Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what?

Genetic susceptibility to temporomandibular joint involvement in juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition of childhood. Temporomandibular joint (TMJ) is among the most commonly affected joints in JIA patients. When JIA involves the TMJ, it may affect condylar growth in the joint; therefore, JIA patients are at risk of unfavourable long-term outcomes from associated joint damage. If undetected, TMJ involvement can lead to various functional disabilities such as reduced mandibular mobility and disorders of the mastication muscles. Limitations in sagittal and vertical mandibular growth can result in micrognathia and anterior open bite with aesthetic and functional restrictions.

OBJECTIVE

Genetic factors may play a role in determining which individuals are more prone to develop TMJ disorders or in predicting the severity of the disease process. Therefore, we applied a GWAS approach to identify loci associated with TMJ involvement in a sample of Estonian patients with JIA. Our aim was to address the potential role of genetic susceptibility factors in TMJ-JIA, a condition not previously studied in this context.

METHODS

The case group consisted of 55 JIA patients with TMJ involvement and 208 patients without TMJ involvement comprised the control group. The entire cohort was genotyped using the Illumina HumanOmniExpress BeadChip arrays. Imputation was performed using a nationwide reference panel obtained of 2240 individuals whose data were obtained from the Estonian Biobank.

RESULTS

We identified six loci as being associated with the risk of TMJ-JIA in Estonian JIA patients. The strongest associations were identified at CD6 rs3019551 (P = 3.80 × 10-6), SLC26A8/MAPK14 rs9470191 (P = 6.15 × 10-6), NLRP3 rs2056795 (P = 8.91 × 10-6) and MAP2K4 rs7225328 (P = 1.64 × 10-5).

CONCLUSION

This study provides first insights into the risk-associated loci between JIA and its manifestation in the TMJ. The reported loci are involved in molecular pathways of immunological relevance and likely represent genomic regions that render the TMJ susceptible to involvement by JIA in Estonian patients.

A randomized controlled educational study to evaluate an e-learning module to teach the physical examination of the temporomandibular joint in juvenile idiopathic arthritis

BACKGROUND

The aim of the study was to evaluate the effectiveness of a novel e-learning module in teaching the physical exam of the temporomandibular joint (TMJ) in Juvenile idiopathic arthritis (JIA.).

METHODS

An e-learning module was developed to convey the TMJ physical examination maneuvers that are considered to be best practice in JIA. Pediatric rheumatology fellows were randomized to two groups. One group received an article describing the physical examination skills while the second group received both the article and module. All participants completed a written pre-test, an in-person objective structured clinical examination (OSCE), a written post-test, and a follow-up survey.

RESULTS

Twenty-two pediatric rheumatology fellows enrolled, with 11 per group. Written test: The two groups improved equally, although there was a trend toward improved defining of maximal incisal opening (MIO) in the module group. OSCE: The mean OSCE score was 11.1 (SD 3.3) in the article group and 13.5 (SD 1.9) in the module group (p = 0.06); significant differences were seen in measuring MIO (p = 0.01), calculating maximal unassisted mouth opening (MUMO; p = 0.01), and assessment of facial symmetry (p = 0.03), all favoring the module. Enjoyment scores in the module group were higher than in the article group (mean 7.7/10 vs. 5.9/10, p = 0.02). The two groups self-reported performing TMJ examinations at comparable rates three months following the intervention.

CONCLUSIONS

The study demonstrated that a formalized educational program improved knowledge of the physical exam of the TMJ in JIA. Learners viewing the module were more adept at obtaining quantitative TMJ measurements.

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 Interplay of Mitochondrial Dysfunction in Oral Diseases: Recent Updates in Pathogenesis and Therapeutic Implications

Mitochondrial dysfunction is linked to various systemic and localized diseases, including oral diseases like periodontitis, oral cancer, and temporomandibular joint disorders. This paper explores the intricate mechanisms underlying mitochondrial dysfunction in oral pathologies, encompassing oxidative stress, inflammation, and impaired energy metabolism. Furthermore, it elucidates the bidirectional relationship between mitochondrial dysfunction and oral diseases, wherein the compromised mitochondrial function exacerbates disease progression, while oral pathologies, in turn, exacerbate mitochondrial dysfunction. Understanding these intricate interactions offers insights into novel therapeutic strategies targeting mitochondrial function for managing oral diseases. This paper pertains to the mechanisms underlying mitochondrial dysfunction, its implications in various oral pathological and inflammatory conditions, and emerging versatile treatment approaches. It reviews current therapeutic strategies to mitigate mitochondrial dysfunction, including antioxidants, mitochondrial-targeted agents, and metabolic modulators.

Imaging of Juvenile Idiopathic Arthritis

MRI, ultrasound, and conventional radiography each play distinct roles in the evaluation of juvenile idiopathic arthritis (JIA), with MRI being the preferred imaging modality of choice for assessing both inflammatory and destructive changes. These various imaging modalities provide valuable insights into JIA in pediatric patients. However, challenges persist in terms of achieving precision, ensuring validity, and distinguishing between pathologic findings and normal anatomic variations. Establishing normal reference values and implementing scoring systems can aid in the precise evaluation of disease activity and provide information to assist treatment decisions for children with JIA. Ongoing advancements in imaging techniques and standardization initiatives aim to bolster the accuracy of JIA diagnosis and assessment, ultimately leading to enhanced patient care and treatment outcomes.

