Signs and symptoms in the masticatory system in ten patients with mixed connective tissue disease

Evaluation of Rheumatic Diseases Affecting the Temporomandibular Joint: A Cone Beam Computed Tomography Study and Literature Review

INTRODUCTION

Due to the silent manifestation of temporomandibular joint (TMJ), dentists and rheumatologists may neglect treatment for this joint.

AIMS

The aim of this study was to investigate the TMJ components in patients with various rheumatic diseases and to compare them with a control group based on cone beam computed tomography (CBCT) images.

MATERIALS AND METHODS

This study comprised an assessment of the CBCT images of 65 patients (130 temporomandibular joints) with various rheumatic diseases (mostly rheumatoid arthritis) affecting the TMJ. Moreover, 65 patients (130 temporomandibular joints) with a similar age and gender distribution were examined as the control group. Pathologies were classified into a total of 12 types for the presence of any osseous changes in the condylar head or articular fossa or for joint space narrowing. Statistical analysis of all data was performed with SPSS version 18. The conformity of continuous variables to a normal distribution was examined by the Kolmogorov-Smirnov test. The Mann-Whitney U test was used to compare the means of two independent groups. The Pearson Chi-square test, Yates correction and Fisher's exact test were used in the analysis of categorical variables.

RESULTS

The mean age of the patient and control groups was 50 ± 13 and 48 ± 16, respectively, and no statistically significant difference was found between the patient and control groups in terms of age distribution (p = 0.123). Condylar erosion, condylar flattening, subcondylar sclerosis, osteophytes, subcortical cysts, articular eminence resorption and articular eminence flattening rates were found to be statistically significantly higher in the patient group than in the control group (p < 0.05).

CONCLUSIONS

Dentomaxillofacial radiologists should examine the bony components of the TMJ in patients with rheumatic diseases, and a multidisciplinary approach involving a dental specialist and rheumatologist is required.

Impact of rheumatic diseases on oral health and quality of life

OBJECTIVE

We investigated the effects of rheumatic diseases on oral symptoms, health habits, and quality of life in subjects with and without rheumatic diseases. The hypothesis was that patients with rheumatic diseases have more oral symptoms impairing their quality of life than healthy controls.

METHODS

A questionnaire was mailed to a random sample of 1500 members of the Finnish Rheumatism Association, including those with and without rheumatic diseases. We focused on symptoms of the mouth and temporomandibular area, and health habits. Oral Health Impact Profile (OHIP14) was used to evaluate the oral health-related quality of life. We analyzed differences between subjects with and without rheumatic diseases, controlled for age, gender, smoking, and non-rheumatic chronic diseases.

RESULTS

Completed questionnaires were received from 995 participants (response rate 66%). Of them, 564 reported rheumatic disease, 431 were used as controls. The patients reported significantly more all orofacial symptoms than controls. Severe dry mouth was reported by 19.6% of patients and 2.9% of controls (P < 0.001), and temporomandibular joint symptoms by 59.2% and 27.2% (P < 0.001), respectively. In the OHIP-14 questionnaire, the mean total score was significantly higher in patients (8.80 ± 11.15) than in controls (3.93 ± 6.60; P < 0.001).

CONCLUSION

The study hypothesis was confirmed by showing that the patients with rheumatic diseases reported oral discomfort and reduced quality of life more often when compared with controls.

Validation and improvement of a predictive model for treatment outcome in patients with temporomandibular disorders

OBJECTIVE

To examine whether it was possible to improve individual prediction of treatment outcome in patients with temporomandibular disorders (TMD) through continuous quality improvement registrations and implementation of changes in clinical routines.

MATERIAL AND METHODS

All 5777 patients referred to a specialist clinic for stomatognathic physiology; 2187 TMD patients started treatment. The patients were divided into Muscle or Mainly TMJ symptom groups. Actual treatment outcome was predicted as Good or Dubious based on patient history and clinical findings. The degree of improvement of initial symptoms was graded using a numeric rating scale 0-100. Improvement in initial complaints of 50% or more was judged as a clinically important difference (CID); 989 patients (76%) completed treatment 1992-1998 (Sample 1) and 769 (86%) treatment 1999-2004 (Sample 2).

RESULTS

For patients with Muscle symptoms in Sample 1, CID was reached by 90% of those predicted Good and by 56% of those predicted Dubious. In Sample 2, the figures were Good 93% and Dubious 57%. In subgroup Mainly TMJ symptoms, CID was reached by 94% of those predicted Good and by 88% if predicted Dubious in Sample 1. In Sample 2, the figures were the same for those predicted Good, i.e. 94%, and Dubious, 73%.

