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- Research Article Prevalence of periapical abscesses in psoriasis patients: a retrospective cross-sectional study
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Ilan Rotstein1,*
, Joseph Katz2, Simone Grandini3, Giulia Malvicini3, Franklin Garcia-Godoy4 -
Restor Dent Endod [Epub ahead of print]
DOI: https://doi.org/10.5395/rde.2026.51.e39
Published online: August 10, 2026
1Department of Endodontics and Periodontics, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
2Department of Oral Medicine, Oral Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
3Unit of Endodontics and Restorative Dentistry, Department of Medical Biotechnologies, University of Siena, Siena, Italy
4Department of Bioscience Research, University of Tennessee Health Science Center, College of Dentistry, Memphis, TN, USA
- *Correspondence to Ilan Rotstein, DDS Department of Endodontics, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA 90007, USA Email: ilan@usc.edu
• Received: December 21, 2025 • Revised: February 8, 2026 • Accepted: March 29, 2026
© 2026 The Korean Academy of Conservative Dentistry
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
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Objective This study was performed to assess the prevalence of acute periapical abscesses (PAs) in patients with psoriasis and to determine whether this relationship remains after adjusting for related systemic, behavioral, and treatment-related confounders.
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Methods A retrospective hospital-based analysis of 2,108,676 patients was conducted using de-identified clinical data. Diagnoses of psoriasis and acute PA without sinus involvement were identified using standardized coding. The association between psoriasis and acute PAs was assessed using odds ratios (ORs) with 95% confidence intervals (CIs). Multivariable logistic regression analyses were performed to adjust for diabetes, nicotine dependence, alcohol-related disorders, and biologic therapy use.
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Results Among 16,084 patients with psoriasis, 224 were diagnosed with acute PAs. Psoriasis was associated with a significantly higher prevalence of acute PAs than in the overall hospital population (OR, 2.21; 95% CI, 1.94–2.53; p < 0.0001). This association remained statistically significant after adjustment for diabetes (OR, 1.40), nicotine dependence (OR, 1.31), alcohol related disorders (OR, 1.89), and biologic therapy use (OR, 1.77). Female patients and white patients with psoriasis exhibited a higher prevalence of acute PAs compared with other demographic groups.
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Conclusions Psoriasis is independently associated with an increased risk of acute PAs, even after accounting for common medical and behavioral risk factors. Greater awareness among clinicians and closer collaboration between dermatology and oral healthcare providers can facilitate earlier diagnosis and preventive treatment.
INTRODUCTION
Psoriasis is a chronic inflammatory skin disease. It presents a global health concern affecting more than 60 million individuals worldwide [1,2]. It impacts both men and women equally and can manifest at any age. The cost of psoriasis care in the United States exceeds $100 billion per annum [3].
Psoriasis is characterized by rash, itchy, and scaly patches most commonly found on the scalp, elbows, knees, and trunk. The condition is cyclic, alternating between flare-ups and remission, which often causes discomfort [1]. Cycle lengths vary by person and are not always predictable.
The etiology of psoriasis is genetic [1]. Psoriasis can be associated with multiple factors such as infections, stress, depression, trauma, smoking, obesity, excessive alcohol consumption, certain systemic diseases, and medications [1–12]. Psoriasis has no cure [1]. Treatment focuses on symptom management, flare reduction, and lifestyle modifications [1].
Psoriasis can be divided into the following groups [13,14]: (1) psoriasis vulgaris, also known as plaque psoriasis, is the most common type; (2) guttate psoriasis; (3) inverse psoriasis; (4) pustular psoriasis; and (5) erythrodermic psoriasis. Different pathological mechanisms were associated with each psoriasis type [13,15–17].
An acute periapical abscess (PA) poses a health risk to patients and requires emergency treatment. In the United States, over 400,000 emergency room visits, resulting in more than $160 million in charges, were attributed to pulpal or periapical dental infections [18]. In addition, more than 60,000 hospitalizations were recorded [19].
An association between psoriasis and dento-oral diseases has been suggested [20,21]. Periodontal disease was commonly associated with psoriasis [22–26]. However, additional information is needed regarding a potential association between psoriasis and periapical disease, mainly acute PAs.
The purpose of this study was to assess in a large dataset the prevalence of acute PAs among patients with psoriasis seeking emergency dental treatment at the hospital and to assess the prevalence after adjusting for related systemic, behavioral, and treatment-related confounders.
METHODS
All the procedures performed in our study followed the ethical standards of the Institutional Review Board (IRB) of the University of Florida (UF) and privacy rules for research on IRB approved de-identified data sets (approval date: April 6, 2021).
