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Periodontal manifestations in a patient with psoriasis: A case report

Article · January 2013

DOI: 10.5348/ijcri-2013-07-334-8

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Kranti Konuganti Raj Mani

Faculty of Dental Sciences ,M. S. Ramaiah University of Applied Sciences
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I J CRI 201 3; 4(7): 372–375. Kran ti et al .
m

CASE REPORT OPEN ACCESS

Periodontal manifestations in a patient with psoriasis:

A case report
Kranti K, Mani R, Shaesta Begaum

I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –

I J CRI 201 3; 4(7): 372–375. Kran ti et al .
www.ijcasereportsandimages.co 6 1
A
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*
B * A 3
S * p
T * r
i
R Kranti K, Mani R,
A Begaum S. Periodontal l
C manifestations in a 2
T patient with psoriasis: A 0
case report. 1
Introduction: It is International Journal of
well established that Case Reports and Images 2
several inflammatory 2013;4(7):372–375. A
c
conditions exist
Kr c
together and at an e
an
increased incidence ti p
in patients with K1 t
psoriasis. Psoriasis is , e
a relatively common M d
chronic immune an
mediated i :
inflammatory R1
, 0
disease, commonly 2
Sh
involving the skin, ae
which usually present sta J
as cutaneous Be
erythematous g u
papules and plaques au
m l
covered by whitish 2
scales. However, only y
Affi l i ati on s: 1 M DS,
few authors have
Professor, Departm en t
reported oral of Peri od on ti cs, M . S 2
involvement in this Ram ai ah Den tal Col l 0
group of patients. eg e, Ban g al ore; 2 M 1
Case Report: The DS, Form er Post G rad
present case report u ate Stu d en t, Departm 2
P
discusses the clinical en t of Peri od on ti cs, M
. S Ram ai ah Den tal Col l u
presentation of
periodontal findings eg e, Ban g al ore.
b
and the importance
l
of diagnosing the oral Correspon d i n g Au th or:
condition in any form Dr. Kran ti K, M DS,
of mucocutaneous Professor, Departm en t i
disorders. of Peri od on ti cs, M SR
Conclusion: An N ag ar, M SRI T Post, M s
. S Ram ai ah Den tal h
accurate diagnosis is
Col l eg e, Ban g al ore -
dependent on a 560054; Ph : (0)
thorough clinical e
9880382393; d
examination, biopsy Em ai l : kra n
of the oral lesions ti re d d y@ re d
and a history of i ffm a i l . c o m :
cutaneous psoriasis.
0
Keywords: Psoriasis, R 1
Oral lesions, Plaque e
like lesions, Biopsy c J
e
and severe
i
periodontitis u
v
* e l
* d
* y
:
*
* 1 2
0
I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –
 I J CRI 201 3; 4(7): 372–375. Kran ti et al .
m * covered by whitish scales study,
* commonly seen on the
* extensor dorsal
* cutaneous surfaces [1].
It has been described
*
for 200 years and affects
* 2–3% of population
* worldwide. Its
* prevalence in India
* ranges from 0.5–5.6%.
Two peaks of age of
d onset are seen. Early
oi onset psoriasis or type I
:1 psoriasis is seen between
0. 15–25 years. The late
5 onset psoriasis or type II
3 psoriasis is seen between
4 57–60 years of age [2]. A
8 family history of
/i psoriasis has been
jc found in at least 35%
r of the affected patients
i- [1]. In pediatric
2 population females are
0 more commonly affected
1 but in adults slightly
3 higher in males [3].
0 Although the etiology
7- of psoriasis remains
3 unclear, the epithelial
3 changes are related to a
4 defect in the control of
8 keratinocyte
proliferation
characterized by
increased proliferative
activity of the cutaneous
I keratinocytes [4].
N In contrast to
T cutaneous psoriasis,
intraoral psoriasis has
R been rarely reported in
O literature. It is strange
D that the existence of oral
U psoriasis seems so rare.
C Other papulo squamous
disorders such as lichen
T planus are frequently
I associated with oral
O manifestations, yet oral
N psoriasis is rare, given
the prevalence of
“What cannot be cutaneous disease.
cured must be endured” In 1903, Oppenheim
—A 14th century proverb. reported the first oral
Psoriasis is a psoriatic lesions with
relatively common confirmatory
chronic inflammatory histological findings. In
and proliferative a study by Baker and
dermatological disease Ryan (1968) involving
characterized by more than
epithelial hyperplasia 100 cases of cutaneous
presenting clinically as pustular psoriasis, only
cutaneous erythematous 5%
papules and plaques showed corresponding
oral lesion. In another
I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –
I J CRI 201 3; 4(7): 372–375. Kran ti et al .
m

