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International Journal of Contemporary Dental and Medical Reviews (2018), Article ID 021218, 6 Pages

REVIEW ARTICLE

Oral manifestations associated with and their management Ahmad A. Bedair1, Azmi M. G. Darwazeh2

1Department of , Ministry of Health, Jordan, 2Department of Oral Medicine and Surgery, Faculty of Dentistry, Jordan University of Science and Technology, Jordan

Correspondence Abstract Dr. Azmi M. G. Darwazeh, Department Background: Psoriasis is a common inflammatory multisystem chronic disease, with of Oral Medicine and Surgery, Faculty predominantly skin and joint manifestations. Several oral lesions and conditions were of Dentistry, Jordan University of Science and Technology, Irbid; P. O. Box described to affect psoriatic patients more common than healthy subjects. Lesions 3030 - Jordan. Phone: +962795885271. such as geographic and fissured were considered by some authors to be oral E-mail: [email protected] manifestations of the disease. Psoriatic patients’ quality of life was reported to be adversely affected by the existence of some of the oral lesions.Aim: The aim of the study Received 07 December 2018; is to increase the awareness of the oral health care professionals in detecting the lesions Accepted 31 December 2018 associated with psoriasis and controlling the disease to help in improving the life quality of psoriatic patients. Conclusion: Multiple oral and perioral lesions are associated with doi: 10.15713/ins.ijcdmr.132 psoriasis and can affect the patient’s life quality. Clinical Significance: Oral health care providers should be aware of the oral manifestations associated with psoriasis and their How to cite this article: management for better control of the disease and better patients’ quality of life. Bedair AA, Darwazeh AMG. Oral manifestations associated with psoriasis Keywords: Candidosis, , , oral manifestations, psoriasis and their management. Int J Contemp Dent Med Rev vol.2018, Article ID: 021218, 2018. 10.15713/ins.ijcdmr.132

Introduction importance for the oral health care providers and physicians alike to be aware of these manifestations, particularly due to the Psoriasis is an inflammatory multisystem chronic disease with proven correlation between the severity of the disease and the predominantly skin and joint manifestations that affects 1–3% existence of some oral manifestations.[8] The aim of this study [1] of the world’s population. The skin disease is characterized by is to review the various oral and perioral lesions and conditions scaly, erythematous patches, papules, and plaques that are often associated with psoriasis and their management, to increase the pruritic and may be painful. Between 5% and 42% of patients with awareness of the oral health care professionals in detecting/ psoriasis have psoriatic , while fingernails are involved in managing the oral lesions associated with psoriasis, and to about 50% of patients. The disease waxes and wanes and have improve the patients’ quality of life. few spontaneous remissions. Psoriasis can cause considerable A comprehensive review of PubMed, Embase, DynaMed morbidity and has a profound negative impact on the quality of Plus, CINAHL Complete, and Medscape databases was the patient’s life.[1] conducted with no time restriction. Articles in English of all The diagnosis of psoriasis relies mainly on identifying study designs were considered for inclusion in the review. Only the characteristic clinical features and the histopathological results from controlled studies were included in table. examination, but regrettably, there is no cure, so far, for the disease. Topical treatment is the mainstay of therapy; including Review the use of topical , salicylic acid, vitamin D analogs, anthralin, tazarotene, and tar.[2] Phototherapy such as Fissured tongue (FT) Psoralen and Ultraviolet A and Ultraviolet B (UVB) is used in FT [Figure 1] is believed to be a common genetically inherited more widespread disease.[2] trait that occurs in widely variable prevalence in different The existence of oral manifestations for psoriasis has populations.[6] It is generally asymptomatic, but debris impaction been repeatedly questioned.[3-7] Apparently, they are less well and subsequent fermentation in deep fissures may result in recognized than cutaneous lesions; nevertheless, it is of prime burning sensation and halitosis.[8]

