Temporomandibular joint damage in juvenile idiopathic arthritis: Diagnostic validity of diagnostic criteria for temporomandibular disorders

Parotid saliva and blood biomarkers in juvenile idiopathic arthritis in relation to temporomandibular joint magnetic resonance imaging findings

BACKGROUND

Juvenile idiopathic arthritis (JIA) often affects the temporomandibular joint (TMJ) caused by an abnormal immune system that includes overactive inflammatory processes. Salivary biomarkers may be a powerful tool that can help establishing diagnosis, prognosis and monitor disease progress.

OBJECTIVE

The objective was to investigate biomarkers in parotid saliva and blood plasma in relation to temporomandibular joint (TMJ) magnetic resonance imaging (MRI) findings in patients with JIA and healthy individuals.

METHODS

Forty-five children aged 6 to 16 years with JIA and 16 healthy age- and sex-matched controls were included. Unstimulated parotid saliva samples and venous blood were collected. Biochemical analyses were performed for the cytokine biomarkers. The participants underwent MR imaging of the TMJs, where changes in the inflammatory and the damage domains were assessed.

RESULTS

In the JIA patients, lower concentrations of IL-6R and gp130 were found in parotid saliva than in plasma. Higher concentrations of IL-6 were found in parotid saliva than in plasma. IL-6, IL-6R and gp130 in parotid saliva explained the presence of bone marrow oedema and effusion in the JIA patients.

CONCLUSIONS

This study suggests that the IL-6 family in parotid saliva is associated with TMJ bone marrow oedema and effusion in patients with JIA, suggesting that IL-6 has promising properties as a parotid saliva biomarker for TMJ inflammatory activity.

The reliability and validity of the juvenile idiopathic arthritis magnetic resonance scoring system for temporomandibular joints

In children with juvenile idiopathic arthritis (JIA), the temporomandibular joint (TMJ) can be involved. To prevent TMJ damage due to inflammation, early recognition is important, for which contrast-enhanced magnetic resonance imaging (MRI) is the gold standard. In this study, the interobserver reliability and construct validity of the Juvenile Idiopathic Arthritis Magnetic Resonance Scoring System for Temporomandibular Joints (JAMRIS-TMJ) was assessed. Two radiologists independently examined 38 MRIs using the JAMRIS-TMJ scoring system. Inter-observer reliability was assessed by Cohen's (weighted) kappa (κ), 95% confidence intervals (CIs) and absolute agreement (%). Construct validity was assessed by correlation between the JAMRIS-TMJ items and TMJ involvement, active maximum interincisal mouth opening (AMIO), and anterior maximum voluntary bite force (AMVBF). The interobserver reliability for the JAMRIS-TMJ items varied from poor to good (κ = 0.18-0.61). Joint enhancement had the highest reliability (κ = 0.61). Correlations were found between TMJ involvement, AMIO, and the JAMRIS-TMJ items, although variation between radiologists and TMJ side existed. No correlation was found between AMVBF and the JAMRIS-TMJ items for both radiologists. The strongest correlations were found between most of the JAMRIS-TMJ items and AMIO. Our findings support the utility of AMIO as a clinical measure of TMJ status in children with JIA.

Prevalence of temporomandibular disorders in juvenile idiopathic arthritis evaluated with diagnostic criteria for temporomandibular disorders: A systematic review with meta-analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a very common systemic inflammatory rheumatic disorder affecting the musculoskeletal system in children below 16 years of age. Joint inflammation and tissue destruction is the prime characteristic of the disease. Along with the systemic involvement in the long joints, several studies are mentioning the increased association of temporomandibular disorders (TMDs) in JIA. This current systematic review intends to find the prevalence rate of TMD in JIA-affected individuals as compared to healthy controls.

METHODS

We have searched in PubMed, Scopus and Ovid SP for articles published between the timeframe 1 January 1990 and 1 June 2023. All the searched articles were subjected to the Population, Exposure, Comparison, and Outcome model (PECO) based on which inclusion or exclusion is carried out. Participants (P) are children below 18 years of age, Exposure (E) is children or adolescents with a diagnosis of JIA, Comparator is age and gender-matched healthy controls who has no JIA or any systemic disorder, Outcome (O) is the prevalence of TMD. Only the studies that evaluated TMD using diagnostic criteria for evaluation of TMD (DC/TMD) were included in the analysis. We have set the exclusion to the following reasons- diagnostic sensitivity studies, case reports, and systematic reviews. The software Review Manager Version 5.4 (Cochrane Collaboration) was used to perform the pooled analysis. We measured the risk ratio (RR) between the two groups (JIA and no JIA) for the outcome TMD.

