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

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

Neuropatisk orofacial smärta : diagnostik och hantering

Ofta är det tandläkaren som först träffar patien­ ten med svårtolkad smärta i det orofaciala om­ rådet. För att kunna bedöma om patienten kan behandlas framgångsrikt hos tandläkaren eller bör remitteras till annan vårdgivare krävs kän­ nedom och aktuella kunskaper om en rad mer sällsynta tillstånd, däribland neuropatisk smär­ta. Målet med denna artikel är att öka tandläka­ rens möjligheter att känna igen – och därmed att diagnostisera – neuropatiskt betingad smärta och verkställa korrekt hantering av patienten.In addition to patients with the more familiar and common orofacial pain conditions, the dentist will occasionally encounter patients with neuropathic pain. The article describes and explains the clinical presentation of neuropathic pain and gives an overview of painful conditions in the trigeminal region attributed to neuropathic causes with a varying degree of certainty. Aetiology, pain mechanisms, prevalence, diagnosis, evidence-based management and prognosis are reviewed, with the aim to enable the dentist to recognize and diagnose neuropathic pain, thereby facilitating correct management

A new digital tool for radiographic bone level measurements in longitudinal studies

Background The reproducibility of measurements on radiographs is influenced by the techniques by which the images as well as the measurements are obtained. Thus, bias resulting from errors in the image and/or image examinations at two points in time may result in wrongful registrations of true biological or pathological changes. The aim of the present study was to propose and evaluate an indirect radiological examination technique, by which bias, when measuring radiographic bone level, could be substantially reduced as compared to the technique using direct mm measurements. Methods A plugin to ImageJ was designed to reduce bias when measuring bone loss on radiographic images. In human dry mandibles, radiographic images of 20 teeth were obtained parallel with the tooth axis (alpha = 0) and at an angle of 30° deviation. The direct technique of measuring radiographic bone level (RBL) and the indirect, length-adjusted RBL were registered by four researchers in a double blinded fashion. Results When mean RBL measured at 0° angle was 7.0 mm, the corresponding mean RBL measured at 30° angle was 7.8 mm, signifying an 11.4 % increase (p = 0.032), whereas the mean length-adjusted RBL increased by 0.6 % (p = 0.9). Conclusions This study showed that the use of the original, direct technique (ImageJ) resulted in markedly biased radiographic bone level at 30° angle, while the proposed indirect length-adjusted technique (ImageJ plugin) did not

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

Abstract 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

Imaging of temporomandibular joint abnormalities in juvenile idiopathic arthritis with a focus on developing a magnetic resonance imaging protocol

Inflammation and damage in the temporomandibular joint (TMJ) often develop without clinical symptoms but can lead to severe facial growth abnormalities and impaired health-related quality of life, making early diagnosis of TMJ changes crucial to identify. Inflammatory and osteochondral changes detectable through magnetic resonance imaging (MRI) occur in TMJs of approximately 40% of children with juvenile idiopathic arthritis (JIA), and no other imaging modality or physical method of examination can reliably detect these changes. Therefore contrast-enhanced MRI is the diagnostic standard for diagnosis and interval monitoring of JIA. However the specific usage of MRI for TMJ arthritis is not standardized at present. There is a recognized need for a consensus effort toward standardization of an imaging protocol with required and optional sequences to improve detection of pathological changes and shorten study time. Such a consensus imaging protocol is important for providing maximum information with minimally necessary sequences in a way that allows inter-site comparison of results of clinical trials and improved clinical management. In this paper we describe the challenges of TMJ imaging and present expert-panel consensus suggestions for a standardized TMJ MRI protocol

Towards Establishing a Standardized Magnetic Resonance Imaging Scoring System for Temporomandibular Joints in Juvenile Idiopathic Arthritis

OBJECTIVES: The temporomandibular joints (TMJs) are frequently affected in children with juvenile idiopathic arthritis (JIA). Early detection is challenging, as major variation is present in scoring TMJ pathology on Magnetic Resonance Imaging (MRI). Consensus-driven development and validation of a MRI scoring system for TMJs has important clinical utility in timely improvement of diagnosis, and serving as an outcome measure. We report on a multi-institutional collaboration towards developing a TMJ MRI scoring system for JIA. METHODS: Seven readers independently assessed MRI scans from 21 patients (42 TMJs, age range 6-16y) using three existing MRI scoring systems from American, German, and Swiss institutions. Reliability scores, scoring system definitions and items were discussed among 10 JIA experts through two rounds of Delphi surveys, nominal group voting, and subsequent consensus meetings to create a novel TMJ MRI scoring system. RESULTS: Average-measure intraclass correlation coefficients (avICC) for the total scores of all three scoring systems were highly reliable at 0.96 each. Osteochondral items showed higher reliability than inflammatory items. An additive system was deemed preferable for assessing minor joint changes over time. Eight items were considered sufficiently reliable and/or important for integration into the consensus scoring system: bone marrow edema and enhancement (avICC=0.57-0.61; %SDD=±45-63% prior to re-defining), condylar flattening (0.95-0.96; ±23-28%), effusions (0.85-0.88; ±25-26%), erosions (0.94; ±20%), synovial enhancement and thickening (previously combined; 0.90-0.91; ±33%), and disk abnormalities (0.90; ±19%). CONCLUSION: A novel TMJ MRI scoring system was developed by consensus. Further iterative refinements and reliability testing are warranted in upcoming studies