Association Between Ankylosing Spondylitis and Periodontitis: A Systematic Review

Clinical Snapshot

Key Findings

• P Value: Not pooled; individual study p-values not synthesised

• Effect Size: No pooled effect size calculated; narrative synthesis only. Periodontal parameters (BOP, PPD, CAL) did not consistently show statistically significant differences between AS patients and controls, but were frequently correlated with AS disease activity indices (MASES, BASDAI, BASFI) and inflammatory markers (CRP)

• Primary Outcome: Prevalence of periodontitis in ankylosing spondylitis patients versus controls — results were conflicting across 18 included studies; no definitive conclusion of increased prevalence could be drawn

• Nnt Or Sensitivity: Not calculable from this review. Clinically relevant signal: anti-TNF-α therapy in AS patients was associated with reductions in PPD and CAL; anti-Porphyromonas gingivalis IgG levels correlated with AS disease activity parameters; periodontitis was associated with elevated IL-6, TNF-α, CRP, and ESR in AS patients

• Confidence Interval: Not reported — no meta-analysis performed

Clinical Application

Periodontal screening is feasible, low-cost, and non-invasive. Referral pathways between rheumatology and periodontology are achievable in most healthcare settings. However, the evidence base is insufficient to mandate formal screening protocols at this stage. The suggestion of reduced drug dosage through periodontal treatment requires prospective RCT confirmation before clinical implementation. In Australia, ankylosing spondylitis (axial spondyloarthritis) is managed under RACGP and Australian Rheumatology Association guidelines. Anti-TNF-α biologics (adalimumab, etanercept, certolizumab pegol, golimumab) are PBS-listed for AS meeting specific criteria (BASDAI ≥4, inadequate NSAID response). The finding that anti-TNF-α therapy may improve periodontal parameters is relevant to Australian rheumatologists and general practitioners co-managing these patients. Periodontal disease is highly prevalent in Australia (approximately 22% of adults have moderate-to-severe periodontitis per AIHW data), making the potential bidirectional inflammatory relationship clinically significant. The TGA has not issued specific guidance on periodontal monitoring for biologic users. RACGP guidelines do not currently include periodontal screening as part of AS management. This review provides preliminary evidence to support interdisciplinary collaboration between rheumatologists, general practitioners, and dental practitioners, but does not yet justify formal guideline change. Adult patients with established ankylosing spondylitis (axial spondyloarthritis) attending rheumatology or specialist care. Findings are most relevant to patients on biologic therapy (anti-TNF-α agents) where periodontal health monitoring may be particularly pertinent.

Abstract

PURPOSE: This systematic review aimed to investigate a potential association between ankylosing spondylitis (AS) and periodontitis (PD), two chronic inflammatory diseases. METHODS AND MATERIALS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, searches were conducted in PubMed, The Cochrane Library, Scopus, and Web of Science. Keywords included 'spondyloarthritis', 'ankylosing spondylitis', 'periodontal diseases', and 'periodontitis'. Study selection was performed by independent authors, and quality was assessed using Scottish Intercollegiate Guidelines Network (SIGN) methodology and the STROBE-MR statement. RESULTS: Out of 255 initial studies, 18 eligible studies (3 cohort, 14 case-control, 1 Mendelian randomisation) were selected, all of acceptable to high quality. The prevalence of PD in AS patients showed conflicting results. Periodontal parameters like bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment loss (CAL) didn't consistently show statistically significant differences but were frequently correlated with AS parameters (eg, MASES, BASDAI, BASFI, CRP, AS duration). AS treatment with anti-TNF-α agents was associated with a decrease in PPD and CAL. Other findings included an increase in Gingival Index in AS patients treated with anti-TNF-α and mixed results for the Decayed, Missing, and Filled Teeth Index. Microbiological studies showed inconsistent results for Porphyromonas gingivalis (Pg), but anti-Pg IgG levels correlated with AS parameters. PD appeared to significantly increase inflammatory markers (IL-6, TNF-α, CRP, ESR) in AS patients. Only one study investigated a genetic association, finding none. CONCLUSION: A definitive conclusion regarding an increased prevalence of PD in AS patients cannot be drawn with certainty from this review, possibly due to heterogeneous classification criteria. However, the correlation between PD and AS parameters, alongside the impact of AS therapy on periodontal health, is noteworthy. Screening and treating periodontal disease in AS patients might delay symptom progression and reduce drug dosage, though targeted clinical trials are necessary to confirm these findings.

References

1. 1.Quemard, V., Pockpa, Z. A. D., Verner, C., Soueidan, A., Bechina, C., & Struillou, X. (2026). Association between ankylosing spondylitis and periodontitis: A systematic review. Oral Health & Preventive Dentistry. https://doi.org/10.3290/j.ohpd.c_2747