Use and accuracy of US guidance for image-guided injections of the temporomandibular joints in children with arthritis

A clinical perspective on imaging in juvenile idiopathic arthritis

In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.

Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls

Ultrasound (US)-guided musculoskeletal intervention of small joints or joints other than the shoulder, elbow, hip, knee, and ankle can be technically challenging. Small joints produce a narrower landing zone for the needle and a smaller target that may be made even more inaccessible by bulky osteophytes. Sonographic (US) guidance offers important advantages including near-field visualization of the joint and soft tissues, ease of access, portability, ability to compare with the contralateral side, and lack of ionization radiation. This review article focuses on the performance of US-guided injections and aspirations involving small joints (joint capacity < 2 mL and/or typically evaluated or injected with a compact linear transducer). For each joint (temporomandibular, acromioclavicular, sternoclavicular, distal radioulnar, symphysis pubis, and joints of the digits of the hands and feet), a brief overview of the relevant anatomy, indications, procedural description, pearls and pitfalls will be highlighted. This article demonstrates the various approaches to diagnostic or therapeutic injection and aspiration of small joints with the aid of US images, cines and graphic illustrations, emphasizing joint positioning, anatomic landmarks, and needle trajectory for a safe and efficacious procedure. A brief review of available literature for each joint will also be provided.

Ultrasound-guided temporomandibular joint aspiration: technique and results in six cases of suspected septic arthritis

OBJECTIVE

The aim of this study is to describe an ultrasound (US)-guided temporomandibular joint (TMJ) arthrocentesis technique and determine its microbial yield in the workup of suspected TMJ septic arthritis.

MATERIALS AND METHODS

A retrospective review of US-guided TMJ arthrocentesis for the work-up of septic arthritis performed by radiologists at two institutions was performed. Patient demographics, risk factors for septic arthritis, blood culture results, and pre-procedural imaging findings were recorded. Procedural data included fluid aspirate quantity, needle gauge and length, and any immediate complications. Post-procedural data included synovial fluid analysis including culture, final diagnosis of TMJ disease, type of treatment, and any delayed complications from arthrocentesis.

RESULTS

A total of six US-guided TMJ arthrocenteses were identified, all of which yielded at least 1 mL of synovial fluid. Five patients were subsequently diagnosed with septic arthritis, and one patient was diagnosed with GVHD arthritis. The synovial fluid in four out of five patients with a final diagnosis of septic arthritis produced positive cultures. There were no immediate or delayed complications from arthrocentesis.

CONCLUSION

Basic US-guided procedural skills are transferrable to TMJ arthrocentesis, which is a low-risk procedure with a high microbial yield in our small series of patients with septic arthritis.

Patient-Reported Quality of Life versus Physical Examination in Treating Temporomandibular Disorders with Intra-Articular Platelet-Rich Plasma Injections: An Open-Label Clinical Trial

Temporomandibular disorders, often manifested by articular pain, limitation of the mouth opening range, and unpleasant acoustic symptoms originating from inside the joint, have been associated with reduced quality of life. These symptoms, among others, can be treated with intra-articular injections of various substances, including repeated platelet-rich plasma (PRP) administration. The reported study was designed as an uncontrolled open-label clinical trial of consecutive cases. The participants completed a Fonseca questionnaire and evaluated acoustic symptoms, and spontaneous and provoked pain on VAS, and were subjected to a physical examination before, during, and after PRP therapy. The total Fonseca questionnaire results were statistically significantly (p < 0.05) correlated with 340 out of 348 (98%) other variables. The fully subjective assessment of the presence and intensity of acoustic symptoms coming from the temporomandibular joints was correlated with the physical examination results (0.45-0.63) and the maximum mouth opening with the maximum pain-free mouth opening (0.73-0.87). There were no correlations observed between the patient's and the physician's assessment of mandibular mobility. The Fonseca questionnaire seems to cover the entire spectrum of temporomandibular disorders, making it a balanced tool for assessing the quality of life in TMDs. However, it is worth considering extending the standard 3-point response scale to an 11-point one. The patient is somewhat able to perform a self-diagnosis with regard to the acoustic symptoms, but it is not possible for them to determine without measurement whether the range of mandibular mobility is appropriate..

Autologous Stem Cells Transplants in the Treatment of Temporomandibular Joints Disorders: A Systematic Review and Meta-Analysis of Clinical Trials

This systematic review aims to analyze the outcomes of the treatment of temporomandibular joint (TMJ) articular pain (AP) and restricted maximum mouth opening (MMO) with intra-articular administration of mesenchymal stem cells (MSCs). The inclusion criteria allowed primary studies involving AP and/or MMO pre-treatment and post-intervention values. Medical databases that were covered by ACM Digital, BASE, EBSCOhost, Google Scholar, PubMed, Scopus, and Web of Science engines were searched. The risk of bias was assessed with RoB 2 and ROBINS-I tools. The results were tabulated, plotted, and analyzed for regression. A total of 5 studies involving 51 patients/69 TMJs were identified, and 4 studies on 50 patients/67 TMJs were synthesized. Interventions were each time effective in decreasing AP and increasing MMO in a 6-month follow-up period by an average of about 85% and over 40%, respectively. Regression analysis showed a good fit of the logarithmic model for AP relief (5.8 − 0.8 ln x; R² = 0.90) and MMO increase (33.5 + 2.4 ln x; R² = 0.89). The results for AP and MMO were based on 3 studies in 39 patients and 4 studies in 50 patients, respectively, all at high risk of bias. The intra-articular administration of MSCs to TMJs, based on weak evidence, may be highly effective in reducing AP and improving MMO. This study received no funding.