De-identified clinical data, extracted from the integrated i2b2 open-source platform provided by the UF Health Office of the Chief Data Officer, were analyzed from October 2016 through October 2025. The i2b2 platform enables querying large sets of clinical and genomic data.
Data from 2,108,676 patients visiting the UF Health Center were collected via queries on the National Institutes of Health- and UF-supported i2b2 platform. Patient diagnoses were standardized using International Classification of Diseases, 10th Revision (ICD-10) codes. The analysis included a heterogeneous patient population with diverse conditions, including cases of acute paranasal pathology without sinus involvement. All cases of acute PAs admitted to the urgent care clinic were diagnosed and coded with appropriate ICD codes by calibrated, experienced oral healthcare professionals.
Inclusion criteria encompassed all patients with the corresponding code for acute PAs without sinus (ICD-10: K04.7), whether treated or not treated endodontically, and psoriasis (ICD-10: L40). Patient records were digitized, and specific diagnoses of acute PAs and psoriasis in the total hospital population were identified using the appropriate ICD-10 codes. The dataset reflected encounter-level data, and repeated encounters for the same patient were merged to avoid duplication. The dataset also reflected unique individuals, and psoriasis diagnosis preceded acute PAs diagnosis in all cases. The dental caries index was not assessed since patients were seen for emergency dental treatment. If the natural tooth was salvageable, treatment included endodontic treatment and coronal restoration.
The odds ratios (ORs) for the prevalence of acute PAs and their association with psoriasis were evaluated with 95% confidence intervals, and the statistical difference between psoriasis patients and non-psoriasis patients was assessed using MEDCALC software (ver. 23.3.7; MedCalc Software Ltd, Ostend, Belgium). A standard normal deviation (z-value) was calculated as follows: ln(OR)/SE[ln(OR)] [27]. The p-value was defined as the two-tailed area under the normal distribution curve outside the ± z thresholds, with p < 0.05 indicating statistical significance. Sensitivity analyses were evaluated to test the robustness of findings.
Logistic regression was conducted for diabetes (ICD-10: E08–E13), nicotine dependence (ICD-10: Z72.0), and alcohol-related disorders (ARD) (ICD-10: F10) comorbidities, as well as biologic drug use (ICD-10: Z79.620), using the aggregated counts as weights in the model. Biologic drugs included adalimumab, etanercept, ustekinumab, secukinumab, and risankizumab. Biologic drug therapy was analyzed as a binary variable without differentiation by drug class, dose, or duration. Adjustments to such factors were made.
RESULTS
Of the 16,084 psoriasis patients, 224 also had acute PAs (Table 1). Females were more affected than males by a factor of 2. Whites were more affected than African Americans, more than fivefold, and other ethnicities, more than sevenfold (Table 1).
The OR for acute PAs in patients with psoriasis was 2.21 (Table 2). The difference in prevalence compared to the total hospital patient population was statistically significant (p < 0.0001).
After adjustment for diabetes comorbidity, the OR for acute PAs was 1.4, and the difference in prevalence compared with the total hospital patient population was statistically significant (p < 0.0001) (Table 3).
After adjustment for nicotine dependence comorbidity, the OR for acute PAs was 1.31, and the difference in prevalence as compared to the total hospital patient population was statistically significant (p < 0.01) (Table 3).
After adjustment for ARD comorbidity, the OR for acute PAs was 1.89, and the difference in prevalence as compared to the total hospital patient population was statistically significant (p < 0.001) (Table 3).
After adjustment for biologic drug use, the OR for acute PAs was 1.77, and the difference in prevalence compared to the total hospital patient population was statistically significant (p < 0.0001) (Table 3).
DISCUSSION
This large, real-world dataset from a hospital-based study (>2 million records) provides robust evidence of a significant association between psoriasis and acute PAs. It shows that individuals with psoriasis are more than twice as likely to experience acute PAs as the general hospital population. This strong association suggests that psoriasis may influence susceptibility to endodontic infections beyond risk factors such as dental caries and periodontal disease [26]. These data are consistent with previous studies of smaller cohorts, which confirm an association between psoriasis and apical inflammation [26,28].
The demographic distribution shows interesting patterns. Female patients with psoriasis were twice as likely as males to present with acute PAs. This increased risk may be explained by sex-specific immunological and hormonal factors that modulate both oral and systemic inflammation. Female sex is associated with distinct immune responses, including a generally heightened innate and adaptive immune reactivity [29]. Women exhibit increased production of proinflammatory cytokines (such as interleukin [IL]-6 and tumor necrosis factor [TNF]-α), which are central to both psoriasis pathogenesis and the progression of periapical disease [29,30]. The heightened inflammatory milieu may hypothetically accelerate the transition from chronic inflammation to acute abscess formation in patients with psoriasis. Prevalent among women with psoriasis, low vitamin D levels further compromise immune regulation and bone density, increasing susceptibility to oral infections and the development of acute PAs [31]. Nevertheless, the differences between female and male patients may also reflect access to healthcare, utilization patterns, or coding practices rather than biological susceptibility alone.
