Radiographic changes in the temporomandibular joint related to medication in rheumatic diseases

Abstract

Objectives:

The purpose of this study was to assess radiographical changes on temporomandibular joint (TMJ) in relation the autoimmune rheumatic diseases and the medicines that treat this diseases with cone beam computed tomography(CBCT).

Methods:

65 people with rheumatoid diseases were included in the study and divided into five subgroups according to drugs they used. Condyle height (CH), anteroposterior dimension (APD), mesiolateral dimension (MLD) and superior joint space (SJS) were measured in order to evaluate mandibular condyle dimensions. Further, were evaluated in terms of osteoarthritic changes such as erosion, flattening, osteophyte and subchondral cyst in the mandibular condyle. TMJ measurements were compared between study-control groups and subgroups by using Student’s t-test, Mann-Whitney-U test, one-way analysis of variance (ANOVA) and Kruskal-Wallis test. The association between osteoarthritic features, rheumatoid status was tested by using χ2 test. Observers were blinded to all groups. Cohen κ values (0853–0945) and Spearman’s correlation coefficient (0.959–0.997) indicated high interexaminer reliability.

Results:

Condylar dimentions were significantly lower in CH and SJS in rheumatic diseases group (p < 0.001), however APD (p = 0,681) and MLD (p = 0,757) was not different significantly. Osteoarthritic changes such as erosion (p < 0.001), flattening (p = 0.005), osteophyte (p = 0.001) and subchondral cyst (p = 0.001) were significantly higher in the patient group. None of the parameters were different significantly according to subgroups determined according to drugs used(p > 0.05).

Conclusions:

Degenerative changes may cause decrease in condyle size and changes in condyle position. It is a process that can continue despite the use of antirheumatic or immunosuppressive drugs. All of these can become the source of possible TMJ problems.

Introduction

The temporomandibular joint (TMJ) is a synovial joint whose bone components are mandibular fossa, articular eminence and mandibular condyle.¹ Morphological and histological changes can occur in the bone components of the TMJ related to joint disorders and chronic inflammation.²

Rheumatoid arthritis (RA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE) and systemic sclerosis (SS) are admitted to be the major systemic rheumatic diseases. Their etiologies are multifactorial; it includes genetic predisposition factors, immune system disorders, hormonal and environmental factors.³ Rheumatic diseases are chronic systemic diseases characterized by symmetrical joint involvement and erosive synovitis. Chronic inflammation of the synovial tissue of the joint, causes joint deformity, erosion and bone resorption.^4,5 Rheumatic diseases affect also to the TMJ such as other synovial joints. The reported prevalence of afflicted TMJ varies from 4.7 to 88%. The reason for this discrepancy may be patient selection, imaging technique and diagnostic criteria. Most common findings on affected joints are pain in the masticatory muscles and TMJ area, joint sounds, mandible deviation, swelling and restriction in joint function.^6,7

In addition to the clinical examination, generally radiological evaluations are required, cone beam computed tomography (CBCT) is one of the common and current imaging techniques used for joint evaluation. CBCT provides three-dimensional sectional imaging, preventing superpositions; it is preferable over CT because of its low radiation dose and higher spatial resolution.^8,9 Radiographic findings of the bone components of the afflicted TMJ include resorption, condylar flattening (CF), condylar erosions (CE) and sclerosis of the mandibular condyle and/or the glenoid fossa. In addition to these osseous changes, may occur osteophyte (OSP) formation, subchondral cysts (SC) and joint space narrowing.^10,11 CF is a defence mecanism. It is a physical remodeling that occurs to resist extra forces, it compose the first stage of degeneration with CE. CE are seen as an area decreased density of the cortical and subcortical bone in the condylar head on radiographs. Increasing forces causes the broadening joint surface with the formation of new cartilage and bone tissues, in this way OSP form take shape.