RESULTS

The pooled total included subjects were 366 in this review with an established diagnosis of JIA as evaluated by DC/TMD. The overall effect of the pooled data suggests that there is a significant difference in the TMD prevalence in the JIA group when compared to the control, results suggest that TMD is more prevalent in the JIA group RR 3.86; 95% CI [2.59, 5.76].

CONCLUSION

Overall, based on the data we can suggest a positive relationship between JIA and TMD, hence presence of JIA can be a risk factor for the development of TMD. The sensitivity of DC/TMD is low when compared to magnetic resonance imaging.

Increase in stress contributes to impaired jaw function in juvenile idiopathic arthritis: a two-year prospective study

BACKGROUND

Stress in patients with Juvenile Idiopathic Arthritis (JIA) has been found to be associated with orofacial pain, psychological distress, jaw dysfunction and loss of daily activities in a cross-sectional study. The aim of this study was to investigate the relations between stress and change of stress over time versus changes in orofacial pain, psychosocial factors and jaw function over a two-year period in patients with JIA.

METHODS

This is a two-year prospective follow-up study involving 40 JIA patients. At baseline (2015) the median age was 12 years and at two-year follow up (2018) 14 years. The JIA patients were examined clinically and with questionnaires at baseline and follow-up with the diagnostic criteria for temporomandibular disorders (DC/TMD) and completed the same set of DC/TMD questionnaires regarding orofacial pain symptoms and psychosocial factors.

RESULTS

Change in stress was associated with change in catastrophizing, psychological distress as well as limitation in general function and jaw function.

CONCLUSIONS

This study emphasizes the importance of maintaining a low stress level in patients with JIA since an increase in stress level over a two-year period seems to impair jaw function as well as psychological distress and catastrophizing.

Management of temporomandibular joint arthritis in children and adolescents: An introduction for orthodontists

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease of childhood. JIA can affect any joint and the temporomandibular joint (TMJ) is one of the joints most frequently involved. TMJ arthritis impacts mandibular growth and development and can result in skeletal deformity (convex profile and facial asymmetry), and malocclusion. Furthermore, when TMJs are affected, patients may present with pain at joint and masticatory muscles and dysfunction with crepitus and limited jaw movement. This review aims to describe the role of orthodontists in the management of patients with JIA and TMJ involvement. This article is an overview of evidence for the diagnosis and treatment of patients with JIA and TMJ involvement. Screening for the orofacial manifestation of JIA is important for orthodontists to identify TMJ involvement and related dentofacial deformity. The treatment protocol of JIA with TMJ involvement requires an interdisciplinary collaboration including orthopaedic/orthodontic treatment and surgical interventions for the management of growth disturbances. Orthodontists are also involved in the management of orofacial signs and symptoms; behavioural therapy, physiotherapy and occlusal splints are the suggested treatments. Patients with TMJ arthritis require specific expertise from an interdisciplinary team with members knowledgeable in JIA care. Since disorders of mandibular growth often appear during childhood, the orthodontist could be the first clinician to see the patient and can play a crucial role in the diagnosis and management of JIA patients with TMJ involvement.

Challenges in treating juvenile idiopathic arthritis

PURPOSE OF REVIEW

Juvenile idiopathic arthritis (JIA) diagnosis and classification is currently still based on clinical presentation and general laboratory tests. Some joints such as the temporomandibular joint (TMJ) and sacroiliac (SI) are hard to assess and define as actively inflamed based on clinical examination. This review addresses these difficult to assess joints and provides the latest evidence for diagnosis and treatment.

RECENT FINDINGS

Recommendations on clinical examination and radiological examination are available. Recent 2021 ACR recommendations were made for TMJ arthritis and in 2019 for sacroiliitis.

SUMMARY

New evidence to guide clinical suspicion and need for further investigations are available for these hard to assess joints. These guidelines will help healthcare providers in diagnosis and treatment assessment.

Pathogenesis and Differential Diagnosis of Temporomandibular Joint Disorders

Temporomandibular disorders (TMDs) are an umbrella term including disorders of the temporomandibular joint and muscles of the masticatory system. They are the most common nonodontogenic cause of pain in the orofacial region. A clear understanding of various conditions, underlying mechanisms, clinical presentation, and examination skills is required to effectively diagnose and manage these patients.

Magnetic resonance imaging texture analysis for quantitative evaluation of the mandibular condyle in juvenile idiopathic arthritis

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease that affects the joints and other organs, including the development of the former in a growing child. This study aimed to evaluate the feasibility of texture analysis (TA) based on magnetic resonance imaging (MRI) to provide biomarkers that serve to identify patients likely to progress to temporomandibular joint damage by associating JIA with age, gender and disease onset age.

