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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

Temporomandibular joint (TMJ) involvement is a frequent feature in cross-sectional prevalence studies among patients with juvenile idiopathic arthritis (JIA). In this followup study, patients were reviewed after 5 years to study the course of TMJ involvement in relation to disease characteristics.

Methods

Children with JIA from a previous study on TMJ involvement were included. A rheumatologic evaluation including the 6 parameters of the JIA core set and an orthodontic evaluation including an orthopantomogram (OPT) were performed. OPTs were scored according to Rohlin's grading system (grades 0–5).

Results

The overall prevalence of patients with condylar alterations decreased from 49% to 40%. Improvement of the alterations was seen in 69% of the initially affected condyles, and consequently improvement was seen in 83% of the initially affected patients. Normalization of the alterations was seen in 67% of the improved condyles, and consequently in 44% of the patients. This proves that the condyle has a regenerative capacity. Improvement was related to low disease activity and a less extensive therapeutic regimen.

Conclusion

In patients with JIA, condylar alterations can improve and even regenerate. Condylar improvement is associated with a low disease activity.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Juvenile idiopathic arthritis (JIA) is a term that indicates a childhood disease characterized primarily by arthritis persisting for at least 6 weeks, starting before the sixteenth birthday. JIA is divided into 7 subtypes based on clinical symptoms during the first 6 months of the disease (1). These subtypes all have a different initial presentation, course, and prognosis (2).

All joints can be involved in JIA, including the temporomandibular joint (TMJ). One or both TMJs can be involved in JIA, early or late in the course of the disease, and the TMJ can even be the initial joint to be involved (3, 4). Diamantberger first described mandibular underdevelopment in patients with JIA in 1890 (5). Since then, the reported frequency of TMJ involvement has varied in the literature from 17% to 87% depending upon the population investigated, the subtypes of JIA represented, and the diagnostic methods used (6–14). Most reports describe more bilaterally affected TMJs in patients with JIA, although it should be noted that in 27–50% of patients with TMJ involvement, only 1 of the TMJs is initially involved (6, 14, 15).

The most important growth center of the mandible is located on the articular surface of the mandibular condyle head; therefore, destructive changes during the growth period affect mandibular development with subsequent alteration in dental occlusion and may even affect the total craniofacial growth and development, resulting in the so-called “bird face,” micrognathia (6). The few followup studies performed have demonstrated an increased frequency of TMJ involvement during followup and progression of the existing condylar alterations (3, 10, 16, 17).

The Temporomandibular Joint Rheumatologic Involvement Project (TRIP) was initiated as in most studies on TMJ involvement in JIA, where patients were selected based on different criteria, such as onset type, age, disease course, and sometimes even TMJ status, and only a few followup studies were performed (3, 4, 6–17). Also, insights into the treatment of JIA have changed markedly in the past 15 years (18). The patient cohort of the TRIP studies was based on a cross-sectional population of 97 consecutive patients representing all subtypes of JIA. In the initial study (TRIP 0), the frequency of TMJ involvement diagnosed with an orthopantomogram (OPT) was 45% (14). TRIP 1 (1 year later) reported a yearly incidence of 7% and a decrease in the frequency of TMJ involvement, and consequently an improvement of condylar lesions was noticed (19). The goal of the TRIP 5 followup survey was to longitudinally study the course of condylar alterations in relation to disease characteristics after 5 years of followup.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Patients.

In TRIP 0, 97 consecutive patients with JIA according to the Edmonton criteria were routinely referred for a comprehensive orthodontic evaluation (1). These patients were reviewed 5 years later (TRIP 5) to evaluate changes in condylar alteration during followup.

Patients of the initial cohort were included if a rheumatologic evaluation and an orthodontic evaluation with OPT were available at both evaluations. The Medical Ethical Committee of the Erasmus MC University Medical Centre Rotterdam approved the study, and written consent was obtained from all patients.

Data collection.

Data were obtained from medical records and through clinical investigation. The following data were collected: patient characteristics (including sex, age at onset, and age at orthodontic and rheumatologic examination), type of disease onset and course (oligoarticular or polyarticular), and disease activity. Therapeutic interventions during the course of the disease and a visual analog scale (VAS) of the disease activity assessed by the treating pediatric rheumatologist were used as indicators for the assessment of disease activity and severity during the followup period. Drug treatments considered were nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), immunosuppressive drugs such as corticosteroids and methotrexate, and biologic drugs such as etanercept.

