Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions
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International Journal of Molecular Sciences Review Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions Rafael Scaf de Molon 1,* , Carlos Rossa Jr. 1, Rogier M. Thurlings 2, Joni Augusto Cirelli 1 and Marije I. Koenders 2 1 Department of Diagnosis and Surgery, School of Dentistry at Araraquara, Sao Paulo State University–UNESP, Araraquara 14801-903, Sao Paulo, Brazil 2 Department of Rheumatology, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands * Correspondence: [email protected]; Tel.: +55-16-99730-9293 Received: 4 July 2019; Accepted: 20 August 2019; Published: 13 September 2019 Abstract: The association between rheumatoid arthritis (RA) and periodontal disease (PD) has been the focus of numerous investigations driven by their common pathological features. RA is an autoimmune disease characterized by chronic inflammation, the production of anti-citrullinated proteins antibodies (ACPA) leading to synovial joint inflammation and destruction. PD is a chronic inflammatory condition associated with a dysbiotic microbial biofilm affecting the supporting tissues around the teeth leading to the destruction of mineralized and non-mineralized connective tissues. Chronic inflammation associated with both RA and PD is similar in the predominant adaptive immune phenotype, in the imbalance between pro- and anti-inflammatory cytokines and in the role of smoking and genetic background as risk factors. Structural damage that occurs in consequence of chronic inflammation is the ultimate cause of loss of function and disability observed with the progression of RA and PD. Interestingly, the periodontal pathogen Porphyromonas gingivalis has been implicated in the generation of ACPA in RA patients, suggesting a direct biological intersection between PD and RA. However, more studies are warranted to confirm this link, elucidate potential mechanisms involved, and ascertain temporal associations between RA and PD. This review is mainly focused on recent clinical and translational research intends to discuss and provide an overview of the relationship between RA and PD, exploring the similarities in the immune-pathological aspects and the possible mechanisms linking the development and progression of both diseases. In addition, the current available treatments targeting both RA and PD were revised. Keywords: periodontal disease; rheumatoid arthritis; alveolar bone loss; bone; periodontitis; bone resorption 1. Introduction The possible association between rheumatoid arthritis (RA) and periodontal disease (PD) has been investigated because of the numerous similarities in pathological and immunological characteristics, including: (1) Increased infiltration of inflammatory and immune cells including neutrophils, monocytes, and T and B lymphocytes; (2) increased release of pro-inflammatory mediators such as the tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6), and matrix-degrading enzymes (MMPs, Cathepsin); (3) increased activation of the receptor activator of the factor nuclear kappa B (NF-κB) ligand (RANK-L) pathway induced by soluble mediators released by immune cells [1], with subsequent osteoclast differentiation and maturation. In addition, decreased levels of anti-inflammatory mediators, such as the IL-10 and transforming growth factor-β (TGF-β) are also Int. J. Mol. Sci. 2019, 20, 4541; doi:10.3390/ijms20184541 www.mdpi.com/journal/ijms Int. J. Mol. Sci. 2019, 20, 4541 2 of 35 Int. J. Mol. Sci. 2019, 20, x FOR PEER REVIEW 2 of 34 reportedβ (TGF- inβ) are both also RA reported and PD in [ both2–5]. RA PD and and PD RA [2–5]. also PD lead andto RA systemic also lead inflammation, to systemic inflammation, indicated by increasedindicated levels by increased of the C-reactive levels of th proteine C-reactive (CRP) protein in the (CRP) plasma in the [6]. plasma Environmental [6]. Environmental factors (smoking) factors and(smoking) genetic backgroundand genetic background (gene polymorphisms) (gene polymorphism are alsos) considered are also considered risk factors risk for factors both conditions.for both A summaryconditions. of A the summary overlapping of the overlapping features of RA features and PD of RA is presented and PD is inpresented Figure1 .in Figure 1. FigureFigure 1. 