Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies
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Transcript of Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies
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Randy Q. Cron, MD, PhD Univ. of Alabama at Birmingham
Temporomandibular Joint Arthritis in Pediatric
Inflammatory Arthropathies
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What is the Temporomandibular Joint?
The temporomandibular joint (TMJ) is a typical sliding "ball and socket" which has a disc sandwiched between it. The TMJ is used many thousands of times a day in moving the jaw, biting and chewing, talking, yawning, etc. It is one of the most frequently used of all the joints in the body. http://www.medicinenet.com/temporomandibular_joint__disorder/page1.htm#1whatis
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Diagnosis of TMJ Arthritis
• Clinical history • Physical exam findings • Imaging studies
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Challenges in Assessing Pediatric TMJ disease
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Asymptomatic TMJ Disease in JIA
• Twilt, et al. 2004 – 45% without pain
• Wallace, et al. 2000
– 70% asymptomatic UAB 2010
Percentage of Symptomatic Patients by Age Range
Ages 0-
6
Ages 7-
10
Ages 11
-1940
50
60
70
80
% o
f Pat
ient
s
50% 56% 74%
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Tooth-to-tooth Gap/ Inter-incisor Distance
3 finger rule
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Measure of Tooth-to-Tooth Gap
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Mouth Opening by Age Twilt et al. 2004
Age (yrs):
0-6 6-11 11-16 16-21
Ingervall 1970
49 mm 51 mm
Sheppard 1965
42 mm 46 mm 51 mm 49 mm
- OPG 2004
43 mm 48 mm 53 mm 53 mm
+ OPG 2004
42 mm 43 mm 47 mm 57 mm
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Normal range of mouth opening in children ages 5-17 years
97.5% 75% 25% 2.5%
N = 307 = 47 mm
Pediatr Rheumatol Online J. 2012 Jun 20;10(1):17. [Epub ahead of print]
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Prevalence/Incidence of TMJ Arthritis in JIA
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New Juvenile Idiopathic Arthritis (JIA) Criteria
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Classification of JIA ACR 1977
JRA 1. Systemic onset 2. Polyarticular >4 joints
3. Pauciarticular <5 joints Spondyloarthropathies (HLA-B27) 1. Psoriatic 2. Ankylosing spondylitis 3. IBD associated 4. SEA syndrome
ILAR 1997 JIA 1. Systemic 2. Polyarticular RF- 3. Polyarticular RF+
4. Oligoarticular
a) Persistent (< 5 joints) b) Extended (>4 joints)
5. Psoriatic 6. Enthesitis related
7. Unspecified (none or
more than 1 category fulfilled) J Rheumatol. 2004 Feb;31(2):390-2.
Behrens EM, Beukelman T, Cron RQ.J Rheumatol. 2007 Jan;34(1):234
Behrens
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JIA Subtype & Frequency of TMJ Arthritis (orthopantomogram)
0
10
20
30
40
50
60
70
So Oligo RF+ RF- SEA Psor
Subtype
% w
ith T
MJ
invo
lvem
ent
Twilt, et al. J. Rheumatol. 2004;31:1418.
N=97
Twilt
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2010 UAB Data, n=183 JIA patients screened by MRI
Cannizzaro 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.
Saurenmann
Stoll
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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)
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Micrognathia
Pediatr Clin North Am. 2005 Apr;52(2):413-42, vi.
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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
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AVOID THIS!
Courtesy of David D. Sherry, MD
*
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Treatment of TMJ Arthritis
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Do Biologics Treat TMJ Arthritis? Systemic Medication Use in TMJ Arthritic Patients Comparing Any Use vs. Use Only at Time of MRI
NSAIDMTX
TNF-a Inhibito
r (plus A
nakinra)
Steroid
0
20
40
60
80 Have Ever UsedUsed At Time of MRI
% o
f Pat
ient
sN=95
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.
Beukelman
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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.
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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
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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
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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
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Retrospective Study of Intraarticular Steroid Injection of TMJ Arthritis in JIA
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Demographics
Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.
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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.
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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.
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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.
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CT Guidance
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Data Collection
• Tooth-to-tooth gap measurements • Pain assessment • MRI findings
– Effusions – Erosions – Condylar flattening
• Side effects
Bita Arabshahi, MD
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TMJ Anatomy
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Resolution of Effusion Following Intraarticular Steroid Injection
Arabshahi & Cron. Curr Opin Rheumatol. 2006;18:490-495.
Pre Post
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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.
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Increase in Tooth-to-Tooth Gap (< 6 yrs old)
Tooth-tooth gap, ages 0-6 (n=5)
pre-in
jectio
n
post-
injec
tion
norm
als2
3
4
5
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Increase in Tooth-to-Tooth Gap (7-10 yrs old)
Tooth-tooth gap, age 7-10 (n=10)
pre-in
jectio
n
post-
injec
tion
norm
als2
3
4
5
6
P=
cm
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Increase in Tooth-to-Tooth Gap (11-16 yrs old)
Tooth-tooth gap, age 11-16(n=5)
pre-in
jectio
n
post-
injec
tion
norm
als
2.5
5.0
7.5
P=
P=
cm
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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.