Cone-Beam Computed Tomography (CBCT) Analysis of Mandibular Condyles' Diameters in Patient with Juvenile Idiopathic Arthritis and Temporomandibular Joint Affection: A Cross-Sectional Investigation

Objectives: The aim of this study was to evaluate through analysis using CBCT the transverse and axial diameters of the mandibular condyles in subjects affected by juvenile idiopathic arthritis (JIA) and compare them with those of healthy subjects. Methods: The study was conducted on CBCT scans from the digital archive of the Department of Biomedical Surgical and Dental Sciences, University of Milan, including patients with JIA and using healthy subjects as controls. Inclusion criteria: aged between 7 and 25 years old at the time of the CBCT examination; Caucasian ethnicity; diagnosis of JIA according to the International League of Associations for Rheumatology (ILAR) criteria documented in patients' records; TMJ involvement; good quality CBCTs covering our region of interest (ROI), from the glabella to the mandibular inferior border; no previous orthodontic/orthopedic treatment; no history of craniofacial trauma or congenital birth defects involving the craniofacial area. Each CBCT scan underwent examination using 3Diagnosys® software. Since data were normally distributed, parametric tests were used for analysis. The sample was divided into three groups: (1) bilateral JIA subjects, (2) unilateral JIA subjects, and (3) healthy controls. Results: We found a statistically significant reduction (p < 0.0001) in the transverse diameter (TR-Diam) of the affected condyles by an average of 1.7 mm, while the axial diameter (AX-Diam) again showed a slight reduction, on average by 0.1 mm, with a non-statistically significant value. Another comparison was made between the unaffected condyles of patients with unilateral JIA and the healthy condyles of the control group. The unilateral unaffected condyles were found to be slightly smaller than those of healthy patients, but without statistically significant differences. We found that in both JIA males and females, the condylar growth tends to stop earlier than the healthy ones. Conclusions: The transverse diameter was found to be more affected than the axial one, causing typical bone resorption and condylar shape. Moreover, we showed that the pathology, in the case of unilateral JIA, does not compromise only the affected condyles; the corresponding condyle that seems to be healthy is actually partially compromised. In addition, we observed that the growth of affected condyles of JIA subjects tends to stop earlier than the condyles of the healthy controls.

Asymptomatic intraspinal epidermoid cyst in a 7-year-old male with juvenile idiopathic arthritis identified by an advanced physiotherapist practitioner: a case report

BACKGROUND

Pediatric intraspinal epidermoid cysts are rare with potential to cause life-altering outcomes if not addressed. Reports to date describe symptomatic presentations including loss of bladder or bowel function and motor and sensory losses. This case report identifies the diagnostic challenge of an asymptomatic intraspinal epidermoid cyst in the cauda equina region presenting in a 7-year-old male with juvenile idiopathic arthritis (JIA).

DIAGNOSIS

An advanced physiotherapist practitioner assessed and diagnosed a previously healthy 7-year-old-male of South Asian descent with JIA based on persistent knee joint effusions. Complicating factors delayed the investigation of abnormal functional movement patterns, spinal and hip rigidity and severe restriction of straight leg raise, all atypical for JIA. Further delaying the diagnosis was the lack of subjective complaints including no pain, no reported functional deficits, and no neurologic symptoms. A spinal MRI investigation 10-months from initial appointment identified intraspinal epidermoid cysts occupying the cauda equina region requiring urgent referral to neurosurgery.

DISCUSSION

Clinical characteristics and pattern recognition are essential for diagnosing spinal conditions in pediatric populations. Diagnostic challenges present in this case included co-morbidity (JIA), a severe adverse reaction to treatment, a lack of subjective complaints and a very low prevalence of intraspinal epidermoid cysts.

IMPACT STATEMENTS

Early signs of pediatric asymptomatic intraspinal epidermoid cysts included abnormal functional movement patterns, rigidity of spine, severely limited straight leg raise and hip flexion without pain. Advanced physiotherapist practitioners can be integral to pediatric rheumatology teams considering their basic knowledge in musculoskeletal examination and functional mobility assessment when identifying rare spinal conditions that present within the complex context of rheumatic diseases.

Temporomandibular involvement in children and adolescents with juvenile idiopathic arthritis: a 2-year prospective cohort study

This study aimed to clinically evaluate temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) and the ability to identify and/or predict development of TMJ-deformities over time using cone beam computed tomography (CBCT). The predictive value of self-reported TMJ pain was also assessed. A prospective longitudinal cohort study comprising 54 children with JIA, 39 girls and 15 boys, was performed. All children had active disease at baseline, 50% with the subtype oligoarthritis. Repeated clinical orofacial and CBCT examinations were performed over a two-year period. At baseline, 39% had radiographic TMJ deformities (24% unilateral, 15% bilateral), at 2-year follow-up, 42% (p > 0.05). Both progressing and improving TMJ deformities were observed. An association was found between TMJ-deformities and self-reported TMJ pain at baseline (p = 0.01). Maximum unassisted mouth opening (MUO) was smaller for children with TMJ-deformities (p < 0.05). The prevalence of palpatory muscle pain was high (48-59%) but not predictive of development of TMJ-deformities. TMJ noises increased over time and crepitations were associated with TMJ-deformities (p < 0.05). In conclusion, in children with JIA, self-reported TMJ pain and dysfunction were common and predictive of TMJ deformities. TMJ deformities were associated with smaller MUO and palpatory TMJ pain as well as crepitations. Trial registration. ClinicalTrials.gov Protocol id: 2010/2089-31/2.

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.

Clinically Established Temporomandibular Involvement in Adults With Juvenile Idiopathic Arthritis

OBJECTIVE

To study clinical variables defining temporomandibular function in adults with juvenile idiopathic arthritis (JIA) and healthy controls.

METHODS

In this cross-sectional study, the temporomandibular joint (TMJ) screening protocol, mandibular range of motion (MROM), and anterior maximum voluntary bite force (AMVBF) were compared between adults with JIA and healthy controls. Unadjusted and adjusted models with corrections for sex and disease duration were constructed for active maximum interincisal mouth opening (AMIO) and AMVBF.