Role of Ultrasound Evaluation of Temporomandibular Joint in Juvenile Idiopathic Arthritis: A Systematic Review

Background: Juvenile idiopathic arthritis (JIA) is childhood’s most frequent chronic rheumatic disease. JIA is a broad term that includes all arthritides starting before 16 years, lasting at least six weeks, and of unknown cause. The temporomandibular joint (TMJ) could be involved in JIA both at onset and during the disease course. The presence of TMJ synovitis might severely impair dentofacial maturation in pediatric patients. The ultrasound (US) application to detect early signs of TMJ synovitis in children with JIA has provided contradictory results. We sought to assess the current role of TMJ US in JIA through a systematic literature review. Methods: The systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Results: The literature search found 345 records. After duplicates removal, 253 records were screened, 20 full-text articles were reviewed to assess their eligibility, and 7 of them were included in the qualitative analysis. Joint effusion was the most recorded parameter, followed by bony condylar abnormalities. Compared to contrast enhancement MRI, the capability to detect signs of active synovitis of TMJ by US is low, especially at the early stages. Conclusion: Understanding how US may help diagnose and manage children with JIA is advisable for several reasons. MRI cannot be frequently repeated, may need sedation, and is expensive. The constant technical improvement of US will undoubtedly allow for better evaluation of what, in the past, was not clear or not even captured by sonography. So far, the role of US in the assessment of TMJ involvement in JIA is indubitably secondary to the MRI. Even so, we think that a baseline MRI of TMJ and the repetition of the sonography over time might both help the interpretation of US images and intercept significative changes.

The Role of Ultrasound in Temporomandibular Joint Disorders: An Update and Future Perspectives

Temporomandibular joint (TMJ) disorder is the second most common chronic pain condition affecting the general population after back pain. It encompasses a complex set of conditions, manifesting with jaw pain and limitation in mouth opening, influencing chewing, eating, speaking, and facial expression. TMJ dysfunction could be related to mechanical abnormalities or underlying inflammatory arthropathies, such as rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA). TMJ exhibits a complex anatomy, and thus a thorough investigation is required to detect the TMJ abnormalities. Importantly, TMJ involvement can be completely asymptomatic during the early stages of the disease, showing no clinically detectable signs, exposing patients to delayed diagnosis, and progressive irreversible condylar damage. For the prevention of JIA complications, early diagnosis is therefore essential. Currently, magnetic resonance imaging (MRI) is described in the literature as the gold standard method to evaluate TMJ. However, it is a high-cost procedure, not available in all centers, and requires a long time for image acquisition, which could represent a problem notably in the pediatric population. It also suffers restricted usage in patients with claustrophobia. Ultrasonography (US) has emerged in recent years as an alternative diagnostic method, as it is less expensive, not invasive, and does not demand special facilities. In this narrative review, we will investigate the power of US in TMJ disorders based on the most relevant literature data, from an early screening of TMJ changes to differential diagnosis and monitoring. We then propose a potential algorithm to optimize the management of TMJ pathology, questioning what would be the role of ultrasonographic study.

Treatment of Mandibular Hypomobility by Injections into the Temporomandibular Joints: A Systematic Review of the Substances Used

INTRODUCTION

Hyaluronic acid, steroids and blood products are popularly injected into the temporomandibular joint (TMJs) to relieve pain and increase the extent of mandibular abduction. The purpose of this review is to identify other injectable substances and to evaluate them in the above-mentioned domains.

MATERIAL AND METHODS

The review included articles describing clinical trials of patients treated with intra-articular injections with or without arthrocentesis.

RESULTS

The following emerging substances were initially evaluated to be effective in treating TMJ pain and increasing the amplitude of mandibular abduction: analgesics, dextrose with lidocaine, adipose tissue, nucleated bone marrow cells and ozone gas.

DISCUSSION

Better effects of intra-articular administration are achieved by preceding the injection with arthrocentesis.

CONCLUSIONS

The most promising substances appear to be bone marrow and adipose tissue.

Ultrasonography in Pediatric Rheumatology

This review highlights the increasing evidence from the last few years supporting the use of musculoskeletal ultrasonography (MSUS) in the evaluation and management of patients with pediatric rheumatic diseases, particularly focusing on juvenile idiopathic arthritis. Recently developed definitions for the sonographic appearance of healthy and pathologic joints in children are discussed. Further topics explored include how MSUS enhances the diagnosis of inflammatory joint disease (synovitis, enthesitis, tenosynovitis), including the detection of subclinical synovitis. There is a brief summary on the use of ultrasonography in the evaluations of myositis, Sjögren syndrome, and scleroderma.

Clinical and ultrasonographic evaluation of ultrasound-guided single puncture temporomandibular joint arthrocentesis

Objective: To evaluate the effects of successful TMJ treatment on relief of pain, improvement of mandibular movement and capsular width with clinical and ultrasonography (US) findings. In this study, TMJ changes were evaluated by clinical and US examination after US-guided single-puncture arthrocentesis, which represents a novel approach.Methods: Clinical measurements were obtained before each procedure and at 1 day, 7 days, and 3 months thereafter. Capsular width was measured via the US at the 3-month follow-up.Results: Significant improvements were evident at the short term of 3 months post-arthrocentesis with supportive treatment, including splint therapy and jaw exercises.Conclusion: Arthrocentesis in conjunction with splint therapy and jaw exercises demonstrated significant clinical improvement at the short-term follow-up of 3 months. US imaging can be helpful for follow-up evaluation of the pre- and post-treatment capsule width. Longer follow-up studies are necessary to validate the effectiveness of this treatment protocol.

Efficacy and safety of intraarticular corticosteroid injections in adolescents with juvenile idiopathic arthritis in the temporomandibular joint: a Norwegian 2-year prospective multicenter pilot study

BACKGROUND

Intraarticular corticosteroids (IACs) have been used to treat temporomandibular joint (TMJ) arthritis. However, prospective clinical studies with magnetic resonance imaging (MRI) scoring are lacking. The aim of this study was to examine efficacy and safety of a single IAC in the TMJ in adolescents with juvenile idiopathic arthritis (JIA) in a clinical setting.

