Bone

Osteoporosis

Periodontal disease, tooth loss, and osteoporosis are major public health problems that affect the aging population. Therefore, prevention and early detection of both periodontitis and osteoporosis are very important.

Aging individuals are at greatest risk for osteoporosis and osteopenia and related fractures. More than 33% of the female population above the age of 65 years in western societies suffers from signs and symptoms of osteoporosis, with estrogen deficiency being the dominant pathogenic factor for osteoporosis in women.

Studies have reported significant relationships between periodontitis and systemic bone metabolism, and investigators have put forward some different beliefs. Some believe that periodontitis is not initiated by poor systemic bone metabolism, but rather that poor bone metabolism may either predispose the host to periodontitis, or modify its progress. Others believe that poor systemic bone metabolism plays a role in the initiation of periodontitis. Both beliefs have revealed that nutrition is an important modifiable factor in bone mass development and maintenance, osteoporosis prevention and treatment, and periodontal disease prevention.

A positive relationship between tooth loss and systemic osteoporosis has been demonstrated, along with a similar relationship between periodontitis and osteoporosis. However, controversy concerning causal relationships between bone status and various oral conditions exist.

Rheumatoid Arthritis (RA)

RA is a chronic multisystem disease of supposed autoimmune etiology. It is estimated that arthritis and other rheumatoid conditions affect 42.7 million Americans.

Medical complications due to RA and its treatment may affect the provision of oral health care. Considerable inflammatory similarities between periodontal disease and rheumatoid arthritis have also been reported. While the etiology of these two diseases may differ, the underlying pathogenic mechanisms are remarkably similar and it is possible that individuals manifesting both periodontitis and rheumatoid arthritis may suffer from an underlying systemic regulation of the inflammatory response. In light of these findings, the implications for the use of disease-modifying medications in the management of these two chronic inflammatory conditions are apparent.

RA is an autoimmune disease affecting multiple organ systems, although the principle characteristic is persistent inflammatory synovitis. The synovitis and subsequent joint pain and destruction can vary widely among patients. RA affects women three times more frequently than men, and the majority of patients are in the fourth or fifth decades at the time of diagnosis.

Although oral signs of RA are uncommon, oral complications to RA treatment do occur. Approximately 50% of individuals with RA will have TMJ involvement. However, less than half this number will develop symptoms such as joint stiffness, TMJ pain, and limited range of motion. A small number of individuals with RA have aggressive and progressive TMJ destruction, leading to fibrosis, ankylosis, and anterior open bite due to condylar destruction. When Sjorgen’s syndrome occurs with RA, xerostomia can increase the risk for caries and periodontal disease. One report exists that suggests that alveolar bone loss may be a complication of RA independent of xerostomia.

In most individuals with RA, the condition will not require changes in routine dental care. However, considerations will include the individual’s ability to maintain good oral hygiene, address the associated xerostomia (dry mouth) and its related complications, the individual’s susceptibility to infections, impaired homeostasis, and unpleasant drug actions and interactions. Individuals with RA may require antibiotic prophylaxis owing to joint replacement and/or immune suppression procedures. Intra- and extra-oral conditions such as ulcerations, gingival overgrowth, disease-associated periodontitis and temporomandibular joint (TMJ) pathology also need to be recognized and addressed with the help of a health care professional. If an individual’s manual dexterity is compromised, their ability to clean their teeth can be significantly reduced. Customized toothbrush holders, irrigation and other devices, such as a floss holder, have proven to be beneficial for these RA individuals. If xerostomia is present, caries prevention should include dietary changes, the use of fluoride, and dental sealants that are applied by the dentist if and where appropriate.

Medicinal Complications

If immunosuppressant medications are prescribed, there is an increased risk for oral candidiasis and/or stomatitis. The side effects of medications used to treat RA may have severe side effects on appetite and dietary and nutrient intake. Dietary management focuses on the level of oral and joint function, dexterity, and range of motion of the hand, arms, and hands. Nutrition and energy needs vary with the individual’s initial health status, which organs systems are affected, and the pharmacological management of the patient. Early intervention is critical to successful therapy.

Nutritional Complications and Management

In most individuals with RA, the condition will not require changes in routine dental care. However, considerations will include the individual’s ability to maintain good oral hygiene, address the associated xerostomia (dry mouth) and its related complications, the individual’s susceptibility to infections, impaired homeostasis, and unpleasant drug actions and interactions. Individuals with RA may require antibiotic prophylaxis owing to joint replacement and/or immune suppression procedures. Intra- and extra-oral conditions such as ulcerations, gingival overgrowth, disease-associated periodontitis and temporomandibular joint pathology also need to be recognized and address with the help of a health care professional. If an individual’s manual dexterity is compromised, their ability to clean their teeth can be significantly reduced. Customized toothbrush holders, irrigation and other devices, such as a floss holder, have proven to be beneficial for these RA individuals. If xerostomia is present, caries prevention should include dietary changes, the use of fluoride, and dental sealants that are applied by the dentist if and where appropriate.