The data collected by the orthodontist included mandibular function, estimated by measuring (in mm) the interincisal distance at maximal mouth opening adjusted for overbite; protrusion adjusted for overjet; side deviations at maximal opening and protrusion; and lateral movements between the midlines adjusted for midline discrepancies at the intercuspal position.

Radiographic examination.

Standardized radiographic evaluation was acquired by means of OPTs. The OPTs were scored using the following 6 categories of the grading system developed by Rohlin and Petersson (20): grade 0 = normal conditions, grade 1 = slight abnormality, grade 2 = definite early abnormality, grade 3 = moderate destructive abnormality, grade 4 = severe destructive abnormality, and grade 5 = mutilating abnormality. TMJ involvement was defined as grades 1–5. Two examiners independently scored the OPTs and were blinded to the patient names for all OPTs. The 2 different OPTs of the patients were scored independently.

Disease activity.

The 6 different parameters of the JIA core set, also used in the American College of Rheumatology (ACR) pediatric 30 criteria (21), were used to assess disease activity in TRIP 5. This JIA core set is an international validated measure for disease activity, and comprises the following 6 items: global assessment of disease severity by the physician by means of a VAS, global assessment of overall well-being by the patient or parent by means of a VAS, functional ability by means of the Childhood Health Assessment Questionnaire (C-HAQ), number of active joints (joints with swelling not due to deformity), number of joints with limitation of motion, and erythrocyte sedimentation rate (ESR) (21).

Statistical analysis.

Continuous group data were summarized as means. Comparisons of categorical variables between the groups of children with and without TMJ involvement were performed by Fisher's exact test. A t-test was used for continuous variables and the chi-square was used for ordinal values between groups. SPSS 12.0 Software package (SPSS, Chicago, IL) was used for all data analysis.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

General results.

In TRIP 5, 84 (87%) of the initial 97 patients were examined (31 boys and 53 girls). Thirteen patients (13%) could not be included, 8 were not willing to cooperate, 3 could not be traced, and 2 lived abroad. Consequently, the TRIP 0 cohort was adjusted to include only patients who were also represented in the TRIP 5 cohort. The mean interval between the consecutive evaluations was 5.7 years (range 4.1–6.8 years).

Patient results.

Patients with all subtypes of JIA were included, corresponding with percentages found in a Dutch pediatric rheumatology population. Of the 84 patients, 52 (62%) were still visiting the outpatient department of pediatric rheumatology and/or orthodontics: 25 were visiting both departments, 17 were visiting only the pediatric rheumatology department, and 10 were visiting only the orthodontic department. Of the 42 (38%) patients no longer visiting the pediatric rheumatology department, 25 were released after followup and 17 were referred to another rheumatologist, mainly a rheumatologist for adults. In TRIP 5, the mean age of the cohort was 15.9 years (range 8.3–24.7 years) and the mean period since diagnosis was 10.2 years (range 6.3–18.9 years). The number of patients per subtype and the mean age at onset per subtype are shown in Table 1.

Table 1. TMJ involvement in the TRIP 5 and adjusted TRIP 0 study (n = 84)*
JIA typeNo. of patientsTMJ involved unilaterallyTMJ involved bilaterallyTMJ involvement, %Age at onset, mean (range) years
TRIP 5TRIP 0TRIP 5TRIP 0TRIP 5TRIP 0TRIP 5
  • *

    TMJ = temporomandibular joint; TRIP = Temporomandibular Joint Rheumatologic Involvement Project; JIA = juvenile idiopathic arthritis; RF = rheumatoid factor. ERA = enthesitis-related arthritis.

Systemic15445760733.8 (0.8–8)
Oligoarticular        
 Persistent20661335455.8 (1.4–15.8)
 Extended15642353464.8 (1.5–12.3)
Polyarticular RF pos6020003310.6 (9.17–12.5)
Polyarticular RF neg14512750574.7 (1.25–10.3)
Psoriatic arthritis3100133338.6 (7.5–9.2)
ERA701000149.7 (4.1–13.3)
Undifferentiated4220050503.6 (1.2–8.5)
Total842420102140495.8 (0.8–15.8)

Frequency of TMJ involvement.

