Abstract
Background
Involvement of the temporomandibular joint can be shown in 40–90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.
Methods
The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.
Results
Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrast-enhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intra-articular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.
Conclusion
Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.
The temporomandibular joint is relatively frequently affected in a number of diverse, chronic autoimmune diseases. In chronic rheumatic arthritis of the temporomandibular joint, the degrees of severity range from synovitis through deforming bone lesions and growth disorders in childhood to total condylar resorption and temporomandibular joint ankylosis (table 1) (1).
Table 1. Prevalences of symptoms, clinical signs, and long-term sequelae of JIA with temporomandibular involvement.
| Symptoms and clinical signs at the time of diagnosis | |
| Temporomandibular joint pain – At rest – In motion | 20% 13% |
| TMJ pain on palpation | 13% |
| TMJ sounds (in patient history) | 7% |
| Limited jaw opening | 20% |
| Long-term sequelae | |
| Anterior open bite | 10% |
| Micrognathia | 18% |
| Retrognathia | 56% |
| Facial asymmetry | 34% |
| Total condylar resorption | 4.7% |
| Anklyosis | Rare complication (isolated case reports) |
JIA, juvenile idiopathic arthritis; TMJ, temporomandibular joint
Juvenile idiopathic arthritis (JIA), with a prevalence of 70/100 000 in childhood and adolescence (2), and rheumatoid arthritis (RA), with a prevalence of 1% of adult patients, are two of the most common underlying rheumatic diseases (3). With figures ranging between 40 and 93% for JIA and 45 and 92% for RA (4), the frequency of temporomandibular involvement in the aforementioned clinical pictures was long underestimated (5). This can be attributed to, among other things, the fact that the temporomandibular joint rarely exhibits classic signs of inflammation (6) compared to other synovial joints, hence subjective symptoms frequently do not correlate with imaging findings (7). Despite radiological signs of substantial joint damage, it is not rare to see low-symptom or even asymptomatic disease (8). This makes early diagnosis—which is of central importance in the prevention of the abovementioned complications and sequelae—significantly more challenging.
The basis of care lies in the patient’s attachment to a rheumatology center and their further referral to interdisciplinary temporomandibular joint outpatient clinics, including orthodontics/dentistry, oral and maxillofacial surgery, radiology, and physiotherapy. However, the levels of competence here can vary considerably.
The particular relevance of the topic is illustrated not least by an accumulation of consensus papers by international multidisciplinary working groups (Temporomandibular Joint Juvenile Arthritis Working Group [TMJaw], Outcome Measures in Rheumatology [OMERACT]), which have attempted in recent years to standardize the diagnosis and treatment of chronic rheumatic arthritis of the temporomandibular joint (9– 11, e1– e3). However, a fundamental problem in this regard is the limited number of available studies, with publications showing a low level of evidence (primarily uncontrolled retrospective study designs with inhomogeneous methodology and small patient cohorts) and a high risk for systematic bias. This situation gives rise to the need for an evidence- and consensus-based S3 guideline.
Methods
Literature search, selection, and evidence appraisal
The literature search in the PubMed, Embase, and Cochrane Library databases, as well as with the help of the Livivo search portal, was conducted in February 2018 and yielded a total of 3771 hits. After the sources had been selected by two independent reviewers (AN, CS) and a literature update carried out (April 2021), 394 publications were included in the draft guideline (efigure 1).
eFigure 1.
Identification of studies in databases
Literature search: PRISMA flow diagram 2020 (http://prisma-statement.org/prismastatement/flowdiagram.aspx)
When generating the search terms, the term “temporomandibular joint” was combined with the individual terms “rheumatoid arthritis,” “psoriatic arthritis,” “ankylosing spondylitis,” and “juvenile idiopathic arthritis.” Use of the German and the English language was defined as an inclusion criterion. The search was not restricted to a particular publication period or specific study type due to the limited number of available studies.
