1. Introduction
Periodontal diseases are infection-inflammatory conditions that lead to the destruction of connective tissue and bone, and that can systemically impact on the overall health of individuals [
1] and interfere with other pathologies and their recovery. Periodontitis has been associated with different types of autoimmune diseases including rheumatoid arthritis (RA), as both diseases share common immunological features as well as common risk factors, one of particular importance being smoking [
1,
2]. Both RA and periodontitis are characterized by self-sustaining inflammation in a fluid-filled compartment adjacent to bone, in which inflammatory cells and other phlogistic factors lead to common clinical manifestations (pain, swelling, tenderness) and, eventually, to destruction of the adjacent bone [
1,
2,
3].
A recent 2022 study aimed at determining the perceptions held by people with RA relating to their oral health found that people with RA have unique oral health perceptions and experience significant challenges with oral health care, thus requiring adaptation of oral hygiene recommendations and professional oral care delivery [
4]. However, few studies have investigated the knowledge and attitudes of rheumatologists and rheumatoid arthritis patients towards periodontal health. The existing information indicates the periodontal health knowledge of medical practitioners is somewhat inadequate, and a closer interaction between medical doctors and dentists is needed. A study of 222 general practitioners (GPs) found that respondents had a much poorer knowledge of the relationship between periodontal disease and joint disease (43%) compared to other systemic diseases such as diabetes mellitus (72%) and cardiovascular disease (CVD) (55%) [
5]. Their attitude regarding periodontal status was also assessed by asking how often they performed an oral examination, whether they asked their patients about gingival bleeding, or whether they receive regular dental care and if they would refer patients with systemic diseases to a dentist [
5]. The results showed a severe deficit in knowledge and attitudes among GPs toward the association between periodontal disease and RA.
Similarly, a regionwide survey in the north of France found that GPs had poor knowledge of the association between periodontitis and RA, with only 35.18% of surveyed GPs identifying it as a possible risk factor [
6]. This study also inquired as to whether GPs asked their patients about any dental pain or tooth mobility, or advised regular follow-ups with their dental surgeon [
6]. A qualitative study interviewing patients with RA found that despite acknowledging the importance of maintaining good oral hygiene, it was not a priority compared to the burden of the comorbidity they had to live with [
7]. The debilitating nature of RA meant that maintaining proper oral hygiene was an added burden, being especially difficult when RA flare-ups occurred [
7]. This added comorbidity limited the patients’ mobility, made transport to their dental appointments much more difficult, and compounded their risk of poor oral hygiene and subsequent periodontal disease, which would potentially further increase the incidence and severity of RA in a continuing vicious cycle.
The high prevalence of periodontitis in the adult population worldwide and in Australia [
3] and the likely two-way relationship between RA and periodontal disease [
2], would benefit from improved knowledge in relation to their association, and could potentially have significant benefits in their clinical and public health implications. Further investigation between their links such as their pathophysiology, diagnosis, impact, and management would aid in the development of appropriate educational courses to improve on these gaps in knowledge, leading to appropriate and effective management of both diseases.
Aims and Objectives
The aim of the present study was to assess the knowledge, attitudes, behaviours, practices, and education preferences about periodontal health and disease among rheumatoid arthritis patients and rheumatologists.
2. Materials and Methods
2.1. Study Design and Data Collection
All aspects of the project were conducted in line with the ethical principles as stated by the World Medical Association Declaration of Helsinki and were submitted to and approved by the Human Research Ethics Committee of UWA (2021/ET000558).
Full disclosure of the aims and methods of the study was provided to the participants. The participants were given the right to accept or decline their participation in the survey, including the right to not answer specific questions. The participants had the decisional capacity to answer the survey and understood that by participating in the survey there may be no direct self-benefit. All participant details remained confidential and were only be used for the purpose of the study. Participant details were not distributed or used for any other circumstances. Informed consent was required by the participants to ensure their understanding of the above.
Two questionnaires, one for rheumatologists and another for rheumatoid arthritis patients, were designed using an online survey software, Qualtrics. The questionnaires included demographic items, items about knowledge, attitudes and behaviour about periodontal health and disease, as well as information about training and preferences regarding further education in the area. A link to the survey was provided via email to participants. It was estimated that the survey would take a maximum of ten minutes to complete. All responses were anonymous.
