Find a Registered Dental Hygienist


Knowledge Network

CDHO Advisory: Rheumatoid Arthritis









Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with rheumatoid arthritis.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Rheumatoid Arthritis, 2023-06-27


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).



Rheumatoid arthritis


Advanced practice nurses
Dental assistants
Dental hygienists
Health professional students
Public health departments
Regulatory bodies


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have rheumatoid arthritis, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.


Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Parents, guardians, and family caregivers of children, young persons and adults with rheumatoid arthritis.


For persons who have rheumatoid arthritis: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.



Terminology used in this Advisory

Resources consulted

Rheumatoid arthritis is a long-term autoimmune disorder that leads to inflammation of joints, and surrounding tissues, which variously results in

  1. inflammatory synovitis
  2. joint destruction
  3. bone destruction
  4. muscle atrophy
  5. effects on 
    1. lungs
    2. eyes
    3. blood vessels
    4. skin 
    5. other organs.

Other terminology used in this Advisory is as follows.

  1. Burning mouth syndrome, causes persistent burning pain in the mouth, which
    1. may affect the
      1. gums
      2. inside of the cheeks
      3. lips
      4. roof of the mouth
      5. whole mouth or most of it
      6. tongue
    2. may be severe, as if the mouth is scalded 
    3. is often of unknown cause
    4. can usually be brought under control
    5. may be called 
      1. burning lips syndrome
      2. burning tongue syndrome
      3. glossodynia
      4. scalded mouth syndrome
      5. stomatodynia.
  2. Candida, oral candidiasis, also termed thrush or oral moniliasis, is 
    1. a yeast infection of the mouth or throat 
    2. most commonly caused by Candida albicans.
  3. Hemostasis
    1. the process by which blood flow is stopped
    2. includes the processes of clot formation.
  4. Immunosuppression (CDHO Advisory), suppression of immunity with medications, the uses of which include the treatment of certain autoimmune diseases, such as rheumatoid arthritis; its main drawback is the increased risk of infection for the duration of treatment.
  5. Lesion, a term variously and loosely used in medicine to refer to such things as
    1. any abnormality of tissue in the body, including the mouth and skin
    2. any localized abnormal structural change in a bodily part
    3. a mass especially before a definite diagnosis is established
    4. cancer
    5. an injury to living tissue, such as a cut or break in the skin.
  6. Oral ulcer, an open lesion, often painful, inside the mouth or upper throat, an alternative name for 
    1. aphthous stomatitis, also known as a canker sore
    2. aphthous ulcer
    3. cancerous ulcer
    4. mouth ulcer.
  7. Palliative care, services of care for persons towards the end of life with terminal illnesses, when the focus of the care 
    1. is relieving symptoms
    2. is attending to physical and spiritual needs.
  8. Peripheral neuropathy, damage to the peripheral nervous system, which transmits information
    1. from the brain and spinal cord to every part of the body
    2. sensory information to the brain and spinal cord.
  9. Purpura, purplish discoloration due to bleeding underneath the skin, which may result in swelling. 
  10. Rheumatoid nodules, firm, non-tender, subcutaneous nodules which
    1. develop in 20% to 30% of persons with rheumatoid arthritis
    2. are commonly found at pressure points like the elbow, back of the forearm, and metacarpophalangeal joint
    3. may vary in size during the course of the disease
    4. usually occur in active cases of rheumatoid arthritis
    5. are commonly associated with 
      1. severe joint deformities
      2. serious non-joint manifestations in the lungs, eyes, and blood vessels.
  11. Rheumatoid vasculitis, a condition in which blood vessels 
    1. are inflamed
    2. are weakened 
    3. are increased in size, or become narrowed, even to the point of stopping blood flow
    4. cause blood supply problems for skin, nerves, and internal organs.
  12. Scleritis, inflammation of the sclera, which
    1. occurs commonly in autoimmune disorders
    2. creates symptoms that include
      1. red or pink eye
      2. eye pain
      3. light sensitivity
      4. tearing
      5. blurred vision.
  13. Serum rheumatoid factor, an antibody that 
    1. attaches to other antibodies
    2. is present in the blood of many persons with rheumatoid arthritis
    3. is used as a means of diagnosis.
  14. Sicca syndrome, a term reserved for the combination of dryness of the mouth and eyes, regardless of cause; when accompanied by lymphocyte infiltration of the salivary glands is named Sjögren syndrome (CDHO Advisory).
  15. Sjögren syndrome, a serious, systemic, persistent autoimmune disorder that may be associated with rheumatoid arthritis and which
    1. is considered to be one of the most prevalent autoimmune diseases
    2. is often under-recognized and under-treated
    3. most commonly
      1. attacks and damages the salivary, tear and mucus-secreting glands
      2. results in xerostomia
      3. results in swollen salivary glands
    4. may cause or be associated with 
      1. arthritis
      2. debilitating fatigue
      3. neuropathy
      4. painful, weak muscles
    5. may cause or be associated with inflammation of 
      1. blood vessels
      2. brain
      3. gastrointestinal system
      4. kidneys
      5. liver
      6. lungs
      7. thyroid gland. 
  16. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the condition or its treatment.
  17. Synovitis, inflammation in the lining of the joint, the synovium, characterized by
    1. swelling
    2. redness
    3. warmth.
  18. Xerostomia, abnormal dryness of the mouth resulting from decreased secretion of saliva; has various causes including
    1. sicca syndrome
    2. Sjögren syndrome (CDHO Advisory)
    3. some medications.

