Correlation between Psoriasis Severity and Periodontal Pocket Depth

in Psoriasis Vulgaris

Sofa Inayatullah

, Anita H. Joedo

Githa Rahmayunita

, and Evita Halim Effendi

Department of Dermatology and Venereology Faculty of Medicine Universitas Indonesia / Dr. Cipto Mangunkusumo

National General Hospital, Jakarta

Department of Dental and Oral Medicine, Dr. Cipto Mangunkusumo National General Hospital, Jakarta

Keywords: Infection, periodontitis, psoriasis

Abstract: Psoriasis is a chronic inflammatory skin disease, characterized by erythematous plaques and scales,

with Koebner phenomenon and Auspitz sign. One of the trigger factors that contributes is infection.

Periodontitis is an infection that occurs in periodontal tissue and can be one of the infection focus. This

research aimed to determine the proportion of periodontitis in patients with psoriasis vulgaris and the

correlation between psoriasis severity and periodontal pocket depth. This cross-sectional study was

conducted in July-November 2017 in Dermatovenereology clinic of dr. Cipto Mangunkusumo National

General Hospital, Jakarta. Anamnesis and physical examination of skin lesions were done by

investigator, dental and oral examination were done by periodontist. Total of 34 subjects were

examined with median age of 37.5 years (range 19-58 years old). The subjects consisted of 20 patients

(58.8%) with mild psoriasis and 14 patients (41.2%) with moderate-severe psoriasis. The result showed

16 patients (47.1%) with periodontitis and 18 patients (52.9%) without periodontitis. Periodontitis was

obtained in 8 patients (23.53%) in each group of mild and moderate-severe psoriasis. There was no

statistically significant correlation between psoriasis severity and periodontal pocket depth (r = 0.126, p

= 0.478). The results might be due to counfounding factors that affect both psoriasis severity and

pocket depth.

1 INTRODUCTION

Psoriasis is a chronic inflammatory skin disease,

characterized by erythematous plaque and scales,

with Koebner phenomenon and Auspitz sign

(Gudjonson et al., 2012).

Trigger factors for

psoriasis are infection, drugs, trauma, stress, obesity,

smoking, and alcohol consumption (Sharma et al.,

2015; Ungprasert et al., 2016).

Recurrence and

persistence of psoriatic lesions may occur and

disrupt patients quality of life. One of the trigger

factors that contributes is infection (Sharma et al.,

2015).

The focus of infection sources are varied,

including oral, ear, and throat infections (Ungprasert

et al., 2016; Brezewski et al., 2013). Management of

infection is one of the keys for achieving skin

remission (Brezewski et al., 2013).

Oral infection in psoriasis patient is common and

may act as a source of focal infection. The

prevalence of periodontal disease in psoriasis

patients in some studies ranged from 24-27%

(Rysstad et al.,2014; Lazaridou et al., 2013).

Periodontitis is a chronic infection and inflammatory

disease of periodontal tissue characterized by gum

bleeding, periodontal pocket formation, periodontal

tissue destruction, and alveolar bone destruction

(Sharma et al., 2015). The periodontal pockets are

assessed by measuring the pocket depth, the distance

measured from gingival edge to pocket base in

millimetres (Page & Eke, 2007).

Both of psoriasis and periodontitis have immune

responses toward microbiota on epithelial surface. It

is suspected that damage or disturbance in

periodontal tissue may associate with psoriasis

exacerbation. On the other side, remission of

psoriasis may correlate with remission of

periodontal tissue destruction (Sharma et al., 2015).

Pocket depth correlate with periodontitis severity

(Page & Eke, 2007). We suspected that psoriasis

severity might be correlated with pocket depth.

Several studies aimed to know the difference

between periodontitis and periodontal status in

Inayatullah, S., Joedo, A., Rahmayunita, G. and Effendi, E.

Correlation between Psoriasis Severity and Periodontal Pocket Depth in Psoriasis Vulgaris.

DOI: 10.5220/0008151200780082

In Proceedings of the 23rd Regional Conference of Der matology (RCD 2018), pages 78-82

ISBN: 978-989-758-494-7

psoriasis patients compared with control group

(Sharma et al., 2015).