METHODS

In this Norwegian prospective multicenter pilot study 15 patients with JIA (mostly persistent oligoarthritis or RF negative polyarthritis categories) and a clinically and MRI-verified diagnosis of TMJ arthritis were treated with IACs and followed for 2 years. Demographics, systemic medication, general disease activity and outcome measures were recorded including a pain-index score and maximal incisal opening (MIO). Inflammation and bone damage scores were assessed, using two recently published MRI scoring systems with masked radiological evaluation.

RESULTS

Among the 15 patients, 13 received a single IAC (5 bilateral), and 2 repeated IACs once unilaterally. Thus, the total number of IACs was 22. Median age was 15 years and the majority had an age not thought of as critical regarding mandibular growth retardation due to steroid injection. During the 2-year observation period systemic medication with disease modifying antirheumatic drugs (DMARDs) including biologics was initiated or adjusted in 10/15 (67%) patients. At the 2-months study visit after injection we observed a minimal improvement in MIO from median 44 (1st, 3rd quartiles; 36, 48) mm to 45 (43, 47) mm, p = 0.045 and decreased MRI mean additive inflammatory score from 4.4 ± 1.8 standard deviations (SD) to 3.4 ± 2.0, p = 0.040. From baseline to the 2-months follow-up pain improved in 6/11 patients but pain scores were not significantly improved. MRI-assessed damage increased in two patients with repeated IACs, and decreased in 3 patients but most of the patients were stable over the 2-year follow-up. Intra-rater repeatability of the MRI scoring system domains varied from poor to excellent.

CONCLUSIONS

In this pilot study of predominately single IACs to the TMJ in combination with systemic treatment we observed improvement in MRI-assessed inflammation, mostly stable condylar bone conditions and minimal clinical improvement in adolescents with JIA and TMJ arthritis. No severe side effects were seen.

Ultrasonography-guided arthrocentesis versus conventional arthrocentesis in treating internal derangement of temporomandibular joint: a systematic review

OBJECTIVES

This systematic review assessed the clinical question: 'Does ultrasonography (USG)-guided arthrocentesis provide better outcomes than conventional arthrocentesis in patients with temporomandibular disorder (TMD)?'

MATERIALS AND METHODS

The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An initial search was performed on electronic databases-including Medline, PubMed, and Cochrane Library-followed by manual and reference searches until the date September 27, 2019. The articles selected were evaluated for study and patient characteristics, arthrocentesis procedure details, and treatment outcomes (post-operative pain, maximum mouth opening (MMO), procedure time, and attempts of needle positioning). Risk of bias was assessed with the Cochrane Consumers and Communication Review Group's data extraction template and Critical Appraisal Skills Programme (CASP).

RESULTS

Out of the 325 initially identified articles, four studies with 144 patients were included in the final qualitative analysis. No significant differences were found in pain reduction and improved MMO between sample groups receiving conventional arthrocentesis and USG-guided arthrocentesis. Needle positioning attempts and procedural times were conflicting between the two groups.

CONCLUSIONS

This systematic review found that the outcomes of USG-guided arthrocentesis were not superior to conventional arthrocentesis. Conflicting data was found in the attempts of needle positioning and procedural time. Standardized treatment protocols and data from well-designed USG-guided arthrocentesis randomized clinical trials were lacking.

CLINICAL RELEVANCE

Arthrocentesis with or without USG guidance are both effective for treating patients with TMD to reduce pain and to improve MMO. USG-guided arthrocentesis was not found to be superior to conventional arthrocentesis.

Musculoskeletal ultrasound in children: Current state and future directions

Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic inflammatory arthritides that if inadequately treated, may be associated with chronic disability and deformity. Early diagnosis and treatment initiation is essential in the management of patients with JIA. Conventional means of evaluation of disease presence, disease activity and response to therapy including physical exam, labs and x-rays are at times limited and may be insufficient in making an accurate assessment. Musculoskeletal ultrasound (MSUS) is a well-established modality that is patient and family-friendly, non-invasive, does not require sedation and can be performed at the bedside in real-time. MSUS offers information that cannot be attained by standard outcome measures, and may help to advance both diagnosis and treatment of patients with JIA ultimately improving patient outcomes. This review explores the background of MSUS and the current evidence to support its potential role as a diagnostic, disease activity monitoring and interventional tool.

Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

The purpose of this study was to clinically evaluate the efficacies of three treatment methods and to compare their outcomes in patients with painful disc displacement. The study group comprised 45 patients with unilateral temporomandibular disorders who fell into Axis I group II (with limited mouth opening) of the Research Diagnostic Criteria for Temporomandibular Disorders. Magnetic resonance imaging was used for definitive diagnosis. The patients were divided randomly into three groups according to the treatment method: splint therapy, splint therapy with ultrasound-guided arthrocentesis, and splint therapy with low-level laser therapy. Patients were followed up after treatment for 6 months. The groups were compared in terms of pain and functional jaw movements (unassisted mouth opening without pain, maximum unassisted mouth opening, and contralateral movements). At the end of treatment, functional jaw movements were significantly increased while pain values were significantly decreased in all groups (P<0.05). Group 2 had a quicker improvement in terms of mouth opening scores at the end of the first month, and unassisted mouth opening without pain was found to be more than 35 millimetres in all groups at the end of 6 months. All treatment modalities showed effective results on pain and functional jaw movements in the treatment of temporomandibular disorders.

Imaging of the Pediatric Temporomandibular Joint

Imaging of the temporomandibular joint in pediatric patients is a critical component in the evaluation and treatment of children with temporomandibular joint symptoms. MRI can provide detailed joint anatomy and identify inflammation, sometimes before symptom onset. Ultrasound scan is a convenient emerging modality to evaluate the joint and guide therapeutic injections. Radiography and computed tomography offer osseous detail to recognize early morphologic changes of the mandibular condyle and provide operative planning. Imaging promises to direct treatment to prevent future joint destruction and maintain function.

Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what?