Overview of rheumatoid arthritis

Resources consulted


Rheumatoid arthritis

  1. affects about 374,000 adult Canadians, about 1 percent of the population
  2. occurs three times more often in women than men
  3. develops typically in the age range 30 to 60 years though also can manifest in children (as juvenile arthritis) and in elderly adults.


Rheumatoid arthritis

  1. is an autoimmune inflammatory disease
  2. is of unknown cause
  3. may be linked to infection, genes, and hormone changes.

Risk factors

Rheumatoid arthritis is believed to be subject to risk factors that include

  1. age: can occur at any age, but most commonly begins between the ages of 30 and 60
  2. cigarette smoking: increases the risk of rheumatoid arthritis; quitting smoking may reduce the risk
  3. family history: may increase the risk of rheumatoid arthritis, though the belief holds that it is the predisposition to rheumatoid arthritis rather than the rheumatoid arthritis itself that is inherited
  4. sex: women are more likely to develop rheumatoid arthritis than men.

Signs and symptoms

Rheumatoid arthritis

  1. has a variable course, with the results of treatments differing from person to person
  2. is subject to flares, which 
    1. are acute exacerbations of the symptoms
    2. may last from a few days to a few weeks
  3. may affect any joint, but typically 
    1. affects joints on both sides of the body equally
    2. affects
      1. ankles
      2. feet
      3. fingers
      4. knees
      5. wrists
  4. often starts slowly, with 
    1. fatigue
    2. minor joint pain
    3. stiffness
  5. as it develops is associated with symptoms and signs
    1. in joints, such as
      1. pain and swelling
        1. in the same joint on both sides of the body
        2. sufficient to impair mobility and activities of daily living
      2. morning stiffness, which lasts more than an hour
      3. warmth, tenderness and stiffness following  an hour’s inactivity
      4. deformation and damage that
        1. occurs even in cases when the pain is not severe
        2. occurs commonly in the early years of the disease 
        3. when severe, produces permanent joint deformity and loss of range of motion
    2. in other organs, including
      1. eye burning with discharge, itching, or drainage 
      2. nodules under the skin 
      3. numbness, tingling, or burning in the hands and feet
      4. sharp chest pain with deep breaths
      5. Sjögren’s syndrome. 

Medical investigation

Rheumatoid arthritis

  1. lacks a definitive test
  2. is characterized by the presence of 
    1. inflammatory arthritis
      1. of three or more joints
      2. with symptoms that last more than six weeks
      3. that is usually symmetrical (same joints on both sides of the body)
    2. morning stiffness in and around joints lasting at least one hour before maximum improvement 
    3. rheumatoid nodules
    4. serum rheumatoid factor
  3. may  include
    1. anti-CCP antibody test
    2. complete blood count
    3. C-reactive protein
    4. erythrocyte sedimentation rate
    5. joint ultrasound or MRI
    6. joint x-rays
    7. synovial fluid analysis.


of Rheumatoid arthritis

  1. emphasizes early, aggressive treatment to delay joint destruction
  2. typically requires lifelong treatment, which variously includes
    1. medications
    2. physical therapy, including
      1. deep heat or electrical stimulation to reduce pain and improve joint movement
      2. frequent rest periods between activities
      3. joint protection techniques, heat and cold treatments, and splints or orthotic devices 
      4. range-of-motion exercises and other exercise programs 
    3. surgery for severely damaged joints, including
      1. removal of the joint lining
      2. total joint replacement of
        1. ankle
        2. hip
        3. knee 
        4. shoulder replacement.


of rheumatoid arthritis lacks any known universally effective means, although quitting cigarette smoking may reduce risk.


of rheumatoid arthritis depends on

  1. severity of symptoms
  2. age of development, at a young age, it deteriorates relatively rapidly
  3. severity of the disease, which appears to be related to the presence of
    1. rheumatoid factor
    2. subcutaneous nodules 
  4. treatment, early treatment with appropriate medications appears to reduce or delay joint pain and damage.

Social considerations

for persons with rheumatoid arthritis, requirements include trustworthy information and means by which they can connect with each other; such resources include

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with rheumatoid arthritis but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions for rheumatoid arthritis, which can affect almost all parts of the body, include the following.