RESULTS

A total of 100 adults with JIA and 59 healthy adults were included in this study. In adults with JIA, 56% had clinically established TMJ involvement. AMIO was the MROM variable most reduced by TMJ involvement; AMIO was 8.8 mm (95% CI -11.40 to -6.12; P < 0.001) less in adults with JIA with TMJ involvement compared to JIA without TMJ involvement. No differences of AMIO were found between healthy adults and adults with JIA without TMJ involvement (-2.52, 95% CI -5.13 to 0.10; P = 0.06). Male sex was associated with a higher AMIO, and disease duration was associated with a decreased AMIO. Collinearity between the subtype prebiologic era and disease duration was found. AMVBF did not differ between adults with JIA and healthy adults.

CONCLUSION

The high prevalence of clinically established TMJ involvement in adults with JIA indicates the need for awareness of TMJ problems in adults with JIA. TMJ involvement negatively influenced AMIO and should therefore be part of the TMJ screening in adults with JIA. AMVBF seems to have less utility for TMJ screening in adult populations.

Photobiostimulation conjugated with stem cells or their secretome for temporomandibular joint arthritis in a rat model

BACKGROUND

Temporomandibular joint (TMJ) arthritis is a debilitating, challenging condition and different methods have been implicated for its treatment. This study aimed to test the therapeutic potentials of low-level laser therapy (LLLT) associated with adipose derived stem cells (ADSC) or their derived secretome on a murine model induced arthritis.

METHODS

Forty eight rats were divided into four groups where group I was the sham control, the rest of animals were subjected to arthritis induction using complete Freund's adjuvant, then divided as follows: group II received phosphate buffered saline (PBS) intraarticular injection and irradiation of 0 j/cm2, group III received ADSCs derived secretome and irradiation of 38 j/cm2, and group IV received ADSCs and irradiation of 38 j/cm2 as well. One and three weeks after treatment, animals were euthanized, and paraffin blocks were processed for histological assessment by hematoxylin and eosin stain with histomorphometrical analysis. Histochemical evaluation of joint proteoglycan content was performed through toluidine blue stain, and immunohistochemical staining by the proinflammatory marker tumor necrosis factor-α (TNF-α) was performed followed by the relevant statistical tests.

RESULTS

The arthritis group showed histological signs of joint injury including cartilage atrophy, articular disc fibrosis, irregular osteochondral interface, and condylar bone resorption together with high inflammatory reaction and defective proteoglycan content. In contrast, the treated groups III and IV showed much restoration of the joint structure with normal cartilage and disc thickness. The inflammation process was significantly suppressed especially after three weeks as confirmed by the significant reduction in TNF-α positive immunostaining compared to the arthritic group, and the cartilage proteoglycan content also showed significant increase relative to the arthritic group. However, no significant difference between the results of the two treated groups was detected.

CONCLUSION

LLLT conjugated with ADSCs or ADSCs derived secretome can efficiently enhance the healing of arthritic TMJs. Stem cell secretome can be applied as a safe, potent therapy. However, further investigations are required to unravel its mechanism of action and pave its way as a safe, novel, cell free therapy.

Comparison between ultrasound and magnetic resonance imaging of the temporomandibular joint in juvenile idiopathic arthritis: A systematic review

OBJECTIVES

The objectives of this systematic review were to evaluate the correlation between Ultrasound (US) and Magnetic Resonance Imaging (MRI) in patients with JIA and to investigate the association with Temporomandibular Disorders (TMD).

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42022312734). Databases Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature were searched. Eligibility criteria were patients with JIA subjected to diagnostic evaluation using US and MRI. No language restrictions were applied. After duplicate study selection, data extraction and risk of bias assessment according to Cochrane were conducted. Data extraction of patients was conducted by two independent authors.

RESULTS

Five observational studies were included with 217 participants (153 females and 64 males; mean age 11.3 years). The quality of the studies was overall satisfactory. The correlation between US and MRI in children with JIA was 'moderate' in acute arthritis while the chronic arthritis correlated positively in two studies.

CONCLUSIONS

Even if MRI remains the more accurate imaging modality for the detection of TMJ of patients with JIA, US may be useful to early detect pathological conditions and to address the patient with JIA and putative TMJ involvement to a more accurate diagnosis with MRI and consequent appropriate treatment management.

CLINICAL RELEVANCE

MRI should be deemed necessary only secondary to less-invasive assessments with US just to confirm the diagnosis or to increase sensitivity, accuracy of positive predictive values detected.

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.

Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis: The Results from a Retrospective Cohort Tertial Center Study

Our study aimed to evaluate the clinical and laboratory features of juvenile idiopathic arthritis (JIA) children with temporomandibular joint (TMJ) arthritis. In the retrospective cohort study, we analyzed data of 753 patients with JIA aged 2-17 years, depending on TMJ arthritis or not. TMJ arthritis can to be diagnosed in the presence of at least two of the following clinical signs of inflammation: pain in TMJ, jaw opening limitation, jaw opening deviation, and micrognathia. We compared clinical, laboratory, and treatment features in JIA patients depending on the involvement of TMJ. TMJ arthritis was detected in 43 (5.7%) of our patients and associated with a longer course of the disease, polyarticular JIA category, treatment with systemic corticosteroids, and longer achievement of the remission and involvement of cervical spine, hip, and shoulder. Active joints >8 (OR = 14.9, p = 0.0000001), delayed remission >7 years (OR = 3.1; p = 0.0004), delayed hip involvement (OR = 4.6; p = 0.041), hip osteoarthritis (OR = 4.0; p = 0.014), cervical spine arthritis (OR = 10.3, p = 0.000001), and corticosteroid treatment (OR = 2.3, p = 0.0007) were associated with TMJ involvement. Patients with TMJ arthritis require more biologics (OR = 3.2, p = 0.0006, HR = 2.4, p = 0.005) and have decreased probability of remission achievement (p = 0.014). Consequently, TMJ arthritis was associated with a severe disease course. Early biologic treatment and corticosteroid avoidance might decrease TMJ involvement.