Thus, the joint is stabilized and resistance to forces is provided. Chronic osteoartrit-related SC lesions are located below the articular cartilage and have a sclerotic border. There are different theories for the pathogenesis of the SC, but it is thought to develop as a result of synovial fluid infiltration under the subcortical bone in the degenerated joint.^12–14

Drugs that are used for rheumatic diseases are broadly divided into two group; drugs that treat the symptoms of arthritis and suppress inflammatory disease. First group consist of corticosteroids and nonsteroidal anti inflammatory drugs, second group consist of disease-modifying anti rheumatic drugs (DMARDs), immunosuppressant (IS) drugs. Sulfasalazine (SSZ), methotrexate (MTX), hydroxychloroquine (HCQ) and leflunomide (LFN) groups are used as first‐line DMARDs.^15–17

This study was undertaken to assess radiographic changes on TMJ in relation with the autoimmune rheumatic diseases and the medicines that treat this diseases with CBCT.

Methods and materials

The study is a cross-sectional study; it was realized retrospectively in the Erciyes University Faculty of Dentistry Department of Oral and Maxillofacial Radiology and it was approved by the Erciyes University Clinical Research Ethics Committee.

The persons to be included in the study were patients with autoimmune rheumatic disease who applied to the Department of Oral and Maxillofacial Radiology with dental complaints between 2014 and 2020. Informations about their medicinal conditions and medications they used was obtained from anamnesis records. The diagnoses of rheumatic diseases had made in rheumatology clinics at least 2- at most 7 years ago. The patients had treated for rheumatic diseases for at least 2 years and had using the same and only one medication for at least 6 months. Drug dose used had not changed for 6 months and there had no increase in their symptoms during this period. Patients who were diagnosed with the disease less than 2 years ago, who used the specified drug (used for rheumatic disease) for less than 6 months and who used more than one drug for rheumatic disease were excluded from the study. Further, patients with any systemic disease that could affect bone metabolism (chronic kidney failure, hyperparathyroidism, Paget’s disease etc.) and who used corticosteroids and/or bisphosphonates for any reason were excluded from the study. Patients have CBCT images taken simultaneously with the anamnesis date and for dental reasons.

The study group consisted of 65 rheumatic patients, 57 female and eight male; patients aged between 21 and 75 years. In order to evaluate the effects of the DMARDs and IS, the patient group was divided into five subgroups according to the drugs used by the patients. Group SSZ was formed with 12 patients of using SSZ, group MTX was formed with 12 patients of using MTX, group HCQ was formed with 16 patients of using HCQ, group LFN was formed with 12 patients of using LFN, group IS was formed with 13 patients of using other IS drugs. In addition, all patients were using nonsteroidal anti inflammatory drugs for the control of arthralgic pain.

The control group was composed randomly with healthy people who applied to Erciyes University Faculty of Dentistry for general dental treatments. The people in the control group did not have any metabolic bone disease and were not using drugs that affect bone turnover (corticosteroids, bisphosphonates), also clinically there was no joint complaints and/or TMJ disorders symptoms such as crepitation, clicking, popping, snapping, pain, limited mouth opening and deflection. This group consisted of 65 people, 57 female and 8 male; patients aged between 21 and 75 years. Images of patients who were included in the study and control groups and had CBCT images for different dental reasons were scanned. Images were taken with the same device (Newtom5G, QR, Verona, Italy) and scans for all patient were performed with closed mouth in a centric relation. CBCT images were evaluated in terms of planned parameters. These parameters are;

1. Condyle height (CH): was measured on the corrected coronal view as the linear distance between the most superior point of the condyle (S) and the line measuring the condyle’s medio-lateral dimension.

2. Condyle AP dimension (APD): was measured on the corrected sagittal view as the distance between the most prominent anterior (A) and posterior (P) points of the condylar head.

3. Condyle ML dimension (MLD): was measured on the corrected coronal view as the distance between the most prominent medial (M) and lateral (L) points of the condylar head.