METHODS

The radiological database was retrospectively reviewed. A total of 45 patients were first divided into control group (23) and JIA group (22). TA was performed using grey-level co-occurrence matrix (GLCM) parameters, in which 11 textural parameters were calculated using MaZda software. These 11 parameters were ranked based on the p value obtained with ANOVA and then correlated with age, gender and disease onset age.

RESULTS

Significant differences in texture parameters of condyle were demonstrated between JIA group and control group (p < 0.05). There was a progressive loss of uniformity in the grayscale pixels of MRI with an increasing age in JIA group.

CONCLUSIONS

MRI TA of the condyle can make it possible to detect the alterations in bone marrow of patients with JIA and promising tool which may help the image analysis.

Predictability of Maxillary Molar Distalization and Derotation with Clear Aligners: A Prospective Study

Clear aligners are employed daily for the treatment of Class II malocclusions, when a valid option involves distalization and derotation of the upper first and second molars. Evidence regarding the predictability of these movements is slight, and the treatment outcome that clinicians plan may not be achieved. Therefore, the purpose of this study is to assess the accuracy of distalization and derotation with clear aligners. Geomagic Control X, a 3D quality control software, was used to superimpose digital models of the pre-treatment, post-treatment, and virtual plan (ideal post-treatment) measurements of 16 patients (4 M, 12 F; mean age 25.7 ± 8.8 years). Linear and angular measurement tools were used to calculate the amount of tooth movement prescribed and achieved. Distal displacement of the buccal cusps had an overall accuracy of 69% for the first molar and 75% for the second molar. The accuracy of molar derotation was higher for the first molar (77.5%) than for the second molar (62.7%). The aligners were not able to achieve 100% of the ideal post-treatment result; thus, planning of refinements is often needed. However, clear aligners can be regarded as a valuable option for the distalization of first and second molars.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children

BACKGROUND

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed.

OBJECTIVE

The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings.

METHODS

Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children.

RESULTS

The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children.

CONCLUSION

The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Temporomandibular joint in juvenile idiopathic arthritis: magnetic resonance imaging measurements and their correlation with imaging findings

OBJECTIVE

The aim of this study was to investigate the TMJ components in patients with juvenile idiopathic arthritis (JIA) and to compare them with a control group based on magnetic resonance imaging (MRI) measurements.

METHODS

This study comprised an assessment of MRI measurements of 96 temporomandibular joints (TMJ) following classification criteria set by the International League of Associations for Rheumatology (ILAR). Three measurements were considered for study: condyle excursion angle (CEA), height of articular eminence (HAE) and inclination of articular eminence (IAE). All TMJs were assessed by linear measurements made by using the OnDemand 3D software. The comparison between the groups was performed by using Mann-Whitney's test.

RESULTS

Lower measurement values were found for IAE, HAE and CEA in JIA patients (P-values < 0.001, 0.005 and < 0.001, respectively).

CONCLUSION

The study showed the differences in MRI measurements between JIA patients and controls, with the former with the lowest indices.

Electromyographic Activity of Masticatory Muscles in Subjects with Juvenile Idiopathic Arthritis: A Case—Control Study

The aim of this study was to evaluate the effect of juvenile idiopathic arthritis (JIA) on the activity of masticatory muscles using surface electromyography (sEMG). Forty-one JIA subjects (ten males, thirty-one females; average age 13 years ± 3) and thirty-two healthy control subjects (twenty-seven females, five males; average age 14 years ± 2) were recruited. sEMG of anterior temporalis (TA), masseter (MM), and sternocleidomastoid (SCM) muscles was performed by using the occlusal contact analyzer software called Teethan (BTS S.p.A., Garbagnate Milanese, Milan, Italy). Comparisons between groups were assessed with unpaired t-tests for non-normally distributed data and with Mann–Whitney U tests for normally distributed parameters. The JIA group showed a significant increased percentage overlapping coefficient of TA (POC TA) (p = 0.01) and impact index (IMP) (p = 0.003). No significant differences were observed for the POC MM, POC SCM, percentage overlapping coefficient between posterior and anterior teeth contact (BAR), the torsion index (TORS), and the asymmetry index (ASIM). Masticatory muscles seemed to be slightly affected by JIA. sEMG could be an effective aid in the early clinical detection of TMJ involvement in JIA. Further research is needed to confirm its validity.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis-Symptoms, clinical signs and radiographic findings

BACKGROUND

Although many children with juvenile idiopathic arthritis (JIA) develop arthritis and deformity of the temporomandibular joint (TMJ), many go undetected.

OBJECTIVE

This study investigates whether findings from patient history and clinical examination using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) can be used to diagnose TMJ involvement.