1 Bedair and Darwazeh Oral manifestations and management of psoriasis

As shown in Table 1, FT was detected significantly more than across the tongue by healing on one edge while extending any other oral lesion in psoriatic patients.[5,7,9,10] The prevalence on another. These erythematous zones are devoid of filiform of FT has been shown to correlate positively with the severity of papillae, while other tongue papillae are unaffected. GT is the cutaneous disease.[9] This data would allow suggesting that neither of known etiology nor curative treatment and generally FT may be considered an oral manifestation of psoriasis, or a late symptomless, but some individuals exhibit sensitivity to spicy and permanent expression of it, in spite of that the cause-effect or hot foods or drinks. EM appears on non-lingual relationship between these two diseases is unproven yet.[5,7] causing lesions similar in appearance to that of GT but with far Some studies have reported that FT was more frequent in plaque less prevalence. type[5] and pustular type psoriasis.[6] In otherwise healthy subjects, GT prevalence ranges from In general, no treatment is necessary for FT unless it becomes 0.28% to 14.4% [Table 1]. Historically, GT/EM has been linked symptomatic. The patient should be encouraged to clean the to many diseases and conditions such as , mellitus, tongue with toothbrush and to use antiseptic mouthwash. Mild reactive bronchitis, respiratory disorders, Reiter’s syndrome, symptomatic lesions may be treated with topical corticosteroids, stress, hormonal disturbances, Down’s syndrome, lithium [11] whereas oral methotrexate has been tried in severe cases. Case therapy, and nutritional deficiencies.[14] reports suggest that symptomatic FT in psoriatic patients may Interestingly, there is a striking clinical and histological respond well to systemic treatment with retinoid or anti-tumor similarity between psoriasiform lesions, GT, and EM,[15] and [12] necrosis factor (anti-TNF) agents. Surprisingly, a major there is a positive correlation between GT and the severity improvement and disappearance of deep tongue fissures have of psoriasis.[8] In addition, -Cw6 been reported in a psoriatic patient treated for 5 months with antigen has been detected in 59.1% of psoriatic patients and infliximab; a biologic systemic agent used in the management of 43.8% of the patients with GT.[16] Moreover, some clinical [13] psoriasis. studies noticed a parallel improvement of skin lesions and tongue lesions with the retinoid treatment of psoriasis.[7] Geographic tongue (GT) and migrans (EM) Patients with GT have been shown to exhibit more severe GT is an inflammatory disorder of the tongue mucosa F[ igure 1], psoriasis compared to those without the tongue lesions.[17] which presents clinically as one or more erythematous patches All these data support that GT/EM can be a form of oral with a raised white or yellow border. Lesions may migrate psoriasis.[7,9,18] Patients with symptomatic GT are encouraged to gently brush the dorsum of the tongue using a soft toothbrush to eliminate debris that may serve as an irritant, in addition, to use topical prednisolone. Treatment with topical anesthetic agents, anti-inflammatory mouthwashes, , anxiolytic agents, and light application of liquid nitrogen was documented in literature.[9] Topical application of 0.1 tretinoin solution has proven effective in controlling symptomatic GT lesions in many patients.[19] However, the patients should be assured about the benign nature of the lesions. A severe case of refractory symptomatic GT was reported to be treated successfully by the administration of systemic Figure 1: (a) Fissured and (b) geographic tongue in a psoriatic cyclosporine microemulsion preconcentrate, 3 mg/kg/day, patient for 2 months.[20] Topical and systemic antihistamines with

Table 1: The prevalence of geographic tongue and FT compared to control subjects in different countries Reference Country Geographic tongue Fissured tongue Psoriatic patients Control subjects Psoriatic patients Control subjects Hernández‑Pérez et al. (2008)[5] Mexico 10/80 (12.5%) 6/127 (4.7%) 38/80 (47.5%) 26/127 (20.4%) Daneshpazhooh et al. (2004)[6] Iran 28/200 (14%) 12/200 (6%) 66/200 (33%) 19/200 (9.5%) Costa et al. (2009)[7] Brazil 30/166 (18.1%) 7/166 (4.2%) 57/166 (34.3%) 27/166 (16.2%) Picciani et al. (2014)[8] Brazil 43/348 (12%) 10/348 (3%) 125/348 (36%) 70/348 (20%) Darwazeh et al. (2012)[9] Jordan 17/100 (17%) 9/100 (9%) 35/100 (35%) 13/100 (13%) Tomb et al. (2010)[10] Lebanon 31/400 (7.7%) 10/1000 (1%) 133/400 (33.2%) 99/1000 (9.9%) Singh et al. (2013)[17] India 34/600 (5.6%) 7/800 (0.8%) 272/600 (45.3%) 320/800 (40%)

2 Oral manifestations and management of psoriasis Bedair and Darwazeh cyclosporine were also used with successful outcomes.[21] A recent case report has described improvement with systemic retinoid or anti-TNF agent therapy.[12] Topical or systemic antifungal should be used if secondary candidosis is evident.[21]

