FACT SHEET: Rheumatoid Arthritis (also referred to as “RA”)
Note: This Fact sheet focuses on RA in adults. Rheumatoid arthritis in children is addressed in more detail in the Juvenile Arthritis Fact Sheet.
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
Is medical consult advised?
- No (assuming patient/client is already under medical care for rheumatoid arthritis and does not have cervical spine instability).
Is the initiation of invasive dental hygiene procedures contra-indicated?**
Is medical consult advised?
- No (assuming patient/client is already under medical care for rheumatoid arthritis, is being appropriately monitored, and does not have cervical spine instability).
- Potentially, if the patient/client is on long-term or high-dose corticosteroid therapy (to ensure adrenal insufficiency is not an issue).
Is medical clearance required?
- Possibly, if patient/client is being treated with medications associated with immunosuppression (e.g., corticosteroids, biologic response modifier drugs [including biosimilars], cyclosporine, methotrexate, etc.).
- Yes, if the patient/client has recently undergone or is about to undergo joint replacement.
Is antibiotic prophylaxis required?
- No (although extended use of corticosteroids and other immunosuppressive drugs [including biologics/biosimilars] may warrant consideration of antibiotic prophylaxis).1
Is postponing treatment advised?
- No, in most circumstances, although a flare may warrant postponement pending better disease control.
- Yes, if the patient/client lacks sufficient stamina.
- Yes, if patient/client’s ability to open mouth is excessively compromised by temporomandibular joint (TMJ) involvement.
- Yes, if there is 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).
- Yes, following recent joint replacement or revision surgery unless clearance is given by the patient/client’s orthopaedic surgeon. Typically, all routine office-based dental hygiene, including invasive procedures, should be delayed for several weeks post-surgery. Practice patterns vary among orthopaedic surgeons, with some surgeons adopting 6 weeks post-joint replacement as reasonable for dental/dental hygiene procedures, and others adopting 3 to 6 months.
Oral management implications
- Because patients/clients may have multiple joint involvement with associated immobility and pain, dental hygiene appointments should be kept as short as possible. The patient/client should be allowed to make frequent position changes as required. The semi-supine position may be more comfortable than the supine position. Physical aids, such as a rolled towel or pillow, may be used to provide support for deformed joints, limbs, or neck.
- Patients/clients with RA often take aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs), which can increase the risk of bleeding with scaling and root planing. However, the prolonged bleeding is usually not of clinical significance.
- For patients/clients taking long-term corticosteroids, delayed wound healing and increased risk of infection are considerations. The oral health practitioner must also be alert to the possibility of adrenal insufficiency when any stressful treatment or surgery is planned.
- RA often affects the wrist joints and the proximal finger joints, and this may limit a patient/client’s ability to perform oral self-care measures. To reduce pain and swelling, patients/clients may use splints on wrists and hands to support the affected joints and let them rest. An occupational therapist can assist with splint and other assistive devices selection.
- Brushing can be made easier for patients/clients by using an electric toothbrush (which has a larger handle and requires fewer motor skills), enlarging the handle of a standard toothbrush with a bike handlebar grip or tennis ball, or by using large-handled toothbrushes.
- Flossing can be made easier for patients by using U-shaped flossers as an alternative to dental string.
- Patient/client education is indicated regarding the risk of temporomandibular (TMJ) joint involvement. Regular panoramic radiographs may be employed to assess mandibular condylar wear and TMJs. (Radiographically, involved TMJs show a flattened condylar head with irregular surface features, irregularity of the temporal fossa surface, and anterior displacement of the condyle.) Premedication may be indicated before dental services.
- Anterior open bite can be addressed palliatively with interocclusal splints, physical therapy, and medication. However, surgical intervention may ultimately be required to decrease pain, restore function, or improve appearance.
- A potential long-term consequence of chronic rheumatoid arthritis is the destruction of joint structures to the extent that joint replacement with synthetic materials may be indicated. Patients/clients with prosthetic joint replacements (most commonly hip and knee, followed by shoulder, elbow, wrist, and ankle) commonly present in dental practice; for the vast majority of such patients/clients, antibiotic prophylaxis is not recommended or required).
- Cervical spine instability may result from longstanding RA. In affected patients/clients, appropriate precautions should be taken to ensure safe dental hygiene practice (e.g., neck brace to minimize C-spine movement).
- RA is associated with xerostomia (dry mouth), which increases the risk of dental caries.
- As with other autoimmune diseases, compromise of the immune system (be it from the disease or the treatment) elevates the risk of periodontal disease.
- Up to 75% of RA patients/clients eventually develop involvement of the temporomandibular joint (TMJ), which, while usually clinically insignificant, may be associated with pain and reduced range of motion. Movement of the jaw, as during talking and mastication, may be limited because of stiffness and pain. Clicking and snapping of the TMJ are not common, but may result from alterations in the articular cartilage and meniscus.
- Anterior open bite can result from the destruction of the condylar heads and loss of condylar height.
- Rheumatoid arthritis in children (particularly Still’s disease variant of juvenile rheumatoid arthritis), when it involves the TMJ, can cause malocclusion with protrusion of maxillary incisors and an anterior open bite. There may also be deformation of the mandible, with shortening of the body and reduction in the height of the ramus.
