Lessons learnt on patient safety in dentistry through a 5-year nationwide database study on iatrogenic harm

Safe delivery of care is a priority in dentistry, while basic epidemiological knowledge of patient safety incidents is still lacking. The objectives of this study were to (1) classify patient safety incidents related to primary dental care in Denmark in the period 2016-2020 and study the distribution of different types of dental treatment categories where harm occurred, (2) clarify treatment categories leading to "nerve injury" and "tooth loss" and (3) assess the financial cost of patient-harm claims. Data from the Danish Dental Compensation Act (DDCA) database was retrieved from all filed cases from 1st January 2016 until 31st December 2020 pertaining to: (1) The reason why the patient applied for treatment-related harm compensation, (2) the event that led to the alleged harm (treatment category), (3) the type of patient-harm, and (4) the financial cost of all harm compensations. A total of 9069 claims were retrieved, of which 5079 (56%) were found eligible for compensation. The three most frequent categories leading to compensation were "Root canal treatment and post preparation"(n = 2461, 48% of all approved claims), "lack of timely diagnosis and initiation of treatment" (n = 905, 18%) and "surgery" (n = 878, 17%). Damage to the root of the tooth accounted for more than half of all approved claims (54.36%), which was most frequently a result of either parietal perforation during endodontic treatment (18.54%) or instrument fracture (18.89%). Nerve injury accounted for 16.81% of the approved claims. Total cost of all compensation payments was €16,309,310, 41.1% of which was related to surgery (€6,707,430) and 20.4% (€3,322,927) to endodontic treatment. This comprehensive analysis documents that harm permeates all aspects of dentistry, especially in endodontics and surgery. Neglect or diagnostic delays contribute to 18% of claims, indicating that harm does not solely result from direct treatment. Treatment harm inflicts considerable societal costs.

Effects of orthopedic treatment (distraction splint) on dentofacial deformities in patients with juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joint (TMJ), which can alter mandibular growth and development and result in dentofacial deformities.

OBJECTIVE

To assess the outcomes of orthopedic treatment with distraction splint (DS) in patients with JIA-related dentofacial deformity.

METHODS

The retrospective study involved 30 patients with JIA and unilateral TMJ involvement, another study group of 20 patients with JIA and bilateral TMJ involvement, and a control group of 18 non-JIA orthodontic patients with Class II and III malocclusions. The inclusion criteria were DS treatment and cone-beam computed tomography (CBCT) scans before (T0) and 2 years after treatment (T1). Dentofacial morphology and deformity were evaluated based on a validated three-dimensional CBCT-based morphometric analysis. Intergroup differences in outcome measures were compared at T0 and T1, and intragroup changes between T0 and T1 were assessed using the Kruskal-Wallis test.

RESULTS

Initial evaluations at T0 revealed significant differences between the unilateral and bilateral JIA groups and the control group for three out of eight dentofacial deformity variables: inter-side difference in total posterior mandibular height, mandibular axial angle, and posterior/anterior face height (ratio). At follow-up (T1), significant inter-group differences were only observed in total posterior mandibular height indicating that intergroup differences were less pronounced after splint treatment. Assessing inter-group changes between T0 and T1 showed that all parameters remained constant except posterior/anterior face height ratio, which significantly decreased between T0 and T1.

CONCLUSIONS

The findings demonstrate the potential of DS treatment for patients with JIA and unilateral or bilateral TMJ involvement to generally support normal dentofacial growth or at least limit further deterioration of dentofacial deformities.

Apical incisor root resorption due to ectopic maxillary canine eruption: Association with time of diagnosis and type of intervention in a retrospective population-based cohort study

OBJECTIVES

The primary aim was to study upper incisor severe apical root resorption (RR) related to ectopic canine eruption and its association with timing of diagnosis and type of intervention conducted. The secondary aim was to correlate resorption with other dental anomalies.

MATERIALS AND METHODS

Digital journals and radiographic material of all ectopic maxillary canines registered in 2012 in the regional public paediatric dental clinics in the Council of Aarhus were inspected retrospectively. Data related to 10 variables were retrieved. Post-treatment radiographs were used for evaluation of incisor RR.

RESULTS

A total of 260 ectopic maxillary canines were diagnosed in 2012. The majority were found in the 9-13-year-old age group (0.8% prevalence within the total population). In all, 244 canines were assessed for eligibility and 181 had adequate final radiographs for evaluation of RR. Among ectopic maxillary canines, 9.4% caused severe incisor RR to neighbouring teeth. Timely palpation for canine eruption significantly reduced the odds for upper incisor resorption by 80%. Multiple regression showed that when the permanent canine cannot be palpated and the deciduous has been extracted, delaying the first X-rays was associated with a 38% odds ratio increase for RR for each year of delay after the age of 10 years. No significant associations were found between incisor RR and intervention conducted or other dental anomalies.

CONCLUSION

Palpation of erupting maxillary canines is crucial for timely diagnosis of ectopic eruption and initiation of treatment to avoid RR. If the canine cannot be palpated at 10 years of age, radiographic examination is highly recommendable.

Will supplemental cone beam computed tomography change the treatment plan of impacted maxillary canines based on 2D radiography? A prospective clinical study

AIM

To evaluate the impact of cone beam computed tomography (CBCT) on treatment planning for impacted maxillary canines; secondly, to identify CBCT factors influencing a change in the treatment plan; and thirdly, to assess 2D radiographic factors that can aid in selecting appropriate candidates for CBCT.

MATERIAL AND METHODS

Patients with impacted maxillary canines and an overlap of a neighboring tooth in 2D radiographs and the suspicion of root resorption were referred for CBCT examination. An initial treatment plan was based on 2D radiographs, and the final treatment plan was established after the CBCT examination. Logistic regression analyses and t-tests were performed to evaluate differences in radiographic findings between the groups with and without a change in treatment plan.