Diagnosis of juvenile idiopathic arthritis with asymptomatic involvement of the temporomandibular joint: A case report

Juvenile idiopathic arthritis (JIA) is a broad term that describes a group of heterogeneous rheumatologic diseases, mainly characterized by inflammation in the joints of children and young people up to 16 years of age. Its etiology is still not well understood and the diagnosis, essentially clinical, begins with the exclusion of other joint diseases. When the disease affects the temporomandibular joint, diagnosis is a challenge, as many patients are asymptomatic. The objective of this paper is to present a case of JIA with severe involvement of the temporomandibular joint and to discuss the clinical, radiographic, laboratory findings and the importance of early diagnosis. The lack of diagnosis of active arthritis in the temporomandibular joint in patients with JIA can cause irreversible effects such as micrognathia, malocclusion and reduced maximum mouth opening. Early diagnosis of temporomandibular joint involvement in JIA is important and needs to be investigated early in the clinical manifestation of systemic disease. Laboratory tests and clinical history are important to define treatment and prognosis, but not to predict temporomandibular joint arthritis. Imaging exams are important diagnostic tools to identify morphological changes in soft and hard tissues of the temporomandibular joint.

Reliability and measurement error of anterior maximum voluntary bite force in children with juvenile idiopathic arthritis and healthy children

In children with juvenile idiopathic arthritis (JIA) the temporomandibular joint (TMJ) can be involved. As a consequence, the oral function can be impaired due to joint and/or muscle involvement of the masticatory system with a negative influence on the maximum bite force. The aim of this cross-sectional study was to establish the reliability of AMVBF in children with JIA and healthy children. Children with JIA and healthy children conducted three attempts of AMVBF. The reliability of AMVBF measurement was determined by the intra-class correlation coefficient (ICC) by age, standard error of measurement (SEM), smallest detectable change (SDC), and limits of agreement (LoA). A total of 298 children with JIA and 168 healthy children were examined. The AMVBF measurements showed an good to excellent reliability in children with JIA based on the ICCs corrected for age (0.782-0.979). In healthy children, the reliability was moderate to excellent (0.546-0.999). The SDC in our study indicated that values above 11.4N might be a clinical relevant change over time in children with JIA. The LoA showed a wide spread of variability in both children with JIA (-72.6-44.4N) and healthy children (-79.9-72.8N). The Bland-Altman plots indicated that the differences between the test and retest increased in value proportionally to the biteforce value.

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.

Advances in Musculoskeletal Imaging in Juvenile Idiopathic Arthritis

Over the past decade, imaging of inflammatory arthritis in juvenile arthropathies has significantly advanced due to technological improvements in the imaging modalities and elaboration of imaging recommendations and protocols through systematic international collaboration. This review presents the latest developments in ultrasound (US) and magnetic resonance imaging (MRI) of the peripheral and axial joints in juvenile idiopathic arthritis. In the field of US, the ultra-wideband and ultra-high-frequency transducers provide outstanding spatial resolution. The more sensitive Doppler options further improve the assessment and quantification of the vascularization of inflamed tissues, and shear wave elastography enables the diagnosis of tissue stiffness. Concerning MRI, substantial progress has been achieved due to technological improvements in combination with the development of semiquantitative scoring systems for the assessment of inflammation and the introduction of new definitions addressing the pediatric population. New solutions, such as superb microflow imaging, shear wave elastography, volume-interpolated breath-hold examination, and MRI-based synthetic computed tomography open new diagnostic possibilities and, at the same time, pose new challenges in terms of clinical applications and the interpretation of findings.

Modified Delphi study to identify priority clinical questions for the Australian living guidelines for the management of Juvenile Idiopathic Arthritis

BACKGROUND

Juvenile Idiopathic Arthritis (JIA) is the most common rheumatic inflammatory disease in childhood. Optimal management requires clinicians to be up to date with the rapidly evolving evidence base. 'Living' evidence-based clinical practice guidelines, which integrate new evidence as soon as it is available, are a novel method to enhance the translation of research into practice. To determine the most relevant questions that should be prioritised in national Australian JIA living guidelines, we invited Australian and New Zealand paediatric rheumatologists and other relevant health professionals to identify and rank their most important questions in order of priority.

METHODS

All 47 members of the Australian Paediatric Rheumatology Group (APRG) were invited to participate in a modified Delphi study comprising two rounds. The first round identified demographic information of respondents, current attitudes to guideline use and invited submission of priority management questions. The second round asked respondents to rank 27 collated and refined questions identified in round one in order of priority.

RESULTS

There were 29 (62%) and 28 (60%) responses to the first and second survey rounds respectively. About two thirds were rheumatologists or trainees (66, 68%), nearly half had more than 10 years of experience (45, 46%) and practice setting was largely hospital (79, 86%) and urban (86, 75%). Most respondents used clinical guidelines in their practice (72% sometimes, 24% often), most frequently American College of Rheumatology (ACR) (66%) and European Alliance of Associations for Rheumatology (EULAR) (59%) guidelines. Reported barriers to guideline use included that they are not up to date and access difficulties. Most respondents (83%) considered Australian guidelines were necessary and two-thirds indicated they would use them if integrated into practice software. The highest ranked topics were down-titration and discontinuation of disease modifying anti-rheumatic drugs (ranked first), best outcome measures (second) and treatment targets in JIA (third).

CONCLUSIONS

There is strong clinician support for the development of Australian living guidelines for JIA. Consensus was reached on the ten top-ranked priority questions. Our guidelines will develop evidence-based recommendations for these high priority questions that will be updated in real time as needed to facilitate rapid translation of evidence into clinical practice.

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.

