Reliability of clinical symptoms in diagnosing temporomandibular joint arthritis in juvenile idiopathic arthritis

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

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

Transition to Adult Rheumatology Care: A Disease-Specific Guide

ABSTRACT

Young adults with childhood-onset rheumatic diseases are more frequently establishing and continuing care with adult rheumatologists. The transfer of care can be challenging for both the young adult patients and their adult rheumatologists, in large part due to differences between pediatric-onset rheumatic diseases and their adult-onset counterparts, or due to the rarity of some pediatric-onset rheumatic conditions. Other challenges are due to cultural differences between pediatric and adult medical care and to the young adult needing to increasingly perform self-management skills that were previously managed by parents or other caregivers. In this review, we will provide a summary of strategies for working effectively with young adults as they transition to adult care. We will then discuss a subset of childhood-onset rheumatic diseases-including juvenile idiopathic arthritis, localized scleroderma, autoinflammatory diseases, pediatric-onset systemic lupus erythematosus, juvenile-onset dermatomyositis, and autoimmune encephalitis-for which clinical manifestations, management, and prognosis frequently differ between pediatric onset and adult onset. Our aim is to highlight differences that make caring for this population of transitioning young adults unique, providing tools and knowledge to empower the adult rheumatologist to care for these young adults in ways that are evidence-based, effective, efficient, and rewarding.

Provider assessment of the temporomandibular joint in Juvenile idiopathic arthritis: a retrospective analysis from the CARRA database

BACKGROUND

Temporomandibular joint (TMJ) involvement is an often underrecognized complication of juvenile idiopathic arthritis (JIA) that can cause decreased mandibular growth, altered facial morphology, and orofacial pain. It is estimated that the TMJ is affected in 30-45% of children with JIA. Standardized physical examination and imaging evaluations are important in accurately assessing active TMJ arthritis and sequalae. Little is known about the rate at which providers evaluate TMJ involvement in their clinical practice.

METHODS

Data were obtained from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. Data fields related to assessment for TMJ arthritis were added in 2019. Patients were included in the study if they had a diagnosis of JIA and had data recorded between January 2020 and August 2021. Standard descriptive statistics were used to describe demographic and clinical features.

RESULTS

A total of 17,761 visits were reviewed for a total of 7473 patients with JIA. A total of 52.7% of patients had maximal mouth opening (MMO) recorded as finger breadths or total incisal distance (TID). Only 8% had TID measured. A total of 5.0% had MRI with contrast performed. A total of 939 patients had a diagnosis of TMJ arthritis. Of these, 28.5% had an MRI documented, 83% had an MMO documented, and 40% had TID measured. Few patient-level characteristics were statistically related to having MMO assessed. MRI was more likely to be obtained in older and in female patients. MMO was recorded at a given visit > 80% of the time at 17 sites, and it was recorded < 1% of the time at 8 sites. MRIs were infrequently performed at all sites, with 27 sites having no MRIs obtained and only 7 sites having an MRI obtained at > 10% of visits.

CONCLUSIONS

MMO is not consistently measured in patients with JIA, and it is rarely measured quantitatively. Similarly, TMJ MRIs are rarely obtained in patients with JIA. Site of care is more associated with TMJ assessments than patient-level characteristics. These data suggest that provider education is needed to improve the assessment of the TMJ in patients with JIA to enable earlier recognition and prevent long-term complications.

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.

Does the use of panoramic radiography add information in the temporomandibular joint evaluation in Juvenile Idiopathic Arthritis patients? A case control study

OBJECTIVE

To determine the frequency of radiographic changes in the temporomandibular joint, in a representative population of patients with Juvenile Idiopathic Arthritis (JIA) and to compare with findings in healthy controls matched by sex and age.

PATIENTS AND METHODS

One hundred and thirty-seven panoramic radiographies (PR) from JIA patients of a pediatric rheumatology outpatient clinic were prospectively evaluated and compared to 137 PR from healthy individuals.

RESULTS

102 (74.5%) JIA patients and 47 (34.3%) controls showed at least one radiological alteration (p < 0.001). The following radiographic alterations were more frequently observed in JIA patients than in controls: erosion (p < 0.001), altered condylar morphology (p < 0.001), disproportion between condylar process and the coronoid process (p < 0.001) and accentuated curve in the antegonial notch (p = 0.002). Twenty patients (14.6%) presented the four radiographic alterations simultaneously compared to only two controls (1.5%) (p < 0.001).

CONCLUSION

Due to the difference in the frequency of findings in the PR of patients and controls, we concluded that PR has value as a screening tool. In the presence of major changes in the mandible head in the PR of patients with a confirmed diagnosis of JIA, MRI should be considered to detect an active inflammatory process in this joint.

Cone beam computed tomography in the assessment of TMJ deformity in children with JIA: repeatability of a novel scoring system

BACKGROUND

The temporomandibular joint (TMJ) is frequently involved in juvenile idiopathic arthritis (JIA). Diagnostic imaging is necessary to correctly diagnose and evaluate TMJ involvement, however, hitherto little has been published on the accuracy of the applied scoring systems and measurements. The present study aims to investigate the precision of 20 imaging features and five measurements based on cone beam computed tomography (CBCT).

METHODS

Imaging and clinical data from 84 participants in the Norwegian study on juvenile idiopathic arthritis, the NorJIA study, were collected. Altogether 20 imaging features and five measurements were evaluated independently by three experienced radiologists for intra- and interobserver agreement. Agreement of categorical variables was assessed by Fleiss', Cohen's simple or weighted Kappa as appropriate. Agreement of continuous variables was assessed with 95% limits of agreement as advised by Bland and Altman.