RESULTS

The study prospectively included 125 impacted canines, and 43 (34.4%) of them had a change in treatment plan after the CBCT examination. The most common change was a modification in the direction of cantilever traction (n = 28; 22.4%), while the least common was the change in decision to remove/keep the canine (n = 4; 3.2%). The size of the alpha and lateral angles had a significant impact on the decision to change the treatment plan. Other radiographic findings did not influence a change in treatment plan.

CONCLUSIONS

One-third of the canines had a change in treatment plan after supplemental CBCT examination. Canines with large alpha and lateral angles measured in the panoramic image were found to be significantly more likely to undergo changes in the initial direction of cantilever traction or changes to the canine extraction strategy following CBCT examination.

Management of temporomandibular joint arthritis in children and adolescents: An introduction for orthodontists

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease of childhood. JIA can affect any joint and the temporomandibular joint (TMJ) is one of the joints most frequently involved. TMJ arthritis impacts mandibular growth and development and can result in skeletal deformity (convex profile and facial asymmetry), and malocclusion. Furthermore, when TMJs are affected, patients may present with pain at joint and masticatory muscles and dysfunction with crepitus and limited jaw movement. This review aims to describe the role of orthodontists in the management of patients with JIA and TMJ involvement. This article is an overview of evidence for the diagnosis and treatment of patients with JIA and TMJ involvement. Screening for the orofacial manifestation of JIA is important for orthodontists to identify TMJ involvement and related dentofacial deformity. The treatment protocol of JIA with TMJ involvement requires an interdisciplinary collaboration including orthopaedic/orthodontic treatment and surgical interventions for the management of growth disturbances. Orthodontists are also involved in the management of orofacial signs and symptoms; behavioural therapy, physiotherapy and occlusal splints are the suggested treatments. Patients with TMJ arthritis require specific expertise from an interdisciplinary team with members knowledgeable in JIA care. Since disorders of mandibular growth often appear during childhood, the orthodontist could be the first clinician to see the patient and can play a crucial role in the diagnosis and management of JIA patients with TMJ involvement.

Incidence of Orofacial Manifestations of Juvenile Idiopathic Arthritis From Diagnosis to Adult Care Transition: A Population-Based Cohort Study

OBJECTIVE

To estimate the cumulative incidences of orofacial conditions related to temporomandibular joint (TMJ) juvenile idiopathic arthritis (JIA) between diagnosis in childhood to transition into adult care, and to identify features in JIA associated with TMJ involvement.

METHODS

A population-based cohort analysis was conducted of patients with JIA involving longitudinal data on orofacial health from 2000 to 2018. Regardless of TMJ status, the patients were referred to the Regional Specialist Craniofacial Clinic of Western Denmark for routine orofacial examinations. Data collection included information about disease-specific background characteristics, TMJ involvement, JIA-induced dentofacial deformity, and orofacial symptoms and dysfunction.

RESULTS

A total of 613 patients were followed up with a mean clinical TMJ observation time of 4.0 years. From JIA onset to transition into adult care, the cumulative incidence of patients with JIA involvement of the TMJ was 30.1%. Furthermore, 20.6% of the cohort had developed arthritis-induced dentofacial deformity. A substantial proportion of the cohort experienced several events with orofacial symptoms (23.5%) and dentofacial dysfunction (52%). Young age at diagnosis (<9 years), female gender, and antinuclear antibody positivity were significantly associated with TMJ involvement.

CONCLUSION

Orofacial signs and symptoms were frequent findings in children and adolescents with JIA. TMJ involvement was seen in 30.1% of the cohort; and 20.6% of the total cohort developed JIA-related dentofacial deformity before transition into adult care. This is the first population-based study in the era of available biologic treatments to document these frequent orofacial complications in children with JIA.

A novel method for assessment of human midpalatal sutures using CBCT-based geometric morphometrics and complexity scores

INTRODUCTION

Management of dentofacial deficiencies requires knowledge about sutural morphology and complexity. The present study assesses midpalatal sutural morphology based on human cone-beam computed tomography (CBCT) using geometric morphometrics (GMM) and complexity scores. The study is the first to apply a sutural complexity score to human CBCT datasets and demonstrates the potential such a score has to improve objectiveness and comparability when analysing the midpalatal suture.

MATERIALS AND METHODS

CBCTs of various age and sex groups were analysed retrospectively (n = 48). For the geometric morphometric analysis, landmark acquisition and generalised Procrustes superimposition were combined with principal component analysis to detect variability in sutural shape patterns. For complexity analysis, a windowed short-time Fourier transform with a power spectrum density (PSD) calculation was applied to resampled superimposed semi-landmarks.

RESULTS

According to the GMM, younger patients exhibited comparable sutural patterns. With increasing age, the shape variation increased among the samples. The principal components did not sufficiently capture complexity patterns, so an additional methodology was applied to assess characteristics such as sutural interdigitation. According to the complexity analysis, the average PSD complexity score was 1.465 (standard deviation = 0.010). Suture complexity increased with patient age (p < 0.0001), but was not influenced by sex (p = 0.588). The intra-class correlation coefficient exceeded 0.9, indicating intra-rater reliability.

CONCLUSION

Our study demonstrated that GMM applied to human CBCTs can reveal shape variations and allow the comparison of sutural morphologies across samples. We demonstrate that complexity scores can be applied to study human sutures captured in CBCTs and complement GMM for a comprehensive sutural analysis.

Challenges in treating juvenile idiopathic arthritis

PURPOSE OF REVIEW

Juvenile idiopathic arthritis (JIA) diagnosis and classification is currently still based on clinical presentation and general laboratory tests. Some joints such as the temporomandibular joint (TMJ) and sacroiliac (SI) are hard to assess and define as actively inflamed based on clinical examination. This review addresses these difficult to assess joints and provides the latest evidence for diagnosis and treatment.

RECENT FINDINGS

Recommendations on clinical examination and radiological examination are available. Recent 2021 ACR recommendations were made for TMJ arthritis and in 2019 for sacroiliitis.