BACKGROUND

Arthritis involving the temporomandibular joint (TMJ) complicates 40 - 96% of cases of juvenile idiopathic arthritis (JIA), potentially leading to devastating changes to form and function. Optimal evaluation and management of this joint remains a matter of ongoing discussion.

METHODS

We performed a PubMed search for all articles with keywords "temporomandibular" and "arthritis", covering the dates 2002 through February 28, 2018. A separate PubMed search was performed for all articles with keywords "temporomandibular joint", "arthritis", and "treatment" covering the same dates.

FINDINGS

The TMJ is a particularly challenging joint to assess, both clinically and with imaging studies. Clinical assessment of the TMJ is hampered by the low sensitivity of joint pain as well as the absence of physical exam findings early in the disease process. As with all joints, plain radiography and computed tomography only detect arthritic sequelae. Additionally, there is mixed data on the sensitivity of ultrasound, leaving magnetic resonance imaging (MRI) as the optimal diagnostic modality. However, several recent studies have shown that non-arthritic children can have subtle findings on MRI consistent with TMJ arthritis, such as joint effusion and contrast enhancement. Consequently, there has been an intense effort to identify features that can be used to differentiate mild TMJ arthritis from normal TMJs, such as the ratio of the enhancement within the TMJ itself compared to the enhancement in surrounding musculature. With respect to treatment of TMJ arthritis, there is minimal prospective data on medical therapy of this complicated joint. Retrospective studies have suggested that the response to medical therapy of the TMJ may lag behind that of other joints, prompting use of intraarticular (IA) therapy. Although most studies have shown short-term effectiveness of corticosteroids, the long-term safety of this therapy on local growth as well as on the development of IA heterotopic bone have prompted recommendations to limit use of IA corticosteroids. Severe TMJ disease from JIA can also be managed non-operatively with splints in a growing child, as well as with surgery.

CONCLUSION

In this review, we summarize literature on the diagnosis and management of TMJ arthritis in JIA and suggest a diagnostic and therapeutic algorithm for children with refractory TMJ arthritis.

Benefit of Temporomandibular Joint Lavage With Intra-Articular Steroids Versus Lavage Alone in the Management of Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis

PURPOSE

The aim of the present investigation was to evaluate, in patients with juvenile idiopathic arthritis, the effect of lavage with or without intra-articular corticosteroid (IACS) injection on clinical temporomandibular joint (TMJ) signs and symptoms of inflammation and changes in acute inflammation as assessed using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Forty-one patients (mean age, 13.6 ± 4.0 yr) with juvenile idiopathic arthritis participating in a large prospective juvenile inflammatory rheumatism cohort study (JIRcohorte) were included in this study. Clinical history, examination, and MRI were carried out at baseline and 6 months after intervention, if any. Twenty-one patients underwent lavage and IACS injection in at least 1 TMJ, 8 patients underwent lavage of at least 1 TMJ, and 12 patients were followed with no intervention. Outcomes measured were maximal mouth opening, Helkimo dysfunction index scores, pain intensity, and acute inflammation as assessed using MRI.

RESULTS

All groups showed a mean increase in mouth opening and mean decrease in pain intensity. The mean Helkimo clinical dysfunction score decreased for the 2 intervention groups but not for the control group. The mean Helkimo anamnestic dysfunction score decreased for the lavage with IACS group but not for the lavage-only group. The only statistically relevant difference was found for the Helkimo anamnestic dysfunction score comparing the lavage-only with the lavage with IACS group, with a more positive effect found in the lavage with IACS group. More than 50% of joints in each group showed no change at MRI examination. Joints with lavage and ICAS injection showed better improvement than joints that had lavage only or no intervention.

CONCLUSION

TMJ lavage with or without IACS injection cannot be claimed to systematically decrease pain, increase mouth opening, or resolve acute inflammation. Despite a tendency for improvement, response to this treatment is very patient dependent and can be determined by an array of other variables.

Juvenile Idiopathic Arthritis Practice Patterns Among Oral and Maxillofacial Surgeons

PURPOSE

The purpose of this investigation is to assess the current clinical practices by oral and maxillofacial surgeons (OMSs) in the United States regarding diagnosis and treatment of temporomandibular joint (TMJ) involvement in children with juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

We implemented a cross-sectional survey of academic OMSs in the United States via an electronic survey. The survey included respondent demographic data, patient volumes, diagnostic methods, and management practices for children with JIA and TMJ involvement. The results of the survey were analyzed using descriptive statistics.

RESULTS

The study respondents were composed of 52 surgeons. Most respondents were men (n = 43, 87.8%), were aged 51 to 60 years (n = 20, 39.2%), were in full-time academics (n = 42, 84%), had more than 20 years of experience (n = 26, 50%), and were seeing 1 to 5 patients with JIA per month (n = 21, 46.7%). Most patients were aged 11 to 15 years (n = 22, 61.1%) and were managed with 1 to 2 systemic medications (n = 30, 81.1%). All OMSs reported evaluating TMJ involvement by reviewing patient history, clinical examination, and imaging. The most commonly used imaging modality was panoramic radiographs (n = 24, 63.2%) and magnetic resonance imaging (n = 22, 57.9%). OMSs decided to inject intra-articular medication based on history and symptoms (n = 36, 94.7%). Once in remission, patients were followed up at yearly (n = 12, 36.4%) or 6-month (n = 10, 30.3%) intervals.

CONCLUSIONS

Our study shows that, in general, there is consensus among US OMSs regarding diagnosis of TMJ involvement in children with JIA. There is less concordance among the respondents regarding treatment. Currently, management of TMJ involvement in children with JIA is mostly based on expert opinions and retrospective studies. This study further highlights the need for randomized clinical trials and multi-institution collaboration to allow for evidence-based diagnosis and treatment.

Is Intra-Articular Steroid Injection to the Temporomandibular Joint for Juvenile Idiopathic Arthritis More Effective and Efficient When Performed With Image Guidance?

