Archives of 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*.

ABSTRACTChronic 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 Figure 2: Deep lesions on scalp. 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,

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15, 23, 25, 38, 36, 35, 34, 33, 32, 31, 43, 44, 45, 46, 47, 48.

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

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with the minimal amount of plaque. It has been suggested that actual periodontal breakdown may be 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.

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history of psoriasis. Calif Med. 1961; 95: 6-11.2. Elder JT, Nair RP, Henseler T, et al. The genetics

of psoriasis 2001: the odyssey continues. Arch Dermatol. 2001; 137: 1447-1454.

3. Telfer NR, Chalmers RJ, Whale K, Colman G. The role of streptococcal infection in the initiation of guttate psoriasis. Arch Dermatol. 1992; 128: 39–42.

4. Poikolainen K, Reunala T, Karvonen J. Smoking, alcohol and life events related to psoriasis among women. Br J Dermatol. 1994; 130: 473–477.

5. Kinane D, Bartold PM. Clinical relevance of the host responses of periodontitis. Periodontol 2000. 2007; 43: 278–293.

6. Yamada J, Amar S, Petrungaro P. Psoriasis-Associated Periodontitis: A Case Report. J Periodontol. 1992; 63:854-857.

7. Sabat R, Philipp S, Hoflich C, et al. Immunopathogenesis of psoriasis. Exp Dermatol 2007; 16: 779–98.

8. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc. 1964; 68: 7-13.

9. Carranza AF. Clinical Diagnosis. Newman MG, Takei HH, Carranza FA, 10th eds. Clinical Periodontology, Philadelphia: Elsevier; 2007: 540-560.

10. Preus HR, Khanifam P, Kolltveit K, Mork C, Gjermo P.. Periodontitis in psoriasis patients. A blinded, case-controlled study. Acta Odontologica Scandinavica 2010; 68: 165–170.

11. Candia L, Marquez J, Hernandez C, Zea AH, Espinoza LR. Toll-like receptor-2 expression is upregulated in antigen presenting cells from patients with psoriatic arthritis: a pathogenic role for innate immunity? J Rheumatol 2007; 34: 374–9.

12. Mahanonda R, Pichyangkul S. Toll-like receptors and their role in periodontal health and disease. Periodontol 2000 2007;43:41–55.

13. Cutler CW, Jotwani R. Dendritic cells at the oral mucosal interface. J Dent Res 2006; 85: 678–89.

14. Sharma CG, Pradeep AR. Anti-neutrophil cytoplasmic autoantibodies: a renewed paradigm in periodontal disease pathogenesis? J Periodontol 2006;77:1304-1313.

15. Burns E, Bachrach G, Shapira L, Nussbaum G. Cutting Edge: TLR2 is required for the innate response to Porphyromonas gingivalis: activation leads to bacterial persistence and TLR2 deficiency attenuates induced alveolar bone resorption. J Immunol 2006;177:8296–300.

16. Hurst J, Von Landenberg P. Toll-like receptors and autoimmunity. Autoimmune Rev 2008; 7: 204–8.

Correspondence:Dr. Anuj Sharma Department of Periodontics, Government Dental College and Research Institute, Bangalore-560002, INDIA.Email: dranuj31oct@yahoo.co.in

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