SUMMARY

New evidence to guide clinical suspicion and need for further investigations are available for these hard to assess joints. These guidelines will help healthcare providers in diagnosis and treatment assessment.

Quality assessment of online information on orthodontic Web sites in the United States

INTRODUCTION

The objective of this study was to assess the quality of online information on orthodontic treatment provided by orthodontic Web sites in the United States and investigate their claims.

METHODS

Three hundred and one American orthodontic Web sites were identified after an advanced Google search. Data collection included: the location of the clinic, treatment options offered, quality-of-information assessment using the DISCERN tool, and finally, claims when promoting 1 treatment option against another, as well as the presence of information on relapse risk and retention needs.

RESULTS

All Web sites belonged to private clinics, with more than half (60.5%) in a single location. Invisalign (Align Technology, Santa Clara, Calif) was the most commonly promoted treatment option (94%), followed by the full fixed appliance (FFA) (92%). The mean DISCERN total score was poor (36.78 out of 80.00), whereas the mean reliability (questions 1-8) and quality-of-information (questions 9-15) scores were 17.06 out of 40.00 and 16.85 out of 35.00, respectively. Almost one-third (28%) of the Web sites compared aligners to FFA, whereas 25% claimed that aligners are less painful than FFA, faster than FFA (14%), or give better results than FFA (1%). Almost half of the Web sites (47%) failed to display information on relapse risk and retention needs after orthodontic treatment (41%). The Web sites that displayed such info had higher DISCERN total scores (P <0.001).

CONCLUSIONS

Invisalign seems to be the treatment modality most commonly mentioned online. According to DISCERN, U.S. orthodontic Web sites display poor or fair quality information. On many Web sites, aligner treatment was compared with FFA, with some stating that aligners cause less pain than FFA or are more efficient/faster than FFA. Moreover, almost half of the American orthodontic Web sites failed to display information on the relapse risk or retention need. Display of such information can be an indicator of better-quality Web sites. There is ample room for improvement in the online information American orthodontists provide to potential patients.

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.

Assessment of Orofacial Symptoms in Juvenile Idiopathic Arthritis: Validation of a Consensus-Based Short Patient Questionnaire

OBJECTIVE

To develop, validate, and test the performance of patient-reported outcomes (PROs) in a short patient questionnaire (< 5 minutes in length) in order to assess the multidimensional aspects of orofacial symptoms related to juvenile idiopathic arthritis (JIA) among patients aged ≥ 10 years.

METHODS

The study was conducted by an interdisciplinary task force from the Temporomandibular Joint Juvenile Arthritis Working Group. The project consisted of a multiphased approach including the following: (1) conceptual phase with online international survey of 167 healthcare workers, (2) item generation and drafting of preliminary questionnaire(s) (ie, face validity), (3) cognitive script interview and probing (ie, content validity; 16 patients with JIA), (4) assessment of construct validity (ie, convergence and divergence; 53 patients with JIA), (5) test of reliability, and (6) test of clinical performance and psychometric characteristics (95 patients with JIA).

RESULTS

In total, 7 PROs were included in the final patient questionnaire: (1) pain frequency, (2) pain intensity, (3) pain location, (4) jaw function, (5) specific questions related to symptoms and dysfunction, (6) changes in face and jaw pain since last visit, and (7) changes in jaw function since last visit. In total, 80% of the patients were able to complete the questionnaire in less than 5 minutes.

CONCLUSION

We have developed and validated a short patient questionnaire to assess the multidimensional aspects of JIA-related orofacial symptoms. The PROs included in our questionnaire show acceptable validity and reliability. The questionnaire is applicable to routine monitoring of subjects with JIA, as well as future research studies.

Restricted upper airway dimensions in patients with dentofacial deformity from juvenile idiopathic arthritis

BACKGROUND

This retrospective, cross-sectional study aimed to assess the pharyngeal airway dimensions of patients with juvenile idiopathic arthritis (JIA) and moderate/severe JIA-related dentofacial deformity (mandibular retrognathia/micrognathia), and compare the results with JIA patients with a normal mandibular appearance and a group of non-JIA patients.

METHODS

Seventy-eight patients were retrospectively included in a 1:1:1 manner as specified below. All patients had previously been treated at the Section of Orthodontics, Aarhus University, Denmark. All had a pretreatment cone beam computed tomography (CBCT). Group 1 (JIA+); 26 JIA patients with severe arthritis-related dentofacial deformity and mandibular retrognathia/micrognathia. Group 2 (JIA-); 26 JIA patients with normal mandibular morphology/position. Group 3 (Controls); 26 non-JIA subjects. Dentofacial morphology and upper airway dimensions, excluding the nasal cavity, were assessed in a validated three-dimensional (3D) fashion. Assessment of dentofacial deformity comprised six morphometric measures. Assessment of airway dimensions comprised nine measures.

RESULTS

Five morphometric measures of dentofacial deformity were significantly deviating in the JIA+ group compared with the JIA- and control groups: Posterior mandibular height, anterior facial height, mandibular inclination, mandibular occlusal inclination, and mandibular sagittal position. Five of the airway measurements showed significant inter-group differences: JIA+ had a significantly smaller nasopharyngeal airway dimension (ad2-PNS), a smaller velopharyngeal volume, a smaller minimal cross-sectional area and a smaller minimal hydraulic diameter than JIA- and controls. No significant differences in upper airway dimensions were seen between JIA- and controls.

CONCLUSION

JIA patients with severe arthritis-related dentofacial deformity and mandibular micrognathia had significantly restricted upper airway dimensions compared with JIA patients without dentofacial deformity and controls. The restrictions of upper airway dimension seen in the JIA+ group herein were previously associated with sleep-disordered breathing in the non-JIA background population. Further studies are needed to elucidate the role of dentofacial deformity and restricted airways in the development of sleep-disordered breathing in JIA.

