Perio Pathogens CAUSE Rheumatoid Arthritis– Now What?

“Rheumatoid arthritis is a chronic disease affecting over 1.3 million Americans and as much as 1% of the worldwide population.” ( There is a growing body of research indicating a causal association between specific periodontal pathogens and rheumatoid arthritis (RA). In a 2009 study, in Compendium of Continuing Education in Dentistry, the authors indicate that a specific perio pathogen, Porphyromonas gingivalis (P.g.), produces an enzyme capable of modifying specific proteins. The bacterial enzymes catalyze a protein folding reaction. The body recognizes this folded protein as a foreign entity. The body mobilizes an auto-immune response to these proteins, which culminates clinically in the joint destruction typically seen in RA susceptible individuals. The authors conclude that if further research affirms the initiation of rheumatoid arthritis by P.g., periodontal disease prevention and treatment may lead to the prevention of  RA in susceptible individuals. A number of studies reached the same conclusions of the Smolik, et al study.1

A 2015 study, in Best Practice & Research: Clinical Rheumatology, stated the following “Converging and reproducible evidence now makes a clear case for the role of specific periodontal infective pathogens in initiating, amplifying and perpetuating rheumatoid arthritis. The unique enzymatic properties of the periodontal pathogen Porphyromonas gingivalis and its contribution to the burden of citrullinated peptides is now well established.”2

As recent as 2016, a study published in the journal Science Translational Medicine had the following conclusion “These studies identify the periodontal pathogen A.a. as a candidate bacterial trigger of autoimmunity in RA.”3

Worthy of note is this research is not indicating a relationship between periodontal disease and RA. Rather the causal link to be considered is between P.g. & RA and A.a. & RA. Interestingly, the tissue destructive mechanisms in periodontitis and rheumatoid arthritis are remarkably similar. The immunological and pathological processes occurring in periodontitis and RA are nearly identical. Both conditions are characterized by chronic inflammation in a soft tissue site adjacent to bone.

When a patient in our dental practice indicates that they have RA are we going to practice as usual? I challenge us to take into consideration the periodontal pathogens/RA link. Test for the presence of the two periodontal pathogens that have been linked to RA (A.a &P.g.). Knock down the population of these bacterial species if testing confirms their presence. This is a great opportunity to potentially impact someone’s health and quality of life.

1. Compendium of Continuing Education in Dentistry. 2009 May;30(4):188-197
2. Best Pract Res Clin Rheumatol. 2015 Apr;29(2):189-201
3. Sci Transl Med. 2016 Dec 14;8(369):369ra176

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Richard H. Nagelberg, DDS

Richard H. Nagelberg, DDS

Dr. Richard Nagelberg has been practicing general dentistry in suburban Philadelphia for 34 years. He has international practice experience, having provided dental services in Thailand, Cambodia, and Canada. He is an advisory board member, speaker, key opinion leader and clinical consultant for several dental companies and organizations. Richard has a monthly column in Dental Economics magazine, “GP Perio-The Oral-Systemic Connection”. He is a recipient of Dentistry Today’s Top Clinicians in CE, 2009-2016. A respected member of the dental community, Richard lectures internationally on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity.
Richard H. Nagelberg, DDS

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3 thoughts on “Perio Pathogens CAUSE Rheumatoid Arthritis– Now What?

  1. Jai Sungaran says:

    Being a specialist of arthritis diseases I have treated enormous numbers of patients and still in this field. And I never heard something like this before that Rheumatoid Arthritis is caused by the bacteria that have been shown to considerably contribute to periodontitis. Anyway, now if it has been said as the cause of RA, then people should be very careful while considering the Periodontics.

    1. Patti says:

      Yes. As dental hygienists/periodontal therapists, we can diagnose periodontal disease and with a saliva test. The test determines the quality and quantity of the oral pathogens that are driving the infection. With comprehensive periodontal therapy, including bacteria specific antibiotics if applicable, we can lower the bacterial burden and reduce both oral inflammation and systemic inflammation driving the rheumatic disease.

  2. Patti says:

    Yes. We have found that patients can have high quantities of PG and AA and not even have symptoms of periodontitis. Personalized, objective testing for specific bacteria and personalized periodontal treatment can lower and or take away a inflammation burden and risk of RA progressing. All patients with a risk of developing RA or already has the diagnosis should see a periodontal therapist/ dental hygienist for a comprehensive evaluation of possible oral infections.
    Thank you for working with the dental professionals on your patients’ health care team for better patient outcomes!

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