CONCLUSION

Continuous quality improvement registrations and implementation of changes in clinical routines improved the ability to predict individually the actual treatment outcome between patients predicted Good or Dubious, respectively. Rheumatic disease turned out not to be a negative predictor for treatment outcome.

Clinical, radiographic and MRI findings of the temporomandibular joint in patients with different rheumatic diseases

The aim of this study was to investigate the condition of the temporomandibular joint (TMJ) in patients with different rheumatic diseases, and report correlations between the clinical, radiographic and magnetic resonance imaging (MRI) findings. The 67 patients were divided into four groups: 16 with rheumatoid arthritis (RA), 15 with mixed connective tissue disease (MCTD), 18 with ankylosing spondylitis (AS) and 18 with spondyloarthropathy (SPA). They were clinically examined, and panoramic tomography, lateral panoramic radiography and MRI of the TMJ were performed. MRI showed reduced articular cartilage in 25% (4/16) of RA, 0% (0/15) of MCTD, 17% (3/18) of AS and 17% (3/18) of SPA patients. Condylar changes included erosion, osteophytes and abnormal shape. Disc alterations included perforation, abnormal anterior position and decreased movement. These abnormalities were most frequent in RA patients, and least frequent in MCTD and SPA patients. Crepitation and reduced maximum opening of the mouth correlated with abnormalities of the disc and articular cartilage as shown by MRI. Severe condylar erosion in panoramic tomograms significantly correlated with MRI findings of condylar erosion (P<0.01), diminished thickness of condylar cartilage, abnormal condylar shape, and abnormal shape of the temporal surface of the TMJ (P< or =0.001). The presence of crepitation, limited mandibular movement and/or pain on movement of the jaw often indicated structural damage to the TMJ. Panoramic radiographs provide an alternative method to MRI but, to obtain a more detailed anatomic picture, MRI is recommended for patients with acute unexplained pain or as part of preoperative work up. A panoramic recording is not indicated when MRI is planned.

Treatment of mixed connective tissue disease

Mixed connective tissue disease (MCTD) is believed to be incurable and seems to have a variable prognosis. Some patients have a mild self-limited disease, whereas others develop major organ involvement that requires aggressive treatment. Because no controlled clinical trials have been performed to guide therapy in MCTD, treatment strategies must rely largely upon the conventional therapies that are used for similar problems in other rheumatic conditions (systemic lupus erythematosus, scleroderma, polymyositis). Given the heterogeneous clinical course of MCTD, therapy should be individualized to address the specific organ involved and the severity of underlying disease activity. Corticosteroids, antimalarials, methotrexate, cytotoxics (most often cyclophosphamide), and vasodilators have been used in the treatment of MCTD with varying degrees of success.

Oral and salivary parameters in patients with rheumatic diseases

We studied the presence of secondary Sjögren's syndrome (SS) and the composition of saliva, prevalence of oral pathogens, periodontitis, mouth mucosa, and teeth in patients with various rheumatic diseases and in healthy controls. The hypothesis was that different rheumatic diseases might cause differences in oral health characteristics because of the liability of secondary SS in the patients. The study involved 77 patients and 77 age-matched and sex-matched controls. Twenty patients were suffering from spondylarthropathy (SPA), 18 from ankylosing spondylitis (AS), 24 from rheumatoid arthritis (RA), and 15 from mixed connective tissue disease (MCTD). Clinical and radiographic oral health status was recorded and salivary flow rates were measured. Selected salivary proteins and immunoglobulins were analysed by routine methods. Minor salivary gland biopsy samples were taken from the patients for assessment of inflammatory focus scores. Differences between patients and controls and in between the different rheumatic diseases were analysed statistically. Secondary SS was diagnosed in 39% (30/77) of the patients. A severe periodontal condition (community periodontal index of treatment needs score 3 or 4) occurred in 58% (45/77) of the rheumatic patients compared with only 26% (20/77) of the controls (p < 0.0001). The severity of focal sialadenitis (focus score) correlated significant with salivary IgA, IgG, and IgM concentrations. Salivary albumin, total protein, IgG, and IgM concentrations were higher in all patient groups than in the controls. The number of patients with low salivary flow rates was higher in all patient groups compared to controls. Oral yeast counts were significantly higher in the patients than in the controls (p < 0.001). In a subgroup analysis, patients with SS had higher values for salivary IgA and IgM than patients without SS. Dental caries and oral lactobacilli were more frequent in patients with SS, but SS was not associated with periodontitis. No major differences were noted in other salivary biochemical parameters between these two groups. Patients with rheumatic diseases, irrespective of specific diagnosis, thus had various alterations in salivary flow and composition and oral health. The findings may reflect the autoimmune inflammation of the salivary glands frequently observed in these patients.