Periodontitis was found more

frequently in psoriasis patients than in control group

(Rysstad et al.,2014). Metaanalysis studies reported

that patients with periodontitis had a greater risk of

psoriasis (Ungprasert et al., 2016;Keller et al.,

2012).

Prevalence of psoriasis varies across countries

with range of 0.09-11.4% (Gujonson et al.,

2012;Anonym, 2016).

In developing countries, the

prevalence ranges from 1.5-5% (Anonym, 2016).

The 2013 Indonesian National Health Research

Report (known as RISKESDAS) reported the

population proportion with dental and mouth

problems were 25.9%. The proportion of

Indonesians with proper behavior in teeth brushing

was only 2.3%. Most Indonesian brushed their teeth

every day during morning and afternoon shower

(Anonym, 2013).

The high proportion of periodontitis in patients

with psoriasis vulgaris in earlier studies and low

proportion of Indonesian population with proper

behavior in brushing were become our consideration

to determine the proportion of periodontitis in

psoriasis vulgaris. The study was aimed to find the

proportion of periodontitis in patients with psoriasis

vulgaris and report the correlation between psoriasis

severity and periodontal pocket depth. In this study,

patients with smoking habit and alcohol

consumption were excluded

2 METHODS

The study was an analytic descriptive study with

cross sectional design. Total subjects were 34

psoriasis vulgaris patients in Dermatovenereology

clinic of dr. Cipto Mangunkusumo National General

Hospital according to inclusion and exclusion

criteria. General physical examination, vital signs,

skin lesions, and determination of psoriasis severity

using psoriasis area and severity index (PASI) scores

were performed by principal investigator. Patients

with PASI score less than 7 were classified as mild

psoriasis and patients with PASI score 7 or greater

were classified as moderate-severe psoriasis.

Patients were assessed by a periodontist to examine

pocket depth, clinical attachment level (CAL),

plaque index, calculus index, and papillary bleeding

index. Periodontitis were assessed based on pocket

depth and CAL. Periodontitis definition in this study

was based on case definition proposed by the

Centers for Disease Control and Prevention (CDC)

and the American Academy of Periodontology

(AAP). Moderate periodontitis was defined as

having ≥2 interproximal sites with CAL ≥4 mm (not

on same tooth), or ≥2 interproximal sites with pocket

depth ≥5 mm (not on same tooth). Severe

periodontitis was defined as having ≥2 interproximal

sites with CAL ≥6 mm (not on same tooth) and ≥1

interproximal site with pocket depth ≥5 mm

(Rysstad et al., 2014; Page & Eke, 2007). Subjects

with certain indications or clinical doubts will be

underwent panoramic radiography.

3 RESULTS

Total subjects were 34 patients during July-

November 2017. The proportion of periodontitis can

be seen in table 1 and correlation between psoriasis

severity and periodontal pocket depth can be seen in

figure 1.

4 DISCUSSION

4.1 Proportion of Periodontitis in Psoriasis

Vulgaris Patients

Total of 34 subjects consist of 20 patients (58.8%)

with mild psoriasis and 14 patients (41.2%) with

moderate-severe psoriasis. Median of PASI scores

was 4.1 (range 1.8-27.5). Median of age was 37.5

years old with range 19-58 years old. Subjects

consist of 27 female (79.4%), and 7 male (20.6%).

The results showed that 16 patients (47.1%) with

periodontitis and 18 patients (52.9%) without

periodontitis. There were 8 patients (23,53%) with

mild psoriasis and 8 patients (23,53%) with

moderate-severe psoriasis diagnosed with

periodontitis.

The proportion of periodontitis in psoriasis

vulgaris patients in this study is higher than previous

studies conducted by Lazaridou et al. (2013), Fadel

et al.

(2013), and Rysstad et al. (2014). Lazaridou et

al. (2013) showed the proportion of periodontitis in

psoriasis patients were 27%, which is 46% of the

patients were active smokers. In our study, smokers

were excluded. There was no age restriction in

Lazaridou’s study, while in our study the age was

limited at 18-59 years old. Fadel et al. (2013)

showed the proportion of periodontitis in psoriasis

vulgaris patients were 24%. The results showed that

patients with psoriasis have lower pH of saliva,

fewer teeth number, and lower level of alveolar bone

compared to control group (p <0.05). Rysstad et al.

