ADRF RESEARCH REPORT Australian Dental Journal 2002;47:(3):208-213 Arthritis and use of dental services: A population based study V Pokrajac-Zirojevic,* LM Slack-Smith, D Booth Abstract Background: Rheumatoid arthritis (RA) and osteoarthritis (OA) are chronic systemic conditions that can have a profound effect on oral health as the result of physical disability, immunosuppressant and other medications and autoimmune disease. However, there is insufficient information available on the use of dental services by the people suffering from RA or OA. The purpose of this study was to investigate dental visits and factors associated with dental attendance in those with RA and OA in order to improve access to dental care in these groups. Methods: The study used population based data from the 1995 National Health Survey (total n=53 828). The main variables of interest were reported RA (n=1193) and OA (n=3091) and the main outcome variable was having visited a dental professional in the previous 12 months. Chi-square analysis was performed using SAS software. Results: The proportion of people visiting a dental professional in previous 12 months was significantly less in both RA and OA respondents compared to non-arthritic respondents. Both males and females with RA and OA were found to be less likely to have visited a dental professional when compared to general population (p=0.001 in each case). Furthermore, the findings have revealed that RA and OA patients living in metropolitan centres were more likely to have a dental visit than those living in rural or remote areas (p=0.001 in each case). Conclusions: When compared to non-arthritic subjects, all patients with RA and OA were less likely to receive dental care, in particular preventive care. This is especially important in patients with Sjögren s Syndrome and those who are immunosuppressed. Key words: Rheumatoid arthritis, osteoarthritis, dental services. (Accepted for publication 5 October 2001.) *Student, School of Dentistry, The University of Western Australia. Senior Lecturer, School of Dentistry and Senior Lecturer, School of Population Health, The University of Western Australia. Oral and Maxillofacial Surgeon and Consultant Oral Pathologist, School of Dentistry, The University of Western Australia. INTRODUCTION Rheumatoid arthritis (RA) and osteoarthritis (OA) are two chronic systemic conditions, which are likely to result in physical impairment or disability with age, and therefore restrict one s lifestyle. 1,2 About 1 per cent of the world s population is afflicted by RA, with female to male ratio of three to one. 1,2 Osteoarthritis is a disease of older people affecting 6.4 per cent of the population in Australia. 3 The prevalence of OA increases rapidly beyond the age of 50, 1 and the disease is found to be more severe and more generalized in older women. 2,3 Both RA and OA may have a profound effect on oral health as a result of physical disability, inflammatory and degenerative processes and the effects of medications. 4,5 According to a 1993 report on disability and disabling conditions, 67 per cent of men and 59 per cent of women who had arthritis had also experienced restrictions, i.e., disability, and were likely to need assistance from others. 6 The RA and OA patient s poor ability to maintain proper oral hygiene may result in accumulation of plaque and calculus, and significantly increases the risk of periodontal disease and dental caries. In addition, the pathogenesis of RA is possibly related to the activation of the immune system. Inflammatory reactions involved in autoimmune disease process have been suggested to increase the risk of periodontal disease and contribute to periodontal destruction. 7 This is consistent with significantly higher prevalence of periodontal disease in patients with RA reported in a study by Mercado and co-workers. 7 The study has shown that 62.5 per cent of patients with RA had advanced forms of periodontal disease, and thus supported the positive correlation between the physical disability, inflammatory processes and periodontal destruction. The medications used in treatment of arthritis may significantly alter requirements for dental treatment. Patients with RA or OA are at greater risk of infections due to suppression of the immune system, and exhibit delayed wound healing and prolonged bleeding time. Xerostomia (dry mouth) has been reported by more than 50 per cent of patients with RA. 8 Oral dryness is also a characteristic symptom of Sjögren s syndrome, an autoimmune disease of the exocrine glands frequently 208 Australian Dental Journal 2002;47:3.
