TEMPOROMANDIBULAR
JOINT DISEASE IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS
AUTHORS:
Terry L. Moore, M.D.
Director, Division of Pediatric
and Adult Rheumatology
Professor of Internal Medicine
and Pediatrics
Didem O. Ince, D.D.S., M.S., Ph.D.
Former Graduate Student
Graduate Program in Orthodontics
Akgun Ince, M.D.
Associate Clinical Professor of
Internal Medicine
Division of Rheumatology
Saint Louis University Health Sciences
Center
Key Words: TEMPOROMANDIBULAR JOINT, JUVENILE
IDIOPATHIC ARTHRITIS
Contact: Terry L. Moore, M.D.
Director, Division of Pediatric
Rheumatology
Saint Louis University Health Sciences
Center
Room 211A, Doisy
Hall
1402 South Grand
St. Louis, MO 63104
Ph#: (314) 577-8469
Fax#: (314) 268-5117
E-mail: mooretl@slu.edu
Abstract
Juvenile
idiopathic arthritis (JIA) is a chronic, systemic disease of children
characterized by chronic synovitis [1]. JIA has been
shown to cause inflammation in the temporomandibular
joint (TMJ) and to decrease facial growth, resulting in micrognathia
[2]. Figure
1 shows typical TMJ changes seen by panoramic radiography. The frequency of
TMJ involvement varies and the subjective, clinical, and radiological findings
do not always agree, probably because of differences in methods and patient
samples [3-7]. The prevalence of micrognathia in JIA patients ranges from 5-100% [3, 4,
7-8]. Dentofacial
morphology of JIA children has, also, been well described in several
studies. Overall, small dimensions of
the mandible, posterior rotation of the mandible in relation to the cranial
base or a retrognathic mandible, steep mandibular plane, short ramus,
obtuse gonial angle, increased antegonial
notching, gonial apposition, increased anterior
facial convexity, and decreased posterior facial heights are common findings
[3,7,8].
Juvenile Idiopathic Arthritis
It is
generally agreed that a healthy TMJ condyle is
essential for normal mandibular development [7,
9-10]. However, many investigators
believe that the reduction in mandibular function in
JIA can also be of etiologic importance [9-10].
Recent studies have been performed to further evaluate the TMJ and mandibular growth alterations in patients with JIA. Ronchezel et al [3]
determined the frequency and type of lesions of the TMJ as well as orthodontic
alterations in 26 patients with JIA that they evaluated clinically and by
high-resolution computer tomography (CT).
CT detected TMJ alterations in 13 of 26 (50%) of patients with JIA. Bilateral lesions were the most
frequent. TMJ alterations were
especially observed in young patients with JIA with systemic and polyarthritis type of onset who had worse functional class
and previous corticosteroid therapy.
They observed orthodontic alterations in 18 patients with JIA (69%),
including midline deviation, convex facial profile, Class II molar relation,
crowded lower anterior teeth, anterior open bite, and reduction in maximum
opening of the mouth [3]. Severe TMJ
lesions were correlated to cephalometric alterations,
suggesting decreased mandibular growth [3].
Subsequently,
our group further evaluated the effects of polyarthritis,
pauciarthritis, and systemic onset JIA on facial
morphology and TMJ joint form and function, and also facial and mandibular growth [5,6].
Mericle et al [5] evaluated 30 patients with
JIA, 17 pauciarthritis and 13 polyarthritis
onset. We took medical and dental
histories, intraoral, lateral cephalometric,
and panoramic radiographs, facial photographs, and dental study models on these patients. Measures of TMJ dysfunction were gathered
during the clinical examination, and an index of condylar
morphology was inferred from the panoramic radiographs. The lateral cephalograms
were traced, and data from 34 linear and angular measures used to compare the
facial morphology of the two JIA onset types, both to normative standards and
to each other. As indicated by the
higher TMJ dysfunction and condylar index scores, polyarthritis affects the form and function of the TMJ more
frequently and severely, but so does pauciarthritis. Moreover, compared to normative cephalometric standards, the patients with polyarthritis had small, short facies
with underdeveloped mandibles. Overall,
both polyarthritis and pauciarthritis
onset JIA have a negative effect on the form, function, and esthetics of the
face and mandible; however, the effects were more pronounced with polyarthritis than the pauciarthritis
onset [5].
