Download psoriasis associated with chronic periodontitis: a rare

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Oral Sciences & Research
ASSOCIATION BETWEEN PSORIASIS AND CHRONIC PERIODONTITIS: A
RARE CASE REPORT
Anuj Sharma*, Nishanth S. Rao*, Nehal P. Mehta†, A R Pradeep*, M.V. Ramchandraprasad*.
ABSTRACT
Chronic periodontitis is a consequence of a persistent bacterial infection and chronic inflammation of the
supportive tissues surrounding the tooth, including the periodontal ligament, cementum and alveolar bone.
Psoriasis is a chronic, remitting and relapsing inflammatory skin disorder with a strong genetic predisposition.
Both psoriasis and periodontal diseases are characterized by an exaggerated response of the immune system to
the epithelial surface microbiota, hence there may be a possible association between these two conditions.
Dermatologic psoriasis associated with periodontal lesions have rarely been reported in the literature. We
present a case of psoriasis in a 40-year-old male patient in which exacerbation of the cutaneous disease was
accompanied by periodontal destruction. Clinical, radiographic and histologic characteristics are discussed
hereby.
AOSR 2011;1(1):5-7.
Key Words: Chronic Periodontitis, Psoriasis, Periodontal health.
*Department of Periodontics, Govt. Dental College & Research Institute, Bangalore 560002, INDIA.
† Resident, Govt. Dental College & Research Institute, Bangalore 560002, INDIA.
INTRODUCTION:
Psoriasis is a relatively common chronic
dermatological disease characterized by epithelial
hyperplasia presenting clinically as cutaneous
erythematous papules and plaques covered by whitish
scales commonly observed on the extensor-dorsal
cutaneous surfaces.1 Usually it develops first in young
adults and may be followed by periods of exacerbation
and remission.2 The autoimmune-type inflammation
of the skin has a strong genetic background, but is also
influenced by environmental factors. Streptococcal
infections may precipitate psoriasis.3 Other disease
modifying factors may be trauma, drugs, sunlight and
metabolic and psychogenic factors, as well as alcohol
and smoking.4
Chronic destructive periodontal disease is a family of
bacterial infections characterized by immunologically
motivated destruction of periodontal supporting
tissues.5 Both psoriasis and periodontal diseases are
characterized by an exaggerated immune response to
the microbiota residing on epithelial surfaces.
To our knowledge, only few published
studies6,7 have shown an association between psoriasis
and chronic destructive periodontal disease. This
paper reports a case of psoriasis accompanied by
periodontal destruction.
CASE REPORT:
A 40 yr old male patient reported to the Department of
Periodontics, Government Dental College and
Research Institute, Bangalore for supportive
periodontal therapy. Patient complained of loose teeth.
According to the patient, the “loose teeth” had been
present for last two months. The patient was fully
dentate and occasionally, bleeding occurred while
brushing teeth. The patient’s medical history revealed
that he was not presently taking any medications and
had no known allergies. He reported being diagnosed
with psoriasis by a dermatologist approximately 10
months previously following the appearance of
cutaneous lesions on his scalp. The lesions appeared as
small erythematous papules and plaque like areas
covered with fine whitish-silvery scales (figure 1).
The patient’s family history revealed a positive history
as his father was also suffering from psoriasis.
Figure 1: Cutaneous
on scalp.
Figure 2: Deep lesions
Periodontal pocket in
relation to upper left
first premolar.
Intraoral examination revealed generally good oral
hygiene [Simplified oral hygiene index8 (0.4)] with
light deposits of marginal plaque on labial, lingual, and
interproximal surfaces. Small deposits of subgingival
calculus were found interproximally. Generalized deep
periodontal pockets were found to be present (figure
2,3). Generalized gingival recession was also seen.
Grade I mobility was present with respect to teeth # 17,
15, 23, 25, 38, 36, 35, 34, 33, 32, 31, 43, 44, 45, 46,
47, 48.
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Anuj Sharma et al.
Figure 3: Deep periodontal
Figure 4: Intra oral
pocket in relation to lower periapical radiographs
right first molar.
revealing extensive
bone loss
Figure 5: Skin biopsy revealing extensive bone loss
Grade II with respect to teeth # 18, 14, 13, 12, 11, 21,
22, 28, 41, 42 and Grade III with respect to teeth #
24, 26, 27, 37. Mobility of the tooth was graded on the
basis of ease and extent of tooth movement.9 There
was no difference found in clinical as well as
radiographical features at second visit (2 month after
first visit)
Routine hematological investigations were done and
they were found to be within the normal parameters.