The evidence analysis of the literature followed the Oxford criteria (e4) and was complemented by a risk assessment for bias using the SIGN checklists (SIGN, Scottish Intercollegiate Guidelines Network) (e5). Both of the abovementioned measures were carried out by two independent reviewers (TE, CS).
Structured consensus development, external review, and adoption
The Delphi procedure formed the methodological basis for consensus development (e6). Based on this, recommendations/statements were first approved in three internal rounds of voting by the guideline group TMJ surgery of the German Society for Oral and Maxillofacial Surgery and, in this way, a first draft guideline was developed. In three interdisciplinary consensus rounds, the draft was further developed and approved under the collaboration of eight specialist societies (including five sub-groups) as well as one patient association (eTable 1).
eTable 1. Participating specialist societies and patient organizations (in alphabetical order) (*collaborators).
| Specialist society | Mandate holders/co-authors |
| Deutsche Gesellschaft für Mund-, Kiefer-, Gesichtschirurgie (DGMKG) | Prof. Dr. med. Dr. med. dent. Prof. h.c. (BNMU, Kyiv) Andreas Neff |
| Deutsche Gesellschaft für Neuroradiologie (DGNR) | PD Dr. med. Tim Hilgenfeld* |
| Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC) | Dr. med. Martin Arbogast |
|
Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK) – Arbeitsgemeinschaft für Oral- und Kieferchirurgie (AGOKi) – Deutsche Gesellschaft für Funktionsdiagnostik und -therapie (DGFDT) – Deutsche Gesellschaft für Kieferorthopädie (DGKFO) – Deutsche Gesellschaft für Kinderzahnheilkunde (DGKiZ) – Deutsche Gesellschaft für Prothetische Zahnmedizin und Biomaterialien (DGPro) |
Dr. med. Dr. med. dent. Andreas Schön* PD Dr. med. dent. Oliver Ahlers* Prof. Dr. med. dent. Bernd Koos* Prof. Dr. med. dent. Christian Hirsch* Prof. Dr. med. dent. Peter Ottl* |
| Deutsche Röntgengesellschaft (DRG) | PD Dr. med. Wolfgang Wüst* |
| Deutscher Verband für Physiotherapie (ZVK) | Ima Feurer* |
| Gesellschaft für Kinder- und Jugendrheumatologie (GKJR) | Dr. med. Boris Hügle |
| Gesellschaft für Pädiatrische Radiologie (GPR) | PD Dr. med. Thekla von Kalle |
| Patient association | Mandate holder |
| Deutsche Rheuma-Liga: Bundesverband | Mario Habermann-Krebs* |
| Institute/practice | Members |
| Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsklinikum Münster, Germany | Prof. Dr. med. Dr. med. dent. Johannes Kleinheinz* |
| Universitätsklinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätskliniken/Tirol Kliniken, Austria | Prof. Dr. med. Dr. med. dent. Andreas Kolk * |
| Medizin & Ästhetik, Praxisklinik für Mund-, Kiefer- und Gesichtschirurgie, München, Germany | Prof. Dr. med. Dr. med. dent. Christoph Pautke* |
| MVZ R(h)einZahn, Bonn, Germany | Prof. Dr. med. Dr. med. dent. Rudolf Reich* |
| Praxis für Gesichtschirurgie und Kiefergelenkchirurgie, Hamburg, Germany | Dr. med. Dr. med. dent. Marcus Teschke* |
Following unanimous approval of the draft guideline by the chairpersons of the participating groups, the S3 guideline containing 32 recommendations and 45 statements was published on 28.07.2021 by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).