Hanna
et al [6] further evaluated 24 patients with systemic onset JIA to determine
its effects on facial morphology and TMJ form and function. The patients again were evaluated with
medical and dental histories, facial photographs, intraoral
examination, TMJ examination, lateral tomograms or panoramic radiographs, cephalograms, and impressions for study models. The cranial mandibular
index (CMI) was used to quantitate mandibular movement, tenderness, and TMJ noise. Symptoms were measured by symptom severity
index (SSI). CMI data from the patients
with systemic onset JIA were compared to a group of 24 children without
JIA. Our study indicated the facial
morphology of patients with systemic onset JIA is similar to that of the
healthy children except for a mild convex facial profile and backward rotation
of the mandible. Changes in facial form
were associated with radiographic condylar
abnormalities. CMI scores and SSI scores
of systemic onset patients were significantly greater than controls, and
radiographic condylar changes were noticed in 29%
percent of the patients with systemic onset JIA. Our study also indicated that systemic onset
JIA significantly affects TMJ form and function. Facial form was only affected in a few
patients with significant radiographic condylar
changes [6].
A
recent study by Vierucci et al [11] evaluated the
incidence of TMJ damage and its consequence on the growth modality of the craniofacial
complex in JIA. They evaluated 120 JIA
children’s TMJ anatomy and craniofacial complex by panoramic and lateral head
x-rays. Radiological signs of deviation
in the condylar shape were recorded. They found that radiological signs of
remodeling of mandibular condyles
were present in 60% of children, even though only 12% complained of subjective
symptoms of TMJ pain or dysfunction. Cephalometric angles between the mandibular
body, and palatal and cranial base plane, indicative of vertebral growth
pattern in a face, were also significantly increased. The whole mandibular
body assumed a more posterior and backward position. The profile of patients with condylar dysplasia results in
convexity and characterized by a short and retropositioned
mandible. The authors recommended early
and close orthodontic supervision in all JIA children, even with no sign of TMJ
pain or dysfunction, in order to limit the facial growth discrepancies due to
TMJ involvement [11].
Another
study by Schramm et al [12] evaluated 102 patients with JIA and introduced the Helkimo diagnostic index and Manley’s functional chewing
test in to the diagnostic standard of their outpatient clinic, which improved
early diagnosis of TMJ involvement. A
further study by Pedersen et al [13] evaluated condylar
changes of the TMJ in 169 consecutive patients with JIA on orthopantograms. They found that 62% of the patients exhibited
condylar resorption similar
to the previous results of Vierucci et al. [11]. The highest prevalence was seen again in
children with polyarthritis onset and early age at
onset. Severe resorption
was also frequent in these groups.
Patients with a positive ANA also had a high prevalence, but with a mild
degree of resorption.
Overall, however, the bone resorptive process
was mild [13].
Kuseler et al [14] evaluated 15
children with newly diagnosed JIA with radiographs and with magnetic resonance
imaging (MRI) enhanced with gadolinium diethylene
thiamine pentacetic acid (Gd-DTPA)
and 10 healthy children. The MRI variables
included T1-weighted images before and after administration of Gd-DTPA with and without fat suppression. They showed that MRI enhanced with Gd-DTPA indicated inflammatory activity in 87% of the
patients. Conventional MRI without
contrast proved to be insignificant in diagnosing early inflammatory
changes. There assumption was that
enhanced MRI is very efficient in diagnosing early inflammatory changes of the
TMJ and is a more sensitive method than the clinical examination and
radiographs [14].