Table 1. Rheumatoid arthritis and type of dental treatment Dental treatment Rheumatoid arthritis Other (n=81) % (n=4323) % Extraction 7 8.6 169 3.9 X-ray 3 3.7 136 3.1 Clean and polish-teeth, denture 16 19.7 328 7.6 Fluoride treatment 0 0 70 1.6 Fillings 20 24.7 784 18.1 Denture preparation/fitting 5 6.2 67 1.5 Denture repair/maintenance 6 7.4 47 1.1 Braces/bands 1 1.2 280 6.5 Check up 19 23.5 1013 23.4 Other dental treatment 15 18.5 344 7.9 No dental treatment 0 0 17 0.4 associated with RA. 5,8 Xerostomia is caused by reduced salivary secretion rate due to inflammatory changes in salivary glands, as well as medications used in the treatment of the disease. It is known to cause oral soreness and discomfort, and to significantly increase the risk of oral infections and mucosal ulcerations. 4,5 Perhaps the most striking change noted in the oral cavity is a severe and rapid increase in dental caries, characteristically involving smooth surfaces and incisal edges. 4 Restoration of the teeth may be difficult due to recurrent decay, and dentition can be lost quickly if appropriate intervention is not undertaken. The lack of moisture may also compromise retention of the removable prostheses. Therefore, it is evident that preventive care and regular dental attendance are of prime importance for arthritic patients in order to prevent development of complex oral conditions associated with the systemic disease progression and its sequelae. We currently lack data regarding dental service needs in those with arthritis. The aim of this research was to investigate the use of dental services by those with RA or OA, in order to better understand their dental service needs. MATERIALS AND METHODS This study was an analysis of National Health Survey 1995 released by the Australian Bureau of Statistics as a confidentialized unit record file. The dataset included 53 828 subjects from the national database. The subjects with self-reported RA or OA were considered separately as outcome variables and those with ambiguous arthritic status, i.e., who did not know the type of arthritis; those with the other form of arthritis studied and other less common forms of arthritis were excluded. The main variables of interest were reported in RA (n=1193) and OA (n=3091) and the main outcome variable was having visited a dental professional in the previous 12 months. Responses with the answer to when was the last time you consulted a dentist or a dental professional? given as don t know were excluded with the number of these responses insignificant (for RA n=4 or 0.3 per cent; for OA n=16 or 0.5 per cent). Demographic variables investigated include age, gender, income level, education, state of residence, living in rural or metro area, country of birth and first language. Other outcomes investigated include the frequency of dental visits (visited dentist in previous two weeks, three to six months, six to 12 months and over 12 months) and the treatment they received at last visit (only available for group who visited in previous two weeks). The data were analysed using PROC FREQ command within SAS 6.12 software and associations investigated using chi-square (for association) and Mantel-Haenszel tests (for trend). It is recognized when multiple chi-square tests are conducted the effects of repeated tests may be considered important and to allow interpretation, p-values are given in this paper. RESULTS Both RA and OA groups were significantly less likely to have visited a dental professional in the previous 12 months than their respective controls. The results for these disorders will now be considered separately. Rheumatoid arthritis Those with reported RA were significantly less likely to have visited a dentist or dental professional in the previous 12 months when compared to their non-ra counterparts (p=0.001). Forty one per cent of patients with RA and 51.3 per cent of non-ra subjects visited a dental professional within the previous 12 months. This trend was also apparent in those who had not seen a dental professional for a considerable time, e.g., 44.5 per cent of RA patients had not visited a dental professional for two years or more, compared to 28.3 per cent of non-ra patients (p=0.001). Both males and females with RA were less likely to have visited a dental professional (p=0.001) than those who do not have RA. Only 36.9 per cent of males with RA visited a dental professional within the previous 12 months compared to 48.3 per cent of non-ra males, whereas females showed better dental attendance (42.9 per cent of females with RA visited the dentist within the previous 12 months compared to 54.3 per cent of non-ra females). Rheumatoid arthritis and type of dental treatment Within the previous two weeks, only about 6.8 per cent (n=81) of RA patients visited the dentist or a Australian Dental Journal 2002;47:3. 209