This article presents the most important results of the guideline development. In the text, recommendations are designated as follows:
Grade of recommendation (A: strong recommendation, B: recommendation, 0: open recommendation)
Strength of consensus (↑↑: strong consensus, ↑: consensus)
Level of evidence (I–V, eTable 2).
eTable 2. Table of evidence on diagnosis.
| Publication | Study design | Methodology | n | Outcome |
| Küseler et al. 1998 (19) | Cross-sectional controlled | Comparison of clinical examination, panoramic dental X-ray (orthopantomography [OPG]), and contrast-enhanced MRI in JIA (n = 10) and a healthy control group (clinical examination and MRI without contrast medium only) (n = 10) | 25 | ● JIA: Detection of temporomandibular joint involvement in 87% using contrast-enhanced MRI, 40% using OPG, and 60% with clinical examination ● No significant difference between JIA and healthy controls using MRI without contrast medium |
| Müller et al. 2009 (e12) | Cross-sectional controlled | Comparison of clinical examination (rheumato- logical and orthopedic), ultrasound, and contrast- enhanced MRI | 30 | ● Rheumatological examination Sensitivity: 58%, specificity: 82% ● Orthopedic examination Sensitivity: 47%, specificity: 36% ● Ultrasound Sensitivity: 33%, specificity: 82% → No reliable prediction of temporomandibular joint arthritis possible compared to the reference standard MRI |
| Pedersen et al. 2008 (7) | Prospective controlled study | Comparison of clinical examination, orthopantomography (OPG), and contrast-enhanced MRI four times over 2 years in JIA and a healthy control group (baseline) | 25 | ● Significantly lower detection rate of radiological changes on OPG compared to the reference standard MRI(**) ● Restricted translation movements in JIA correlate with resorptive changes on MRI (*) and OPG (*) ● Condylar changes on MRI in JIA increased over the observation period and were found in 80% of JIA patients at the end of the observation period (**) |
| Koos et al. 2014 (e13) | Cross-sectional controlled | Comparison of clinical examination to contrast-enhanced MRI in JIA and a healthy control group | 268 | ● Average values for the individual examination elements Sensitivity 42%, specificity 81% Average values in combination Sensitivity: 73%, specificity: 70% → No reliable prediction of temporomandibular joint arthritis possible compared to the reference standard MRI |
| Resnick et al. 2016 (e14) | Retrospective controlled study | To determine a ratio of contrast enhancement between temporomandibular joint and longus capitis muscle to detect temporomandibular joint arthritis in JIA (healthy control group) | 145 | ● Using a ratio of 1.55, it was possible to detect synovitis with a sensitivity of 91% and a specificity of 96 % ● Strong intraexaminer and interexaminer agreement |
Significance levels: (*): p < 0.05; (**): p < 0.01; (***): p < 0.001; JIA, juvenile idiopathic arthritis; MRI, magnetic resonance imaging
Statements are given together with strength of consensus and level of evidence.
Definition and clinical aspects
According to international expert consensus (TMJaw), chronic rheumatic arthritis of the temporomandibular joint is defined as “active (pathogen-independent) inflammation of the temporomandibular joint.” Its diagnosis is made independently of subjective symptoms and clinical signs and is based solely on the demonstration of inflammatory changes in soft tissue by means of contrast-enhanced magnetic resonance imaging (MRI). Temporomandibular joint involvement in the rheumatic setting, on the other hand, includes all anomalies presumed to be attributable to temporomandibular joint arthritis (for example, bone erosions) (9).
Frequent symptoms of chronic rheumatic arthritis of the temporomandibular joint include, initially, pain and sounds in the region of the temporomandibular joint, as well as restricted jaw mobility (12). In the further course, resorption of the condylar head, including the chondylar process (condylar resorption), and restricted mandibular growth can result in severe facial deformities (for example, asymmetry of the lower face, micrognathia, and retrognathia) and lead to impaired occlusion (for example, anterior open bite) (13).
In the case of restricted mouth opening and its most severe form—temporomandibular joint ankylosis—one must expect impairments in everyday life in terms of, among other things, speech, food intake, oral hygiene, and medical care (dental treatment, endoscopic procedures, option to intubate) (14, 15). As a general rule, disease courses vary considerably between individuals and are characterized by alternation between acute phases and remission. In 60% of affected JIA patients, temporomandibular joint arthritis proves to be inactive in adulthood (60% of these cases being in spontaneous remission) (16).
