Gender Differences in PsA Presentation with Temporomandibular Joint Involvement

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A new study discovered gender differences in the presentation of psoriatic arthritis (PsA): Males tend to present with more peripheral joint movement (inflammation on knees, ankles, wrists), and females tend to exhibit more axial involvement (spine, sacroiliac joints, and temporomandibular joint).¹

“The reasons for this variation in joint involvement patterns between genders are not well understood and may be influenced by both hormonal and genetic factors,” wrote investigators, led by Sara Bernardi, from the University of L’Aquil in Italy.

The team aimed to assess various aspects of PsA affecting the temporomandibular joint (TMJ)—psoriasis pathogenesis, TMJ clinical presentation, diagnostic approaches, and available treatment strategies. Furthermore, investigators wanted to examine gender differences in the presentation of PsA since males and females have differences in pain distribution and hormonal fluctuations.

Investigators performed their narrative and comprehensive review by using a search strategy. They searched the terms “psoriasis,” “psoriatic arthritis,” temporomandibular joint,” “temporomandibular disorders,” “pathogenesis” and “gender differences” on Pubmed, Web of Science, and Scopus databases. The authors included clinical studies, epidemiological studies, reviews and systematic reviews, case series, and case reports.

Pathogenesis of PsA Affecting the TMJ

Studies have identified several susceptibility genes linked to PsA, including HLA-B27, HLA-Cw6, and IL23R, which play a role in immune regulation and inflammatory pathway activation. The gene HLA-B27 has been linked to a more severe disease course and an increased risk of axial involvement in PsA. Little is known about how genes are related to TMJ involvement in PsA.

Though research has found pro-inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-a), interleukin 17 (IL-17), and interleukin 23 (IL-23), which are produced by several immune cells, play an important role in the pathogenesis of PsA impacting the TMJ. The cytokines are found in the synovial fluid and tissues of affected TMJs.

Immune dysregulation also plays a part in the pathogenesis of PsA affecting the TMJ. A study observed people with PsA have reduced function of regulatory T cells.

“Restoring Treg function may hold therapeutic potential in managing TMJ involvement in PsA,” investigators wrote.

Presentation of Psoriatic Arthritis in the TMJ

When patients have psoriatic arthritis in the TMJ, they experience pain in or near the TMJ such as on the face, temple, and neck. People describe the pain as “dull, aching, or throbbing” and may worsen by jaw movement, chewing, or talking.2 The pain intensity can vary.

Patients with PsA affecting the TMJ also often have joint swelling, which may or may not be visible.1 Some people experience “clicking, popping, or grating sounds during jaw movement,” called crepitus.

These patients also may have limited jaw movement due to the inflammation and swelling. This can make it hard to open the mouth wide, chew, or perform other daily routines. Their jaw might get “locked” or “stuck” in place, requiring them to manually adjust their jaw.

This group of individuals may struggle to speak with proper pronunciation, causing speech impediments or slurring.

Gender differences exist in the clinical presentation of PsA with TMJ involvement. Males often present more peripheral joint involvement—inflammation in the larger joints such as the knees, ankles, and wrists. In contrast, women exhibit more axial involvement, which is inflammation in the spine, sacroiliac joints, and TMJ. Still, the variations in joint involvement patterns between males and females are fully understood.

Research has shown males with PsA may be more likely to have increased disability and functional impairment. Women, however, may be more likely to report greater levels of pain, fatigue, and psychological distress due to their PsA. Investigators noted the findings are not consistent across all studies so more research is needed.

It has been observed hormonal factors play a role in the gender differences for PsA with TMJ involvement, specifically experienced by females during reproductive years and menopause. Estrogen has been thought to influence the inflammatory response and joint damage in PsA. Thus, fluctuations in estrogen levels during the menstrual cycle and pregnancy may influence disease activity and symptoms.

“When managing patients whose TMJ is involved in PsA, gender has to be considered, also due to the possibility of pregnancy and hormonal changes in female patients,” investigators said. “Pregnancy itself can have variable effects on the course of PsA, with some women experiencing improvement in symptoms during pregnancy, while others may experience disease flares. It is important for healthcare providers to closely monitor TMJ symptoms during pregnancy and adjust the treatment plan accordingly.”

References

1. ^{Bernardi S, Memè L, Belfioretti C, Bambini F, Gerardi D, Macchiarelli G, Bianchi S, Mummolo S. Psoriatic Arthritis Involving TMJ: A Review on Pathogenesis and Consideration on Eventual Gender Differences. Dentistry Journal. 2024; 12(2):31. https://doi.org/10.3390/dj12020031}
2. ^{Mustafa MA, Al-Attas BA, Badr FF, Jadu FM, Wali SO, Bawazir YM. Prevalence and Severity of Temporomandibular Disorders in Rheumatoid Arthritis Patients. Cureus. 2022;14(1):e21276. Published 2022 Jan 15. doi:10.7759/cureus.21276}