Translation and cross-cultural adaptation of the sleep-related breathing disorder scale of the Pediatric Sleep Questionnaire into Danish language

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is common but often underestimated in children. The gold standard for assessing SDB is polysomnography, but it is expensive and time-consuming. The Paediatric Sleep Questionnaire (PSQ/SRDB) is a validated screening tool for SDB, which represents an efficient and alternative tool for screening SDB among children. However, a translated and validated Danish version of the PSQ/SRDB is not available yet. Our aim was to cross-culturally translate the PSQ/SRDB into Danish language for use in clinical and research settings.

PATIENTS/METHODS

The translation was carried out through forward-backward translation techniques performed by a panel of experts, and the cross-cultural adaptation was achieved by pretesting of the pre-final version. Internal consistency of the Danish PSQ/SRDB version was measured by Cronbach's alpha coefficients, while Cohen's kappa was used to evaluate test-retest reliability. Construct validity was assessed by factor analysis of the principal components.

RESULTS

The Danish PSQ/SRDB was administered to the caregivers of 348 children. An overall Cronbach's alpha of 0.72 was found, confirming the survey's consistency, with the results for the domains ranging 0.52-0.70. The Danish PSQ/SRDB showed moderate to perfect reliability for all items, except for one question (C14). Factor analysis performed on the Danish PSQ/SRDB showed that the predetermined four factors were similar with the original version of the PSQ/SRDB.

CONCLUSIONS

The Danish version of the PSQ/SRDB has been successfully translated and cross-culturally adapted, suggesting that it can be used as an appropriate paediatric screening tool for SDB in Denmark.

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.

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.

Efficacy and safety of intraarticular corticosteroid injections in adolescents with juvenile idiopathic arthritis in the temporomandibular joint: a Norwegian 2-year prospective multicenter pilot study

BACKGROUND

Intraarticular corticosteroids (IACs) have been used to treat temporomandibular joint (TMJ) arthritis. However, prospective clinical studies with magnetic resonance imaging (MRI) scoring are lacking. The aim of this study was to examine efficacy and safety of a single IAC in the TMJ in adolescents with juvenile idiopathic arthritis (JIA) in a clinical setting.

METHODS

In this Norwegian prospective multicenter pilot study 15 patients with JIA (mostly persistent oligoarthritis or RF negative polyarthritis categories) and a clinically and MRI-verified diagnosis of TMJ arthritis were treated with IACs and followed for 2 years. Demographics, systemic medication, general disease activity and outcome measures were recorded including a pain-index score and maximal incisal opening (MIO). Inflammation and bone damage scores were assessed, using two recently published MRI scoring systems with masked radiological evaluation.

RESULTS

Among the 15 patients, 13 received a single IAC (5 bilateral), and 2 repeated IACs once unilaterally. Thus, the total number of IACs was 22. Median age was 15 years and the majority had an age not thought of as critical regarding mandibular growth retardation due to steroid injection. During the 2-year observation period systemic medication with disease modifying antirheumatic drugs (DMARDs) including biologics was initiated or adjusted in 10/15 (67%) patients. At the 2-months study visit after injection we observed a minimal improvement in MIO from median 44 (1st, 3rd quartiles; 36, 48) mm to 45 (43, 47) mm, p = 0.045 and decreased MRI mean additive inflammatory score from 4.4 ± 1.8 standard deviations (SD) to 3.4 ± 2.0, p = 0.040. From baseline to the 2-months follow-up pain improved in 6/11 patients but pain scores were not significantly improved. MRI-assessed damage increased in two patients with repeated IACs, and decreased in 3 patients but most of the patients were stable over the 2-year follow-up. Intra-rater repeatability of the MRI scoring system domains varied from poor to excellent.

CONCLUSIONS

In this pilot study of predominately single IACs to the TMJ in combination with systemic treatment we observed improvement in MRI-assessed inflammation, mostly stable condylar bone conditions and minimal clinical improvement in adolescents with JIA and TMJ arthritis. No severe side effects were seen.

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.

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.

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.

Longterm Outcomes of Temporomandibular Joints in Juvenile Idiopathic Arthritis: 17 Years of Followup of a Nordic Juvenile Idiopathic Arthritis Cohort

OBJECTIVE

To determine the prevalence of orofacial symptoms, dysfunctions, and deformities of the temporomandibular joint (TMJ) in juvenile idiopathic arthritis (JIA) 17 years after disease onset.

METHODS

Drawn from a prospective, population-based Nordic JIA cohort with disease onset from 1997 to 2000, 420 consecutive cases were eligible for orofacial evaluation of TMJ involvement. The followup visit included demographic data, a standardized clinical orofacial examination, and full-face cone-beam computed tomography (CBCT). For comparison, 200 age-matched healthy controls were used.

RESULTS

Of 420 eligible participants with JIA, 265 (63%) were included (mean age 23.5 ± 4.2 yrs) and completed a standardized clinical orofacial examination. Of these, 245 had a full-face CBCT performed. At least 1 orofacial symptom was reported by 33%. Compared to controls, the JIA group significantly more often reported TMJ pain, TMJ morning stiffness, and limitation on chewing. Further, among participants reporting complaints, the number of symptoms was also higher in JIA. The mean maximal incisal opening was lower in the JIA group (p < 0.001), and TMJ pain on palpation was more frequent. Condylar deformities and/or erosions were observed in 61% as assessed by CBCT, showing bilateral changes in about 70%. Risk factors of condylar deformities were orofacial dysfunction or biologic treatment; enthesitis-related arthritis was protective.

CONCLUSION

This study of the longterm consequences of TMJ involvement in a population-based JIA cohort reports persistence of comprehensive symptoms, dysfunctions, and damage of the TMJ into adulthood. We suggest interdisciplinary followup of JIA patients also in adulthood.

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.

Standardizing Terminology and Assessment for Orofacial Conditions in Juvenile Idiopathic Arthritis: International, Multidisciplinary Consensus-based Recommendations

OBJECTIVE

To propose multidisciplinary, consensus-based, standardization of operational terminology and method of assessment for temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA).