With regard to the underlying rheumatic disease, a distinction is made between juvenile idiopathic arthritis (JIA) and chronic rheumatoid arthritis on the basis of age of onset. JIA is a diagnosis of exclusion defined as manifesting for the first time before the age of 16 years and lasting at least 6 weeks (17). The classic forms of chronic rheumatic disease in adulthood include, above all, rheumatoid arthritis (45–92%), psoriatic arthritis (29–62%), and ankylosing spondylitis (10–32%) due to the frequency of temporomandibular joint involvement.
Risk factors for temporomandibular joint involvement include long disease duration (for example, RA > 5 years), greater disability, and high underlying disease activity. For JIA, early disease onset (<4 years) as well as the polyarticular and systemic subtype are also cited. Females are three times more likely to be affected than their male counterparts (14).
Diagnosis
Clinical examination
In view of the inconsistent correlation between symptoms and imaging (7), a clinical examination alone is not sufficient for the diagnosis of temporomandibular joint arthritis (18) and should be complemented by imaging techniques [A, ↑↑, IIb].
Nevertheless, the clinical examination is deemed to play a crucial role in initial screening, the assessment of progression, and the evaluation of interventions (10) [↑↑, IIIb]. Therefore, particularly in childhood and adolescence [A, ↑↑, IV], as well as beyond [A, ↑↑, IIb], clinical follow-up of the temporomandibular joint should be performed annually. The short screening protocol developed by the TMJaw Working Group offers a comparatively fast and easy-to-perform option here (11) [↑↑, IIIb] (Tabelle 2).
Table 2. Examination protocol according to Stoustroup et al. (11).
| Item | Possible findings*1 |
| 1. Localization(s) of craniomandibular pain based on patient history | Regions of pain noted on a facial map |
| 2. Temporomandibular joint pain on palpation with mouth open and closed | No pain, unilateral right-sided temporomandibular joint pain, unilateral left-sided temporomandibular joint pain, bilateral temporomandibular joint pain |
| 3. Mandibular deviation (≥ 3 mm) at maximum mouth opening | No deviation, right-sided deviation, left-sided deviation |
| 4. Maximum active mouth opening | Absolute value in millimeters (norm in adults > 35 mm) |
| 5. Assessment of frontal facial symmetry | No asymmetry, right-sided asymmetry, left-sided asymmetry |
| 6. Assessment of facial profile | Straight, mildly convex, moderately convex, micrognathia |
Imaging techniques
Due to its ability to detect acute inflammatory processes in soft tissue, contrast-enhanced MRI is considered the best technique to visualize active arthritis in the temporomandibular joint (7, 19) [↑↑, IIb] (etable 2). As such, it is the first choice for the early diagnosis and monitoring of temporomandibular joint arthritis in JIA [↑↑, IIb] (clinical algorithm, see Figure). If contrast-enhanced MRI in rheumatic arthritis of the temporomandibular joint fails to provide sufficient information regarding the involvement of bony structures, computed tomography (CT) or cone beam computed tomography (CBCT) represent possible alternatives in some cases (20) [↑↑, IIb]. However, both techniques are considered unsuitable to assess early-stage arthritis of the temporomandibular joint, since this is characterized primarily by inflammatory changes in soft tissue [↑↑, IIb]. CBCT, CT, and possibly in the future also MRI offer the option to measure bony cranial structures (3D cephalometry) to scale and, thus, assess dentofacial morphology and growth deviations in detail (21) [↑↑, IIIb].
Figure.
