Studies have found elevated serum levels of antibodies to periodontal bacteria in subjects with rheumatoid arthritis compared to subjects without rheumatoid arthritis (Masoud, 2019; Kim, et al., 2018). Other authors report evidence of DNA and RNA of periodontal bacteria in the synovial fluid (fluid found in the joints) of subjects diagnosed with rheumatoid arthritis (Beyer et al., 2018; Ceccarelli et al., 2019; Hammad, et al., 2020; Masoud, 2019). However, this could reflect the impaired dexterity in patients with rheumatoid arthritis and the resultant decline in oral hygiene and development of periodontal disease. As is the case with the association of Alzheimer’s disease and periodontal disease, the temporal nature of the association must be addressed: which came first, the rheumatoid arthritis or the periodontal disease? Research linking periodontal disease and rheumatoid arthritis with more rigorous population-based research is needed with higher numbers of subjects and careful consideration and documentation of confounding factors (Ceccarelli, et al., 2019). The following are recommendations for dental practitioners who have patients diagnosed with rheumatoid arthritis: ● Inform patients of the findings of the most current research examining rheumatoid arthritis and periodontal disease. ● Encourage patients to maintain excellent oral hygiene. ● Provide oral hygiene instruction. ● Encourage patients to keep recall appointments for professional cleanings and examinations. It may be necessary to schedule more frequent recall appointments for these patients. ● Suggest brushing and flossing aids. (See the section on osteoarthritis for a list.) ● Recommend over-the-counter or prescription fluoride rinses and antibacterial mouth rinses.
environmental factor (CDC, 2017b). Although inflammation leading to the destruction of the joints is a hallmark of the disease, other organs may be involved (CDC, 2017b). Numerous studies have investigated a potential link between rheumatoid arthritis and periodontal disease. Several authors reviewing these studies have noted a trend suggesting an association between the two diseases (Renvert, et al., 2020; Beyer, et al., 2018; Ceccarelli, et al., 2019; Peckel, 2017). Rheumatoid arthritis and periodontal disease share a common underlying pathogenesis, chronic inflammation, and both diseases exhibit soft and hard tissue destruction resulting from the inflammatory nature of the disease process (Ceccarelli, et al., 2019). Rheumatoid arthritis has been found to increase the risk for periodontal disease (Beyer, et al., 2018) . Review of the literature has shown that both clinical attachment loss (Ayravainen et al., 2017; Beyer et al., 2018; Hashimoto, et al., 2022; Peckel, 2017) and tooth loss (Peckel, 2017; Zhao, et al., 2018). are greater in subjects with rheumatoid arthritis than in subjects without the disease. Conversely, case control studies also suggest that periodontal disease increases the incidence of rheumatoid arthritis (Masoud, 2019; Kim, et al., 2018; Peckel, 2017). Although the association is likely not causal, periodontal disease may play a role in the development of rheumatoid arthritis (Masoud, 2019). Symptoms attributed to arthritis significantly improved when subjects with rheumatoid arthritis were treated for periodontal disease (with scaling, root planing, and oral hygiene instruction) compared to subjects with rheumatoid arthritis who did not receive periodontal treatment (Zhao, et al., 2018). The potential for the bidirectional mechanisms between rheumatoid arthritis and periodontal disease need continued research and investigation (Peckel, 2017).
ORAL HEALTH AND THE INSTITUTIONALIZED OLDER ADULT
are significant disparities in access to professional dental services in older adults residing in nursing homes and consequently poor oral health is a common occurrence (Lowe & Rossopoulos, 2018). Smith and colleagues’ 2008 study found that the two greatest barriers to adequate oral health in nursing homes were resistance by both general dentists and specialty dentists to treating long-term care residents at the nursing home or in private offices and financial concerns regarding payment for treatment. Upon admission to long-term care facilities, most patients pay the costs of nursing home care out of pocket and/or through long-term care insurance. When these funds are exhausted, the patient is eligible for Medicaid (Heberbrand, 2021). This is problematic for nursing home residents when it comes to paying for professional dental care because Medicare does not pay for dental services (Bersell, 2017; Garvin, 2022) except in rare instances (e.g., extractions prior to radiation treatment for cancer involving the jaw, oral exam preceding kidney transplant or heart valve replacement). In addition, Medicaid coverage for adults varies from state to state, with some states having no adult dental benefits or covering only dental emergencies. Even if a state provides dental coverage through Medicaid, the reimbursement is so low that many dental providers choose not to participate as providers in the Medicaid program. Therefore, older adults who rely on Medicare and Medicaid as their payor are left without a dental provider unless they can pay out of pocket. The Incurred Medical Expense Benefit may help to alleviate this problem. If the nursing home resident is covered by Medicaid, and the resident needs a dental service that is not covered by Medicaid, the dental service may be billed as an
Approximately approximately 1.2 million – of adults age 65 and older live in long-term care facilities with this number estimated to increase to 1.9 million by 2030 (Mather, et al., 2019). In 1987, the Omnibus Budget Reconciliation Act (OBRA) was passed to improve the level of care in nursing homes. Final regulations went into effect in 1992 (U.S. Government Printing Office, 2017). Oral care was a part of OBRA, which mandated that all nursing homes that receive payment from Medicare or Medicaid: ● Provide routine and emergency dental care for nursing home residents, with care being provided either within the facility by a dental professional who contracts with the facility or out of the facility in a private practice setting. ● Assist residents in making dental appointments. ● Arrange for transportation to and from the dental office. ● Promptly refer residents with broken or lost dentures to a dental professional. However, accountability and oversight to ensure compliance with this mandate are lacking. The states send surveyors into nursing homes to conduct inspections every 9 to 15 months on behalf of the Centers for Medicare & Medicaid Services (CMS) to evaluate the quality of care and report deficiencies (CMS, 2016). Formerly these inspections paid little attention to the oral health status of the residents but the Centers for Medicare & Medicaid Services have since worked to improve the surveys with their new Minimum Data Set (MDS) 3.0 protocol (CMS, 2015). Oral health among nursing home residents is among the worst of all groups of older adults (Lavigne, 2018). There
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