4. Superior joint space (SJS): was measured on corrected sagittal view as the distance between the most deepest point of the mandibular fossa and the most superior point of the condylar head (Figure 1).

5. Osteoarthritic features: Osteoarthritic features were evaluated on the corrected sagittal and corrected coronal views including; CE, CF and sclerosis in condylar head; OSP and SC (Figure 2).

Figure 1.

Mandibular condyle measurement; a: on the corrected coronal view, condylar height (CH) and mediolateral dimension of condyle (MLD) were measured, b: on the corrected sagittal view, antero posterior dimension (APD) was measured, c: on the corrected coronal view, superior joint space (SJS) was measured.

Figure 2.

TMJ radiographic osteoartheritic changes; a: corrected coronal view showing mandibular condyle head flattening, b: coronal view showing mandibular condyle head erosions, c: on the corrected sagittal view showing mandibular condyle head osteophytes, d: corrected coronal view showing mandibular condyle head subchondral cysts.

The CBCT images were analyzed in the NNT software (V.9.1) which is an original software of the CBCT machine (Newtom5G, QR, Verona, Italy) and in a Dell Precision T5400 workstation (Dell, Round Rock, TX, USA) with 19-inch 1920 × 1080 resolution monitor(Dell E190S, China). The images were analyzed by two oral and maxillofacial radiologists (G.Ş.S. and M.A.). Each observer were blinded with respect to the subject’s group or the clinical or medication information of the patients.

CBCT has a multiplanar reformatting (MPR) system that enables two-dimensional images to be created of real time in coronal, sagittal, axial and oblique/curved planes. The images of axial, coronal and sagittal sections move in a way that is dependent on each other in this system.¹⁸ In our study, right and left condyles have been evaluated within themselves and MPR system has been used while analyzing the images. First, the axial section on the related side has been adjusted to be parallel to the Frankfort horizontal plane. MLD has been measured in the section where the condyle was thought to be the widest mediolaterally on the determined axial plane (Figure 3a). Then, the highest point of the condyle has been determined by moving the sections in anteroposterior direction keeping the axial section constant. CH has been measured perpendicular to the standardized axial plane from the highest point of the condyle. (Figure 3b) In the same coronal section, SJS has been measured between the highest point of the condyle and the deepest point of the mandibular fossa. (Figure 3b) Finally, without making any changes on the axial plane, APD has been measured in the section where the condyle was thought to be the widest anteroposteriorly, by moving the sections in the mediolateral direction in the dependent sagittal image on the axial plane. (Figure 3c) Right and left TMJs were evaluated separately, resulting in a total of 260 TMJs.

Figure 3.

a: condyle mediolateral dimension in axial section (1), b: condylar height (2) and superior joint space (3) in coronal section, c: condylar anteroposterior dimension (4) in sagittal section.

Statistical analysis was performed using SPSS software (SPSS^® v.16.0 for Windows (SPSS, Chicago, IL)). To determine interexaminer agreement/reliability between the two radiologists, the Cohen κ (k) was calculated for the categorical outcomes and Spearman’s correlation coefficient was used for TMJ measurements. Cohen κ statistic values of 0.853–0.945 showed a strong interexaminer agreement and Spearman’s correlation coefficient (0.959–0.997) indicated high interexaminer reliability.

Results

Both the study group and the control group consisted of 57 female and eight male patients. There was no statistically significant difference between mean age of the two groups (p < 0.001). The mean age of the rheumatic diseases group was 49,75 (11,2) years while the mean age of the control group was 49,67 (10,9) years.

According to normality test results, MLD measurements showed normal (parametric) distribution while APD, CH and SJS showed non-parametric distribution. Rheumatic diseases group showed significantly lower mean CH condylar dimension and SJS than the control group (p < 0.001). But, there was no statistically significant difference of mean APD (p = 0,681) and MLD (p = 0,757) dimensions between the two groups (Table 1).