PURPOSE

To compare short-term outcomes and procedure times for intra-articular steroid injection (IASI) to the temporomandibular joint (TMJ) with and without the use of intraoperative image guidance for patients with juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

This is a retrospective study of children with JIA who underwent TMJ IASI at Boston Children's Hospital (Boston, MA). Patients were divided into groups according to IASI technique: 1) "landmark" group if performed by an oral and maxillofacial surgeon using an anatomic landmark technique with no intraoperative image guidance or 2) "image-guided" group if performed by an interventional radiologist using intraoperative ultrasound and computed tomography. Predictor variables included IASI technique (landmark vs image guided), age, gender, JIA subtype, category of medications for arthritis, and presence of family history of autoimmune disease. Outcome variables were changes in patient-reported pain, maximal incisal opening (MIO), synovial enhancement ratio (ER), and total procedure time.

RESULTS

Forty-five patients with 71 injected TMJs were included. Twenty-two patients with 36 injected TMJs were in the landmark group and 23 patients with 35 injected joints were in the image-guided group. There were no relevant differences in age, gender, family history of rheumatologic disease, or disease subtype between groups. There were no differences in resolution of pain (P = 1.00), increase in MIO (P = .975), or decrease in ER (P = .492) between groups, but procedure times averaged 49 minutes longer for the image-guided group (P < .008).

CONCLUSIONS

There were no statistical differences in short-term outcomes, but procedure times were longer for the image-guided group. Although specific indications for the use of image guidance might exist, routine use of this procedure cannot be justified.

Quantifying the Effect of Temporomandibular Joint Intra-Articular Steroid Injection on Synovial Enhancement in Juvenile Idiopathic Arthritis

PURPOSE

To quantify the effect of intra-articular steroid injections (IASIs) on temporomandibular joint (TMJ) synovitis in children with juvenile idiopathic arthritis (JIA) using gadolinium-enhanced magnetic resonance imaging (MRI).

MATERIALS AND METHODS

The present study was a retrospective study of children with JIA who had undergone TMJ IASIs at Boston Children's Hospital. The patients were included if they had undergone contrast-enhanced MRI both before and after IASI and if the pre-IASI MRI had demonstrated synovitis (enhancement ratio [ER] >1.55). Patients with TMJ pathology or pain unrelated to JIA or a history of facial trauma were excluded. The predictor variables were age, gender, JIA subtype, exposure to medications for arthritis, and a family history of autoimmune disease. The primary outcome variable was the ER. Additional outcome variables included patient-reported pain and the maximal incisal opening (MIO).

RESULTS

Twenty-nine subjects (83% female) with a total of 50 injected TMJs were included. The average age at JIA diagnosis and at IASI was 6.8 ± 1.7 years and 12.1 ± 1.9 years, respectively. The mean follow-up period was 22.9 ± 4.3 months (range 5 to 48). The ER decreased in all injected joints, with a mean reduction of 1.05 ± 1.01 (P < .001). The post-IASI ER was less than the normal threshold (1.55) in 18% of the injected TMJs. IASI was associated with an elimination of pain in 89% of the subjects (P < .001) and in augmentation of the MIO by 5.8 ± 2.6 mm (P < .001).

CONCLUSIONS

In children with JIA and TMJ synovitis, TMJ IASI was associated with a reduction in synovial enhancement, decreased pain, and an increased MIO. Only 18% of injected joints, however, experienced complete resolution of synovitis. These results support the use of IASI in the management of the pain and dysfunction associated with TMJ synovitis. Further study is required to determine the efficacy of IASI in limiting inflammation and future joint destruction.

Ultrasound in juvenile idiopathic arthritis

BACKGROUND

In the recent years, musculoskeletal ultrasound (MSUS) has been regarded as especially promising in the assessment of juvenile idiopathic arthritis (JIA), as a reliable method to precisely document and monitor the synovial inflammation process.

MAIN CONTENT

MSUS is particularly suited for examination of joints in children due to several advantages over other imaging modalities. Some challenges should be considered for correct interpretation of MSUS findings in children, due to the peculiar features of the growing skeleton. MSUS in JIA is considered particularly useful for its ability to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, for the definition of remission, as guidance to intraarticular corticosteroid injections and for capturing early articular damage. Current evidence and applications of MSUS in JIA are documented by several authors. Recent advances and insights into further investigations on MSUS in healthy children and in JIA patients are presented and discussed in the present review.

CONCLUSIONS

MSUS shows great promise in the assessment and management of children with JIA. Nonetheless, anatomical knowledge of sonographic changes over time, underlying immunopathophysiology, standardization and validation of MSUS in healthy children and in patients with JIA are still under investigation. Further research and educational efforts are required for expanding this imaging modality to more clinicians in their daily practice.

Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management

The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.

Juvenile idiopathic arthritis and the temporomandibular joint: A comprehensive review

Juvenile idiopathic arthritis is the most common inflammatory rheumatic disease of childhood and represents a series of chronic inflammatory arthritides of unknown cause. Involvement of the temporomandibular joint has been reported in up to 87% of children with juvenile idiopathic arthritis when based on magnetic tomography imaging; it can be asymptomatic and may lead to severe long term complications. In this review a summary of the contemporary literature of imaging of the temporomandibular joint in children with juvenile idiopathic arthritis will be provided, including ultrasound which is a valuable method for guided joint injections, but does not necessarily allow detection of acute inflammation, cone beam computed tomography, which has emerged as a feasible and accurate low-dose alternative as compared to conventional computed tomography to detect destructive change, and magnetic resonance imaging which is considered the method of choice for assessing acute, inflammatory change, although the lack of normative standards remains a challenge in children.