Peri-oral psoriasis Psoriasis involving the perioral region is rare.[22,23] The available reports describe non-specific diffuse erythema, fissuring, silvery scales, and desquamation starting from the commissures and spreading to involve .[22,23] It may be associated with bleeding, serous exudate, as well as itching and discomfort, and may be aggravated by movement.[22] However, due to the close similarity of these lesions with other lip lesions such as chronic eczema, solar , or fungal infections, the diagnosis of perioral psoriasis may have been overlooked. Figure 2: Bilateral caused by Candida albicans

Gingivitis and periodontitis persons.[30] Skinner et al. reported 14 psoriatic patients in whom the oropharynx was colonized with Candida albicans.[31] Studies Some studies have shown that the prevalence of periodontal surveying oral lesions in psoriatic patients have reported angular disease, teeth mobility, and loss was significantly higher among [18,24] cheilitis [Figure 2] and erythematous and pseudomembranous psoriatic patients. The fact that /periodontitis candidosis in 11.0% and 8.7% of the patients, respectively.[3,5] share the same underlying inflammatory pathogenetic process Asymptomatic Candida species were isolated in significantly of psoriasis tempted the researchers to suggest common higher prevalence and count from the oral cavity of psoriatic underlying pathogenic risk factors between the two diseases. patients compared to control subjects,[29] and there was a Two clinically non-specific erythematous lesions, one on the positive correlation between psoriasis severity and Candida attached gingiva and the other on the hard were reported colony count,[32] whether oral candidosis is a manifestation of [25,26] in two psoriatic patients. The histopathologic examinations psoriasis, or a consequence to the immunosuppressive therapy proved that lesions were related to psoriasis, and adalimumab is not clear. therapy resulted in dramatic resolution of oral and cutaneous The majority of oral candidal infections can be successfully [25] lesions. treated with topical antifungal applications. Guidelines from Reviewing the literature revealed several reports of the Infectious Diseases Society of America for the management [18,27] associated with psoriasis. These of oropharyngeal candidosis in psoriatic patients recommend lesions were histologically consistent with the diagnosis of topical antifungal therapy (clotrimazole troches or nystatin [27] psoriasis. suspensions or pastilles) as first-line treatment for patients with There is a correlation between stress, alcohol consumption, initial episodes of mild disease for at least 7–14 days, whereas tobacco use, and , as these factors may also moderate to severe infections, such as esophageal candidosis, [28] have an impact on the systemic health of the psoriatic patient. are treated by oral fluconazole (100-200 mg) once daily for As in otherwise healthy subjects, the management of gingivitis 7–14 days.[33] Nevertheless, the development of candidosis does and periodontitis in psoriatic patients should focus on achieving not usually necessitate alteration or interruption to the psoriasis meticulous plaque control, whereas best efforts should be treatment regimen.[33] exercised to avoid oral soft tissue injury during periodontal scaling.[25] Symptomatic desquamative gingivitis lesions are Miscellaneous oral mucosal lesions managed by topical, systemic, or intralesional corticosteroids.[25] Non-specific diffuse oral erythema was described in 5.5%of psoriatic patients.[6] and physiologic melanin Oral candidosis pigmentation were more frequent in patients with psoriasis.[5] A case control study in 100 psoriatic patients has shown However, these two observations were far from explanation. approximately 3% of psoriatic patients to have clinically Younai and Phelan[4] described a case of oral mucositis with and microbiologically evident oral candidosis (two cases of generalized erythema on the hard palate, a white scaly lesion erythematous candidosis and one case of median rhomboid on the upper lip and multiple pustules, in addition, to striated ) compared to none in the control subjects.[29] Henseler lesions on the tongue, the buccal mucosa and the floor of the reviewed the medical records of 44,695 dermatologic patients mouth. Goldman and Bloom[34] described an irregular, whitish and concluded that psoriatic patients had 1.3–1.6 more relative gray lesion on the floor of the mouth. Ulcerative palatal lesions risk for developing mucocutaneous candidosis than healthy with reddened throat and glottis, clinically and histologically

