Rheumatoid arthritis medication and your gums: what to tell your dentist

In Germany, patients on several long-term medicines are usually given a printed medication plan (Medikationsplan) listing active ingredients, doses and timing. Photograph it and keep the picture on your phone.

Show it before treatment starts rather than afterwards. Three things follow from it: which procedures can go ahead as normal and which need a word with your rheumatologist first; whether a complaint in your mouth is likely to be a medication effect rather than a dental problem; and whether extra caution is sensible around bleeding, infection or healing.

Dentists do not adjust rheumatology medication and should not be asked to. They adjust dentistry around it. That distinction runs through this article.

The most widely used long-term drug in rheumatoid arthritis, and the one with the most recognisable oral signal: mouth ulcers, sometimes called stomatitis. They can appear on the cheeks, the tongue or the palate, are usually painful out of proportion to their size, and tend to come in bouts.

Rheumatologists routinely prescribe folic acid alongside methotrexate, and one of its purposes is to reduce exactly this. If ulcers appear or become more frequent, report them to your rheumatologist — any adjustment is their call, not something to improvise. Your dentist can ease the local discomfort and rule out other causes, such as a sharp filling edge or a fungal infection.

Steroids reduce inflammation everywhere, including in the gums, and that has an awkward consequence: they can make gum disease look milder than it is. Less redness and less swelling do not mean less bone loss underneath.

Long-term use is also associated with slower wound healing, a greater susceptibility to infections including oral thrush (a whitish coating on the tongue or palate that can be wiped away), and reduced bone density over the years — which is why many patients on long-term steroids end up on bone medication as well. Regular measured check-ups matter more here, not less, precisely because the visible signs are dampened — see Periodontitis treatment – service page (EN).

TNF inhibitors, interleukin-6 inhibitors, rituximab, abatacept and the JAK inhibitors all modulate the immune system in some way. For the mouth, two practical consequences follow.

Infections may present less dramatically. A dental abscess that would normally announce itself with obvious swelling and fever can be quieter. That means a persistent dull ache, a bad taste or a small swelling deserves an earlier appointment than you would otherwise make, not a wait-and-see approach.

Blood values can mislead. Interleukin-6 inhibitors in particular suppress CRP, so a normal inflammatory value does not exclude an infection.

For routine dental care — check-ups, fillings, professional cleaning, periodontal therapy — interrupting this kind of medication is generally not considered necessary. For larger surgical procedures, whether timing should be coordinated with the dosing interval is a question for the rheumatologist, and the answer differs between drugs and patients. Never skip a dose to “be safe” before an appointment. Whether antibiotic cover is needed is likewise decided case by case between the two doctors; immunosuppressive therapy alone is not an automatic reason for it.

NSAIDs such as ibuprofen or diclofenac, taken regularly for joint pain, can slightly increase the tendency to bleed during cleaning or treatment. They also do something subtler: they mask dental pain. A tooth problem that would normally have driven you to the phone weeks earlier can stay below the threshold until it is more advanced.

If you already take an NSAID regularly, say so before anything is recommended for dental pain — the combination is something to check with your doctors, not to stack up at home.

Sulfasalazine, hydroxychloroquine, leflunomide and similar drugs each have their own profile, and mouth symptoms — ulcers, taste changes, dryness — appear among the possible effects of several of them. The rule is unchanged: mention what you take, and report any new, persistent change in the mouth to the prescribing doctor.

Many people with rheumatoid arthritis, especially after long-term steroid treatment, also take medication to protect the bones: bisphosphonates (as tablets or infusions) or denosumab as an injection.

These drugs slow the breakdown of bone throughout the body, including the jaw. In a small number of patients they are associated with a complication called medication-related osteonecrosis of the jaw (Kiefernekrose), in which an area of jawbone fails to heal after a tooth extraction or a surgical procedure and remains exposed. The risk with the doses used for osteoporosis is low — considerably lower than with the high-dose infusions used in cancer care — but it is real, and it changes how a dentist plans.

What follows from it in practice:

• Tell your dentist before any extraction, implant or gum surgery. This is the single most important line in this article.
• If you are about to start such a medication, German dental and medical societies recommend a dental examination first, so that necessary treatment can be done while the mouth heals normally.
• Do not stop the medication to make dentistry easier. A pause is sometimes discussed between doctors for specific procedures, but it is a decision for the prescribing physician, weighed against your fracture risk. Stopping on your own trades a low risk for a higher one.
• Report any area of the mouth that does not heal within a couple of weeks after an extraction, or any exposed bone, promptly.

Reduced saliva is the most underrated oral problem in rheumatology patients, and it has two possible sources: the medication itself, and Sjögren’s syndrome, which occurs alongside rheumatoid arthritis in a proportion of patients. Saliva buffers acid and carries minerals back into the enamel, so without enough of it decay can appear quickly and in unusual places — at the gumline and on exposed root surfaces.

The countermeasures are dental, not pharmacological: saliva substitutes, sugar-free chewing gum, alcohol-free rinses, fluoride products where your dentist recommends them, and shorter intervals between check-ups. Persistent dryness together with dry eyes belongs in front of your rheumatologist or GP (Hausarzt), because that combination is investigated medically. More on this in Dry mouth in rheumatoid arthritis and Sjögren’s syndrome.

For anything surgical, the sequence that works is straightforward:

1. You bring the medication list to the dental appointment. 2. The dentist identifies whether anything on it affects bleeding, infection risk, healing or bone. 3. Where necessary, the two practices speak to each other — a short note or call between dentist and rheumatologist settles most questions, and you can ask for that explicitly. 4. Timing is agreed before a date is booked, not on the morning of the procedure. 5. You keep taking your medication exactly as prescribed unless the prescribing doctor tells you otherwise in person.

If your German is limited, this is where things fall through the cracks, because the coordination happens between two practices in German. Ask for the plan in writing, and choose a dental practice where you can hold the conversation in a language you are comfortable in: English-Speaking Dentist in NRW.

Contact your rheumatologist or GP about: recurring ulcers after starting or increasing a medication, persistent dry mouth and dry eyes together, and anything you suspect is a medication side effect. They can act on it. Your dentist can only work around it.