Table 2. Proportion of respondents who have visited a dental professional within the previous 12 months and the area of residence Area Rheumatoid arthritis Others p value % % Capital city/metropolitan 41.9 51.2 0.001 Large/Small rural centres 28.7 48.3 0.001 Remote/Other rural areas 36.9 48.9 0.001 dental professional compared to 9.3 per cent (n=4323) of their non-ra counterparts (p=0.05). This result further supports previous findings that those suffering from RA are less likely to visit a dentist or dental professional than non-ra patients. Rheumatoid arthritis patients were more likely to have visited for dental problems, whereas non-ra subjects were more likely to visit a dental professional for a check up (p=0.05). The main reasons for dental visits in both groups were fillings and check ups (see Table 1). Interestingly, RA patients were found to have considerably more extractions than the general population (8.6 and 3.9 per cent respectively). They also attended dental professionals more than their non-ra counterparts for prosthodontic treatment, such as construction and insertion of dentures, denture maintenance and repairs, as well as for denture and teeth cleaning and polishing. However, dental visits for preventive services were found to be neglected in this group. Characteristics investigated for association with rheumatoid arthritis Patients with RA living in the capital cities or metropolitan centres were more likely to utilize dental care (p=0.001) than those living in remote or rural areas. However, the difference in the use of dental services between the general population and patients suffering from RA was much less evident for those living in the metropolitan centres than for those living in rural and remote areas (Table 2). Within the previous 12 months, RA patients visited a dentist or a dental professional less than the general population in all Australian states and this was significant in New South Wales, Victoria, South Australia, Tasmania and Northern Territory (Table 3). The highest proportion of respondents who visited a dentist or a dental professional within the previous year was in South Australia (53.9 per cent) and the lowest proportion in Tasmania (47.7 per cent). The overall association between socio-economic status and RA was highly significant (p=0.001). However, dental attendance in RA patients was shown to be significantly related to their socio-economic status only in a low income group (AUS$0-20 000 per annum), whereas for other income groups dental behaviour of RA patients was apparently not influenced by socio-economic status. Those RA patients with low socio-economic status were shown to be less likely to visit a dental professional than their non-ra counterparts (35.8 and 40.9 per cent respectively; p=0.006). The relationship between the level of education and dental visits in RA patients did not demonstrate a statistically significant association for any of the following categories: higher degree, post-graduate diploma, bachelor degree, undergraduate diploma, associate diploma, skilled, and basic vocational education. The association was significant only in the group of respondents who described themselves as not having any of the given qualifications (p=0.001). In this group, RA subjects were again found less likely to have a dental visit than their non-ra counterparts (43.7 and 55.9 per cent respectively). The association between dental attendance and RA was investigated by age in 20 year intervals. The association remained significant only in those aged 0-20 (p=0.006). About 36 per cent of young RA patients have had a dental visit in the previous year compared to 41 per cent of their non-ra counterparts. The association between dental visits and country of birth was significant for countries including Australia (p=0.001) and New Zealand (p=0.022). Within the previous 12 months, Australian and New Zealand born individuals with RA were found similarly less likely to seek dental care than the general population. Of those who were born in Australia and had RA, about 41 per cent have visited a dental professional in the previous year, whereas only about 24 per cent of those RA respondents born in New Zealand have had a dental visit. About 40.7 per cent of RA respondents who speak English as their first language had had a dental visit within the previous year, compared with 51.6 per cent of non-ra respondents (p=0.001). However, the Table 3. Proportion of respondents having visited a dental professional within the previous 12 months and the state of residence State of residence Rheumatoid arthritis Others Total % subjects having % % visited dentist <12 months p value New South Wales 40.3 49.7 49.4 0.010 Victoria 35.5 49.6 49.2 0.001 Queensland 44.3 52.3 52.1 n.s. South Australia 43.3 54.2 53.9 0.001 Western Australia 44.5 51.5 51.3 n.s. Tasmania 33.7 48.2 47.7 0.006 Northern Territory 28.2 51.4 51.1 0.004 Australian Capital Territory 54.9 56.2 56.2 n.s. 210 Australian Dental Journal 2002;47:3.