TMJ involvement was present in 40% of the patients at TRIP 5 compared with 49% of the patients at TRIP 0. Table 1 summarizes TMJ involvement per subtype at TRIP 0 and TRIP 5. At both evaluations, the highest percentage of TMJ involvement was found in the patients with systemic JIA. None of the polyarticular patients who were rheumatoid factor (RF) positive showed condylar alterations at TRIP 5.

Condylar alterations at TRIP 0 and TRIP 5 were more frequent if the arthritis had a polyarticular course (>5 joints involved) irrespective of the JIA onset type (TRIP 0: 58% in polyarticular course versus 36% in oligoarticular course, P = 0.04; TRIP 5: 50% in polyarticular course versus 38% in oligoarticular course, P = 0.03).

Characteristics of patients with and without TMJ involvement at TRIP 0 and TRIP 5 are summarized in Table 2. At both TRIP 0 and TRIP 5, patients with TMJ involvement were younger at onset than patients without involvement (P = 0.04 and 0.01, respectively). The patients with present condylar alterations at TRIP 5 had a significantly longer disease duration than patients without condylar alterations at TRIP 5 (P = 0.02), which is in contrast with TRIP 0 (P = 0.20). Apparently, the patients whose condylar alterations normalized during followup had a relatively shorter disease duration than the patients with remaining condylar alterations.

Table 2. Characteristics of patients with and without TMJ involvement at TRIP 0 and TRIP 5*
CharacteristicsTRIP 0TRIP 5
TMJ noninvolved (n = 43)TMJ involved (n = 41)PTMJ noninvolved (n = 50)TMJ involved (n = 34)P
  • *

    Values are the mean (range) unless otherwise indicated. TMJ = temporomandibular joint; TRIP = Temporomandibular Joint Rheumatologic Involvement Project; ACR = American College of Rheumatology; VAS = visual analog scale; C-HAQ = Childhood Health Assessment Questionnaire; ESR = erythrocyte sedimentation rate.

  • Significant P value (< 0.05).

Female sex, absolute no. (%)25 (58)28 (68)0.2333 (66)20 (59)0.33
Age at onset, years6.7 (1.2–15.8)4.7 (0.8–13.1)0.046.7 (1.2–15.8)4.3 (0.8–9.5)0.01
Disease duration, years4.1 (0.6–9.9)4.9 (0.6–12)0.209.4 (6.3–18.8)11.2 (6.8–17.5)0.02
Age, years10.8 (2.8–17.2)9.6 (3.3–18.8)0.2416.1 (8.4–24.1)15.6 (8.3–24.7)0.65
ACR pediatric 30      
 VAS physician   6.9 (0–82)14.1 (0–83)0.02
 VAS well-being   14.5 (0–98)13.9 (0–57)0.53
 C-HAQ   0.5 (0–3.0)0.5 (0–3.0)0.71
 Active joints   0.9 (0–19)2 (0–18)0.42
 Limited joints   1.5 (0–11)4.2 (0–21)0.03
 ESR   13.5 (0–74)12.9 (3–60)0.37

Unilateral and bilateral involvement.

Both condyles (i.e., bilateral involvement) showed alterations in 21 (51%) of the 41 patients with condylar alterations at TRIP 0, and in 10 (29%) of the 34 patients with condylar alterations at TRIP 5. Normalization of the condylar alterations (i.e., no condylar alterations present at TRIP 5) (Table 3) was seen in 12 (60%) of the 20 patients with unilateral involvement at TRIP 0 and in 3 (14%) of the 21 patients with bilateral involvement at TRIP 0 (P = 0.003). Nine (43%) of the 21 patients with bilateral involvement at TRIP 0 improved and showed unilateral involvement at TRIP 5, leading to an increase in the overall prevalence of patients with unilateral involvement at TRIP 5.

Table 3. Changes in condylar alterations at TRIP 5 with respect to TRIP 0, scored according to Rohlin's grading system (n = 168)*
 TRIP 0
Grade 0Grade 1Grade 2Grade 3Grade 4Grade 5
  • *

    The grades from TRIP 0 are presented horizontally and the grades from TRIP 5 are presented vertically. Accordingly, 3 patients had grade 1 at TRIP 0 and TRIP 5. Five patients had grade 4 in TRIP 0 and grade 1 in TRIP 5. TRIP = Temporomandibular Joint Rheumatologic Involvement Project.