An Evaluation of Jaw Tracking Movements in Patients with Total Joint Replacements versus a Control Group

Background and Objectives: One form of treatment for degenerative temporomandibular joint diseases such as osteoarthritis, rheumatic arthritis, TMJ ankylosis, and condylar resorption is total joint replacement. The aim of this study was to examine the function of the temporomandibular joint after prosthetic joint replacement. Materials and methods: Fifteen patients with unilateral or bilateral TMJ total joint replacements and 15 healthy controls were evaluated via a SICAT JMT+ device. This non-invasive system measures 3D position and linear movements in all degrees of freedom and allows undisturbed functional mandibular movements to provide a quantitative evaluation. In addition, a TMJ questionnaire consisting of the subjective symptoms was also obtained. To date, no similar studies have been cited in the literature. Results: Mandibular movements after prosthetic joint replacement were recorded during opening, closing, protrusion, and lateral excursive movements and were all significantly decreased compared to those of controls. In the treatment group, the maximum incisal opening was 33.46 ± 5.47 mm, left lateral movement was 1.91 ± 2.7 mm, right lateral movement was 1.74 ± 1.74 mm, and protrusive movement was 2.83 ± 2.05 mm. The p-value comparison study and control group indicated significant difference (p < 0.0001) between the two groups. The study group stated a high level of satisfaction with the total joint replacement. Conclusion: Within the limitations of the study, the following conclusions can be drawn: (1) TMJ replacement patients showed significantly limited jaw movements compared to the control group; (2) a small percentage of TMJ replacement patients still present low levels of pain but improved chewing ability and quality of life.

A 3D CBCT Analysis of Airway and Cephalometric Values in Patients Diagnosed with Juvenile Idiopathic Arthritis Compared to a Control Group

Introduction: The temporomandibular joint (TMJ) is affected in 30–45% of juvenile idiopathic arthritis (JIA) patients, with all JIA subtypes at risk for TMJ involvement. JIA patients with TMJ involvement may present with altered craniofacial morphology, including micrognathia, mandibular retrognathia, a hyperdivergent mandibular plane angle, and skeletal anterior open bite. These features are also commonly present and associated with non-JIA pediatric patients with obstructive sleep apnea (OSA). Materials and Methods: The study was comprised of a group of 32 JIA patients and a group of 32 healthy control subjects. CBCT images were taken for all patients and were imported into Dolphin Imaging software. The Dolphin Imaging was used to measure the upper airway volumes and the most constricted cross-sectional areas of each patient. Cephalometric images were rendered from the CBCT data for each patient, and the following cephalometric values were identified: SNA angle, SNB angle, ANB angle, anterior facial height (AFH), posterior facial height (PFH), mandibular plane angle (SN-MP), FMA (FH-MP), overjet (OJ), and overbite (OB). Airway volumes, the most constricted cross-sectional area values, and cephalometric values were compared between the JIA and control groups. Results: For airway values, statistically significant differences were seen in the nasopharynx airway volume (p = 0.004), total upper airway volume (p = 0.013), and the most constricted cross-sectional area (p = 0.026). The oropharynx airway volume was not statistically significant (p = 0.051). For cephalometric values, only the posterior facial height showed a statistically significant difference (p = 0.024). Conclusions: There was a significant difference in airway dimensions in the JIA patients as compared to the control patients. In addition, the posterior facial dimensions seem to be affected in JIA patients. The ODDs ratio analysis further corroborated the findings that were significant.

Therapeutic strategies for treating juvenile idiopathic arthritis

Recent development of new medications has changed the juvenile idiopathic arthritis (JIA) treatment goal to inactive disease. With numerous options, how does a clinician choose which medication to use? Treatment options may depend on the clinical classification and a new paradigm considers the JIA subtypes in reference to categories of adult inflammatory arthritis; poligo JIA, spondyloarthritis JIA, and systemic JIA that can help guide a clinician in determining treatment options. Treatment strategies such as consensus treatment plans can provide guidance on treatment escalation. However, a treat-to-target strategy using frequent standardized disease activity measurements, shared decision making with the patient, and treatment escalation to achieve the disease activity target can provide a personalized approach to managing JIA.

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.

Juvenile Idiopathic Arthritis: A Review of Novel Diagnostic and Monitoring Technologies

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood and is characterized by an often insidious onset and a chronic relapsing-remitting course, once diagnosed. With successive flares of joint inflammation, joint damage accrues, often associated with pain and functional disability. The progressive nature and potential for chronic damage and disability caused by JIA emphasizes the critical need for a prompt and accurate diagnosis. This article provides a review of recent studies related to diagnosis, monitoring and management of JIA and outlines recent novel tools and techniques (infrared thermal imaging, three-dimensional imaging, accelerometry, artificial neural networks and fuzzy logic) which have demonstrated potential value in assessment and monitoring of JIA. The emergence of novel techniques to assist clinicians' assessments for diagnosis and monitoring of JIA has demonstrated promise; however, further research is required to confirm their clinical utility.

MRI in the Assessment of TMJ-Arthritis in Children with JIA; Repeatability of a Newly Devised Scoring System

RATIONALE AND OBJECTIVES

The temporomandibular joint (TMJ) is commonly involved in children with juvenile idiopathic arthritis. The diagnosis and evaluation of the disease progression is dependent on medical imaging. The precision of this imaging is under debate. Several scoring systems have been proposed but transparent testing of the precision of the constituents of the scoring systems is lacking. The present study aims to test the precision of 25 imaging features based on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Clinical data and imaging were obtained from the Norwegian juvenile idiopathic arthritis study, The NorJIA study. Twenty-five imaging features of the TMJ in MRI datasets from 86 study participants were evaluated by two experienced radiologists for inter- and intraobserver agreement. Agreement of ordinal variables was measured with Cohen´s linear or weighted Kappa as appropriate. Agreement of continuous measurements was assessed with 95% limit of agreement according to Bland-Altman.