METHODS

As a part of the screening program, 59 consecutive JIA patients age 7-14 years underwent a clinical examination according to RDC/TMD including self-reported orofacial pain and pain related to jaw function, and cone beam computer tomography (CBCT). Data were obtained from the patient's medical charts. Patients were divided into two groups based on the presence or absence of TMJ deformities on CBCT.

RESULTS

Self-reported TMJ symptoms before inclusion were reported by 52% of children with and 18% of children without TMJ deformities on CBCT (p = .020). On a group level, the maximum unassisted (mouth) opening (MUO) with and without pain was within the normal range, but children with TMJ deformities showed a significantly smaller MUO with pain (p = .035). A diagnosis of osteoarthritis and osteoarthrosis was more prevalent in children with TMJ deformities.

CONCLUSION

Although there were few differences between children with and without radiographic TMJ deformities, self-reported previous TMJ symptoms and reduced MUO with pain could indicate the presence of TMJ involvement. However, radiographic examinations are needed to confirm TMJ involvement. Thus, this study indicates that the RDC/TMD protocol is a blunt tool when targeting TMJ involvement in JIA.

Reciprocal effects of scleroderma and temporomandibular dysfunction between patient cohorts

OBJECTIVE

To estimate the prevalence of temporomandibular dysfunction in scleroderma patients according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and to correlate it with disease variables.

METHODS

Temporomandibular dysfunction was evaluated in 75 scleroderma patients and 74 healthy controls using DC/TMD. Gastrointestinal symptoms were evaluated through the University of California Los Angeles (UCLA) score in scleroderma patients.

RESULTS

There was no difference of prevalence in temporomandibular dysfunction [30 (40%) vs 30 (40.5%); p > 00.05] between scleroderma patients and healthy controls. Scleroderma patients had a significant reduction in all oral movements compared to healthy controls. Scleroderma patients with temporomandibular dysfunction had a statistically higher score in the UCLA distention/bloating item [1.75 (0.5-2.38) vs 0.75 (0.25-1.75); p < 0.05] than scleroderma patients without temporomandibular dysfunction.

DISCUSSION

Temporomandibular dysfunction prevalence between scleroderma patients and healthy controls is similar. In scleroderma patients, temporomandibular dysfunction reduces oral mobility and opening, which worsens distension/bloating.

In children and adolescents with temporomandibular disorder assembled with juvenile idiopathic arthritis - no association were found between pain and TMJ deformities using CBCT

Background

Children and adolescents with juvenile idiopathic arthritis (JIA) may suffer from temporomandibular disorder (TMD). Due to this, imaging diagnosis is crucial in JIA with non-symptomatic TM joint (TMJ) involvement. The aim of the study was to examine the association between clinical TMD signs/symptoms and cone-beam computed tomography (CBCT) findings of TMJ structural deformities in children and adolescents with JIA.

Methods

This cross-sectional study is part of a longitudinal prospective multi-centre study performed from 2015–2020, including 228 children and adolescents aged 4–16 years diagnosed with JIA, according to the International League of Associations for Rheumatology (ILAR). For this sub-study, we included the Bergen cohort of 72 patients (32 female, median age 13.1 years, median duration of JIA 4.5 years). Clinical TMD signs/symptoms were registered as pain on palpation, pain on jaw movement, and combined pain of those two. The severity of TMJ deformity was classified as sound (no deformity), mild, or moderate/severe according to the radiographic findings of CBCT.

Results

Of 72 patients, 21 (29.2%) had pain on palpation at and around the lateral pole, while 41 (56.9%) had TMJ pain upon jaw movement and 26 (36.1%) had pain from both. Of 141 TMJs, 18.4% had mild and 14.2% had moderate/severe structural deformities visible on CBCT. CBCT findings were not significantly associated with either the pain on palpation or the pain on jaw movement. A significant difference was found between structural deformities in CBCT and the combined pain outcome (pain at both palpation and movement) for both TMJs for the persistent oligoarticular subtype (p = 0.031).

Conclusions

There was no association between painful TMD and CBCT imaging features of the TMJ in patients with JIA, but the oligoarticular subtype of JIA, there was a significant difference associated with TMJ pain and structural CBCT deformities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01870-z.