RESULTS

"Overall impression of TMJ deformity" showed almost perfect intraobserver agreement with a kappa coefficient of 0.81 (95% CI 0.69-0.92), and substantial interobserver agreement (Fleiss' kappa 0.70 (0.61-0.78)). Moreover, both "flattening" and "irregularities" of the eminence/fossa and condyle performed well, with intra- and interobserver agreements of 0.66-0.82 and 0.55-0.76, respectively. "Reduced condylar volume" and "continuity" of the fossa/eminence had moderate intra- and interobserver Kappa values, whereas continuity of the condyle had Kappa values above 0.55. Measurements of distances and angles had limits of agreement of more than 15% of the sample mean.

CONCLUSIONS

We propose a CBCT-based scoring system of nine precise imaging features suggestive of TMJ deformity in JIA. Their clinical validity must be tested.

Is Orthognathic Correction with TMJ Preservation A Stable Treatment Option for Patients with Juvenile Idiopathic Arthritis?

Purpose

The purpose of this study was to evaluate the long-term skeletal stability of orthognathic correction of dentofacial deformities secondary to juvenile idiopathic arthritis (JIA) in individuals without total alloplastic joint reconstruction.

Materials and Methods

The investigators designed and implemented a retrospective case series of patients diagnosed with JIA who underwent bimaxillary orthognathic surgery. To evaluate the long-term skeletal changes, the maxillary palatal plane to mandibular plane angle, anterior facial height, and posterior facial height measurements were evaluated through cephalograms.

Results

Six patients met inclusion criteria. All subjects were female (mean 16.2 years). Four patients demonstrated < 1° of change of the palatal plane to mandibular plane angle, and all patients had < 2° of change. Three patients had < 1% change in the anterior to posterior facial height ratio. Three patients demonstrated relative posterior facial shortening compared to anterior facial height (< 4%). No patients developed postoperative anterior open-bite malocclusion.

Conclusion

Orthognathic correction of the JIA DFD deformity with TMJ preservation is a viable modality to improve facial esthetics, occlusion, upper airway and speech swallowing and chewing mechanisms in select patients. The measured skeletal relapse did not affect the clinical outcome.

The reliability of Juvenile Arthritis Magnetic Resonance Imaging Scoring system in the evaluation of the shoulder joint in juvenile idiopathic arthritis

Objectives

We aimed to evaluate shoulder joint by magnetic resonance imaging (MRI) using the Juvenile Arthritis Magnetic Resonance Imaging Scoring (JAMRIS) system in children with juvenile idiopathic arthritis (JIA) and to compare clinical, laboratory parameters and disease activity scores with MRI parameters.

Patients and methods

A total of 32 shoulder joints of 20 patients (16 males, 4 females; mean age: 8.9±3.5 years; range, 2.5 to 14 years) with a known diagnosis of JIA and a clinical suspicion of shoulder joint involvement and underwent MRI were included. Reliability was determined by inter- and intra-observer correlation coefficients. Correlation of the clinical and laboratory parameters with JAMRIS scores was done using the non-parametric tests. Sensitivity of clinical examination to detect shoulder joint arthritis was also determined.

Results

Of the 32 joints, 27 joints in 17 patients showed MRI changes. Seven joints in five patients fulfilled the definition of clinical arthritis, all revealed MRI changes. In 25 joints without clinical arthritis, early and late MRI changes were seen in 19 (67%) and 12 (48%) joints, respectively. The inter- and intra-observer correlation coefficients for JAMRIS system were excellent. No correlation was found between MRI parameters, clinical, laboratory, and disease activity scores. The sensitivity of clinical examination to detect shoulder joint arthritis was 25.9%.

Conclusion

The JAMRIS system is reliable and reproducible to determine shoulder joint inflammation in JIA. Detection of shoulder joint arthritis by clinical examination has a poor sensitivity.

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.

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.

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.

Clinical Practice Guideline: The Diagnosis and Treatment of Rheumatoid Arthritis and Juvenile Idiopathic Arthritis of the Temporomandibular Joint

BACKGROUND

Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.

METHODS

The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.

RESULTS

Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrastenhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intraarticular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.

CONCLUSION

Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.

The Temporomandibular Joint in Juvenile Idiopathic Arthritis

Patients with juvenile idiopathic arthritis (JIA) often have involvement of the temporomandibular joint (TMJ) during their disease course. Active arthritis of the TMJ remains difficult to assess. Clinical signs and symptoms alone are unreliable, and active TMJ arthritis needs confirmation by gadolinium-enhanced MRI. In recent years, changes in treatment approach have occurred. This article discusses the latest evidence on diagnosis and treatment of JIA-associated TMJ arthritis.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Understanding Early-Stage Posttraumatic Osteoarthritis for Future Prospects of Diagnosis: from Knee to Temporomandibular Joint

PURPOSE OF REVIEW

Many mechanical load-bearing joints of the body are prone to posttraumatic osteoarthritis (PTOA), including the knee joint and temporomandibular joint (TMJ). Early detection of PTOA can be beneficial in prevention or alleviating further progression of the disease.

