Management of Orofacial Manifestations of Juvenile Idiopathic Arthritis: Interdisciplinary Consensus-Based Recommendations

Involvement of the temporomandibular joint (TMJ) is common in juvenile idiopathic arthritis (JIA). TMJ arthritis can lead to orofacial symptoms, orofacial dysfunction, and dentofacial deformity with negative impact on quality of life. Management involves interdisciplinary collaboration. No current recommendations exist to guide clinical management. We undertook this study to develop consensus-based interdisciplinary recommendations for management of orofacial manifestations of JIA, and to create a future research agenda related to management of TMJ arthritis in children with JIA. Recommendations were developed using online surveying of relevant stakeholders, systematic literature review, evidence-informed generation of recommendations during 2 consensus meetings, and Delphi study iterations involving external experts. The process included disciplines involved in the care of orofacial manifestations of JIA: pediatric rheumatology, radiology, orthodontics, oral and maxillofacial surgery, orofacial pain specialists, and pediatric dentistry. Recommendations were accepted if agreement was >80% during a final Delphi study. Three overarching management principles and 12 recommendations for interdisciplinary management of orofacial manifestations of JIA were outlined. The 12 recommendations pertained to diagnosis (n = 4), treatment of TMJ arthritis (active TMJ inflammation) (n = 2), treatment of TMJ dysfunction and symptoms (n = 3), treatment of arthritis-related dentofacial deformity (n = 2), and other aspects related to JIA (n = 1). Additionally, a future interdisciplinary research agenda was developed. These are the first interdisciplinary recommendations to guide clinical management of TMJ JIA. The 3 overarching principles and 12 recommendations fill an important gap in current clinical practice. They emphasize the importance of an interdisciplinary approach to diagnosis and management of orofacial manifestations of JIA

CBCT characteristics and interpretation challenges of temporomandibular joint osteoarthritis in a hand osteoarthritis cohort.

OBJECTIVES: To characterise osteoarthritis (OA) in the temporomandibular joints (TMJs) by means of cone beam CT in a hand OA population, and identify interpretation challenges. METHODS: The TMJs of 54 individuals (mean age 71.3) recruited from the “The Oslo hand OA cohort”, independently of TMJ-related symptoms, were examined with cone beam CT (ProMax MidCBCT). Images were analysed for bone change characteristics and each joint was diagnosed with either OA, no OA or as indeterminate for OA. The image analysis criteria developed for the Research Diagnostic Criteria for Temporomandibular Disorders were used. Frequencies of bone changes, joint diagnoses and severity grades (1–2) were calculated, as well as κ values for observer agreement. RESULTS: In the OA joints, the most frequent bone changes occurred in the condyle: flattening (79%), osteophyte (72%) and subcortical sclerosis (70%). The most frequent changes in the fossa/eminence were flattening (57%), erosion (49%) and subcortical sclerosis (47%). 53 (49%) of the 108 joints were diagnosed with TMJ OA (68 % Grade 2), 29 joints (27%) with no OA, and 26 joints (24%) were indeterminate for OA. Inter- and intraobserver agreement showed mean κ values of 0.67 and 0.62, respectively. CONCLUSIONS: TMJ changes were common in elderly with hand OA and characterised by bone productive changes. The radiologic features indicated a late stage TMJ OA. Interpretation challenges related to subtle changes were identified and are reflected by the rather low observer agreement. The diagnosis of TMJ OA should be based on evident and clear abnormalities only

Improvement of Bone-Erosive Temporomandibular Joint (TMJ) Abnormalities in Adolescents Undergoing Non-Surgical Treatment: A Longitudinal Study

