MANAGEMENT OF A PATIENT WITH PSORIASIS AND ...doctorjaen.com/wp-content/uploads/2019/01/Psoriasis.pdfla articulación temporomandibular de pacientes con artritis reumatoidea, artritis

MANAGEMENT OF A PATIENT WITH PSORIASIS AND TEMPOROMANDIBULAR DISORDERS

A case presentation

Dr. Fernando R. Jaén is a Dentist graduated from the School of Dentistry of the University of Panama and with a GPR from Louisiana State University School of Dentistry. Is a member of the AACP, the AGD and the Panamanian Dental Association. Teaches as a part time full tenure professor at the School of Dentistry of the University of Panama and has dedicated his practice to TMD, Facial Pain, Occlusion and Sleep Disorders since 1983. Contacts: (507) 263-7313, www.doctorjaen.com, [email protected] ABSTRACT The Masticatory or occlusal system, is an orthopedic system in nature; complex, adaptable and efficient and in charge of speech, respiration, mastication, sleep and swallow throughout our lives, all on which life depends. The system has 3 complex anatomical components; the 2 temporomandibular joints (TMJ), the neuromuscular and the interdental relationship and its supporting tissues that can be damaged in similar ways to those of the rest of the human body or present in comorbidity. The intention of this case presentation is to describe the conservative management of the Phase I and Phase II1 of a patient with neck pain,

dysphagia, premature contacts, psoriatic arthritis (PA) of the temporomandibular joints (TMJ), muscular co-contraction and bruxism2. Keyword; psoriatic arthritis, psoriasis, muscular co-contraction, maladaptive interdental relationship, bruxism, premature contacts. INTRODUCTION This a case of a 48 years old female male patient (pt) referred to my office by her ENT specialist and first seen in March 14, 2017. The occlusal analysis3 revealed; 1. Chief Complaint; “problems with mastication and to swallow and throat ache”. She first went to the ENT specialist that referred her to me because he suspected it was an articular condition. 2. Medical History;

a. Psoriasis for many years. b. Medications; She could not recall the name of medication prescribed by her attending dermatologist for the psoriatic dermatitis, she was not currently taking it and has not visited the dermatologist recently.

c. Weight: known, 136 lbs. d. Blood pressure; unknown. Taken in the office: 88/63 right wrist. 3. The sleep apnea questionnaire and the Epworth scale in Spanish4,5 (fig. 1) was only positive to non-repairing sleep and 7 hours sleep. 4. Dental history; orthodontics in her youth. 5. Articular-muscular history; History of 1.5 weeks with the actual chief complaints and without previous history. She did refer a history of 3 years with daily awakening and daytime headaches, neck pain and whole body aches, all without treatment or diagnosis. The pt was aware of the difficulty in closure and that she had the habit of repetitively moving the jaw during the day to be able to close the mouth. She has had joint sounds for years. 6. Muscular examination; Palpation indicated pain and slight swelling of bilateral masseter, temporal, SCM and trapezius muscles. Psoriatic lesions were observable in her neck (fig. 2). 7. Articular examination; Both TMJ were painful on palpation and crepitation6 was heard during opening and lateral with the Doppler™. 8. Range of motion examination: Painful opening and closing in both TMJ, with a 30 mm inter incisal right side shift (fig. 3). 9. Posture examination; Deviated omicron line and anterior posture of head (figs. 4 & 5). Psoriatic lesions in the arms were hidden by the long sleeves.

10. Interdental examination; Two anterior bite relationships were observed before obtaining Maximum Intercuspidation (MI) (fig. 6, 7, 8 and Movie). The dysphagia and salivation could be seen. Wear facets in all molars. 11. Intraoral examination; Retruded tongue and generalized gingivitis. (Movie) 12. Images examination; Asymmetrical and irregular condyles with a large Ellis cyst in the right. The airway seemed open (fig. 9, 10 & 11)10. The diagnosis 2 were; 1. R/O Psoriatic Arthritis of both TMJ 7,8,9 . 2. Muscular Co contraction 3. Capsulitis, bilateral 4. Sleep and awake Bruxism11 5. Maladaptive Occlusion12,13, 14, 15

The Phase I treatment started immediately with #1 and #2 at the consultation appointment with: 1. An urgent referral to her dermatologist. The dermatologist saw her one week later and prescribed SoritecTM 10 mg per day. 2. Plaque disclosing was done, brushing and flossing indications were given and instructions for .012 chlorhexidine solution one-minute rinse after meals for two weeks. She was referred to her attending dentist for periodontal evaluation16. 3. An initial session of 30 minutes with TENS by Bioresearch™ and delivery, in the resultant mandibular position, of a mandibular full coverage neuromuscular appliance (fig. 12) with anterior guidance and even contacts obtained with a Parkell IITM ribbon 17, 18, 19 4. Use of the appliance 24 hours a day, removal only to eat and oral hygiene and follow up/adjustment appointments every 2 weeks for at least 2 months. The # 3 and # 4 treatments were started March 23, 2017. She complied and reported constant reduction of all signs and symptoms and improved sleep and was fully asymptomatic by May 20, 2017, thus obtaining the goals of Phase I of pain control, bruxism cessation and restoration of mandibular function. Post op photos, a bite registration in the postural adapted centric relation (PACR)20 and models were taken (figs. 13, 14, 15, 16 & 17). The lesions in the neck had decreased in size and redness and she could now wear short sleeves. The discrepancy between PACR and MI indicated an Occlusal Equilibration as a Phase II option of treatment20, 21. In June 1, 2017 I did the case

