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. Author manuscript; available in PMC: 2022 Nov 14.
Published in final edited form as: J World Fed Orthod. 2021 Mar 5;10(2):70–73. doi: 10.1016/j.ejwf.2021.01.003

Management of juvenile idiopathic arthritis: Preliminary qualitative findings from the National Dental Practice-Based Research Network

Chung How Kau a,*, Veerasathpurush Allareddy b, Peter Stoustrup c, Thomas Pedersen d, Brian Kinard e, Randy Q Cron f, Matthew L Stoll f, Gregg H Gilbert g
PMCID: PMC9641639  NIHMSID: NIHMS1825046  PMID: 33678562

Abstract

Introduction:

JIA is the most common chronic arthritis in childhood and represents a series of chronic inflammatory arthritides that develop before 16 years of age.

Materials and Methods:

In 2020, investigators with an interest in the management of Juvenile Idiopathic Arthritis (JIA) engaged the National Dental Practice-Based Research Network by conducting a preliminary qualitative questionnaire (“Quick Poll”) that comprised 6 questions about JIA management.

Results:

A total of 604 persons responded. Results suggested that there was an interest in the management of JIA, but many clinicians did not feel that they had the necessary knowledge or experience to treat these patients.

Conclusions:

The study clearly highlights a distinct gap in awareness and understanding of JIA among clinicians polled. Future work in this area should focus on education and awareness across multiple specialties, clinical guidelines for the management of JIA, and a data repository of long-term outcomes.

Background and Introduction:

JIA is the most common chronic arthritis in childhood and represents a series of chronic inflammatory arthritides that develop before 16 years of age1. It has no identifiable cause and most categories of JIA are significantly distinct from adult rheumatoid arthritis. JIA affects up to 1 in 1000 children around the globe and has a significant debilitating effect on these young children2. The “TMJ”, often regarded as the “forgotten joint”, is affected in at least half the children with JIA3. Depending on the subtype, TMJ involvement of JIA patients may occur in 30–45% and is dependent on diagnostic criteria and patient ethnicity4,5.

The clinical presentation of JIA patients with TMJ involvement is challenging, as the reported prevalence of signs and symptoms varies considerably between studies6. Some of these include pain, loss of function, stiffness, headaches and reduced opening of the jaws7. These arthritis-induced orofacial signs and symptoms can continue into adulthood. There is a general consensus that TMJ arthritis is common in JIA, based on findings from gadolinium-based, contrast enhanced magnetic resonance imaging (Gd-MRI)8. This imaging method is currently regarded as the gold standard for detection of early stage TMJ involvement9,10. Imaging modalities like plain film radiographs, panoramic and lateral cephalograms provide limited information and are 2D representations of a complex problem. 3D Computed Tomographs (CT) and Cone Beam CTs are methods to visualize the shape and destruction of the bony surfaces of the joint. These modalities, however, have a low sensitivity to detect early change and require radiation11. Nonetheless, CBCTs have been shown to allow for dynamic tracking12 and surgical planning in the clinical management of these cases13.

In cases where TMJ involvement is extensive, treatment strategies can present as difficult dilemmas, especially during the growth period of life, as these lead to dento-facial deformities and malocclusions (Fig 1). In addition, the active disease precludes the patient from receiving adequate orthodontic treatment because of the lack of growth on the affected side and the resulting compensatory development of the dental occlusion. Bilateral joint involvement occurs in about 53% to 83% of the cases, and the rates increase as the patient gets older 14,15. Bilateral cases often require more-severe interventions.

Figure 1.

Figure 1.

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Clinical pictures and CBCT images of representative patient with JIA. The patient was referred to the Orthodontic Department and received referral from the Division of Pediatric Rheumatology, Children’s Hospital of Alabama. (A) Facial pictures of patient with JIA showed facial asymmetry due to affected left temporomandibular joint (TMJ). (B) CBCT images of the right TMJ which shows normal structure of the joint. (C) CBCT images of the left side TMJ which shows destruction of the joint due to JIA.

Clinical Management:

Systemic treatment of TMJ arthritis typically involves the use of Disease Modifying Anti-Rheumatic Drugs (DMARDs), and these appear to slow down or prevent further joint damage. Methotrexate (MTX) is the most widely used of these medications and has been found to reduce the TMJ deformation and dentofacial disproportion 16. Nevertheless, systemic management of patients often requires the use of biological agents, or “biologics”, to control TMJ arthritis.

In addition to these therapies, active clinical management of the joints can include orthodontic treatment with occlusal splints, functional appliances and regular braces17 (Fig 2). In some instances, physiotherapy is also recommended and provides symptomatic relief as well as continued normal function. Recent systematic reviews have concluded that consensus about orthodontic management of children with JIA is low and sub-optimal18. Some clinical studies have shown that functional appliance treatment relieves jaw pain and helps to correct mandibular retrognathia. Another type of appliance known as the mandibular distraction splint has also been used. This distraction device is an active appliance that alters the mandibular position by gradually thickening the splint on the affected side in unilateral cases and on both sides in bilateral cases. Once this stabilizes the soft tissue envelope and TMJs, a second phase of orthodontic treatment with functional appliances or activator treatment is initiated19. This type of treatment is carried out predominantly in European countries and has not been attempted on a wide scale in the United States20. Lastly, surgical management by oral and maxillofacial surgeons includes TMJ corticosteroid injections, joint lavages with sodium hyaluronate injections, orthognathic surgery and total joint replacements.