1.Possible Possible biological biological intersections intersections between rheu rheumatoidmatoid arthritis arthritis (RA) (RA) and and periodontal periodontal disease disease (PD):(PD): Common Common risk risk/predisposing/predisposing factors factors andand reciprocalreciprocal biological influences. influences. The The exposure exposure to tocertain certain environmentalenvironmental factors, factors, e.g., e.g., smoking, smoking, geneticgenetic background (HLA-DRB1-SE), (HLA-DRB1-SE), gut gut microbiome, microbiome, infection infection withwithP. P. gingivalis gingivalisand and more recently recently with with A. A.actinomycetemcomitans actinomycetemcomitans (microbial(microbial dysbiosis) dysbiosis) leads to leads local to localprotein protein alteration alteration by bycitrullination. citrullination. In Incombinat combinationion with with an aninflammatory inflammatory process process stimulated stimulated by by macrophages,macrophages, dendritic dendritic cells, cells, and and T cells, T cells, a host a host response response to citrullinated to citrullinated proteins proteins in predisposed in predisposed patients willpatients occur. Immunewill occur. cells Immune will produce cells will proinflammatory produce proinflammatory mediators (Interleukins mediators (Interleukins (ILs), Prostaglandins (ILs), (PGs),Prostaglandins Tumor Necrosis (PGs), FactorTumor (TNF),Necrosis and Factor metalloproteinases (TNF), and metalloproteinases (MMPs), which (MMPs), also contribute which also to the aggravationcontribute ofto thethe immune aggravation response. of the IL-17, immune an importantresponse. cytokineIL-17, an ofimportant the Th17 cytokine induces theof the production Th17 induces the production of CXC chemokines, MMPs, and reactive oxygen species (ROS), as well as the of CXC chemokines, MMPs, and reactive oxygen species (ROS), as well as the osteoblast expression of osteoblast expression of the receptor activator of the factor nuclear kappa B ligand (RANK-L) that the receptor activator of the factor nuclear kappa B ligand (RANK-L) that stimulate osteoclast activation. stimulate osteoclast activation. Stimulated lymphocytes (B and T cells, specifically Th1 and Th17) play Stimulated lymphocytes (B and T cells, specifically Th1 and Th17) play an important function during an important function during bone resorption by means of the RANKL-dependent mechanism in both bone resorption by means of the RANKL-dependent mechanism in both conditions. P.gingivalis infection conditions. P. gingivalis infection lead to the activation of proteases and peptidylarginine deiminase lead to the activation of proteases and peptidylarginine deiminase (PPADs) that generates citrullinated (PPADs) that generates citrullinated proteins and triggers the synthesis of anti-citrullinated proteins proteins and triggers the synthesis of anti-citrullinated proteins antibodies (ACPAs). A resultant antibodies (ACPAs). A resultant signal against citrullinated epitopes in the joints resulting in signal against citrullinated epitopes in the joints resulting in enhanced expression of the rheumatoid enhanced expression of the rheumatoid factor (RF) and ACPAs, assisting in the formation of immune factorcomplexes. (RF) and A. ACPAs,actinomycetemcomitans assisting in the lead formation to the hypercitrullination of immune complexes. of neutrophilsA. actinomycetemcomitans and result in the leadactivation to the hypercitrullination of citrulline enzymes, of neutrophilswhich are also and in resultvolved in in the the activation breakdown of of citrulline the immune enzymes, tolerance which areto also the host involved molecules. in the These breakdown immune of complexes the immune enhance tolerance the host to inflammato the host molecules.ry development, These immunewhich complexesmay aggravate enhance RA. the In addition, host inflammatory the autoantibodies development, produced which during may this aggravate process might RA. In contribute addition, to the autoantibodiesthe inflammatory produced process during by directly this process activating might osteoclast contribute and to resulting the inflammatory in the bone process and cartilage by directly activatingdamage. osteoclast Thus, citrullination and resulting may in represent the bone anda biological cartilage mechanism damage. Thus, bridging citrullination reciprocal may influences represent a biologicalbetween RA mechanism and PD. bridging reciprocal influences between RA and PD. Int. J. Mol. Sci. 2019, 20, 4541 3 of 35 In spite of differences in the etiologies of RA (autoimmune) and PD (dysbiotic microbial biofilm), there are similar biological processes involved, such as citrullination and autoantibody response [7,8] and the pivotal role of bacterial dysbiosis, which may represent direct links between these two conditions [1,9–11]. Citrullination of peptides is mediated by peptidylarginine deiminase (PAD) and is considered a key event in RA [12,13]. Recently, it was reported that the periodontal pathogen P. gingivalis express PAD, may represent a direct biological intersection between PD and RA [13–17]. Accordingly, recent studies have strengthened the hypothesis that PD is a risk factor for the RA development [18,19]. The authors showed that individuals at