Temporomandibular Joint Involvement Research Articles

Evaluation of temporomandibular joint morphology and morphometry in male osteoporotic patients using advanced imaging and biochemical markers: A cross-sectional study.

Osteoporosis is a condition with reduced bone mass and disrupted architecture. Osteoporosis affects the Temporomandibular disorders (TMD) by changing bone density and quality. This study aims to determine the nature and extent of temporomandibular joint (TMJ) involvement in osteoporotic patients by correlating TMJ morphological changes detected by CBCT with systemic bone health indicated by BMD T-scores from DEXA and analyzing BTMs in serum and saliva. This study was a cross-sectional study conducted from May 2021 to December 2022. It involved 50 participants divided into two groups (N=25). One group was healthy male, while the other group had osteoporosis male. Saliva and blood samples were collected, and diagnostic imaging was conducted. The prevalence of various bone changes in the condyle was examined using CBCT. Erosion was found to be the most common, followed by Flattening, Osteophyte, and Subchondral cysts. The study group had significantly higher rates of smooth condyle, erosive lesions, and osteophytes compared to the control group. Pseudocyst decreased on the right side but increased on the left side. Pain on the right side increased more in the study group, and the T score for osteoporosis was higher in the study group. Joint spaces, condyle diameter, and glenoid cavity measurements differed significantly between sick and healthy people, as shown by CBCT (P≤0.001). Only the ALP parameter in the serum showed a significant increase in the study group compared to the control group. Saliva analysis revealed higher levels of calcium, osteocalcin, and ALP in the case group compared to the control group. The results of this study showed that CBCT as a specialized technique in imaging by providing detailed images can be used to evaluate osteoporosis and be used as an accurate diagnostic tool.

Temporomandibular involvement in children and adolescents with juvenile idiopathic arthritis: a 2-year prospective cohort study

This study aimed to clinically evaluate temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) and the ability to identify and/or predict development of TMJ-deformities over time using cone beam computed tomography (CBCT). The predictive value of self-reported TMJ pain was also assessed. A prospective longitudinal cohort study comprising 54 children with JIA, 39 girls and 15 boys, was performed. All children had active disease at baseline, 50% with the subtype oligoarthritis. Repeated clinical orofacial and CBCT examinations were performed over a two-year period. At baseline, 39% had radiographic TMJ deformities (24% unilateral, 15% bilateral), at 2-year follow-up, 42% (p > 0.05). Both progressing and improving TMJ deformities were observed. An association was found between TMJ-deformities and self-reported TMJ pain at baseline (p = 0.01). Maximum unassisted mouth opening (MUO) was smaller for children with TMJ-deformities (p < 0.05). The prevalence of palpatory muscle pain was high (48–59%) but not predictive of development of TMJ-deformities. TMJ noises increased over time and crepitations were associated with TMJ-deformities (p < 0.05). In conclusion, in children with JIA, self-reported TMJ pain and dysfunction were common and predictive of TMJ deformities. TMJ deformities were associated with smaller MUO and palpatory TMJ pain as well as crepitations. Trial registration. ClinicalTrials.gov Protocol id: 2010/2089-31/2.

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

Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joint (TMJ), which can alter mandibular growth and development and result in dentofacial deformities. To assess the outcomes of orthopedic treatment with distraction splint (DS) in patients with JIA-related dentofacial deformity. 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. 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. 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.

Psoriatic Arthritis Involving TMJ: A Review on Pathogenesis and Consideration on Eventual Gender Differences.

Psoriatic arthritis is defined as chronic inflammatory arthritis associated with psoriasis. The current data regarding gender differences in clinical manifestation and therapeutic outcomes of psoriatic arthritis are limited. Generally, men show a peripheral disease manifestation, while women have an axial distribution of the lesions. If we look at temporomandibular joint (TMJ) involvement, epidemiological data on the involvement of the TMJ are hard to find. Few studies on therapeutic management and the related impact on the quality of life are reported in the literature. Given the morpho-functional peculiarities of the TMJ and the different pain burdens between male and female genders, when manifestation of psoriatic arthritis occurs, clinicians should face it using a multidisciplinary approach for a correct diagnosis and successful treatment. This review aims to examine the diagnostic signs of psoriatic arthritis in the TMJ, the eventual variations of this disease in male and female patients, and the therapeutical strategies. The coordination of different specialties is fundamental to the remission of clinical symptoms and lesion regression.