RECENT FINDINGS

Various mouse models, similar to those used in development of novel diagnosis strategies for early stages of OA, have been proposed to study early PTOA. While many studies have focused on OA and PTOA in the knee joint, early diagnostic methods for OA and PTOA of the TMJ are still not well established. Previously, we showed that fluorescent near-infrared imaging can diagnose inflammation and cartilage damage in mouse models of knee PTOA. Here we propose that the same approach can be used for early diagnosis of TMJ-PTOA. In this review, we present a brief overview of PTOA, application of relevant mouse models, current imaging methods available to examine TMJ-PTOA, and the prospects of near-infrared optical imaging to diagnose early-stage TMJ-OA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparing Clinical and Radiological Manifestations of Adolescent Idiopathic Condylar Resorption and Juvenile Idiopathic Arthritis in the Temporomandibular Joint

PURPOSE

This cross-sectional study compared orofacial manifestations at the time of diagnosis in 2 temporomandibular joint (TMJ) conditions: adolescent idiopathic condylar resorption (ICR) and TMJ involvement from juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

This retrospective study included 19 JIAs, 19 ICRs, and 19 control patients, all treated at the Section of Orthodontics, Aarhus University Craniofacial Clinic, Denmark. From patient files, we retrieved radiological data from cone-beam computed tomographies along with information on symptoms and orofacial function at the time of diagnosis. Validated methodologies were used to evaluate TMJ and dentofacial morphology.

RESULTS

We found no statistically significant intergroup differences in severity of deformation of TMJ structures (TMJ deformity) between JIA and ICR patients. However, the ICR group showed significantly greater signs of dentofacial deformity on 4 outcome variables: mandibular inclination, posterior/anterior lower face height ratio, mandibular sagittal position, and mandibular occlusal plane inclination. Significant intergroup differences in clinical presentation were seen in 5 of 20 variables. Thus, the JIA group reported significantly more symptoms of TMJ pain, TMJ morning stiffness, and TMJ pain on palpation during the clinical examination, whereas the ICR group reported significantly more TMJ clicking during function and had a higher proportion of patients with anterior open bite.

CONCLUSIONS

Cone-beam computed tomography examination showed a similar degree of TMJ deformity in ICR and JIA patients at the time of diagnosis. ICR patients presented with a significantly higher degree of dentofacial deformity than JIA patients and healthy controls, which relates to the timing of the diagnosis. Arthralgia, TMJ morning stiffness, and TMJ palpitation pain were more common in JIA patients, whereas TMJ clicking during function and anterior open bites were more common in ICR patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Comprehensive Assessment of Orofacial Health and Disease Related Parameters in Adolescents with Juvenile Idiopathic Arthritis-A Cross-Sectional Study

Background: The aim of this cross-sectional study was to investigate oral health and functional status of adolescents with juvenile idiopathic arthritis (JIA) and its possible link to disease specific parameters. Methods: Patients with JIA were recruited (November 2012–October 2014) and disease specific information was extracted from patients’ records. Oral examination included: dental findings (decayed-, missing- and filled-teeth-index (dmf-t/DMF-T)), gingival inflammation (papilla-bleeding-index (PBI)) and periodontal screening index (PSI). Functional examination followed Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Additionally, modified Helkimo’s Clinical Dysfunction Index and radiographic scoring were recorded. Results: 59 JIA patients were included. The mean dmf-t/DMF-T was 2.6. Only one patient showed no signs of gingival inflammation, while 57.6% had a maximum PSI of 2 or less. Positive functional findings were assessed clinically in more than half of the patients. Major diagnosis by RDC/TMD was osteoarthrosis. Patients with at least one positive anamnestic or clinical functional finding revealed significantly higher radiographic scores (CI = 0.440, p = 0.022). Patients with increased c-reactive-protein had a significantly higher PBI (Z = –2.118, p = 0.034) and increased radiographic scores (CI = 0.408, p = 0.043). Conclusions: Adolescents suffering from JIA show high levels of caries experience and gingival inflammation. Temporomandibular joint dysfunction is often seen in JIA patients. Consequently, special dental care programs would be recommendable.

Quantitative analysis of facial asymmetry based on three-dimensional photography: a valuable indicator for asymmetrical temporomandibular joint affection in juvenile idiopathic arthritis patients?

BACKGROUND

Juvenile idiopathic arthritis (JIA) can cause osseous deformity in the temporomandibular joint (TMJ) and may impair mandibular growth. This study aimed to evaluate whether facial asymmetry determined clinically or by morphometric analysis of three-dimensional (3D) photographs in JIA patients is associated with an asymmetric affection of theTMJ.

METHODS

Of 76 consecutive JIA patients with a mean age of 11.7 years (range: 6.3-17.9), facial asymmetry was evaluated clinically (chin asymmetry, gonion asymmetry), and stereophotogrammetrically with 3D photographs. The facial surfaces were demarcated, then mirrored, superimposed using semi-automated landmarks, and quantitatively assessed (chin asymmetry, Hausdorff distances). Clinical and digital measurements were related to the diagnosis of right and left TMJ involvement derived from magnetic resonance images (MRI).

RESULTS

Twenty-seven (34%) patients had an asymmetrical osseous deformity of the TMJ. By clinical evaluation, chin asymmetry was related to asymmetrical osseous destruction (p = 0.02), but gonion asymmetry was not (p = 0.14). In regard to 3D-photograph based morphometric measurements, chin asymmetry was also related to asymmetrical osseous destruction (p = 0.01), but neither the mean (p = 0.06) nor the maximal Hausdorff distance (p = 0.67). Despite the attested significance, none of the chin asymmetry evaluation methods appeared to hold sufficient predictive value (positive predictive values ≤54%; coefficient of determination ≤7%).

CONCLUSIONS

For the assessment of facial asymmetry in JIA patients, morphometric measurements originating from 3D-photographs seem to deliver results comparable to the clinical assessment methods. The asymmetry of the face, especially around the chin, appears to be related to asymmetrical TMJ destruction, but none of the investigated measurement methods of the face were able to reliably predict the TMJ affection. Thus, facial asymmetry assessments, both qualitatively in a clinical setting and quantitatively based on 3D-photographs, have limited diagnostic value for TMJ involvement in JIA patients.