RESULTS

In the osteochondral domain, the ordinal imaging variables "loss of condylar volume," "condylar shape," "condylar irregularities," "shape of the eminence/fossa," "disk abnormalities," and "condylar inclination" showed inter- and intraobserver agreement above Kappa 0.5. In the inflammatory domain, the ordinal imaging variables "joint fluid," "overall impression of inflammation," "synovial enhancement" and "bone marrow oedema" showed inter- and intraobserver agreement above Kappa 0.5. Continuous measurements performed poorly with wide limits of agreement.

CONCLUSION

A precise MRI-based scoring system for assessment of TMJ in JIA is proposed consisting of seven variables in the osteochondral domain and four variables in the inflammatory domain. Further testing of the clinical validity of the variables is needed.

Three-dimensional volumetric evaluation of the different mandibular segments using CBCT in patients affected by juvenile idiopathic arthritis: a cross-sectional study

BACKGROUND

There is currently no information on how different mandibular segments are affected by juvenile idiopathic arthritis. The aim of this paper is to assess volumetric differences of different mandibular segments in subjects with unilateral and bilateral JIA and to compare them with non-JIA control volumes.

MATERIALS AND METHODS

Forty subjects with unilateral TMJ involvement and 48 with bilateral TMJ involvement were selected for the case group and 45 subjects with no known rheumatic comorbidities for the control group. The mandible of each subject was divided according to a validated method into different paired volumes (hemimandible, condyle, ramus and hemibody).

RESULTS

The ANOVA test revealed a statistically significant difference in all the groups for condylar and ramus volumes, and the pairwise comparison evidenced a statistically significant higher condylar and ramus volume in the control group (1444.47 mm³; 5715.44 mm³) than in the affected side in the unilateral JIA group (929.46 mm³; 4776.31 mm³) and the bilateral JIA group (1068.54 mm³; 5715.44 mm³). Moreover, there was also a higher condylar volume in the unaffected side in the unilateral JIA group (1419.39 mm³; 5566.24 mm³) than in the bilateral JIA group and the affected side in the unilateral JIA group.

CONCLUSIONS

The affected side of unilateral JIA patients showed statistically significant lower volumes in the hemimandible, in the condyle and in the ramus. The largest total mandibular volume was observed in the control group, followed by the unilateral JIA group and, lastly, by the bilateral JIA group.

Comparison of the condyle-fossa relationship and resorption between patients with and without Juvenile Idiopathic Arthritis (JIA)

INTRODUCTION

The most common disease in pediatric rheumatology is juvenile idiopathic arthritis (JIA). JIA is considered to be an autoimmune disease with an onset before the age of 16. The temporal mandibular joint (TMJ) has been reported to be involved in up to 87% of patients with JIA. Even though substantial research has been conducted on JIA, limited research has studied to understand its effect on the condyle-fossa relationship and to evaluate resorption amount on condyle by using a scoring system.

AIM

The purpose of this study was 1) to compare condyle - fossa relationships in the temporomandibular joint (TMJ), 2) was to score condylar resorption by using a TMJ indexing system in patients with JIA and without JIA.

METHODS

The present retrospective cross-sectional study included cone-beam computed tomography (CBCT) images obtained from the sagittal, coronal, and axial slices. In the multidisciplinary Pediatric Rheumatology Outpatient Clinic at The University of Alabama at Birmingham (UAB) children with JIA are also examined by a group of orthodontists working in the same institute from October 2018 to July 2019. The predictor variable consists of patients with JIA and without JIA. The primary outcome variables are the depth of the mandibular fossa, joint spaces, axial angles, medio-lateral width, and condyle resorption. Other study variables were age and sex. In this study, the measurements obtained from 2 different groups (with JIA and without JIA) are compared using a t-test, where Tukey is utilized to adjust for multiple comparisons. The left and right joints are analyzed separately as the paired t test conducted showed a significant difference between the 2 joints (P < .05).

RESULTS

The study was comprised of 34 patients diagnosed with JIA and 34 healthy subjects. The depth of the mandibular fossa, the anterior joint spaces, the axial angles, and the resorption index showed statistically significant differences between the JIA and healthy groups in both left and right sides (P < .05). However, there was no statistically significant difference in the posterior joint spaces and mediolateral width between JIA and healthy groups in both sides (P > .05).

CONCLUSIONS

The results of our study presented the destructive potential of juvenile idiopathic arthritis by using CBCT. CBCT scanning is a helpful tool in the evaluation of the radiographic result of TMJ.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis: A single tertiary-center experience

OBJECTIVES

To describe the clinical and laboratory characteristic, state the treatment and outcome of patients with juvenile idiopathic arthritis (JIA), and describe temporomandibular joint (TMJ) involvement as observed in a large tertiary center.

METHODS

A retrospective cross-sectional study of children diagnosed with JIA was assessed at King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia (2015-2019), which included a descriptive analysis of children who had TMJ involvement among our study group. Subjects diagnosed with the TMJ arthritis were based either on clinical musculoskeletal examination or using contrast-enhanced MRI.

RESULTS

We reviewed 123 cases with different JIA subtypes (57% females). The most frequent subtype is the oligoarticular (36%). TMJ involvement was found in 16% (n=20/123) of the patients, of whom 45% had Polyarticular JIA. The rheumatoid factor was positive in 25%; antinuclear antibody (ANA) in 45% and none showed positivity to HLAB27. Treatment resulted in complete resolution in 95% of cases, while Micrognathia and obstructive sleep apnea were the complications reported in 5% of cases.

CONCLUSION

TMJ involvement in JIA is not uncommon. Females with polyarticular disease were more frequently affected with TMJ arthritis. Positive ANA could be a risk factor for TMJ involvement, while positive HLAB27 might have some protective effects. Early treatment for TMJ arthritis is essential to avoid possible complications.

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.