Long-Term Follow-Up of Orthognathic Surgery in 19 Patients with Juvenile Idiopathic Arthritis.

Dentofacial deformity following juvenile idiopathic arthritis with temporomandibular joint involvement is associated with functional, aesthetic, and psychosocial impairment. Surgical treatment may involve combinations of orthognathic surgery. The aims of this retrospective study were to assess orofacial symptoms, functional and aesthetic status, and stability after orthognathic surgery. Nineteen patients with juvenile idiopathic arthritis of the temporomandibular joint (TMJ) and dentofacial deformities were included. All patients were treated with combinations of bilateral sagittal split osteotomy, Le Fort I and/or genioplasty, between September 10, 2007 and October 17, 2017. Analysis of patient symptoms and clinical registrations, and frontal/lateral cephalograms was performed pre- and postoperative and long-term (mean: 3.8 and 2.6 years, respectively). Patients experienced no changes in orofacial symptoms or TMJ function, and stable normalisation of horizontal and vertical incisal relations at long-term (horizontal overbite; vertical overbite: P < 0.05). Mandibular lengthening was achieved postoperatively (from mean 79.7 to 87.2 mm; P = 0.004) and was stable. Sella-nasion to A point (SNA) and sella-nasion to B point (SNB) angles increased postoperatively (SNA, mean 79.9° to 82.8°; P = 0.022 and SNB, mean 73.9° to 77.8°; P = 0.003), however, largely reverted to preoperative status at long-term. Orthognathic surgery normalized incisal relations while providing stable mandibular lengthening without long-term deterioration of temporomandibular joint function or orofacial symptoms. No long-term effect on jaw advancements was observed.

A rare case of severe isolated temporomandibular joint involvement in juvenile idiopathic arthritis

Background: Juvenile idiopathic arthritis is an inflammatory condition of unknown etiology. Early temporomandibular joint involvement may be asymptomatic or with mild symptomatology, despite radiological signs of substantial joint damage. Early diagnosis and management is of substantial importance, because orofacial symptoms due to temporomandibular joint arthritis may be disabling and interfere with impaired quality of life or even dentofacial abnormalities. When temporomandibular joint involvement is the first and only manifestation - a very rare event – it is easy to remain undiagnosed. It is noteworthy that the current body of published material on isolated arthritis of the temporomandibular joint is limited to 2 case reports and a multinational cohort of pediatric rheumatology centers.

EROSIVE TEMPOROMANDIBULAR JOINT DISORDER IN A PATIENT WITH ULCERATIVE COLITIS: RAREMANIFESTATION OF ARTHROPATHIES, CASE REPORT

Temporomandibular Joint (TMJ) involvement in patients with ulcerative colitis (UC) is a rare manifestation. To the best of our knowledge there are only two cases in the literature reported the presence of TMJ involvement in a patient with UC. We report a case of 23-year-old female with a two-year history of UC she was complaining of unilateral temporomandibular jaw pain, the pain was severe enough to affect her daily activities, she was not able to speak and there was a limitation of mouth opening. The patient was only able to open her mouth for 2.5 cm. C-reactive protein and erythrocyte sedimentation rate were high, rheumatoid factor was negative. The computed tomography (CT) of the mandible and teeth reveals flattening with erosion of the condylar process of the left mandibular joint without the presence of joint effusion or soft tissue swelling. Our patient was managed by biological treatment Ustekinumab for 6 months, as a result the patient improved and she was able to open her mouth up to 4 cm. Clinicians should be aware of the importance of biological treatment in these circumstances, TMJ arthritis in UC patients is considered a rare and unusual picture of extraintesinal IBD manfistations.