Clinical management in symptomatic patients with a known history of RA/JIA based on Stoll et al. (e15) and Alstergren et al. (6)
*1 Representing rheumatic diseases with temporomandibular joint involvement in adults
*2 Borderline MRI findings: low-grade increase in synovial contrast enhancement or low-grade joint effusion
*3 Bone marrow edema/contrast enhancement, synovial contrast enhancement, synovial thickening and joint effusion
*4 Condylar flattening, erosions, and disc changes
*5 Differentiation: rheumatic joint disease: Krenn score ≥ 5 (high grade synovialitis); degenerative joint disease: Krenn score < 5 (low grade synovialitis)
*6The indication for a synovial biopsy performed independently of an otherwise indicated intervention should be made based on strict indication criteria in order to avoid procedures that are not strictly necessary—this applies in particular to patients ≤ 17 years.
CMD, craniomandibular dysfunction; IACI, intraarticular corticosteroid injections; JIA, juvenile idiopathic arthritis; MRI, magnetic resonance imaging; RA, rheumatoid arthritis
As a cost-effective and readily available technique, the panoramic dental X-ray represents an option for initial imaging; however, due to methodological limitations (for example, distortion), it is informative only at advanced stages of bone involvement (7) [↑↑, IIb] (etable 2).
Ultrasound is currently not deemed a suitable method for the diagnosis and monitoring of arthritis of the temporomandibular joint due to a lack of standardization as well as limited evidence (22) [↑↑, IIIb].
Treatment
The basal treatment concept comprises pharmacotherapy of the underlying disease, primarily using non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs). If these fail to sufficiently control symptoms and improve function, adjuvant measures focusing on the temporomandibular joint come into play [↑↑, V]. The level of evidence of treatment studies is limited, with isolated randomized controlled trials (RCTs) and poorly controlled prospective studies. Most publications are designed as uncontrolled retrospective studies and have small patient cohorts.
Conservative treatment
There is evidence that the temporomandibular joint may respond less well to basal treatment with DMARDS compared to other joints (5, 23). Having said that, it is not possible to conclusively assess this due to the limited number of studies.
Particularly in the postoperative setting and in the case of restricted jaw mobility, physiotherapy represents a complementary treatment option [↑↑, IV]. It achieves symptom reduction and improves temporomandibular joint functionality in the short term (24), but there is no evidence as yet for a long-term benefit. In addition, soft foods are recommended in order to spare the temporomandibular joint in acute phases [↑↑, IV].
Occlusal splints promote neuromuscular relaxation of the jaw region and should be used to reduce arthritis-related symptoms (25) [B, ↑↑, IIb] (table 3). However, it is important to note that wearing these splints for long periods of time can impair dentoalveolar growth. Distraction splints permit relief of the temporomandibular joint by displacing the jaw in a ventrocaudal direction. They can be used to reduce asymmetry and normalize mandibular growth (26) [0, ↑↑, IIIb].
Table 3. Evidence for conservative, minimally invasive, and open surgical treatments.
| Publication | Study design | Methodology/intervention | n | Outcome/effects |
| Stoustrup et al. 2014 (25) | Prospective controlled study | ● Intervention: Occlusal splint for at least 8 weeks ● Outcome measures: subjective symptoms and temporomandibular joint function ● Subjects: JIA (n = 28), healthy controls (no occlusal splint therapy) (n = 110) |
138 | ● JIA: pain reduction: Frequency: 4–6 x/week à 1–3 xweek(*), intensity: VAS↓ 14.7 mm(**); MJO↑: by 3.6 mm(**), laterotrusion↑: 1.8 mm(*) ● Worse temporomandibular joint function in JIA compared to controls; difference: MJO: T1 10.6 mm (**), T2 6.7 mm (**); laterotrusion: T1 4.5 mm (**), T2 2.8 mm (**) |