Standardizing the Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: An Interdisciplinary, Consensus-based, Short Screening Protocol

OBJECTIVE

To develop a consensus-based, standardized, short (< 3 min) clinical examination protocol to assess the multidimensional, orofacial manifestations of juvenile idiopathic arthritis (JIA).

METHODS

The study was conducted by a multidisciplinary task force from the Temporomandibular Joint Juvenile Arthritis Working Group (TMJaw). The study used an acknowledged sequential approach involving (1) a global multidisciplinary online questionnaire study, (2) a systematic literature review and consensus meetings to identify items for inclusion, (3) pilot testing of included items, (4) test of reliability in 22 subjects with JIA by 4 examiners, (5) test of construct validity in a case-control study involving 167 subjects, and (6) establishment of final recommendations.

RESULTS

Six items were recommended for the final examination protocol: (1) clinician-assessed pain location, (2) temporomandibular (TMJ) joint pain on palpation (open and closed mouth), (3) mandibular deviation at maximal mouth opening (≥ 3 mm), (4) maximal unassisted mouth opening capacity, (5) frontal facial symmetry, and (6) facial profile. All recommended items showed acceptable reliability and construct validity. The average mean examination time was 2 min and 42 s (SD ± 38.5 s).

CONCLUSION

A consensus-based, short clinical examination protocol was developed. The protocol takes less than 3 min to complete and provides information about orofacial symptoms, TMJ dysfunction, and dentofacial deformity. The standardized examination protocol is applicable to routine clinical care, as well as future research studies.

Assessment of condylar volume and ramus height in JIA patients with unilateral and bilateral TMJ involvement: retrospective case-control study

OBJECTIVES

The objectives of the study are to analyze volumetric differences of condylar volumes in patients with unilateral and bilateral JIA and to compare results with control condylar volumes.

MATERIALS AND METHODS

Forty-six CBCT images were analyzed for all patients affected by JIA, 37 females and 9 males (mean age 10.8 ± 4.2) with TMJ involvement (19 unilaterally, mean age 10.9 ± 4.5; 27 bilaterally, mean age 10.7 ± 4.5), and 25 CBCT of subjects without diagnosis of JIA were selected as controls (mean age 10.8 ± 4.2 years). In the case of unilateral JIA, condylar volumes and ramus lengths were compared with healthy condyle and with the compromised one. In the case of bilateral JIA, condyle volume and ramus lengths were compared with healthy one. The Shapiro-Wilk test was used to assess whether the data was normally distributed. Paired t test was applied to compare affected and non-affected condyle in the same patients (P < 0.05). Independent t test was used to evaluate whether the difference between the groups were comparable or significantly different (P < 0.05).

RESULTS

For the unilateral JIA group, significant differences comparing affected and non-affected condyles were found. A statistically significant reduction of the volume of the head, neck, and ramus was found in the affected side (P < 0.01). For the bilateral JIA group, statistically significant differences have been found considering the condylar head and neck, the whole condylar volume, and the ramus length compared with the control group (P < 0.05).

CONCLUSIONS

Subjects with unilateral JIA have condyles volumetrically smaller than those of the unaffected side and those found in healthy patients. A considerable decrease of the volume of all the anatomical structures considered in the patients with bilateral JIA was found compared with control group.

CLINICAL RELEVANCE

The study presents the effects of JIA on different anatomical structures highlighting their dimensional changes, whose sequelae are irreversible if not diagnosed and treated early.

Interdisciplinary Management of Dentofacial Deformity in Juvenile Idiopathic Arthritis

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

The impact of temporomandibular joint arthritis on functional disability and global health in patients with juvenile idiopathic arthritis

OBJECTIVES

The objective of the study was to evaluate the impact of temporomandibular joint (TMJ) arthritis on the functional disability and quality of life in patients affected by juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

Sixty-two consecutive patients with JIA with or without TMJ arthritis and 35 healthy control subjects were enrolled in the study. The demographic data, disease activity and clinical characteristics were obtained from all patients. The functional disability was assessed using the Italian version of the Childhood Health Assessment Questionnaire (C-HAQ). The oral health-related quality of life (OHRQoL) was assessed using the Child Perception Questionnaire (CPQ11-14). Possible determining factors of TMJ arthritis comprised demographic, disease characteristics and scores derived from questionnaires that were assessed by a uni and multivariable logistic regression analysis.

RESULTS

Compared with patients without TMJs arthritis, JIA patients with TMJ arthritis presented higher functional disability. The multivariable logistic regression analysis performed showed that female subjects (OR = 1.5, P = 0.041), with a JIA duration over 3.9 years (OR = 2.7, P = 0.033) and presenting higher C-HAQ and CPQ11-14 scores (OR = 2.7, P = 0.012 and OR = 2.9, P = 0.015, respectively) were the greatest determining factors for TMJ arthritis.

CONCLUSIONS

JIA patients with TMJ arthritis presented higher functional disability and lower OHRQoL scores compared with JIA patients without TMJ arthritis. TMJ arthritis was strongly associated with JIA duration and activity, especially in female patients.

