Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies


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Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies (TMJ) by Randy Q. Cron, MD, PhD, Univ. of Alabama at Birmingham

Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies

  1. 1. Temporomandibular Joint Arthritis in PediatricInflammatory Arthropathies Randy Q. Cron, MD, PhD Univ. of Alabama at Birmingham
  2. 2. What is the Temporomandibular Joint?The temporomandibular joint (TMJ) is a typicalsliding "ball and socket" which has a discsandwiched between it. The TMJ is used manythousands of times a day in moving the jaw,biting and chewing, talking, yawning, etc. It isone of the most frequently used of all the jointsin the body.http://www.medicinenet.com/temporomandibular_joint__disorder/page1.htm#1whatis
  3. 3. Diagnosis of TMJ Arthritis• Clinical history• Physical exam findings• Imaging studies
  4. 4. Challenges in Assessing Pediatric TMJ disease
  5. 5. Asymptomatic TMJ Disease in JIA• Twilt, et al. 2004 Percentage of Symptomatic Patients by Age Range 80 – 45% without pain 50% 56% 74% 70 % of Patients 60 50• Wallace, et al. 2000 40 – 70% asymptomatic 19 0 6 0- 1 - 7- 11 s s ge s ge ge A A A UAB 2010
  6. 6. Tooth-to-tooth Gap/Inter-incisor Distance 3 finger rule
  7. 7. Measure of Tooth-to-Tooth Gap
  8. 8. Mouth Opening by Age Twilt et al. 2004 Age 0-6 6-11 11-16 16-21 (yrs):Ingervall 49 mm 51 mm1970Sheppard 42 mm 46 mm 51 mm 49 mm1965- OPG 43 mm 48 mm 53 mm 53 mm2004+ OPG 42 mm 43 mm 47 mm 57 mm2004
  9. 9. Normal range of mouth opening in children ages 5-17 years 97.5% 75%N = 307  = 47 mm 25% 2.5% Pediatr Rheumatol Online J. 2012 Jun 20;10(1):17. [Epub ahead of print]
  10. 10. Prevalence/Incidence of TMJ Arthritis in JIA
  11. 11. New Juvenile Idiopathic Arthritis (JIA) Criteria
  12. 12. Classification of JIA ACR 1977 ILAR 1997 JRA JIA 1. Systemic Behrens 1. Systemic onset 2. Polyarticular >4 joints 2. Polyarticular RF- 3. Polyarticular RF+ 4. Oligoarticular 3. Pauciarticular <5 joints a) Persistent (< 5 joints) b) Extended (>4 joints) Spondyloarthropathies (HLA-B27) 5. Psoriatic 1. Psoriatic 6. Enthesitis related 2. Ankylosing spondylitis 3. IBD associated 7. Unspecified (none or more than 1 category 4. SEA syndrome fulfilled)J Rheumatol. 2004 Feb;31(2):390-2.Behrens EM, Beukelman T, Cron RQ.J Rheumatol. 2007 Jan;34(1):234
  13. 13. JIA Subtype & Frequency of TMJ Arthritis (orthopantomogram) 70% with TMJ involvement 60 50 40 30 Subtype 20 N=97 10 0 So Oligo RF+ RF- SEA Psor Twilt, et al. J. Rheumatol. 2004;31:1418. Twilt
  14. 14. 2010 UAB Data, n=183 JIA patients screened by MRI Saurenmann StollCannizzaro E, Schroeder S, Müller LM, Kellenberger CJ, Saurenmann RK. J Rheumatol. 2011;38:510-5.Stoll ML, Sharpe T, Beukelman T, Good J, Young D, Cron RQ. J Rheumatol., in press.
  15. 15. Morbidity with TMJ Arthritis in JIA• TMJ Pain• Local morning stiffness• Impaired function (chewing, speaking)• Pain with chewing• Decreased mouth opening• Earache• Cosmetic appearance (micrognathia, facial asymmetry)
  16. 16. Micrognathia Pediatr Clin North Am. 2005 Apr;52(2):413-42, vi.