Table 1.

Mean, SD values and results of Student’s t-test (MLD) and Mann Whitney U test (CH, APD and SJS) for comparisons between TMJ measurements in two groups

	Rheumatoid group (n = 130)		Control group (n = 130)
TMJ measurements	Mean	SD	Mean	SD	p
CH	4,70	0,90	5,95	0,95	0,000a
APD	7,91	1,05	7,99	1,01	0,681
MLD	18,96	1,14	19,02	1,55	0,757
SJS	3,09	0,71	3,45	0,67	0,000a

APD, Anteroposterior dimension of TMJ; CH, Mandibular condylar height; MLD, Mediolateral dimension of TMJ; SD, Standard deviation; SJS, Superior joint space of TMJ; n, Number of TMJ.

^aSignificant at p ≤ 0.05.

The correlation between osteoarthritic changes and the rheumatic diseases group was significant, rheumatic diseases group showed a higher prevalence of all osteoarthritic changes. CF was present in 15.9% of the control group and 30% of the study group (p = 0.005). CE was present in 6.1% of the control group and 27.7% of the study group (p < 0.001). OSP was present in 1.5% of the control group and 11.5% of the study group (p = 0.001). SC was present in 2.3% of the control group and 13.1% of the study group (p = 0.001). Considering that more than one osteoarthritic changes may occur with the initiation of the degeneration process of a condyle, individuals with any osteoarthritic changes (one or more) were collected under the group titled “total” in order to determine the frequency of degenerative changes in the mandibular condyle. Osteoarthritic changes were present in 22% of the control group and 42.3% of the study group; the correlation between “total” and the rheumatic diseases group was significant (p < 0.001), the prevalence of any change was also higher in the patient group. (Table 2)

Table 2.

Frequencies, percentages and results of χ2 test for relations between osteoarthritic features in two groups

	Rheumatoid group (n = 130)		Control group (n = 130)
OC	N	%	N	%	p
CF	39	30,0%	21	15,9%	0,005a
CE	36	27,7%	8	6,1%	0,000a
OSP	15	11,5%	2	1,5%	0,001a
SC	17	13,1%	3	2,3%	0,001a
Total	55	42,3%	29	22,0%	0,000a

CE, Condylar erosion; CF, Condylar flattening; OC, Osteoarthritic changes; OSP, Osteophyte; SC, Subchondral cyst.

Total; the number of TMJ with any osteoarthritic changes (one or more), n; number of TMJ, N; Numbers of TMJ with positive osteoarthritic changes.

^aSignificant at p ≤ 0.05.

The means of measurements according to the presence of osteoarthritic bone changes and whether the difference between these averages was significant was examined using the t test in independent groups. People of osteoarthritic bone changes positive showed significantly higher mean CH (p < 0.001), MLD (p = 0.040) and SJS (p = 0.028) condylar dimensions than the people of osteoarthritic bone changes negative (Table 3).

Table 3.

Mean, SD values and results of t-test in independent groups for comparisons of measurements according to the presence of osteoarthritic bone changes

	POC (n = 84)		NOC (n = 130)
TMJ measurements	Mean	SD	Mean	SD	p
CH	4,93	1.26	5,52	0,99	0,000a
APD	7,90	1,07	7,97	1,02	0,603
MLD	18,74	1,38	19,11	1,34	0,040a
SJS	3,13	0,79	3,33	0,67	0,028a

APD, Anteroposterior dimension of TMJ; CH, Mandibular condylar height; MLD, Mediolateral dimension of TMJ; NOC, Negative osteoarthritic changes; POC, Positive osteoarthritic changes; SD, Standard deviation; SJS, Superior joint space of TMJ; n, number of TMJ.

^aSignificant at p ≤ 0.05.

