Temporomandibular Joint Arthritis in Pediatric Inflammatory Arthropathies (TMJ) by Randy Q. Cron, MD, PhD, Univ. of Alabama at Birmingham

1. Temporomandibular Joint
Arthritis in Pediatric
Inflammatory Arthropathies
Randy Q. Cron, MD, PhD
Univ. of Alabama at Birmingham

2. 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

3. Diagnosis of TMJ Arthritis
• Clinical history
• Physical exam findings
• Imaging studies

4. Challenges in Assessing
Pediatric TMJ disease

5. Asymptomatic TMJ Disease
in JIA
• Twilt, et al. 2004 Percentage of Symptomatic Patients by Age Range
80
– 45% without pain 50% 56% 74%
70
% of Patients
60
50
• Wallace, et al. 2000
40
– 70% asymptomatic
19
0
6
0-
1
-
7-
11
s
s
ge
s
ge
ge
A
A
A
UAB 2010

6. Tooth-to-tooth Gap/
Inter-incisor Distance
3
finger
rule

7. Measure of Tooth-to-Tooth Gap

8. Mouth Opening by Age
Twilt et al. 2004
Age 0-6 6-11 11-16 16-21
(yrs):
Ingervall 49 mm 51 mm
1970
Sheppard 42 mm 46 mm 51 mm 49 mm
1965
- OPG 43 mm 48 mm 53 mm 53 mm
2004
+ OPG 42 mm 43 mm 47 mm 57 mm
2004

9. Normal range of mouth opening
in children ages 5-17 years
97.5%
75%
N = 307
 = 47 mm
25%
2.5%
Pediatr Rheumatol Online J. 2012 Jun 20;10(1):17. [Epub ahead of print]

10. Prevalence/Incidence of TMJ
Arthritis in JIA

11. New Juvenile Idiopathic Arthritis
(JIA) Criteria

12. Classification of JIA
ACR 1977 ILAR 1997
JRA JIA
1. Systemic Behrens
1. Systemic onset
2. Polyarticular >4 joints 2. Polyarticular RF-
3. Polyarticular RF+
4. Oligoarticular
3. Pauciarticular <5 joints a) Persistent (< 5 joints)
b) Extended (>4 joints)
Spondyloarthropathies
(HLA-B27) 5. Psoriatic
1. Psoriatic 6. Enthesitis related
2. Ankylosing spondylitis
3. IBD associated 7. Unspecified (none or
more than 1 category
4. SEA syndrome fulfilled)
J Rheumatol. 2004 Feb;31(2):390-2.
Behrens EM, Beukelman T, Cron RQ.J Rheumatol. 2007 Jan;34(1):234

13. JIA Subtype & Frequency of TMJ
Arthritis (orthopantomogram)
70
% with TMJ involvement
60
50
40
30 Subtype
20 N=97
10
0
So Oligo RF+ RF- SEA Psor
Twilt, et al. J. Rheumatol. 2004;31:1418. Twilt

14. 2010 UAB Data, n=183 JIA patients
screened by MRI
Saurenmann
Stoll
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.

15. 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)

16. Micrognathia
Pediatr Clin North Am.
2005 Apr;52(2):413-42, vi.

18. 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

19. AVOID THIS!
*
Courtesy of David D. Sherry, MD

20. Treatment of TMJ Arthritis

21. Do Biologics Treat TMJ Arthritis?
Systemic Medication Use in TMJ Arthritic Patients Comparing Any Use vs. Use Only at Time of MRI
80
Have Ever Used
Used At Time of MRI
N=95 60
% of Patients
40
20
0
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oi
SA
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in
er
Beukelman
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us
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to
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hi
In
a
F-
TN
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.

22. 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.

23. 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

24. 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

25. 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

26. Retrospective Study of Intraarticular
Steroid Injection of TMJ Arthritis in JIA

27. Demographics
Arabshahi, et al. Arthritis Rheum. 2005 Nov;52(11):3563-9.

28. 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.

29. 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.

30. 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.

31. CT Guidance

32. Data Collection
• Tooth-to-tooth gap measurements
• Pain assessment
• MRI findings
– Effusions
– Erosions
– Condylar flattening
• Side effects Bita Arabshahi, MD

33. TMJ Anatomy

34. Resolution of Effusion Following
Intraarticular Steroid Injection
Pre Post
Arabshahi & Cron. Curr Opin Rheumatol. 2006;18:490-495.

35. 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.

36. Increase in Tooth-to-Tooth
Gap (< 6 yrs old)
Tooth-tooth gap, ages 0-6 (n=5)
5
4
3
2
s
n
n
al
io
io
rm
ct
ct
je
je
no
-in
in
e-
st
pr
po

37. Increase in Tooth-to-Tooth
Gap (7-10 yrs old)
Tooth-tooth gap, age 7-10 (n=10)
6
5
cm
4
3
P=
2
s
n
n
al
io
io
rm
ct
ct
je
je
no
-in
in
e-
st
pr
po

38. Increase in Tooth-to-Tooth
Gap (11-16 yrs old)
Tooth-tooth gap, age 11-16(n=5)
7.5
5.0
cm
2.5 P=
P=
s
n
n
al
io
io
rm
ct
ct
je
je
no
-in
in
e-
st
pr
po

39. 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.