White patients constituted the vast majority of psoriatic individuals with PAs (>75%). This proportion is notably higher than their representation in either the total psoriasis cohort or the overall acute PAs population. In contrast, African American patients accounted for less than 40% of all acute PAs cases hospital-wide, but only exhibited circa 15% acute PAs among individuals with psoriasis. These discrepancies cannot be explained by the demographic distribution of acute PAs in the overall hospital population. Therefore, it may suggest that psoriasis can act as a disease-specific modifier for increased risk of acute PAs. Differences in oral health behaviors, access to dental care, systemic inflammatory burden, or patterns of healthcare utilization across demographic groups may contribute to this phenomenon.
An important component of this study was the evaluation of whether the association between psoriasis and acute PAs could be attributed to comorbid conditions known to increase the risk of oral and periapical infections [26,32,33]. After adjustment for diabetes, a well-established risk factor [34], the OR decreased but remained highly significant. This decrease indicates that, while diabetes partially explains the increased risk of acute PAs in psoriatic patients, psoriasis retains an independent effect. A similar pattern emerged after controlling for nicotine dependence, underscoring that smoking contributes to, but does not fully account for, the elevated risk [35]. Furthermore, adjustment for ARD produced an OR slightly lower than the unadjusted estimate. It suggests that alcohol consumption, although associated with poor oral hygiene and impaired immune function, is not a major confounder in the psoriasis-acute PAs relationship. Psoriasis itself remains a dominant contributor to infection susceptibility even after accounting for this behavioral risk factor.
Particularly noteworthy is the persistence of a significant association after adjustment for biologic therapy. Biologic agents affect cytokine pathways that are essential to both psoriasis pathogenesis and host defense mechanisms [26]. Patients receiving biologic drugs typically present with more severe or refractory psoriasis. The use of such drugs is likely to act as a proxy for severe or refractory psoriasis. The elevated risk for acute PAs in this subgroup may reflect the systemic inflammatory burden of severe disease rather than a medication effect.
Additionally, since psoriasis severity could not be assessed in this de-identified dataset, biologic therapy may serve as a marker of more severe or refractory disease rather than indicating a direct medication-related effect. Moreover, biologic therapies were analyzed as a single category, precluding assessment of class-specific differences. Taken together, these findings suggest that while biologic therapy may be associated with reduced chronic periapical inflammatory severity [26], patients with more severe psoriasis may remain vulnerable to acute PAs. This observation likely reflects the combined influence of underlying disease severity, systemic inflammatory burden, and immune modulation, rather than a causal effect of biologic agents alone. Studies incorporating validated psoriasis severity scores will aid in understanding medication-related susceptibility in the context of disease-driven vulnerability.
Shared inflammatory pathways support the biological plausibility of an association between psoriasis and acute PAs. Cytokines such as IL-17 and TNF-α, key components of psoriasis immunopathogenesis, are also central mediators in apical inflammation, contributing to bone resorption and tissue destruction [26,36]. Systemic inflammation characteristic of psoriasis may impair host responses to pulpal infection, thereby accelerating the progression from pulp necrosis to abscess formation. Additionally, behavioral and psychosocial factors often linked to psoriasis, including depression, stress, and decreased oral healthcare engagement, may further contribute to delayed detection and increased emergency treatment needs [36].
The novel contribution of this study using a very large hospital dataset enabled robust statistical comparisons and enhanced generalizability within similar healthcare settings. The use of ICD-10–coded diagnoses by trained oral health professionals supports the accuracy of case classification [37]. However, some limitations must be acknowledged. First, the use of de-identified retrospective data limits the ability to assess clinical confounders such as caries index, periodontal status, oral hygiene status, socioeconomic background, dental visit frequency, or severity of psoriasis. Second, causality cannot be inferred from these cross-sectional observational data. Third, this study used a database from a single medical institution in the United States. Socioeconomic factors may affect certain populations' decisions to seek medical and dental care at this specific health center.
Fourth, potential heterogeneities and misclassification inherent to ICD-based diagnoses may limit the ability to assess psoriasis severity scores, disease duration, or flare-up status. Fifth, biologic therapy was analyzed only as a grouped category; individual drug effects might differ. Finally, emergency department-based identification of acute PAs may underestimate the number of less severe cases managed in outpatient dental clinics. Despite these limitations, the findings support an independent association between psoriasis and acute PAs.