Assessing the Reliability of the OMERACT Juvenile Idiopathic Arthritis Magnetic Resonance Scoring System for Temporomandibular Joints (JAMRIS-TMJ)

Contrast-enhanced magnetic resonance imaging (MRI) remains the most comprehensive modality to assess juvenile idiopathic arthritis (JIA)-related inflammation and osteochondral damage in the temporomandibular joints (TMJ). This study tested the reliability of a new JIA MRI scoring system for TMJ (JAMRIS-TMJ) and the impact of variations in calibration and reader specialty. Thirty-one MRI exams of bilateral TMJs were scored independently using the JAMRIS-TMJ by 20 readers consisting of radiologists and non-radiologist clinicians in three reading groups, with or without a calibrating atlas and/or tutorial. The inter-reader reliability in the multidisciplinary cohort assessed by the generalizability coefficient was 0.61–0.67 for the inflammatory and 0.66–0.74 for the damage domain. The atlas and tutorial did not improve agreement within radiologists, but improved the agreement between radiologist and non-radiologist groups. Agreements between different calibration levels were 0.02 to 0.08 lower by the generalizability coefficient compared to agreement within calibration levels; agreement between specialty groups was 0.04 to 0.10 lower than within specialty groups. Averaging two radiologists raised the reliability above 0.8 for both domains. Therefore, the reliability of JAMRIS-TMJ was moderate-to-good depending on the presence of specialty and calibration differences. The atlas and tutorial are necessary to improve reliability when the reader cohort consists of multiple specialties.

Mandibular range of motion in children with juvenile idiopathic arthritis with and without clinically established temporomandibular joint involvement and in healthy children; a cross-sectional study

BACKGROUND

Recognition of temporomandibular joint (TMJ) involvement in children with juvenile idiopathic arthritis (JIA) has gained increasing attention in the past decade. The clinical assessment of mandibular range of motion characteristics is part of the recommended variables to detect TMJ involvement in children with JIA. The aim of this study was to explore explanatory variables for mandibular range of motion outcomes in children with JIA, with and without clinically established TMJ involvement, and in healthy children.

METHODS

This cross-sectional study included children with JIA and healthy children of age 6-18 years. Mandibular range of motion variables included active and passive maximum interincisal opening (AMIO and PMIO), protrusion, laterotrusion, dental midline shift in AMIO and in protrusion. Additionally, the TMJ screening protocol and palpation pain were assessed. Adjusted linear regression analyses of AMIO, PMIO, protrusion, and laterotrusion were performed to evaluate the explanatory factors. Two adjusted models were constructed: model 1 to compare children with JIA and healthy children, and model 2 to compare children with JIA with and without TMJ involvement.

RESULTS

A total of 298 children with JIA and 169 healthy children were included. Length was an explanatory variable for the mandibular range of motion excursions. Each centimeter increase in length increased AMIO (0.14 mm), PMIO (0.14 mm), and protrusion (0.02 mm). Male gender increased AMIO by 1.35 mm. Having JIA negatively influenced AMIO (3.57 mm), PMIO (3.71 mm), and protrusion (1.03 mm) compared with healthy children, while the discrepancy between left and right laterotrusion raised 0.68 mm. Children with JIA and TMJ involvement had a 8.27 mm lower AMIO, 7.68 mm lower PMIO and 0.96 mm higher discrepancy in left and right laterotrusion compared to healthy children.

CONCLUSION

All mandibular range of motion items were restricted in children with JIA compared with healthy children. In children with JIA and TMJ involvement, AMIO, PMIO and the discrepancy between left and right laterotrusion were impaired more severely. The limitation in protrusion and laterotrusion was hardly clinically relevant. Overall, AMIO is the mandibular range of motion variable with the highest restriction (in millimeters) in children with JIA and clinically established TMJ involvement compared to healthy children.

Clinical and Instrumental TMJ Evaluation in Children and Adolescents with Juvenile Idiopathic Arthritis: A Case—Control Study

To investigate temporomandibular joint (TMJ) involvement signs such as muscle pain, the ratio of masseter and temporal muscle activity, mouth opening width and jaw deviation during mouth opening in children and adolescents with juvenile idiopathic arthritis (JIA), a group of 32 subjects with JIA and a control group of 32 healthy subjects were evaluated. Data were collected clinically by muscle palpation (masseters, anterior temporalis and sternocleidomastoids) and instrumental analysis (electromyography and kinesiography). Higher pain was registered in the masseter and sternocleidomastoid muscles on both sides and in the right anterior temporalis in the JIA group compared to the control group (p < 0.05). Electromyography showed no statistically significant difference in the frequency of the pathological ratio of masseter and temporal muscle activity (MM/TA < 1) both in the JIA group and in the control group. Kinesiography showed a statistically significant difference in mouth opening width and jaw deviation during mouth opening between the groups (p < 0.05): JIA subjects showed lower mouth opening values and wider deviation on mouth opening; 29 out of 32 JIA subjects showed jaw deviation towards the right side. JIA affects the TMJ, causing myalgia in the head and neck muscles, a reduction in mouth opening width and an increase in jaw deviation during mouth opening.