Antigen-induced arthritis of the temporomandibular joint via repeated injections of bovine serum albumin in domestic pigs

Rheumatoid arthritis (RA) is a chronic inflammatory disease and the temporomandibular joint (TMJ) is affected in up to 50%, resulting in pain, limited mouth opening and dental malocclusion. The outcome of conservative and surgical therapies is unsatisfying in many cases. The purpose of this study was to establish a large animal model of antigen-induced arthritis (AIA) of the TMJ that enables the investigation of the pathogenesis of RA and the evaluation of new therapies. In five domestic pigs, systemic immunization was performed via consecutive intramuscular injections of bovine serum albumin (BSA). Then, AIA was induced via the application of BSA into the TMJ. Injection with saline served as the control. After ten weeks, the joints and adjacent tissues were harvested for histological analysis and cytokine quantification. The changes observed in the AIA specimens included severe synovial inflammation, cartilage-specific glycosaminoglycan content loss, and cartilage surface and discus alterations as well as the formation of chondrocyte clusters. Protein analyses of the synovia showed enhanced levels of IL-1β, IL-6, TNFα and VEGF. A porcine model of immunologic arthritis of the TMJ was successfully established. This model may be used in future studies to investigate the underlying pathogenesis of RA and new therapeutic strategies.

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

BACKGROUND

Diagnostic criteria reported in the expanded taxonomy for temporomandibular disorders include a standardised clinical examination and diagnosis (DC/TMD 3.B) of temporomandibular joint (TMJ) damage in patients with juvenile idiopathic arthritis (JIA); however, their validity is unknown.

OBJECTIVES

To assess the validity of DC/TMD 3.B for the identification of TMJ damage in JIA-patients, using magnetic resonance imaging (MRI) as gold standard, and to investigate the relation between clinical findings and TMJ damage.

METHODS

Fifty consecutive JIA patients (9-16 years) were recruited. DC/TMD 3.B were compared with TMJs MRI (100 TMJs) performed maximum at 1 month from the visit. The severity of TMJ damage was scored in four grades. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), logistic regression models with odds ratio of DC/TMD 3.B and clinical findings respect to MRI were calculated.

RESULTS

The DC/TMD 3.B were inadequate in the identification of TMJ damage (sensitivity = 0.15, specificity = 0.92, PPV = 0.85, NPV = 0.28, P = 0.350). Chin deviation and TMJ crepitus were associated with worse TMJ damage (P = 0.006; P = 0.034). Reduced mouth opening (OR = 3.91, P = 0.039) and chin deviation (OR = 13.7, P = 0.014) were associated with the presence of TMJ damage. Combining "pain" (history of pain, TMJ pain, pain during movements) and "function" (TMJ crepitus, reduced mouth opening, chin deviation) clinical findings, the sensitivity and the specificity were 0.88 and 0.54.

CONCLUSION

DC/TMD 3.B present a low sensitivity to diagnose TMJ damage. Chin deviation, reduced mouth opening and TMJ crepitus are associated with TMJ damage. We suggest combining "pain" and "function" findings for the evaluation of TMJ damage in JIA patients.

Surgical correction of dentofacial deformities in juvenile idiopathic arthritis: a systematic literature review

The aim of this study was to assess current evidence for the surgical correction of dentofacial deformities in patients with temporomandibular joint (TMJ) involvement from juvenile idiopathic arthritis (JIA). A systematic literature review, according to the PRISMA guidelines, was conducted. Meta-analyses, randomized controlled trials, cohort studies, observational studies, and case reports were eligible for inclusion. Exclusion criteria were no JIA diagnosis, no clearly defined outcomes, dual publications (except meta-analyses), non peer-reviewed studies, non English language publications, and animal studies. The outcome measures assessed were TMJ function, skeletal alignment, and morbidity. The database search identified 255 citations, of which 28 met the eligibility criteria. Of these, 24 were case reports or case series with a low level of evidence that did not allow for meta-analysis. Extrapolated evidence supports orthognathic surgery in skeletally mature patients with controlled or quiescent JIA and a stable dentofacial deformity. Distraction osteogenesis was recommended for severe deformities. Some authors demonstrated unpredictable postoperative mandibular growth with costochondral grafts. Alloplastic TMJ reconstruction was efficacious, but should be used cautiously in skeletally immature patients. TMJ function and skeletal alignment was improved with reconstruction by any technique and morbidity was low. The surgical correction of arthritis-induced dentofacial deformities is indicated but the level of evidence is low. Prospective multicenter studies are needed.

TMJ pathomorphology in patients with JIA-radiographic parameters for early diagnosis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is often accompanied by pathomorphological changes to the temporomandibular joint (TMJ). By analyzing orthodontical orthopantomograms of JIA patients the aims of the study were a) classification of condyle changes, b) quantification of bony asymmetries of condylar destruction and c) detection of relationships between disease duration and TMJ-involvement.

PATIENTS/METHODS

46 caucasian JIA-patients (28 female; 18 male; < 16.0 years) were enrolled, each joint (n = 92) was morphologically assessed by means of orthopantomogram, quantitatively analysed and compared with duration of general disease. Condyle morphology was assessed using the Billiau scale for severity of destruction [1]. The quantitative analysis was based on ratios of condyle, ramus and mandible height.

RESULTS

Patients were divided into groups (Group I - slightly affected, n = 36; Billiau severity 0-2; condyle findings: X-ray normal, condyle erosions, condylar flattening; Group II - severely affected, N = 10; Billiau severity 3-4; condyle findings: condylar flattenings and erosions, unilateral/bilateral complete loss of condyles), based on morphological analysis of condylar destruction. Duration of disease was significantly longer in Group II (8.9 ± 5.2 years) than in Group I (4.6 ± 4.7 years). Asymmetries of condyle, ramus and mandible height, quantitatively analysed by contralateral comparison, were significantly more marked in patients of Group II than of Group I.