  17. 17. Destruction of the Growth Plate• Growth plate is very superficial, located on the surface of the mandibular condyle head• Arthritis leads to micrognathia• Costochondral graft surgery
  18. 18. AVOID THIS! *Courtesy of David D. Sherry, MD
  19. 19. Treatment of TMJ Arthritis
  20. 20. Do Biologics Treat TMJ Arthritis?Systemic Medication Use in TMJ Arthritic Patients Comparing Any Use vs. Use Only at Time of MRI 80 Have Ever Used Used At Time of MRI N=95 60 % of Patients 40 20 0 ID ) d TX ra oi SA M in er Beukelman k N St na A us pl r( to bi hi In a F- TN Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ. J. Oral Maxillofac. Surg. 2012;70:1802-7.
  21. 21. Corticosteroid Injections of TMJs are Harmful?• “A cortisone-wrecked and bony ankylosed temporomandibular joint.” – Plast Reconstr Surg. 1989;83:1084• Temporomandibular joint osteoarthrosis. Histopathological study of the effects of intra- articular injection of triamcinolone acetonide. – Intra-articular injection of steroid into human osteoarthritic temporomandibular joints acts as a lytic agent (n=44). – Haddad. Saudi Med J. 2000 Jul;21(7):675-9.
  22. 22. Corticosteroids are NOT Evil! (for inflammatory TMJ disease)• Vallon, et al. Long-term follow-up of intra-articular injections into the temporomandibular joint in patients with rheumatoid arthritis. Swed. Dent. J. 2002;26:149 – 12 year follow up of 21 adult RA patients following corticosteroid injections (n=11) of TMJs – long-term progression of joint destruction was low for both steroid and non-steroid agents
  23. 23. Intraarticular Corticosteroids are Used to Treat Other Joints in JIA• Intraarticular corticosteroid injection in JIA are safe and effective – Review – Cleary, et al. Arch. Dis. Child. 2003;88:192• Prevents leg length discrepancy – Sherry, et al. Arthritis Rheum. 1999;42:2330• 2nd most common therapy to treat pauciarticular juvenile arthritis – Cron, et al. J. Rheumatol. 1999;26:2036
  24. 24. Intraarticular Corticosteroids for TMJ Arthritis in JIA • Martini, et al. J. Rheumatol. 2001;28:1689 – Case report of arthroscopic synovectomy followed by IA triamcinalone hexacetonide (10 mg) in 15 yo girl with JIA – Decreased pain, increased function and mouth opening Zulian
  25. 25. Retrospective Study of IntraarticularSteroid Injection of TMJ Arthritis in JIA
  26. 26. DemographicsArabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
  27. 27. Pre-Injection MRI Findings• TMJ effusions in 13/23• Bony erosions in 19/23• Condylar flattening 17/23 Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
  28. 28. Sedation for Treatment• Deep intravenous sedation (in combination) – 1-3 µg/kg fentanyl citrate – 2-5 mg/kg pentobarbital sodium – 0.1-0.3 mg/kg midazolam hydrochloride• Continuous cardio-respiratory monitoring – Cahill, et al. AJR Am. J. Roentgenol. 2007;188:182-186.
  29. 29. Therapeutic Approach• Performed by experienced pediatric interventional radiologists• Child placed supine in CT scanner with head rotated 45o away from TMJ to be injected• Axial CT imaging in area of interest• Sterile preparation of access site anterior to tragus• Local anesthesia with bicarbonate buffered 1% lidocaine (30 gauge needle)• CT confirmation of needle placement in mandibular fossa• Injection of triamcinalone acetonide (1cc = 40 mg) into TMJ with 18 or 21 gauge needle – Cahill, et al. AJR Am. J. Roentgenol. 2007;188:182-186.
  30. 30. CT Guidance
  31. 31. Data Collection• Tooth-to-tooth gap measurements• Pain assessment• MRI findings – Effusions – Erosions – Condylar flattening• Side effects Bita Arabshahi, MD
  32. 32. TMJ Anatomy
  33. 33. Resolution of Effusion Following Intraarticular Steroid InjectionPre Post Arabshahi & Cron. Curr Opin Rheumatol. 2006;18:490-495.