TRIP 5      
 Grade 097192231
 Grade 1330151
 Grade 2230210
 Grade 3311360
 Grade 4110060
 Grade 5000001

Condylar changes.

At TRIP 5, the number of condyles without alterations increased from 106 (63%) of the 168 condyles to 124 (74%) of the 168 condyles (P = 0.00). The Rohlin score changes for each condyle during followup are shown in Table 3. Of the 106 initially nonaffected condyles, 97 (92%) remained stable nonaffected condyles and 9 (8%) showed newly developed condylar alterations. Of the 62 initially affected condyles, persistent identical alterations at TRIP 0 and TRIP 5 were seen in 13 (21%), worsening of the initially affected condyles was seen in 6 (10%), and improvement was seen in 43 (69%) of the initially affected condyles. Normalization of the alterations was seen in 27 (63%) of the 43 improved condyles at TRIP 5; therefore, the condyles were regenerated.

Changes in TMJ involvement on a patient level.

Comparison of the alterations on the OPT at TRIP 5 with those at TRIP 0 showed 36 (43%) patients with stable normal condyles, 34 (40%) patients with improvement of the condylar alterations, 5 (6%) patients with identical condylar alterations, and 9 (11%) patients with worsening of the condylar alterations. Of the 34 patients with improvement of the initial condylar alterations, 15 (44%) showed no alterations at TRIP 5; the condylar alterations were normalized.

Improvement of condylar alterations was seen in 83% of the initial 41 patients with condylar involvement and in all the different subtypes of JIA (73% of the patients with systemic JIA, 78% of the patients with oligoarticular persistent JIA, 100% of the patients with oligoarticular extended JIA, 100% of the patients with polyarticular RF-positive JIA, 88% of the patients with polyarticular RF-negative JIA, 100% of the patients with enthesitis-related arthritis and psoriatic arthritis, and 50% of the patients with undifferentiated JIA). Patients with improvement of the condylar alterations had a mean age of 15.7 years (range 8.4–24.7 years), a mean age at disease onset of 5.0 years (range 1.2–11.8 years), and a mean disease duration of 10.7 years (range 6.3–17.5 years).

Disease severity.

The drug intervention used as therapy between TRIP 0 and TRIP 5 was used as a proxy for disease severity and activity in the past. TMJ involvement was seen more in patients with an extensive therapeutic regimen during this 5-year followup period. Patients requiring no treatment or only NSAIDs (n = 26); patients taking NSAIDs and DMARDs (n = 19); patients taking NSAIDs, DMARDs, and immunosuppressive drugs (n = 27); and patients taking NSAIDs, DMARDs, immunosuppressive drugs, and biologic drugs (n = 12) showed 21%, 26%, 60%, and 67% TMJ involvement, respectively, at TRIP 5. Treatment as a sign of disease activity showed a linear-by-linear association with condylar involvement (P = 0.002). If therapy consisted of immunosuppressive drugs and biologic drugs, chances of TMJ involvement increased 5 times (odds ratio 5.38) compared with patients treated with no medication, NSAIDs, and/or DMARDs.

Another method for assessing disease activity is by means of the JIA core set that is also used in the ACR pediatric 30 (21). All items of the JIA core set at TRIP 5 showed low mean values (mean VAS physician 9.77 [range 0–83], mean VAS well-being 14.2 [range 0–98], mean C-HAQ 0.5 [range 0–3.0], mean number of joints with active disease 1.32 [range 0–19], mean number of joints with limited motion 2.55 [range 0–21], and mean ESR 13 mm/hour [range 0–74 mm/hour]), indicating low mean disease activity in most patients. Twenty-five patients observed no alterations in their functional ability (C-HAQ score 0.00) and only 15 patients observed alterations in their functional ability interfering with daily activities (CHAQ score >1.0). When comparing the items of the JIA core set in patients with and without TMJ involvement, a significant difference in the VAS physician and the number of joints with limited motion was noticed (see Table 2).

Clinical signs of TMJ involvement.

