joints, RA will cause swelling and pain. Pain may become severe when chewing and speaking. Most patients find relief with the usual treatments such as anti-inflammatory medications, exercise and heat. RA sometimes damages the TMJ. Then, it is necessary to replace all or part of the joint with an analog made of titanium and a kind of plastic.
Many of the medications that patients take to treat RA and the pain associated with it have oral side effects. NSAIDs such as aspirin and ibuprofen, cause stomach irritation which may lead to nausea and vomiting. The acid of the stomach causes erosion of the enamel, the hard outer covering of teeth. Steroids cause a lower resistance to infection. For that reason, patients may be required to take antibiotics before having dental treatment – especially dental prophylaxis or cleaning. Methotrexate can cause severe mouth sores and irritation.
If you are living with Rheumatoid Arthritis, please take care of your oral health. Brush and floss two or three times a day. Watch your mouth critically for signs of dry mouth (plaque, stains and decay), and gum disease (bleeding and bad breath). See your dentist 3 or more times a year. Most of all, discuss your RA and oral health concerns with your medical doctor and your dentist.