Diagnostic criteria for temporomandibular disorders (DC/TMD) for children and adolescents: An international Delphi study-Part 1-Development of Axis I

Background

Since in children and adolescence prevalence is assessed mainly on self‐reported or proxy‐reported signs and symptoms; there is a need to develop a more comprehensive standardised process for the collection of clinical information and the diagnosis of TMD in these populations.

Objective

To develop new instruments and to adapt the diagnostic criteria for temporomandibular disorders (DC/TMD) for the evaluation of TMD in children and adolescents.

Method

A modified Delphi method was used to seek international consensus among TMD experts. Fourteen clinicians and researchers in the field of oro‐facial pain and TMD worldwide were invited to participate in a workshop initiated by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM scientific network) at the General Session of the International Association for Dental Research (IADR, London 2018), as the first step in the Delphi process. Participants discussed the protocols required to make physical diagnoses included in the Axis I of the DC/TMD. Thereafter, nine experts in the field were added, and the first Delphi round was created. This survey included 60 statements for Axis I, and the experts were asked to respond to each statement on a five‐item Likert scale ranging from ‘Strongly disagree’ to ‘Strongly agree’. Consensus level was set at 80% agreement for the first round, and at 70% for the next.

Results

After three rounds of the Delphi process, a consensus among TMD experts was achieved and two adapted DC/TMD protocols for Axis I physical diagnoses for children and adolescents were developed.

Conclusion

Through international consensus among TMD experts, this study adapted the Axis I of the DC/TMD for use in evaluating TMD in children and adolescents.

Recent progress in the treatment of non-systemic juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease affecting the joints and other organs that occurs in 1 in 1,000 children in the United States. Given the various categories of JIA, interpretation of the literature can be difficult. In this review, new developments in understanding non-systemic JIA and its treatment will be covered. Recent advances in the journey toward personalized treatment in JIA will be highlighted, including a review of currently available biologic modifiers. Uveitis and the temporomandibular joint will be discussed as particularly challenging treatment issues. Recent guideline updates and literature-guided treatment decisions will be reviewed.

Discrete Choice Experiment on a Magnetic Resonance Imaging Scoring System for Temporomandibular Joints in Juvenile Idiopathic Arthritis

OBJECTIVE

To determine the relative importance weights of items and grades of a newly developed additive outcome measure called the juvenile idiopathic arthritis (JIA) magnetic resonance imaging (MRI) scoring system for temporomandibular joints (TMJ, JAMRIS-TMJ).

METHODS

An adaptive partial-profile discrete choice experiment (DCE) survey using the 1000Minds platform was independently completed by members of an expert group consisting of radiologists and non-radiologist clinicians to determine the group-averaged relative weights for JAMRIS-TMJ. Subsequently, an image-based vignette ranking exercise was done, during which experts individually rank-ordered 14 patient vignettes for disease severity while blinded to the weights and unrestricted to JAMRIS-TMJ assessment criteria. Validity of the weighted JAMRIS-TMJ was tested by comparing the consensus-graded, DCE-weighted JAMRIS-TMJ score of the vignettes with their unrestricted image-based ranks provided by the experts.

RESULTS

Nineteen experts completed the DCE survey and 21 completed the vignette ranking exercise. Synovial thickening and joint enhancement showed higher weights per raw score compared to bone marrow items and effusion in the inflammatory domain, while erosions and condylar flattening showed non-linear and higher weights compared to disk abnormalities in the damage domain. The weighted JAMRIS-TMJ score of the vignettes correlated highly with the ranks from the unrestricted comparison method, with median Spearman's rho of 0.92 (intra-quartile range: 0.87-0.95) for the inflammation and 0.93 (0.90-0.94) for the damage domain.

CONCLUSIONS

A DCE survey was used to quantify the importance weights of the items and grades of the JAMRIS-TMJ. The weighted score showed high convergent validity with an unrestricted, holistic vignette ranking method.

Tuina therapy for temporomandibular joint disorder syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Temporomandibular joint disorders (TMD) is common in clinic at present, which seriously affects the mental health and quality of life of patients. With the development of society, the incidence of TMD is gradually increasing. At present, there are many treatment methods, Tuina as a characteristic traditional Chinese medicine therapy, clinical treatment of TMD has a significant effect. In recent years, there are many clinical studies on Tuina in the treatment of TMD, but the clinical efficacy of Tuina in the treatment of TMD has not been systematically evaluated. In this study, we systematically evaluated the relevant literature of Tuina in the treatment of TMD by using the method of evidence-based medicine, in order to provide reference for clinical research in this direction in the future.

METHODS

VIP Chinese database, China knowledge Network, Wanfang, China Biomedical Database, PubMed, Embase, Cochrane Library and Web of Science were searched for clinical randomized controlled trials of Tuina in the treatment of TMD from the establishment of the database to December 2020. The 2 researchers independently screened the literature and carried out quality assessment and data extraction for the included study, and used RevMan5.3 software for risk assessment and Meta analysis.