  1. Autoimmune disorders, which 
    1. produce Sjögren’s syndrome (CDHO Advisory) which in turn may lead to
      1. candidiasis
      2. burning mouth syndrome
      3. mouth ulcers
    2. involve other internal organs
  2. Blood conditions
    1. anemia (CDHO Advisory)
    2. purpura 
  3. Bone 
    1. osteoporosis (CDHO Advisory)
    2. stress fractures 
    3. spinal injury when the neck bones become damaged
  4. Cardiovascular system
    1. arteriosclerosis 
    2. hypertension (CDHO Advisory)
    3. heart disease
      1. heart failure (CDHO Advisory)
      2. myocarditis
      3. pericarditis
    4. rheumatoid vasculitis
  5. Disability arising with
    1. hand-joint deformities
    2. mobility problems
  6. Eye conditions
  7. Infection, most likely to be a complication of treatment, especially immunosuppression
  8. Metabolism
    obesity (CDHO Advisory)
  9. Nervous system
    1. entrapment of nerves at the joints of the
      1. elbow
      2. knee 
      3. wrist, creating carpal tunnel syndrome
    2. peripheral neuropathy
  10. Psychiatric and psychological conditions, which at some point affect some two thirds of persons with rheumatoid arthritis
    1. depression (CDHO Advisory)
    2. fatigue
    3. sleep disturbances
  11. Respiratory disease 
    1. damage to the lung tissue (rheumatoid lung)
    2. lung disease associated with rheumatoid nodules
    3. tuberculosis (CDHO Advisory)

Oral health considerations

Resources consulted

Key considerations include

  1. The importance of the Procedures 
    1. in limiting the growth of harmful bacteria and therefore infection
    2. for combating infection and lowering the risk of osteonecrosis (CDHO Advisory) of the jaw associated with infection.
  2. Infection control.
  3. Oral conditions occurring with rheumatoid arthritis
    1. that may affect oral healthcare include 
      1. the patient/client’s inability to maintain adequate oral hygiene
      2. requirements for modifications in oral self-care methods because of loss of dexterity of hand and fingers
      3. xerostomia and its causes and complications  
      4. susceptibility to infections 
      5. impaired hemostasis
      6. medication side effects
      7. oral ulceration
      8. gingival overgrowth
      9. periodontitis
      10. periodontitis combined with tooth loss 
        1. occurs in older patients/clients
        2. may call for dental hygiene care in consultation with the rheumatologist
      11. periodontal attachment loss which 
        1. appears to be increased 
        2. may only be partially accounted for by inadequacy of oral hygiene
      12. sicca syndrome
      13. temporo-mandibular pathology
    2. signal 
      1. an important role for dental hygienists
        1. in the care of the mouth as a contribution to the overall healthcare 
        2. in early detection because they may be the first to identify signs of rheumatoid arthritis
      2. the requirement for dental hygienists to consider modifications of the Procedures for patients/clients with rheumatoid arthritis.
  4. Requirements for antibiotic prophylaxis arising from 
    1. joint replacement (CDHO Advisory)
    2. immunosuppression (CDHO Advisory) associated with the inflammatory nature of rheumatoid arthritis or with medications. 
  5. Sjögren’s syndrome (CDHO Advisory), with implications for oral health. 
  6. Potential linkages among periodontal disease, joint destruction and severity of bone destruction, involving 
    1. Sjögren’s syndrome (CDHO Advisory)
    2. the element in common between rheumatoid arthritis and gum disease: both are systemic inflammatory disorders.


Sourcing medications information

  1. Adverse effect databases
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

  1. Antimalarials, for treatment of skin rashes, arthritis, and mouth ulcers, include
    1. chloroquine phosphate oral (Aralen® Phosphate)
    2. hydroxychloroquine (Plaquenil®)
  2. Biologic response modifiers (“Biologics”) 
    1. are used to treat moderate to severe rheumatoid arthritis to block specific hormones involved in the process of inflammation
    2. produce immunosuppression, which may interfere with the body’s ability to combat infections
    3. are given by injection at home or by an intravenous infusion at a clinic
    4. include
      abatacept injection (Orencia®)
      adalimumab (Humira®)
      anakinra (Kineret®)
      certolizumab injection (Cimzia®)
      etanercept injection (Enbrel®)
      golimumab injection (Simponi®)
      infliximab injection (Remicade®)
      rituximab injection (Rituxan®)
      sarilumab injection (Kevsara®)

