Isolated Arthritis of the Temporomandibular Joint as the Initial Manifestation of Juvenile Idiopathic Arthritis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric Temporomandibular Joint Pathology

Pediatric temporomandibular joint (TMJ) disorders represent a broad range of congenital and acquired diagnoses. Dentofacial deformities, including facial asymmetry, retrognathism, and malocclusion, commonly develop. Compared with adult TMJ conditions, pain and articular disc pathology are less common. Accurate diagnosis is paramount in planning and prognostication. Several specific considerations apply in preparation for skeletal correction, including timing in relation to disease progression and growth trajectory, expectation for postcorrection stability, reconstructive technique as it applies to expected durability and need for future revision, management of occlusion, and need for ancillary procedures to optimize correction. This article reviews common conditions and treatment considerations.

Idiopathic condylar resorption in adolescents: A scoping review

OBJECTIVE

Idiopathic condylar resorption (ICR), also known as progressive condylar resorption, is poorly understood, particularly in adolescent patients. Therefore, this scoping review aims to summarize the available literature on the prevalence, aetiology, pathogenesis, diagnostic process, treatment and/or any outcome regarding ICR in adolescent individuals.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and its extension for scoping reviews (PRISMA-ScR), as well as Joanna Briggs Institute studies. The search strategy was defined adopting a core search structure for each source, and the search was performed on MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus and Google Scholar. After duplicate removal, two independent reviewers screened abstracts, followed by complete articles, to achieve the definition of included studies. Data collection was performed, and the extracted data were organized in tabular form, along with a narrative summary of main findings that aligns with the objective of this review.

RESULTS

Six observational studies were included in this review. Three studies focused on signs and symptoms, one on prevalence and signs and symptoms, one on treatment and one on disease pathogenesis.

CONCLUSION

This scoping review revealed inadequate published research regarding prevalence, aetiology, early diagnosis, pathogenesis and treatment of ICR in adolescents.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of physiotherapy on orofacial manifestations of juvenile idiopathic arthritis

BACKGROUND

Physiotherapy appears as a promising therapy option for patients with Juvenile Idiopathic Arthritis (JIA) [1, 2], but the effects of physiotherapy and jaw exercises on JIA-related orofacial symptoms remain unknown [3]. The aim of this proof-of-concept study was to assess the impact of orofacial physiotherapy and home-exercise programs in patients with JIA and temporomandibular joint (TMJ) involvement.

METHODS

Twelve patients with JIA and TMJ involvement received a treatment of physiotherapy, complemented by prescribed home exercises spanning over eight weeks. Orofacial symptoms and dysfunction were monitored pre-treatment, during treatment, after treatment, and at a three-months follow-up.

RESULTS

Orofacial pain frequency and intensity significantly decreased during the course of the treatment (p = 0.009 and p = 0.006), with further reductions observed at the three-month follow-up (p = 0.007 and p = 0.002). During treatment, the mandibular function improved significantly in terms of maximal mouth opening capacity, laterotrusion, and protrusion.

CONCLUSIONS

This proof-of-concept study shows favourable effects of physiotherapy and home excercises in the management of JIA-related orofacial symptoms and dysfunctions.

Does MRI Distinguish Juvenile Idiopathic Arthritis from Other Causes of Progressive TMJ Destruction?

PURPOSE

Similarities in initial presentations of temporomandibular joint (TMJ) involvement from juvenile idiopathic arthritis (JIA), idiopathic condylar resorption, and other forms of progressive TMJ destruction in children create diagnostic confusion. Treatment pathways, however, depend on determination of etiology. The purpose of this study was to compare TMJ magnetic resonance images (MRIs) of patients with joint degeneration localized to the TMJs to those with JIA and TMJ involvement.

METHODS

This is a retrospective cross-sectional study including subjects younger than 18 years that presented from February 2008 to October 2019 with clinical TMJ degeneration, a gadolinium-enhanced TMJ MRI and a negative pediatric rheumatologic workup ("non-JIA" group), and a series of age and sex-matched subjects with TMJ degeneration on gadolinium-enhanced MRI and JIA ("JIA group"). MRIs were evaluated in a blinded fashion by 1 pediatric radiologist. The primary outcome variable was the radiologist's accuracy in predicting study grouping, assessed in 1 randomly-selected joint per patient. Secondary outcome variables included MRI characteristics of inflammation, osseous damage and articular disc morphology. Independent samples t-tests, sensitivity/specificity, Fisher's exact and Mann-Whitney tests were computed as applicable, and P < .05 was considered significant.

