Psoriasis of the Attached Gingiva
It can be seen that the literature concerned with oral psoriasis is sparse and reports of psoriasis of the attached gingiva are rare. It is for this reason that the following case is presented.
Case Report
CASE REPORT
This case involves a 60-year-old Caucasian male who presented for routine periodontal examination and treat ment. He had no complaints concerning soreness of his mouth but knew he needed "gum" treatment.
by DOUGLAS I. DOBEN, D.M.D.
History IN THE DIAGNOSIS and treatment of periodontal disease one must be constantly aware of the less common entities which have similar clinical characteristics to the inflam matory lesion. Oral psoriasis is one such disease. Psoriasis has been estimated to affect 1% of the population. However, since the first reported case by Oppenheim in 1903 there have been relatively few cases of oral psoriasis observed. O f these, only three authors have cited a total of five cases affecting the attached gingiva. DeGregori, et a l . in 1971 outlined 15 cases documented by 11 authors and noted that only Brayshaw and Orban found the attached and/or mar ginal gingiva involved. In the same article DeGregori described psoriasis involving the marginal and attached gingiva with the remaining oral mucosa free of involve ment. His histologic examination of the gingiva revealed most of the criteria for psoriasis except the presence of epidermal microabscesses. He did observe microab scesses in the histologic section of the tongue.
Past medical history was noncontributory. He had routine blood tests 3 years ago which were negative, and new blood tests were also within normal limits. He did
15
1
1 1 , 1 6 , 1 7
1 6
Other cases of oral psoriasis that were not included in DeGregori's outline have been recorded. Norins and Yaffee noted a case of psoriasis of the hard palate in 1957. Pisanty and S h i p in 1970 observed psoriasis affecting the "moist mucosa extending into the vestibular areas but not into the alveolar mucosa or skin." Jones and D o l b y reported lesions which involved the attached gingiva. Clinically they felt the lesions resembled des quamative gingivitis. Histologically they suggested that it might represent a nonspecific entity common to a number of diseases such as benign mucous membrane pemphigoid, lichen planus, and erythema multiforme in conjunction with psoriasis or reflect gingival changes in psoriasis itself. Their report was not conclusive. More recently Salmon, et a l . reported a well-docu mented case of psoriasis affecting the oral mucosa of an edentulous patient. They described lesions on the tongue, vermillion border of both lips and the buccal mucosa. This report was valuable in that it possessed all histo pathologic characteristics of psoriasis. These pathogno monic features are (1) parakeratosis (2) acanthosis with thinning of the suprapapillary epiderm (3) elongation of the rete ridges and dermal papilla (4) occasional epider mal microabscesses containing polymorphonuclear neu trophils (5) edema and some clubbing of the dermal papilla and (6) dilated straight capillaries in the dermal papilla. (Fig. 4). 13
15
17
FIGURE 1. Initial visit revealed inflamed tissue approximating full crowns. Note pattern of stippling.
1 8
FIGURE 2. During initial preparation erythematous patches persisted. Pattern is not that associated with inflammation.
19
38
Volume 47 Number 1
Psoriasis of the Gingiva
39
have a history of psoriasis of the scalp which appeared as red scaly patches. Oral
Examination
Materia alba, plaque and subgingival calculus were evident. Marginal periodontal inflammation was coinci dent to large erythematous patches and denture stomati tis was observed and correlated well to the outline of a maxillary partial denture. On inspection of the attached gingiva areas that were deeply stippled and grainy could be seen. Minute multi ple pinpoint spots coalesced to form erythematous patches which bled on slight provocation. These extended from the free gingival margin to the mucogingival junction (Fig. 1). Rarely did these patches extend into the FIGURE 3. Removal of maxillary provisional splint demon strates deep stippling and erythematous patterns consistent mucosa and then only very slightly. They usually began with oral psoriasis. below the free gingival groove and extended in a oara-
FIGURE 4. Tissue section of gingival biopsy showing changes consistent with psoriasis (H & E low power).
FIGURE 5. High power photomicrograph of epithelium. Note infiltration by neutrophilic leucocytes and focal aggregation to form microabscesses. (H & E original magnification x 900.)
