Dentition status and temporomandibular joint disorders in patients with rheumatoid arthritis

Associations of inflammatory polyarthritis with clinical and radiological findings of temporomandibular disorders

OBJECTIVE

To evaluate the association of different forms of inflammatory polyarthritis with clinical signs of temporomandibular disorders (TMD) and radiological findings in temporomandibular joint (TMJ), based on a nationwide health survey in Finland. The aim was also to assess the presence of clinical and radiological TMD findings in subjects with increased risk for developing rheumatoid arthritis (RA).

MATERIAL AND METHODS

Anationally representative sample included 6331 Finnish adults who participated in the Health 2000 Survey (BRIF8901). Subjects were examined for signs of TMD, findings in panoramic radiograph of TMJ, musculoskeletal health and serology (rheumatoid factor, RF, and anti-cyclic citrullinated peptide, aCCP).

RESULTS

Sixty-four percent of seronegative RAand 60% of seropositive RAsubjects had at least one sign of TMD. While adjusting for confounding factors (gender, age, dentures and smoking history), RAwas significantly associated with crepitation and abnormal radiological findings in TMJ. Seronegative RAwas also associated with restricted mouth opening. Systemic autoimmunity associated with RA("at risk of RA") was not associated with clinical or radiological TMD findings.

CONCLUSIONS

Clinical and radiological findings of TMD are more prevalent among subjects with inflammatory polyarthritis than among the population in general in the Finnish adult population.

Temporomandibular disorders in immune-mediated rheumatic diseases of the adult: A systematic review

OBJECTIVE

To systematically review the literature concerning temporomandibular disorders (TMDs) in immune-mediated rheumatic diseases (IMRDs) of the adult. The temporomandibular joint (TMJ) outcomes used in clinical studies, the prevalence of TMDs in IMRDs and the risk factors for their development were qualitatively synthetized.

METHODS

A literature search on PubMed Central, Embase and Cochrane Library databases was performed for studies including TMJ outcomes in IMRDs patients compared with healthy controls, other rheumatic diseases or in the assessed IMRDs patients after follow-up and treatment. Among the IMRDs of the adult, original articles investigating TMJ involvement in inflammatory polyarthritides and/or autoimmune connective tissue diseases were considered. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS).

RESULTS

Of the 3259 screened abstracts, 56 papers were included in the systematic review. Most of the papers (77%) investigated TMDs in rheumatoid arthritis (RA) with a prevalence of signs and symptoms varying from 8% to 70%. The risk factors for TMDs development in RA were female sex, younger age, anti-citrulline peptide autoantibodies (ACPA) positivity, higher disease activity, cervical spine involvement, cardiovascular and neuropsychiatric comorbidities. Ten papers (18%) evaluated TMDs in spondylarthritides (SpA) reporting a prevalence of symptoms and signs in 12%-80% of patients with higher TMDs prevalence in patients with radiographic spine involvement, skin psoriasis and HLADRB1×01 positivity. Among autoimmune connective tissue diseases (CTDs), systemic sclerosis (SSc) displayed the highest evidence of TMDs patient-reported outcomes (PROs) and clinical findings (20-93%), followed by systemic lupus erythematosus (SLE) in 18-85%, primary Sjogren's syndrome (24-54%) and idiopathic inflammatory myopathies (4-26%). In SSc and SLE, TMDs were more frequent in patients with higher disease activity and duration, correlating with the extent of skin fibrosis in SSc and with renal involvement in SLE.

CONCLUSION

TMDs in IMRDs display a significant relevance in the rheumatological clinical practice even if often misdiagnosed. This burden is epidemiologically important in terms of PROs and clinical findings which correlate with disease activity in RA, SpA, SSc and SLE. The early recognition and multidisciplinary management of TMDs is warranted and should be aimed at hindering the TMJ structural damage maximizing the quality of life of patients.

Prevalence and Severity of Temporomandibular Disorders in Rheumatoid Arthritis Patients

Introduction

The temporomandibular joint (TMJ) is an important joint that plays major functions, including dental occlusion, mastication, and facial expressions. Different diseases can affect the TMJ, including chronic inflammatory arthritis. Rheumatoid arthritis (RA) is the most common inflammatory arthritis worldwide associated with TMJ dysfunction. In this study, we assess the prevalence of TMJ among RA patients based on the Fonseca Anamnestic Index.

Methods

Eighty-one patients with rheumatoid arthritis were interviewed by a trained physician to fulfill the Fonseca Anamnestic Index questionnaire. All participants underwent a medical file review to collect their sociodemographic data, RA duration, co-existing comorbidities, and different lab results.

Result

According to the Fonseca score, 29.6% had no temporomandibular disorder (TMD) among RA patients, while 39.5% had mild TMD. Only 6% had severe TMD. The female sex and increased body weight were associated with TMJ disease. 