| Kjellberg et al. 1995 (27) | Prospective controlled study | ● Intervention: functional orthodontic appliance (activator) for 2 years; ● Outcome measures: jaw growth and occlusion ● Subjects: JIA with Angle Class II malocclusion (n = 15), healthy controls with Angle Class II malocclusion (n = 23) (and JIA with normal occlusion [n = 15], no activator therapy) ● Follow-up: 2.6 (JIA) and 3.9 years (healthy subjects) |
53 | ● Normalization of occlusion: JIA: 11/14 patients, healthy subjects: 18/23 patients ● Improvement in deformity in both groups: JIA: improvement in lower jaw position(*); healthy subjects with improved lower jaw position(**), upper jaw position*, the position of the jaws to each other(**), lower jaw length(**), and anterior facial height(**) ● Stable conditions at 2.6–3.9 years after treatment end |
| Kopp et al. 1991 (e10) | Randomized controlled clinical trial | ● Intervention: intra-articular injection of hyaluronic acid (HA) versus glucocorticoids (IACI) versus saline solution (SS) ● Outcome measures: subjective symptoms and temporomandibular joint function ● Subjects : RA ● Follow-up: 4 weeks |
41 | ● IACI: pain ↓ VAS 34 mm(**), MJO↑ 6 mm(*); pain on palpation ↓(**) ● HA: MJO↑ 3 mm (**) ● Significant differences between the IACI and SS groups, with a reduction in subjective symptoms and tenderness on palpation (*) |
| Lochbühler et al. 2015 (31) | Retrospective controlled study | ● Intervention: intra- (IACI) versus (accidental) extra-articular injection (EACI) of glucocorticoids (triamcinolone) ● Outcome measures: inflammatory activity, temporomandibular joint deformity, and ramus height on MRI ● Subjects: JIA ● Follow-up: up to 5 years |
33 | ● Improvement in inflammatory activity: in 53% after IACI(**), in 20% after EACI(**) ● Correlation between frequent use/high cumulative doses and progressive bone deformity (3.2 x, 19 mg) (**) and joint destruction (23 mg) (**) ● In JIA and IACIs, generally lower mandibular growth rate (0.7 mm/year) compared to healthy subjects (1.4 mm/year) (**), negative mandibular growth in IACI (T1: −1 mm/year, T2: −0.5 mm/year) compared to EACI (T1: 0.8 mm/year, T2: 0.5 mm/year) (*) |
| Olsen-Bergem et al. 2014 (33) | Randomized controlled clinical trial | ● Intervention: arthrocentesis and temporomandibular lavage with and without subsequent IACI ● Outcome measures: subjective symptoms and clinical signs ● Subjects: JIA ● Follow-up: 8 months |
21 | ● No significant differences between temporo- mandibular lavage with and without IACI ● Group-independent: MJO ↑ by 13.7 mm (***), MJO ↑ until painful: 20.9 mm (***) ● Pain VAS↓ by 41 mm (**) |
| Antonarakis et al. 2018 (e11) | Prospective controlled study | ● Intervention: temporomandibular lavage and glucocorticoids versus lavage versus control group without intervention ● Outcome measures: subjective symptoms, clinical signs, and active inflammation on MRI ● Subjects: JIA; follow-up: 6 months |
41 | ● Improvement in Helkimo Clinical Dysfunction Index with lavage plus IACI compared to lavage(*) ● Otherwise, no significant differences between groups |
| Israel et al. 2010 (34) | Controlled clinical trial | ● Intervention: early (eA) versus late (lA) intervention with arthroscopy following pain onset ● Outcome measures: subjective symptoms, clinical signs ● Subjects: RA |
44 | ● eA = 5.4 months and lA = 33 months after pain onset ● Pain: eA VAS↓ by 51.4 mm (**), lA VAS↓by 28.4 mm (**); MJO↑: eA by 12.38 mm (**), lA by 7.7 mm*, chronic pain in two lA patients ● No significant differences between groups |
| Bjornland et al. 1995 (35) | Prospective controlled study | ● Intervention: synovectomy and diskectomy ● Outcome parameters: subjective symptoms, clinical signs ● Subjects: RA (n = 15) and patients with internal derangement (ID) (n = 20) ● Follow-up: 3 years |
35 | ● Pain↓ in 73% of RA(**), in 80% of ID(**); MJO↑: RA 13.7 mm(**), ID 9.1 mm(**); laterotrusion↑: RA 3.4 mm(***), ID 2.9 mm(**) ● Generally no significant differences between groups |
Significance levels: (*): p < 0.05; (**): p < 0.01; (***): p < 0.001; ↑: increase, ↓: reduction; JIA, juvenile idiopathic arthritis; MJO, maximum jaw opening;
MRI, magnetic resonance imaging; RA, rheumatoid arthritis; VAS, visual analog scale
From an orthodontic perspective, functional orthodontic appliances (for example, activators) can be used to correct typical dentofacial deformities (27) [0, ↑↑, IIb] (table 3).
