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Our study has strengths and weaknesses. The main limitations are the cross-sectional design, which complicates the generation of causal inferences. Moreover, there is a limited sample size. However, without a signal at all in any of the periodontitis parameters, it is unlikely that a larger sample size would yield fundamentally different results. Among the strengths of this study are the comprehensive periodontal assessment that had been performed, in addition to the serological and microbiological investigations for the comparison of cases and controls. To our knowledge this is one of the first studies assessing the periodontal condition in the full spectrum of SpA including axSpA and pSpA patients. Moreover, all SpA patients included were not previously or currently exposed to TNF blockers. TNF-alpha has an important role in the pathogenesis of periodontitis. Medications such as TNF blockers have been considered as a factor that may influence the risk of periodontitis and even improve the periodontal condition 24. In this study we have avoided such potential confounding.
A higher percentage of patients were taking NSAIDs and sulphasalazine and the effect of these medications with regard to the modulation of periodontal condition has not been clearly established. While multiple studies have investigated the effect of NSAIDs on the periodontal condition in terms of reducing gingival inflammation and influencing alveolar bone loss 25, 26, more information is needed investigating the role of NSAIDs as modulatory agents of periodontal disease progression in patients with SpA 27, 28.
A point of concern may be the high prevalence of periodontitis in the Colombian general population. A nation-wide population study led by the Colombian Ministry of Health reporting on the oral health status in adults ≥18 years old (ENSAB IV), found a prevalence of periodontitis of 62% 29. Moreover, a higher percentage of men had periodontitis in comparison to women (67% vs. 58%). This national-data are in concordance with the prevalence found in the control-group in the current study, taking into account that SpA has a male-predominance and the sample had been matched by gender. This finding implies that Colombia may have a higher prevalence of periodontal disease than other countries such as the United States (47%) 30 or Germany (51%) 31. In this context, country-specific differences with regard to the prevalence of periodontitis in the general population, should be considered in the interpretation and the external validity of our findings.
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