Conclusion

The majority of rheumatoid arthritis patients (70%) suffer from some degree of temporomandibular joint disorder. 

Radiographic changes in TMJ in relation to serology and disease activity in RA patients

OBJECTIVES

This study was undertaken as an attempt to assess radiographic temporomandibular joint (TMJ) changes in relation to rheumatoid factor (RF), anticitrullinated protein (ACCP) antibodies and disease activity score 28 (DAS28) in rheumatoid arthritis (RA) patients to find the best predictor of rheumatoid affection of the TMJ with the ultimate goal of maintaining TMJ function and preventing joint damage.

METHODS

20 Rheumatoid Arthritis patients as well as 20 volunteers were included in this study. RA group were assessed for RF, ACCP, DAS28. Both groups were assessed by CBCT for TMJ dimensions and radiographic osteoarthritic changes. All data were statistically analyzed.

RESULTS

Rheumatoid Arthritis group showed significantly less condylar height and more radiographic osteoarthritic changes than the control group. RF showed no significant correlation with either TMJ measurements or TMJ radiographic osteoarthritic changes. ACCP showed significant inverse correlation with condylar height and anteroposterior (AP) dimensions, but non-significant relation with mediolateral dimension and radiographic osteoarthritic changes. DAS28 showed significant inverse correlation with condylar AP and mediolateral dimensions. It also showed significant correlation with flattening of the TMJ condylar head and flattening of the articular fossa. Patients with high and moderate disease activity showed significantly smaller AP TMJ dimension than patients with low disease activity. Disease activity showed statistically significant direct correlation with all osteoarthritic changes except for erosions of the glenoid fossa and condyle.

CONCLUSION

Disease Activity Score28 score and disease activity are strong indicators of TMJ affection in RA patients when compared to RF and ACCP. ACCP is a better indicator of changes in condylar measurements than TMJ osteoarthritic changes. While RF is the least efficient indicator of TMJ involvement in RA patients.

Expression of human and Porphyromonas gingivalis glutaminyl cyclases in periodontitis and rheumatoid arthritis-A pilot study

OBJECTIVES

Human glutaminyl cyclases (QC and isoQC) play an important role in maintaining inflammatory conditions. Meanwhile a glutaminyl cyclase synthesized by Porphyromonas gingivalis (PgQC), a key pathogen in developing periodontitis and a potential link of periodontitis with rheumatoid arthritis (RA), was discovered. This study was aimed to determine the expression of QC, isoQC and PgQC in patients with chronic periodontitis (CP) and RA.

DESIGN

Thirty volunteers were enrolled in a pilot study and divided into 3 groups (healthy, CP and RA individuals). Blood samples, biofilm and gingival crevicular fluid (GCF) were analysed for mRNA expression of QC, isoQC and P. gingivalis QC. Major bacteria being associated with periodontal disease were quantified in subgingival biofilm and protein levels for monocyte chemoattractant protein (MCP)-1, MCP-3 and interleukin (IL)-1β) were determined in the GCF. Expression of PgQC on the mRNA and protein levels was assessed in two P. gingivalis strains.

RESULTS

PgQC is expressed in P. gingivalis strains and the protein seems to be located mainly in peri-plasmatic space. mRNA expression of QC was significantly increased in the peripheral blood from RA patients vs. healthy subjects and CP patients (p = 0.013 and p = 0.003, respectively). In GCF of RA patients, QC mRNA was detected more frequently than in healthy controls (p = 0.043). In these samples IL-1β levels were also elevated compared to GCF from periodontally healthy individuals (p = 0.003). PgQC was detected in eight out of the 13 P. gingivalis positive biofilm samples.

CONCLUSION

Activity of QC may play a supportive role in maintaining chronic periodontal inflammation and destruction in RA. PgQC is expressed in vivo but further research is needed to evaluate biological importance of this enzyme and if it constitutes a potential target in periodontal antimicrobial therapy.

Clinical and magnetic resonance imaging findings of the temporomandibular joint in patients with rheumatoid arthritis

Background

The aim of this study is to evaluate temporomandibular joint (TMJ) involvement in patients with rheumatoid arthritis by magnetic resonance imaging (MRI), jaw clenching force, mouth opening, and Fonseca’s questionnaire, and to establish the relationship between these findings and clinical, radiologic, and laboratory activity parameters that are unique to rheumatoid arthritis.

Methods

Included in the study were 30 RA patients and 30 healthy volunteers. Jaw clenching force of the entire cases was measured with Istanbul Bite Force Recorder (kg) and the mouth opening was measured with a ruler (cm). Additionally, hand grip forces of patients with rheumatoid arthritis were measured with hand dynamometer (kg). Hand and feet graphs and TMJ MRIs of patients were obtained. MRI findings were classified as normal, mild, medium, and severe. DAS28 and sharp scores of patients were estimated. Sedimentation rate (ESR), C-Reactive protein (CRP) and rheumatoid factor (RF) were checked in the patient group and Fonseca’s questionnaires were filled in.