Table 4. Osteoarthritis and type of dental treatment Dental treatment Osteoarthritis Other (n=191) % (n=4323) % Extraction 16 8.4 169 3.9 X-ray 6 3.1 136 3.1 Clean and polish-teeth, denture 27 14.1 328 7.6 Fluoride treatment 1 0.5 70 1.6 Fillings 67 35.1 784 18.1 Denture preparation/fitting 24 12.6 67 1.5 Denture repair/maintenance 13 6.8 47 1.1 Braces/bands 0 0 280 6.5 Check up 38 19.9 1013 23.4 Other dental treatment 27 14.1 344 7.9 No dental treatment 2 1.0 17 0.4 association between dental visits in RA and first language was not statistically significant for languages other than English. Osteoarthritis As found for RA patients, when compared to general population patients with OA were found to visit dental professionals less. About 42 per cent of OA patients visited the dentist within the previous 12 months, whereas 51.3 per cent of non-arthritic patients saw a dentist in the past year (p=0.001). The findings have further revealed that 43 per cent of OA respondents had not visited a dentist or a dental professional for two years or more, whereas only about 28 per cent of non-arthritic subjects had not seen a dental professional within the previous two years (p=0.001). Furthermore, only about 6.18 per cent of OA patients had had a dental consultation or treatment done within the past two weeks compared to 9.27 per cent of non-arthritic patients (p = 0.001). The association between OA and gender was proven highly statistically significant, with females more commonly affected with OA than males (p=0.001). The results have revealed that both males and females with OA were less likely to visit a dentist or a dental professional (p=0.001). About 42.4 per cent of arthritic males visited the dentist in the past year compared to 48.3 per cent of non-arthritic males. The difference in dental visits was slightly more marked in females, with 42 per cent of arthritic females having their last dental consultation within the last 12 months compared to 54.3 per cent of their non-arthritic counterparts. However, when comparing males with OA to females with OA, the use of dental services and the level of dental care was very similar in both groups: 42.4 per cent of arthritic males had their last dental check-up within the previous 12 months compared to 42 per cent of females. Osteoarthritis and type of dental treatment Within the previous two weeks, about 6 per cent of patients with OA visited the dentist compared to about 9 per cent of non-arthritic patients (p=0.001). However, those suffering from OA were found more likely to have dental problems than their non-arthritic counterparts. It appears that those respondents Table 5. Proportion of respondents who have visited a dental professional within the previous 12 months and the area of residence Osteoarthritis Others Area p value % % Capital City/Metropolitan 44.8 51.2 0.001 Large/Small rural centres 34.8 48.3 0.001 Remote/Other rural areas 33.7 48.9 0.001 suffering from OA required considerably more extractions and fillings than non-arthritic patients. Furthermore, patients with OA were found most likely to visit the dentist for restorative (35.1 per cent) and prosthodontic (33.5 per cent) treatment involving construction and insertion of dentures, as well as denture repairs, and denture and teeth cleaning. However, they were less likely to visit dentists for check ups and caries preventive treatment, such as fluoride treatment (Table 4). Characteristics investigated for association with osteoarthritis Dental visits in osteoarthritic patients were significantly associated with the area of their residence, i.e., metropolitan, rural or remote area (p=0.001 in each case). Patients with OA living in metropolitan or capital city centres were more likely to visit a dentist or a dental professional than those living in rural centres or remote areas. Of osteoarthritic patients living in metropolitan areas 44.8 per cent visited the dentist within the previous 12 months, compared to only 34.8 per cent of those living in rural and 33.7 per cent of those living in remote areas who received dental care in that period (Table 5). The proportion of those who had visited a dental professional in the previous 12 months was lower in those reporting OA for all states and significantly different in all but two states, those being Western Australia and the Australian Capital Territory. When compared to the general population, OA respondents were again less likely to have a dental visit in