I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –

I J CRI 201 3; 4(7): 372–375.
m
Hietanen et al. (1984),
reported a 2% incidence
of intra oral lesions
mostly occur in the
presence of cutaneous
disease [5]. Therefore,
the diagnosis of psoriasis
should usually include
simultaneous
presentation of oral and
cutaneous disease. It
usually occurs with white
“plaque like” lesions,
erythematous lesions or
a mixed appearance,
increased frequency of
geographic tongue is
seen but any gingival and
periodontal changes
appear to be the most
obscure with only five
reported evidence of
periodontal disease [6].
Psoriasis may present
with severe systemic
involvement and in some
cases may be fatal.
However, it may also
undergo spontaneous
remissions for weeks,
months or even years.
Little information is
currently available for
the treatment of lesions
associated with psoriasis.
This case report
describes the clinical
presentation of
periodontal findings in a
patient having cutaneous
psoriasis.
C B
A thinned
S cutaneous lesions (A) Dorsal
E Dorsal aspect of hand.
R cells
E
P
O
R
T
A 45yearold female
presented to the
Department of
Periodontics, M.S.
Ramaiah Dental College
and Hospital, Bangalore,
with a complaint of
loosening of upper and
I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –
Kran ti et al .
lower front teeth since An intraoral clinical
two months. It was examination presented
associated with missing teeth i.r.t 15, 31,
intermittent pain since 32, 44, 45 and 46. Oral
two months. Her medical hygiene was poor with
history revealed that she increased local factors.
was a known case of There was generalized
psoriasis past 22 years. gingival inflammation
She was allergic to with increased tendency
penicillin. Her family to bleed on probing.
history was positive for Periodontal examination
psoriasis and she was on revealed probing depth
medication for same. of 8–10 mm. All the
Scaly type cutaneous remaining teeth were
lesions, whitish to red found to be in
in color, were seen on compromised
the extensor aspect of periodontal health with Figure 2: Frontal view of
generalized Grade III missing teeth with
forearms, legs, and also
generalized recession.
the scalp (Figures 1 and mobility. There was also
2). generalized recession
present (Figure 2).
Orthopantomogram
revealed severe
horizontal bone loss
around all the teeth.
Bone loss was greater
A than apical third of the
roots of all the teeth.
Grade III furcation i.r.t
16, 26 and grade IV
furcation 47 (Figure
3). Blood investigations
showed normal values
except for erythrocyte
sedimentation rate
(ESR) which was high. Figure 3:
A biopsy was obtained, Orthopantomogram
Histopathologic features showing severe horizontal
showed parakeratinized bone lors around all the
stratified epithelium with teeth.
elongated tube like
reteridges. Epithelium
over the connective
tissue papillae was
with the
Figure 1: Scaly type proximity of the
vascularized stromal
aspect of forearm, (B)
tissue. Intense pooling of
chronic inflammatory
was evident
suggestive of psoriasis
(Figure 4).
I J CRI 201 3; 4(7): 372–375. Kran ti et al .
m

