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Physical signs for the general dental practitioner

From Volume 40, Issue 5, June 2013 | Page 429

Authors

Steve Bain

Professor of Medicine (Diabetes), University of Wales, Swansea

Articles by Steve Bain

Rhydian Davies

Dermatology LAS, ABMU Health Board, Wales Singleton Hospital, Swansea

Articles by Rhydian Davies

Article

Steve Bain
Dr Rhydian Davies

‘Physical Signs for the General Dental Practitioner’ aims:

  • To increase awareness of the value of identifying general clinical signs.
  • To enable the interpretation of selected clinical signs that are visible in the clothed patient.
  • To indicate the potential relevance of these clinical signs to the dental management of the patient.

    • The series will contribute to non-verifiable CPD requirements.

    This patient, a 55-year-old man, has had problems with a skin rash since his late twenties. He also has problems with his joints and has type 2 diabetes.

  • What clinical signs are seen?
  • What is the likely diagnosis?
  • What other diseases are associated with this?
  • What therapies are available?

    • Answers: Case 104

  • There is a well-demarcated rash affecting the dorsal aspect of the hand. There is evidence of thickening and scaling of skin on the extensor surfaces of joints. There is also onycholysis (separation of nail from nail bed) and pitting of the nails. There may also be some joint swelling and deformity of the middle finger.
  • Psoriasis. This is a chronic and very common (affecting 2% of the UK population) inflammatory skin condition. It is a clinical diagnosis and has a tendency to run in families.
  • The association between psoriasis and inflammatory arthritis has long been known. More recently, a link between psoriasis, type 2 diabetes, obesity and increased cardiovascular risk is becoming more apparent. Up to 30% of patients will develop some form of arthritis. There are five patterns of joint involvement: a pattern similar to rheumatoid arthritis; a pattern similar to ankylosing spondylosis; an asymmetrical type; arthritis mutilans – a severe and disabling variant; and, as in this case, a distal interphalangeal predominant variant.
  • There is a multitude of available treatments. The latter two in this list have an effect on psoriatic arthritis as well: Topical ointments – moisturisers, Vitamin D analogues, steroids, anti-inflammatories such as coal tar and Dithranol; UV light therapy; Immunosuppression – Methotrexate, Cyclosporin and Acitretin; Synthesized monoclonal antibodies directed at TNFα.