Oral and Systemic Health Issues in Psoriasis

Oral and Systemic Health is part of the field of knowledge mapped by the Systematic Review and Meta-Analysis project entitled “Protocol: Complementary Therapies for Chronic Plaques Psoriasis”, for stress management and improvement in mental health psoriasis patients’ levels, according to the WHO and NCCIH / NIH theoretical frameworks and published in 2014 The Cochrane Library [1].

As confirmed by additional publications on the same line research [1-3] the field of knowledge of Oral and Systemic Health considers the impact of oral health status on systemic health and vice versa, and therefore an increase in frequency of outcomes unexpected and unfavorable outcomes observed in these patients, especially when aspects of the oral implications are not observed, since the evidence pointed to important practical implications related to both the pathophysiology of the disease and the clinical manifestations observed directly related to the management of these patients, which are classify in different issues as:

A. Issues related to the pathogenesis of disease

B. Oral findings in psoriasis

C. Psoriasis-related lesions and with histopathological report compatible with cutaneous forms of the disease

i. Geographic Tongue (GT)

ii. Benign Migratory Stomatitis (BMS): Injuries that also occur in psoriasis, but without histopathological report compatible with the cutaneous forms of the disease, such as: whitish ulcers surrounded by reddish spots similar to skin lesions, ulcers red and shiny, white ulcer with positive Auspitz sign, lesions on plaques on the lips, raised plaques on the palate or floor of the mouth, papules clustered or pustules, scabs on the lips. Spread by oral mucosa, these lesions cannot be considered as pathognomonic for psoriasis. All of them are likely to be found simultaneously with the forms of pustular psoriasis and erythrodermic psoriasis, but may also be oral manifestations of several other diseases, such as:

• Rheumatologic diseases (lupus erythematosus, Behçets disease, Reiter’s syndrome, Sweet’s syndrome);

• Microbial diseases (herpetic stomatitis, varicella, herpes zoster, hand-foot-mouth disease, herpangina, infectious mononucleosis, acquired immunodeficiency syndrome, tuberculosis, syphilis and some serious mycoses);

• Skin diseases (erosive lichen planus, chronic ulcerative stomatitis, pemphigus, erythema multiforme, dermatitis herpetiformis, linear IgA disease, epidermolysis bullosa and other dermatoses);

• Malignant neoplasms;

• Blood dyscrasias (anemia, leukemia, neutropenia, other white cell diseases), gastrointestinal diseases (chronic ulcerative colitis, Crohn’s disease, celiac disease);

• Reactions to medications (NSAIDs, nicorandil, cytotoxic drugs and bisphosphonates);

• Arising from procedures such as radiotherapy (eosinophilic ulcer);

• Due to diseases of uncertain pathogenesis (hemorrhagic bullous angina, eosinophilic ulcer, necrotizing sialometaplasia.

iii. Oral psoriasis arthritis at temporomandibular joint (TMJ).

D. Issues related to the clinical implications due Psoriasis

i. Periodontal diseases related to the psoriasis.

ii. Conventional treatments and oral outcomes:

• Inducing oral adverse outcomes.

• Worsening oral adverse outcomes.

• Inducing oral favorable outcomes.

iii. Conventional treatments for diseases related to psoriasis inducing oral adverse events. The scope is not to assess the impact of medications in Dentistry but is relevant to consider the dental issues for drugs used in management of diseases related to the psoriasis, due the potential risk factors can overlap, resulting in adverse outcomes.

• For Prior Morbidities related to psoriasis.<./

• For Co Morbidities related to psoriasis.<./

• For Post Morbidities related to psoriasis.<./

iv. Dental treatments and psoriasis:<./

• Inducing systemic favorable outcomes to psoriasis.<./

• Triggering systemic psoriasis.<./

• Worsening psoriasis.<./

v. Oral risk factors able to induce exacerbation to psoriasis: The scope was to assess its impact only on oral issues when related to the exacerbations of psoriasis. At this scenario, some oral structures e.g. fissured Tongue (F.T.), coated tongue (C.T.), teeth edges, dental decays can overlap with local environmental factors e.g. oral dysbiosis and produce unfavorable outcomes, such desquamative gingivitis. As well as, there are also reports of specific symptoms such as xerostomia and oral burning syndrome.

According to the evidence obtained, among the most important practical implications of the study, it is considered that the interaction of directly and indirectly related risk factors of different nature indicates that the high level of emotional stress produced by psoriasis lesions negatively affects the mental health of the patients with consequent reduction of their quality of personal care, especially those related to the maintenance of oral hygiene. This contributes directly to the occurrence of oral dysbiosis, the most serious of oral health issues and psoriasis, which leads to worsening of the disease evolution and low clinical responsiveness to the treatments undertaken [4-6].

Following an Evidence-Based Health assumption, after a systematic review and meta-analysis was completed, an observational study was conducted with 343 patients with psoriasis and other inflammatory dermatoses treated at the Oral and Systemic Health Sector of the Department of Dermatology of the Escola Paulista de Medicina EPM / UNIFESP, for 46 consecutive months. The results obtained were more eloquent than the data obtained in the systematic review of the impact of the dental biofilm on the condition of dysbiosis in the worsening of the disease in 96.2% of the cases treated.

Psoriasis is a disease of great complexity, it is recommended professional must adopt an assessment risk scales, such as the “physical status classification system” from the American Society of Anesthesiologists (ASA). Psoriasis requires the observation of the technical assumptions e.g. the American Dental Association, it is recommended professional must adopt guidelines, prior to any interventions, concerning to the degree of coverage and invasiveness of each dental procedure and the risk of adverse events before, during and after the consultation for psoriasis patients.

1. Monson CA, Silva V, Andriolo RB, Kozasa EH, Sabbag CY, et al. (2014) Protocol: complementary therapies for chronic plaque psoriasis. Cochrane Library 8.
2. Monson CA, Porfirio G, Riera R, Petri V, Tweed JA, et al. (2016) Periodontal aspects for psoriasis: a systematic review. Clin Res Dermatol Open Acess 3(4): 1-8.
3. Monson CA (2012) Glossary for CAMs. NLM 2013: US national library of medicne-complementary therapies. Tree Structures, USA.
4. Monson CA, Silva V, Porfírio G, Riera R, Tweed JÁ, et al. (2016) Oral health issues in psoriasis: an overview of the literature. IJCDR 4(4): 94-103.
5. Moreira RZ, Monson CA (2016) Psoriasis: an action Plan. Wounds in Need. Association for Advanced Wound Care (AACC). Pennsylvania, USA.
6. Monson CA, Monson ASC (2018) Saúde Oral e Sistêmica: Terapias Complementares na Perspectiva da Saúde Baseada Evidências (SBE). (1st edn), Appris Ed Curitiba, Brazil.