Comprehensive Management of Rheumatic Diseases Affecting the Temporomandibular Joint

Abstract

The temporomandibular joint (TMJ) is a synovial joint and thus is vulnerable to the afflictions that may affect other joints in the fields of rheumatology and orthopedics. Too often temporomandibular complaints are seen strictly as dental or orofacial concerns. Similarly, patients with known rheumatic disease may not have their TMJs included in routine screening and monitoring protocols. The purpose of this review is to highlight the rheumatic conditions likely to affect the TMJ and outline medical and surgical management in these patients with a focus on the need for continued patient reassessment and monitoring.

Keywords: inflammatory arthritis; juvenile idiopathic arthritis; rheumatic disease; rheumatoid arthritis; temporomandibular disorder; temporomandibular joint.

Figure 1

A 26-year-old female presented for evaluation with chief complaints of right TMJ popping and pre-auricular pain for one year. She reported a strong family history of both systemic lupus erythematosus and Sjogren Syndrome. C-reactive protein was elevated and anti-nuclear antibodies showed speckled and homogenous patterns in high titers. (a) Dotted line indicates location of pain per patient; (b) CT was intentionally obtained with contrast to evaluate for TMJ and soft tissue abnormalities. Note an intra-parotid lesion lying immediately lateral to the mandibular condyle; (c) Intra-parotid lesion removed and found to be a basal cell adenoma. The patient’s symptoms resolved after treatment.

Figure 2

A 56-year-old female presented for evaluation with chief complaints of right TMJ pain and limited mandibular opening. Her history was most notable for long-standing RA refractory to multiple medications. (a) Bilateral toe involvement requiring Hoffman procedure; (b) Bilateral wrist involvement; (c) CT of the face showed early unilateral right TMJ ankylosis, lateral pannus formation, and heterotopic bone formation. The left TMJ was completely normal.

Figure 3

Basic framework for incorporating rheumatology referral and evaluation in patients presenting with signs and symptoms of a temporomandibular joint disorder. Patients found to have rheumatic diseases should undergo period TMJ imaging.

Figure 4

Recommended algorithm for treatment. Abbreviations: CCG—costochondral grafting; DO—distraction osteogenesis; IACS—intra-articular corticosteroids; mod—moderate; PT—physical therapy; TJR—total joint replacement.

Figure 5

Recommended monitoring protocol. Abbreviations: q6m—every 6 months; q12m—every 12 months; PE—physical exam; S/S—signs and symptoms; tx—treatment.