Clinical signs noticed by the patient and orthodontist during examination at TRIP 0 are summarized in Table 4. These signs were even more significantly associated with TMJ involvement at TRIP 5 than at TRIP 0. Signs were not frequently present in patients with JIA; however, if present, they were more common in patients with (persistent) TMJ involvement during followup (Table 4). Symptoms of limited jaw function, such as limited chewing ability, limited maximal opening, and pain during jaw excursion in the past, were especially indicators for TMJ involvement. Also, significantly more patients who had mouth breathing at TRIP 0 had condylar alterations at TRIP 5.

Table 4. Symptoms in the adjusted TRIP 0 related to TMJ involvement in patients with juvenile idiopathic arthritis (n = 84) at TRIP 0 and TRIP 5*
SignsPatients with signs at adjusted TRIP 0Patients with TMJ involvementOR (95% CI)P
TRIP 0TRIP 5TRIP 0TRIP 5TRIP 0TRIP 5
  • *

    Values are the number (percentage) unless otherwise indicated. TRIP = Temporomandibular Joint Rheumatologic Involvement Project; TMJ = temporomandibular joint; OR = odds ratio; 95% CI = 95% confidence interval.

  • Significant P value (P < 0.05).

Noticed by the patient       
 Limited chewing ability8 (10)7 (88)7 (88)8.91 (1.0–76.1)13.2 (1.5–113.1)0.0220.006
 Limited maximal mouth opening8 (10)6 (75)6 (75)3.7 (0.7–19.7)5.5 (1.0–29.4)0.1030.036
 Pain11 (13)7 (64)6 (75)2.01 (0.54–7.45)1.93 (0.54–6.92)0.230.24
 Pain during jaw excursion9 (11)7 (64)6 (55)4.2 (0.82–21.7)6.22 (1.21–32.1)0.070.021
 Clicking/crepitation18 (21)12 (67)7 (39)2.6 (0.86–7.62)0.92 (0.32–2.67)0.0740.55
 Mouth breathing20 (24)16 (80)15 (75)1.94 (0.69–5.4)2.93 (1.04–8.27)0.1530.036
Orthodontic examination       
 Asymmetric opening/protrusion20 (24)16 (80)15 (75)7.0 (2.0–23.9)7.1 (2.3–23.5)0.0010.000
 Absence of translation22 (26)17 (77)15 (68)5.6 (1.8–17.3)5.1 (1.74–14.67)0.0010.002
 Clicking/crepitation16 (19)10 (63)9 (56)1.44 (0.65–6.09)2.2 (0.73–6.7)0.1740.126

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

In this 5-year followup study of pediatric patients with all subtypes of JIA according to the Edmonton criteria, a decrease in the frequency of TMJ involvement from 49% to 40% was observed. Of the patients with TMJ involvement in the initial cross-sectional survey (TRIP 0), 83% showed improvement of the condylar alterations. Of these, 44% did not show any more condylar alteration (Rohlin grade 0) at TRIP 5. This finding is suggestive of a regenerative capacity of the condyle. In the literature, the few followup studies on TMJ involvement in patients with JIA all demonstrate progression of the condylar alterations (3, 10, 16, 17), except the 1-year followup study of the cohort described in this article (TRIP 1) (18). The trend noticed in the 1-year followup (TRIP 1) persevered in this 5-year followup study (TRIP 5).

The frequency of TMJ involvement among patients with the different subtypes was in accordance with the distribution at TRIP 0, with the highest prevalence in patients with systemic JIA. The TRIP 5 study also confirms an increased chance of TMJ involvement in patients with a polyarticular course of arthritis and a long disease duration.

Patients with polyarticular RF-positive JIA had a relatively low frequency of TMJ involvement at TRIP 0. Surprisingly, none of the polyarticular RF-positive patients showed TMJ involvement at the TRIP 5 study. This finding is remarkable because this subtype of JIA is known for its erosive, destructive character. This subtype is, however, also known for its late onset, and in our initial survey we postulated that the condyle is less vulnerable in older patients than in young patients (14). This late onset is the reason for the low frequency of TMJ involvement in this group. This postulation is also supported by the fact that patients with TMJ involvement have a much earlier onset than patients without involvement. We are aware that some subtypes affect only a limited number of patients. However, the representation of the subtypes in this cohort is divided as expected in a tertiary medical center.

