Could early rheumatoid arthritis resolve after periodontitis treatment only?: case report and review of the literature

Abstract

Rheumatoid arthritis (RA) is an immune-mediated polyarthritis; currently no pathogenic agent has been identified as a disease trigger. A patient with RA, presumably caused by periodontal infection, whose remission has been observed after periodontitis treatment in absence of specific RA therapy, is reported here for the first time, to our knowledge. A 61-year-old male patient presented migrant arthritis associated with antibodies against citrullinated protein antigens positivity. The clinical features allowed to make RA diagnosis according to the 2010 European League against Rheumatism/American College of Rheumatology RA classification criteria. X-ray of the second upper molar showed chronic apical periodontitis. After its treatment, arthritis remission has been observed in the absence of specific RA therapy. It has been suggested that periodontitis may have a trigger role in RA pathogenesis. This could be explained by the enzymatic action of Porphyromonas gingivalis, probably leading to break tolerance to collagen. The identification and subsequent treatment of periodontitis should therefore be considered pivotal in RA prophylaxis and management.

FIGURE 1

Ultrasonography images of second MCP joint of the left hand and fat-sat gadolinium-enhanced T1-weighted Turbo Spin Echo coronal and transverse magnetic resonance imaging images of left hand and wrists at baseline (A–C) and after periodontal disease treatment (D–F). (A) Moderate active synovitis of the II MCP joint of the left hand (power-doppler grade II). (B) Microerosions of second and third metacarpal head and inflammatory involvement of digital synovial sheaths of third and fourth finger and recessus ulnaris (prestyloideus). (C) Diffuse thickening (enhancement) of sheath of superficial and deep digital flexor tendon and extensor carpi ulnaris tendon of right wrist; less thickening of left wrist. (D) Second MCP joint of the left hand: absence of synovitis (power-doppler negative). (E) Marked reduction of synovial thickening of recessus ulnaris (prestyloideus) and the synovial sheath of third and fourth finger of flexor tendon; persistence of the minimal erosion of third metacarpal head (contrast enhancement). (F) Remarkable reduction of right flexor tendon and extensor carpi ulnaris tendon sheaths thickening. MCP = metacarpophalangeal.

FIGURE 2

(A) Second upper molar x-ray showed a chronic apical periodontitis on the mesiobuccal root. (B) Bone reconstitution appeared complete in the last second upper molar x-ray.