I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –

I J CRI 201 3; 4(7): 372–375. Kran ti et al .
m
comorbidly and at an cascade of cytokines, psoriasis is very rare
increased incidence in creating an which could be
patients with psoriasis inflammatory response. attributed to cell
[7]. This has been Once activated dendritic turnover rate.
attributed to the antigen presenting cells Considering this rarity,
common inflammatory and T cells release this case can enlighten
pathways with similar cytokines, chemokines on the new insights on
pathogenic mechanism, and growth factors which the pathogenesis of
involving cytokine trigger keratinocyte periodontal disease and
dysregulation in proliferation, altered its relevance on the
psoriasis and several differentiation and an severity of periodontal
Figure 4: Biopsy showing associated diseases such angiogenic tumor lesion which can alter the
parakeratinized stratified response giving rise to treatment goals, and
as arthritis, diabetes,
epithelium psoriatic lesions. further questions
(H&E stain, x100)
cardiovascular disease
and irritable bowel There is presently whether it is a cause or a
syndrome which are no definitive treatment consequence of disease
referred to as immune for psoriasis and severity need to be
Based on the clinical mediated inflammatory managing the intraoral established.
and radiological diseases [7, 8]. lesions is not well
appearance a diagnosis As illustrated by this documented in literature. *
of aggressive case, a definitive Spontaneous remission *
periodontitis was made, diagnosis of oral of these conditions have *
in a known case of psoriasis can pose a been reported. However, *
psoriasis. Patient was significant challenge for patient with persistant
*
advised to undergo full the clinican. Further, it is lesions usually require
therapy directed at *
mouth extraction generally agreed that the
followed by replacement. major criterion in palliation of *
Patient was recalled and confirming a diagnosis symptomatic lesions. *
followup was done. of oral psoriasis is the This may be in form of *
presence of topical anaesthetics,
mucocutaneous lesions diphenhydramine A
DISCUSSION which has been so in the hydrochloride and alkali u
present case report. rinses. However, t
An intelligent person The immune system treatment will only h
once stated “Beware the has been strongly usually provide o
man with one case”. implicated in the temporary relief of
r
Although it is true that pathogenesis of psoriasis symptoms. This case
no generalizations are to that resembles a T cell report throws a light on
mediated, autoimmune, the severity of C
be made and no definite
conclusions are to be inflammatory disease [7, periodontal disease o
drawn from a single 8]. T cells are associated with n
event, some interesting accompanied by increase psoriatic lesions. t
observations can be number of dermal Treatment goals are r
made in this rather dendritic cells, directed towards i
unique case. macrophages and mast palliation of symptomatic b
A definitive diagnosis cells. It is thought that lesions. u
of psoriasis associated a stimulus such as t
with periodontitis can trauma or infection
i
pose a significant which could be plaque C
induced periodontal
o
challenge for a clinician. O n
The marked gingival infection triggers a N
lesions observed in this plexus of cellular s
case, along with severe events by initiating a C Kranti K – Substantial
destruction of the L contributions to
periodontal tissues U conception and
affecting almost all the design, Acquisition of
S data, Drafting the article,
teeth. It is possible I
that this form of severe revising it critically for
periodontitis could have O important intellectual
been a coincidental N content, Final approval
finding, unrelated to of the version to be
psoriasis. However, Although psoriasis is published
literature suggest that a common Mani R – Substantial
several inflammatory papulosquamous disease contributions to
conditions, exist of the skin, oral conception and design,
Analysis and
I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –
 I J CRI 201 3; 4(7): 372–375. Kran ti et al .
www.ijcasereportsandimages.co
interpretation of data, conflic
m
Drafting the article, Final t of
approval of the version to interes
be published Shaesta t.
Begaum –
Substantial C
contributions to o
conception and design, p
Drafting the article, y
Revising it critically for r
important intellectual
i
content, Final approval
of the version to be g
published h
t
G © Kranti K et al. 2012;
u This article is distributed
under
a
the terms of Creative
r Commons attribution 3.0
a License which permits
n unrestricted use,
t distribution and
o reproduction in any
r means provided the
The corresponding original authors and
author is the original publisher are
guarantor of properly credited.
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I J CRI – I n tern ati on al J ou rn al of Case Reports an d I m ag es, Vol . 4 N o. 7, J u l y 201 3. I SSN –
I J CRI 201 3; 4(7): 372–375. Kran ti et al .
www.ijcasereportsandimages.co
m
I J CRI 201 3; 4(7): 372–375. Kran ti et al .
www.ijcasereportsandimages.co
www.ijcasereportsandimages.com/copyrightpolicy.php
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patients with Psoriasis: Clinical presentation and
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