  34. 34. Retrospective Study Results• 13/23 with pain prior to injections (only 3 with pain following injections)• Tooth to tooth gap increased from 3.59+/-0.725 to 4.07+/-0.606 (P=0.0017) – 43% of patients had a T-T gap increase >0.5 cm.• In 23 TMJs followed up by MRI: – 11/23 absent or decreased effusions – 2/23 increased effusions (both re-injected) – Bony resorption remained stable in the majority of pts Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
  35. 35. Increase in Tooth-to-Tooth Gap (< 6 yrs old) Tooth-tooth gap, ages 0-6 (n=5) 5 4 3 2 s n n al io io rm ct ct je je no -in in e- st pr po
  36. 36. Increase in Tooth-to-Tooth Gap (7-10 yrs old) Tooth-tooth gap, age 7-10 (n=10) 6 5 cm 4 3 P= 2 s n n al io io rm ct ct je je no -in in e- st pr po
  37. 37. Increase in Tooth-to-Tooth Gap (11-16 yrs old) Tooth-tooth gap, age 11-16(n=5) 7.5 5.0 cm 2.5 P= P= s n n al io io rm ct ct je je no -in in e- st pr po
  38. 38. Complications/Side Effects• Accidental injection of 1cc of ethanol prior to injection of corticosteroids• Increase in TMJ pain following injection (n=2)• No infections, subcutaneous atrophy, or hypopigmentation at injection sites• Cushingoid features in one child injected by oromaxillofacial surgery (prior to this study) Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
  39. 39. Summary of Retrospective Study• CT-guided corticosteroid injection of the TMJ in children with JIA appears safe• Corticosteroid injection of TMJ arthritis in children with JIA is associated with decreased TMJ pain, increased mouth opening, and decreased TMJ effusions as detected by MRI• +ANA and polyarticular disease may be risk factors for TMJ arthritis Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
  40. 40. Intraarticular corticosteroids for TMJ arthritis in JIA Zurich Seattle Germany Philly Ringold S, Cron RQ. Pediatr Rheumatol Online J. 2009 May 29;7(1):11.
  41. 41. Toronto ConnollyPediatr Radiol. Pediatr Radiol. 2010;40:1498-504.
  42. 42. Prospective Study of TMJ Arthritis in JIA• Determine the point prevalence of TMJ arthritis at disease onset in children with JIA using MRI and ultrasound • Subaim: comparative study of MRI versus ultrasound for diagnosing TMJ arthritis• Development of a screening protocol to predict those children with JIA at greatest risk for developing TMJ arthritis • Using demographics, serologies, physical examination, CHAQ, and questionnaire on TMJ functionality/pain
  43. 43. Inclusion Criteria:• Meet the diagnostic criteria for JIA• Able to complete study within 8 weeks of diagnosis Exclusion Criteria:• Inability to undergo MRI due to metal implants, braces, pacemakers
  44. 44. New-onset JIA Cohort
  45. 45. Jaw Symptoms & PE Findings
  46. 46. MRI: Condylar Flattening & Erosion
  47. 47. MRI: Joint Effusion & Condylar Erosion
  48. 48. MRI FindingsN MRI pattern Unilateral Bilateral Oligo:Poly8/20 Minimal to 62% 38% 1:1(40%) mild effusion17/20 Enhancement 31% 69% 0.9:1(85%)9/20 Condylar 50% 50% 1:3(45%) Flattening
  49. 49. MRI Findings• All the patients with effusion AND enhancement AND condylar flattening had polyarticular disease.• All the patients with effusion AND enhancement but NO condylar flattening had oligoarticular disease.• No other correlations with MRI pattern and age/ duration of disease/ JIA subtype/ CHAQ score/ serologies. Goldsmith
  50. 50. Ultrasound Appearance ofCondyle Flattening (L>R) Right Left
  51. 51. Comparison of MRI and US Findings Comparison of MRI and US in detection of effusions and condylar erosions (n=40 TMJs) 20 MRInumber of TMJs US Concordance 10 0 effusions erosions TMJ appearance
  52. 52. TMJ Arthritis Detection(Dis)agreement by MRI & US
  53. 53. Summary of Acute vs Chronic Findings• Acute: presence of effusion or enhancement – Seen in all but two patients (83% bilateral)• Chronic: presence of condylar flattening – Seen in 69% by MRI, most with Poly JIA, 26% by US• Concordance of MRI and US: – 0% agreement in detection of effusions – 22% agreement in detection of condylar flattening• Length of disease, CHAQ score, and erythrocyte sedimentation rate (ESR) did NOT correlate significantly with either chronicity or acuity on MRI.