METHODS

Using a sequential expert group-defined terminology and methods-of-assessment approach by (1) establishment of task force, (2) item generation, (3) working group consensus, (4) external expert content validity testing, and (5) multidisciplinary group of experts final Delphi survey consensus.

RESULTS

Seven standardized operational terms were defined: TMJ arthritis, TMJ involvement, TMJ arthritis management, dentofacial deformity, TMJ deformity, TMJ symptoms, and TMJ dysfunction. CONCLUSION: Definition of 7 operational standardized terms provides an optimal platform for communication across healthcare providers involved in JIA-TMJ arthritis management.

Orofacial symptoms and oral health-related quality of life in juvenile idiopathic arthritis: a two-year prospective observational study

BACKGROUND

Little is known about the chronicity of orofacial symptoms and how this influences the oral health-related quality of life in juvenile idiopathic arthritis (JIA). Therefore, our objectives were to study the long-term changes in self-reported orofacial symptoms, and to define the impact of orofacial symptoms on oral health-related quality of life in JIA.

METHODS

At baseline (T0), 157 consecutive JIA patients ≤20 years completed a patient pain questionnaire that incorporates domains related to the orofacial area. At the 2 year follow-up (T1), 113 patients completed the same questionnaire (response rate 72%) in addition to the Child Perception's Questionnaire; a validated 31-item questionnaire addressing oral health-related quality of life.

RESULTS

At T0, 53% (60/113) of patients reported the presence of orofacial pain, and 36% (41/113) of patients reported compromised orofacial function. At T1, 77% (46/60) of patients with pain at T0 reported persistent pain, and 66% (27/41) of patients with functional disability at T0 reported persistent disability. Patients with orofacial symptoms reported a significantly greater prevalence of negative impact of orofacial conditions on general quality of life and within the domains of emotional and social well-being compared to asymptomatic patients.

CONCLUSION

Self-reported orofacial pain and functional disability were common findings in a cohort of JIA patients followed over 2 years. These symptoms seem to persist over time in most patients, and have a significant negative impact on oral health-related quality of life.

Assessment of dentofacial growth deviation in juvenile idiopathic arthritis: Reliability and validity of three-dimensional morphometric measures

Introduction

Patients with juvenile idiopathic arthritis (JIA) and involvement of the temporomandibular joint (TMJ) often experience abnormal facial growth. Three-dimensional (3D) assessment of dentofacial growth deviation has become more common with advancement and commercialization of imaging technologies. However, no standardized guidelines exist for interpretation of 3D imaging in patients with JIA. The aim of this study was to propose and validate morphometric measures for the 3D radiographic assessment of dentofacial growth deviation in patients with JIA to enhance: 1) Description of dentofacial growth deviation; 2) Treatment planning; 3) Longitudinal follow-up.

Methods

The study was conducted in a standardized sequential-phased approach involving: 1) Preliminary decision-making; 2) Item generation; 3) Test of content-validity; 4) Test of reliability; 5) Test of construct validity; 6) Establishment of final recommendations.

Results

Twenty-one morphometric measures were evaluated. Based on results of reliability and validity-testing including subjects with JIA (n = 70) and non-JIA controls (n = 19), seven measures received a “high recommendation” score. Those measures were associated with posterior mandibular height, occlusal cant, mandibular asymmetry, mandibular inclination, and anterior/posterior lower face height. Nine other measures were “moderately recommended” and five received a “somewhat recommendation” score.

Conclusion

Seven morphometric measures were considered very useful in the 3D assessment of growth deviation in patients with TMJ disease associated with JIA. These variables can be used to standardize the description of dentofacial deformities and to plan corrective interventions.

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

OBJECTIVE

To describe characteristics of patients with juvenile idiopathic arthritis (JIA) presenting with isolated arthritis of the temporomandibular joints (TMJ).

METHODS

Patients with JIA with isolated TMJ arthritis from 4 large tertiary pediatric rheumatology centers were included. Demographic and clinical data were analyzed using descriptive statistics.

RESULTS

Fifty-five patients were identified (65% bilateral presentation). Six patients developed arthritis in other joints (median time 6 mos); 4 patients developed uveitis, all prior to arthritis. At last followup, 9% were still taking antirheumatic medications.

CONCLUSION

JIA TMJ arthritis can occur in isolation, and is probably underdiagnosed. Care providers including dentists and orthodontists should be aware of this presentation.

Idiopathic condylar resorptions: 3-dimensional condylar bony deformation, signs and symptoms

INTRODUCTION

Our aim was to describe 3-dimensional condylar deformation of the temporomandibular joint (TMJ) and symptoms and signs of temporomandibular dysfunction (TMD) in patients with idiopathic condylar resorption (ICR).

METHODS

We included 25 patients with ICR and 25 controls. We performed cone-beam computed tomographic scans and analyzed condylar width, length, and height as well as the condylar axial angle and the condylar neck angle. TMJ cross sections were evaluated for degenerative characteristics and location of bony deformations. Furthermore, symptoms and signs of TMD were described in the ICR group.

RESULTS

In the ICR group, we found statistically significantly reduced condylar width (mean difference, 2.0 mm), height (mean difference, 4.9 mm), and condylar axial angle (mean difference, 10.6°); 84% of the TMJs had a posterior condylar neck angle (control group, 22%). The most common degenerative changes were noncongruent shape of the condyle-fossa relationship (72%), condylar resorption (56%), and nonintact cortex (40%). More than 70% of the joints with bony deformations showed changes along the entire condylar head. Most patients with ICR showed symptoms and signs of TMD; nevertheless, 12% had no signs or symptoms of TMD.

CONCLUSIONS

ICR in the TMJ changes the shape and reduces the size of the condyle. Deformity locations are unspecified, and the entire condyle is often affected. Most patients with ICR have signs or symptoms of TMD; however, a small group was asymptomatic and without clinical signs.

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.