presentation, she understood and accepted it. It was done in July 8, 2017, with 2 tune ups in July 22 and August 6, 2017 and progressive loading of the system with gradual removal of the appliance. She was instructed to visit her dermatologist regularly, to maintain the appliance for possible relapses and to call us ASAP if signs or symptoms reappear. SUMMARY The Temporomandibular Disorders2 can be painful, incapacitating, move or wear teeth, alter the sleep, the general health and wellbeing. Their sign and symptoms can be perplexing, its diagnosis can be difficult or can present with comorbidity with other medical conditions. The alternatives of Phase I relieve pain and restore or improve muscular and articular function. The Phase II alternatives, rehabilitate the altered occlusal table. BIBLIOGRAPHY 1. The American Academy of Craniofacial Pain. Standards for History, Examination, Diagnosis Treatment of Temporomandibular Disorders (TMD). A Position Paper. The J of Craniomand. Practice Jan. 1990, Volume 8 Number 1. 2. American Academy of Orofacial Pain. Okeson JP (ed). Orofacial Pain. Guidelines for Assessment, Diagnosis, and Management. Chicago. Quintessence Publishing Co. 1996. 3. Jaén FR. Análisis Oclusal de Filtro en10 Minutos. El Odontol. Agosto 1991. 4. Chiner E, Arriero J, Signes-Costa J, Marco J, Fuentes I. Validation of the Spanish version of the Epworth Sleepiness Scale in patients with a sleep apnea syndrome. Archivos de Bronconeumología. October 1999;35(9):422-427. 5. Baldwin C, Choi M, McClain D, Celaya A, Quan S. Spanish translation and cross-language validation of a sleep habits questionnaire for use in clinical and research settings. Journal Of Clinical Sleep Medicine. 2012; 8(2): 137. 6. Manfredini D, Tognini F, Melchiorre D, Bazzichi L, Bosco M. Ultrasonography of the temporomandibular joint: Comparison of findings in patients with rheumatic diseases and temporomandibular disorders. A preliminary report. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontology. 2005;100(4):481-485. 7. Farronato, Giampietro; Garagiola, Umberto; Carletti, Vera; Cressoni, Paolo; Bellintani, Claudio. Psoriatic Arthritis, Temporomandibular Joint

Involvement as the First Articlar Involvement. Quintessence International. 2010, Vol. 41 Issue 5, p395-398 8. Könönen, Mauno. Clinical Signs of Craniomandibular Disorders in Patients with Psoriatic Arthritis. Scandinavian Journal of Dental Research. Jun1987, Vol. 95 Issue 4, p340-346. 7p. 9. Dervis, E. The prevalence of temporomandibular disorders in patients with psoriasis with or without psoriatic arthritis. Journal of Oral Rehabilitation. Nov2005, Vol. 32 Issue 11, p786-793. 10. Bengt; Könönen, Mauno; Kallenberg, Anna Cambios radiográficos en la articulación temporomandibular de pacientes con artritis reumatoidea, artritis psoriátics y espondilitis anquilosante. Wenneberg,. Journal of Craniomandibular Disorders. Winter1990, Vol. 4 Issue 1, p35-39. 5p. 11. Fernandes G. et al. Temporomandibular disorders, sleep bruxism, and primary headaches are mutually associated. Orofac Pain 2013 Winter; Vol. 27 (1),14-20. 12. Brown, CE. Infante, L. Thinking of a maladaptive occlusion as an orthopedic cumulative trauma disorder. Cranio. Jan 2015, Vol. 33 Issue 1, p19-22. 13. Gremillion, H. TMD and maladaptive occlusion: does a link exist? Cranio: The Journal Of Craniomandibular Practice. October 1995;13(4):205-206. 14. Learreta J A, Beas J, Bono AE, Durst, A. Muscular Activity Disorders in Relation to Intentional Occlusal Interferences. The Journal of Craniomandibular Practice. Jul 2007, Vol. 25 Issue 3, 193-199. 15. Li B, Zhou L, Guo S, Zhang Y, Lu L, Wang M. An investigation on the simultaneously recorded occlusion contact and surface electromyographic activity for patients with unilateral temporomandibular disorders pain. Journal Of Electromyography And Kinesiology: June 2016;28:199-207. 16. Sezer, U; Şenyurt, Süleyman Z; Gündoğar, H; Erciyas, K; Üstün, K; Kimyon, G; Kırtak, N; Taysı, S; Onat, A. Effect of Chronic Periodontitis on Oxidative Status in Patients With Psoriasis and Psoriatic Arthritis. Journal of Periodontology. May2016, Vol. 87 Issue 5, p557-565. 17. Kent, JN. Conservative and Surgical Management of TMJ Disorders. Louisiana State University, School of Dentistry 1982. 18. Abdel Fattah, R.A. Intraoral Appliances in Management of Temporomandibular Disorders, Revised. Cranio, Oct. 1996, vol. 14 #4 344-346. 19. Yamashita, A, Yamashita, J., Kondo, Y. Thirty-year follow-up of a TMD case treated based on the neuromuscular concept. CRANIO Jul. 2014, Vol. 32 #3, 224-234.

20. Dawson, Peter E. New definition for relating occlusion to varying conditions of the temporomandibular joint. J Prosthet Dent, 1995; 74:619-27. 20. Solow, Roger A. Clinical protocol for occlusal adjustment: Rationale and application. CRANIO. May 2018, Vol. 36 Issue 3, p195-206. 21. Solow, Roger A. Diagnosis, equilibration, and restoration of an orthodontic failure. General Dentistry. Sep/Oct 2010, Vol. 58 Issue 5, p444-455. 12p. 32 FIGURES AND MOVIE Figure 1

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Figure 3

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Figure 5

Figure 6 (#1 position)

Figure 7 (#2 position)

Figure 8 (MI)

Figure 9

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Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17