|Year : 2017 | Volume
| Issue : 11 | Page : 1501-1504
Temporomandibular joint involvement in psoriatic arthritis
Alime Okkesim, Mehmet Zahit Adisen, Melda Misirlioglu
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Kirikkale University, Turkey
|Date of Acceptance||21-Jul-2016|
|Date of Web Publication||05-Jan-2018|
Dr. Alime Okkesim
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Kirikkale University
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Psoriasis is a chronic, papulosquamous, and an inflammatory skin disease. It has been found that between 5% and 24% of patients develop psoriatic arthritis (PA) at the same time after or even prior to skin findings. The involvement of temporomandibular joint (TMJ) is a rare condition. In this report, a-46-year-old male patient was referred to our clinic with the complaint of pain in the bilateral TMJs, and a limited jaw movement. Medical anamnesis revealed he had psoriasis for the last 21 years, and developed a seronegative polyarthritis with destructive changes for 8 years. On extra-oral examination, crepitation at TMJs and limitation of jaw movements was detected. The radiographic examination with cone-beam CT revealed the bilaterally decreased joint spaces, erosion, and the loss of cortical edge of the joint on the condylar heads. The definitive diagnosis of PA was made with the help of patient's history and radiological findings. The uses of non-steroidal anti-inflammatory drugs and occlusal splint have been suggested for conservative treatment.
Keywords: Arthritis, cone-beam CT, occlusal splint, psoriasis, temporomandibular joint (TMJ)
|How to cite this article:|
Okkesim A, Adisen MZ, Misirlioglu M. Temporomandibular joint involvement in psoriatic arthritis. Niger J Clin Pract 2017;20:1501-4
| Introduction|| |
Psoriasis is a chronic, papulosquamous, and an inflammatory skin disease, affecting 1-3% of world population and both sexes equally. It can begin at any age, but mostly between ages 30 and 50. However, rare cases of patients under 8 years have also been reported. In Italy, the prevalance of psoriasis showed a big difference between regions such as: lowest in Sardinia with 0.5% and higher in northern regions with 4.5%.
In Europe, the prevalence ranges from 0.6% to 6.5%.
Psoriatic arthritis (PA) is an inflammatory state that commonly involves the distal interphalangeal joints of the fingers. The other affected joints include knees, elbows, shoulders, ankles, spine, and toes. The involvement of temporomandibular joint (TMJ) is a rare condition. The first case of psoriasis and arthritis occurring together in the same patient was recognized as early as in the first half of the 19th century.
The etiology of PA is unclear but genetic influences, environmental, and immunologic factors may contribute in the development of the disease. The inflammatory nature of the skin and joint lesions in PA is demonstrated by synovial-lining, cell hyperplasia, and mononuclear infiltration that indicates the presence of autoimmunity, perhaps mediated by complement activation.
This paper aims to describe different epidemiological, clinical, and radiological characteristics of PA, with a significance on the involvement of TMJs in the general manifestation of the disease as exemplified by the clinical case of a 46-year-old male patient.
| Case Report|| |
A-46-year-old male patient was referred to our clinic with the complaint of pain in bilateral TMJs and a limited jaw movement. He had mild symptoms for one year in TMJs, but the pain was aggravated in the last two weeks with a gradual reduction in mouth opening. The medical anamnesis revealed that the patient had psoriasis [Figure 1] for 21 years and developed a seronegative polyarthritis with destructive changes, involving his ankles and knees, for 8 years. On extra-oral examination, crepitation at TMJs and limitation of jaw movements, with the maximal inter-incisal distance of 13 mm without deviation, was detected. He had pain and tenderness in both TMJs. The panoramic radiograph revealed bilaterally decreased joint spaces [Figure 2]. Cone-beam CT (CBCT) images were obtained for advanced imaging of TMJs. The tomographic images detected erosion, and the loss of cortical edge of the functional surface of the joint on the condylar heads. In addition, erosive and osteoporotic changes on the subchondral bone and surface of the temporal bone were observed [Figure 3]. The definitive diagnosis of PA was made with the help of patient's history and radiological findings. For the conservative treatment of PA, 50 mg of diclofenac sodium 3 times daily was prescribed to patient, and used for one month at the same time with occlusal splint therapy. Occlusal splint was used continually and the patient was followed up. The improvements to the patient's condition, increasing movements of mandible, and reduction of pain were observed in the one month after the conservative treatment. The patient is still being followed up.