RESULTS

The sample included 34 subjects: 16 non-JIA (75% female, age 13.9 ± 2.8 years) and 18 JIA (77% female, age 13.6 ± 2.8 years) (P ≥ .738). The radiologist correctly classified 64.7% of subjects as non-JIA or JIA (P = .078, sensitivity = 94.4%, specificity = 31.3%). Inflammatory and osseous findings were similar between groups (P ≥ .073). The disc was anteriorly displaced in 9 non-JIA and 0 JIA joints (P < .001, sensitivity = 100%, specificity = 100%) and flattened in 3 non-JIA and 14 JIA joints (P = .006, sensitivity = 38.9%, specificity = 90.6%).

CONCLUSION

Inflammatory and osseous findings on gadolinium-enhanced TMJ MRIs are insufficient to determine the etiology of progressive TMJ destruction. Disc characteristics, however, significantly differ between JIA and non-JIA etiologies and may be important in differentiating these conditions.

Management of Orofacial Manifestations of Juvenile Idiopathic Arthritis: Interdisciplinary Consensus-Based Recommendations

Involvement of the temporomandibular joint (TMJ) is common in juvenile idiopathic arthritis (JIA). TMJ arthritis can lead to orofacial symptoms, orofacial dysfunction, and dentofacial deformity with negative impact on quality of life. Management involves interdisciplinary collaboration. No current recommendations exist to guide clinical management. We undertook this study to develop consensus-based interdisciplinary recommendations for management of orofacial manifestations of JIA, and to create a future research agenda related to management of TMJ arthritis in children with JIA. Recommendations were developed using online surveying of relevant stakeholders, systematic literature review, evidence-informed generation of recommendations during 2 consensus meetings, and Delphi study iterations involving external experts. The process included disciplines involved in the care of orofacial manifestations of JIA: pediatric rheumatology, radiology, orthodontics, oral and maxillofacial surgery, orofacial pain specialists, and pediatric dentistry. Recommendations were accepted if agreement was >80% during a final Delphi study. Three overarching management principles and 12 recommendations for interdisciplinary management of orofacial manifestations of JIA were outlined. The 12 recommendations pertained to diagnosis (n = 4), treatment of TMJ arthritis (active TMJ inflammation) (n = 2), treatment of TMJ dysfunction and symptoms (n = 3), treatment of arthritis-related dentofacial deformity (n = 2), and other aspects related to JIA (n = 1). Additionally, a future interdisciplinary research agenda was developed. These are the first interdisciplinary recommendations to guide clinical management of TMJ JIA. The 3 overarching principles and 12 recommendations fill an important gap in current clinical practice. They emphasize the importance of an interdisciplinary approach to diagnosis and management of orofacial manifestations of JIA.

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.

Does Combined Temporomandibular Joint Reconstruction With Patient Fitted Total Joint Prosthesis and Orthognathic Surgery Reduce Symptoms in Juvenile Idiopathic Arthritis Patients?

PURPOSE

Patients with juvenile idiopathic arthritis (JIA) and TMJ involvement may have major dentofacial deformities, pain, and jaw dysfunction. The aim of this study was to evaluate surgical outcomes for JIA patients relative to TMJ pain, headache, jaw function, diet, disability, and quality-of-life (QOL) after TMJ reconstruction with patient-fitted total joint prostheses (TJP) and concomitant orthognathic surgery.

METHODS

A retrospective cohort study was conducted on a JIA patient group (JIAG) with significant dentofacial deformity, reconstructed with TJP and concomitant orthognathic surgery, and was compared to a control group (CG) of non-JIA patients that received the same surgical protocol with similar surgical movements. Primary predictors were the 2 groups: JIAG and CG. Data were evaluated and compared presurgery and at longest follow-up using Likert analog scales for the primary variables: TMJ pain, headache, jaw function, diet, and disability. Maximum interincisal opening (MIO) was measured in mm. QOL was rated in JIAG as improved, same, or worse. Comparative data were tested for significance (α = 0.05) using Wilcoxon signed rank and paired T-tests.