CONCLUSIONS

Orthopantomogram imaging can be used in orthodontics clinical routine to detect TMJ-pathologies and is an important reference for monitoring progression of JIA. Classification into severe and slightly affected TMJ is possible by analysis of condylar pathomorphology. An association between degree of destruction, extent of lower jaw asymmetry and disease duration is suggested by the results.

Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children

After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.

Developing a reference MRI database for temporomandibular joints in healthy children and adolescents

BACKGROUND

Recognition of normal temporomandibular joints (TMJs) is essential to assess arthropathic changes. Few, if any, prior studies have evaluated the morphological appearance of growing TMJs by magnetic resonance (MR) examinations in the pediatric population.

OBJECTIVE

This study aimed to determine normative osseous appearance of growing TMJs according to age and gender, both qualitatively and quantitatively, concerning structural and bone marrow changes.

MATERIALS AND METHODS

From 1,036 MR scans screened, one joint was included from each of 157 patients (76% female; 2-18 years) presenting with at least one normal-appearing TMJ was included. Quantitatively, mandibular condyle was characterized by measuring the following: (i) head-neck angle, (ii) anteversion angle, (iii) condylar dimensions (mediolateral, craniocaudal and anteroposterior [AP]) and (iv) condylar volume. Furthermore, qualitative categorization of condylar shape, into one of three types, and condylar bone marrow type was performed.

RESULTS

The head-neck angle significantly correlated with age (bivariable regression β =0.60, P<0.001), indicating an increase of 1.6 degrees per year. Except for AP diameter of condyles, all other mandibular dimensions and condylar volume increased with age (β =0.20-0.59, P≤0.001-0.004). Significant age difference was observed among the different condylar shapes (P<0.001), indicating a change from rounded head without anterior tilt to rectangular head with anterior tilt. Lastly, mandibular condylar size, measured by volume and by AP and mediolateral dimensions, appeared larger in males.

CONCLUSION

The morphology of the mandibular condyles changes with age. During development, the shape of the condyles changes from round to rectangular in contour with the development of the anterior condylar tilt, as measured by the head-neck angle.

Imaging of temporomandibular joint abnormalities in juvenile idiopathic arthritis with a focus on developing a magnetic resonance imaging protocol

Inflammation and damage in the temporomandibular joint (TMJ) often develop without clinical symptoms but can lead to severe facial growth abnormalities and impaired health-related quality of life, making early diagnosis of TMJ changes crucial to identify. Inflammatory and osteochondral changes detectable through magnetic resonance imaging (MRI) occur in TMJs of approximately 40% of children with juvenile idiopathic arthritis (JIA), and no other imaging modality or physical method of examination can reliably detect these changes. Therefore contrast-enhanced MRI is the diagnostic standard for diagnosis and interval monitoring of JIA. However the specific usage of MRI for TMJ arthritis is not standardized at present. There is a recognized need for a consensus effort toward standardization of an imaging protocol with required and optional sequences to improve detection of pathological changes and shorten study time. Such a consensus imaging protocol is important for providing maximum information with minimally necessary sequences in a way that allows inter-site comparison of results of clinical trials and improved clinical management. In this paper we describe the challenges of TMJ imaging and present expert-panel consensus suggestions for a standardized TMJ MRI protocol.

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.

Toward Establishing a Standardized Magnetic Resonance Imaging Scoring System for Temporomandibular Joints in Juvenile Idiopathic Arthritis

OBJECTIVE

The temporomandibular joints (TMJs) are frequently affected in children with juvenile idiopathic arthritis (JIA). Early detection is challenging, as major variation is present in scoring TMJ pathology on magnetic resonance imaging (MRI). Consensus-driven development and validation of an MRI scoring system for TMJs has important clinical utility in timely improvement of diagnosis and serving as an outcome measure. We report on a multi-institutional collaboration toward developing a TMJ MRI scoring system for JIA.

METHODS

Seven readers independently assessed MRI scans from 21 patients (42 TMJs, from patients ages 6-16 years) using 3 existing MRI scoring systems from American, German, and Swiss institutions. Reliability scores, scoring system definitions, and items were discussed among 10 JIA experts through 2 rounds of Delphi surveys, nominal group voting, and subsequent consensus meetings to create a novel TMJ MRI scoring system.

RESULTS

Average-measure absolute agreement intraclass correlation coefficients (avICCs) for the total scores of all 3 scoring systems were highly reliable at 0.96 each. Osteochondral items showed higher reliability than inflammatory items. An additive system was deemed preferable for assessing minor joint changes over time. Eight items were considered sufficiently reliable and/or important for integration into the consensus scoring system: bone marrow edema and enhancement (avICC 0.57-0.61, smallest detectable difference [SDD] ± 45-63% prior to redefining), condylar flattening (avICC 0.95-0.96, SDD ± 23-28%), effusions (avICC 0.85-0.88, SDD ± 25-26%), erosions (avICC 0.94, SDD ± 20%), synovial enhancement and thickening (previously combined, avICC 0.90-0.91, SDD ± 33%), and disk abnormalities (avICC 0.90, SDD ± 19%).

CONCLUSION

A novel TMJ MRI scoring system was developed by consensus. Further iterative refinements and reliability testing are warranted in upcoming studies.

Conventional radiography in juvenile idiopathic arthritis: Joint recommendations from the French societies for rheumatology, radiology and paediatric rheumatology

BACKGROUND

Juvenile idiopathic arthritis (JIA) can cause structural damage. However, data on conventional radiography (CR) in JIA are scant.

OBJECTIVE

To provide pragmatic guidelines on CR in each non-systemic JIA subtype.