MR Imaging of Rheumatic Diseases Affecting the Pediatric Population

This article reviews the application of magnetic resonance imaging (MRI) to pediatric rheumatic diseases. MRI can detect early manifestations of arthritis, evaluate the extent of disease, and monitor disease activity and response to treatment.Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disorder, representing a diverse group of related diseases that share a definition of joint inflammation of unknown origin with onset before 16 years of age and lasting > 6 weeks. JIA may lead to significant functional impairment and is increasingly imaged with MRI to assess for active inflammation as a target for therapy. This is particularly true for juvenile spondyloarthritis that includes multiple subgroups of JIA and primarily involves the spine and sacroiliac joints.Other less common pediatric rheumatic diseases considered here are chronic recurrent multifocal osteomyelitis and collagen vascular diseases including polymyositis, dermatomyositis, scleroderma, and juvenile systemic lupus erythematosus.

Juvenile idiopathic arthritis of the temporomandibular joint - no longer the forgotten joint

Juvenile idiopathic arthritis (JIA) of the temporomandibular joint (TMJ) is common in children, with an increasing awareness of the condition in all healthcare professionals. TMJ involvement presents a challenge in both diagnosis and treatment, as late presentation can still occur as the disease often develops asymptomatically. This can result in facial deformity and/or functional difficulties including obstructive sleep apnoea. Early diagnosis is therefore essential, requiring a high index of clinical suspicion coupled with the judicious use of gadolinium contrast magnetic resonance imaging (MRI). Long-term management is best provided by a multidisciplinary team as patients often need a combination of pharmacological management, surgical interventions, orthodontics, and psychological support. End stage deformity can be treated by different surgical options, each with their own risks and benefits, however recently there is increasing recognition for the role of total alloplastic TMJ replacement. This review focuses on the diagnosis and management of TMJ arthritis and aims to highlight the important role of maxillofacial surgeons in JIA treatment.

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.

Management of juvenile idiopathic arthritis: Preliminary qualitative findings from the National Dental Practice-Based Research Network

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is the most common chronic arthritis in childhood and represents a series of chronic inflammatory arthritides that develop before 16 years of age.

METHODS

In 2020, investigators with an interest in the management of JIA engaged the National Dental Practice-Based Research Network by conducting a preliminary qualitative questionnaire ("Quick Poll") that comprised 6 questions about JIA management.

RESULTS

A total of 604 persons responded. Results suggested that there was an interest in the management of JIA, but many clinicians did not feel that they had the necessary knowledge or experience to treat these patients.

CONCLUSIONS

The study clearly highlights a distinct gap in awareness and understanding of JIA among clinicians polled. Future work in this area should focus on education and awareness across multiple specialties, clinical guidelines for the management of JIA, and a data repository of long-term outcomes.

Comprehensive Management of Rheumatic Diseases Affecting the Temporomandibular Joint

The temporomandibular joint (TMJ) is a synovial joint and thus is vulnerable to the afflictions that may affect other joints in the fields of rheumatology and orthopedics. Too often temporomandibular complaints are seen strictly as dental or orofacial concerns. Similarly, patients with known rheumatic disease may not have their TMJs included in routine screening and monitoring protocols. The purpose of this review is to highlight the rheumatic conditions likely to affect the TMJ and outline medical and surgical management in these patients with a focus on the need for continued patient reassessment and monitoring.

Management of inflammatory temporomandibular joint collapse in children

Juvenile idiopathic arthritis is the most common pediatric rheumatologic condition.( Abramowicz et al., 2016 Jul) 2 The etiology and pathogenesis have not been fully elucidated; a combination of environmental and certain immunogenic factors is suspected. This review will provide current knowledge and concepts of diagnosis and management of children with JIA and TMJ arthritis.

Association between degenerative temporomandibular joint disorders, vertical facial growth, and airway dimension

BACKGROUND

The goal of this study was to determine whether preexisting degenerative temporomandibular joint (TMJ) disorders are associated with hyperdivergent facial phenotype and decreased airway dimensions.

METHODS

Cone-beam computed tomography scans of adult female and male individuals, 16 years of age and older, distributed in a case group defined as those with degenerative temporomandibular joint disorder (dTMJD; n = 31) or controls with normal TMJ findings (n = 242) were included. Odds ratios were calculated based on facial type and gender. Analysis of variance was used to compare the airway volume and cross section and mandibular measurements between the groups.

RESULTS

Condylar, ramus, and mandibular heights were significantly smaller in the case group compared with the control group. The odds of having a long face subject was significantly higher (P < 0.00001) in the dTMJD group than in the control group with 81% of the dTMJD subjects versus 11% of the control group having long vertical facial dimensions. The smallest cross-sectional area of the airway of the dTMJD group was significantly narrower (P < 0.0361) compared with the controls. Within the control group, ramus height and mandibular alveolar housing for central incisors were significantly smaller (P < 0.0001; P < 0.007) in the long face subjects.

CONCLUSIONS

The study shows that a long facial type is associated with findings of degenerative TMJ disorders and related condylar growth disturbances. These degenerative and growth changes may contribute to specific skeletal and dentofacial adaptations resulting in smaller condylar process, mandibular ramus, and body height; thinner alveolar housing at the lower incisor region; and smaller cross-sectional area of the airway.

Temporomandibular Joint Disorders: A Pictorial Review

Temporomandibular joint (TMJ) disorders are commonly encountered in the general population but often ignored or unrecognized. The detection and characterization of lesions has drastically improved over the years due to technological advances in cone beam computed tomography (CBCT) and magnetic resonance imaging (MRI). However, adequate knowledge of the normal imaging appearance on different imaging modalities as well as the broad variety of pathology is required to provide a proper radiologic assessment. This pictorial review focuses on TMJ pathology and its appearance on CBCT and MRI. A short overview of the technical aspects and normal anatomy are provided to round out this complete summary on the subject.

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.