40. 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.

41. Intraarticular corticosteroids for
TMJ arthritis in JIA
Zurich
Seattle
Germany
Philly
Ringold S, Cron RQ. Pediatr Rheumatol Online J. 2009 May 29;7(1):11.

42. Toronto
Connolly
Pediatr Radiol. Pediatr Radiol. 2010;40:1498-504.

43. Prospective Study of TMJ
Arthritis in JIA
• 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

44. Inclusion Criteria:
• 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

45. New-onset JIA Cohort

46. Jaw Symptoms & PE Findings

47. MRI: Condylar Flattening
& Erosion

48. MRI: Joint Effusion &
Condylar Erosion

49. MRI Findings
N MRI pattern Unilateral Bilateral Oligo:Poly
8/20 Minimal to 62% 38% 1:1
(40%) mild effusion
17/20 Enhancement 31% 69% 0.9:1
(85%)
9/20 Condylar 50% 50% 1:3
(45%) Flattening

50. 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

51. Ultrasound Appearance of
Condyle Flattening (L>R)
Right
Left

52. Comparison of MRI and US
Findings
Comparison of MRI and US in
detection of effusions and
condylar erosions
(n=40 TMJs)
20
MRI
number of TMJs
US
Concordance
10
0
effusions erosions
TMJ appearance

53. TMJ Arthritis Detection
(Dis)agreement by MRI & US

54. 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.

55. Predictors of TMJ Arthritis in
New-onset JIA

56. Change in MIO after
Corticosteroid Injection

57. 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
Pam Weiss, MD
dependence of US
Weiss, et al. Arthritis Rheum. 2008;58:1189-96.

58. Funding
Nickolett Family Awards Ethel Brown Foerderer
Program for JRA Research Fund for Excellence

59. 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)

61. 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.

62. Synovial Enhancement in a
Normal Control
C
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).

63. Acta Radiol. 2009 Dec;50(10):1182-6.
96 Children without autoimmune disease screened
94% entirely normal TMJ MRI
Tzaribachev

64. 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

65. 1.2 mm Arthroscope

66. P = .001
J. Oral Maxillofac. Surg. 2012;70:1802-7.

67. Mouth Opening Improved
Following IA-Steroids to TMJs
Post-lnjection MIO Changes
Improvement
7% Worsening
Unchanged
27%
65%
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.

68. All JIA Subtypes Respond to
IA-Steroids
M IO Change by Subtype
6
4.56
5
4
2.82
2.20
3
1.50 1.54
mm
2
1 -0.67
0
-1
A
d
tic
ic
o
)
eg
lig
te
ER
m
ia
N
ia
e
O
or
F-
-2
st
nt
Ps
(R
Sy
e
er
ly
iff
Po
nd
U
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.

69. MRI Findings Improved
Following IA-Steroids to TMJs
Post-Injection MRI Results
Some Improvement
Complete Resolution
Unchanged or Worse
34%
49%
Young
17%
Stoll ML, Good J, Sharpe T, Beukelman T, Young D, Waite PD, Cron RQ.
J. Oral Maxillofac. Surg. 2012;70:1802-7.

70. 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).

71. Intra-articular anti-TNF to
treat TMJ arthritis
• Scand J Rheumatol. 2008 Mar-Apr;37(2):155-7.
Alstergren
• 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. per.alstergren@ki.se
• 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.

72. Intra-articular Infliximab Treatment of
Refractory TMJ Arthritis in Children with JIA
Morlandt
Stoll ML, Morlandt A,
Terrawattanapong S,
Young D, Waite PD,
Cron RQ. Manuscript
submitted.
Intra-articular: steroids anti-TNF
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

73. 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.

74. Parotitis seen on TMJ MRI
C

75. Screening for TMJ Arthritis in
Other Pediatric Arthritides
Fain
Fain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ.
J Rheumatol. 2011 Oct;38(10):2272-3

76. TMJ Arthritis in Pediatric
Sjogren and Sarcoidosis
Atkinson
Fain ET, Atkinson GP, Weiser P, Beukelman T, Cron RQ.
J Rheumatol. 2011 Oct;38(10):2272-3

77. Contrast weighted MRI sagittal section through the TMJ of a
child with juvenile dematomyositis.
C: condyle; Arrow indicates synovial enhancement after administration of contrast.

78. TMJ Arthritis in Pediatric
JDMS and MCTD
MIO with Post
Patient Age at positive TMJ Peripheral injection Repeat
number dx Gender Dx MRI Deviation arthritis MIO 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

79. 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.

80. In Memory of
Dr. Frida Gudmundsdottir

81. Questions??