Correlation between Psoriasis Severity and Periodontal Pocket Depth in Psoriasis Vulgaris

(2014) showed the proportion of moderate-severe

periodontitis in psoriasis patients were 24%, while

68% of subjects were in immunosuppressant

therapy. Patients with systemic therapy and smoking

habit still be included in Rysstad’s study, while in

our study those patients were excluded.

Table 1. Proportion of periodontitis in subjects (n = 34)

Periodontitis

n (%)

Without periodontitis

n (%)

Total

n (%)

Mild psoriasis

8 (23.5)

12 (35.3)

20 (58.8)

Moderate-severe

psoriasis

8 (23.5)

6 (17.6)

14 (41.2)

Total n (%) 16 (47.1) 18 (52.9) 34 (100)

Figure 1. Correlation between PASI score and periodontal pocket depth (n = 34)

The reports of 2013 RISKESDAS showed that

proportion of Indonesian population with dental and

mouth problems were 25.9%. Proper behavior in

teeth brushing is the habit of brushing every day

after breakfast and before bedtime. Almost all

population with age ≥10 years brushed their teeth

every day (93.8%), Jakarta was the highest

proportion (98.1%) and Papua was the lowest

(49.6%). Most of them actually brushed their teeth

during morning and afternoon shower. Improper

behavior of teeth brushing were found in almost all

age groups, while the proper behavior were only

2.3% (Anonym, 2013). These might be the cause of

high proportion of periodontitis in this study

compared with other researches

4.2 Correlation between Psoriasis Severity

and Periodontal Pocket Depth

This study showed no significant and very weak

correlation (r = 0.126; p = 0.478) between PASI

score and pocket depth (figure 1). This results

showed that increase in pocket depth were not

followed by an increase in PASI score. Although

this study found that there were no correlation

between psoriasis severity and periodontal pocket

depth, but there was positive correlation between

them. We assumed that pocket depth was not

enough to affect psoriasis severity. This result may

be caused by confounding factors that affect both

pocket depth and psoriasis severity.

There were many factors that can affect both

PASI score and pocket depth. The characteristics of

subjects were heterogeneous, with wide age range

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

(18-59 years old). Emotional stress and diabetes

mellitus may also be the cause of the absence of

significant correlation.

Wide age range (18-59 years old) could be a

counfounding factor for correlation between

psoriasis severity and periodontal pocket depth in

this study. Brown et al.

(1990) reported 5.7%

subjects with 4-6mm pocket depth in the age group

of 18-24 years old. This proportion was increased

three fold (18.1%) in the age group of 55-64 years

old.

This study did not evaluate stress factors.

Lakshmy et al. (2015) reported psychiatry morbidity

in psoriasis vulgaris and the correlation with

psoriasis severity. The results showed that 71

patients (78.9%) have depression and 69 patients

(76.7%) have anxiety disorders. There was positive

correlation between psoriasis severity and

psychological variables (depression, anxiety, and

stress). Psoriasis severity correlated significantly

with depression (r = 0.465, p = 0.000), anxiety (r =

0.515, p = 0.000), and stress (r = 0.544, p = 0.000).

Rosania et al.

(2009) reported there were positive

correlation between the score of stress and pocket

depth (r = 0.23, p = 0.06) and also with number of

missing teeth (r = 0.54, p <0.001).

Diabetes mellitus is a frequent comorbid in

psoriasis and periodontitis patients (Anonym, 2016;

Holmstrup et al., 2017).

There were 5 patients

(14.7%) with history of diabetes mellitus. Diabetes

mellitus could act as a counfounding factor between

psoriasis severity and periodontal pocket depth in

this study.

5 CONCLUSION

The high proportion of periodontitis was found in

psoriasis vulgaris patients and there was no

statistically significant correlation between psoriasis

severity and periodontal pocket depth. In the

management of psoriasis vulgaris, all trigger factors

should be eliminated so that psoriatic lesions do not

get worse and recurrent. Although this study found

that there was no correlation between psoriasis

severity and periodontal pocket depth, but the high

proportion of periodontitis in psoriasis vulgaris

patients should increase the physician awareness to

identify and treat the focus of infection properly.