Temporomandibular joint steroid injections in patients with juvenile idiopathic arthritis: an observational pilot study on the long-term effect on signs and symptoms

BACKGROUND

Temporomandibular joint (TMJ) inflammation in patients with juvenile idiopathic arthritis (JIA) can lead to orofacial pain and malfunction of the TMJ. Intra-articular corticosteroid injections (IACI) have been suggested as a treatment modality against TMJ arthritis-related orofacial signs and symptoms. However, knowledge of the effect-durability of these injections remains unanswered. The aim of this pilot study was to evaluate the short and long-term effects of IACI on orofacial symptoms in a prospective observational study based on pre-specified clinical examination standards.

METHODS

Thirteen patients with JIA and arthritis-related orofacial signs and symptoms were included in this prospective pilot study (median 17.2 years, IQR 15-18.4 years). All patients received TMJ IACI (11 bilateral and two unilateral) due to an insufficient response to previous pain-management treatments. Three standardized clinical examinations were carried out: T1 prior to treatment, T2 short-term follow-up (mean 34 days post-treatment), T3 long-term follow-up (mean 333 days post-treatment).

RESULTS

Significant pain reduction was observed at the short-term follow-up (T2). Resolution of orofacial pain after IACI was a rare finding at T2. Generally, the pain significantly worsened between T2 and T3 examinations. The reported pain levels rose between T2 and T3 indicating a loss of effect of the IACI at the long-term follow-up examination (T3). Non-significant improvements in TMJ mobility were observed at T2 and T3.

CONCLUSION

Our results suggest a palliative (not curative) effect of IACI for TMJ arthritis-related orofacial symptoms in patients with long-term orofacial pain complaints. The short-term improvements in signs and symptoms were partly resolved at the long-term follow-up.

Magnetic Resonance Imaging Findings following Intraarticular Infliximab Therapy for Refractory Temporomandibular Joint Arthritis among Children with Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate the involvement of intraarticular (IA) infliximab (IFX) in the management of temporomandibular joint (TMJ) arthritis associated with juvenile idiopathic arthritis (JIA) that is refractory to systemic treatment and IA corticosteroid therapy.

METHODS

Ours was a retrospective study of children with JIA who received IA IFX into the TMJ. The effectiveness of treatment on the progression of acute and chronic changes was assessed by a quantitative magnetic resonance imaging scoring system.

RESULTS

Median acute and chronic scores worsened by 0.25 and 0.75, respectively. In multivariate analysis, worsening acute scores and passage of time predicted worsening of the chronic scores.

CONCLUSION

IA IFX allowed for progression of refractory TMJ arthritis in most but not all children with JIA.

EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice

To develop evidence based points to consider the use of imaging in the diagnosis and management of juvenile idiopathic arthritis (JIA) in clinical practice. The task force comprised a group of paediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Eleven questions on imaging in JIA were generated using a process of discussion and consensus. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, scintigraphy and positron emission tomography. The experts used the evidence obtained from the relevant studies to develop a set of points to consider. The level of agreement with each point to consider was assessed using a numerical rating scale. A total of 13 277 references were identified from the search process, from which 204 studies were included in the systematic review. Nine points to consider were produced, taking into account the heterogeneity of JIA, the lack of normative data and consequent difficulty identifying pathology. These encompassed the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission. Level of agreement for each proposition varied according to the research evidence and expert opinion. Nine points to consider and a related research agenda for the role of imaging in the management of JIA were developed using published evidence and expert opinion.

Signs and symptoms after temporomandibular joint washing and cannula placement assessed by cone beam computerized tomography

OBJECTIVE

Analyses of temporomandibular joint synovial fluid using the hydroxocobalamin push-pull technique are increasingly used. However, objective complications and subjective experiences from this procedure have not been described. Firstly, this study aimed to describe discomfort and potential side-effects of this method with special emphasis on symptoms related to the arthrocentesis to be used for future patient information and Ethical Committee applications. Secondly, this study aimed to evaluate the use of cone beam computed tomography (CBCT) as control of intra-capsular cannula placement.

METHODS

Twenty healthy, young adult volunteers were included. Extensive objective and subjective questionnaires were completed before and 14 days after the synovial fluid sampling. With the cannula inside the joints a CBCT was done to investigate if this procedure can be used to verify intra-capsular cannula position.

RESULTS

The subjective findings: Most subjects did experience mild pain or discomfort post-operatively. In 12 of 20 subjects symptoms had resolved after 2 days and no subjects had symptoms for more than a week. The longer lasting symptoms were mainly transient joint sounds on mandibular movement. Objective findings: 14 days after the sampling mandibular protrusion had improved 1 mm, but all other objective measures were equal compared to baseline. CBCT showed a large variation in cannula position and no conclusions could be drawn from this.

CONCLUSION

The hydroxocobalamin push-pull synovial fluid sampling may cause minor, transient symptoms. CBCT does not seem to provide any clinical benefits concerning the correct cannula position in relation to the upper joint compartment and disc.

Magnetic Resonance Imaging Assessment of Temporomandibular Joint Involvement and Mandibular Growth Following Corticosteroid Injection in Juvenile Idiopathic Arthritis

OBJECTIVE

To assess whether intraarticular corticosteroid injection (CSI) reduces inflammation of the temporomandibular joint (TMJ), prevents growth disturbances of the mandibular condyle, and restores normal growth of the mandibular ramus.

METHODS

Retrospective longitudinal magnetic resonance imaging (MRI) evaluation of inflammatory activity, TMJ deformity, and mandibular ramus height in 33 children (23 girls, median age 5.2 yrs) over a median period of 5 years following repetitive CSI to the TMJ.

RESULTS

Intraarticular location of CSI led to inflammatory grade improvement in 53% at first MRI followup compared to 20% with extraarticular location (p = 0.005), with more improvement of the mean inflammatory grade after intraarticular CSI (p = 0.001). Rate of osseous deformities of the TMJ deteriorated from 51% at study inclusion to 62% at end of observation period, with progression to severe condylar destruction in 26% of joints including 24% with development of intraarticular calcifications/ossifications. Mean short-term growth rates of the mandibular ramus were negative for intraarticular CSI while positive for extraarticular CSI (p = 0.036). Mean longterm mandibular ramus growth rate (0.7 ± 0.8 mm/yr) after CSI was significantly lower than reported normal mean age- and sex-matched growth rate (1.4 ± 0.1 mm/yr, p < 0.0001).

