Effect of periodontal treatment on rheumatoid arthritis

INTERVENTION: For patients in the treatment group we will undertake a course of conventional periodontal examination and treatment This will include oral hygiene instruction and full mouth cleaning over a 4 week period. These visits (30 minutes weekly for 4 weeks) will involve cleaning around the teeth under local anaesthesia, doing a quarter of the mouth at a time (upper right, upper left, lower left, lower right). Following this, regular periodontal maintenance involving a periodontal assessment, oral hygiene instruction and full mouth cleaning will be carried out 2,4 and 6 months after completion of the initial conservative periodontal treatment. CONDITION: Periodontal Disease Rheumatoid arthritis PRIMARY OUTCOME: Anti‐CCP antibody levels in serum Change in Disease Activity Score (DAS‐28) Serum CRP SECONDARY OUTCOME: Periodontal response to periodontal treatment. This is achieved by a standard periodontal examination which includes measuring the periodontal pockets, clinical attachment levels, gum bleeding, gum colour and collection of a sample of gingival crevicular fluid. Periodontal pockets and clinical attachment levels are determined using a periodontal probe which is a small metallic instrument with millimetre markings on it. The probe is gently inserted into the space between the gum and the tooth and the depth it sinks to is recorded in millimetres. This is a relatively painless procedure and is standard clinical practice. Gum colour and gum bleeding are assessed visually. Collection of gingival crevicular fluid involves placement of a piece of filter paper adjacent to the position of where the gum meets the tooth. It is left in place for 30 seconds to collect the fluid which naturally seeps out of the periodontal pocket into the oral cavity. This is a painless and atraumatic clinical procedure. The levels of inflammatory cytokines (eg IL‐1), CRP, citrullinated proteins and anti‐CCP antibodies in the collected fluid are then measured in our laboaratory. INCLUSION CRITERIA: All participants must have rheumatoid arthritis. Willingness to participate and return for multiple visits; presence of gingivitis, mild, moderate or advanced chronic periodontitis, partially or fully dentate patients (at least 20 teeth); no evidence of known systemic modifiers of periodontal disease such as: type I and II diabetes mellitus, osteoporosis, disorders of cellular immunity (e.g. AIDS, cyclic neutropenia, or other known specific leukocyte defects which we know predisposes to periodontitis), medications known to influence the periodontal tissues, or any conditions that would contraindicate a periodontal examination (e.g. risk of bacterial endocarditis). To be included in the RA group, all participants must have rheumatoid arthritis. Patients will need to indicate a willingness to participate and return for multiple visits and be partially or fully dentate patients (at least 20 teeth). Individuals with evidence of sicca symptoms will not