Prosthetic temporomandibular joint reconstruction in a cohort of adolescent females with juvenile idiopathic arthritis

BACKGROUND

Temporomandibular joint (TMJ) arthritis and involvement is commonly seen in Juvenile Idiopathic Arthritis (JIA). Therapy includes conservative measures, but also includes intraarticular corticosteroid injections (IASI) and systemic immunosuppressive therapy. Despite aggressive medical therapy, some patients develop arthritic changes and frank TMJ ankylosis that can result in persistent pain and limitation in range of motion (ROM). A surgical option is prosthetic TMJ replacement with concurrent correction of dentofacial deformities, which can be performed simultaneously. The objective of this study was to evaluate the outcomes of prosthetic TMJ replacement in a cohort of adolescent females with JIA and severe TMJ involvement.

METHODS

This is a retrospective case series that took place at one tertiary care center. Patients with a diagnosis of JIA who also underwent alloplastic TMJ replacement were identified through electronic medical record system (EMR) and reviewed. Chart review included analysis of all documents in the EMR, including demographic data, JIA history, surgical complications, ROM of TMJ measured by maximal incisal opening in millimeters (mm) and TMJ pain scores (4-point Likert scale: none, mild, moderate, severe) obtained pre- and postoperatively.

RESULTS

Five female patients, ages 15-17 year when TMJ replacement was performed, had nine total joints replaced with a post-operative follow-up period of 12-30 months. All patients had polyarticular, seronegative JIA and were treated with IASI and multiple immunosuppressive therapies without resolution of TMJ symptoms. One patient had bilateral TMJ ankylosis. Three of the five patients demonstrated significant dentofacial deformities, and all underwent simultaneous or staged orthognathic surgery. All patients had improvement in TMJ pain with most (80%) reporting no pain, and all had similar or improved ROM of their TMJ postoperatively. There was one delayed postoperative infection with Cutibacterium Acnes that presented 15 months after surgery and required removal and reimplantation of prosthesis.

CONCLUSION

The sequelae of TMJ arthritis and involvement from JIA in the adolescent population can be difficult to treat. Current medical therapy can be successful, however, in select cases that develop chronic changes in the TMJ despite extensive medical therapy, early results show that prosthetic joint replacement maybe a reasonable surgical option. With prosthetic joint replacement pain levels were reduced and range of motion was maintained or improved for all patients.

Temporomandibular joint involvement in patients with juvenile idiopathic arthritis: a retrospective chart review

OBJECTIVE

To study the proportion of patients with temporomandibular joint (TMJ) involvement among patients with juvenile idiopathic arthritis (JIA), as well as associated clinical characteristics and signs/symptoms.

METHOD

We performed a retrospective chart review on consecutive patients followed in the Hamburg Centre for Paediatric and Adolescent Rheumatology Eilbek between January 2010 and July 2012. TMJ involvement was diagnosed based on clinical examination; a subgroup of patients was also assessed by magnetic resonance imaging (MRI).

RESULTS

The study included 2413 patients with JIA (52.1% girls, mean age at JIA onset 9.5 years). The most frequent JIA category was oligoarthritis (46.6%), followed by enthesitis-related arthritis (ERA; 38.1%). TMJ involvement was diagnosed in 843/2413 patients (34.9%) (677 MRI-confirmed, four not MRI-confirmed, no MRI examination in 162). Female gender (p = 0.017), higher number of additional joints with active arthritis (p < 0.001), anti-nuclear antibody (ANA) positivity (p = 0.005), higher age (p = 0.020), and oligoarthritis (persistent and extended; p = 0.043) were significantly associated with TMJ involvement. Human leucocyte antigen-B27-positive patients were less likely to have TMJ involvement (p = 0.023). Pain on palpation and pain while chewing were statistically significantly associated with TMJ involvement (p = 0.008 and p = 0.020, respectively).

CONCLUSIONS

Based on our findings, to identify TMJ involvement special attention should be paid to JIA patients with female gender, ANA positivity, and oligoarthritis, as well as those with a higher number of additional joints with active arthritis; and regular examinations of the TMJ should be performed.

Limited Mandibular Movements as a Consequence of Unilateral or Asymmetrical Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis Patients

This study aimed to assess the asymmetry of the lower face and motor dysfunction of the masticatory system resulting from unilateral or asymmetrical bilateral temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) patients. The study consisted of clinical examination and cone beam computed tomography (CBCT) of TMJs. Statistical analysis showed correlations between several factors: facial asymmetry and mandibular lateral deviation; the direction of mandibular deviation and the degree of radiological deformities in TMJs; the child's age at the time of the onset and the range of lateral movement towards the healthy or less destructed joint. In addition, there was a significant difference in ranges of lateral movements; a significantly smaller range was observed for the joint with fewer condylar abnormalities compared to the range in the opposite direction. In JIA children, among the clinical markers of unilateral or asymmetrical TMJ involvement, the asymmetry of the lower face, deviation of the mandible on opening, and an uneven range of mandibular lateral movements deserve attention. The obtained results do not show a relationship between the degree of condylar changes and the asymmetry of the lower face and the presence and degree of mandibular motor dysfunction.

Polyphenols as Potential Agents in the Management of Temporomandibular Disorders

Temporomandibular disorders (TMD) consist of multifactorial musculoskeletal disorders associated with the muscles of mastication, temporomandibular joint (TMJ), and annexed structures. This clinical condition is characterized by temporomandibular pain, restricted mandibular movement, and TMJ synovial inflammation, resulting in reduced quality of life of affected people. Commonly, TMD management aims to reduce pain and inflammation by using pharmacologic therapies that show efficacy in pain relief but their long-term use is frequently associated with adverse effects. For this reason, the use of natural compounds as an effective alternative to conventional drugs appears extremely interesting. Indeed, polyphenols could represent a potential therapeutic strategy, related to their ability to modulate the inflammatory responses involved in TMD. The present work reviews the mechanisms underlying inflammation-related TMD, highlighting the potential role of polyphenols as a promising approach to develop innovative management of temporomandibular diseases.