Background/Purpose:

Periodontitis (PD) is a putative risk factor for rheumatoid arthritis (RA) risk and progression.  PD is defined as inflammation of the supporting tissues of the teeth, progressive attachment and bone loss and is characterized by pocket formation and/or gingival recession.  No single definition of PD has been well established and consistently applied in research.  Although results from standardized periodontal examinations are considered the ‘gold-standard’ for PD classification, studies examining the relationship of PD with RA have also relied on patient self-report for case ascertainment.  The goal of this study was to examine the performance of patient self-reporting in identifying PD based on results from a standardized periodontal exam in patients with established RA.

Methods:

In a multicenter study, RA patients satisfying ACR classification criteria underwent a standardized, calibrated, periodontal evaluation.  PD was defined as the presence of clinical attachment loss ≥ 6 mm for 2 or more teeth and one or more sites with a probing depth ≥ 5 mm (consistent with severe PD).  Characteristics of patients with and without PD were compared using the Student’s t-test or Chi-square test.  Patients responded to 6 questions previously used in research studies to assess for a history of PD, treatment, and/or related signs and symptoms (Table); the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the questions were calculated.

Results:

Of the RA patients examined (n = 245), 82 (33.5%) had PD based on examination.  Factors associated with an increased PD frequency included age (mean 62 vs. 57 yrs for PD vs. no PD, p = 0.014), male gender (82% vs. 53%, p < 0.001), ever smoking (78% vs. 55%, p < 0.001), and seropositivity for RF (92% vs. 81%, p = 0.025) or anti-CCP antibody (93% vs. 77%, p = 0.004).  There were no associations of race, education, alcohol use, select comorbidity (diabetes, hypertension, heart disease), or medication use (prednisone, methotrexate, or biologic therapy) with the presence of PD.  The metric properties of PD-related questions are shown:

	RA / +PD	RA / No PD	Sens.	Spec.	PPV	NPV
Do your gums bleed after you brush your teeth?	32%	14%	0.317	0.858	0.531	0.713
Have you ever been told that you have periodontal or gum disease involving bone loss or deep pockets?	37%	16%	0.366	0.839	0.536	0.722
Have you ever been told that you need periodontal or gum treatment (e.g. scaling and root planning or a “deep cleaning”)?	39%	20%	0.390	0.804	0.500	0.724
Do you see a periodontist for treatment or cleanings?	28%	25%	0.284	0.748	0.365	0.672
Do you have “loose” teeth?	21%	4%	0.207	0.957	0.708	0.706
Have you ever had periodontal surgery?	16%	13%	0.159	0.875	0.394	0.670
Positive response to ≥ 1 PD screening question	70%	50%	0.707	0.497	0.414	0.771

Affirmative responses to the PD-questions were all more common (p ≤ 0.002) in RA patients with PD vs. No-PD, with differences in all but questions 4 and 6 being statistically significant. 

Conclusion:

In studies examining the relationship of PD with RA, patient self-report does not represent an adequate surrogate of clinically defined PD.  In this study severe PD is very common in patients with established RA, affecting ~1 in 3 patients.  Although demonstrating moderate to good specificity in some cases, questions commonly used to assess for the presence of PD yield insufficient sensitivity (< 40%) in this population.  Both PPV and NPV of these questions were consistently below 80% in this population, suggesting that misclassification and study bias are likely to occur in RA studies using patient self-report for PD case ascertainment.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/poor-to-moderate-performance-of-patient-self-report-in-indentifying-periodontitis-in-patients-with-rheumatoid-arthritis/