A
further indication that early diagnosis is indeed necessary was found by Silva
et al [15] who evaluated 36 patients with JIA, 22 systemic onset, 7 oligoarthritis, and 7 polyarthritis
for oral-facial evaluation. They
evaluated tooth decay, missing and filled, plaque and gum bleeding indices,
clinical dysfunction, and mandibular dysfunction
index. Their study showed that the
biggest frequency of tooth decay and gum bleeding in patients with JIA was
associated with their TMJ limitation, indicating the necessity of frequent
dental evaluation in relation to orthodontic evaluation for long-term care of
these patients [15].
Recently,
three papers have addressed possible therapeutic modalities in patients with
early TMJ involvement. Routine care has
been orthodontic care, dental followup, non-steroidal
anti-inflammatory drugs (NSAIDs), and monitoring
peripheral joint involvement. A study by
our group, Ince et al [16], evaluated 27 JIA patients
with polyarthritis.
Of these, 18 were receiving methotrexate (MTX)
and NSAIDs, and 9 were receiving NSAIDS alone. A routine physical examination including a
detailed joint exam and a craniofacial examination were performed, which
included a radiographic TMJ evaluation with panoral
and corrected axial tomograms. Radiographic
evidence of condylar degeneration was apparent in 83%
of the polyarthritis JIA patients. However, the patients receiving MTX showed
less severe TMJ involvement than those not receiving MTX. A further study by our group also indicated
that the polyarthritis-onset JIA patients receiving
MTX showed less severe TMJ involvement than the polyarthritis
patients not receiving MTX [7]. In the
children with polyarthritis, the craniofacial
structure was affected to a greater extent and overall there was a correlation
between the severity of condylar lesions and cephalometric findings (mandibular
retroposition, posterior rotation, smaller ramus, and mandibular dimensions)
and the onset and duration of disease [7].
We found that MTX therapy was effective in minimizing TMJ destruction
and craniofacial dysmorphology in JIA patients with polyarthritis onset [7].
Lastly, a study by Martini et al [17] evaluated a patient with isolated
TMJ arthritis. She underwent
arthroscopic synovectomy followed by an intraarticular steroid injection. They stated that these methods may reduce
pain, improve jaw function, and prevent irreversible deformities.
These
studies have indicated that close followup and use of
NSAIDs, such as naproxen at 10-20 mg/kg or tolmetin at 20-30 mg/kg, are indicated at onset. The use of occlusal
splints, can, also, decrease the force on the articular
surfaces and thereby decrease pain [18].
The use of these splints is especially helpful when jaw clenching or bruxism is present.
However, the occlusion of JIA patients should be closely monitored since
heavy posterior occlusal contacts can cause the
development of an anterior bite. It
should be noted that the improvement of the occlusion does not always help or
prevent the TMJ problem.
It is
possible that future studies may demonstrate that more aggressive medical
therapy for JIA may decrease the frequency and severity of TMJ disease. For
example, the use of intraarticular steroids or synovectomy [17], and/or the early use of methotrexate [7,16] may prove valuable in reducing TMJ
dysfunction and pain. Also, the early
use of tumor-necrosis factor inhibitors may be helpful in preventing long-term
TMJ deformities.
In
summary, inflammation of the TMJ occurs in a surprisingly high percentage of
patients with all onset-types of JIA, especially those with polyarthritis.
This TMJ disease may have major cosmetic and dental consequences. We recommend
screening all patients who have TMJ pain or report any functional problems with
limitation of jaw movement, especially restriction in opening. The best and most cost-efficient way to
screen these patients is controversial as noted [5-15]. We would suggest
utilizing panoramic radiography which is available in many dental offices and
provides an excellent image of the bony structures of the condyles
[5-7]. However, articular
fossae are sometimes partially obscured, especially
if the patient has limited mandibular opening
resulting in superimposition of the articular fossa. Lateral
tomograms provide a more accurate view of the TMJ. They give a more detailed and accurate
picture concerning hard tissue changes and the joint space of the TMJ than
panoramic or transcranial radiography. The
disadvantage is they are costly, inconvenient to perform, and the patient is
exposed to higher levels of radiation than with other techniques [5-7]. Lastly,
the use of enhanced MRI may be the most efficient method of diagnosing early
TMJ changes, but may be cost prohibitive [14].
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