  54. 54. Predictors of TMJ Arthritis in New-onset JIA
  55. 55. Change in MIO afterCorticosteroid Injection
  56. 56. TMJ Arthritis: Prevalence, Diagnosis, and Predictors of Active Disease • What we’ve learned: – Prevalence of TMJ arthritis is quite high – Unable to establish predictors of active disease at this time given the high prevalence – MRI appears much more sensitive than US in detecting early inflammatory changes in the TMJ, especially given operatorPam Weiss, MD dependence of US Weiss, et al. Arthritis Rheum. 2008;58:1189-96.
  57. 57. FundingNickolett Family Awards Ethel Brown FoerdererProgram for JRA Research Fund for Excellence
  58. 58. Credit Where Credit is DueCHOP Rheumatology CHOP RadiologyBita Arabshahi Anne Marie CahillEsi DeWitt Robin KayePam Fitch Marissa BilaniukSandy Burnham Ann JohnsonDavid Sherry Kevin Baskin Carol Wallace (Seattle)
  59. 59. Questions that Arise:• Since bilateral enhancement is so common, could it be a normal post-contrast finding?• Could condylar flattening by itself, or with enhancement, be a normal finding?• If the above is true: 50% of the kids currently found to have abnormal TMJs by MRI could be normal.• Therefore: Important to have controls, especially to help make treatment decisions.
  60. 60. Synovial Enhancement in a Normal Control CT1-weighted parasagittal MRI image with fat saturation of the TMJ joint of a normal 7year old child, showing synovial enhancement (arrow) superior to the condyle (C).
  61. 61. Acta Radiol. 2009 Dec;50(10):1182-6.96 Children without autoimmune disease screened94% entirely normal TMJ MRI Tzaribachev
  62. 62. Treatment of TMJ Arthritis in JIA without radiographic guidance Peter D. Waite, M.P.H., D.D.S., M.D. University of Alabama at Birmingham
  63. 63. 1.2 mm Arthroscope
  64. 64. P = .001J. Oral Maxillofac. Surg. 2012;70:1802-7.
  65. 65. Mouth Opening ImprovedFollowing IA-Steroids to TMJs Post-lnjection MIO Changes Improvement 7% Worsening Unchanged 27% 65% Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ. J. Oral Maxillofac. Surg. 2012;70:1802-7.
  66. 66. All JIA Subtypes Respond to IA-Steroids M IO Change by Subtype 6 4.56 5 4 2.82 2.20 3 1.50 1.54 mm 2 1 -0.67 0 -1 A d tic ic o ) eg lig te ER m ia N ia e O or F- -2 st nt Ps (R Sy e er ly iff Po nd U Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ. J. Oral Maxillofac. Surg. 2012;70:1802-7.
  67. 67. MRI Findings ImprovedFollowing IA-Steroids to TMJs Post-Injection MRI Results Some Improvement Complete Resolution Unchanged or Worse 34% 49% Young 17% Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ. J. Oral Maxillofac. Surg. 2012;70:1802-7.
  68. 68. What do we do for TMJ arthritisnot responsive to IA-steroids?• Many have already failed repeated (2 or more) IA-steroid injections.• The vast majority are already on high dose, aggressive systemic arthritis therapy (e.g. methotrexate and anti-TNF agents at high doses).