Full mouth intra oral periapical radiographs revealed
extensive bone loss that did not correlate with the
scant amount of local factors present (figure 4).
A skin biopsy was submitted for histological analysis
(figure 5). The histopathological examination of the
lesion revealed acanthosis, hyperkeratotic epidermis,
elongated rete ridges as well as capillary dilatation and
moderate chronic inflammatory cell infiltration in the
papillary dermis.
Chronic inflammatory changes in marginal gingival,
presence of periodontal pockets, loss of clinical
attachment and evidence of bone loss determined by
radiograph suggests diagnosis of chronic periodontitis
even though minimal amount of local factors was
present. Diagnosis of aggressive periodontitis can be
ruled out due to presence of systemic disease. The
diagnosis of Psoriasis associated with chronic
generalized periodontitis was thus confirmed
according
to
clinical,
radiological
and
histopathological patterns.
DISCUSSION:
This case represents a rare presentation of psoriasis
along with periodontal involvement. To date, only few
cases has been reported correlating periodontal disease
with psoriasis. The author’s reported that bursts of
periodontal disease activity correlated with periods of
cutaneous psoriasiform lesions exacerbations.6
Characteristically, psoriasis is symmetrically
distributed, with lesions frequently located on the ears,
elbows, knees, umbilicus, gluteal cleft and genitalia.
The joints (psoriatic arthritis), nails, scalp and sites of
local trauma (Koebner's phenomenon) may also be
affected.7 In our patient, lesions were present only on
the scalp.
Psoriasis patients have significantly fewer
teeth than their age-and gender matched controls, as
well as a significantly larger distance from the
cemento-enamel junction to the alveolar crest in the
lateral segments of the dentition.10 Our case too
presented with bone loss and increased distance from
the cemento-enamel junction to the alveolar crest.
The magnitude of tooth mortality as well as
reduced bone level in psoriasis patients indicates that
there may be an association between the two diseases.
One may speculate as to what mechanisms might be
involved in explaining this possible co-morbidity. One
speculation might be that the innate immune system
that is directing the subsequent adaptive immune
response (T- and B-cell response) is important in the
pathogenesis of both psoriasis and periodontitis.11,12
Both psoriasis and periodontal diseases are
characterized by an exaggerated immune response to
the microbiota residing on epithelial surfaces.
Dendritic cells (DCs) play an important role in driving
an exaggerated immune response7,13 and are crucial to
the initiation and regulation of both innate and
adaptive immunity. They form a bridge between the
two immune systems by trafficking from the epithelial
barriers to the regional lymph nodes. In addition it has
been proposed that anti-neutrophil cytoplasmic
autoantibodies could be triggered by the periodontal
pathogens and eventually result in periodontal tissue
breakdown by various neutrophil-mediated and other
cellular mechanisms.14 Even stress can cause behavior
modification, which may result in greater severity of
periodontal disease as well as psoriasis. Recent studies
have demonstrated an upregulation of Toll-like
receptor (TLR)-2 in psoriatic skin, as well as in the
periodontium of patients with periodontitis.15 High
expression of TLR will amplify the inflammatory
reaction and subsequent T-cell activation. Studies in
the Yaa mouse model have shown that a twofold
increase in TLR gene dosage can dramatically induce
an autoimmune pathology.16 Thus, one may speculate
that a common genetic trait affecting DCs, TLR
expression or other components of the innate immune
response could predispose patients to both
periodontitis and psoriasis.
A very striking feature that was noticed in
our case was that the probing pocket depth and
amount of radiographic bone loss did not correlate
with the minimal amount of plaque. It has been
suggested that actual periodontal breakdown may be
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Psoriasis and Chronic Periodontitis
associated with exacerbation of psoriasis and that
exacerbations and remissions of psoriasis may
correlate with bursts and remissions of periodontal
breakdown.6 Also our patient was diagnosed as
suffering from psoriasis only 10 months ago and he
noticed loosening of his teeth since 2 months,
suggesting that the two may be somehow related. This
may correlate exacerbation of psoriasis with burst of
periodontal destruction in this case report.
CONCLUSION:
This case illustrates, a very rare presentation of
psoriasis and chronic periodontitis. We can conclude
that there appears to be a possible association between
psoriasis and chronic destructive periodontal disease.
However, since there have been very few previous
reports on such possible co-morbidity, conclusions
must be drawn with caution, and experimental studies
should be designed to test the hypothetical causality
between periodontal disease and psoriasis.
8.
9.
10.
11.
12.
13.
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Correspondence:Dr. Anuj Sharma
Department of Periodontics, Government Dental
College and Research Institute, Bangalore-560002,
INDIA.
Email: [email protected]
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