Is high-resolution ultrasonography suitable for the detection of temporomandibular joint involvement in children with juvenile idiopathic arthritis?

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 joint involvement in patients with Juvenile Idiopathic Arthritis: comparison of ultrasonography and magnetic resonance imaging in assessing the periarticular space width

OBJECTIVES

This study aimed to compare the performance of Ultrasonography (US) and Magnetic Resonance Imaging (MRI) in assessing the Lateral Periarticular Space (LPAS) of Temporomandibular Joints (TMJs) in patients with Juvenile Idiopathic Arthritis (JIA).

METHODS

The LPAS width was evaluated in two different patient groups. In the JIA group, including 29 children (13 ± 2.8 years) with JIA, the LPAS width was measured with both MRI and US. In the healthy group, including 28 healthy children (12.6 ± 2.5 years), the LPAS width was measured only with US. Comparisons of LPAS width based on patient groups and TMJ contrast enhancement in MRI were evaluated by applying the Mann-Whitney U test. Correlation and agreement between MRI and US measurements in JIA group were tested using Spearman rank correlation and Bland-Altman method.

RESULTS

The LPAS width was significantly greater in the JIA group than in the healthy group. In the JIA group, the LPAS width was significantly greater in TMJs with moderate/severe enhancement than those with mild enhancement. A positive significant correlation between MRI and US measurements of LPAS width was found in the JIA group. In the same group, Bland-Altman method showed a good level of agreement between MRI and US measurements.

CONCLUSION

Although, US cannot replace MRI in the evaluation of TMJ in patients with JIA, US could be used as a supplementary imaging method to MRI in assessing the TMJ disease.

Diagnostic efficacy of quantitative ultrasonography for anterior disc displacement of the temporomandibular joint

Background

Ultrasonography has been applied as an alternative method in the assessment of temporomandibular joint (TMJ) pathology including anterior disc displacement (ADD). However, a concrete screening or diagnostic method which is feasible in clinical practice has not yet been established. The study aimed to establish a quantitative ultrasonographic method and determine its diagnostic efficacy for ADD of the TMJ.

Methods

A total of 75 joints were allocated to either the normal disc position (NDP) group or the ADD group using magnetic resonance imaging (MRI) as the reference standard. Longitudinal scans of the lateral articular compartment were obtained by a 14-MHz L-shaped linear array transducer. The width of the lateral joint space (LJS), the upper lateral joint space (ULJS), and the lower lateral joint space (LLJS), as well as the position of the lateral articular disc edge (ADE), were investigated by stepwise logistic regression analysis to identify significant indicators of ADD and to build a diagnostic model. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were computed at the optimal cut-off value.

Results

MRI detected 25 joints in the NDP group and 50 joints in the ADD group. Correlation analysis indicated that all 4 variables were associated with ADD. With the best performance of the area under the receiver operating characteristic (ROC) curve (AUC) of 0.939, LJS and ULJS were identified as predictors of ADD and subsequently adopted to build a diagnostic model by stepwise logistic regression. The optimal cut-off value of the 2-variable regression model for diagnosing ADD was 0.800, with a sensitivity of 82%, specificity of 96%, PPV of 97.6%, NPV of 72.7%, and an accuracy of 86.7%.

Conclusions

The quantitative ultrasonographic diagnostic method showed promising diagnostic efficacy. It has the potential to be used for ADD screening in future clinical practice.

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

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

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

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

An ultrasound protocol for temporomandibular joint in juvenile idiopathic arthritis: a pilot study

OBJECTIVES

As it is well known, the diagnosis of temporomandibular joint (TMJ) involvement in patients affected by Juvenile Idiopathic Arthritis (JIA) is important to avoid the impairment of mandibular growth. In this context, Magnetic Resonance Imaging (MRI) is the gold-standard for detection of TMJ involvement, however it is expensive and requires patients' collaboration. The aim of this study was to evaluate if ultrasound may be used as an alternative tool to investigate the acute signs of TMJ involvement in JIA patients.