all Australian states (Table 6). The highest proportion of respondents who visited a dental professional in the previous year was in South Australia and the lowest proportion in Tasmania (Table 6). The overall association between OA and socioeconomic status in terms of gross annual income was found to be statistically significant (p=0.001). The relationship between the socio-economic status and dental attendance in OA patients was shown to be significant in those OA patients who had gross annual income from $15 000 to $19 999 (p=0.003), $70 000 to $74 999 (p=0.011) and those earning over $75 000 per annum (p=0.017). Contrary to the general trend, those OA respondents earning between $15 000 and $19 999 were more likely to visit a dentist or a dental professional than their non-oa counterparts (53.2 and 41.7 per cent respectively). Furthermore, the findings have revealed a marked difference in dental attendance Australian Dental Journal 2002;47:3. 211
Table 6. Proportion of respondents having visited a dental professional within the previous 12 months and the state of residence State of residence Osteoarthritis Others Total % subjects having % % visited dentist <12 months p value New South Wales 38.7 49.5 48.7 0.001 Victoria 40.5 49.3 48.8 0.001 Queensland 39.2 52.2 51.3 0.001 Australia 46.5 53.9 53.4 0.001 Western Australia 46.0 51.3 50.9 n.s. Tasmania 31.8 48.1 46.9 0.001 Northern Territory 40.4 51.2 50.7 0.014 Australian Capital Territory 53.8 56.1 55.9 n.s. between arthritic patients and the general population in high socio-economic group. Those subjects with OA and with high socio-economic status visited the dentist or a dental professional in the previous 12 months almost twice as much as their non-arthritic counterparts (90.9 and 51.2 per cent respectively). The level of education appeared not to influence dental attendance in OA patients, except in the group with post-graduate diploma (p=0.006) and the group of respondents who had none of the qualifications stated, i.e., higher degree, post-graduate diploma, bachelor degree, undergraduate diploma, associate diploma, skilled and basic vocational qualification (p=0.001). In the post-graduate group, OA patients were found to seek dental care considerably more than non-oa subjects did within the previous year (87.5 per cent and 59.3 per cent respectively). From this, it could be concluded that higher education positively contributes to oral health awareness in the group with the disease. However, it does not explain why the association between the degree higher than post-graduate diploma and dental visits in OA patients was not significant. Small numbers limited detailed investigation by age in the OA group. However, when the analysis was performed in five year intervals, significant association between age and dental attendance was only found for the following age groups: 15 years of age (p=0.049); 45-49 years of age (p=0.017) and 60-64 years of age (p=0.036). The results have revealed that none of the 15-year-old arthritic patients visited the dentist in the previous 12 months, whereas arthritic patients in the other two groups visited dental professionals more than their respective controls. However, when the ages were grouped, the findings have revealed that those under 49 years of age and suffering from OA utilized dental care less than non-arthritic individuals (46.71 and 54.08 per cent, respectively; p=0.001). The association between dental attendance and the country of birth was highly significant only for Australia (p=0.001) and just significant for Greece (p=0.047). Osteoarthritic respondents who were born in Australia had less dental visits in the previous 12 months than their non-arthritic counterparts (41.9 and 52.5 per cent respectively). The same trend was even more marked in OA respondents born in Greece, e.g., 23 per cent of OA patients had a dental visit in the past year compared to 43 per cent of their counterparts. Dental visits in the OA population were found to be associated with the disease in those respondents who usually spoke English (p=0.001). In this group, dental attendance in OA patients followed the general trend, e.g., about 42 per cent of OA respondents had a dental visit in the previous year, whereas 51.4 per cent of their respective controls received dental care in that period. The association was not significant for those who did not speak English as their first language. DISCUSSION The strength of this study is the large