Results

A significant difference was not observed between age, gender, and level of education of the groups. Jaw clenching force and mouth opening were established as significantly low in RA group compared to the control group (P < 0.001). A significant correlation was found between jaw clenching force, hand grip force, mouth opening, questionnaire, and MRI findings with the disease duration sharp score, DAS28, and hand grip force of the RA group (P < 0.05). However, a significant correlation was not established with ESR, CRP, and RF (P < 0.001).

Conclusions

Jaw clenching force, mouth opening, and Fonseca’s questionnaire can be used as parameters pointing to TMJ involvement in patients with RA. Yet, further studies in which TMJ involvement is followed up since the onset of the disease are of necessity.

Temporomandibular joint involvement in rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis

The aim of the present study was to estimate the prevalence of temporomandibular joint (TMJ) symptoms and clinical findings in Albanian patients with rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis. The authors examined 124 consecutive hospitalized patients (88 with rheumatoid arthritis, 22 with systemic lupus erythematosus and 14 with systemic sclerosis) and 124 age- and gender-matched healthy controls using a questionnaire and an oro-facial clinical examination for assessing the presence of TMJ sounds, pain in the TMJ area, tenderness of masticatory muscles and limited mouth opening. Significantly more patients (67%) reported TMJ symptoms than controls (19%). A significantly higher proportion of patients (65%) exhibited clinical signs of temporomandibular dysfunction compared with controls (26%). The most frequent findings in rheumatoid arthritis were temporomandibular sounds and pain. Pain was found in a significantly higher proportion in patients with systemic lupus erythematosus compared with controls. Difficulty and limitation in mouth opening were observed in the majority of systemic sclerosis patients, and in only a minority of rheumatoid arthritis patients. This study supports the notion that TMJ examination should be encouraged in the rheumatology setting and clinicians should be able to provide pain management and patient support.

Temporomandibular joint disorders in patients with rheumatoid arthritis

BACKGROUND

Temporomandibular joint disorders (TMD) are not uncommon in patients with rheumatoid arthritis (RA). However, the extent of involvement and its clinical relevance have not been well characterized. This study evaluated the correlation between the severity of RA-related TMD and RA, as well as determined the potential predictors for early identification and management of TMD in RA patients.

METHODS

We sequentially recruited 56 adult RA patients from our Arthritis Clinic. TMD and RA were surveyed, clinically by questionnaires and physical examinations, and radiologically by tomography in TMD and conventional radiography in RA. The patients were stratified into no, mild and severe TMD groups according to the physical and tomographic examinations. The correlation of the severity of TMD and RA were evaluated. The relative importance of relevant predictors of severe TMD was analyzed by a logistic regression model.

RESULTS

Physical and radiologic temporomandibular joint abnormalities were found to be highly prevalent (85.7% and 74.5%) in these patients, and the occurrence increased to as much as 92.9% when the 2 data sets were combined. More than half of the patients had severe TMD presenting with debilitating symptoms or with a significant degree of bony destruction. The severity of TMD was variably correlated with RA severity. The score of hand-joint space narrowing was found to be the most influential predictor of severe TMD by logistic regression analysis.

CONCLUSION

There was a high prevalence of TMD in RA patients. The severity of TMD variably correlated with RA severity. Clinically, a high score of hand-joint space narrowing may serve as an early indicator of RA patients at risk of severe TMD. This may facilitate early management and prevent the functional impairment of the temporomandibular joint.

The long-term effect of anti TNF-α treatment on temporomandibular joints, oral mucosa, and salivary flow in patients with active rheumatoid arthritis: A pilot study

OBJECTIVE

The objective of this study was to evaluate the long-term effects of anti-TNF-alpha treatment on temporomandibular joints (TMJs), oral mucosa, and salivary flow in RA.

STUDY DESIGN

Seventeen patients received infusions of TNF-alpha blocking agents after 0, 2, and 6 weeks, and then every 8 weeks until week 54 (follow-up). Clinical dysfunction index (Di) for the TMJ system, salivary flow, disease activity score (DAS28), and other medical assessments were calculated at weeks 0 and 54.

RESULTS

Median Di was 5.0 (range 0-21) at baseline and 1.0 (range 0-6) (P = .001) at follow-up. Mean salivary flow was 3.2 mL/15 minutes at baseline and 4.6 at follow-up (P = .055). Two (11.7%) of the patients developed oral candidiasis during the period of treatment. The median DAS28 was 6.2 (range, 4.7-7.7) at baseline and 4.1 (range, 1.6-6.8) at follow-up (P = .001).

CONCLUSION

We conclude that anti-TNF-alpha blocking treatments have beneficial effects on oral as well as general manifestations of RA.