RESULTS

Forty JIAG patients (8 males, 32 females) met the inclusion criteria, median age 17.5 years, median follow-up 26.5 months, and 26 CG patients (1 male, 25 females), median age 35.5 years, follow-up 24 months. Significant improvements (P ≤ .05) occurred postsurgery for TMJ pain, headache, jaw function, diet, and disability for both groups. Mean increase MIO for JIAG was 36.4 to 43.3 mm, for CG was 35.2 to 37.8 mm. Thirty-eight JIA patients (95%) improved in QOL, 2 had no change, and none were worse.

CONCLUSIONS

This study suggests that patient-fitted TJP for TMJ reconstruction in conjunction with orthognathic surgery for the JIA patient provides long-term improvement relative to TMJ pain, headache, jaw function, diet, disability, MIO, and QOL.

Does Combined Temporomandibular Joint Reconstruction With Patient-Fitted Total Joint Prosthesis and Orthognathic Surgery Provide Stable Skeletal and Occlusal Outcomes in Juvenile Idiopathic Arthritis Patients?

PURPOSE

To determine skeletal and occlusal surgical changes and long-term stability outcomes for patients diagnosed with juvenile idiopathic arthritis (JIA) after TMJ reconstruction with TMJ Concepts patient-fitted total joint prostheses (TJP) and concomitant maxillary orthognathic surgery.

MATERIAL/METHODS

A retrospective cohort study was conducted of all patients diagnosed with JIA, receiving TJP, and concomitant maxillary orthognathic surgery between 1991 and 2019, at Baylor University Medical Center treated by 1 surgeon. Patient evaluations presurgery (T1), immediate postsurgery (T2), and at longest follow-up (LFU) (T3) were analyzed using 20 cephalometric landmarks to compute 29 linear and angular measurements to determine surgical changes, long-term skeletal and occlusal stability, as well as oropharyngeal airway changes. Comparative data were tested for significance (α = 0.05) using paired and unpaired t tests.

RESULTS

Forty-two patients met the JIA inclusion criteria, with a median age of 17.5 years and median postsurgical follow-up of 26 months. There were significant surgical changes (T1-T2) (P ≤ .05) for all parameters associated with mandibular linear and angular surgical changes, except for the horizontal position of posterior nasal spine and the vertical/horizontal position of gonion, indicating highly stable surgical outcomes. There were significant improvements in the oropharyngeal airway dimensions.

CONCLUSIONS

This study suggests that TMJ Concepts patient-fitted TJP for TMJ reconstruction in conjunction with maxillary orthognathic surgery for counterclockwise rotation of the maxillo-mandibular complex for the JIA patients provides long-term skeletal and occlusal stability as well as dimensional improvement in the oropharyngeal airway.

Alloplastic Temporomandibular Joint Replacement in Patients With Systemic Inflammatory Arthritis and Connective Tissue Disorders

PURPOSE

We present a retrospective study to report the outcomes of total temporomandibular joint (TMJ TJR) replacement with alloplastic devices in patients suffering from systemic inflammatory arthropathies.

METHODS

A total of 39 patients with a diagnosis of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PA), juvenile idiopathic rheumatoid arthritis (JIA), or systemic lupus, underwent alloplastic total joint replacement(s) (TJR) from 1999 to 2019. Maximal interincisal opening (in mm) was recorded before surgery (T0), at 1-year post-surgery (T1) and at last follow-up (T2). A visual analog scale (from 0 to 10) was used for subjective examination of pain before surgery (T0) and at last follow-up (T2). Comparisons were conducted with statistical significance set at P < .05.