Objectives: To investigate the longitudinal changes of the imaging temporomandibular joint (TMJ) characteristics in young patients with TMJ-related symptoms and treated with non-surgical methods. The severity of self-reported symptoms at follow-up was also investigated. Methods: A cone beam CT (CBCT)/CT follow-up examination [median follow-up 4.1 (1.3–6.4) years] was performed in 22 patients with erosive TMJ abnormalities [baseline median age 16 (12–18) years]. Imaging characteristics were analyzed and the changes between the examinations were categorized as (A) improvement, (B) no change, or (C) worsening. Severity of follow-up symptoms was evaluated using Jaw Functional Limitation Scale (JFLS-8) and Graded Chronic Pain Scale (Grade 0–IV). Analyses were performed separately for left and right TMJ. Findings at baseline and follow-up were compared using McNemar test to account for dependencies. Changes in proportions of hard tissue findings between examinations were assessed using Wilcoxon signed ranks test. Results: A significant reduction in the proportion of patients with erosive abnormalities was found [59.1%, 95% CI (36.4–79.3) %]. Baseline erosions improved in 9/12 (75%) right and 14/15 (93%) left TMJs. About half repaired; developed an intact cortical outline. Number of joints with osteophytes increased (right: p < 0.04, left: p < 0.003). New osteophytes were mostly found in joints with erosive findings. Low or no limitation of jaw function (Jaw Functional Limitation Scale) was found in 12/22 (55%) and no or low intensity of pain (Graded Chronic Pain Scale Grade 0 or I) in 19/22 (86%) at follow-up. Conclusion: We found a high potential for repair of erosive TMJ abnormalities. However, the patient series was small. The majority of patients assessed their symptom severity at follow-up as low

Frequency of temporomandibular joint osteoarthritis and related symptoms in a hand osteoarthritis cohort

Objective: The prevalence of osteoarthritis (OA) in the temporomandibular joints (TMJs) in hand OA patients is largely unknown. Our aims were to explore (1) The frequency of TMJ-related symptoms and clinical findings; (2) The TMJ OA frequency defined by cone beam computed tomography (CBCT); and (3) The relationship between TMJ-related symptoms/clinical findings and CBCT-defined TMJ OA, in a hand OA cohort. Methods: We calculated the frequencies of TMJ-related symptoms, clinical findings and diagnosis of TMJ OA by CBCT and clinical examination in 54 patients from the Oslo hand OA cohort (88% women, mean (range) age 71 (61–83) years). Participants with and without CBCT-defined TMJ OA were compared for differences in proportions (95% confidence interval (CI)) of symptoms and clinical findings. Sensitivity and specificity of the clinical TMJ OA diagnosis were calculated using CBCT as reference. Results: Self-reported symptoms and clinical findings were found in 24 (44%) and 50 (93%) individuals (93%), respectively, whereas 7 (13%) had sought healthcare. Individuals with CBCT-defined TMJ OA (n = 36, 67%) reported statistically significantly more pain at mouth opening (22%, 95% CI 4–40%), clicking (33%, 95% CI 14–52%) and crepitus (25%, 95% CI 4–46%). By clinical examination, only crepitus was more common in TMJ OA (33%, 95% CI 29–77%). Clinical diagnosis demonstrated low sensitivity (0.42) and high specificity (0.93). Conclusions: CBCT-defined TMJ OA was common in hand OA patients, suggesting that TMJ OA may be part of generalized OA. Few had sought healthcare, despite high burden of TMJ-related symptoms/findings. Clinical examination underestimated TMJ OA frequency

No Association between types of unilateral mandibular condylar abnormalities and facial asymmetry in orthopedic-treated patients with juvenile idiopathic arthritis

Introduction: Dentofacial asymmetries are often observed in patients with juvenile idiopathic arthritis (JIA) and temporomandibular joint (TMJ) involvements. The aim of this split-face study was to associate types of radiologic TMJ abnormalities with the degree of dentofacial asymmetry in patients with unilateral TMJ involvements assessed with cone-beam computed tomography. Methods: Forty-seven JIA patients and 19 nonarthritic control subjects were included in the study. Normal condylar radiologic cone-beam computed tomography appearance in at least 1 TMJ was the inclusion criterion for all patients with JIA. The contralateral TMJ was thereafter scored as either “normal,” “deformed,” or “erosive,” consistent with predefined criteria. Based on the bilateral radiologic TMJ appearances, 3 JIA groups were assigned: normal/normal, normal/deformed, and normal/erosive. The severity of the dentofacial asymmetry was compared between the JIA groups and control subjects. Dentofacial asymmetry was expressed as interside ratios and angular measurements. Results: Eighty-seven percent of the JIA patients were being treated or had previously received treatment with a functional orthopedic appliance at the time of the cone-beam computed tomography. Significantly greater dentofacial asymmetries were observed in the 2 groups of JIA patients with unilateral condylar abnormalities (deformation or erosion) than in the other groups. A similar degree of dentofacial asymmetry was observed in JIA patients with bilateral normal TMJs and in the nonarthritic control group. Conclusions: JIA patients with unilateral condylar abnormalities (deformation or erosion) exhibited significantly more severe dentofacial asymmetries than did the JIA patients without condylar abnormalities and the control subjects. We found the same degree of dentofacial asymmetry when dividing patients with condylar abnormalities into deformation and erosion groups