It is known that in JIA, erosive lesions in joints observed on plain radiographs can improve if the disease is in a nonactive state (22). The TMJ appears to act in the same way as all of the other joints that may be involved in JIA. Patients with low disease activity, measured indirectly by drug use or the 6 parameters of the JIA core set, show more improvement of the TMJ than patients with high disease activity. Arthritis of the TMJ can develop individually in each condyle, and TMJ involvement is frequently asymmetrical in patients with JIA. A quiet phase of the disease can lead to normalization in function and growth of the joint. Because low disease activity can be induced by drug treatment, the TMJ should be included when deciding on a therapeutic regimen. All patients in our study were treated with systemic drugs; no local intraarticular injections were administered. According to Arabshahi et al, intraarticular injections can be used, especially if the TMJ is the only joint with active arthritis (23). However, investigators recently observed a reduced mandibular growth in antigen-induced arthritis in the rabbit TMJ when treated with intraarticular corticosteroid injections (24). In theory, this could also apply to children with JIA. In our opinion, intraarticular injections of corticosteroids into the TMJ should be thoroughly investigated before being considered as a treatment option in children. We hypothesize an increased sensitivity to corticosteroid injections in patients with JIA due to the superficial position of the growth center in the mandibular condyle.

During the past 2 decades, insights into the treatment regimen for JIA and consequently the treatment have changed markedly. The greatest change has been the tendency to switch to second-line antirheumatic drugs earlier in the course of the disease in accordance with the subtype represented. Treatment has shifted gradually from chasing failure (gradual add-on approach) to early aggressive therapy (18). This early aggressive therapy will probably lead to low disease activity earlier in the course of the disease, and might explain why condylar improvement has not been observed in past studies.

In the initial study (TRIP 0), we observed that clinical signs were scarce, but if present, the chance of TMJ involvement increased (14). However, if signs were absent, chances of TMJ involvement were still high. At TRIP 5, we observed that patients with signs of TMJ involvement at TRIP 0 had an increased chance of TMJ involvement at TRIP 5; in other words, the prognosis of these patients with regard to the condylar alterations was worse than patients without clinical signs. Therefore, these clinical subjective signs of condylar alterations noticed by the patient are important predictors of TMJ involvement and the course of condylar alterations. Altogether, these symptoms alone are not able to determine a distinction between absence or presence of condylar alterations; a radiologic examination remains necessary.

Clinical practice has limitations due to availability of diagnostic methods. Nowadays, magnetic resonance imaging (MRI) is considered to be the gold standard to diagnose TMJ involvement; however, MRI has shortcomings, including the necessity for sedation in small children and increased costs. Unlike the OPT, MRI is not available in all orthodontic and dental practices. The OPT is a good diagnostic tool for evaluating erosive alterations. Because the kappa statistics for the intraobserver and interobserver agreement are high for the Rohlin scores, this method is a useful tool in the followup of erosive changes in all patients with JIA (12). In the future, other diagnostic methods need to be investigated, such as ultrasound sonography. Sonography is increasing as a diagnostic tool in arthritis. Sonography of the TMJ was performed by Jank et al (25), who demonstrated a significant correlation between pathologic findings, duration of JIA, and the number of affected peripheral joints. In the future, sonographic investigation could be used as a diagnostic screening method (25).

A selection bias could have occurred because not all patients included in the initial cohort were represented in this followup study. However, the number of missing patients was almost equally divided among the subtypes and TMJ status at TRIP 0.

Acknowledging arthritis of the TMJ in patients with JIA is important because it does not only lead to growth disturbances of the mandible with consequent aesthetic problems, such as the well-known “bird face” appearance, but it can also lead to oral health problems, such as difficulty chewing, and can cause problems with intubations.

This study demonstrated drastic improvement of condylar alterations as determined by OPT, and even normalization of the condyle was observed. This proves that the condyle has a regenerative capacity. Improvement was seen in all subtypes of JIA, and mostly in patients with low disease activity. Controlling JIA with systemic drugs is important for the improvement of condylar alterations.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Dr. Twilt had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Twilt, Schulten, Prahl-Andersen, van Suijlekom-Smit.

Acquisition of data. Twilt, Schulten, Verschure, Wisse, Prahl-Andersen, van Suijlekom-Smit.

Analysis and interpretation of data. Twilt, Schulten, Verschure, Wisse, van Suijlekom-Smit.

Manuscript preparation. Twilt, Schulten, van Suijlekom-Smit.

Statistical analysis. Twilt.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
  • 1
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