INTRODUCTION
1)
Juvenile idiopathic arthritis (JIA), also known as juvenile chronic arthritis and juvenile rheumatoid arthritis, is a common chronic rheumatic disease in childhood. JIA is one of the most common rheumatoid diseases of childhood, affecting at 14-200 per 100,000 children
1). Recently, the treatment of this disease has
Corresponding author : Yeon-Hee Lee Department of Orofacial Pain and Oral Medicine,
Kyung Hee University Dental Hospital, #26 Kyunghee-daero, Dongdaemun-gu, Seoul, 02447, Korea
Phone: 82-2-958-9454 Fax: 82-2-968-0787
E-mail: [email protected]
Received: 2017-05-10improved a lot, but disease flares are still common
2). JIA is an autoimmune disorder that is divided into 7 subtypes according to the clinical symptoms during the first 6 months
3). These distinct subtypes are as follows: systemic arthritis, oligoarticular arthritis, polyarticular rheumatoid factor (RF)positive arthritis, polyarticular RFnegative arthritis, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis.
JIA can affect various joints, including temporomandi- bular joint (TMJ). The prevalence of orofacial symptoms and functional impairments of the TMJ are 26-74% of JIA patients with TMJ arthritis depending on the population studied, the subtypes of JIA, and the criteria by which involvement is diagnosed
4,5). TMJ arthritis and degenerative changes on joint in patients with JIA may interfere with optimal joint and muscular function. JIA can lead to mandibular growth disturbances
4,6,7). TMJ
Diagnosis and Treatment of Patients with Juvenile Idiopathic Arthritis with Temporomandibular Joint Involvement:
A Literature Review
Yeon-Hee Lee, D.D.S.,Ph.D. Candidate
Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital
Juvenile idiopathic arthritis or Juvenile rheumatoid arthritis is a broad term that describes a heterogenous group of arthritides of unknown etiology. This disease is characterized by joint effusion with persisted symptoms for more than six weeks and onset before the age of 16 years. Recently, it is classified into 7 categories according to the International League of Associations for Rheumatology (ILAR) as follows: systemic arthritis, polyarthritis (RF negative), polyarthritis (RF positive), oligoarthritis, with enthesitis-related arthritis, psoriatic arthritis, and undifferentiated. One of the most important long-term complications of JIA is the decrease in bone mineral density, causing deficiency and alteration in bone growth and overall maturation. These alterations may cause the impairment of mandibular and condylar growth, leading orofacial alterations that are crucial in the patients with JIA and may have direct and negative impact on the quality of their life. Thus, early diagnosis of impaired facial growth and temporomandibular joint disorder (TMD) is important. This article aims to provide a review of literature on TMJ involvement in JIA patients and its orofacial consequences.
Key words : Juvenile idiopathic arthritis, Temporomandibular joint, Age of 16 years, Growth
arthritis may cause asymmetric and reduced mandibular growth, unstable occlusion, disturbed TMJ function which can cause orofacial symptoms as well as non-esthetic appearance
8). In JIA, the TMJ can be only and/or the first affected joint, and it could be unilateral or bilateral
9). JIA patients can be affected by their disease for a long time in their personal life and prospects.
The etiologies of TMJ involvement in JIA are not clear. This article aims to provide a review of literature on TMJ involvement in JIA patients and its orofacial consequences. In addition, previous results on the pathophysiology, clinical features, diagnosis, and treatment of TMJ involvement in JIA also provided.
Methods
Using the preferred reporting item for systemic review and meta-analyses (PRISMA), critical appraisal of the literature was summarized. The author performed a search in the electronic databases Pubmed and Embase from January 1, 1995 until December 31, 2014, with the key words including <juvenile idiopathic arthritis>,
<juvenile rheumatoid arthritis>, <arthritis>, <TMD>,
<face>, <facial>, and <TMJ>. Of all, the author screened all titles and abstracts for the applicability to the research topic according to the predefined inclusion criteria.
Results
A total of 327 articles were selected roughly. The 327 articles were screened based on their title and abstract.
With the correction for duplicates, 238 articles remained.
Of those, 36 studies were finally selected for analysis based on the critical appraisal.
Pathophysiology
Wide spectrum of TMJ pathology occurs in JIA patients. The pathophysiology of JIA, and its process to TMJ involvement is not completely understood
10,11). Autoimmune response, genetic factors, and environment are suggested as crucial factors for the inflammatory cascade and JIA progress
12). Several pathophysiologic factors are associated with the destruction of bone,
inhibition of osteoblasts, and stimulation of osteoclasts, including: interleukins such as IL-1, IL-6, and IL-8, receptor activator of NF?B ligand (RANKL), macrophage colony-stimulating factor, and tumor necrosis factor
13,14). In general, the articular impairment observed in chronic arthritis. It starts in the synovial membrane, and inflammatory alterations called synovitis usually observed.
At the active phase, a continuous immunological event proceeds. Inflammatory cells release pro-inflammatory cytokines, which in turn stimulate the release of proteases, causing alteration and damage to the joint tissue
15-17). It develops into the chronic process of the disease. The granulation tissue can form with the joint tissue destruction. In turn, joint cartilage and subchondral bone become weaker and pannus is formed. As a results, the hyaline cartilage replaced with dense fibrous tissue, and thus, it could or could not generate ankyloses. Fibrous ankyloses observed is more prevalent than the bony type
17).