Oral health-related quality of life, impaired physical health and orofacial pain in children and adolescents with juvenile idiopathic arthritis – a prospective multicenter cohort study

BackgroundKnowledge on oral health-related quality of life (OHRQoL) in children and adolescents with juvenile idiopathic arthritis (JIA) is limited, and longitudinal studies are lacking. We aimed to describe OHRQoL in children and adolescents with JIA compared to controls, and to explore the validity and internal consistency of the Early Childhood Oral Health Impact Scale (ECOHIS) and the Child Oral Impact on Daily Performance (Child-OIDP). Furthermore, we wanted to investigate associations between OHRQoL and orofacial pain, physical health, disease activity, and temporomandibular joint (TMJ) involvement in JIA.MethodsThe Norwegian prospective, multicenter cohort study recruited participants with JIA between 4 and 16 years of age and corresponding controls from three pediatric university hospital departments and public dental health services. In the present study, we analyzed OHRQoL in all children < 12 years with the ECOHIS and adolescents ≥ 12 years with the Child-OIDP at the first visit and the two-year follow-up. Associations between OHRQoL and JIA characteristics, collected in clinical exam and questionnaires, were analyzed in logistic regressions.ResultsThe same OHRQoL questionnaire was completed both at first visit and two-year follow-up in 101 children < 12 years (47 JIA, 54 controls) and 213 adolescents ≥ 12 years (111 JIA, 102 controls). The frequency of OHRQoL impacts in children was similar at the first visit and the two-year follow-up (ECOHIS > 0: JIA group 81% and 85%, p = 0.791; control group 65% and 69%, p = 0.815), while adolescents with JIA reported fewer impacts at the two-year follow-up (Child OIDP > 0: JIA group 27% and 15%, p = 0.004; control group 21% and 14%, p = 0.230). The internal consistency of the OHRQoL instruments was overall acceptable and the criterion validity indicated that the instruments were valid at both visits. Orofacial pain was more frequent in children and adolescents with JIA than in controls. We found associations between OHRQoL impacts and orofacial pain, impaired physical health, disease activity, and TMJ involvement.ConclusionsChildren and adolescents with orofacial pain or impaired physical health were more likely to report impacts on daily life activities than those without. Pediatric rheumatologists and dentists should be aware of impaired OHRQoL in individuals with JIA with active disease or temporomandibular joint involvement.Trial registrationRegistered on clinicaltrials.gov (NCT03904459, 05/04/2019).

Nutritional problems in rheumatoid arthritis patients with temporomandibular joint involvement

Rheumatoid arthritis (RA) is an inflammatory arthritis that affects synovial joints, and it is not surprising that the temporomandibular joint (TMJ), a synovial joint, is also affected. However, TMJ is rarely the first affected joint in the course of RA. Often, RA patients come to the physician with more focus on complaints in other peripheral joints. Therefore, asking TMJ complaints and symptoms, and TMJ examination in RA patients is often neglected by doctors too, because they focus more on other joints. This neglect may cause serious damage to the joints and cause disability. Examination of TMJs, which is a crucial component of vital activities such as nutrition and speech, should be added to the routine. Also, further studies may be focused on adding TMJ assessment to disease activity scales and health assessment questionnaires.

Nutritional problems in rheumatoid arthritis patients with temporomandibular joint involvement

Rheumatoid arthritis (RA) is an inflammatory arthritis that affects synovial joints, and it is not surprising that the temporomandibular joint (TMJ), a synovial joint, is also affected. However, TMJ is rarely the first affected joint in the course of RA. Often, RA patients come to the physician with more focus on complaints in other peripheral joints. Therefore, asking TMJ complaints and symptoms, and TMJ examination in RA patients is often neglected by doctors too, because they focus more on other joints. This neglect may cause serious damage to the joints and cause disability. Examination of TMJs, which is a crucial component of vital activities such as nutrition and speech, should be added to the routine. Also, further studies may be focused on adding TMJ assessment to disease activity scales and health assessment questionnaires.

Temporomandibular joint disorders in seronegative spondyloarthritis: what a rheumatologist needs to know?

