Dr. Craig Gimbel
Craig Gimbel, DDS is a retired dentist and researcher, as well as an esteemed member of SAA’s Board of Directors.
Your visit to the dentist is important to the health of the rest of your body, not just your teeth and gums. It is important to be aware of the effects of spondylitis on the health of your mouth as well as the head and neck areas. At your initial dental appointment it is important to discuss your health history with your dental professional. For example, though ankylosing spondylitis primarily affects the axial spine, other axial parts of the body may be involved, as well, including the mouth. There are secondary effects of drug therapy that may cause dry mouth, infection or jaw bone degeneration. Secondary osteoporosis can even affect the jaw bone and the joint that allows movement of the mandible.
Correlations have been found between poor oral health and systemic disease. For example, there is a link between gum disease and cardiovascular disease and respiratory illness. The body’s impaired autoimmune defenses compromise the inflammatory response of oral infection. Be aware that spondyloarthritis is one possible factor that can lead to temporomandibular joint dysfunction, which includes clicking and impaired mouth opening.
Seated in the Dental Chair
Spondyloarthritis, being an axial and peripheral joint disease, has an effect on the posture and positioning of your head, neck and the rest of the body in the dental chair. Cervical spine stiffness or deformities may make it uncomfortable, or even painful, to sit in the dental chair for extended periods of time. If inflammation of the costovertebral joints of the chest wall occurs, limitation of chest expansion could result. Extraarticular manifestations include fibrosis of the lungs. This would force an individual to maintain respiration by labored diaphragmatic movement, making it more difficult to sit still. Cervical spine involvement may range from slight limitation of neck movement to complete fusion, usually in flexion or bending of the neck.
Fatigue is common among people with ankylosing spondylitis (AS). It is associated with inflammation and pain, in many cases. Your dentist should be made aware of these difficulties at the time of appointment scheduling. There may be a need for shorter appointments or making your dentist or hygienist aware that you must be accommodated with alternating periods of sitting in the dental chair, interrupted by position changing or standing in order to alleviate stiffness and pain. Just raise your hand. These requests can be accommodated very easily and will make your visit more comfortable.
Positioning of the head during a dental visit so that there will be proper support and minimal movement is very important. Many dental procedures require pressure or vibration. They range from the use of a dental drill or scaling instrument to that of an extraction surgical instrument that places pressure and subluxation movement on the jaw, head and neck areas.
For all oral surgical procedures, the preoperative workup should include evaluation of cervical bone erosion and ankylosis. In 21 percent of those with ankylosing spondylitis (AS), erosion of the odontoid process (projection from second vertebra of neck around which the first vertebra rotates) and transverse ligament (allows joint flexion) occur which could lead to anterior subluxation (rotation and displacement) of the cervical spine. This is associated with possible morbidity. In such cases, symptoms of occipital pain and tingling can occur due to degrees of spinal cord compression. This is more common in those patients with peripheral joint involvement.
Caution must also be taken to determine if vertebral fracture occurs at C5 – C6 or C6 – C7. Failure to detect fractures could lead to complication during surgery. Extremes of neck extension and flexion should be avoided during positioning of the head and oral cavity as they could lead to spinal cord compression.
This risk of subluxation is especially dangerous during general anesthesia procedures when neck movements are severely restricted and mouth opening is limited due to temporomandibular joint dysfunction. In these cases fiberoptic guided awake nasal intubation should be considered. Placement of a soft cervical collar is a visual reminder of an unstable spine, but does not provide any support in these instances.
Secondary osteoporosis and brittle bone due to spondyloarthritis have an effect on the mouth and surrounding joints. Even the jawbone holding the teeth in position can be affected. Osteoporosis causes osteoclastic bone remodeling and poor bone quality leading to loss of teeth, temporomandibular (TMJ) jaw joint problems or even mandible fracture.
Depending on the degree of osteoporosis activity, rheumatologists and other physicians may prescribe a class of drug known as a bisphosphonate, which prevents bone deterioration. These include Fosamax, Actonel, Boniva and Reclast. Even an oral dose of these drugs runs the remote risk of causing an exposed, “unhealing”, crumbling of the bone (osteonecrosis) at the surgical site following removal of a tooth or any bone recontouring procedure. It is extremely important that you advise your dental professional of your use of this drug regimen at the time of taking the medical history. A January 2009 article from the University of Southern California published in the Journal of the American Dental Association (JADA) estimates osteonecrosis risk from oral bisphosphonates at 4 percent. The American Dental Association Council on Scientific Affairs published an advisory statement in 2008 concluding the risk to be fewer than 10 percent of all patients taking orally administered bisphosphonate drugs.
It behooves one on bisphosphonates to practice meticulous home oral hygiene and visit their dentist for periodic exams and cleanings every six months or sooner.