RESULTS

In this study, the efficacy and safety of Tuina in the treatment of TMD were evaluated by effective rate, visual analog score (VAS) of temporomandibular joint pain, dysfunction index ((DI), palpation index (PI), craniomandibular index (CMI), maximum mouth opening (MMO), incidence of adverse reactions and so on.

CONCLUSION

This protocol can provide evidence-based basis for the treatment of TMD, with Tuina to significantly improve the symptoms and function of patients with TMD.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/J75A8.

Safety and Effects of the Rapid Maxillary Expander on Temporomandibular Joint in Subjects Affected by Juvenile Idiopathic Arthritis: A Retrospective Study

BACKGROUND

In Juvenile Idiopathic Arthritis (JIA) temporo-mandibular joints are often affected causing skeletal and dental malocclusions. The most frequent condition is mandibular hypoplasia, that may be associated with maxillary hypoplasia. The aim of this retrospective case control study is to investigate the effects and the safety of rapid maxillary expansion (RME) in growing patients affected by JIA. It was evaluated whether RME could be performed without complications on TMJs of JIA patients using DC/TMD protocol, and naso-maxillary transversal parameters were compared with the ones obtained on healthy patients.

METHODS

Twenty-five patients affected by JIA that ceased to manifest TMJ (Temporo-Mandibular Joint) symptoms in the previous year were treated with RME to solve the maxillary transverse hypoplasia. Postero-anterior cephalometric tracings were collected before and after treatment; linear measurements were obtained to study maxillary and nasal cavity modifications. Data were compared to those of a similar group of twenty-five healthy patients. Paired t-test and Independent t-test were used to evaluate changes before and after treatment in each group and to perform a comparison between the groups.

RESULTS

All patients demonstrated a statistically significant increase in nasal cavity width, maxillary width and upper and lower intermolar width. No patients presented a worsening of their TMJs condition. Intragroup comparisons revealed significant changes of cephalometric measurements, but no difference was found when comparing JIA and healthy patients.

CONCLUSIONS

Growing patients with JIA that ceased to show signs of active TMJ involvement for at least one year could be safely treated with RME, expecting similar benefits to those of healthy patients. Dentists and rheumatologists should be informed of safety and potential benefits of palatal expansion in JIA patients in order to improve the outcome of orthodontic treatment and reduce the indication for more invasive procedures (i.e., Surgical Assisted Rapid Maxillary Expansion).

Prevalence of temporomandibular disorder in children and adolescents with juvenile idiopathic arthritis - a Norwegian cross- sectional multicentre study

Background

Children and adolescents with juvenile idiopathic arthritis (JIA) may suffer pain from temporomandibular disorder (TMD). Still, routines for the assessment of temporomandibular joint (TMJ) pain in health and dental care are lacking. The aims of this study were to examine the prevalence of TMD in children and adolescents with JIA compared to their healthy peers and to investigate potential associations between JIA and TMD.

Methods

This comparative cross-sectional study is part of a longitudinal multicentre study performed during 2015–2020, including 228 children and adolescents aged 4–16 years with a diagnosis of JIA according to the ILAR criteria. This particular substudy draws on a subset of data from the first study visit, including assessments of TMD as part of a broader oral health examination. Children and adolescents with JIA were matched with healthy controls according to gender, age, and centre site. Five calibrated examiners performed the clinical oral examinations according to a standardised protocol, including shortened versions of the diagnostic criteria for TMD (DC/TMD) and the TMJaw Recommendations for Clinical TMJ Assessment in Patients Diagnosed with JIA. Symptoms were recorded and followed by a clinical examination assessing the masticatory muscles and TMJs.

Results

In our cohort of 221 participants with JIA and 221 healthy controls, 88 (39.8%) participants with JIA and 25 (11.3%) healthy controls presented with TMD based on symptoms and clinical signs. Painful TMD during the last 30 days was reported in 59 (26.7%) participants with JIA vs. 10 (5.0%) of the healthy controls (p <  0.001). Vertical unassisted jaw movement was lower in participants with JIA than in controls, with means of 46.2 mm vs. 49.0 mm, respectively (p <  0.001). Among participants with JIA, a higher proportion of those using synthetic disease-modifying antirheumatic-drugs and biologic disease-modifying antirheumatic-drugs presented with painful masticatory muscles and TMJs at palpation.

Conclusion

Symptoms and clinical signs of TMD were seen in approximately half of the JIA patients compared to about one fourth of their healthy peers. Painful palpation to masticatory muscles and decreased vertical unassisted jaw movement were more frequent in participants with JIA than among healthy controls and should be part of both medical and dental routine examinations in patients with JIA.