METHODS

Lateral periarticular space (LPAS) and joint effusion were evaluated by ultrasound in a study Group A of 8 JIA children (11.6±3.5 years old) with 14 TMJs involved, as confirmed by MRI, and in a control Group B of 7 healthy children (9.3±1.2 years old) without temporomandibular disorders (TMD). The LPAS width values were compared between the two groups using the Mann-Whitney test. The ultrasound images of the JIA group were then matched with the corresponding MR images; the Spearman Rank Correlation test and the Bland-Altman test were used to evaluate the differences.

RESULTS

The LPAS values in Group A were statistically significantly higher than those in Group B (p < 0.001). There was no overlap of the LPAS values confidence intervals (CIs) between the two groups. No signs of joint effusion were identified in groups A and B. The Spearman test applied to the values of LPAS measured in ultrasound and the corresponding MR images showed a proportional positive correlation with a ρ of 0.623 and a p < 0.05.

CONCLUSIONS

Ultrasound can detect differences in the TMJ features between JIA patients and healthy patients and it might be used as a follow-up tool in the assessment of TMJ involvement in subject affected by JIA.

Ultrasonography-guided invasive procedures of the temporomandibular joint

Temporomandibular joint (TMJ) complex is one of the most complex joints, which connects the mandible to the skull. This kind of joint system has the ability to perform complex and bilateral movements. Due to complex anatomy, there is a need for a thorough investigation to find the correct etiology of TMJ disorders. For a thorough investigation, starting from clinical examination to imaging strategies should be performed meticulously. Radiographic imaging is an important element in the correct diagnosis. Because of the anatomic complexity of the temporomandibular joint and its proximity to the temporal bone, mastoid air cells, and auditory structures, imaging of the joint structures should also be investigated. Therefore, careful clinical and radiological examinations are essential in the evaluation of TMJ. The manuscript examines the potential use and technique of ultrasonography (USG) in fine-needle aspiration biopsy and intra-articular sodium hyaluronate/steroid injection.

Musculoskeletal ultrasound in children: Current state and future directions

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

Is power Doppler ultrasound useful to evaluate temporomandibular joint inflammatory activity in juvenile idiopathic arthritis?

OBJECTIVE

To evaluate the effectiveness of power Doppler ultrasound (US) in assessing the temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) patients using contrast-enhanced magnetic resonance imaging (MRI) as the reference standard.

METHODS

We evaluated the US and MRI examinations of the TMJs from 92 JIA patients. These exams were done and scored for inflammatory activity on the same date.

RESULTS

There were considerable differences between the US and MRI findings, with MRI detecting more effectively the TMJ involvement. No association was found between synovial inflammation obtained using power Doppler US to assess synovial vascularity determined by US images and synovial enhancement determined by MRI images. US had very poor sensitivity and very low positive predictive value to detect TMJ arthritis in JIA patients compared with MRI as the reference standard.

CONCLUSIONS

Power Doppler US cannot replace MRI for the detection of TMJ inflammatory involvement in JIA patients.Key Points• The early diagnosis of TMJ involvement in JIA patients is very important in order to prevent disturbances in the mandibular growth.• Power Doppler US could be a useful diagnostic tool as a screening exam to identify inflammatory activity in this joint.• However, power Doppler US did not show to have this function and cannot replace MRI for the detection of TMJ inflammatory involvement in JIA patients.

Comparison of the effectiveness of high resolution ultrasound with MRI in patients with temporomandibular joint dısorders

OBJECTIVES

To assess the effectiveness of a high resolution ultrasound for temporomandibular joint (TMJ) evaluation in comparison to MRI in patients with TMJ disorders.