Infiltrative therapy
Intra-articular corticosteroid injections (IACI) have been shown to improve subjective symptoms and jaw function in the short and medium term in chronic rheumatic arthritis of the temporomandibular joint in both childhood and adolescence, with a low complication rate (28). However, the use of these injections is only indicated if pharmacological therapy fails [↑↑, V]. The reason for this lies in the increased number of reports on severe long-term complications particularly in the case of repeated use. These include:
A chondrotoxic effect (29) through to complete destruction of the temporomandibular joint
Heterotopic ossification of the temporomandibular joint (30)
Restricted mandibular growth (31) in growing patients with JIA.
Against this backdrop, IACI in temporomandibular joint arthritis should only be used—if at all—as a single injection [↑↑, IIIb]. Continuously repeated or ongoing therapy should be avoided under all circumstances [↑↑, IIIb] (table 3). Particularly in JIA, IACI should be reserved for treatment-refractory cases [B, ↑↑, V].
Surgical treatment
Minimally invasive techniques
If conservative treatment fails or has been exhausted (<10% of patients with chronic rheumatic arthritis of the temporomandibular joint presenting to a temporomandibular joint clinic [32]), minimally invasive techniques should be used in a first step [B, ↑↑, IIb] (table 3). Arthrocentesis and joint lavage is one option here that can be performed as an alternative to minimally invasive arthroscopy (33) [0, ↑↑, Ib] (table 3). Arthroscopy combined with lysis and joint lavage enables the removal of adhesions, debris, and inflammatory mediators from the intra-articular space. It should be used for the temporary reduction of pain, the improvement of temporomandibular joint function, and, where necessary, for the further diagnostic work-up (34) [B, ↑↑, IIb] (table 3).
Open surgical techniques in adults
If all aforementioned treatment options have been exhausted (approximately 1% of patients with chronic rheumatic arthritis of the temporomandibular joint presenting to a temporomandibular joint clinic [32]) and there is a prospect that the patient could benefit from a procedure with regard to symptoms, joint function, or aesthetics, an open surgical intervention shall be considered [A, ↑↑, IV].
In the case of severe long-term pain, including high-grade functional impairment and signs of causative active synovitis, synovectomy should be performed (35) [B, ↑↑, IIb] (table 3). Here, however, one needs to take into account the risk of recurrent synovitis (10%), as well as the close proximity of the medial joint capsule to branches of the trigeminal nerve, the carotid artery, and the internal jugular vein (36). In the rare case of an irreparably damaged, collapsed/destroyed, or ankylosed temporomandibular joint, total alloplastic joint replacement represents the gold standard and, as such, can be the primary indication in chronic arthritis of the temporomandibular joint (approximately <15 procedures/year in JIA/RA in Germany) (37).
In contrast to the alloplastic replacement approach, autologous transplants, as endogenous material in the inflammatory environment, may be subject to degenerative changes, as well as fibrosis, heterotopic ossification, and ankylosis. Thus, in view of the lower success rates, total alloplastic joint replacement should be favored over autologous transplants in chronic rheumatic arthritis of the temporomandibular joint in adults (38) [B, ↑↑, IIIb].