Clinical features
According to on prospective study with 100 JIA
patients, approximately 55% have at least one sign or
symptom attributable to the TMJ, and 78% exhibited
condylar lesions
8). The results of the reports using
conventional radiographic and computed tomography
(CT) of TMJ showed that condylar abnormalities in
50-78 of JIA patients
8,18). TMJ abnormalities in JIA
patients were more frequently observed when using
contrast-enhanced magnetic resonance imaging (MRI),
with frequency of 87%
19). This higher frequency with
MR imaging can be explained with improved
visualization of the TMJ inflammation, and of abnormal
intra-articular alterations. Temporomandibular joint
disorder (TMD) is accompany by the following
symptoms: TMJ and facial pain, headaches, decreased
mandibular movement, malocclusion, and impairment of
condylar growth
20). MRI assessment on TMJ, particularly
the detection of the degree of active arthritis can allow
early diagnosis of TMJ involvement in JIA patients, and
can also allow decrease of these TMD symptoms
20,21).
Additionally, JIA can be related to the incurrence of
craniofacial abnormalities, most commonly retrognathia
and micrognathia
8). When compared to healthy controls, patients with JIA have smaller jaw dimensions, as well as shorter mandibular height
22). Because TMJ have a relatively thin layer of fibrocartilage, mandibular condyle growth plate can be relatively easily affected
20). Furthermore, it can lead to various TMD symptoms such as facial asymmetry, cosmetic abnormalities, limited mouth opening, and TMJ pain. The high reported incidence of TMJ involvement in JIA patients and the potential long-lasting mandibular deformities highlight the importance of early diagnosis and detection.
Diagnosis
First classification system of JIA was proposed in 1995
23), was revised two times in 1997 and in 2001 by International League of Associations for Rheumatology (ILAR)
24). According to the number of the joint affected, JIA can be classified into oligoarthritis (=4 joints involved), polyarthritis (= 5 joints involved), and systemic type. However, detection and diagnosis of TMJ involvement by JIA is has been known to be complicated and difficult.
A contrast-enhanced MRI is the gold standard to detect TMJ synovitis
25). MRI is useful for early diagnosis of JIA, as it can detect early changes in synovial cartilage, muscle, as well as bone
26). Assessment of TMJ using MRI is recommended in JIA patient even when they are asymptomatic
27). TMJ involvement of JIA also commonly diagnosed based on clinical examination, and other imaging modalities including planar panoramic radio- graphy, computed tomography, and ultrasonography
25). Clinical characteristics of TMJ involvement are as follows: retrognathia, micrognathia, facial asymmetry, malocclusion, limited mouth opening, deviation or deflection at mouth opening, trismus, swelling of the TMJ area, limitation of mandibular eccentric movement, TMJ noise, TMJ pain, and morning stiffness
12). However, clinical examination alone could be inadequate to detect TMJ arthritis despite the clinical examination of JIA has a high specificity
20,21). Furthermore, according to Twilt M et al., swelling and pain are not accompanied in most cases of TMJ involvement
11). A correct diagnosis is crucial and the clinician can distinguish between skeletal
malocclusion caused by dental problem and bone discrepancy.
Treatment
The treatment aim of the TMJ arthritis by JIA is to control the present symptom and prevent further progression of JIA. Pharmacologic intervention is the first treatment option for reducing pain related to JIA.
Nonsteroidal anti-inflammatory drugs (NSAIDS) are commonly prescribed
28). Corticosteroids including triamcinolone acetonide and triamcinolone hexacetonide can be injected to reduce TMJ inflammation
29,30). However, after the injection of corticosteroids, transient pain, subcutaneous atrophy, lipoatrophy, scar formation, and skin hypopigmentation at the injection site can occur
31). Methotrexate, a kind of disease-modifying anti-rheumatic drug (DMARD), has been reported to be effective in reducing or minimizing TMJ alteration and destruction in JIA patients
32). A positive outcome was reported in the management of the resorption process in both condyles using splint therapy
33). Applications of physical therapy, oral appliance, orthodontic treatment, surgery, or a combination of these therapies were also recommended
31).
When TMJ involvement is unilateral, more functional and cosmetic abnormalities which result from facial asymmetry and deformity can happen
8). In the patients in whom condylar deformities and cosmetic problems are developed, surgical approach can be a treatment option
34). Multiple treatment modalities can be applied to the treatment of facial deformity, varying from a oral appliance to a total joint replacement
31). Orthodontic treatment also had positive outcome, with a noticeable improvement in occlusion, mandibular function, and esthetics
35,36).
TMJ involvement by JIA has been researched that it
had a high incidence
12,27). However, there is no consensus
on the treatment of TMJ problem and pathogenesis in
patients with JIA. Unfortunately, the articles are
heterogeneous, and treatment varies from counseling to
surgery with the relatively low level of evidence. Further
research on long-term and effective treatments for TMJ
involvement by JIA is needed.
Conclusion
With the results of this review, previous results on the pathophysiology, clinical features, diagnosis, and treatment of TMJ involvement in JIA patients were provided. Early diagnosis of TMJ involvement seems to minimize long-term and broad problems in JIA patients and lead to successful treatment. Future research in this field to support in the development of guidelines for early detection in JIA is needed. Evidence-based guidelines can be helpful to evaluate the TMJ, thus it can ultimately optimize the individualized therapy. Long-term TMJ morbidity also can be reduced.
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국문초록
턱관절이 이환 된 소아 특발성 관절염 환자의 진단 및 치료: 문헌 고찰
