Physical Findings Associated With Active Temporomandibular Joint Inflammation in Children With Juvenile Idiopathic Arthritis

doi:10.1016/j.joms.2013.04.009

Journal of Oral and Maxillofacial Surgery

Volume 71, Issue 10, October 2013, Pages 1683-1687

Presented at the 94th Annual Meeting of the American Association of Oral and Maxillofacial Surgeons, San Diego, CA, September 10-15, 2012.

https://doi.org/10.1016/j.joms.2013.04.009 Get rights and content

Purpose

To identify the physical findings associated with active temporomandibular joint (TMJ) inflammation (ie, synovitis) in children with juvenile idiopathic arthritis (JIA).

Patients and Methods

This was a retrospective study of children with JIA evaluated at Boston Children's Hospital. The patients were included if they had a confirmed diagnosis of JIA and had undergone a TMJ magnetic resonance imaging (MRI) study with contrast. Medical records and imaging studies were reviewed to document the demographic, physical (ie, facial asymmetry, joint noises, maximal incisal opening, deviation on opening, occlusal cant), and MRI findings. The outcome variable was TMJ synovitis on the MRI study. Descriptive and bivariate statistics were computed. Multiple regression models were used to identify associations (P ≤ .05, significance).

Results

A total of 51 patients with JIA were evaluated during the study period. Of these, 43 patients (33 girls) with a mean age of 11.4 years met the inclusion criteria. MRI demonstrated TMJ synovitis in 27 patients. The age-adjusted limited maximal incisal opening (MIO) and deviation on opening were the only physical findings significantly associated with synovitis on MRI (P = .003 and P = .043, respectively). Using these parameters as predictors of synovitis, a limited MIO and deviation on opening had a high specificity (86% and 94%, respectively). Patients with a limited MIO were 6.7 times more likely to have synovitis than those with a normal MIO. All patients with a limited MIO and deviation on opening had TMJ synovitis on the MRI scan.

Conclusions

The results of this study indicate that, in children with JIA, limited MIO and deviation on opening can be used to predict the presence of TMJ synovitis. Documentation of these parameters should be an essential part of the clinical examination and longitudinal follow-up of children with JIA.

Section snippets

Patients and Methods

This was a retrospective study (institutional review board approval no. M10-03-0129 and M09-12-0641) of children with JIA evaluated at Boston Children's Hospital from September 2009 to September 2012. JIA was diagnosed by a pediatric rheumatologist according to the International League of Associations for Rheumatology criteria. Patients were included if they had a confirmed diagnosis of JIA, had been evaluated by the Rheumatology and Oral and Maxillofacial Surgery services and had undergone a

Results

A total of 51 patients with JIA were evaluated during the study period. We identified 43 patients (33 girls) with mean age of 11.4 years (range, 3-16) who met the inclusion criteria. The arthritis medications included disease-modifying antirheumatic drugs such as methotrexate (n = 30, 69.8%); biologic agents, such as tumor necrosis factor-α inhibitor such as infliximab (n = 10, 23.3%); scheduled nonsteroidal anti-inflammatory medications such as naproxen (n = 7, 16.3%); and other (n = 1, 2.3%).

Discussion

Untreated TMJ synovitis can lead to functional limitations, jaw asymmetry, and/or malocclusion.1, 2, 3, 7, 15 Early detection and treatment can minimize these adverse outcomes. Although MRI with contrast is the most sensitive method for detecting TMJ synovitis in children with JIA,10, 11, 13 it has some limitations. MRI is costly, time consuming, can require general anesthesia, and specific TMJ surface coils might not be available at every facility.

Despite the occasional presence of pain, this

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Cited by (39)

