The Diagnosis and Treatment of Rheumatoid and Juvenile Idiopathic Arthritis of the Temporomandibular Joint

Abstract

Background: Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.

Methods: The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.

Results: Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrast-enhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intra-articular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.

Conclusion: Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.

Figure

Clinical management in symptomatic patients with a known history of RA/JIA based on Stoll et al. (e15) and Alstergren et al. (6) ^*1 Representing rheumatic diseases with temporomandibular joint involvement in adults *² Borderline MRI findings: low-grade increase in synovial contrast enhancement or low-grade joint effusion *³ Bone marrow edema/contrast enhancement, synovial contrast enhancement, synovial thickening and joint effusion *⁴ Condylar flattening, erosions, and disc changes *⁵ Differentiation: rheumatic joint disease: Krenn score ≥ 5 (high grade synovialitis); degenerative joint disease: Krenn score < 5 (low grade synovialitis) *⁶The indication for a synovial biopsy performed independently of an otherwise indicated intervention should be made based on strict indication criteria in order to avoid procedures that are not strictly necessary—this applies in particular to patients ≤ 17 years. CMD, craniomandibular dysfunction; IACI, intraarticular corticosteroid injections; JIA, juvenile idiopathic arthritis; MRI, magnetic resonance imaging; RA, rheumatoid arthritis

eFigure 1

Identification of studies in databases Literature search: PRISMA flow diagram 2020 (http://prisma-statement.org/prismastatement/flowdiagram.aspx)

eFigure 2

Clinical algorithm on correcting skeletal deformities in juvenile idiopathic arthritis (JIA) [modified from Resnick et al. (e3)] *¹: A loss of vertical height is a causal component of dentofacial deformity/asymmetry in JIA—hence the algorithm does not include a decision pathway without this pathology. *²: Ideally, if no progression is seen ≥ 1 year and there are no signs of acute inflammatory activity on magnetic resonance imaging (MRI) *³: Functional orthodontic treatment to correct/mitigate growth inhibition plus dentoalveolar compensation therapy *⁴: Surgical intervention postponed until better inflammatory control is achieved or spontaneous remission occurs. *⁵: Only if inflammation in the temporomandibular joint is well controlled Color key: blue = pharmacological treatment option; olive green = orthodontic treatment option; red = open surgical treatment option