CONCLUSION

Despite improving the inflammatory activity as seen on MRI, repetitive CSI to the TMJ does not reach the treatment goals to prevent progressive osseous deformation and to normalize mandibular ramus growth in children with juvenile idiopathic arthritis.

The diagnostic value of high-resolution ultrasonography for the detection of anterior disc displacement of the temporomandibular joint: a meta-analysis employing the HSROC statistical model

The study aimed to assess the diagnostic value of high-resolution ultrasonography (HR-US) in the detection of anterior disc displacement (ADD) of the temporomandibular joint. Relevant trials reported in MEDLINE, the Chinese National Knowledge Infrastructure Database, the Chinese Biomedical Literature Database, and Embase were identified. A manual search was also performed. The quality of retrieved data was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. Data were extracted and cross-checked, and a statistically rigorous meta-analysis was performed using a hierarchical summary receiver operating characteristic model (HSROC). The clinical utility of results was assessed using Fagan nomograms (Bayes theory). All data were evaluated using Stata software. A total 11 studies including 1096 subjects were included in the analysis; all reported the utility of HR-US for the diagnosis of ADD with reduction (ADDWR) and without reduction (ADDWoR). For ADDWR, the weighted sensitivity and specificity were 0.83 (95% confidence interval (CI) 0.78-0.88) and 0.85 (95% CI 0.76-0.92) respectively. The lambda value was 3.41 (95% CI 2.37-4.46) and the Fagan nomogram pre-test probability 58%, with a positive likelihood ratio (LR) of 6.01. The positive post-test probability was 89%, with a negative LR of 0.20. The negative post-test probability was 21%. The positive increase in diagnostic utility was 31% and the negative decrement in that value 37%. For ADDWoR, the weighted sensitivity and specificity values were 0.72 (95% CI 0.59-0.81) and 0.90 (95% CI 0.86-0.93), respectively. The lambda value was 3.69 (95% CI 2.39-4.99) and the Fagan nomogram pre-test probability 38%, with a positive LR of 7.00. The positive post-test probability was 82%, with a negative LR of 0.32. The negative post-test probability was 16%. The increase in diagnostic utility was 44% and the negative decrement in that value 22%. HR-US delivers acceptable performance when used to diagnose ADD, being superior for the detection of ADDWoR than ADDWR, and exhibiting a lower negative diagnostic value in the detection of ADDWoR than ADDWR. HR-US may serve as a new method for the rapid diagnosis of ADD. The method has the advantages of simplicity and low cost. Given the uncertainty in some of the estimated values, more high-quality studies are needed to assess that diagnostic efficacy.

Imaging of juvenile idiopathic arthritis: a multimodality approach

Juvenile idiopathic arthritis (JIA) is a heterogeneous group of diseases characterized by synovial inflammation and is the most common rheumatic complaint in children. To facilitate research and treatment, JIA has been further classified on the basis of the number of joints involved, additional symptoms, family history, and serologic findings. Imaging in patients with JIA has historically relied on radiography, which allows the accurate assessment of chronic changes of JIA, including growth disturbances, periostitis, and joint malalignment. However, radiographic findings of active inflammation are nonspecific, and, in the past, clinical evaluation has taken precedence over imaging of acute disease. Recent advances in disease-modifying therapeutic agents that can help prevent long-term disability in patients with JIA have led to greater emphasis on the detection of early joint-centered inflammation that cannot be accurately assessed radiographically and may not be evident clinically. Both contrast material-enhanced magnetic resonance (MR) imaging and Doppler ultrasonography (US) are well suited for this application and are playing an increasingly important role in diagnosis, risk stratification, treatment monitoring, and problem solving. Contrast-enhanced MR imaging is the most sensitive technique for the detection of synovitis and is the only modality that can help detect bone marrow edema, both of which indicate active inflammation. US is more sensitive than radiography for the detection of synovial proliferation and effusions and is particularly useful in the evaluation of small peripheral joints. The complexity of the temporomandibular and sacroiliac joints limits the usefulness of radiographic or US evaluation, and contrast-enhanced MR imaging is the preferred modality for evaluation of these structures.

Imaging of the temporomandibular joint in juvenile idiopathic arthritis

OBJECTIVE

Temporomandibular joint (TMJ) arthritis in children with juvenile idiopathic arthritis (JIA) is extremely common but frequently asymptomatic. Magnetic resonance imaging (MRI) with contrast remains the gold standard for identifying TMJ arthritis in JIA. A reliable scoring system with published MRI examples of typical acute and chronic TMJ arthritis changes will be invaluable for future prospective treatment trials of TMJ arthritis in JIA.

METHODS

MRIs were collected from routine clinical studies assessing TMJ arthritis in JIA. Representative images were selected for publication to depict acute (synovial fluid, bone marrow edema, and synovial enhancement) and chronic (pannus, disc derangement, and condylar head flattening and erosions) TMJ arthritis findings. A preliminary MRI-based scoring system for assessing degrees of acute and chronic TMJ arthritis was developed and tested for inter- and intrareader reliability.

RESULTS

TMJ MRIs representative of acute and chronic TMJ arthritis in JIA were selected from among thousands taken (>500 TMJ MRI studies annually at Children's of Alabama) since September 2007. Moreover, computed tomography scans depicting select bony changes (osteophyte formation, micrognathia) were chosen for publication. A description of the MRI protocol for assessing TMJ arthritis is included. A preliminary scoring system weighted for degree of acute and chronic TMJ arthritis MRI findings was found to have substantial inter- and intrareader reliability.