METHODS

A multidisciplinary task force of 16 French experts (rheumatologists, paediatricians, radiologists and one patient representative) formulated research questions on CR assessments in each non-systemic JIA subtype. A systematic literature review was conducted to identify studies providing detailed information on structural joint damage. Recommendations, based on the evidence found, were evaluated using two Delphi rounds and a review by an independent committee.

RESULTS

74 original articles were included. The task force developed four principles and 31 recommendations with grades ranging from B to D. The experts felt strongly that patients should be selected for CR based on the risk of structural damage, with routine CR of the hands and feet in rheumatoid factor-positive polyarticular JIA but not in oligoarticular non-extensive JIA.

CONCLUSION

These first pragmatic recommendations on CR in JIA rely chiefly on expert opinion, given the dearth of scientific evidence. CR deserves to be viewed as a valuable tool in many situations in patients with JIA.

KEY POINTS

• CR is a valuable imaging technique in selected indications. • CR is routinely recommended for peripheral joints, when damage risk is high. • CR is recommended according to the damage risk, depending on JIA subtype. • CR is not the first-line technique for imaging of the axial skeleton.

Temporomandibular joint atlas for detection and grading of juvenile idiopathic arthritis involvement by magnetic resonance imaging

Contrast-enhanced magnetic resonance imaging (MRI) is considered the diagnostic standard for identifying involvement of the temporomandibular joint by juvenile idiopathic arthritis. Early or active arthritis is shown as bone marrow oedema, joint effusion, synovial thickening and increased joint enhancement. Subsequent joint damage includes characteristic deformity of the mandibular condyle, bone erosion, disk abnormalities and short mandibular ramus due to impaired growth. In this pictorial essay, we illustrate normal MRI findings and growth-related changes of the temporomandibular joint in children. The rationale and practical application of semiquantitative MRI assessment of joint inflammation and damage are discussed and presented. This atlas can serve as a reference for grading temporomandibular joint arthritis according to the scoring systems proposed by working groups of OMERACT (Outcome Measures in Rheumatology and Clinical Trials) and the EuroTMjoint research network. Systematic assessment of the level of inflammation, degree of osteochondral deformation, and growth of the mandibular ramus by MRI may aid in monitoring the course of temporomandibular joint arthritis and evaluating treatment options.

Qualitative and semi-quantitative assessment of temporomandibular joint MRI protocols for juvenile idiopathic arthritis at 1.5 and 3.0T

OBJECTIVE

Temporomandibular joints (TMJs) frequently develop silent inflammatory and osteochondral changes in children with juvenile idiopathic arthritis. Data-driven recommendations for TMJ imaging protocol are needed to reduce measurement error and scanning time. This study compares the impact of different protocols, imaging coils, and magnet strength on the reliability of image assessment and the subjective quality of images.

MATERIALS AND METHODS

Three groups of bilateral TMJ MR studies were retrospectively collected from two institutions, including 24 1.5T and 19 3.0T studies using dedicated TMJ surface coils, and 23 1.5T studies with head coil. Post-contrast sequences were re-compiled from the full protocol to create minimum protocol studies for the three groups. Two radiologists and two non-radiologists first scored the three minimum protocol images according to pre-specified definitions, then scored the full protocol images. Minimum-to-full protocol agreement, inter-reader agreement, and subjective item visibility scores were assessed.

RESULTS

With dedicated TMJ dual surface coils, minimum-vs-full protocol agreement was moderate to good (0.5-0.8 intraclass correlation coefficients or kappa) for most items, and was not influenced by the magnet strength. Inter-reader reliability was more significantly influenced by the imaging coil and reader's training background than by protocol length or magnet strength differences. Sagittal and coronal planes weighted on PD, T2 Fat Suppressed and T1 Fat Suppressed -postcontrast adequately visualized all the different features, whereas the axial plane was more limited to visualizing synovium.

CONCLUSION

Inter-reader reliability and qualitative measure of image quality improved more consistently with the coil offering the higher resolution, rather than increased magnet strength.

Temporomandibular Joint Involvement in Association With Quality of Life, Disability, and High Disease Activity in Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate the demographic, disease activity, disability, and health-related quality of life (HRQOL) differences between children with juvenile idiopathic arthritis (JIA) and their healthy peers, and between children with JIA with and without clinical temporomandibular joint (TMJ) involvement and its determinants.

METHODS

This study is based on a cross-sectional cohort of 3,343 children with JIA and 3,409 healthy peers, enrolled in the Pediatric Rheumatology International Trials Organisation HRQOL study or in the methotrexate trial. Potential determinants of TMJ involvement included demographic, disease activity, disability, and HRQOL measures selected through univariate and multivariable logistic regression.

RESULTS

Clinical TMJ involvement was observed in 387 of 3,343 children with JIA (11.6%). Children with TMJ involvement, compared to those without, more often had polyarticular disease course (95% versus 70%), higher Juvenile Arthritis Disease Activity Score (odds ratio [OR] 4.6), more disability, and lower HRQOL. Children with TMJ involvement experienced clearly more disability and lower HRQOL compared to their healthy peers. The multivariable analysis showed that cervical spine involvement (OR 4.6), disease duration >4.4 years (OR 2.8), and having more disability (Childhood Health Assessment Questionnaire Disability Index >0.625) (OR 1.6) were the most important determinants for TMJ involvement.

CONCLUSION

Clinical TMJ involvement in JIA is associated with higher disease activity, higher disability, and impaired HRQOL. Our findings indicate the need for dedicated clinical and imaging evaluation of TMJ arthritis, especially in children with cervical spine involvement, polyarticular course, and longer disease duration.

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.

Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies

OBJECTIVE

To develop international consensus-based recommendations for the orofacial examination of patients with juvenile idiopathic arthritis (JIA), for use in clinical practice and research.