None of the parameters of condylar dimensions and all osteoarthritic changes was significantly between to the subgroups (p > 0.05). (Table 4) The relationship between the subgroups and presence of parameters of osteoarthritic changes was no significant difference was found between them (p > 0.05) (Table 5).

Table 4.

Mean, SD values and results of one-way analysis of variance (ANOVA) and Kruskal-Wallis test for comparisons between five subgroups

	Group A (SSZ) (n = 24)		Group B (MTX) (n = 24)		Group C (HCQ) (n = 32)		Group D (LFN) (n = 24)		Group E (other IS) (n = 26)
TMJ measurements	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	p
CH	4,71	1,11	4,72	1,07	4,62	0,57	4,82	0,65	4,65	1,10	0,609
APD	4,70	0,90	7,92	1,22	7,93	1,04	7,90	1,04	7,91	0,92	0,993
MLD	18,98	1,10	18,95	0,95	18,97	1,49	18,97	0,88	18,95	1,11	1,000
SJS	3,12	0,65	3,12	0,81	3,04	0,65	3,09	0,82	3,07	0,69	0,989

APD, anteroposterior dimension of TMJ; CH, mandibular condylar height; HCQ, Hydroxychloroquine; IS, Immunosuppressant; LFN, Leflunomide; MLD, Mediolateral dimension of TMJ; MTX, Methotrexate; SD, Standard deviation; SJS, Superior joint space of TMJ; SSZ, Sulfasalazine; n, number of TMJ;p ≤ 0.05, Significant.

^aSignificant at p ≤ 0.05.

Table 5.

Frequencies, percentages and results of χ2 test for relations between osteoarthritic features in five subgroups

	Group SSZ (n = 24 Joints)		Group MTX (n = 24 Joints)		Group HCQ (n = 32 Joints)		Group LFN (n = 24 Joints)		Group IS (n = 26 Joints)
OC	N	%	N	%	N	%	N	%	N	%	p
CF	17	70,8%	17	70,8%	23	71,9%	19	79,2%	15	57,7%	0,574
CE	19	79,2%	18	75,0%	22	68,8%	19	79,2%	16	61,5%	0,571
OSP	21	87,5%	21	87,5%	29	90,6%	22	91,7%	22	84,6%	0,937
SC	20	83,3%	22	91,7%	28	87,5%	22	91,7%	21	80,8%	0,718
Total	14	58,3%	15	62,5%	19	59,4%	16	66,7%	11	42,3%	0,466

CE, Condylar erosion; CF, Condylar flattening; HCQ, Hydroxychloroquine; IS, Immunosuppressant; LFN, leflunomide; MTX, Methotrexate; OC, Osteoarthritic changes; OSP, Osteophyte; SC, Subchondral cyst; SSZ, Sulfasalazine.

n; number of TMJ, N; Numbers of TMJ with positive osteoarthritic changes, Total; the number of TMJ with any osteoarthritic changes (one or more), Significant at p ≤ 0.05

Discussion

Rheumatic diseases are inflammatory chronic diseases and progress with uncontrolled proliferation of the synovial tissues and involvement of TMJ that is a synovial joint is an expected case. The incidence is higher among females, different rates are given, such as 3:1 6:1. Our study has about 7:1 female-to-male predilection.^19,20

A study that was evaluating the effect of rheumatic diseases on the TMJ with scintigraphy proved that the patients with RA, AS, and spondyloarthritis are at a high risk of developing TMJ arthritis.²¹ According to the study findings of Lin et al., TMJ symptoms developed in about 30% of RA patients within 1 year after the beginning of the generalized disease, and in about 52% developed more than 1 year after the beginning of the generalized disease.⁷ TMJ’s arthritis progresses through the serial processes of inflammation. The receptor activator of nuclear factor-kB (RANK) to activated by the inflammatory cells and affected synovial cells. RANK stimulate receptor activator of nuclear factor-kB ligand (RANKL), and promotes osteoclasts, Thus, bone destruction occurs.^22,23 Bone destructions result in conditions such as erosion, sclerosis, systemic bone mass loss, joint surface remodeling, narrowing of the superior joint space and the development of osteophytes.²⁴ In addition to this chronic inflammatory-related joint components changes, peri-articular osseous demineralization is a classic complication, this demineralization occurs in two forms. First form is located of the close areas of infection, and degree is connected to disease activity. The other form is more generalized and related to disease activity, medical therapy, and immobility.^25,26 Joint destructions caused by chronic inflammation may require a surgical reconstruction. Therefore, with or without symptom patients at risk of TMJ arthritis is clinically important.²⁷