Normative values for mandibular mobility in Scandinavian individuals 4-17 years of age

Assessment of mandibular mobility is an important part of the clinical oro-facial examination of paediatric and adolescent patients. The aims of the present cross-sectional study were to establish age-related normative values for mandibular mobility in a Scandinavian paediatric and adolescent cohort and to assess the validity of universal cut-off values for lower 'normal' mandibular ranges of motion. A total of 1114 Danish individuals between 4-17 years of age were included. Maximal mouth opening capacity and laterotrusion capacity were assessed, in each individual, according to a standardised measurement protocol. The mean maximal mouth opening capacity gradually increased from 38 mm (SD 6·1 mm) at age 4 to 54·5 mm (SD 6·8 mm) at age 17. No inter-gender difference in maximal mouth opening capacity was observed (P > 0·15). The mean maximal laterotrusion capacity gradually increased from 7·4 mm (SD. 1·1 mm) at age four to 10·1 mm (SD 1·9 mm) at age 17. A statistical significant inter-gender difference of 0·8 mm (SD 0·4 mm) was observed in relation to the total laterotrusion capacity; however, the clinical relevance of this significant difference is questionable. Normative values of mandibular function was established in individuals 4-17 years of age. Our findings oppose the use of a single universal cut-off value for 'normal' range of motion in paediatric and adolescent patients. Instead, we recommend to use the age-related normative values of mandibular range of motion as basis for the assessment of the development of oro-facial function.

Temporomandibular joint steroid injections in patients with juvenile idiopathic arthritis: an observational pilot study on the long-term effect on signs and symptoms

BACKGROUND

Temporomandibular joint (TMJ) inflammation in patients with juvenile idiopathic arthritis (JIA) can lead to orofacial pain and malfunction of the TMJ. Intra-articular corticosteroid injections (IACI) have been suggested as a treatment modality against TMJ arthritis-related orofacial signs and symptoms. However, knowledge of the effect-durability of these injections remains unanswered. The aim of this pilot study was to evaluate the short and long-term effects of IACI on orofacial symptoms in a prospective observational study based on pre-specified clinical examination standards.

METHODS

Thirteen patients with JIA and arthritis-related orofacial signs and symptoms were included in this prospective pilot study (median 17.2 years, IQR 15-18.4 years). All patients received TMJ IACI (11 bilateral and two unilateral) due to an insufficient response to previous pain-management treatments. Three standardized clinical examinations were carried out: T1 prior to treatment, T2 short-term follow-up (mean 34 days post-treatment), T3 long-term follow-up (mean 333 days post-treatment).

RESULTS

Significant pain reduction was observed at the short-term follow-up (T2). Resolution of orofacial pain after IACI was a rare finding at T2. Generally, the pain significantly worsened between T2 and T3 examinations. The reported pain levels rose between T2 and T3 indicating a loss of effect of the IACI at the long-term follow-up examination (T3). Non-significant improvements in TMJ mobility were observed at T2 and T3.

CONCLUSION

Our results suggest a palliative (not curative) effect of IACI for TMJ arthritis-related orofacial symptoms in patients with long-term orofacial pain complaints. The short-term improvements in signs and symptoms were partly resolved at the long-term follow-up.

Signs and symptoms after temporomandibular joint washing and cannula placement assessed by cone beam computerized tomography

OBJECTIVE

Analyses of temporomandibular joint synovial fluid using the hydroxocobalamin push-pull technique are increasingly used. However, objective complications and subjective experiences from this procedure have not been described. Firstly, this study aimed to describe discomfort and potential side-effects of this method with special emphasis on symptoms related to the arthrocentesis to be used for future patient information and Ethical Committee applications. Secondly, this study aimed to evaluate the use of cone beam computed tomography (CBCT) as control of intra-capsular cannula placement.

METHODS

Twenty healthy, young adult volunteers were included. Extensive objective and subjective questionnaires were completed before and 14 days after the synovial fluid sampling. With the cannula inside the joints a CBCT was done to investigate if this procedure can be used to verify intra-capsular cannula position.

RESULTS

The subjective findings: Most subjects did experience mild pain or discomfort post-operatively. In 12 of 20 subjects symptoms had resolved after 2 days and no subjects had symptoms for more than a week. The longer lasting symptoms were mainly transient joint sounds on mandibular movement. Objective findings: 14 days after the sampling mandibular protrusion had improved 1 mm, but all other objective measures were equal compared to baseline. CBCT showed a large variation in cannula position and no conclusions could be drawn from this.

CONCLUSION

The hydroxocobalamin push-pull synovial fluid sampling may cause minor, transient symptoms. CBCT does not seem to provide any clinical benefits concerning the correct cannula position in relation to the upper joint compartment and disc.

Therapy. Intra-articular steroids for TMJ arthritis--caution needed

In the past decade, the consequences of temporomandibular joint arthritis in patients with juvenile idiopathic arthritis have received increasing attention. Intra-articular corticosteroid injections have been suggested as a treatment option, but concerns that this treatment could reduce mandibular growth have been raised and are supported by new data published in The Journal of Rheumatology.

Cytokines in healthy temporomandibular joint synovial fluid

Analysis of temporomandibular joint (TMJ) synovial fluid may elucidate the aetiology of temporomandibular disorders and arthritic conditions, as well as the inflammatory mechanisms involved. Knowledge about healthy synovial fluid is necessary to understand TMJ pathologies. We aimed to quantify the proinflammatory cytokines interleukin (IL)-1β, IL-2, IL-6 and tumour necrosis factor (TNF), and the anti-inflammatory cytokines IL-10 and interferon (IFN)-γ in healthy TMJ synovial fluid to serve as reference values for future studies on TMJ pathologies. Twenty healthy, young adult volunteers without temporomandibular dysfunction were included. Bilateral synovial fluid samples were obtained using the push-pull technique with hydroxocobalamin described by Alstergren in 1999. Cytokines were quantified with Luminex multiplex assays and compared using nonparametric statistical analysis. No serious adverse effects were reported. Of 40 possible samples, 14 fulfilled the strict sampling criteria and were included in the analysis. Cytokine values (reported as medians with interquartile ranges) were as follows: TNF, 23 (13-37) pg mL(-1) ; IL-2, 1·8 (0-22) pg mL(-1) ; and INF-γ, 10 (0-47) pg mL(-1) . IL-1β, IL-6 and IL-10 were almost undetectable. In addition, TNF and INF-γ cytokine levels correlated. We demonstrated that TNF was consistently detected and IFN-γ and IL-2 sporadically detected in the TMJ synovial fluid of healthy individuals using the hydroxocobalamin method and a multiplex assay. The cytokines IL-10, IL-1β and IL-6 were barely detectable in this sample of healthy TMJs.

