Temporomandibular Joint Involvement in Children With Systemic Arthritis - Preliminary Report

Abstract

Statement of the ProblemThe temporomandibular joint (TMJ) is frequently involved in children with autoimmune arthritis, yet there is little in the literature to guide clinicians in their evaluation and management. The purpose of this study was to document the presence and severity of clinical symptoms and radiographic findings in the TMJs of these patients and to correlate the findings with those in other joints.Materials and MethodsThis is a retrospective cross-sectional study of children with autoimmune inflammatory arthritis evaluated by the Pediatric Rheumatology and Oral and Maxillofacial Surgery (OMFS) Services at Children's Hospital Boston. Patients were included if they had autoimmune arthritis, were less than 16 years of age and were referred for jaw complaints. Medical records and imaging studies were reviewed. Demographic data (gender, race/ethnicity), history of disease (age at presentation to OMFS, duration, reason for referral, type of arthritis), clinical findings (pain, joint noise, maximal incisal opening, symmetry, occlusion), and radiographic findings (condyle symmetry and/or flattening, gonial angle notching) were recorded. Descriptive statistics were computed.Results of InvestigationThere were 65 subjects (48 females) with systemic arthritis and TMJ symptoms included in this study. The mean age was 11.7 +/− 3.8 years. Arthritis diagnoses were: juvenile idiopathic (N=35), psoriatic (N=18), and enthesitis related (N=12). Arthritis medications included: disease-modifying anti-rheumatic drugs (N=40, 61%) such as methotrexate; biologics (N=32, 49%) such as tumor necrosis inhibitor; anti-inflammatory medications (N=19, 29%) and other (N=2, 3%). Seven patients (10.8%) were taking no medications and 19 (29.2%) were taking 2 or more. At time of initial arthritis diagnosis, all patients had symptomatic joints: knee (N=44), ankle (N=15), finger (N=12), wrist (N=8), hip (N=4), and/or shoulder (N=4) and 11 patients (17%) had jaw symptoms. There were 35 (54%) patients with symptoms in more than 1 joint. At time of TMJ evaluation, patients had arthritis for an average of 4.6 years and 10 had symptoms in other joints. Most common findings were limited mouth opening (N=25), malocclusion or asymmetry (N=24), jaw pain (N=23), joint noises (N=11); 21 patients had more than 1 symptom. Mean maximal incisal opening was 35 mm (range 22-51 mm). Plain radiographs revealed symmetric condyles with normal morphology (N=34), symmetric condyles with abnormal morphology (N=11) and asymmetric condyles with abnormal morphology (N=13) such as condylar flattening (N=11) or accentuated antigonial notch (N=6). Of the patients with malocclusion/asymmetry, 14 patients (58.3%) had abnormal radiographs. Patients who had muscle tenderness only and no TMJ pain, swelling or tenderness, and normal condylar size and morphology on panoramic radiographs (N=37, 53%) were diagnosed with myofascial pain. They were managed with jaw rest, soft diet, warm compresses, physical therapy, occlusal bite splint, and/or anti-inflammatory medications. Patients with TMJ tenderness and abnormal condyles on radiographic examinations (N=28, 43%) were diagnosed with TMJ arthritis. These children were treated with intra-articular steroid injections with Aristospan (n=12 patients, 20 joints) or a change in systemic medications (n=16).ConclusionIn this sample of 65 children with systemic arthridities and jaw symptoms, 57% had myofascial pain without intra-articular TMJ disease and 43% had TMJ arthritis. Because children with autoimmune arthritis have a high incidence of myofascial pain without intra-articular pathology, OMFS must differentiate between the two groups to help determine the appropriate treatment strategy. In the next phase of this longitudinal study, progression of disease and response to therapy will be documented. Statement of the ProblemThe temporomandibular joint (TMJ) is frequently involved in children with autoimmune arthritis, yet there is little in the literature to guide clinicians in their evaluation and management. The purpose of this study was to document the presence and severity of clinical symptoms and radiographic findings in the TMJs of these patients and to correlate the findings with those in other joints. The temporomandibular joint (TMJ) is frequently involved in children with autoimmune arthritis, yet there is little in the literature to guide clinicians in their evaluation and management. The purpose of this study was to document the presence and severity of clinical symptoms and radiographic findings in the TMJs of these patients and to correlate the findings with those in other joints. Materials and MethodsThis is a retrospective cross-sectional study of children with autoimmune inflammatory arthritis evaluated by the Pediatric Rheumatology and Oral and Maxillofacial Surgery (OMFS) Services at Children's Hospital Boston. Patients were included if they had autoimmune arthritis, were less than 16 years of age and were referred for jaw complaints. Medical records and imaging studies were reviewed. Demographic data (gender, race/ethnicity), history of disease (age at presentation to OMFS, duration, reason for referral, type of arthritis), clinical findings (pain, joint noise, maximal incisal opening, symmetry, occlusion), and radiographic findings (condyle symmetry and/or flattening, gonial angle notching) were recorded. Descriptive statistics were computed. This is a retrospective cross-sectional study of children with autoimmune inflammatory arthritis evaluated by the Pediatric Rheumatology and Oral and Maxillofacial Surgery (OMFS) Services at Children's Hospital Boston. Patients were included