Temporomandibular joint (TMJ) can be affected in the context of spondyloarthritis (SpA) with detrimental impact on individuals' quality of life. Intra-articular inflammation, synovitis, enthesitis, disc displacement and cervical vertebrae malalignment are some of the pathophysiological phenomena involved. Temporomandibular joint disorders (TMD) incidence appears to be higher in patients with ankylosing spondylitis and psoriatic arthritis, especially when clinical evaluation includes not only imaging but relevant history, TMJ examination and diagnostic criteria for TMD. The Visual Analogue Scale (VAS) pain score and Health Assessment Questionnaire Disability Index (HAQ) quality of life score could be useful tools. Panoramic radiographs and ultrasound can be used for screening but in symptomatic patients magnetic resonance imaging (MRI) is preferable. Conservative management and early pharmacological treatment can prevent permanent joint impairment. For refractory cases, early referral to Legislation for Oral and Maxillofacial Surgery (OMFS) specialists is indicated. The aim of this narrative review is to address the involvement of TMJ in SpA and to encourage clinicians to incorporate TMJ assessment in their physical examination and basic screening.

Bilateral fibro-osseous TMJ ankylosis in Marie-Strumpell disease: a case report

Reporting a case of bilateral fibro-osseous TMJ ankylosis in Marie-Strumpell disease. Managed with interposition gap arthroplasty with temporalis myofacial flap. Marie-Strumpell disease or ankylosing spondylitis is a chronic inflammatory disorder affecting predominantly the axial skeleton although peripheral joint involvement may be a significant feature. Temporo-mandibular joint involvement in ankylosing spondylitis varies from 4% to 35%. A 53-year-old male patient reported to our department with a chief complaint of difficulty in opening his mouth and difficulty in eating food. The case was diagnosed as a case of bilateral fibro-osseous TMJ ankylosis associated with ankylosing spondylitis. The individual was managed with aggressive resection of ankylotic segments and inter-position of the temporalis myofascial flap bilaterally with early mobilization and aggressive physiotherapy. Aggressive resection of the ankylotic mass with inter-positional gap arthroplasty with early mobilization and aggressive physiotherapy is a highly effective and safe surgical management option for the management of TMJ ankylosis and with acceptable immediate and long-term outcome with minimum re-ankylosis and have produced satisfactory mandibular movements.

Impact of physiotherapy on orofacial manifestations of juvenile idiopathic arthritis

BackgroundPhysiotherapy appears as a promising therapy option for patients with Juvenile Idiopathic Arthritis (JIA) [1, 2], but the effects of physiotherapy and jaw exercises on JIA-related orofacial symptoms remain unknown [3]. The aim of this proof-of-concept study was to assess the impact of orofacial physiotherapy and home-exercise programs in patients with JIA and temporomandibular joint (TMJ) involvement.MethodsTwelve patients with JIA and TMJ involvement received a treatment of physiotherapy, complemented by prescribed home exercises spanning over eight weeks. Orofacial symptoms and dysfunction were monitored pre-treatment, during treatment, after treatment, and at a three-months follow-up.ResultsOrofacial pain frequency and intensity significantly decreased during the course of the treatment (p = 0.009 and p = 0.006), with further reductions observed at the three-month follow-up (p = 0.007 and p = 0.002). During treatment, the mandibular function improved significantly in terms of maximal mouth opening capacity, laterotrusion, and protrusion.ConclusionsThis proof-of-concept study shows favourable effects of physiotherapy and home excercises in the management of JIA-related orofacial symptoms and dysfunctions.

Otological symptoms in patients with rheumatoid arthritis of the temporomandibular joint

ABSTRACT Objective The aim of the current study was to describe the pattern of otological symptoms in patients with rheumatoid arthritis (RA), having clinical temporomandibular joint (TMJ) involvement. This issue had not been previously addressed. Methods A questionnaire and examination findings protocol was applied for 141 patients with RA and 141 control subjects. Results Otological symptoms (otalgia, hearing loss, tinnitus, and vertigo), all had a significantly higher incidence in RA patients, compared to control subjects (P = .001). Conclusion The onset and maintenance of otological symptoms in patients with TMJ involvement by RA probably result from peripheral, as well as central nervous system alterations in sensory stimuli programming.