|Figure 2: Panoramic radiograph revealed bilaterally decreased joint spaces, erosion and the loss of cortical edge on condylar heads|
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|Figure 3: A) Cross-sectional images on right condylar heads showing osteoporotic changes. B) Cross-sectional images on left condylar heads showing osteoporotic changes|
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| Discussion|| |
The manifestations of psoriasis may involve the oral cavity in a variety of locations including buccal mucosa, lip, palate, and gingiva. While buccal mucosa is the most commonly affected area, the palate and gingiva are unusual sites for psoriatic lesions. Younai and Phelan, in their review of literature, reported that among 57 patients with intraoral psoriasis, 44% of cases presented with white “plaque-like” intraoral lesions, 24% with erythematous lesions, and 13% with a mixed appearance. The remaining lesions presented as ulcerative, vesicular, pustular or indurated. A higher prevalence of benign migratory glossitis, and fissured tongue in psoriatic patients compared to the general population has also been cited in many studies. The primary lesions in oral cavity may be asymptomatic and collaboration with a dermatologist is necessary along with clinical examination and biopsy of the intraoral lesion.
PA is an inflammatory seronegative arthritis that affects 5-8% of patients with psoriasis. PA in axial and peripheral joints is an indicator of mean previous or recent psoriasis. Almost 15% of psoriatic patients never show skin indication after joint involvement. Generally, PA progresses slowly with mild symptoms, however, it can also develop quickly with severe symptoms. The etiology is multifactorial and results in an autoimmune mechanism with inflammatory and destructive features. The joint involvements are typically asymmetrical and commonly involve the distal interphalangeal joints of the fingers. The other affected joints include: knees, elbows, shoulders, ankles, spine, and toes. The common symptoms are stiffness and pain in the joints. Five PA subgroups have been recognized: symmetric polyarthritis, asymmetric oligo-arthritis, arthritis of the distal interphalangeal joints, spondylitis, and destructive arthritis.
The involvement of the TMJ correlates with the severity and duration of the systemic disease. The psoriatic lesions of the TMJ were defined as mainly erosive type. The orofacial symptomatology of psoriatic arthritis includes: noises in the TMJs, limited mandibular movements, stiffness of the jaws, pain in the jaws or face, fatigue, ear pain, and symptoms concerned to masticatory muscles. Arthralgia of TMJ itself, is a clinical sign of arthritis related to generalized PA. As the disease progresses, an increased tendency towards fibrosis can occur. Crepitus is associated with structural changes in the joint. Ankylosis, an uncommon late finding is bilateral. Boyle and Buchanan gave the following three requirements before a diagnosis of PA of the TMJ could be made: (i) psoriasis, (ii) erosive polyarthritis, and (iii) negative serologic test for rheumatoid factor.
The radiographic findings in PA of TMJ were first described by Lundberg and Ericson. The radiographic features of the disease include: erosion of the condylar head (resulting from subchondral osteolysis) with osteoporotic lesions (healing after inflammation), formation of osteophytes, narrowing of the joint space, flattening of the condylar head, and subchondral sclerosis in later chronic disease. MRI shows an unchallenged higher sensitivity than other radiological examinations. Additionally, ultrasound can be used to show effusion. In PA patients with pain, MRI displayed effusion and disc disorders in 54% of the cases.
While Könönen  believed that a generalized type of PA creates symptoms in the masticatory system after only seven years, Farronato et al. presented the case of a patient whose first symptoms of PA appeared on the right TMJ. Dervis  found the prevalence of TMJ symptoms in 60% PA patients on clinical examination. Similarly, Salonen et al. also found that 35% of patients reported TMJ symptoms.
The first aim of treatment is to relieve pain, initially using counselling and reassurance, as stress may exacerbate the disease within the joint. Therefore, eliminating any factor that cause stress, forms an important part of the treatment plan. Rest and the use of non-steroidal anti-inflammatory drugs have been encouraged. The use of steroids, analgesia, physiotherapy, and various types of splints have also been used in the treatment of psoriatic arthritis of the TMJs.
| Conclusion|| |
The involvement of TMJ in the general clinical picture of psoriasis is rare and atypical condition. The TMJ symptoms include: pain, psychological discomfort, physical disability, and the limitation of mandibular movements can become chronic in time, affecting the quality of life negatively. Hence, collaboration between the dentist and rheumatologist is very important for early diagnosis of PA to avoid severe complications in TMJs. We suggest a conservative approach with non-steroidal anti-inflammatory drugs, and occlusal splint therapy for dental health care professionals for the initial treatment of such cases before any surgical intervention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]