Other Manifestations of Mixed Connective Tissue Disease

This article describes other manifestations of mixed connective tissue disease (MCTD). We focus on inflammatory arthritis, the gastrointestinal tract (the esophagus in particular), the kidney, skin, and hematologic changes such as thrombocytopenia. Due to the complexity of potential organ involvements in MCTD, vigilance with appropriate diagnosis and treatment is warranted.

Clinical and radiographic findings of the temporomandibular joint in patients with various rheumatic diseases. A case-control study

OBJECTIVES

To investigate subjective, clinical and radiographic findings relating to the temporomandibular joint (TMJ) in patients with rheumatoid arthritis (RA), mixed connective tissue disease (MCTD), ankylosing spondylitis (AS), and spondyloarthropathy (SPA), and to compare the findings with those in age- and sex-matched control subjects.

STUDY DESIGN

Eighty patients (24 with RA, 16 with MCTD, 19 with AS, 21 with SPA) and 80 matched controls participated in the study. Replies to a questionnaire covering oral and TMJ symptoms were analysed in conjunction with medical histories, results of clinical examination of the stomatognathic system, and panoramic and lateral panoramic radiographs.

RESULTS

Patients with rheumatic disease reported severe TMJ symptoms significantly oftener than control subjects (P < .001). Patients with AS reported symptoms most frequently (7/19, 37%). Mean maximal opening of the mouth (SD) was significantly less in patients with rheumatic disease (46.3 mm (8.6 mm)) than in control subjects (55.0 mm (7.4 mm)) (P < .001). Marked erosions were observed in 4 RA patients (17%), 3 MCTD patients (19%), 8 SPA patients (38%), 7 AS patients (37%), and 1 control subject (1%) (P < .001). The existence of erosion was associated with evidence of restricted movement of condyle in panoramic radiographs (P < .001). There was correlation between radiographic findings relating to the TMJ and subjective and clinical stomatognathic-system symptoms in patients with rheumatic disease. Subjective TMJ symptoms were associated with evidence of restricted movement of condyle in panoramic radiographs (P < .001). Impairment of laterotrusion movement was significantly associated with erosion (P < .001).

CONCLUSIONS

The TMJ is commonly affected in patients with RA, and in patients with other forms of rheumatic disease. There are associations between radiographic findings and subjective symptoms, and between radiographic findings and restricted TMJ movement. In screening for suspected TMJ destruction, it would be appropriate to look for restricted maximal mouth opening, masticatory muscle tenderness and restricted laterotrusion.

Focal sialadenitis in patients with ankylosing spondylitis and spondyloarthropathy: a comparison with patients with rheumatoid arthritis or mixed connective tissue disease

OBJECTIVES

To investigate the occurrence of and risk factors for focal sialadenitis in patients with rheumatoid arthritis (RA), mixed connective tissue disease (MCTD), ankylosing spondylitis (AS), and spondyloarthropathy (SpA).

METHODS

A total of 85 patients (25 with RA, 19 with MCTD, 19 with AS, 22 with SpA) participated in the study. Each patient filled out a questionnaire for eye and oral symptoms and for the use of medication, and was interviewed; other tests included Schirmer's test, laboratory tests, collection of unstimulated and stimulated whole saliva, and minor salivary gland biopsy. A focus score of > or =1 was regarded as an indicator of focal sialadenitis.

RESULTS

Focal sialadenitis was observed in 68% (57/84) of all patients. It affected 80% (20/25) of the patients with RA, 94% (17/18) of those with MCTD, 58% (11/19) of those with AS, and 41% (9/22) of those with SpA (chi(2) test, p=0.0013). Salivary secretion correlated negatively with the focus scores-that is, severity of focal sialadenitis. Patients with focal sialadenitis had both decreased salivary secretion and decreased tear secretion significantly more often than did patients without (chi(2) test, p=0.0074 and p=0.048 respectively). Patients with positive rheumatoid factor (RF), antinuclear antibodies (ANA), or SSA or SSB antibodies had sialadenitis significantly more often than did patients with negative antibodies. In the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and the presence of these antibodies.

CONCLUSION

In addition to patients with RA or MCTD, focal sialadenitis also affects a very high proportion of patients with AS or SpA. Focus scores are significantly higher in patients with RA or MCTD than in those with AS or SpA. A significant association exists between focal sialadenitis and RF, ANA, SSA and SSB. However, in the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and serological markers or clinical symptoms.