Intra-articular steroid injection for temporomandibular joint arthritis in juvenile idiopathic arthritis: A systematic review on efficacy and safety

OBJECTIVE

To determine the current level of evidence for the use of intra-articular corticosteroid injections (IACI) against temporomandibular joint (TMJ) arthritis in patients with juvenile idiopathic arthritis (JIA) with a particular focus on clinical and radiological improvements and safety profile.

METHODS

A comprehensive electronic search strategy was performed in all major medical databases in February 2012. Studies were selected independently by two reviewers in accordance with a pre-specified protocol and a risk of bias assessment for all included studies.

RESULTS

Ninety-four unique citations were identified of which seven remained after the inclusion criteria were applied and all of these were assessed to have a high risk of bias. The current limited level of evidence suggests potential beneficial properties of IACI in patients with TMJ arthritis-related symptoms and/or MRI-verified signs of TMJ inflammation. Currently, no scientific evidence substantiates the effect of IACI in terms of (I) improving maximal mouth opening capacity significantly, (II) reducing radiological disease progression, (III) normalising/improving mandibular growth, and (IV) increasing efficacy upon repeated injections.

CONCLUSION

The current level of evidence allows only very limited conclusions on the effect of IACI therapy in patients with TMJ arthritis. Knowledge on the long-term impact of IACI on mandibular growth is not available. Future studies designed in accordance with evidence-based standards are needed to allow a more general conclusion on efficacy and safety of this treatment modality in patients with TMJ arthritis.

Condylar lesions in relation to mandibular growth in untreated and intra-articular corticosteroid-treated experimental temporomandibular joint arthritis

OBJECTIVES

To evaluate condylar lesions in relation to mandibular growth in experimental temporomandibular joint (TMJ) arthritis and to assess the outcome of treating this condition with repeated intra-articular corticosteroid injections (IACIs).

METHODS

Forty-two 10-week-old rabbits were randomly divided into four groups. Seven animals served as controls. Experimental TMJ arthritis was induced in five animals which received intra-articular TMJ saline injections. Fifteen animals had TMJ arthritis induced and were left untreated and 15 animals had TMJ arthritis induced and were treated with IACIs one week after each TMJ antigen-challenge procedure. Inter-group growth differences were evaluated from head computerised tomography scans taken at the time of arthritis induction and 12 weeks later. The variables assessed were: progression of condylar lesions (erosions/flattening/osteophytes), mandibular bone volume changes, condylar and sagittal ramus growth.

RESULTS

No inter-group differences in the progression of condylar lesions were observed despite reduced mandibular growth in all three experimental groups. The most pronounced unfavourable mandibular growth alterations were observed in the corticosteroid-treated arthritis animals.

CONCLUSIONS

No evidence was found in support of a relation between reduced mandibular growth and condylar lesions. We propose that: 1) condylar lesions are not the only causative factor of reduced mandibular growth in experimental TMJ arthritis, and 2) repeated IACIs have a very unfavourable impact on mandibular growth in experimental TMJ arthritis - treatment is more detrimental to mandibular growth than the TMJ arthritis itself.

Intra-articular vs. systemic administration of etanercept in antigen-induced arthritis in the temporomandibular joint. Part II: mandibular growth

BACKGROUND

Temporomandibular joint (TMJ) arthritis in children causes alterations in the craniomandibular growth. Resultant abnormalities include; condylar erosions, a posterior mandibular rotation pattern, micrognathia, malocclusion with an anterior open bite, altered joint and muscular function occasionally associated with pain. These alterations may be prevented by early aggressive anti-inflammatory intervention. Previously, we have shown that intra-articular (IA) corticosteroid reduces TMJ inflammation but causes additional mandibular growth inhibition in young rabbits. Local blockage of TNF-alpha may be an alternative treatment approach against TMJ involvement in juvenile idiopathic arthritis (JIA). We evaluated the anti-inflammatory effect of IA etanercept compared to subcutaneous etanercept in antigen-induced TMJ-arthritis in young rabbits in terms of mandibular growth. This article (Part II) presents the data and discussion on the effects on facial growth. In Part I the anti-inflammatory effects of systemic and IA etanercept administration are discussed.

METHODS

Arthritis was induced and maintained in the TMJs of 10-week old pre-sensitized rabbits (n = 42) by four repeated IA TMJ injections with ovalbumin, over a 12-week period. One group was treated weekly with systemic etanercept (0.8 mg/kg) (n = 14), another group (n = 14) received IA etanercept (0.1 mg/kg) bilaterally one week after induction of arthritis and one group (n = 14) served as an untreated arthritis group receiving IA TMJ saline injections. Head computerized tomographic scans were done before arthritis was induced and at the end of the study. Three small tantalum implants were inserted into the mandible, serving as stable landmarks for the super-impositions. Nineteen variables were evaluated in a mandibular growth analysis for inter-group differences. All data was evaluated blindedly. ANOVA and T-tests were applied for statistical evaluation using p < 0.05 as significance level.

RESULTS

Significant larger mandibular growth disturbances were observed in the group receiving IA saline injections compared with the systemic etanercept group. The most pronounced unfavourable posterior mandibular rotation pattern was observed in the group receiving IA saline injections.

