Digital archive of theses discussed at the University of Pisa


Thesis etd-04012017-125937

Thesis type
Tesi di dottorato di ricerca
Thesis title
Rheumatoid arthritis and control of the periodontal infection: epidemiological evaluation and randomized clinical trial
Academic discipline
Course of study
tutor Prof. Graziani, Filippo
  • epidemiologia
  • artrite reumatoide
  • trattamento parodontale
  • parodontite
Graduation session start date
Aim: (i) To assess the prevalence and severity of Periodontitis (P) among patients affected by rheumatoid arthritis (RA) and to describe their clinical and serological profile comparing it with a control population affected by RA but not suffering from P. (ii) To evaluate the possible beneficial additional value of non-surgical periodontal therapy on systemic markers of inflammation and clinical and serological parameters of RA.
Materials & Methods: Medical records of patients affected by RA from the outpatient clinics of Rheumatology and Dentistry and Oral Surgery of the University Hospital of Pisa were screened for inclusion and subjects were invited to participate and sign the informed consent. Included subjects underwent a full-mouth periodontal examination including probing depth, gingival recession, plaque index, bleeding on probing and a full rheumatologic visit. RA disease activity was scored with DAS28. Serum analyses investigated levels of rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPAs), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and fibrinogen. Information concerning smoking, body mass index (BMI) and RA medical therapy (biological or disease-modifying antirheumatic drugs) was also collected.
For the randomized clinical trial (RCT), subjects presenting with (i) at least 15 teeth, (ii) generalized severe periodontitis, that is interesting at least 25% of sites, and (iii) absence of non-surgical periodontal treatment in the 6 months preceding the beginning of the study underwent non-surgical periodontal treatment. RCT patients were randomly assigned to either immediate (test group) or delayed (control group), that is performed at the completion of the 3-month follow-up, non-surgical periodontal treatment. Periodontal and rheumatologic clinical and serological parameters were registered before and after treatment.
Results: The final cohort consisted of 92 patients with RA. Fifty subjects, representing 54.3% of the study sample, resulted affected by periodontitis (RA-P group), while the other 45.7% only had RA (RA group). Both groups were comparable for age, gender distribution and BMI and consisted of 20% of current smokers. The number of teeth present was statistically lower in the RA-P compared to the RA group (p < 0.05). DAS28 mean value (± standard deviation, SD) in RA-P group was 3.14 (± 1.1), while the respective value in the RA group was 2.81 (± 1.0); these differences were not statistically significant (p > 0.05). With regards to RA serological profile (RF and ACPAs), there were statistically more subjects seropositive for ACPAs in the RA group (66.7% versus 42%, p < 0.05) whereas no statistical differences were observed when comparing the seropositivity for RF of the two groups. Furthermore, the concentrations of the serum inflammatory biomarkers (CRP, ESR and Fibrinogen) in the two groups were comparable. Finally, patients with P and RA had an unadjusted OR = 2.4 (95% confidence interval [CI] 0.99 – 5.81) of presenting a moderate-severe DAS28 score (DAS28 ≥ 3.2); after adjusting for RA medication, FR, ACPAs, smoking status and gender the OR resulted 2.62 (95% CI 0.96 – 7.12).
For the RCT, a total of 16 subjects were included and completed the 3-month follow-up from January 2015 to December 2016. Non-surgical periodontal treatment produced significant clinical benefits in terms of standard periodontal parameters (p < 0.05). DAS28 mean (± SD) value in test group (immediate treatment) was 3.05 (± 1.1) at pre-treatment and 2.73 (± 1.2) post-treatment, while the respective values in the control group (delayed treatment) were 2.77 (± 1.3) at pre-treatment and 3.29 (± 1.5) post-treatment. These changes were not statistically significant (p > 0.05), but a trend of amelioration may be observed among the patients of the test group. With regards to serum levels of CRP, ESR, Fibrinogen, IL-6 and TNF-α no statistically significant differences between the two groups were observed 3 months after non-surgical periodontal treatment (p > 0.05).
Conclusions: Among RA subjects a considerably higher prevalence of severe P has been observed. Furthermore, the clinical severity of RA appears to be strongly correlated with the clinical periodontal parameters and RA subjects also affected by P seem to have an OR of 2.62 for presenting with a moderate-severe RA (DAS28 score ≥ 3.2).
The non-surgical periodontal treatment appears to determine a trend for amelioration of DAS28 scores among RA patients with periodontitis without determining a statistically significant change in their serological profile. A larger study sample with a longer follow-up period is needed in order to better elucidate the effects of non-surgical periodontal treatment on the clinical and serological parameters of patients affected by rheumatoid arthritis.