RESULTS

Seventy-four joints were replaced in 39 patients. Thirty-two were female. The mean age was 36 years old (range 18-61) and the mean follow-up was 45.9 months (SD 49.4). The most common diagnosis was RA (n = 21), followed by JIA (n = 5) and AS (n = 5), PA (n = 4), lupus (n = 3), and mixed connective tissue disorder (n = 1). The mean pain score had fallen from 6.8 (SD 3.2) at T0 to 1.3 (SD 2.4) (P < .001) at T2. The maximal interincisal opening had improved from a mean of 22.1 mm (SD 13.3) at T0 to 34.3 mm (SD 8.5) (P < .001) at T2. One patient got persistent dysesthesia in the V3 distribution. There were no serious late complications.

CONCLUSION

Patients suffering from systemic inflammatory arthropathies involving the TMJs can be successfully treated by TJR with alloplastic devices. The long-term reduction of TMJ symptoms and functional improvement in this initial study suggest good predictability for this treatment.

Condylar changes in patients with idiopathic condylar resorption: retrospective 2-year follow-up CBCT-based case-control study

OBJECTIVES

To compare condylar development and changes in condylar radiological appearance in patients with idiopathic condylar resorption (ICR) to a healthy, age- and gender matched, control group.

MATERIALS AND METHODS

This case-control study included 16 ICR patients [mean age: 15years, 9 months; standard deviation (SD): 4 years) and 16 controls (mean age: 16 years, 8 months; SD: 4 years, 7 months), with diagnostic (T0) and 2-year follow-up (T1) CBCT examinations. Condylar changes were evaluated through changes in condylar neck angle (CNA), and the transversal, vertical and anteroposterior displacement of five condylar points between T0 and T1. The magnitude and direction of condylar changes were evaluated using vector analyses. A qualitative radiological evaluation of the TMJ was performed based on healthy, erosive and repaired morphological appearance. Linear and angular measurements were assessed using ANOVA and a Tukey post-hoc test, and vectors were tested using an independent-sample 2-tailed t-test. Fisher's exact test was used for the qualitative evaluation.

RESULTS

At T0, ICR patients exhibited decreased condylar height, smaller condylar width and posteriorly inclined CNA compared with the control group (P < 0.05). During observation, condylar vertical growth was smaller in the ICR group than in the control group (P < 0.05). Vector analysis showed an upward direction of vertical displacement for all condylar points in the control group; the ICR group showed a downward direction (P < 0.003). The radiological appearance of 75% of the ICR condyles and 94% of the control condyles did not change during the 2-year follow-up period.

CONCLUSIONS

ICR condyles displayed reduced vertical development compared with control condyles. The radiological appearance remained unchanged for most joints. Observed changes in radiological appearance did not always follow a progressive model of degenerative joint disease.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Cumulative Incidence of Orofacial Manifestations in Early Juvenile Idiopathic Arthritis: A Regional, Three-Year Cohort Study

OBJECTIVE

To estimate the cumulative incidence of arthritis-induced orofacial symptoms, dysfunction, and dentofacial deformities in growing individuals with juvenile idiopathic arthritis (JIA) in a 36-month regional cohort study and to identify predictors for the development of arthritis-induced dentofacial deformities.

METHODS

Data were retrieved from the Aarhus JIA temporomandibular joint (TMJ) cohort register, which contains standardized, longitudinal, observational data regarding orofacial conditions in patients with JIA (n = 1,040). This regional cohort represents the majority of all subjects with JIA from the western part of Denmark between 1990 and 2016, regardless of TMJ arthritis status. Cumulative incidences of orofacial conditions were reported using Kaplan-Meier methods, and predictors for dentofacial deformity were identified using Cox proportional hazards analysis.

RESULTS

Follow-up data from 351 subjects for 36 months were included in this study. Median age at first clinical examination was 6.6 years (interquartile range 4.8-9.9 years). Orofacial symptoms and dysfunctions were common findings at 36 months after the first clinical examination and 5 years after JIA onset, with a cumulative incidence of 38% and 53%, respectively. Dentofacial deformities were found in 35% of subjects at the 36-month follow-up and were significantly associated with the presence of orofacial dysfunction.

CONCLUSION

Orofacial conditions were frequently observed in individuals with JIA and were represented in all JIA subcategories in this regional study. One-third of subjects had arthritis-induced dentofacial deformities that required orthopedic appliance treatment at the 36-month follow-up.

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.