METHODS

Our study comprised 50 patients (35 female and 15 male) with a mean age of 30.61. Clinical examination was performed. Bilateral imaging of TMJ was conducted by using a high-resolution ultrasound and 1.5 Tesla MR. Diagnostic accuracy of ultrasound was assessed for disc displacement and joint effusion in comparison to MRI. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and accuracy (Ac) were calculated for ultrasound. Measurements were compared by Bland & Altman and intraclass correlation coefficient (ICC). Significance level was set at p < 0.05.

RESULTS

Most frequent complaints were noise 42 (84%) and 34 (68%) pain. For disc position assessment with ultrasound for both sides and closed-open mouth, sensitivity, specificity, PPV, NPV and accuracy ranged between, 0.88 - 1, 0.60 - 0.87, 0.70 - 0.97, 0.75 - 1, and 0.84 - 0.98, respectively. For the diagnosis of effusion with ultrasound for both sides, sensitivity, specificity, PPV, NPV and accuracy ranged between 0.65 - 0.81, 0.91 - 1, 0.96 - 1, 0.45 - 0.46 and 0.72 - 0.84, respectively. ICC values calculated for intraobserver agreement for right and left TMJ for all measurements were found to be statistically significant (p < 0.001). ICC values ranged between 0.964 and 0.995 suggesting excellent correlation among ultrasound and MRI. In general, for ultrasound measurements we found a mean difference ranging between -0.182 and +0.130 mm in comparison to MRI.

CONCLUSION

Ultrasound can be suggested as an adjunct to common imaging modalities in the assessment of TMJ.

Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what?

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Ultrasound versus magnetic resonance imaging of the temporomandibular joint in juvenile idiopathic arthritis: a systematic review

A systematic review of published articles on ultrasound (US) and magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) in juvenile idiopathic arthritis (JIA) was performed to answer the question "What is the sensitivity and specificity of US as compared to MRI in diagnosing acute and chronic joint changes in patients with JIA?" The most recent evidence was sought in published articles via a search of the PubMed, Ovid, and Embase databases. Article appraisal was performed by two reviewers. Nineteen articles reporting prospective or ambispective studies comparing US to MRI in TMJ imaging were found. Six of these articles were specific to JIA patients. The heterogeneity of these articles made comparison difficult. Of the acute and chronic changes assessed (disk displacement, joint effusion, bony deformity), only joint effusion was appropriately assessed by multiple authors, with US having a sensitivity of 0-72% and specificity of 70-83% as compared to MRI. There was a paucity of studies specific to JIA, with many studying adult, non-rheumatic patients. This systematic review found that dynamic imaging with high-resolution US improves sensitivity and specificity compared to static, low-resolution US. Additionally, there is evidence to suggest that US imaging following a baseline MRI can increase US sensitivity and specificity and may have a future role in disease surveillance.

Juvenile Idiopathic Arthritis Practice Patterns Among Oral and Maxillofacial Surgeons

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Histologic effects of mandibular protrusion splints in antigen-induced TMJ arthritis in rabbits

BACKGROUND

Although it is common clinical practice to treat children with Juvenile Idiopathic Arthritis (JIA) with functional appliances, the scientific evidence for this is limited. The aim of this study was to study the histologic effects of mandibular protrusion splints in temporomandibular joint (TMJ) arthritis in rabbits.

METHODS

Twenty-eight ten-week old New Zealand white rabbits were randomly divided into four groups: AO (TMJ arthritis, no splint), AS (TMJ arthritis, mandibular splint advancement), OS (no arthritis, mandibular splint advancement) and OO (no arthritis, no splint). TMJ arthritis was induced in the groups AO and AS; 1 week later mandibular protrusion splints were placed on the upper incisors of the AS and OS animals. After 60 days the animals were sacrificed and a semiquantitative histologic evaluation of each TMJ was carried out to analyze the amount of inflammation and bone modeling.