METHODS

Using a sequential phased approach, a multidisciplinary task force developed and evaluated a set of recommendations for the orofacial examination of patients with JIA. Phase 1: A Delphi survey was conducted among 40 expert physicians and dentists with the aim of identifying and ranking the importance of items for inclusion. Phase 2: The task force developed consensus about the domains and items to be included in the recommendations. Phase 3: A systematic literature review was performed to assess the evidence supporting the consensus-based recommendations. Phase 4: An independent group of orofacial and JIA experts were invited to assess the content validity of the task force's recommendations.

RESULTS

Five recommendations were developed to assess the following 5 domains: medical history, orofacial symptoms, muscle and temporomandibular joint function, orofacial function, and dentofacial growth. After application of data search criteria, 56 articles were included in the systematic review. The level of evidence for the 5 recommendations was derived primarily from descriptive studies, such as cross-sectional and case-control studies.

CONCLUSION

Five recommendations are proposed for the orofacial examination of patients with JIA to improve the clinical practice and aid standardized data collection for future studies. The task force has formulated a future research program based on the proposed recommendations.

HLA II class alleles in juvenile idiopathic arthritis patients with and without temporomandibular joint arthritis

BACKGROUND

Temporomandibular joint (TMJ) arthritis is seen very often (38-87 %) in children with juvenile idiopathic arthritis (JIA). With contrast enhanced magnetic resonance imaging (MRI) we can detect more cases of TMJ arthritis than ever before. Previous studies show that HLA II class alleles may have protective or risk importance in JIA subtypes. Our objective is to identify HLA II class alleles of risk and protection in JIA patients with TMJ arthritis.

METHODS

During the period from 2010 to 2015 MRI for TMJ was performed in 85 JIA patients who were genotyped for HLA- DRB1; DQB1 and DQA1 using RT-PCR with sequence-specific primers. As a control group, data of 100 individuals were taken from the genetic bank of RSU Joint Laboratory of Clinical Immunology and Immunogenetics. Associations of DRB1; DQB1; DQA1 alleles in patients were examined individually using the χ (2) test. P-value (<0.05) and odds ratio were calculated using EPI INFO 6.0 software.

RESULTS

Out of 85 JIA patients with mean age of 13.7 ± 3.0 years (range 6.9-17.9 years), 59 (69 %) were girls and 26 (31 %) were boys. The mean duration of the disease was 3.07 ± 2.35 years (range 0.2-11.0 year). JIA subtypes were as follows: seronegative polyarthritis 51 (60 %), seropositive polyarthritis 6(7 %), oligoarthritis extended 7(8 %), oligoarthritis persistent 2 (2 %) arthritis with enthesitis 14 (17 %), undifferentiated 3 (4 %) and 2 (2 %) systemic arthritis. Two groups where separated after TMJ MRI exam: first with at least two signs of active inflammation and/or any structural damage (n = 62); second with no pathologic signs or with slight contrast enhancement (n = 23). We discovered that there are risk alleles that are found in all JIA patient's groups (MRI positive and negative groups) versus controls such as DRB1*07:01, DQB1*03:03; DQB1*05:01. Also some protective alleles as DRB1*18:01, DQB1*06:02-8 were found in overall JIA group. Alleles DRB1*12:01, DQB1*03:01; DQA1*05:01 were found to be protective for TMJ arthrits.

CONCLUSION

In our study there were no convincing risk alleles, but there are alleles that probably are protective for TMJ arthritis like DRB1*12:01, DQB1*03:01; DQA1*05:01.

Disk abnormality coexists with any degree of synovial and osseous abnormality in the temporomandibular joints of children with juvenile idiopathic arthritis

BACKGROUND

MRI manifestation of temporomandibular joint arthritis is frequently reported in children with juvenile idiopathic arthritis. However, little attention has been paid to temporomandibular joint disk abnormalities.

OBJECTIVE

To assess combinations of MRI findings in the symptomatic temporomandibular joint in children with juvenile idiopathic arthritis with focus on disk abnormalities.

MATERIALS AND METHODS

This was a retrospective study of 46 patients with juvenile idiopathic arthritis, mean age 12 years (range: 5-17 years). Mean disease duration was 70 months (standard deviation: 61 months). MR images of 92 temporomandibular joints were scored for thickness of abnormally enhancing synovium (synovitis), joint effusion, bone marrow oedema, abnormal bone shape, bone erosion and disk abnormalities.

RESULTS

The 92 temporomandibular joints were categorized as A: No synovitis and normal bone shape (30/92; 33%), B: Synovitis and normal bone shape (14/92: 15%), C: Synovitis and abnormal bone shape (38/92; 41%) and D: No synovitis but abnormal bone shape (10/92; 11%). Thirty-six of the 46 patients (78%) had synovitis and 33/46 (72%) had abnormal bone shape, most frequently in combination (30/46; 65%). Disk abnormalities (flat disk, fragmented disk, adherent disk and displaced disk) were found in 29/46 patients (63%). Disk abnormalities were found in all categories of juvenile idiopathic arthritis involved temporomandibular joints (B: 8/14 [57%]; C: 25/38 [66%] and D: 7/10 [70%]). Disk displacement was found in half of the joints (7/14) in category B. Synovitis was most pronounced in this category.

CONCLUSION

Disk abnormalities were frequent. Disk displacement also occurred in joints with early temporomandibular joint arthritis, i.e., with normal bone shape. Other disk abnormalities were found in joints with bone abnormalities. Attention should be paid to disk abnormalities both in early and long-standing temporomandibular joint arthritis in children with juvenile idiopathic arthritis.