This study was conducted to better understand TMJ changes in individuals with rheumatoid diseases using CBCT images and their relationship with the drugs used. In this way, to reach early diagnosis and effective timely treatment was aimed. CBCT is an indispensable method for determining the morphological changes in bone components, providing images in all planes, allowing localization arrangements in different planes, providing reliable measurements, therefore indispensable for TMJ assessment.^9,28

The other joints have various methods such as Sharp’s and Largen’s classification methods to measure, evaluate and score of the changes.^29,30 However, TMJ assessments do not have a specific method. Therefore, in our study, the changes in the dimensions of the condyle head and the evaluation of osteoarthritic bone changes were planned. Firstly, condyle head dimensions were compared with the healthy control group. According to our study results, the CH was significantly lower in the patient group, and no significant difference was found in the APD and MLD. This case was interpreted as that bone destruction occurred alone and/or highly in the upper regions of the condyle and decreased the CH. Mohammed et al had determined RA disease activity using serology and disease activity score 28, and associated with osteoarthritic changes. As a result, they concluded that all osteoarthritic changes other than erosion are related to the level of disease activity. Also, they evaluated condylar dimensions and reported of decrease in the mandibular CH, but no significant change in APD and MLD. These results are parallel with our study.⁹ Available studies were generally conducted on the clinical findings of TMJ disorders, in one article, decrease in condyle height was reported in RA patients, but changes in other dimensions were not mentioned.³¹

Hand-joint space narrowing is a finding, specific and used to determine disease activity in the rheumatic diseases, also joint space narrowing with erosion in main structural changes on radiographs.^7,32 Based on this information, SJS was evaluated and a significant difference was found between the two groups. The people with rheumatological diseases had a significant SJS narrowing. This situation was interpreted as the result of deterioration and CF of the existing convex structure and increasing the joint contact surface due to the intensity of bone destruction on the upper surfaces of the condyle head. There are few studies on SJS, and Goupille et al reported a decrease in SJS in the rheumatologic patient group.³³ In a study examining the TMJ morphology of AS patients, erosion and narrowing of the SJS were seen as the most common features, the narrowing in the joint space was present to approximately 88% of the patient group.^34,35

Previous studies agreed that individuals with rheumatic diseases have a higher prevalence of radiographic osteoarthritic changes in TMJ than healthy individuals.^12,35,36 In our study, the comparisons between control and patient groups in terms of osteoarthritic bone changes revealed that the patient group had significantly higher CE, CF, OSP, and SC compared to the control group in line with literature. Although all of the patient group used antirheumatic drugs to prevent erosion, especially CE frequency was higher, it was present in 27.7% of the patient group. Additionally, changes in condyle head dimensions were evaluated in individuals with osteoarthritic bone changes. Accordingly, CH, MLD and SJS averages to the individuals of without any osteoarthritic bone changes were significantly higher than the individuals with osteoarthritic bone changes. It is thought that osteoarthritic changes that occur as a result of chronic inflammation eventuated a decrease in condyle dimensions and this may constitute a basis for TMJ disorders.