RESULTS

AO and AS animals had a higher inflammation score (AO = 1.3; AS = 1.8) than the non-arthritis groups (OO = 0.6; OS = 0.4). Whereas in the untreated control (OO) the amount of apposition and resorption was almost in balance (+1), OS animals displayed significantly more apposition (+9) and AO animals significantly more resorption (-3) than the untreated control. Arthritis animals with protrusion appliances (AS), however, had remarkably more bone apposition (+3) than resorption, indicating a similar bony reaction as in healthy animals, although reduced in extent.

CONCLUSIONS

Mandibular advancement in rabbits with TMJ arthritis is possible without detrimental histologic reactions and appears to partially compensate for the bone loss seen in rabbits with TMJ arthritis but without protrusion splints.

Temporomandibular joint involvement in childhood arthritis: comparison of ultrasonography-assessed capsular width and MRI-assessed synovitis

OBJECTIVES

Ultrasonography is an effective, low-cost, low-threshold and convenient diagnostic tool in childhood arthritis, but its value in temporomandibular joint (TMJ) involvement is not clear. The purpose of our study was to explore the reliability of ultrasonography to assess TMJ inflammation using contrast-enhanced MRI as reference standard, in order to deduce cut-off values for TMJ capsular width to detect enhanced synovial thickening (synovitis).

METHODS

124 ultrasonography and MRI examinations in 55 patients [mean age 12.4 ± 3.5 years (±standard deviation)], the majority obtained within 1 day, were scored for subcondylar and condylar capsular width (ultrasonography images) and amount of synovitis (MR images). The correlations of these findings were calculated. A receiver operating characteristic (ROC) curve analysis, with MRI findings as reference standard, was obtained.

RESULTS

The correlation between ultrasonography-assessed capsular width and MRI-assessed amount of synovitis was moderate both at the subcondylar and condylar level [Spearman's rho (ρ): 0.483; p < 0.001 and 0.347; p < 0.001 respectively]. The ROC curve indicated the best discriminatory ability at the subcondylar level with an area under the curve of 0.77 (95% confidence interval 0.69-0.85) and a cut-off value of 1.2 mm (sensitivity 72%, specificity 70%) for the capsular width.

CONCLUSIONS

A moderate correlation between ultrasonography-assessed capsular width and MRI-assessed synovitis was found in childhood arthritis with the best discriminatory ability at the subcondylar level. This indicates that ultrasonography may be a valuable diagnostic tool in the initial assessment of TMJ inflammation.

Contemporary management of TMJ involvement in JIA patients and its orofacial consequences

Juvenile idiopathic arthritis is the most common chronic rheumatic condition during childhood. Temporomandibular joint arthritis is frequently asymptomatic. When it takes place during childhood, it may affect condylar growth; therefore, these children are at risk of unfavorable long-term outcomes from the associated joint damage. The etiology is not completely understood, but it is considered as multifactorial with both genetic and environmental factors involved.

The standardized examination and imaging protocols serve important purpose to diagnose temporomandibular joint (TMJ) arthritis not only to establish an early interventional strategy but also to assess craniofacial growth and the progression of signs and symptoms in those patients. Although the treatment of juvenile idiopathic arthritis (JIA) has changed dramatically over the last decades due to new therapeutic options, TMJ arthritis still can develop during the course of the disease. In clinical experience, TMJs appear to respond less well to the standard of care used to treat other joints. More individualized approach to the patient’s treatment serves as the main goal of personalized medicine. It could be achieved by adopting new methods of medical imaging such as conebeam computer tomography as well as developing reliable biomarkers which may assist with predicting disease type, course, or severity and predicting response to medication.

This article provides an overview of current information on orofacial complications in JIA and its management. Based on information provided in this review, more precise diagnosis, proper tools for recognizing people at risk, and more efficient treatment approaches could be implemented. This may lead to more personalized treatment management strategies of TMJ complications of JIA patients.