E10 Temporo-mandibular joint involvement risk factors in juvenile idiopathic arthritis

Abstract Introduction Recent recommendations suppose temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) is a risk factor of poor outcomes and severe disease course. Objectives To compare the clinical characteristics of patients with juvenile idiopathic arthritis with and without TMJ involvement. Methods We analyzed the data of 753 patients with juvenile idiopathic arthritis aged 2–17 years, depending on TMJ arthritis (n = 43; 5.7%) or no TMJ arthritis (n = 710; 94.3%). Clinical, laboratory characteristics and treatment regimens were compared. Odds ratio (OR) analysis of sensitivity (Se) and specificity (Sp) was performed to obtained the predictors of TMJ involvement. Results Despite the similar age of onset, TMJ arthritis was associated with longer course of the disease, polyarticular JIA category, use of systemic corticosteroids and longer achievement of remission with similar rate of biologic administration. TMJ arthritis was associated with involvement of cervical spine, hip and shoulder arthritis. The main risk factors, associated with TMJ involvement in JIA were active joints &amp;gt; 8 (OR = 14.9 (5.8; 38.3), P = 0.0000001), delayed remission &amp;gt; 7 years (OR = 3.1 (1.6; 5.8), P = 0.0004), delayed hip involvement (OR = 4.6 (0.9; 22.6), P = 0.041), hip osteoarthritis (OR = 4.0 (1.2; 13.0), P = 0.014), and avascular necrosis of the hip. Cervical spine arthritis (OR = 10.3 (5.4; 19.8), P = 0.000001), and corticosteroid treatment (OR = 2.3 (1.2; 4.4), P = 0.0007) were associated with TMJ arthritis. Patients with TMJ arthritis required more biologics (OR-3.2 (1.6; 6.2), P = 0.0006). Oligoarticular JIA category and uveitis were protective against TMJ involvement. Data are in the table. Conclusion TMJ involvement is marker of poor disease prognosis. Early initiation of biologics and avoidance of corticosteroids might improve the risk of TMJ involvement. Ethics Written consent was obtained according to the declaration of Helsinki. This retrospective study's protocol was approved by the local Ethical Committee of Saint Petersburg State Pediatric Medical University (protocol number 11/10 from 23.11.2020).

Temporomandibular joint involvement in patients with Juvenile Idiopathic Arthritis: comparison of ultrasonography and magnetic resonance imaging in assessing the periarticular space width

ObjectivesThis study aimed to compare the performance of Ultrasonography (US) and Magnetic Resonance Imaging (MRI) in assessing the Lateral Periarticular Space (LPAS) of Temporomandibular Joints (TMJs) in patients with Juvenile Idiopathic Arthritis (JIA).MethodsThe LPAS width was evaluated in two different patient groups. In the JIA group, including 29 children (13 ± 2.8 years) with JIA, the LPAS width was measured with both MRI and US. In the healthy group, including 28 healthy children (12.6 ± 2.5 years), the LPAS width was measured only with US. Comparisons of LPAS width based on patient groups and TMJ contrast enhancement in MRI were evaluated by applying the Mann–Whitney U test. Correlation and agreement between MRI and US measurements in JIA group were tested using Spearman rank correlation and Bland–Altman method.ResultsThe LPAS width was significantly greater in the JIA group than in the healthy group. In the JIA group, the LPAS width was significantly greater in TMJs with moderate/severe enhancement than those with mild enhancement. A positive significant correlation between MRI and US measurements of LPAS width was found in the JIA group. In the same group, Bland–Altman method showed a good level of agreement between MRI and US measurements.ConclusionAlthough, US cannot replace MRI in the evaluation of TMJ in patients with JIA, US could be used as a supplementary imaging method to MRI in assessing the TMJ disease.

Clinically Established Temporomandibular Involvement in Adults With Juvenile Idiopathic Arthritis.