Open procedures in juvenile idiopathic arthritis
In JIA with temporomandibular joint involvement, a broad distinction can be made between two target groups:
Target group 1: Patients that, despite exhausting conservative and minimally invasive procedures, suffer from persistent active synovitis and the resulting joint damage. The removal of tissue altered by inflammation and destroyed articular structures constitutes a treatment approach here, and the clinical management is similar in its essential features to that of adult patients.
Target group 2: Patients affected by skeletal deformities (for example, retrognathia, micrognathia, and asymmetry) secondary to the underlying disease. Surgical correction of malposition of the jaw represents a corrective treatment option here.
For target group 1, the following recommendations apply: In contrast to the evidence for adult patients, it was not possible to identify any informative studies on synovectomy for JIA.
Due to its potential to grow, the costochondral graft (CCG) is favored by a number of authors for joint replacement in adolescents (39). However, this graft has attracted increased criticism in recent years due to its unpredictable growth patterns (over-/undergrowth, lack of growth) and the devastating effects it can have (39, e7). In the absence of better alternatives at present, the CCG can be used for temporomandibular reconstruction in JIA despite its sometimes serious adverse effects [0, ↑↑, IV]. However, annual follow-up is required until temporomandibular joint growth is complete in order to identify complications early on (39) [A, ↑↑, IV].
Based on a handful of individual case reports published to date (e8, e9), alloplastic temporomandibular joint replacement may represent a promising alternative to CCG in selected cases in the future (37).
For target group 2, the following recommendations were made: In the case of severe deformity, orthognathic surgery should be considered, assuming that the underlying disease is inactive/well controlled and that there is sufficient residual condylar mass [B, ↑↑, IV]. Typically, orthognathic surgery is performed once bone growth is complete; however, in exceptional cases (for example, severe psychological impairment), it is also possible to operate during the growth phase [↑↑, IV]. The most commonly used treatment options include bilateral sagittal split osteotomy, mandibular distraction osteogenesis to advance the lower jaw forward, the Le Fort I osteotomy to correct occlusion and anterior open bite, and genioplasty to optimize facial aesthetics (40) (clinical algorithm in eFigure 2).
eFigure 2.
Clinical algorithm on correcting skeletal deformities in juvenile idiopathic arthritis (JIA) [modified from Resnick et al. (e3)]
*1: A loss of vertical height is a causal component of dentofacial deformity/asymmetry in JIA—hence the algorithm does not include a decision pathway without this pathology.
*2: Ideally, if no progression is seen ≥ 1 year and there are no signs of acute inflammatory activity on magnetic resonance imaging (MRI)
*3: Functional orthodontic treatment to correct/mitigate growth inhibition plus dentoalveolar compensation therapy
*4: Surgical intervention postponed until better inflammatory control is achieved or spontaneous remission occurs.
*5: Only if inflammation in the temporomandibular joint is well controlled
Color key: blue = pharmacological treatment option; olive green = orthodontic treatment option; red = open surgical treatment option
Summary
With the publication of this guideline, a crucial contribution has been made to standardizing the diagnosis and treatment of chronic rheumatic arthritis of the temporomandibular joint. In addition to improving patient care, this guideline is also intended to turn the focus on a clinical picture that has long received scant attention.
Despite increased efforts, there is still a clear need for publications with higher levels of evidence—this applies in particular to IACI and surgical techniques in JIA.
Acknowledgments
Clinical guidelines in the Deutsche Ärzteblatt, as in numerous other specialist journals, are not subject to a peer review procedure, since S3 guidelines represent texts that have already been evaluated, discussed, and broadly agreed upon multiple times by experts (peers).
Translated from the original German by Christine Rye.
Footnotes
Conflict of interest statement
Prof. Neff received speaker‘s fees and study support (third-party funding) from Karl Storz. He is a member of the European Society of Temporomandibular Joint Surgeons and the Strasbourg Osteosynthesis Research Group.
The remaining authors declare that no conflict of interest exists.
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