ACKNOWLEDGEMENT

The author thanks to the patients for their

participation in this study. And also special thanks to

dr. Windy Keumala Budianti, SpKK, dr. Endi

Novianto, SpKK, drg. Cut Intan Safitri, Sp.Perio,

and drg. Siti Marhamah, Sp.Perio for their help in

data collection. The author also thanks to dr. Rompu

Roger Aruan, SpKK from Koja District Hospital

who had participated in referring his patients for this

study.

REFERENCES

Anonym, 2016. Global report on psoriasis. World Health

Organization.

Anonym, 2013. Riset Kesehatan Dasar 2013. Badan

penelitian dan pengembangan kesehatan Kementerian

Kesehatan RI.

Brezewski, PL., Spalkowska, M., Podblelska, M.,

Chmlelewska, J., Wolek, M., Malec, K., Malec, K., &

Wojas-Pelc, A., 2013. The role of focal infections in

the pathogenesis of psoriasis and chronic

urticaria. Advances in Dermatology and

Allergology/Postȩpy Dermatologii I

Alergologii, 30(2), 77.

Brown, L. J., Oliver, R. C., & Loe, H., 1990. Evaluating

periodontal status of US employed adults. Journal of

the American Dental Association (1939), 121(2),

pp.226-232.

Fadel, H. T., Flytström, I., Calander, A. M., Bergbrant, I.

M., Heijl, L., & Birkhed, D, 2013. Profiles of dental

caries and periodontal disease in individuals with or

without psoriasis. Journal of periodontology, 84(4),

pp. 477-485.

Gudjonson, JE., Elder, JT, 2012. Psoriasis.

In: Goldsmith

LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ,

Wolff K, editors. Fitzpatrick’s dermatology in general

medicine. 8th Edition. New York: McGraw-Hill;

p.169-93.

Holmstrup, P., Damgaard, C., Olsen, I., Klinge, B.,

Flyvbjerg, A., Nielsen, C.H. and Hansen, P.R., 2017.

Comorbidity of periodontal disease: two sides of the

same coin? An introduction for the clinician. Journal

of oral microbiology, 9(1), p.1332710.

Keller, J. J., & Lin, H. C. 2012. The effects of chronic

periodontitis and its treatment on the subsequent risk

of psoriasis. British Journal of Dermatology, 167(6),

pp.1338-1344.

Lakshmy, S., Balasundaram, S., Sarkar, S., Audhya, M., &

Subramaniam, E., 2015. A cross-sectional study of

prevalence and implications of depression and anxiety

in psoriasis. Indian journal of psychological

medicine, 37(4),pp. 434.

Lazaridou, E., Tsikrikoni, A., Fotiadou, C., Kyrmanidou,

E., Vakirlis, E., Giannopoulou, C., ... & Ioannides, D.,

2013. Association of chronic plaque psoriasis and

Correlation between Psoriasis Severity and Periodontal Pocket Depth in Psoriasis Vulgaris

severe periodontitis: a hospital based casecontrol

study. Journal of the European Academy of

Dermatology and Venereology, 27(8),pp. 967-972.

Page, R. C., & Eke, P. I., 2007. Case definitions for use in

population-based surveillance of periodontitis. Journal

of periodontology, 78(7S), pp. 1387-1399.

Rosania, A. E., Low, K. G., McCormick, C. M., &

Rosania, D. A., 2009. Stress, depression, cortisol, and

periodontal disease. Journal of periodontology, 80(2),

pp. 260-266.

Sharma, A., Raman, A., Pradeep, AR., 2015. Association

of chronic periodontitis and psoriasis: Periodontal

status with severity of psoriasis. Oral diseases, 21(3),

pp. 314-319.

Skudutyte-Rysstad, R., Slevolden, E. M., Hansen, B. F.,

Sandvik, L., & Preus, H. R, 2014. Association

between moderate to severe psoriasis and periodontitis

in a Scandinavian population. BMC Oral

health, 14(1), pp. 139.

Ungprasert, P., Wijarnpreecha, K., Wetter, DA., 2016.

Periodontitis and risk of psoriasis: A systematic

review and meta-analysis Journal of the European

Academy of Dermatology and Venereology, 31(5), pp.

857-862.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018