Fig 2 .

Fig 2 .

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An occlusal splint used to treat a patient with JIA. Acrylic is added incrementally to the affected side to equilibrate the jaw and provide relief.

Aim:

Despite the wide-ranging approaches to clinical diagnosis and management, there is very little information on the comprehensive co-operation between orthodontics, dental specialties, medical, and surgical specialties. There is a consensus-based group called the TMJaw group that is trying to harmonize the information above but is more European based. The results of the poll will significantly help Orthodontists understand their role within this large network of multidisciplinary team members.

“Quick Poll”:

The National Dental Practice-Based Research Network is a consortium of participating practices and dental organizations committed to advancing knowledge of dental practice and ways to improve it. The major source of funding for this network is the National Institute of Dental and Craniofacial Research (NIDCR), part of the U.S. National Institutes of Health (NIH). On a recurring basis, “Quick Polls” are done by the network as a simple, low-cost means to engage network members in clinical topics of interest, with an expectation that findings from these preliminary polls will inform the design of a subsequent, rigorously-designed, full-scale clinical study that the network might conduct later. A single invitation to complete the poll is sent to network members. No follow-up of non-respondents is done because all data are captured in anonymized form, so it is not possible to identify who responded. The JIA “Quick Poll” was constructed on the following 6 broad questions:

  1. Please indicate the area of expertise within oral health care that describes your work the most.

  2. What is your overall knowledge about the orofacial manifestations of JIA?

  3. How many different patients with JIA do you personally treat in your clinic each year?

  4. What are the types of care you provide to those with JIA in your clinic (select all applicable)?

  5. In your opinion, please indicate your motivation to provide oral health care for those with Juvenile Idiopathic Arthritis.

  6. In your opinion, please indicate the barriers to providing dental care for those with JIA.

Results:

A total of 604 practitioners responded to the Quick Poll. Approximately 52% of respondents conducted routine periodic dental examinations in their clinics for JIA patients, 45% exposed radiographs in their clinics, 46% provided oral hygiene, 30% delivered restorative care, 39% provided orthodontic care (both limited and comprehensive phases of orthodontic treatment), 6% replaced joints, 12% did orthognathic surgery and 5% provided intraarticular corticosteroid treatment. Only 38% referred JIA patients to a rheumatologist.

The largest respondent group was orthodontists (46%), followed by general dentists (37%). Several factors were identified as motivators for providing oral health care for those with JIA. These included: want to help those with this craniofacial anomaly (57% of respondents); experience providing dental care to patients with cleft and dentofacial anomalies (39%); personal connection/experience (26%); community engagement (20%); prior educational training (20%); increase revenue/production of practice (9%); and marketing of practice (4%).

The Quick Poll attempted to identify potential barriers for practitioners to providing oral health care for those with JIA. Barriers for providing care included: Little or no knowledge of JIA (77%); lack of education and training on JIA (59%); lack of experience providing dental care to patients with JIA (44%); proximity to a craniofacial team (29%); insurance issues (27%); financial implications (26%); compliance of patients (23%); and practice set-up (15%).

Limitations of the Quick Poll methodology:

The Quick Poll conveys qualitative results meant to provide a cross-sectional snapshot of the clinical landscape. Quick Polls are not obtained from a rigorously designed, quantitative questionnaire using random selection of participation, but instead are intended to inform a thoroughly designed quantitative study envisioned for later.

Important findings and conclusions:

The study clearly highlights a distinct gap in awareness and understanding of JIA among clinicians polled. Future work in this area should focus on education and awareness across multiple specialties, clinical guidelines for the management of JIA, and a data repository of long-term outcomes. Orthodontists need to understand their role in the management of this debilitating disease. The poll suggests that much more work is needed in the future.

Highlights.

This special article showcases:

  • The network of the PBRN in large scale research

  • The deficiency in knowledge about JIA

  • The deficiency in management of patients with JIA

  • The need for further work to educate different specialties on JIA

Acknowledgements

  1. This preliminary inquiry was supported by NIDCR grant U19-DE-28717.

  2. The study acknowledges all the participants who responded to the Quick Poll qualitative questionnaire.

Footnotes

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References

  • 1.El Assar de la Fuente S, Angenete O, Jellestad S, Tzaribachev N, Koos B, Rosendahl K. Juvenile idiopathic arthritis and the temporomandibular joint: A comprehensive review. J Craniomaxillofac Surg. 2016;44(5):597–607. [DOI] [PubMed] [Google Scholar]
  • 2.Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369(9563):767–778. [DOI] [PubMed] [Google Scholar]
  • 3.Arabshahi B, Cron RQ. Temporomandibular joint arthritis in juvenile idiopathic arthritis: the forgotten joint. Curr Opin Rheumatol. 2006;18(5):490–495. [DOI] [PubMed] [Google Scholar]
  • 4.Abramowicz S, Levy JM, Prahalad S, Travers CD, Angeles-Han ST. Temporomandibular joint involvement in children with juvenile idiopathic arthritis: a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127(1):19–23. [DOI] [PubMed] [Google Scholar]
  • 5.Fischer J, Skeie MS, Rosendahl K, et al. Prevalence of temporomandibular disorder in children and adolescents with juvenile idiopathic arthritis - a Norwegian cross- sectional multicentre study. BMC Oral Health. 2020;20(1):282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Stoll ML, Kau CH, Waite PD, Cron RQ. Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what? Pediatr Rheumatol Online J. 2018;16(1):32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Foeldvari I, Tzaribachev N, Cron RQ. Results of a multinational survey regarding the diagnosis and treatment of temporomandibular joint involvement in juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2014;12:6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Bollhalder A, Patcas R, Eichenberger M, et al. Magnetic Resonance Imaging Followup of Temporomandibular Joint Inflammation, Deformation, and Mandibular Growth in Juvenile Idiopathic Arthritis Patients Receiving Systemic Treatment. J Rheumatol. 2020;47(6):909–916. [DOI] [PubMed] [Google Scholar]
  • 9.Stoll ML, Vaid YN, Guleria S, Beukelman T, Waite PD, Cron RQ. Magnetic Resonance Imaging Findings following Intraarticular Infliximab Therapy for Refractory Temporomandibular Joint Arthritis among Children with Juvenile Idiopathic Arthritis. J Rheumatol. 2015;42(11):2155–2159. [DOI] [PubMed] [Google Scholar]
  • 10.Kellenberger CJ, Abramowicz S, Arvidsson LZ, Kirkhus E, Tzaribachev N, Larheim TA. Recommendations for a Standard Magnetic Resonance Imaging Protocol of Temporomandibular Joints in Juvenile Idiopathic Arthritis. J Oral Maxillofac Surg. 2018;76(12):2463–2465. [DOI] [PubMed] [Google Scholar]
  • 11.Ringold S, Cron RQ. The temporomandibular joint in juvenile idiopathic arthritis: frequently used and frequently arthritic. Pediatr Rheumatol Online J. 2009;7:11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.He S, Kau CH, Liao L, Kinderknecht K, Ow A, Saleh TA. The use of a dynamic real-time jaw tracking device and cone beam computed tomography simulation. Ann Maxillofac Surg. 2016;6(1):113–119. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Kyteas PG, McKenzie WS, Waite PD, Kau CH. Comprehensive treatment approach for condylar hyperplasia and mandibular crowding with custom lingual braces and 2-jaw surgery. Am J Orthod Dentofacial Orthop. 2017;151(1):174–185. [DOI] [PubMed] [Google Scholar]
  • 14.Weiss PF, Arabshahi B, Johnson A, et al. High prevalence of temporomandibular joint arthritis at disease onset in children with juvenile idiopathic arthritis, as detected by magnetic resonance imaging but not by ultrasound. Arthritis Rheum. 2008;58(4):1189–1196. [DOI] [PubMed] [Google Scholar]
  • 15.Twilt M, Schulten AJ, Nicolaas P, Dulger A, van Suijlekom-Smit LW. Facioskeletal changes in children with juvenile idiopathic arthritis. Ann Rheum Dis. 2006;65(6):823–825. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Ince DO, Ince A, Moore TL. Effect of methotrexate on the temporomandibular joint and facial morphology in juvenile rheumatoid arthritis patients. Am J Orthod Dentofacial Orthop. 2000;118(1):75–83. [DOI] [PubMed] [Google Scholar]
  • 17.Resnick CM, Frid P, Norholt SE, et al. An Algorithm for Management of Dentofacial Deformity Resulting From Juvenile Idiopathic Arthritis: Results of a Multinational Consensus Conference. J Oral Maxillofac Surg. 2019;77(6):1152 e1151–1152 e1133. [DOI] [PubMed] [Google Scholar]
  • 18.Te Veldhuis EC, Te Veldhuis AH, Koudstaal MJ. Treatment management of children with juvenile idiopathic arthritis with temporomandibular joint involvement: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(5):581–589 e582. [DOI] [PubMed] [Google Scholar]
  • 19.Stoustrup P, Kuseler A, Kristensen KD, Herlin T, Pedersen TK. Orthopaedic splint treatment can reduce mandibular asymmetry caused by unilateral temporomandibular involvement in juvenile idiopathic arthritis. Eur J Orthod. 2013;35(2):191–198. [DOI] [PubMed] [Google Scholar]
  • 20.Pedersen TK, Gronhoj J, Melsen B, Herlin T. Condylar condition and mandibular growth during early functional treatment of children with juvenile chronic arthritis. Eur J Orthod. 1995;17(5):385–394. [DOI] [PubMed] [Google Scholar]

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