Preserving your natural dentition promotes better nutrition. Most Americans do not consume the recommended levels of calcium. Supplementation with calcium and vitamin D is necessary to achieve and maintain peak bone mass, along with weight-bearing exercise to prevent osteoporosis. There is no scientific evidence in the literature to support discontinuing bisphosphonate therapy for dental treatment in order to improve treatment outcomes. Still, alternative dental treatment which does not include invasive oral surgery or extensive bone remodeling for implant placement may place you at less risk. Consult with your dentist and physicians to determine the best way to manage your treatment. This would include determination of bone mineral density (BMD), degree of risk of spine and hip fractures and duration of bisphosphonate therapy.
Secondary Sjogren’s Syndrome
Spondylitis may cause secondary Sjogren’s Syndrome, an autoimmune connective tissue disorder. It is characterized by inflammation of the exocrine glands (whose ducts ultimately open onto the external surfaces of the body) that leads to secretory hypofunction and dryness of the mucosal surfaces, most commonly of the eyes and mouth. A large majority with this disorder experience salivary gland dysfunction which can cause various oral symptoms and ultimately compromised dental health.
Sjogren’s Syndrome is the second most common autoimmune rheumatic disorder. The two forms combined (primary and secondary) have been estimated to effect up to 1 percent of the US population. The most frequent manifestation is dry mouth (xerostomia). Swollen parotid salivary glands may occur concurrently. In severe cases, ulceration and fungal infections of the mucosal lining of the mouth can occur. Dry mouth ultimately can cause severe tooth decay and gum disease. Saliva’s constant flow and natural buffering pH capacity helps to prevent decay and gum disease. Saliva contains calcium and phosphate ions that are responsible for remineralizing enamel. This protects the enamel surface from the destruction of acid forming bacteria in the mouth. A dry mouth creates an oral environment for gum disease. Difficulty with eating, swallowing and speaking may occur. Patients with secondary Sjogren’s Syndrome should see their dentists more often in order to prevent severe tooth decay or gum disease. A strict regimen of home oral hygiene is an excellent preventive measure. A large percentage of decay due to dry mouth is at the gum line. The enamel is thinner here and without salivary flow to flush out the gum sulcus which surrounds each tooth, decay and gum disease occur.
Salivary replacement therapy for dry-mouth symptoms are available either by a prescription or in the form of over-the-counter mouthwashes, toothpastes and sugar free lozenges and gum containing xylitol (ie: Biotene products). With the guidance of your dental professional, fluoride therapy (PreviDent 5000 prescription strength fluoride toothpaste) can protect the teeth against the ravages of decay. Oral lubricants such as vitamin E can be effective in soothing irritated tissue lining the mouth.
It should be noted that certain prescription medications can cause dry mouth and therefore exacerbate the condition. Alcohol has a drying effect and therefore should be avoided in beverages and in mouthwashes. Caffeine-containing drinks (coffee, tea, certain soft drinks) act as mild diuretics which promote fluid loss and could worsen dry mouth. Mouth breathers can also exacerbate the condition and therefore are encouraged to try to increase nasal breathing. If this is found to be difficult, an examination by an otolaryngology specialist is encouraged. The ambient air in many modern homes is found to be dry, especially in the winter, due to their heating systems. Therefore, the use of a humidifier, especially at night, is encouraged.
Dentists often have the opportunity to initially recognize secondary Sjogren’s Syndrome. With your co-diagnosis, early intervention can lead to appropriate preventive management, thereby minimizing or eliminating negative health consequences of tooth decay or gum disease leading to tooth loss.
TNF Alpha Blockers
The effects of drugs that mediate the immune system, such as the TNF alpha blockers (Enbrel, Humira, Remicade, Simponi), can increase the risk of serious infection compared to the general population, according to clinical studies. Accordingly, it is recommended that these drugs not be started in someone who has an active dental infection. It may be best to avoid these drugs with serious recurrent or chronic infections. TNF blockers should be temporarily discontinued when a serious dental infection develops or when antibiotics are required to treat an infection. With minor infections, at the discretion of your medical professional, TNF therapy may be continued because the benefits may outweigh the risks of temporarily stopping it. With elective surgery, such as surgical gum treatment or implant placement, there are no recommendations from the drug companies as to whether or not to temporarily stop treatment, as there are limited and conflicting data on the effect of TNF blockers on surgical outcome. Therefore, consult your dental and medical professionals as to their recommendations.
Sinus infection is sometimes encountered with TNF therapy. Any signs or symptoms should be discussed with your dentist. These may include headache, pressure in regions of the head or neck, mucous discharge or even tooth pain since the roots of upper teeth are in close approximation to the sinuses. Care must be taken since sinus drip may lead to secondary bronchitis or other respiratory problems. At any signs of fungal infection, therapy must be stopped immediately.