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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.
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Intraarticular corticosteroids for TMJ arthritis in JIA
Ringold S, Cron RQ. Pediatr Rheumatol Online J. 2009 May 29;7(1):11.
Zurich Seattle Germany Philly
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Pediatr Radiol. Pediatr Radiol. 2010;40:1498-504.
Toronto
Connolly
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• 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
Prospective Study of TMJ Arthritis in JIA
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• 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
Inclusion Criteria:
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New-onset JIA Cohort
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Jaw Symptoms & PE Findings
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MRI: Condylar Flattening & Erosion
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MRI: Joint Effusion & Condylar Erosion
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MRI Findings
N MRI pattern Unilateral Bilateral Oligo:Poly
8/20 (40%)
Minimal to mild effusion
62% 38% 1:1
17/20 (85%)
Enhancement 31% 69% 0.9:1
9/20 (45%)
Condylar Flattening
50% 50% 1:3
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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
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Ultrasound Appearance of Condyle Flattening (L>R)
Right
Left
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Comparison of MRI and US Findings
Comparison of MRI and US indetection of effusions and
condylar erosions(n=40 TMJs)
effusions erosions0
10
20MRIUSConcordance
TMJ appearance
num
ber
of T
MJs
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TMJ Arthritis Detection (Dis)agreement by MRI & US
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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.
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Predictors of TMJ Arthritis in New-onset JIA
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Change in MIO after Corticosteroid Injection
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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 operator dependence of US
Weiss, et al. Arthritis Rheum. 2008;58:1189-96.
Pam Weiss, MD
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Funding
Nickolett Family Awards
Program for JRA Research
Ethel Brown Foerderer
Fund for Excellence
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Credit Where Credit is Due
CHOP Rheumatology CHOP Radiology Bita Arabshahi Anne Marie Cahill
Esi DeWitt Robin Kaye
Pam Fitch Marissa Bilaniuk
Sandy Burnham Ann Johnson
David Sherry Kevin Baskin
Carol Wallace (Seattle)
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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.
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Synovial Enhancement in a Normal Control
T1-weighted parasagittal MRI image with fat saturation of the TMJ joint of a normal 7 year old child, showing synovial enhancement (arrow) superior to the condyle (C).
C
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96 Children without autoimmune disease screened
94% entirely normal TMJ MRI
Acta Radiol. 2009 Dec;50(10):1182-6.
Tzaribachev
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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
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1.2 mm Arthroscope
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P = .001
J. Oral Maxillofac. Surg. 2012;70:1802-7.
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Post-lnjection MIO Changes
65%
27%
7%
ImprovementWorsening
Unchanged
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.
Mouth Opening Improved Following IA-Steroids to TMJs
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MIO Change by Subtype
System
icOlig
o
Poly (R
F-Neg
)ERA
Psoria
tic
Undifferen
tiated
-2
-1
0
1
2
3
4
5
6
mm
4.56
2.82
2.20
1.54
-0.67
1.50
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.
All JIA Subtypes Respond to IA-Steroids
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Post-Injection MRI Results
34%
17%
49%
Some ImprovementComplete ResolutionUnchanged or Worse
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.
MRI Findings Improved Following IA-Steroids to TMJs
Young
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What do we do for TMJ arthritis not 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).
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Intra-articular anti-TNF to treat TMJ arthritis
• Scand J Rheumatol. 2008 Mar-Apr;37(2):155-7. • 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. [email protected] • 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.
Alstergren
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Intra-articular Infliximab Treatment of Refractory TMJ Arthritis in Children with JIA
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
Intra-articular: steroids anti-TNF
Stoll ML, Morlandt A, Terrawattanapong S, Young D, Waite PD, Cron RQ. Manuscript submitted.
Morlandt
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Do non-JIA children with other rheumatic 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.
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Parotitis seen on TMJ MRI
C
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Fain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ. J Rheumatol. 2011 Oct;38(10):2272-3
Screening for TMJ Arthritis in Other Pediatric Arthritides
Fain
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TMJ Arthritis in Pediatric Sjogren and Sarcoidosis
Fain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ. J Rheumatol. 2011 Oct;38(10):2272-3
Atkinson
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Contrast weighted MRI sagittal section through the TMJ of a child with juvenile dematomyositis.
C: condyle; Arrow indicates synovial enhancement after administration of contrast.
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TMJ Arthritis in Pediatric JDMS and MCTD
Patient number
Age at dx Gender Dx
MIO with positive TMJ
MRI Deviation Peripheral
arthritis
Post injection
MIO Repeat
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 yes
Peter Weiser, Stephen Johnson, Robert M. Lowe, Randy Q. Cron. Submitted for publication.
Weiser
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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.
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In Memory of Dr. Frida Gudmundsdottir
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Questions??