3 Bedair and Darwazeh Oral manifestations and management of psoriasis compatible with psoriasis, were also described.[35] However, all general examination, and even less commonly, mucosal these lesions were sporadic with no specific diagnosis assigned. for known cases of psoriasis are performed makes the true incidence of oral manifestations of psoriasis really (TMJ) disorders unknown and doubtful.[6] However, there are currently no TMJ involvement was detected in 31–69% of patients with definite accepted clinical criteria by which an oral lesion can [26] psoriatic arthritis. Clinically, the patients presented with TMJ be unequivocally diagnosed as psoriasis. Although skin pain and tenderness, facial pain, and restricted jaw movement.[36] constitutes a significant part of the diagnostic workup Crepitus is usually the most characteristic TMJ sound in these process, there is no consensus regarding the histopathologic patients, which may persist after all other features of oral psoriasis. Histological picture similar to skin have disappeared.[36] psoriasis was found in cases of non-specific inflammation TMJ radiographic findings of psoriatic arthritis are non- of the oral mucosa in otherwise healthy patients; thus, one specific and include reduced translation, abnormalities in condyle should approach the diagnosis of intraoral psoriasis with [5,15,27] position, condylar head erosions, and osteoporosis.[37] Magnetic caution. In addition, some case reports have described [4] resonance imaging has shown itself to be the gold standard in oral psoriasis despite no dermal involvement. Therefore, a the diagnostics of TMJs afflicted by psoriasis, altogether with a definitive diagnosis of oral psoriasis is difficult to establish negative rheumatoid factor.[37] with absolute certainty. Patients should be advised to use modified oral Not all oral lesions diagnosed in association with psoriasis hygiene aids when psoriatic arthritis hinders adequate oral are necessarily an actual part of the disease. Oral candidosis, hygiene.[19] Rasmussen and Bakke[37] managed TMJ affections in particular, can be a consequence to immunosuppressive for four psoriatic arthritis patients by therapy of psoriasis. Topical cortisone, when applied on large passive stretching, and bite splints with pivots with fairly good surface areas of skin for a long duration (as might be in the case results. Palliative care for joint pain with nonsteroidal anti- of psoriasis), may be systematically absorbed, and hence the [29] inflammatory agents and steroids, in addition to, physiotherapy systemic side effects of cortisone can be expected. will enhance the efficacy of occlusal splints, whereas TMJ surgery The literature review reveals that gingiva and palate are should be limited to extreme cases like joint ankylosis.[38] unusual sites for oral manifestations of psoriasis, and may not be different than that observed in otherwise healthy persons. It is, therefore, tempting to investigate Discussion whether controlling the biofilms responsible for the initiation Although patients with psoriasis do not present oral lesions and perpetuation of gingival and periodontal disease may not found in the general population, some forms of oral lesions influence the progress and the severity of the cutaneous and conditions, for example, GT and FT are present with disease. higher prevalence in psoriatic patients compared to otherwise Psoriatic arthritis is a well-recognized manifestation of healthy persons. Supported by the observation of GT and EM psoriasis. TMJ affection seems to adversely affect the patients’ lesions to appear and disappear with the cutaneous lesions quality of life by inducing orofacial pain and altering chewing [36] of psoriasis have led to the conclusion that these lesions may and other jaw functions. Symptomatic oral psoriasis and constitute an oral presentation of psoriasis.[7,9,18] However, TMJ affection may cause oral discomfort and concern for the the existence of oral psoriasis lesions in the absence of skin patient, which may worsen the life quality of psoriatic patients [36] lesions is controversial.[4] It is generally known that some and altering chewing and other jaw functions. In addition, of GT and FT cases are symptomatic and may distress the the painful mouth opening may render the personal oral health affected patient, and adversely affecting the life quality in practice by the patient difficult, which necessitates advice and aid psoriatic patients.[9,18] The possibility of the presence of a from the oral health care provider to maintain a high standard of shared genetic basis for psoriasis and FT is one of the possible oral health. Improper oral hygiene will make the future dental explanations for the frequent occurrence of FT in psoriatic treatment needed for those patients problematic, due to the patients. Another assumption for this frequent occurrence is impaired ability of prolong wide mouth opening during future the possible interaction between genetic and pathophysiologic dental treatment. Therefore, both physicians and oral health care etiologies of either disorder.[7] providers should be familiar with the spectrum of oral signs and The precise prevalence of GT in psoriatic patients may be symptoms, diagnostic workup, and management strategies for difficult to determine and may have been underestimated in the symptomatic oral psoriasis to improve the quality of patient’s cross-sectional studies. This is due to the clinical nature of the life. condition, which is characterized by intermittent flare-ups and remissions, which may point to the necessity for longitudinal Conclusions studies. The fact that few psoriatic patients have their oral Some oral lesions and conditions are more prevalent in cavities clinically examined as a part of the patient routine psoriatic patients compared to otherwise healthy subjects, and

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