CONCLUSION

Intervention with systemic etanercept monotherapy equivalent to the recommended human dose allows a mandibular growth towards an original morphology in experimental TMJ arthritis. Systemic administrations of etanercept are superior to IA TMJ administration of etanercept in maintaining mandibular vertical growth.

Intra-articular vs. systemic administration of etanercept in antigen-induced arthritis in the temporomandibular point. Part I: histological effects

BACKGROUND

Temporomandibular joint (TMJ) arthritis in children causes alterations in craniomandibular growth. This abnormal growth may be prevented by an early anti-inflammatory intervention. We have previously shown that intra-articular (IA) corticosteroid reduces TMJ inflammation, but causes concurrent mandibular growth inhibition in young rabbits. Blockage of TNF-alpha has already proven its efficacy in children with juvenile idiopathic arthritis not responding to standard therapy. In this paper we evaluate the effect of IA etanercept compared to subcutaneous etanercept in antigen-induced TMJ-arthritis in rabbits on histological changes using histomorphometry and stereology. This article presents the data and discussion on the anti-inflammatory effects of systemic and IA etanercept. In Part II the data on the effects of systemic and IA etanercept on facial growth are presented.

METHODS

Forty-two rabbits (10 weeks old) pre-sensitized with ovalbumin and locally induced inflammation in the temporomandibular joints were divided into three groups: a placebo group receiving IA saline injections in both joints one week after arthritis induction (n = 14), an IA etanercept group receiving 0.1 mg/kg etanercept per joint one week after arthritis induction (n = 14) and a systemic etanercept group receiving 0.8 mg/kg etanercept weekly throughout the 12-week study (n = 14). Arthritis was maintained by giving four inductions three weeks apart. Additional IA saline or etanercept injections were also given one week after the re-inductions. Histomorphometric and unbiased stereological methods (optical fractionator) were used to assess and estimate the inflammation in the joints.

RESULTS

The histomorphometry showed synovial proliferation in all groups. The plasma cell count obtained by the optical fractionator was significantly reduced when treating with systemic etanercept but not with IA etanercept. Semi-quantitative assessments of synovial proliferation and subsynovial inflammation also showed reduced inflammation in the systemic etanercept group. However, the thickness of the synovial lining and volume of the subsynovial connective tissue showed no differences between the groups.

CONCLUSION

An anti-inflammatory effect of systemic etanercept on the synovial tissues in the temporomandibular joint was shown. However, IA etanercept at the given dose had no significant effect on the severity of chronic inflammation on the parameters here tested in ovalbumin antigen-induced arthritis.

Quantitative histological changes of repeated antigen-induced arthritis in the temporomandibular joints of rabbits treated with intra-articular corticosteroid

BACKGROUND

To compare the inflammatory changes of antigen-induced temporomandibular joint (TMJ) arthritis in rabbits by different histological methods and to evaluate the immunomodulatory effect of intra-articular corticosteroid injections histologically.

METHODS

35 rabbits (10 weeks old) pre-sensibilized with ovalbumin were divided into three groups: a placebo group of five (saline), an arthritis group of 15 (ovalbumin) and a steroid-treated group of 15 (ovalbumin + corticosteroid). Additionally, a group of seven rabbits receiving no sensibilization with ovalbumin and no intra-articular injections served as controls. Histomorphometry of the inflammatory changes in the subsynovial connective tissue (SSCT) of the TMJ included: (i) semi-quantitative (S-Q) scoring of inflammation and synovial proliferation, (ii) thickness measurements and fractional surface and (iii) stereological quantitative assessment of volume and plasma cells in thick sections of the SSCT by an optical fractionator.

RESULTS

The histomorphometry showed synovial proliferation in both the arthritis and the steroid groups. The plasma cell count obtained by the optical fractionator was significantly reduced when treating the TMJ with corticosteroids. However, the thickness of the synovial lining and volume of the SSCT as well as S-Q scoring of inflammation showed no difference between the arthritis and the steroid-treated groups. The optical fractionator proved a superior tool compared to S-Q assessments.

CONCLUSION

Counting of plasma cells in the SSCT showed that corticosteroids reduced the inflammation, but did not eliminate it. Semiquantitative scoring of synovial proliferation and inflammation demonstrated low sensitivity regarding changes in immunomodulation in antigen-induced arthritis compared to stereological quantitative estimations using an optical fractionator.

Reduced mandibular growth in experimental arthritis in the temporomandibular joint treated with intra-articular corticosteroid

The aim of this investigation was to study the effect of intra-articular (i.a.) corticosteroid injections (IACIs) in the temporomandibular joint (TMJ) on mandibular development in antigen-induced TMJ arthritis. Ten-week-old female New Zealand white rabbits (n = 42) were randomly divided into four groups: group A, control (no injections); group B, placebo (repeated i.a. TMJ saline injections); group C, untreated arthritis (repeated induction of TMJ arthritis); and group D, steroid (repeated induction of TMJ arthritis + IACI). All animals had two tantalum implants inserted in the right side of the mandible serving as stable landmarks for later growth analysis. One implant was inserted close to the symphysis and one in the molar region. Computerized tomographic (CT) full-head scans were carried out at 14 (T1) and 26 (T2) weeks of age. (Dropout of animals at T2; group C, n = 7, and group D, n = 3.) Absolute and relative intra- and inter-group growth variations were evaluated during the growth period by comparison of CT scans. One-way analysis of variance was used for T1 statistical analysis, and absolute intra-group and relative inter-group growth differences between T1 and T2 were evaluated by Student's t-tests. At T2, the animals in the group A had greater sagittal and vertical mandibular growth compared with the other three groups. TMJ arthritis caused diminished mandibular growth. However, relative mandibular growth was significantly less in group D. The findings of this study do not indicate a positive long-term effect in the use of IACI in the TMJ as an early treatment intervention against TMJ inflammation in growing individuals.