  69. 69. Intra-articular anti-TNF to treat TMJ arthritis• Scand J Rheumatol. 2008 Mar-Apr;37(2):155-7. Alstergren• Successful treatment with multiple intra-articular injections of infliximab in a patient with psoriatic arthritis.• Alstergren P, Larsson PT, Kopp S.• Department of Clinical Oral Physiology, Institute of Odontology, Karolinska Institutet, Huddinge, Sweden. per.alstergren@ki.se• Abstract• This case report presents the clinical and radiographic course of temporomandibular joint (TMJ) involvement in a patient with severe TMJ symptoms from psoriatic arthritis (PsA) resistant to both systemic infliximab and intra-articular glucocorticoid and who therefore received multiple intra- articular infliximab injections for 36 weeks. TMJ symptoms improved after the first bilateral intra-articular infliximab injections but even more so after the second injections. The considerable improvement remained for the 36 weeks studied. Bilateral computerized tomography showed no progression in radiographic changes during the treatment. No adverse reaction was observed from the intra-articular injections.
  70. 70. Intra-articular Infliximab Treatment ofRefractory TMJ Arthritis in Children with JIA Morlandt Stoll ML, Morlandt A, Terrawattanapong S, Young D, Waite PD, Cron RQ. Manuscript submitted. Intra-articular: steroids anti-TNF Unchanged or improved Pre-post IACI Pre-post IAII p-value Acute changes 9 / 34 (26%) 23 / 34 (68%) 0.001 Chronic changes 9 / 34 (26%) 21 / 34 (62%) 0.008
  71. 71. Do non-JIA children with otherrheumatic diseases develop TMJ arthritis?• Many other pediatric rheumatic disorders are associated with arthritis (SLE, myositis, sarcoidosis, Sjogren, MCTD, etc.).• Some children with the above disorders have PE findings or complaints suggestive of TMJ arthritis.
  72. 72. Parotitis seen on TMJ MRI C
  73. 73. Screening for TMJ Arthritis in Other Pediatric Arthritides FainFain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ.J Rheumatol. 2011 Oct;38(10):2272-3
  74. 74. TMJ Arthritis in Pediatric Sjogren and Sarcoidosis AtkinsonFain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ.J Rheumatol. 2011 Oct;38(10):2272-3
  75. 75. Contrast weighted MRI sagittal section through the TMJ of a child with juvenile dematomyositis. C: condyle; Arrow indicates synovial enhancement after administration of contrast.
  76. 76. TMJ Arthritis in Pediatric JDMS and MCTD MIO with Post Patient Age at positive TMJ Peripheral injection Repeat number dx Gender Dx MRI Deviation arthritis MIO TMJ 1 15y female MCTD 3.2 yes yes 2 16y female MCTD 3.6 yes yes 3 12y female MCTD 4.8 no yes 4 4y female JDMS 3 no no 3.4 Negative 5 20m female JDMS 3.1 no no 4.20 Negative 6 10y female JDMS 4.6 no yes Active 7 5y male JDMS 1.85 yes yesPeter Weiser, Stephen Johnson, Robert M. Lowe, Randy Q. Cron.Submitted for publication. Weiser
  77. 77. Things to Consider• 50-75% of children with JIA develop TMJ arthritis.• All subtypes of JIA develop TMJ arthritis.• TMJ arthritis is frequently asymptomatic.• Inflammation of the TMJ leads to growth plate arrest (micrognathia).• MRI is the most sensitive modality for detecting TMJ arthritis.• Intraarticular corticosteroid injection is effective treatment for TMJ arthritis in JIA.• TMJ arthritis can develop while being treated with methotrexate plus a TNF inhibitor.• TMJ arthritis may be active while other joints are in remission.• Intraarticular infliximab injection treats refractory TMJ arthritis.• Children with sarcoidosis, Sjogren, JDMS, and MCTD can develop destructive TMJ arthritis.
  78. 78. In Memory ofDr. Frida Gudmundsdottir
  79. 79. Questions??