      tocilizumab injection (Actemra®)
  3. Corticosteroids 
    1. that mimic cortisone are used to treat severe inflammation of joints accompanied by troublesome pain and stiffness, and for rheumatoid arthritis affecting the lining of the lungs and blood vessels
    2. in pill form are used to reduce inflammation if many joints are affected at the same time
    3. include
      prednisone (Prednisone Intensol®, Sterapred®)
  4. Disease-modifying anti-rheumatic drugs (DMARDS), which act by blocking inflammation via immunosuppression to inhibit the immune system from attacking the joints, but they do not reverse existing damage; they include
    azathioprine (Azasan®, Imuran®)
    baracitinib (Olumiant®)
    cyclosporine (Gengraf®, Neoral®, Sandimmune®)
    hydroxychloroquine (Plaquenil®)
    leflunomide (Arava®)
    methotrexate (Rheumatrex®, Trexall®)
    sulfasalazine (Azulfidine®)
    tofacitinib (Xeljanz®)
    upadacitinib (Rinvoq®)
  5. Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling
    1. over-the-counter examples
      aspirin (ASA, Acetylsalicylic acid)
      ibuprofen (Advil®, Motrin®)
      naproxen (Aleve®, Anaprox® among others) 
    2. prescription examples
      celecoxib (Celebrex®)
      diclofenac (Cataflam®, Voltaren®-XR)
      indomethacin (Indocin®)
      nabumetone (Relafen®)
      sulfasalazine (Azulfidine®)
      sulindac (Clinoril®)

Side effects of medications

See the links above to the specific medications. 


The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. flares
    2. immunosuppression
    3. joint replacement (CDHO Advisory)
    4. the patient/client’s understanding and acceptance of the need for oral healthcare
    5. medications considerations, including over-the-counter medications, herbals and supplements
    6. problems with previous dental/dental hygiene care
    7. problems with infections generally and specifically associated with dental/dental hygiene care
    8. the patient/client’s current state of health
    9. how the patient/client’s current symptoms relate to
      1. bleeding tendency
      2. health generally
      3. oral health
      4. recent changes in the patient/client’s condition.


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.


The dental hygienist 

  1. should not implement the Procedures without  prior consultation with the appropriate primary or specialist care provider(s)
    1. if the patient/client’s treatment includes immunosuppression
    2. if the patient/client has recently undergone or is about to undergo joint replacement (CDHO Advisory)2
    3. if the patient/client’s condition or co-morbidity or treatment calls for antibiotic prophylaxis.
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears debilitated
    2. is in a flare
    3. is experiencing symptoms suggestive of complications of rheumatoid arthritis or its treatment
    4. has cervical spine instability for which appropriate precautions are unable to be taken to ensure safe dental hygiene practice (e.g., neck brace to minimize C-spine movement)
    5. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician 
    6. has recently changed significant medications, under medical advice or otherwise
    7. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    8. is unable to provide the dental hygienist with sufficient information about
      1. medications
      2. transplantation
      3. treatment for the rheumatoid arthritis
    9. has symptoms or signs of 
      1. exacerbation of the medical condition
      2. comorbidity, complication or an associated condition of liver disease
    10. not recently or ever sought and received medical advice relative to oral healthcare procedures
    11. is deeply concerned about any aspect of his or her medical condition.


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of rheumatoid arthritis, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.


The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test 
    1. that he or she has a history of rheumatoid arthritis
    2. to the medications he or she is taking
  2. should discuss, as appropriate
    1. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
      3. taking medication(s) as prescribed for pre-medication including antibiotic prophylaxis
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth including the advice given for Sjögren’s Syndrome (CDHO Advisory)
    4. the importance of an appropriate diet in the maintenance of oral health
    5. for persons at an advanced stage of a disease or debilitation
      1. regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to rheumatoid arthritis, comorbidities, complications or associated conditions, medications or diet
    9. pain management.



  1. Promoting health through oral hygiene for persons who have rheumatoid arthritis.
  2. Reducing the adverse effects, such as failure to recognize that a patient/client is receiving immunosuppression, by
    1. emphasising the importance of the medications history
    2. using appropriate techniques of communication
  3. Reducing the risk that oral healthcare needs are unmet.


  1. Causing infection in a patient/client who has received or is about to receive a joint replacement.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client’s rheumatoid arthritis is in a flare
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with rheumatoid arthritis.
  4. Inappropriate management of pain or medication.






2010-07-15; 2012-01-01; 2019-09-24; 2023-06-27


College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists


College of Dental Hygienists of Ontario


College of Dental Hygienists of Ontario, Practice Advisors


Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

Lisa Taylor

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage


The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2010, 2012, 2019, 2023 College of Dental Hygienists of Ontario


1 Persons includes young persons and children
2 Most patients/clients with prosthetic joints do not require antibiotic prophylaxis for invasive dental hygiene procedures, as per the 2016 Canadian Orthopaedic Association/Canadian Dental Association/Association of Medical Microbiology and Infectious Disease Canada Consensus Statement. Patients/clients with RA, however, may be on immunosuppressive medications that warrant antibiotic consideration.