Table 3.
Recommendations for the management of temporomandibular joint (TMJ) arthritis and the related orofacial manifestations of juvenile idiopathic arthritis (JIA)
| Recommendations | Level of evidence* | SoR† | Agreement |
|---|---|---|---|
| Overarching principles | |||
| TMJ arthritis is a common finding in patients with JIA and standardized evaluation is recommended. | – | – | 100% |
| Goals of management are to 1) provide timely diagnosis of TMJ arthritis and TMJ involvement, 2) reduce TMJ inflammation, 3) reduce TMJ arthritis–related symptoms and dysfunction, 4) normalize dentofacial development, and 5) address dentofacial deformities. | – | – | 100% |
| Optimal TMJ arthritis management requires an interdisciplinary approach and longitudinal evaluation into adulthood regardless of the current TMJ disease activity. | – | – | 100% |
| Diagnosis | |||
| Contrast‐enhanced MRI is currently the best method to detect active TMJ arthritis. | 2 | 8.4 ± 2.1 | 94% |
| Patient (or proxy) history should be used to assess TMJ involvement. While often absent, orofacial symptoms should be regularly reassessed. A standardized approach is recommended. | 3 | 8.8 ± 2.2 | 100% |
| Clinical examination should be used to diagnose TMJ arthritis–related dysfunction; a standardized approach is recommended to monitor changes over time. | 3 | 8.5 ± 2.7 | 100% |
| All patients should be evaluated for dentofacial deformity; a standardized approach is recommended to monitor changes over time. | 3 | 8.9 ± 2 | 100% |
| Treatment of TMJ arthritis (active TMJ inflammation) | |||
| Optimal systemic treatment should be considered for active TMJ arthritis in patients with JIA. | 4 | 7.9 ± 2.4 | 90% |
| Skeletally immature patients: Intraarticular glucocorticoid injection is not recommended as first‐line management of TMJ arthritis in skeletally immature patients. Intraarticular glucocorticoids may be used cautiously in patients with refractory TMJ arthritis and orofacial symptoms. Repeated glucocorticoid injection is not recommended. | 2 | 8.3 ± 2.5 | 97% |
| Skeletally mature patients: Intraarticular glucocorticoid injection may be indicated in skeletally mature patients with active TMJ arthritis and orofacial symptoms. | 4 | 7.7 ± 2.4 | 87% |
| Treatment of TMJ dysfunction and symptoms | |||
| Occlusal splints and/or physical therapy may be beneficial in patients with orofacial symptoms and/or TMJ dysfunction. | 4 | 8.3 ± 2.2 | 100% |
| Intraarticular glucocorticoid injection may be indicated in arthritis‐induced refractory and symptomatic TMJ dysfunction, but is not recommended for first‐line management in skeletally immature patients (see recommendation 6). | 2 | 7.4 ± 2.7 | 87% |
| Intraarticular lavage (without steroid) may be beneficial for TMJ arthritis–related symptoms and dysfunction. Lavage without steroid can be used in both growing and skeletally mature patients. No additional effect of lavage with steroid injection has been reported. | 4 | 6.5 ± 2.6 | 90% |
| Treatment of arthritis‐related dentofacial deformity | |||
| Dentofacial orthopedics and orthodontics may improve facial development, occlusion, and function in skeletally immature patients. | 4 | 8.1 ± 2.5 | 100% |
| Skeletal surgery may be indicated in skeletally immature and skeletally mature patients with dentofacial deformities and quiescent/controlled TMJ arthritis. | 4 | 8.1 ± 2.4 | 97% |
| Other | |||
| Screening and monitoring of the oral cavity with a focus on dental decay, gingivitis, and ulcerations are recommended. | 3 | 6.5 ± 3.4 | 84% |
*
Level of evidence according to criteria from the Oxford Center of Evidence Based Medicine (1 = highest evidence level, 5 = lowest evidence level). MRI = magnetic resonance imaging.
†
Mean ± SD strength of recommendation (SoR) is based on a visual analog scale of 0–10, with 0 being no SoR and 10 being great SoR.