The findings of this study highlight the importance of increased dental surveillance in psoriasis patients, particularly among those with behavioral risk factors or undergoing biologic therapy. An interdisciplinary collaboration between dermatology and dental care to establish early diagnosis and preventive treatment is encouraged. It should include frequent consultation and medication review, increased recall dental visits, a comprehensive oral exam, and patient education emphasizing rigorous oral hygiene.
CONCLUSIONS
In conclusion, psoriasis is independently associated with a higher prevalence of acute PAs, even after adjustment for systemic, behavioral, and treatment-related confounders. This association suggests that systemic inflammation and immune dysregulation may increase susceptibility to acute PAs. Future research should focus on prospective clinical studies that incorporate standardized assessments of psoriasis severity, detailed endodontic clinical evaluations, and stratification by specific biologic therapies to clarify how systemic inflammation and immunomodulatory treatment influence the risk and presentation of odontogenic and endodontic infections.
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CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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FUNDING/SUPPORT
The authors have no financial relationships relevant to this article to disclose.
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AUTHOR CONTRIBUTIONS
Conceptualization: Rotstein I, Garcia-Godoy F. Investigation, Methodology: Rotstein I, Katz J. Writing - original draft: Rotstein I. Writing - review & editing: Grandini S, Malvicini G, Garcia-Godoy F. All authors read and approved the final manuscript.
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DATA SHARING STATEMENT
The datasets are available from the corresponding author upon reasonable request.
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DISCLOSURE OF GENERATIVE AI IN SCIENTIFIC WRITING
No generative AI tools were used in the preparation of this manuscript.
Table 1.
Demographic distribution of acute PAs and psoriasis patients among the total hospital population (n = 2,108,676)
Table 2.
Association between psoriasis and acute PAs in hospital patients
| Variable | PAs | No PAs | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Psoriasis | 224 | 15,860 | 2.21 (1.94–2.53) | <0.0001 |
| No psoriasis | 13,247 | 2,079,345 | 1.00 (Reference) | - |
Table 3.
Association between psoriasis and acute PAs after adjustment for diabetes, nicotine dependence, ARD, and biologic drug use
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XML DownloadPrevalence of periapical abscesses in psoriasis patients: a retrospective cross-sectional study
Prevalence of periapical abscesses in psoriasis patients: a retrospective cross-sectional study
| Characteristic | Psoriasis patients with acute PAs | Total psoriasis patients | Total acute PAs |
|---|---|---|---|
| No. of patients | 224 | 16,084 | 13,473 |
| Sex | |||
| Female | 146 (65.2) | 9,434 (58.7) | 7,543 (56.0) |
| Male | 78 (34.8) | 6,650 (41.4) | 5,930 (44.0) |
| Race/ethnicity | |||
| African American | 32 (14.3) | 989 (6.2) | 4,847 (36.0) |
| White | 172 (76.8) | 10,269 (63.9) | 7,437 (55.2) |
| Other | 20 (8.9) | 4,826 (30.0) | 1189 (8.8) |
| Age (yr) | |||
| <18 | 10 (4.5) | 569 (3.5) | 1,650 (12.3) |
| ≥18 | 214 (95.5) | 15,515 (96.5) | 11,823 (87.8) |
| Variable | PAs | No PAs | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Psoriasis | 224 | 15,860 | 2.21 (1.94–2.53) | <0.0001 |
| No psoriasis | 13,247 | 2,079,345 | 1.00 (Reference) | - |
| Adjustment | Psoriasis (PAs) | No psoriasis (PAs) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Diabetes | 143 | 13,328 | 1.40 (1.18–1.65) | <0.0001 |
| Nicotine dependence | 134 | 13,337 | 1.31 (1.10–1.55) | <0.01 |
| ARD | 194 | 13,277 | 1.89 (1.64–2.18) | <0.0001 |
| Biologic drug use | 181 | 13,290 | 1.77 (1.53–2.05) | <0.0001 |
Table 1. Demographic distribution of acute PAs and psoriasis patients among the total hospital population (n = 2,108,676)
Values are presented as number or number (%). PA, periapical abscess.
Table 2. Association between psoriasis and acute PAs in hospital patients
CI, confidence interval; PA, periapical abscess.
Table 3. Association between psoriasis and acute PAs after adjustment for diabetes, nicotine dependence, ARD, and biologic drug use
ARD, alcohol-related disorders; CI, confidence interval; PA, periapical abscess.