Discrete Choice Experiment on a Magnetic Resonance Imaging Scoring System for Temporomandibular Joints in Juvenile Idiopathic Arthritis

Objective To determine the relative importance weights of items and grades of a newly developed additive outcome measure called the juvenile idiopathic arthritis (JIA) magnetic resonance imaging (MRI) scoring system for the temporomandibular joint (TMJ) (JAMRIS-TMJ). Methods An adaptive partial-profile, discrete choice experiment (DCE) survey using the 1000Minds platform was independently completed by members of an expert group consisting of radiologists and non-radiologist clinicians to determine the group-averaged relative weights for the JAMRIS-TMJ. Subsequently, an image-based vignette ranking exercise was done, during which experts individually rank ordered 14 patient vignettes for disease severity while blinded to the weights and unrestricted to JAMRIS-TMJ assessment criteria. Validity of the weighted JAMRIS-TMJ was tested by comparing the consensus-graded, DCE-weighted JAMRIS-TMJ score of the vignettes with their unrestricted image-based ranks provided by the experts. Results Nineteen experts completed the DCE survey, and 21 completed the vignette ranking exercise. Synovial thickening and joint enhancement showed higher weights per raw score compared to bone marrow items and effusion in the inflammatory domain, while erosions and condylar flattening showed nonlinear and higher weights compared to disk abnormalities in the damage domain. The weighted JAMRIS-TMJ score of the vignettes correlated highly with the ranks from the unrestricted comparison method, with median Spearman's ρ of 0.92 (interquartile range [IQR] 0.87–0.95) for the inflammation and 0.93 (IQR 0.90–0.94) for the damage domain. Conclusion A DCE survey was used to quantify the importance weights of the items and grades of the JAMRIS-TMJ. The weighted score showed high convergent validity with an unrestricted, holistic vignette ranking method

Assessing the reliability of the OMERACT juvenile idiopathic arthritis magnetic resonance scoring system for temporomandibular joints (JAMRIS-TMJ)

Contrast-enhanced magnetic resonance imaging (MRI) remains the most comprehensive modality to assess juvenile idiopathic arthritis (JIA)-related inflammation and osteochondral damage in the temporomandibular joints (TMJ). This study tested the reliability of a new JIA MRI scoring system for TMJ (JAMRIS-TMJ) and the impact of variations in calibration and reader specialty. Thirty-one MRI exams of bilateral TMJs were scored independently using the JAMRIS-TMJ by 20 readers consisting of radiologists and non-radiologist clinicians in three reading groups, with or without a calibrating atlas and/or tutorial. The inter-reader reliability in the multidisciplinary cohort assessed by the generalizability coefficient was 0.61–0.67 for the inflammatory and 0.66–0.74 for the damage domain. The atlas and tutorial did not improve agreement within radiologists, but improved the agreement between radiologist and non-radiologist groups. Agreements between different calibration levels were 0.02 to 0.08 lower by the generalizability coefficient compared to agreement within calibration levels; agreement between specialty groups was 0.04 to 0.10 lower than within specialty groups. Averaging two radiologists raised the reliability above 0.8 for both domains. Therefore, the reliability of JAMRIS-TMJ was moderate-to-good depending on the presence of specialty and calibration differences. The atlas and tutorial are necessary to improve reliability when the reader cohort consists of multiple specialties