if they had autoimmune arthritis, were less than 16 years of age and were referred for jaw complaints. Medical records and imaging studies were reviewed. Demographic data (gender, race/ethnicity), history of disease (age at presentation to OMFS, duration, reason for referral, type of arthritis), clinical findings (pain, joint noise, maximal incisal opening, symmetry, occlusion), and radiographic findings (condyle symmetry and/or flattening, gonial angle notching) were recorded. Descriptive statistics were computed. Results of InvestigationThere were 65 subjects (48 females) with systemic arthritis and TMJ symptoms included in this study. The mean age was 11.7 +/− 3.8 years. Arthritis diagnoses were: juvenile idiopathic (N=35), psoriatic (N=18), and enthesitis related (N=12). Arthritis medications included: disease-modifying anti-rheumatic drugs (N=40, 61%) such as methotrexate; biologics (N=32, 49%) such as tumor necrosis inhibitor; anti-inflammatory medications (N=19, 29%) and other (N=2, 3%). Seven patients (10.8%) were taking no medications and 19 (29.2%) were taking 2 or more. At time of initial arthritis diagnosis, all patients had symptomatic joints: knee (N=44), ankle (N=15), finger (N=12), wrist (N=8), hip (N=4), and/or shoulder (N=4) and 11 patients (17%) had jaw symptoms. There were 35 (54%) patients with symptoms in more than 1 joint. At time of TMJ evaluation, patients had arthritis for an average of 4.6 years and 10 had symptoms in other joints. Most common findings were limited mouth opening (N=25), malocclusion or asymmetry (N=24), jaw pain (N=23), joint noises (N=11); 21 patients had more than 1 symptom. Mean maximal incisal opening was 35 mm (range 22-51 mm). Plain radiographs revealed symmetric condyles with normal morphology (N=34), symmetric condyles with abnormal morphology (N=11) and asymmetric condyles with abnormal morphology (N=13) such as condylar flattening (N=11) or accentuated antigonial notch (N=6). Of the patients with malocclusion/asymmetry, 14 patients (58.3%) had abnormal radiographs. Patients who had muscle tenderness only and no TMJ pain, swelling or tenderness, and normal condylar size and morphology on panoramic radiographs (N=37, 53%) were diagnosed with myofascial pain. They were managed with jaw rest, soft diet, warm compresses, physical therapy, occlusal bite splint, and/or anti-inflammatory medications. Patients with TMJ tenderness and abnormal condyles on radiographic examinations (N=28, 43%) were diagnosed with TMJ arthritis. These children were treated with intra-articular steroid injections with Aristospan (n=12 patients, 20 joints) or a change in systemic medications (n=16). There were 65 subjects (48 females) with systemic arthritis and TMJ symptoms included in this study. The mean age was 11.7 +/− 3.8 years. Arthritis diagnoses were: juvenile idiopathic (N=35), psoriatic (N=18), and enthesitis related (N=12). Arthritis medications included: disease-modifying anti-rheumatic drugs (N=40, 61%) such as methotrexate; biologics (N=32, 49%) such as tumor necrosis inhibitor; anti-inflammatory medications (N=19, 29%) and other (N=2, 3%). Seven patients (10.8%) were taking no medications and 19 (29.2%) were taking 2 or more. At time of initial arthritis diagnosis, all patients had symptomatic joints: knee (N=44), ankle (N=15), finger (N=12), wrist (N=8), hip (N=4), and/or shoulder (N=4) and 11 patients (17%) had jaw symptoms. There were 35 (54%) patients with symptoms in more than 1 joint. At time of TMJ evaluation, patients had arthritis for an average of 4.6 years and 10 had symptoms in other joints. Most common findings were limited mouth opening (N=25), malocclusion or asymmetry (N=24), jaw pain (N=23), joint noises (N=11); 21 patients had more than 1 symptom. Mean maximal incisal opening was 35 mm (range 22-51 mm). Plain radiographs revealed symmetric condyles with normal morphology (N=34), symmetric condyles with abnormal morphology (N=11) and asymmetric condyles with abnormal morphology (N=13) such as condylar flattening (N=11) or accentuated antigonial notch (N=6). Of the patients with malocclusion/asymmetry, 14 patients (58.3%) had abnormal radiographs. Patients who had muscle tenderness only and no TMJ pain, swelling or tenderness, and normal condylar size and morphology on panoramic radiographs (N=37, 53%) were diagnosed with myofascial pain. They were managed with jaw rest, soft diet, warm compresses, physical therapy, occlusal bite splint, and/or anti-inflammatory medications. Patients with TMJ tenderness and abnormal condyles on radiographic examinations (N=28, 43%) were diagnosed with TMJ arthritis. These children were treated with intra-articular steroid injections with Aristospan (n=12 patients, 20 joints) or a change in systemic medications (n=16). ConclusionIn this sample of 65 children with systemic arthridities and jaw symptoms, 57% had myofascial pain without intra-articular TMJ disease and 43% had TMJ arthritis. Because children with autoimmune arthritis have a high incidence of myofascial pain without intra-articular pathology, OMFS must differentiate between the two groups to help determine the appropriate treatment strategy. In the next phase of this longitudinal study, progression of disease and response to therapy will be documented. In this sample of 65 children with systemic arthridities and jaw symptoms, 57% had myofascial pain without intra-articular TMJ disease and 43% had TMJ arthritis. Because children with autoimmune arthritis have a high incidence of myofascial pain without intra-articular pathology, OMFS must differentiate between the two groups to help determine the appropriate treatment strategy. In the next phase of this longitudinal study, progression of disease and response to therapy will be documented.