- The use of corticosteroids (such as prednisone) in the treatment of RA can lead to oral candidiasis (yeast infection) and other oral infections as a result of immunosuppression.
- Some disease-modifying anti-rheumatic drugs (DMARDs), such as cyclosporine and gold compounds, have side-effects which include gingival bleeding, oral ulcerations, stomatitis, and tender or swollen gums.2 Gold can also lead to redness and soreness of the tongue. Methotrexate can cause mouth sores, in addition to sore throat.
- Some biologic response modifier drugs (i.e., tumour necrosis factor [TNF] inhibitors [e.g., etanercept, infliximab, adalimumab, certolizimab, and golimumab] and non-TNF targeted biologic agents [e.g., tocilizumab, rituximab, sarilumab, and abatacept]), can cause sore throat and/or nasal congestion. The side-effect profile of anakinra (a biologic interleukin-1 inhibitor) includes runny nose, while sore throat and cough are associated with the use of (a biologic selective co-stimulation modulator).
Related signs and symptoms
- Rheumatoid arthritis is an autoimmune inflammatory disease that causes pain, swelling, stiffness (particularly in the morning), and loss of function of multiple joints. The arthritis is typically symmetrical; i.e., if one hand or knee is affected, the other one also is. Females are more likely to develop RA than males. The usual age at onset is 30 to 60 years, although RA may begin at any age. Prevalence in the general adult population is about 1.0%, equating to about 374,000 Canadians.3 Juvenile rheumatoid arthritis (JRA; also known as juvenile arthritis, or JA) onsets before the age of 17 years.
- In RA, the synovium (the tissue which lines the joint capsule) becomes inflamed, resulting in warmth, redness, swelling and pain. Hands, wrists, elbows, ankles, feet, and neck are particularly affected. As the disease progresses, the inflamed synovium damages the cartilage and bone of the joint. Surrounding muscles, ligaments, and tendons may become weakened. If RA affects the wrists, carpal tunnel syndrome (CTS) can result.4 Generalized bone loss may also occur, which can lead to osteoporosis (fragile bones which may lead to fracture).
- RA can also involve parts of the body other than the joints. These extra-articular effects include anemia, dry eyes and mouth, and neck pain, and, less commonly, vasculitis (inflammation of the lining of the blood vessels), pleurisy (inflammation of the lining of the lungs), and pericarditis (inflammation of the sac enclosing the heart). Systemic inflammation can affect the brain (reduced cognitive function and cerebrovascular events), heart (myocardial infarction and heart failure), and exocrine glands (secondary Sjögren syndrome). As well, persons with RA may suffer from fatigue, fevers, and general malaise.
- Rheumatoid nodules, ranging in size from a pea to a mothball, occur subcutaneously in 20% to 30% of persons with RA. These firm, typically painless bumps usually occur over pressure points and areas subject to trauma such as the elbows, knuckles, and lower legs, although they can also form over the spine, back of the heel, and other locations.
- The course of rheumatoid arthritis ranges from mild to severe. In most affected persons, the disease is a chronic, lifelong condition. For some patients/clients, periods of relatively mild disease are punctuated by flares, whereas in others, signs/symptoms are relatively constant.
- Although rheumatoid arthritis is primarily a disease of the joints, its effects are not just physical. Many people with RA also experience issues related to depression, anxiety, and low self-esteem.
- Early diagnosis of RA (i.e., within 6 months of symptom onset) is important in order for treatment to begin as soon as possible to slow or halt disease progression. However, early diagnosis is challenging because the symptoms of early RA can be non-specific (e.g., malaise, weakness, fatigue, muscle soreness, low-grade fever, weight loss).
- RA increases the risk of lymphoma.
References and sources of more detailed information
- College of Dental Hygienists of Ontario
- de Souza S, Bansal RK, Galloway J. Managing patients with rheumatoid arthritis. BDJ Team. 2017;4:17064.
- Gottenberg J-E, Morel, Perrodeau E, Bardin T, Combe B, Dougados M, et al. Comparative effectiveness of rituximab, abatacept, and tocilizumab in adults with rheumatoid arthritis and inadequate response to TNF inhibitors: prospective cohort study. BMJ. 2019; 364:l67.
- Government of Canada
- Canadian Agency for Drugs and Technology in Health
- Arthritis Society
- Canadian Dental Association
- Canadian Orthopaedic Association
- Centers for Disease Control and Prevention
- National Institutes of Health
- Arthritis Foundation
- American College of Rheumatology
- Mayo Clinic
- National Rheumatoid Arthritis Society
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8th edition). St. Louis: Elsevier; 2023.
2 Newer, targeted, synthetic DMARDs include the Janus kinase (JAK) inhibitors baricitinib, tofacitinib, and upadacitinib. Older DMARDs include gold compounds, cyclosporine, azathioprine, sulfasalazine, and hydroxychloroquine (the latter being an antimalarial drug).
3 Medical investigation of rheumatoid arthritis includes: physical examination (including joints, skin, liver, spleen, and eyes); blood tests (such as rheumatoid factor [RF], erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], anti-cyclic citrullinated peptide [anti-CCP], and complete blood count [CBC]); and other tests (such as joint x-rays, chest x-ray, and aspiration and examination of synovial fluid from swollen joints).
4 In RA-related CTS, inflammation compresses the median nerve, which results in pain, tingling, and numbness in the hand.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.