Main Oral Manifestations in Immune-Mediated and Inflammatory Rheumatic Diseases

Oral manifestations are frequent in patients with rheumatic diseases. The aim of this review is to offer readers practical advice concerning the onset, diagnosis and treatment of the main oral manifestations encountered in rheumatological and dental clinics. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, periodontal disease, and dysphagia may be the first expression of a number of rheumatic diseases. Some of these manifestations are aspecific and very frequent, such as oral aphthosis, which can be the first manifestation in patients with systemic lupus erythematosus; some are potentially dangerous, such as jaw claudication during the course of giant cell arteritis; and some are very rare but peculiar, such as strawberry-like gingivitis in patients with granulomatosis with polyangiitis. Other oral manifestations are due to adverse reactions to disease-modifying anti-rheumatic drugs. Oral alterations in rheumatic diseases are frequently overlooked in clinical practice, but their prompt recognition not only allows the local lesions to be appropriately treated, but also makes it possible to identify an underlying systemic disease.

Temporomandibular joint magnetic resonance imaging findings in adolescents with anterior disk displacement compared to those with juvenile idiopathic arthritis

BACKGROUND

Deformation of the mandibular condyle can be associated with anterior disk displacement (ADD) or involvement of the temporomandibular joint (TMJ) by juvenile idiopathic arthritis (JIA). Diagnostic differentiation is critical for proper management.

OBJECTIVES

To compare morphology and inflammation between TMJs with ADD and JIA.

METHODS

Retrospective assessment of contrast-enhanced TMJ MRI in 18 adolescents (15 female, mean age 15.1 ± 1.9 years) with ADD and age- and gender-matched patients with JIA. Articular disk findings, inflammatory signs and osseous morphology were compared.

RESULTS

In the ADD group, 31 of 36 disks were displaced. In total, 28 of 31 displaced disks showed thickening of the bilaminar zone. In JIA patients, the disks were mainly flattened (19/36), centrally perforated (12/36) and/or anteriorly displaced (2/36). In total, 19 of 31 TMJs with ADD showed various degrees of inflammation, with joint effusion, synovial thickening and joint enhancement not significantly different from JIA patients. Osseous deformity was present in 27 of 31 TMJs with ADD, with frequent erosions in both groups (ADD 25/31; JIA 32/36, P = 0.55) but lower grades of condylar and temporal bone flattening than in JIA (P ≤ 0.001). Glenoid fossa depth was preserved in 28 of 31 joints with ADD and decreased in 26 of 36 joints with JIA (P < 0.0001). Mandibular ramus height was decreased in both groups.

CONCLUSION

In adolescents, inflammatory signs are common MRI findings in symptomatic TMJs with ADD and thus should not be considered diagnostic for JIA involvement. In this cohort, both entities had high rates of condylar deformity, while TMJs with ADD showed a better-preserved and often normal shape of the glenoid fossa.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis: a preliminary report

OBJECTIVE

Children with juvenile idiopathic arthritis (JIA) are at risk for temporomandibular joint (TMJ) arthritis. This can lead to pain, limited mouth opening, facial asymmetry, and malocclusion. Our objective was to characterize patients with JIA and TMJ involvement in a single center.

STUDY DESIGN

This was a retrospective study of children with JIA evaluated at Children's Healthcare of Atlanta. Inclusion criteria were confirmed JIA and jaw complaints. Medical records were reviewed to document demographics, JIA information, age at first TMJ complaint, and involvement of other joints. Descriptive statistics were computed.

RESULTS

Majority of patients were white (mean age 13 years; range 5-18 years) with polyarticular rheumatoid factor (RF) negative or oligoarticular persistent JIA. Some were antinuclear antibody (ANA) positive, RF positive, or human leukocyte antigen (HLA)-B27 positive. Patients had involvement of other joints (e.g., fingers, knees, wrists). Of those with TMJ symptoms, 6 (10%) had TMJ arthritis.

CONCLUSIONS

In our cohort, 60 (10%) of patients were diagnosed with TMJ arthritis. In this population, patients who are female, white, RF negative, HLA-B27 negative, ANA negative, and polyarticular RF-negative subtype and have involvement of other joints have a higher likelihood of having TMJ symptoms. If a patient meets these criteria, careful evaluation of TMJs should take place.

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.