Effects on the Facial Growth of Rapid Palatal Expansion in Growing Patients Affected by Juvenile Idiopathic Arthritis with Monolateral Involvement of the Temporomandibular Joints: A Case-Control Study on Posteroanterior and Lateral Cephalograms

BACKGROUND

Juvenile idiopathic arthritis (JIA) affecting temporomandibular joints (TMJ) in growing patients results in maxillofacial deformities, especially if only one condyle has been affected by the rheumatic disease. Mandibular hypoplasia is the most common issue and it may be associated with maxillary hypoplasia. The aim of this retrospective case-control study is to evaluate the effects of rapid maxillary expansion (RME) in these patients.

METHODS

25 growing patients affected by maxillary hypoplasia, currently in a quiescent phase of JIA for at least one year and monolateral involvement of the TMJs, were treated with RME. Data gathered from posteroanterior and lateral cephalograms before and after 1 year from RME were compared to those of 25 non-JIA controls.

RESULTS

Nasal cavity width, maxillary width and upper and lower intermolar width statistically increased. Maxillary and mandibular symmetry indexes presented a statistically significant increase, so did the skeletal class. No signs or symptoms of TMJ activity of JIA occurred according to Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) criteria. No difference was found when comparing JIA and non-JIA patients apart from the better improvement of several mandibular symmetry indexes in the affected TMJ side of JIA patients. This event is allegedly due to a worse baseline asymmetry in JIA patients that underwent a bigger relative improvement after treatment.

CONCLUSIONS

Results suggest that solving maxillary hypoplasia and, therefore, premature contacts are likely to have allowed mandibular repositioning and condylar growth. RME is a safe and effective solution that can substantially improve maxillary and mandibular symmetry in growing patients affected by JIA with TMJ involvement.

Orofacial pain in juvenile idiopathic arthritis is associated with stress as well as psychosocial and functional limitations

BACKGROUND

The aim of this study was to investigate relations between psychosocial factors, signs and symptoms of orofacial pain and jaw dysfunction in patients with juvenile idiopathic arthritis (JIA).

METHODS

Forty-five patients with JIA (median age 12 years) and 16 healthy matched controls (median age 13 years) were examined according to the diagnostic criteria for temporomandibular disorders (DC/TMD). The subjects answered the DC/TMD questionnaires regarding psychosocial factors (pain intensity, pain-related disability, depression, stress, catastrophizing, pain locations and jaw function).

RESULTS

JIA patients with orofacial pain had higher degree of stress, depression, catastrophizing and jaw dysfunction compared to subjects without. In turn, these factors were associated with orofacial pain intensity. Also, patients with orofacial pain had higher systemic inflammatory activity.

CONCLUSIONS

Orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity appears to be an important factor contributing to orofacial pain in JIA.

Interdisciplinary Management of Dentofacial Deformity in Juvenile Idiopathic Arthritis

Temporomandibular joint (TMJ) arthritis impacts mandibular growth and development. This can result in skeletal deformity, such as facial asymmetry and/or malocclusion asymmetry. This article reviews the unique properties of TMJ and dentofacial growth and development in the setting of juvenile idiopathic arthritis (JIA). Specific orthopedic/orthodontic and surgical management of children with JIA and TMJ arthritis is discussed. The importance of interdisciplinary collaboration is highlighted.

The Psychological Impact of Dental Aesthetics in Patients with Juvenile Idiopathic Arthritis Compared with Healthy Peers: A Cross-Sectional Study

This study aimed to assess whether dental aesthetics had a different impact on the psychosocial domains of adolescents with juvenile idiopathic arthritis (JIA) as compared with healthy peers. Fifty JIA patients and eighty controls aged between 13 and 17 years were enrolled. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) was administered along with tools for the self-assessment of malocclusion and self-esteem. An objective evaluation of malocclusion severity was performed through a clinical evaluation with the Dental Aesthetic Index (DAI). The sample was divided according to the DAI stages of malocclusion severity; a two-way analysis of variance (ANOVA) was performed to assess whether there was a difference in the studied variables according to the malocclusion and the presence of JIA. The results showed no interaction between the malocclusion severity and the presence of JIA in all analyzed variables (all p > 0.05). According to the DAI stages, the Dental Self-Confidence domain of the PIDAQ and the Perception of Occlusion Scale showed statistically significant differences only within the controls (p = 0.027 and p = 0.014, respectively). Therefore, JIA adolescents seem to be less concerned about their dental aesthetics compared with healthy peers, and clinicians should take particular care when proposing orthodontic treatments aiming only to improve dental aesthetics.