40
J. Periodontol. January, 1976
Doben
contraindication to periodontal and/or prosthetic man agement of the patient with oral psoriasis. Recognition of the disease allows for understanding and anticipation of tissue reaction during therapy. SUMMARY
Psoriasis of the gingiva is a rarely diagnosed disease entity. A case is presented with both clinical and histologic documentation that fulfills all basic criteria. It is suggested that oral psoriasis does not contraindicate periodontal or prosthetic management. ACKNOWLEDGEMENTS
FIGURE 6. Tissue texture is most obvious during surgery. I am grateful to Dr. Marshall Fagin for his prosthetic Friability seen when clean incision line is not obtainable. Tissue management of this case, to Dr. John Richardson, Oral tears and bleeds easily.
bolic design to the mucogingival junction (Fig. 2, 3). Biopsy specimens were obtained from the marginal attached gingiva of both dentulous and edentulous areas. Histopathologic
Report
Following preparation of the specimens and staining with hematoxylin and eosin, random sections were observed. Microscopical study of tissue sections revealed marked acanthosis of the epithelium with parakeratosis (Fig. 4). The clubbed rete extensions were elongated and variably coalescent at their bases. Occasional small neutrophilic aggregates (microabscesses) were noted in the epithelium with a chronic inflammatory infiltrate and slight dilation of blood vessels (Fig. 5). This pathologic report is consistent with and pathognomonic of psoria sis. DISCUSSION
Oral psoriasis should be considered in the differential diagnosis of desquamative lesions of the gingiva. Due to the infrequent occurrence of this disease a conclusive diagnosis of oral psoriasis should be made by the fulfillment of all histologic criteria, with the presence of concomitant external lesions. It is suggested that in oral psoriasis the clinical appearance and characteristics are expressions of the microscopic features of the disease. For example, the pinpoint spots and deep stippling observed may reflect the elongation of rete ridges whereas erythematous patches may result from thinning of the suprapapillary epiderm and edema of the dermal papillae. The parakeratotic surface over a hyperemic connective tissue papilla allows the surface layer to be easily removed and the result is bleeding with slight provocation. Another clini cal manifestation of oral psoriasis noted during periodon tal surgery was the inability to obtain clean incision lines. A ragged or torn edge occurred even when great care was taken (Fig. 6). This may result from an altered tissue texture which is a reflection of acanthosis of the prickle cell layer with thinning of the suprapapillary layer and elongation of the rete ridges. It was the author's impression that there is no
Pathologist, Boston University School of Graduate Den tistry, for his time and effort in the histologic evaluation and presentation, and to Dr. Alan Griffel for his criticism and encouragement. REFERENCES
1. Oppenheim, M.: Psoriasis mucosae oris. Monatsschr. Prakt Dermatol 37: 481, 1903. 2. Jordan, A.: Psoriasis vulgaris mucosae oris. Arch Derma tol Syph, Part 1, 140: 64, 1921. 3. Keller, P.: Ueber psoraisis der mundschleim haut. Dermatol Wchnschr 75: 917, 1922. 4. Dore, S. E.: Psoriasis of the lower lip. Proc R Soc Med (Sect Dermatol) 17: 84, 1924. 5. Scheer, M . : Psoriasis of the mucous membranes of the lip. Arch Dermatol Syph 9: 594, 1924. 6. Becker, S., and Ritchie, E.: Psoriasis buccalis. Arch Dermatol Syph 22: 745, 1930. 7. Usher, B.: Psoriasis of the mucous membranes. Arch Dermatol Syph 28: 488, 1933. 8. Moyle, R.: Psoriasis of the mucous membranes. Proc R Soc Med 29: 289, 1935. 9. Burks, J., and Montgomery, H.: Histopathologic study of psoriasis. Arch Dermatol Syph 48: 479, 1943. 10. Goldman, H., and Bloom, J.: Oral manifestations of psoriasis. Oral Surg 4: 48, 1951. 11. Brayshaw, H., and Orban, B.: Psoriasis Gingivae. J Periodontol 24: 156, 1953. 12. Levin, H.: Psoriasis of the palate. Oral Surg 7: 380, 1954. 13. Norins, A., and Yaffee, H.: Psoriasis of the hard palate. Arch Dermatol 76: 357, 1957. 14. Cran, J. A.: Lichen planus associated with psoriasis. Aust Dent J 11: 429, 1966. 15. Pisanty, S., and Ship, I.: Oral psoriasis. Oral Surg 30: 351, 1970. 16. DeGregori, G., Pippen, R., and Davies, E.: Psoriasis of the gingiva and tongue: Report of a case. J Periodontol 42: 97, 1971. 17. Jones, Lesley E., and Dolby, A. E.: Desquamative gingivitis associated with psoriasis. J Periodontol 43: 35, 1972. 18. Salmon, T. N., Robertson, G. R. Jr., Tracy, N . J. Jr., and Hiatt, W. R.: Oral psoriasis. Oral Surg 38: 48, 1974. 19. Shafer, W. G., Hine, M . K., and Levy, B. M . : Text book of Oral Pathology, ed 3, p 761-762, Philadelphia. W. B. Saunders Co., 1974. 20. Weathers, Dwight R., Baker, G., Archard, H . , and Burkes, E. J.: Psoriasiform lesions of the oral mucosa (with emphasis on "ectopic geographic tongue"). Oral Surg 37: 872, 1974.