CONCLUSION

A published set of MRIs depicting representative acute and chronic changes will help establish a standardized scoring system to assess TMJ arthritis in children with JIA. Future validation will aid in assessing improvement during treatment trials of TMJ arthritis.

Recent advances of ultrasound imaging in dentistry--a review of the literature

Ultrasonography as an imaging modality in dentistry has been extensively explored in recent years due to several advantages that diagnostic ultrasound provides. It is a non-invasive, inexpensive, painless method and unlike X-ray, it does not cause harmful ionizing radiation. Ultrasound has a promising future as a diagnostic imaging tool in all specialties in dentistry, for both hard and soft tissue detection. The aim of this review is to provide the scientific community and clinicians with an overview of the most recent advances of ultrasound imaging in dentistry. The use of ultrasound is described and discussed in the fields of dental scanning, caries detection, dental fractures, soft tissue and periapical lesions, maxillofacial fractures, periodontal bony defects, gingival and muscle thickness, temporomandibular disorders, and implant dentistry.

Can puncture increase the risk of intra-articular adhesion in the temporomandibular joint?

PURPOSE

This study aims to compare the incidence and severity of intra-articular adhesion under arthroscopy between patients with and without a history of joint puncture.

PATIENTS AND METHODS

Eighty-nine patients with internal derangements of TMJ who underwent arthroscopic disc repositioning and suturing surgery from February 2008 to September 2008 were included in this study. Patients were divided into 2 groups based on whether the patient had undergone joint puncture before surgery or not. The diagnosis of intra-articular adhesion was made according to the manifestation under arthroscopy. Incidence and severity of intra-articular adhesion between these 2 groups was compared.

RESULTS

The incidence of intra-articular adhesion in the patients with a history of puncture was 69.23%, which was higher than that in the patients without a history of puncture (24.36%). The difference was statistically significant (P < 0.05). The incidence of severe adhesions in patients with a history of joint puncture was also higher than that in patients without a history of puncture (26.09% vs. 2.56%, P < 0.01).

CONCLUSIONS

Puncture may increase the risk of intra-articular adhesion in patients with internal derangement.

Intra-articular steroid injection for temporomandibular joint arthritis in juvenile idiopathic arthritis: A systematic review on efficacy and safety

OBJECTIVE

To determine the current level of evidence for the use of intra-articular corticosteroid injections (IACI) against temporomandibular joint (TMJ) arthritis in patients with juvenile idiopathic arthritis (JIA) with a particular focus on clinical and radiological improvements and safety profile.

METHODS

A comprehensive electronic search strategy was performed in all major medical databases in February 2012. Studies were selected independently by two reviewers in accordance with a pre-specified protocol and a risk of bias assessment for all included studies.

RESULTS

Ninety-four unique citations were identified of which seven remained after the inclusion criteria were applied and all of these were assessed to have a high risk of bias. The current limited level of evidence suggests potential beneficial properties of IACI in patients with TMJ arthritis-related symptoms and/or MRI-verified signs of TMJ inflammation. Currently, no scientific evidence substantiates the effect of IACI in terms of (I) improving maximal mouth opening capacity significantly, (II) reducing radiological disease progression, (III) normalising/improving mandibular growth, and (IV) increasing efficacy upon repeated injections.

CONCLUSION

The current level of evidence allows only very limited conclusions on the effect of IACI therapy in patients with TMJ arthritis. Knowledge on the long-term impact of IACI on mandibular growth is not available. Future studies designed in accordance with evidence-based standards are needed to allow a more general conclusion on efficacy and safety of this treatment modality in patients with TMJ arthritis.

Safety and efficacy of intra-articular infliximab therapy for treatment-resistant temporomandibular joint arthritis in children: a retrospective study

OBJECTIVE

TM joint (TMJ) arthritis occurs in up to 80% of children with JIA and can result in substantial deformity. TMJ arthritis can be refractory to systemic immunosuppressive therapy and IA CS injections (IACIs). Multiple studies have shown the benefit of IA infliximab injections (IAIIs) in several different joints, so we used intra-articular infliximab injections (IAIIs) in JIA patients with TMJ arthritis refractory to IACIs. The objective of the study was to test the safety and efficacy of IAII therapy for TMJ arthritis.

METHODS

Retrospective chart review was performed for all children with JIA treated at a single centre who received one or more IAIIs. Outcomes assessed were safety of the injections as well as efficacy as evidenced by maximal incisal opening (MIO) and MRI findings.

RESULTS

Twenty-four children underwent bilateral IAIIs, all of whom had at least one follow-up visit after the final injection. All 24 tolerated the injections without any adverse events. MIOs were unchanged in patients before and after IAII. Findings of acute synovitis were present in 30/46 (65%) TMJs at baseline, 44/48 (92%) following completion of the IACI and 42/48 (88%) following completion of the IAII; findings of chronic synovitis at the three time points were 12/46 (26%), 29/48 (60%) and 38/48 (79%). Resolution of the arthritis was observed in six TMJs.

CONCLUSION

IAII was safe and it reversed the progression of TMJ arthritis in some patients with refractory disease. Future studies will evaluate the efficacy of infliximab vs CS injections as initial therapy for TMJ arthritis.

Towards a role of ultrasound in children with juvenile idiopathic arthritis

US is a powerful tool for the assessment of joint synovitis in children with JIA and has been shown to be more accurate than clinical examination in detecting synovial disease. Recent studies have documented the presence of US-detected synovial pathology in children with JIA in clinical remission. US assessment enables the differentiation of joint synovitis from tenosynovitis, may help detect enthesitis and is valuable for capturing cartilage damage and early bone erosions. Guidance to local injection therapy represents an important application of US in routine care. Although US has a great potential for diffusion among paediatric rheumatologists, several issues need to be addressed. In particular, a thorough knowledge of US anatomy of joints in growing children is necessary to interpret US findings in JIA patients. The present review examines the potential role of US in the assessment of joint disease in children with JIA.