Temporomandibular Joint Acoustic Emissions in Children With Juvenile Idiopathic Arthritis Differ From Those in Healthy Children
2022, Journal of Oral and Maxillofacial Surgery
Articulation of the temporomandibular joint (TMJ) generates sounds with specific characteristics known as joint acoustic emissions (AEs). The purpose of this project was to determine if AEs as described by the joint health score (JHS) in children with juvenile idiopathic arthritis (JIA) differ from AEs in healthy children.
The investigators implemented a cross-sectional study with age- and sex-matched controls to compare AEs from 4 groups: (1) healthy subjects without TMJ sounds, (2) healthy subjects with TMJ sounds, (3) subjects with JIA without TMJ sounds, and (4) subjects with TMJ sounds. Predictor variables were JIA status (ie JIA/healthy) and joint sounds (present/absent). The outcome variable was AEs. Subjects wore a specialized headset and performed specific jaw movements that generated AEs. AEs were recorded and analyzed using an aggregated decision tree classification model that calculates a JHS for each group. JHSs were compared using a receiver operating characteristic curve and classification accuracies. The study team used a 2-tailed unpaired t-test to determine if score distributions were different. Significance was P < .05.
A total of 51 subjects (102 TMJs; 37 females) with an average age of 13.1 years (range, 7 to 18) participated. Children with JIA and TMJ sounds had AEs with large repetitive clicks. Children with JIA without sounds had smaller repetitive clicks. Healthy children had grinding sounds with lower amplitude. The receiver operating characteristic curve had a classification accuracy of 71.6%. This accuracy compares against the gold standard clinical assessment for placing these patients into their groups (JIA vs healthy). JHSs of children with TMJ sounds and children with JIA and TMJ sounds were statistically significant (P < .0001).
In our sample, the AE of TMJs in healthy children may be different than that in children with JIA. Assessment of an AE is a promising and noninvasive technique to determine involvement of TMJs in children with JIA.
A clinical and MRI retrospective cohort study of patients with juvenile idiopathic arthritis (JIA) to determine if initial temporomandibular joint (TMJ) examination findings are associated with severity of TMJ arthritis
2022, Journal of Cranio-Maxillofacial Surgery
The purpose of the present study was to evaluate the association between initial TMJ examination findings and clinical and MRI severity of TMJ arthritis in a cohort of patients with JIA. The clinical variables were signs and symptoms at the initial TMJ evaluation. Outcome was the severity of TMJ arthritis as evaluated clinically by the Helkimo clinical dysfunction indices and by MRI. Associations of signs and symptoms with clinical and MRI severity were analyzed using a Fisher exact test and linear regression. The sample was composed of 101 patients with a mean age of 12.8 years, 76% of which were girls. Subjective difficulty in opening the mouth wide and objective limited MIO were the only clinical findings associated with both the severity of clinical dysfunction (p = 0.001 and p < 0.001, respectively) and the acute (p = 0.008 and p = 0.001, respectively) and chronic (p = 0.006 and p = 0.001, respectively) MRI severity of the TMJ arthritis. The results of this study suggest that in patients with JIA, limited mouth opening at the initial TMJ assessment may be a valid indicator of clinical severity of TMJ arthritis, which correlates with severity as seen on MRI.
Alloplastic Temporomandibular Joint Replacement in Patients With Systemic Inflammatory Arthritis and Connective Tissue Disorders
2021, Journal of Oral and Maxillofacial Surgery
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.
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.
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.
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
Management of inflammatory temporomandibular joint collapse in children
2021, Journal of Oral Biology and Craniofacial Research
Citation Excerpt :
TMJ evaluation should then be performed including evaluation of maximal incisal opening (MIO), deviation and latero-protrusive movements to establish a baseline for follow-up.9,7 A multidisciplinary approach and the evaluation of radiologic and laboratory abnormalities is often necessary for the diagnosis of JIA.7 Patients with JIA have at least two of the following clinical features for more than 6 weeks: joint swelling, pain/tenderness with motion, limitation of joint motion, and calor overlying the joint.6
Interdisciplinary Management of Dentofacial Deformity in Juvenile Idiopathic Arthritis
2020, Oral and Maxillofacial Surgery Clinics of North America
Temporomandibular Joint Reconstruction in Patients With Autoimmune/Connective Tissue Disease
2018, Journal of Oral and Maxillofacial Surgery
To evaluate clinical outcomes in patients with autoimmune or connective tissue (CT) disease undergoing temporomandibular joint (TMJ) reconstruction.
Patients were divided into 2 groups based on type of TMJ reconstruction. Patients in group 1 (n = 9) underwent autogenous reconstruction and had a diagnosis of rheumatoid arthritis (5), lupus arthritis (1), and psoriatic arthritis (3). Patients in group 2 (n = 2l) had alloplastic reconstruction with a patient-fitted total joint prosthesis (TMJ Concepts, Ventura, CA) and had a diagnosis of rheumatoid arthritis (15), lupus (3), and psoriatic arthritis (3). Standardized clinical and radiographic examinations were performed before surgery, immediately after surgery, and at longest follow-up after surgery (T3).
Group l showed no meaningful improvement in maximal opening without pain, a decrease in lateral excursions, minimal decrease in TMJ pain, and a 32% relapse of chin projection at point B at T3. Average postsurgery follow-up time was 58 months. Postsurgical ankylosis was seen in 22% of patients. In contrast, group 2 showed a statistically meaningful decrease in subjective TMJ pain and lateral excursive movements and improvement in jaw function, diet, maximal incisal opening without pain, and only 5% showed a relapse at point B at T3. Average postsurgical follow-up in this group was 78 months.
Improved treatment outcomes were obtained with alloplastic TMJ total joint reconstruction compared with autogenous TMJ reconstruction in patients with autoimmune or CT disease.

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: This project was supported in part by Oral and Maxillofacial Surgery Foundation/American Association of Maxillofacial Surgeons Faculty Educator Development Award (S.A.) and the Massachusetts General Hospital Oral and Maxillofacial Surgery Education and Research Fund.

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PathologyPhysical Findings Associated With Active Temporomandibular Joint Inflammation in Children With Juvenile Idiopathic Arthritis

Purpose

Patients and Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Temporomandibular involvement in juvenile idiopathic arthritis

J Rheumatol

Facioskeletal changes in children with juvenile idiopathic arthritis

Ann Rheum Dis

Juvenile idiopathic arthritis: The silent killer of pediatric temporomandibular joints

Z Rheumatol

Craniofacial growth in juvenile chronic arthritis

Acta Odontol Scand

Frequency of uncommon diseases: Is juvenile idiopathic arthritis under recognized?

J Rheumatol

The temporomandibular joint in juvenile idiopathic arthritis: Frequently used and frequently arthritic

Pediatr Rheumatol

Juvenile idiopathic arthritis an update for the clinician

Bull NYU Hosp Jt Dis

Pathology
Physical Findings Associated With Active Temporomandibular Joint Inflammation in Children With Juvenile Idiopathic Arthritis