It can be seen that the literature concerned with oral psoriasis is sparse and reports of psoriasis of the attached gingiva are rare. It is for this reason that the following case is presented.
Case Report
CASE REPORT
This case involves a 60-year-old Caucasian male who presented for routine periodontal examination and treat ment. He had no complaints concerning soreness of his mouth but knew he needed "gum" treatment.
by DOUGLAS I. DOBEN, D.M.D.
History IN THE DIAGNOSIS and treatment of periodontal disease one must be constantly aware of the less common entities which have similar clinical characteristics to the inflam matory lesion. Oral psoriasis is one such disease. Psoriasis has been estimated to affect 1% of the population. However, since the first reported case by Oppenheim in 1903 there have been relatively few cases of oral psoriasis observed. O f these, only three authors have cited a total of five cases affecting the attached gingiva. DeGregori, et a l . in 1971 outlined 15 cases documented by 11 authors and noted that only Brayshaw and Orban found the attached and/or mar ginal gingiva involved. In the same article DeGregori described psoriasis involving the marginal and attached gingiva with the remaining oral mucosa free of involve ment. His histologic examination of the gingiva revealed most of the criteria for psoriasis except the presence of epidermal microabscesses. He did observe microab scesses in the histologic section of the tongue.
Past medical history was noncontributory. He had routine blood tests 3 years ago which were negative, and new blood tests were also within normal limits. He did
15
1
1 1 , 1 6 , 1 7
1 6
Other cases of oral psoriasis that were not included in DeGregori's outline have been recorded. Norins and Yaffee noted a case of psoriasis of the hard palate in 1957. Pisanty and S h i p in 1970 observed psoriasis affecting the "moist mucosa extending into the vestibular areas but not into the alveolar mucosa or skin." Jones and D o l b y reported lesions which involved the attached gingiva. Clinically they felt the lesions resembled des quamative gingivitis. Histologically they suggested that it might represent a nonspecific entity common to a number of diseases such as benign mucous membrane pemphigoid, lichen planus, and erythema multiforme in conjunction with psoriasis or reflect gingival changes in psoriasis itself. Their report was not conclusive. More recently Salmon, et a l . reported a well-docu mented case of psoriasis affecting the oral mucosa of an edentulous patient. They described lesions on the tongue, vermillion border of both lips and the buccal mucosa. This report was valuable in that it possessed all histo pathologic characteristics of psoriasis. These pathogno monic features are (1) parakeratosis (2) acanthosis with thinning of the suprapapillary epiderm (3) elongation of the rete ridges and dermal papilla (4) occasional epider mal microabscesses containing polymorphonuclear neu trophils (5) edema and some clubbing of the dermal papilla and (6) dilated straight capillaries in the dermal papilla. (Fig. 4). 13
15
17
FIGURE 1. Initial visit revealed inflamed tissue approximating full crowns. Note pattern of stippling.
1 8
FIGURE 2. During initial preparation erythematous patches persisted. Pattern is not that associated with inflammation.
19
38
Volume 47 Number 1
Psoriasis of the Gingiva
39
have a history of psoriasis of the scalp which appeared as red scaly patches. Oral
Examination
Materia alba, plaque and subgingival calculus were evident. Marginal periodontal inflammation was coinci dent to large erythematous patches and denture stomati tis was observed and correlated well to the outline of a maxillary partial denture. On inspection of the attached gingiva areas that were deeply stippled and grainy could be seen. Minute multi ple pinpoint spots coalesced to form erythematous patches which bled on slight provocation. These extended from the free gingival margin to the mucogingival junction (Fig. 1). Rarely did these patches extend into the FIGURE 3. Removal of maxillary provisional splint demon strates deep stippling and erythematous patterns consistent mucosa and then only very slightly. They usually began with oral psoriasis. below the free gingival groove and extended in a oara-
FIGURE 4. Tissue section of gingival biopsy showing changes consistent with psoriasis (H & E low power).
FIGURE 5. High power photomicrograph of epithelium. Note infiltration by neutrophilic leucocytes and focal aggregation to form microabscesses. (H & E original magnification x 900.)