The bone destruction in rheumatic diseases is a phenomenon which is decreasing but continuing in anti-inflammatory treatment with DMARD. Preservation of bone mass and prevention of osteoporosis in rheumatic diseases require further treatment program.³⁷ Treatment experiences of rheumatologists showed that with control of the inflammatory activity of rheumatic diseases decrease the progress of osseous damage. Therefore, the primary destination is to suppress chronic infection from the beginning of the disease.³⁸ The group that is today known as DMARDs appeared in the 1970s to separate some second-line drugs from non-steroidal anti-inflammatory drugs. There are drugs to prevent bone resorption rather than suppressing chronic inflammation. While the destructions of bone progressed as before, such as erosion, systemic bone mass loss and sclerosis, the DMARDs became a promising method to prevent destruction. At the present time, they have become a popular treatment method through their ability retard joint destruction radiographically. Unfortunately, grave adverse effects occur on clinical, therefore, chronic treatment is limited.^39,40

Studies among DMARDs that are used provided a comparison, in terms of their effects on bone structure. In a study comparing MTX and other DMARDs, MTX has been found to further prevent bone destruction, but SSZ was not included in the comparison group. Another study between SSZ and MTX reported that both the drugs had a similar and powerful effect in reducing the radiological progression of the disease.^41,42 In comparison of studies SSZ and HCQ, the decrease in radiographic progression was significantly higher in SSZ group, and the increase in grade of erosions in HCQ group patients was continued. Whichever method is used, it is concluded that SSZ is more effective than HCQ.^38,43 In another study, the effect of DMARDs treatments on present erosions was found statistically superior to placebo, respectively, SSZ, LFN, MTX. The other parameter effects to rate of progression of erosions were found statistically superior to placebo, respectively, LFN, MTX, SSZ.⁴⁴ LFN is an immunosuppressive agent and has a big effect especially in the therapy of RA. LFN has an evident suppressive effect on osteoclast differentiation, through ability to inhibit intracellular signaling RANK-RANKL pathway. Studies have revealed a decrease of structural joint destruction, joint space width and osseous erosion using LFN in patients of rheumatic diseases.^45,46 In LFN, researches usually had an equivalent effect to MTX and SSZ in retarding radiographic progression. In a study comparing MTX and LFN, joint space narrowing was MTX, also more than LFN; this case has developed as a result of more peri-articular osteoporosis.^40,47,48

In the light of all these studies, the patient group was classified according to the drugs used, divided into five subgroups and statistical evaluations were made. However, no statistically significant difference was found between the subgroups in terms of condyle sizes or osteoarthritic changes. In the evaluation made in terms of osteoarthritic changes, regardless of the change, patients with any changes were collected under the “total” heading. Osteoarthritic change or changes were observed in 41.7% of patients using SSZ, 37.5% of patients using MTX, 40.6% of patients using HCQ, 33.3% of patients using LFN, and 57.7% of patients using IS. The low number of patients in the subgroups negatively affected the achievement of a statistically significant result. With an interpretation to percentage values, it can be thought that LFN may be more effective than other IS drugs in the progression of radiological findings of arthritis. However, more comprehensive studies on this are required.

The ages of the individuals in our study ranged from 21 to 75. The prevalence of TMJ degeneration increases with advancing age, and this case may create the basis of existing TMJ disorders in elderly patients.⁴⁹ Therefore, the high mean age was one of the limitations of our study, age-related degenerative changes could not be excluded. As far as it was learned from anamnesis, the treatment of the patients had been continuing in rheumatology clinics for about two years, but we could not reach information about the drug doses used, this case was another limitation for our study.

Conclusion

As a result, TMJ is affected by rheumatic diseases as other synovial joints, radiological imaging is required to evaluate TMJs of people with rheumatological diseases in terms of arthritis risk. Degenerative changes occur, especially in joint contact surfaces and may cause decrease in condyle size and changes in condyle position. It is a process that can continue despite the use of antirheumatic or immunosuppressive drugs. All of these can become the source of possible TMJ problems. Early access to effective treatment can be achieved thanks to early detection.