population based dataset, and access to a wide range of variables of interest, thus the results of the study can be readily applied to the Australian population. However, the dataset is restricted to a small number of dental questions and small numbers for some subgroups with arthritis, including consideration by age. The main findings of the study showed that chronic systemic conditions, such as RA and OA, significantly affect dental attendance. Both RA and OA sufferers were shown to have visited a dental professional less than their non-arthritic counterparts. Dental attendance in osteoarthritic respondents was similar for males and females, whereas in the RA group, females showed slightly better attendance. Systemic disease such as RA, which has specific oral manifestations, is especially common in women and this may explain why women come forward for treatment more frequently. Those with RA or OA and living in metropolitan areas were more likely to visit a dental professional than their counterparts living in rural or remote areas. Perhaps the accessibility of dental services and the level of patient care (dental consultations organized by the family or staff from nursing homes), as well as transport availability affect the use of dental services by patients with RA or OA in metropolitan and rural areas. Positive influence of socio-economic status on increased dental attendance in a high income group of arthritic patients could be explained by better financial position of these subjects and therefore ability to afford regular visits to dentist and dental treatment. The results of this study revealed that highly educated OA respondents were more likely to seek dental care than their non-arthritic counterparts. Possibly higher education positively contributes to oral health awareness in the group with the disease. 212 Australian Dental Journal 2002;47:3.
There is an obvious need to improve the awareness about oral health and the importance of regular dental visits in RA and OA patients. Both RA and OA populations were found more likely to have extractions, and subsequently required more prosthodontic treatment than the general population, while caries preventive care was neglected in both populations studied, despite their increased need for such treatment. Therefore, this study should provide a baseline for future research concerned with the reasons for reduced dental attendance in RA and OA individuals. ACKNOWLEDGEMENTS The authors acknowledge the support of the Australian Dental Research Foundation. Linda Slack- Smith had salary support from the Health Department of Western Australia. Data were provided by the Australian Bureau of Statistics, but they are not responsible for the analysis presented here. The authors would particularly like to thank Rivta Matero for translation of the article by Sorsa and Max Bulsara for statistical advice. REFERENCES 1. Cotran RS, Kumar V, Robbins SL. Robbins pathologic basis of disease. 5th edn. Philadelphia: WB Saunders Co, 1994. 2. Edwards CRW, Bouchier IAD, Haslett C, Chilvers ER, eds. Davidson s principles and practice of medicine. 17th edn. Edinburgh: Churchill Livingstone, 1995. 3. Australian Bureau of Statistics. Health and wellbeing. Canberra: AusStats, 1995. URL: http://www.abs.gov.au. Accessed January 2001. 4. Fox PC. The spectrum of salivary dysfunction in Sjögren s syndrome and the resultant oral complications. In: Homma M, Sugai S, Tojo T, Miyasaka N, Akizuki M, eds. Sjögren s syndrome: state of the art. Amsterdam: Kugler Publications, 1994:37-39. 5. Sorsa S. Dental care for rheumatic patients. Suom Hammaslaakarilehti 1987;34:656-659. 6. Australian Bureau of Statistics. Disability and Disabling Conditions. Main Features. Canberra: AusStats, 1993. URL: http://www.abs.gov.au. Accessed January 2001. 7. Mercado F, Marshall RI, Klestov AC, Bartold PM. Is there a relationship between rheumatoid arthritis and periodontal disease? J Clin Periodontol 2000;27:267-272. 8. Arneberg P, Bjertness E, Storhaug K, Glennas A, Bjerkhoel F. Remaining teeth, oral dryness and dental health habits in middleaged Norwegian rheumatoid arthritis patients. Community Dent and Oral Epidemiol 1992;20:292-296. Address for correspondence/reprints: Dr Linda Slack-Smith School of Population Health Faculty of Medicine and Dentistry The University of Western Australia 35 Stirling Highway Crawley, Western Australia 6009 Email: lindas@cyllene.uwa.edu.au Australian Dental Journal 2002;47:3. 213