40
J. Periodontol. January, 1976
Doben
contraindication to periodontal and/or prosthetic man agement of the patient with oral psoriasis. Recognition of the disease allows for understanding and anticipation of tissue reaction during therapy. SUMMARY
Psoriasis of the gingiva is a rarely diagnosed disease entity. A case is presented with both clinical and histologic documentation that fulfills all basic criteria. It is suggested that oral psoriasis does not contraindicate periodontal or prosthetic management. ACKNOWLEDGEMENTS
FIGURE 6. Tissue texture is most obvious during surgery. I am grateful to Dr. Marshall Fagin for his prosthetic Friability seen when clean incision line is not obtainable. Tissue management of this case, to Dr. John Richardson, Oral tears and bleeds easily.
bolic design to the mucogingival junction (Fig. 2, 3). Biopsy specimens were obtained from the marginal attached gingiva of both dentulous and edentulous areas. Histopathologic
Report
Following preparation of the specimens and staining with hematoxylin and eosin, random sections were observed. Microscopical study of tissue sections revealed marked acanthosis of the epithelium with parakeratosis (Fig. 4). The clubbed rete extensions were elongated and variably coalescent at their bases. Occasional small neutrophilic aggregates (microabscesses) were noted in the epithelium with a chronic inflammatory infiltrate and slight dilation of blood vessels (Fig. 5). This pathologic report is consistent with and pathognomonic of psoria sis. DISCUSSION
Oral psoriasis should be considered in the differential diagnosis of desquamative lesions of the gingiva. Due to the infrequent occurrence of this disease a conclusive diagnosis of oral psoriasis should be made by the fulfillment of all histologic criteria, with the presence of concomitant external lesions. It is suggested that in oral psoriasis the clinical appearance and characteristics are expressions of the microscopic features of the disease. For example, the pinpoint spots and deep stippling observed may reflect the elongation of rete ridges whereas erythematous patches may result from thinning of the suprapapillary epiderm and edema of the dermal papillae. The parakeratotic surface over a hyperemic connective tissue papilla allows the surface layer to be easily removed and the result is bleeding with slight provocation. Another clini cal manifestation of oral psoriasis noted during periodon tal surgery was the inability to obtain clean incision lines. A ragged or torn edge occurred even when great care was taken (Fig. 6). This may result from an altered tissue texture which is a reflection of acanthosis of the prickle cell layer with thinning of the suprapapillary layer and elongation of the rete ridges. It was the author's impression that there is no
Pathologist, Boston University School of Graduate Den tistry, for his time and effort in the histologic evaluation and presentation, and to Dr. Alan Griffel for his criticism and encouragement. REFERENCES
1. Oppenheim, M.: Psoriasis mucosae oris. Monatsschr. Prakt Dermatol 37: 481, 1903. 2. Jordan, A.: Psoriasis vulgaris mucosae oris. Arch Derma tol Syph, Part 1, 140: 64, 1921. 3. Keller, P.: Ueber psoraisis der mundschleim haut. Dermatol Wchnschr 75: 917, 1922. 4. Dore, S. E.: Psoriasis of the lower lip. Proc R Soc Med (Sect Dermatol) 17: 84, 1924. 5. Scheer, M . : Psoriasis of the mucous membranes of the lip. Arch Dermatol Syph 9: 594, 1924. 6. Becker, S., and Ritchie, E.: Psoriasis buccalis. Arch Dermatol Syph 22: 745, 1930. 7. Usher, B.: Psoriasis of the mucous membranes. Arch Dermatol Syph 28: 488, 1933. 8. Moyle, R.: Psoriasis of the mucous membranes. Proc R Soc Med 29: 289, 1935. 9. Burks, J., and Montgomery, H.: Histopathologic study of psoriasis. Arch Dermatol Syph 48: 479, 1943. 10. Goldman, H., and Bloom, J.: Oral manifestations of psoriasis. Oral Surg 4: 48, 1951. 11. Brayshaw, H., and Orban, B.: Psoriasis Gingivae. J Periodontol 24: 156, 1953. 12. Levin, H.: Psoriasis of the palate. Oral Surg 7: 380, 1954. 13. Norins, A., and Yaffee, H.: Psoriasis of the hard palate. Arch Dermatol 76: 357, 1957. 14. Cran, J. A.: Lichen planus associated with psoriasis. Aust Dent J 11: 429, 1966. 15. Pisanty, S., and Ship, I.: Oral psoriasis. Oral Surg 30: 351, 1970. 16. DeGregori, G., Pippen, R., and Davies, E.: Psoriasis of the gingiva and tongue: Report of a case. J Periodontol 42: 97, 1971. 17. Jones, Lesley E., and Dolby, A. E.: Desquamative gingivitis associated with psoriasis. J Periodontol 43: 35, 1972. 18. Salmon, T. N., Robertson, G. R. Jr., Tracy, N . J. Jr., and Hiatt, W. R.: Oral psoriasis. Oral Surg 38: 48, 1974. 19. Shafer, W. G., Hine, M . K., and Levy, B. M . : Text book of Oral Pathology, ed 3, p 761-762, Philadelphia. W. B. Saunders Co., 1974. 20. Weathers, Dwight R., Baker, G., Archard, H . , and Burkes, E. J.: Psoriasiform lesions of the oral mucosa (with emphasis on "ectopic geographic tongue"). Oral Surg 37: 872, 1974.
