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Case Report
Psoriatic triad in a patient presenting with oligodontia Abstract Psoriasis is a common dermatological disease. It can occur at any age but usually develops between 15 and 35 years of age and may persist throughout a person’s lifetime with periods of exacerbation and remission. The hyperproliferative state of the affected epidermis produces a turnover rate that is up to eight times greater than normal. Instead of being shed, the skin cells pile up, causing the visible lesions. Oral manifestations of psoriasis are rare clinical observations. Lesions have been reported on the lips, buccal mucosa, palate, gingiva, and floor of the mouth. We document a presentation of psoriasis showing a triad: skin lesions, arthritis, and oral manifestations (oligodontia being patient’s chief concern). Dental rehabilitation done was in the form of partial dentures. This was done to address the immediate concern of the patient, that is, inability to chew properly. As put forth through this case report, a potential link between psoriasis and oligodontia has scope for further study.
Key words Psoriasis, arthritis, oligodontia
Introduction Psoriasis is a common dermatological disease. It can occur at any age but usually develops between 15 and 35 years of age and may persist throughout a person’s lifetime with periods of exacerbation and remission.[1] The exact etiology of psoriasis is unknown, but it appears to be a multifactorial disease with genetic, immunological, and psychosomatic factors.[2] Various triggers, such as trauma, infection, and stress, may cause new episodes. The epidermal changes that occur in psoriasis seem to be related to a defect in keratinocyte proliferation. The hyperproliferative state of the affected epidermis produces a turnover rate that is up to eight times greater than normal. Instead of being shed, the skin cells pile up, causing the visible lesions.[1]
Rai P, Kumar G1, Chaudhary M2
Professor, Department of Orthodontics, 1Associate Professor, 2 Demonstrator, Department of Pediatric Dentistry, Maulana Azad Institute of Dental Sciences, MAMC Complex, BSZ Marg, Delhi – 110 002, India. Correspondence: Dr. Priyank Rai, Pocket A-2, House No. 12, Sector 5, Rohini, New Delhi – 110 085, India. E-mail:
[email protected]
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Website: www.jisppd.com DOI: 10.4103/0970-4388.76162 PMID: *****************************
Oral manifestations of psoriasis are rare clinical observations. Lesions have been reported on the lips, buccal mucosa, palate, gingiva, and floor of the mouth.[3] They have been described by Weathers as “psoriasiform” lesions.[4] We document a presentation of psoriasis showing a triad: skin lesions, arthritis, and oral manifestations (oligodontia being patient’s chief concern).
Case Report A 13-year-old male presented to the graduate pediatric dentistry clinic for dental rehabilitation of his missing teeth. The patient’s medical history was evaluated by questionnaire and interview. The patient had been diagnosed with psoriasis 5 years back. There was no family history of dermatological problems. At the time of examination and treatment, the patient was using creams, ointments, lotions, and shampoos based on tar. A triad of extensive skin lesions, extreme form of crippling arthritis, and oral manifestations was observed.
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Rai, et al.: Psoriatic triad in a patient presenting with oligodontia
Figure 1: Frontal photograph of the patient showing “psoriatic lesion”
Figure 2: Lateral view of the patient showing the extent of the lesions
Figure 4: Plaque form of scalp lesion showing silvery scales and erythematous margins Figure 3: Marked scaling and flakes on the scalp and ear
Extraorally, the patient presented with “psoriatic lesions” on the scalp, face, torso, and extremities [Figures 1 and 2]. A typical plaque form of psoriasis appeared as patches of raised, reddish skin covered by silvery-white scales. Marked scaling and flakes of the scalp were observed particularly affecting the hair margins [Figures 3 and 4]. Skin of the face, ear, and lips appeared shriveled giving a geriatric look [Figure 5]. Small brown spots were also observed on the facial skin [Figure 1]. Toenails and fingernails appeared pitted, thick, and yellowish in color.
“Oral manifestations” of the patient were rare. Intraorally, the patient had oligodontia and impacted maxillary canines [Figure 9]. In the upper jaw, only incisors and two molars on each side were present. The lower jaw had only first and second molars; a rudimentary second premolar was also seen on the left side [Figure 10]. There was no trace of third molars. The enamel of the teeth lacked translucency [Figure 11]. It was patchy, brownish stained, and yellow in color. Marginal gingiva of the patient was bulbous with diffuse erythematous margins.
An extreme form of “psoriatic arthritis” was seen. Bilaterally the lower limbs showed deformity (arching) in both anteroposterior and lateral planes leading to a wobbly gait and painful joints [Figure 6]. The plantar surfaces were markedly flat [Figure 7]. Toes were bulbous and deformed. Upper limbs were also affected. The skin was shriveled; fingers were short, bulbous, and deformed [Figure 8].
Dental rehabilitation done was in the form of partial dentures [Figures 12 and 13]. This was done to address the immediate concern of the patient, that is, inability to chew properly. Further, brushing demonstration and oral hygiene maintenance protocol were emphasized. He has been kept under observation and in future a more comprehensive rehabilitation in the form of orthodontic disimpaction of canines and
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Rai, et al.: Psoriatic triad in a patient presenting with oligodontia
Figure 5: Skin of the lips and adjacent areas appeared shriveled giving a geriatric look to a 14-year old
Figure 6: An extreme form of “psoriatic arthritis” leading to bilateral deformity of the lower limbs
Figure 7: Markedly flat plantar surface
Figure 8: Upper limbs: shriveled skin, fingers were short, bulbous, and deformed
dental implant supported prosthesis has been planned.
