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Pediatric Rheumatology Literature Review: An Article No One
Should Miss
Reviewer:
Pamela G Fitch, MD
Children’s Hospital
of Philadelphia
Editor of Literature Review:
Randy Q Cron
Children’s Hospital
of Philadelphia
Temporomandibular Involvement in Juvenile
Idiopathic Arthritis. Twilt M, Shell MLM, Arends L, ten Cate R,
van Suifekom-Smit LWA: J Rheum 2004; 31 (7): 1418-22
SIGNIFICANCE:
Temporomandibular (TMJ) involvement in Juvenile
Idiopathic Arthritis (JIA) is a well established morbidity. However,
the frequency of TMJ involvement overall as well as in the subtypes
of JIA is relatively unknown. Furthermore, TMJ involvement is difficult
to determine as the onset is often asymptomatic. The consequences of
unrecognized TMJ arthritis are micrognathia, asymmetric and submaximal
jaw opening, and pain. These authors review their experience in detecting
TMJ arthritis in 97 consecutive patients with JIA who visited the pediatric
rheumatology clinic of the Sophia Children’s Hospital over a period
of 6 months. Their results suggest that the overall prevalence of TMJ
involvement is 45%. Furthermore, they suggest that symptoms reported
by the patient, with the exception of pain with jaw excursion, were
not statistically significant predictors of disease. Conversely, abnormalities
noted on exam by the orthodontist were significantly useful in predicting
disease. They do suggest a trained pediatric rheumatologist can detect
these predictors on exam. It is extremely important, therefore, that
each child with JIA be examined for TMJ involvement at every follow-up
visit, and that pediatric rheumatologists have a low threshold for imaging
if TMJ involvement is suspected.
FINDINGS:
Over
a period of 6 months, 97 children (60 girls, 37 boys) with JIA according
to the ILAR criteria were examined by both a pediatric rheumatologist
and an orthodontist. The mean age of the children was 10 years, 8 months,
the mean age at onset was 5 years, 10 months, and the mean disease duration
at the time of examination was 4 years, 9 months. Orthopantomograms
(OPG), dental X-rays, were done on each child and scored 0-5 according
to the Rohlin system by blinded examiners. Their results suggest that
overall TMJ involvement (grades 1-5) was 45%. Of the 44 patients with
TMJ disease, half had bilateral involvement. Furthermore, children with
earlier onset and longer duration of disease were more likely to have
involvement. Interestingly, children with rheumatoid factor (RF) negative
polyarthritis and systemic onset JIA had the highest frequencies of
TMJ involvement at 59 and 67%, respectively.
The authors also suggest that the symptomatic
complaints of patients, with the exception of pain with jaw excursion,
were not statistically significant predictors of disease (p >
0.05). However, the orthodontic exam was very useful in identifying
significant predictors of disease. These predictors include the following:
absence or impaired translation during maximal jaw opening, asymmetric
opening, crepitation with movement, and protrusion (p < 0.05). Of
these predictors, absence of translation with opening (p < 0.009)
and asymmetry with jaw movement (p < 0.021) were the most significant.
Translation is the second part of jaw opening during which the jaw moves
forward for maximal opening.
These
findings highlight the importance of a thorough physical exam, including
the TMJ region at every visit of patients with JIA. The authors suggest
that if TMJ involvement is suspected then patients should be immediately
referred to an orthodontist. The authors also propose periodic screening
of all JIA patients for TMJ involvement with OPG, even in the absence
of clinical suspicion. Current screening practices of the authors include
yearly orthodontic exams. However, the ideal interval between exams
has yet to be determined.
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