Periodontal (Gum) Disease
Proper oral hygiene is especially important for those with spondyloarthritis. A recent study (Periodontal disease in patients with ankylosing spondylitis; Pichon N et al; Ann Rheum Dis. 2010 Jan;69(1);34-8) shows that patients with AS have a significantly higher risk of periodontal (gum) disease. Autoimmune-mediated chronic inflammatory disorders such as rheumatoid arthritis (RA) and inflammatory bowel disease such as Crohns Disease have also been found to be associated with periodontal disease. Although extensive epidemiologic evidence exists, the biological basis for this remains unclear.
Periodontal disease is a bacterial infection caused by pathogens in the plaque covering teeth. There exists emerging evidence that the oral pathogen porphymonas gingivalis may serve to break immune tolerance or amplify the autoimmune response resulting in inflammatory tissue destruction. Periodontal disease is the most common chronic inflammatory disease in humans. A network of innate and acquired immunity, inflammation, wound healing and bone tissue turnover play important roles in the ultimate outcome. Research suggests the increase of the pro inflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha), is a factor. Research is pointing towards the oral cavity as a major battleground and source for other systemic diseases, including those that are immune-mediated.
A regimen of good home oral hygiene, professional cleanings of dental plaque and regular dental exams are important to potentially prevent the medical comorbidity of spondylitis. Close collaboration between rheumatologists, periodontists and dental hygienists is necessary for control.
Cardiovascular Disease Risk
Atherosclerosis is a major risk factor for cardiovascular disease. It has been demonstrated to have a strong inflammatory component. In the NHANES I and III population studies, there was found to be a strong positive association between periodontal (gum) disease and stroke. Some of the bacteria found in dental plaque enter the bloodstream during episodes of high bacteria. The result of infection with microorganisms interacting with the hosts’ immune and inflammatory response contributes to high levels of inflammatory protein mediators called cytokines and C-reactive proteins (CRP).
Cytokines are released by blood cells called macrophages during their process of bacteria destruction. TNF alpha is an example of a cytokine. They are necessary to signal the immune cells which results in the inflammatory response. If the initial inflammatory response fails to resolve the infection, chronic inflammation occurs which is responsible for soft tissue and underlying bone destruction of gum disease (periodontitis).
During this chronic inflammatory phase, the liver releases C-reactive proteins. This has been shown to induce blood cell platelet aggregation typical of atheroma formation (“hardening of the arteries”) and thrombosis. Similarly, there exists a clinical relevance of CRP in axial involvement ankylosing spondylitis (AS) due to inflammation of the joints. CRP is an indicator of disease activity and chronic inflammation. According to medical literature, those affected by spondyloarthritis have a multiplier risk of 1.5 for cardiovascular disease. The CRP risk factor for cardiovascular disease is increased when periodontitis and AS exist concurrently. Therefore, it is important to maintain proper oral hygiene under the direction of your dental professional.
Temporomandibular Joint Dysfunction
The temporomandibular joint (TMJ) is the bilateral joint of the lower jaw which enables initial rotational movement of the jaw followed by translational movement as the jaw opens widely. Pain and dysfunction of the TMJ is referred as temporomandibular joint dysfunction (TMD) which is commonly felt and heard as a clicking or popping. Inflammation and pain can occur when displacement of the fibrocartilagenous disc between joint capsule bone is displaced and compression of bone, arteries, veins and nerves occurs. Arthritis is a comm
n condition affecting the TMJ. Degenerative and rheumatoid arthritis are the most frequently encountered. Cases of spondylitis related TMJ disorders have been reported. Some limited movement of these joints occur in 10% of those affected with AS. In longer standing AS, the incidence may increase to as much as 30-40%. Conservative and non invasive treatment of the temporomandibular joint are endorsed for initial care. The majority of those with TMD achieve good relief of symptoms with conservative treatment. Good oral hygiene and decay prevention is important as this prevents tooth loss. Tooth movement or loss due to gum disease or tooth decay can alter the bite (occlusion) leading to further degeneration of the joint components. Clenching of the teeth can further aggravate the condition, as well.
Oral Health and Systemic Disease
As an educated partner in your medical and dental care, making your dental professional fully aware of what spondyloarthritis is, and providing a complete medical and drug history, provides information which is important for your treatment and overall health. It is important to practice meticulous oral home care and continue to visit your dental professional just as you would your rheumatologist. Oral health is a constituent of systemic health. We are beginning to understand more and more the links between poor oral health and other diseases of the body. It must also be emphasized that spondylitis has the possibility to predispose patients to oral infection, and once infection is established, it can exacerbate other systemic problems.
This article originally appeared in the Fall 2010 issue of Spondylitis Plus, the quarterly news magazine of Spondylitis Association of America. Members receive every copy of Spondylitis Plus in the mail for free. Get a Membership!