To study clinical variables defining temporomandibular function in adults with juvenile idiopathic arthritis (JIA) and healthy controls. In this cross-sectional study, the temporomandibular joint (TMJ) screening protocol, mandibular range of motion (MROM), and anterior maximum voluntary bite force (AMVBF) were compared between adults with JIA and healthy controls. Unadjusted and adjusted models with corrections for sex and disease duration were constructed for active maximum interincisal mouth opening (AMIO) and AMVBF. A total of 100 adults with JIA and 59 healthy adults were included in this study. In adults with JIA, 56% had clinically established TMJ involvement. AMIO was the MROM variable most reduced by TMJ involvement; AMIO was 8.8 mm (95% CI -11.40 to -6.12; P < 0.001) less in adults with JIA with TMJ involvement compared to JIA without TMJ involvement. No differences of AMIO were found between healthy adults and adults with JIA without TMJ involvement (-2.52, 95% CI -5.13 to 0.10; P = 0.06). Male sex was associated with a higher AMIO, and disease duration was associated with a decreased AMIO. Collinearity between the subtype prebiologic era and disease duration was found. AMVBF did not differ between adults with JIA and healthy adults. The high prevalence of clinically established TMJ involvement in adults with JIA indicates the need for awareness of TMJ problems in adults with JIA. TMJ involvement negatively influenced AMIO and should therefore be part of the TMJ screening in adults with JIA. AMVBF seems to have less utility for TMJ screening in adult populations.

Medication-related osteonecrosis of the external auditory canal - A rapid review of the literature and relevance to special care dentists.

There is growing evidence that anti-resorptive and anti-angiogenic medications can cause medication-related osteonecrosis of the external auditory canal (MROEAC). It is possible that patients taking risk medications may also suffer from concomitant medication -related osteonecrosis of the jaw (MRONJ) or temporomandibular joint(TMJ) involvement. The aim of this paper is to conduct a rapid review of the literature on MROEAC, and, its relevance to special care dentists. A rapid review of the literature was carried out using PubMed, Science Direct and Google Scholar to identify papers relating to MROEAC. The grey literature and non-English papers were also consulted. Overall, 19 papers were identified from 2005 until December 2022. Patients at risk of MRONJ may also be at risk of MROEAC and present to special care dentists. Dental/orofacial disease may cause signs and symptoms suggestive of MROEAC. It should be considered as a potential cause of orofacial pain in special care patients. MROEAC can have a significant impact on a patient's dental treatment, including access, the provision of sedation, communication difficulties, and consent issues.

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.

What matters most to pediatric rheumatologists in deciding whether to discontinue biologics in a child with juvenile idiopathic arthritis? A best-worst scaling survey.

Care for JIA patients has been transformed in the biologics era; however, biologics carry important (although rare) risks and are costly. Flares after biological withdrawal are seen frequently, yet there is little clinical guidance to identify which patients in clinical remission can safely have their biologic discontinued (by stopping or tapering). We examined what characteristics of the child or their context are important to pediatric rheumatologists when making the decision to discuss withdrawal of biologics. We conducted a survey including a best-worst scaling (BWS) exercise in pediatric rheumatologists who are part of the UCAN CAN-DU network to assess the relative importance of 14 previously identified characteristics. A balanced incomplete block design was used to generate choice tasks. Respondents evaluated 14 choice sets of 5 characteristics of a child with JIA and identified for each set which was the most and least important in the decision to offer withdrawal. Results were analyzed using conditional logit regression. Fifty-one (out of 79) pediatric rheumatologists participated (response rate 65%). The threemost important characteristics were how challenging it was to achieve remission, history of established joint damage, and time spent in remission. The threeleast important characteristics were history of temporomandibular joint involvement, accessibility of biologics, and the patient's age. These findings give quantitative insight about factors important to pediatric rheumatologists' decision-making about biologic withdrawal. In addition to high quality clinical evidence, further research is needed to understand the perspective of patients and families to inform shared decision-making about biologic withdrawal for JIA patients with clinically inactive disease. Key Points ● What is already known on this topic-there is limited clinical guidance for pediatric rheumatologists in making decisions about biologic withdrawal for patients with juvenile idiopathic arthritis who are in clinical remission. ● What this study adds-this study quantitatively examined what characteristic of the child in clinical remission, or of their context, are most important to pediatric rheumatologists in deciding whether to offer withdrawal of biologics. ● How this study might affect research, practice or policy-understanding of these characteristics can provide useful information to other pediatric rheumatologists in making their decisions, and may guide areas to focus on for future research.