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

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

Juvenile idiopathic arthritis and the temporomandibular joint: A comprehensive review

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

An Inventory of Current Available Ultrasound Devices for Dental Use

Objective : The first aim of the study was to make an inventory of the currently available ultrasound imaging devices on the market. The second aim was to identify portable ultrasound devices which could be used in general dental offices to image salivary glands, masticatory muscles and lymph nodes. Material and Methods : A list of ultrasound devices was collected from 11 international and American manufacturers using company websites and ultrasound retailer’s websites using the search engine Google^®. Results : A total of 86 ultrasound machines from 11 different manufacturers were identified, of which only 14 devices are portable. Transducers are usually transferrable between devices of the same brand, and the non-portable machines have multiple transducer ports (three or four), while portable machines typically have only one or two ports. Portable machine weights range from 10 to 20 pounds, and often resemble large laptops, which are convenient to carry and take up minimal space in clinics. Conclusion : Some manufacturers provide portable and non-portable ultrasound devices. The first ones could be valuable in dental settings, as they can easily be moved around in the office.

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

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

Evaluation of four different optimized magnetic-resonance-imaging sequences for visualization of dental and maxillo-mandibular structures at 3 T

OBJECTIVES

The purpose of this study was to evaluate four in-house optimized, non-contrast enhanced sequences for MRI-investigation of maxillo-mandibular and dental structures by use of 3 T.

METHODS

12 volunteers with different dental status were examined by using a 3 T MRI with a 20-channel standard head-and-neck coil. All images performed were evaluated by using 3D-techniques, with different slice-thicknesses, in 3D T1- and T2-weighted sequences, as well as by using new techniques of image depictions. In addition phantom measurements were performed to estimate the extent of image artefacts caused by retainers and metal implants.

RESULTS

Mean age of the participants was 33 years (range, 25.5-62.75 years), and the sex ratio was 5 females to 7 males. We identified different techniques to improve osseous and dental structures, despite problems caused by dental implants, tooth crowns or braces.

CONCLUSION

The sequences evaluated offered excellent visualization in 2D and 3D of osseous and dental structures. Anatomical, osseous and dental structures were described at their ROI, in relation to patients with dental and head and neck pathologies. The ability to detect and distinguish pathological processes as soon as possible in 3D with excellent image quality avoiding ionizing radiation remains a challenging domain.

Imaging of the temporomandibular joint in juvenile idiopathic arthritis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Regional 3D superimposition to assess temporomandibular joint condylar morphology

OBJECTIVES

To investigate the reliability of regional three-dimensional registration and superimposition methods for assessment of temporomandibular joint condylar morphology across subjects and longitudinally.

METHODS

The sample consisted of cone beam CT scans of 36 patients. The across-subject comparisons included 12 controls, mean age 41.3 ± 12.0 years, and 12 patients with temporomandibular joint osteoarthritis, mean age 41.3 ± 14.7 years. The individual longitudinal assessments included 12 patients with temporomandibular joint osteoarthritis, mean age 37.8 ± 16.7 years, followed up at pre-operative jaw surgery, immediately after and one-year post-operative. Surface models of all condyles were constructed from the cone beam CT scans. Two previously calibrated observers independently performed all registration methods. A landmark-based approach was used for the registration of across-subject condylar models, and temporomandibular joint osteoarthritis vs control group differences were computed with shape analysis. A voxel-based approach was used for registration of longitudinal scans calculated x, y, z degrees of freedom for translation and rotation. Two-way random intraclass correlation coefficients tested the interobserver reliability.

RESULTS

Statistically significant differences between the control group and the osteoarthritis group were consistently located on the lateral and medial poles for both observers. The interobserver differences were ≤0.2 mm. For individual longitudinal comparisons, the mean interobserver differences were ≤0.6 mm in translation errors and 1.2° in rotation errors, with excellent reliability (intraclass correlation coefficient >0.75).

CONCLUSIONS

Condylar registration for across-subjects and longitudinal assessments is reliable and can be used to quantify subtle bony differences in the three-dimensional condylar morphology.