Multiple choice questions, binary response, and Likert scale questions were employed. The questionnaire tools were validated by iterative feedback from periodontic specialists.
2.2. Subjects/Samples
2.2.1. Rheumatologists
Rheumatologists who were registered under the Australian Rheumatology Association (ARA) practising in Western Australia were contacted by email and phone and invited to complete an online self-administered questionnaire. The online questionnaire was distributed via email.
2.2.2. Rheumatoid Arthritis Patients
RA patients were invited to complete a separate questionnaire specifically designed for patients, which was advertised through the social media pages of the Arthritis and Osteoporosis WA organisation. A lower age limit of 18 was required to participate.
2.3. Statistical Analysis
Appropriate statistical analysis was performed using Chi-squared and Fishers exact tests to measure significant differences in categorical variables. A p value equal to or less than 0.05 was considered statistically significant.
4. Discussion
This study aimed to assess the knowledge and attitudes towards periodontal health among rheumatologists and RA patients. We found that there was a deficit in knowledge about the relationship between periodontal and systemic diseases among both rheumatoid patients and rheumatologists. Rheumatoid arthritis patients who knew what type of RA diagnosis they had were more likely to know about this relationship, and patients that have been living with their diagnosed condition for a longer period were more likely to experience signs of periodontal disease. Those that believed oral hygiene could impact their rheumatoid arthritis were more likely to receive periodontal treatment. Patients who were unemployed visited the dentist less frequently and did not value their oral hygiene as highly as those that were employed.
When evaluating the responses of rheumatologists, a trend was found for those aged 60 and over and those who had been graduated for longer. This group did not agree that oral disease could be linked to systemic disease, and they also less frequently asked patients about their oral hygiene and less frequently performed oral exams. Rheumatologists who agreed oral disease can be linked to systemic disease more frequently asked about patients about their oral hygiene and more frequently performed oral exams.
These results are comparable to results obtained from similar survey studies in different populations. For example, in the 2017 study by Alexia et al. [
5], the main finding was that there is a severe deficit in knowledge about the relationship between periodontal and systemic diseases among GPs [
5]. To evaluate how this was reflected in the GPs’ clinical practices, participants were asked about the frequency they performed oral examinations. Overall, 75% and 15% of answers fell in the sometimes or never categories, respectively, with only 20% answering always [
5]. These findings are consistent with our results, which found that 71% and 15% of GPs answered sometimes or never, respectively, and only 14% answered always. When evaluating RA patients’ responses, 56% of participants did not know of the link between oral and systemic diseases, and 79% did not know that oral hygiene can impact RA. A 2022 study by Protudjer et al. [
4], also found that patients had limited knowledge regarding the associations between arthritis and oral disease, and many participants were not aware of the importance of oral health to their RA [
4]. Another study also highlighted the limited knowledge regarding the association between arthritis and oral diseases among patients with rheumatoid arthritis and the challenges they faced in maintaining oral hygiene due to their condition. In fact, the patients in this study thought that any oral symptoms were the result of the medications alone [
3]. This finding is alarming, as it has been shown that RA patients exhibit an OHRQoL that is significantly worse and independent of their oral health status when compared to a control group of patients not presenting with RA [
8].
The limitations in our study would be the potential sources of bias introduced by self-administered questionnaires and the low response rates obtained. The rheumatologist survey received seven responses out of a WA population size of 28, and the rheumatoid arthritis survey only received 76 responses. Despite several reminders, low response rates can be attributed to a lack of interest, invalid email addresses, failure of receptionists in charge of practice emails to pass messages on to rheumatologists, or lack of social media use by the patients.
The results of our study are important to providing a baseline for the current knowledge levels of rheumatologists and RA patients in Western Australia. This study hopes to influence participants to seek out further educational resources to expand their knowledge on periodontal disease and oral health, with the aim that further studies will encourage better integration of oral health in the management of rheumatoid arthritis and aid in bridging the gap between periodontal disease and rheumatoid arthritis. We hope that this study and others in the future will result in the production of educational resources that can be easily accessed and utilised to further improve knowledge and result in overall better health outcomes.