Reiter’s syndrome, benign migratory glossitis (also known as geographic tongue), and erythema migrans (lesions that are clinically and histologically similar to geographic tongue but involve oral mucosa other than the dorsum of the tongue).[3]
Discussion and Conclusion Clinically, skin lesions appear as papules and plaques covered by silvery scales. When the scales are removed, small pinpoint bleeding is seen (Auspitz sign).[3] Skin lesions are predominantly found on the individual’s extremities and scalp. The microscopic appearance of psoriasis varies with lesion age and activity. The early lesion shows parakeratosis and acanthosis with budding at the tips of the rete ridges and thinning of the suprapapillary plate. Polymorphonuclear leukocytes migrate through the epithelium with the formation of intraepithelial microabcesses. Although the formation of microabcesses (Munro abscesses) is a characteristic of psoriasis, it is not specific to the disease nor are the microabcesses always present.[5] Within the connective tissue papilla, engorgement of the capillaries occurs and a mixed inflammatory cell infiltrate is commonly seen.[6] In the oral cavity, this microscopic presentation, known as psoriasiform mucositis, is shared by psoriasis,
Prevalence of psoriasis is 1–3% in general population, whereas prevalence of psoriatic arthritis is 0.3–1%. Out of them, 5–10% experience some disability.[7,8] Psoriatic arthritis usually first appears between 30 and 50 years of age—often months to years after skin lesions first occur. However, not everyone who develops psoriatic arthritis has psoriasis. About 30% of people who get psoriatic arthritis never develop the skin condition. All types of psoriasis, ranging from mild to severe, can affect a person’s quality of life.[9] Even the simple act of squeezing a tube of toothpaste can hurt. Living with this lifelong condition can be physically and emotionally challenging. Embarrassment is another common feeling found in
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Rai, et al.: Psoriatic triad in a patient presenting with oligodontia
Figure 9: OPG: Oligodontia and impacted maxillary canines
Figure 10: “Oral manifestations” of the patient
Figure 11: Enamel of the teeth was patchy, yellow in color, and lacked translucency
Figure 12: Dental rehabilitation done with partial dentures
you spent most of your life trying to hide your skin?
Figure 13: Close-up view of the same patient after 1 month
such school-going children. What if you extended your hand to someone and the person recoiled? Imagine getting your hair cut and noticing that the stylist or barber is visibly uncomfortable. How would you feel if 300
Although there is no cure for psoriasis, treatment is usually effective. The skin becomes less scaly and may look completely normal: moisturizing creams and ointments will moisturize dry skin and are a substitute for soap when washing the skin. Some of these bath oils contain tar or antiseptics, which can provide other benefits in addition to the moisturizing effect. Regular daily doses of sunlight taken in short exposures can help to improve psoriasis. Sunburn may make psoriasis worse. Tar creams, ointments, lotions, and shampoos help to reduce scaling and have an antiinflammatory effect. Vitamin D based topical (applied to the skin) preparations can be effective. Salicylic acid based applications can help to remove thick layers of overgrown skin and scales. Mild steroid creams and ointments can be used for short periods to treat psoriasis on the face or in body folds.
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Rai, et al.: Psoriatic triad in a patient presenting with oligodontia
With the emergence of several new therapies, including the biologic agents, more and more children are reporting a greatly improved quality of life. We as dental surgeons should view these children with compassion and give our utmost care to provide oral relief and rehabilitation. As put forth through this case report, a possible link between psoriasis and oligodontia has scope for further investigative research.
References 1. Regezi JA, Sciubba JJ. Textbook of Oral pathology: Clinicalpathologic Correlations. WB Saunders, Philadelphia; 1989. p. 134-41. 2. Watson W, Cann HM, Faber EM, Nall ML. The genetics of psoriasis. Arch Dermatol 1972;105:197-207. 3. Shafer WG, Hine MK, Levy BM. Textbook of Oral Pathology.
4th ed. Philadelphia: Saunders; 1993. p. 814-6. 4. Weathers DR, Baker G, Archard HO, Burkes EJ Jr. Psoriasiform lesions of the oral mucosa (with emphasis on “ectopic geographic tongue”). Oral Surg Oral Med Oral Pathol 1974;37:872-88. 5. Montgomery H. Dermatopathology. New York: Harper and Row; 1967. p. 309-52. 6. Lever WF. Histopathology of skin. 4th ed. Philadelphia: J B Lippincott Company; 1967. p. 141-4. 7. Doglas J, Veale D. The epidemiology of psoriatic arthritis: Fact or fiction? J Rheumatol 2000;27:1105-7. 8. Patel S, Veale D, FitzGerald O, McHugh NJ. Psoriatic arthritisEmerging concepts. Rheumatology 2001;40:243-6. 9. American Academy of Dermatology. Psoriasis. Available from: http://www.aad.org/public/Publications/pamphlets/Psoriasis.htm [last accessed on 2008 Aug 26].
Source of Support: Nil, Conflict of Interest: Nil
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