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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.

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ARTHRITIS & RHEUMATISM
Vol. 58, No. 4, April 2008, pp 1189–1196
DOI 10.1002/art.23401
© 2008, American College of Rheumatology
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
Pamela F. Weiss,1 Bita Arabshahi,2 Ann Johnson,2 Larissa T. Bilaniuk,2 Deborah Zarnow,2
Anne Marie Cahill,2 Chris Feudtner,1 and Randy Q. Cron3
arthritis was diagnosed in 69% by MRI and in 28% by
US. Findings of both acute and chronic TMJ disease
were detected by MRI in 53% of the patients. Of those
with acute TMJ arthritis, 71% were asymptomatic, and
63% had normal findings on jaw examination. Fifty-six
percent of patients with acute disease had an improved
maximal incisal opening after corticosteroid injection.
Among these responders, 56% had been asymptomatic
and had normal jaw examination findings.
Conclusion. TMJ arthritis was present in the
majority of patients with new-onset JIA. Findings on
MRI along with responses to treatment among asymptomatic patients with normal jaw examination findings
suggest that a history review and physical examination
are not sufficient to screen for TMJ disease. Our results
also suggest that MRI and US findings are not well
correlated, and that MRI is preferable for the detection
of TMJ disease in new-onset JIA.
Objective. To determine the prevalence of temporomandibular joint (TMJ) disease in a cohort of
children with new-onset juvenile idiopathic arthritis
(JIA), and to compare magnetic resonance imaging
(MRI) with ultrasound (US) for the detection of acute
and chronic changes of TMJ arthritis.
Methods. Between January 2005 and April 2007,
children with newly diagnosed JIA were prospectively
evaluated for TMJ arthritis. Prior to imaging, jaw pain
and disability were assessed with questionnaires and
physical examination. The TMJs of all patients were
imaged with MRI and US within 8 weeks of diagnosis.
Results. Of the 32 patients enrolled, 78% were
female, and the median age was 8.6 years (range 1.5–
17.2 years). Acute TMJ arthritis was diagnosed in 75%
of the children by MRI and in none by US; chronic
Supported by grants from the Ethel Brown Foerderer Fund
for Excellence and the Nickolett Family Awards Program for JRA
Research.
1
Pamela F. Weiss, MD, Chris Feudtner, MD, PhD, MPH:
Children’s Hospital of Philadelphia and University of Pennsylvania
Center for Clinical Epidemiology and Biostatistics, Philadelphia,
Pennsylvania; 2Bita Arabshahi, MD (current address: Fairfax Hospital
for Children, Fairfax, Virginia), Ann Johnson, MD, Larissa T. Bilaniuk, MD, Deborah Zarnow, MD, Anne Marie Cahill, MD: Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania; 3Randy Q. Cron,
MD, PhD: Immunology Graduate Group, University of Pennsylvania,
Philadelphia, Pennsylvania.
Dr. Cron has received speaking fees (less than $10,000) from
the 52nd Annual Lowe Conference on Rheumatic Diseases, Nauvoo,
Alabama.
Address correspondence and reprint requests to Pamela F.
Weiss, MD, Division of Rheumatology, Children’s Hospital of Philadelphia, Children’s Seashore House Room 236, 34th and Civic Center
Boulevard, Philadelphia, PA 19104-4399. E-mail: weisspa@email.
chop.edu.
Submitted for publication August 3, 2007; accepted in revised
form December 14, 2007.
Juvenile idiopathic arthritis (JIA) affects ⬃1 of
1,000 children worldwide (1). Active arthritis of the
temporomandibular joint (TMJ) in patients with JIA
was recognized as early as 1897 (2), but until recently, it
has been relatively ignored (3). The reported prevalence
of TMJ involvement in patients with an established
diagnosis of JIA varies widely (range 17–87%) (4), and
the prevalence of TMJ involvement has not been reported previously in patients with a new diagnosis of JIA
as determined by magnetic resonance imaging (MRI).
Arthritis of the TMJ is a concern, particularly in
patients who are actively growing, because the mandibular growth plate is located below the fibrocartilage and
is therefore susceptible to damage from inflammation.
Damage to the mandibular growth plate leads to asym1189
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WEISS ET AL
metric growth, micrognathia, retrognathia, malocclusion, and a decreased maximal incisal opening (MIO)
(5,6). In addition, the presence of TMJ arthritis in
childhood may predispose patients to jaw pain and
dysfunction in adulthood. In 2 recent longitudinal prospective studies, the prevalences of TMJ symptoms and
jaw dysfunction were significantly higher in patients with
JIA than in matched control subjects after 15 years and
26 years of followup, respectively (7,8).
The detection of TMJ arthritis in patients with
JIA is challenging, because the symptoms and clinical
examination findings may be misleading. Pain with jaw
excursion was found to be a significant predictor of TMJ
disease in one study (9); however, pain at rest, crepitation, clicking, and swelling were not statistically significant predictors of TMJ disease (9). In another case
series, it was reported that only 57% of patients with
active disease, as detected by MRI, had jaw discomfort
(10). Consequently, the diagnosis of TMJ arthritis has
increasingly been based on evidence obtained by imaging. Ultrasound (US), MRI, and orthopantomogram
have all been used in the evaluation and diagnosis of
both active TMJ arthritis and chronic TMJ arthritis
(11–14).
In a prospective study of 66 subjects with TMJ
internal derangement, the sensitivity, specificity, and
accuracy of detection of chronic changes, effusions, and
disk placement were compared between high-resolution
US and MRI; with MRI as the gold standard, US had a
sensitivity of 81% and a specificity of 100% for detection
of effusions (15). A prospective study of 48 patients with
JIA showed that 55% had destructive changes that were
detected by US; effusions and pannus formation were
not evaluated (14). Another group of investigators used
US alone to assess TMJ involvement at the time of
diagnosis of JIA and found that 65% of patients with
JIA had effusions (16). We therefore sought to prospectively determine the prevalence of TMJ disease and to
compare the ability of US with that of MRI for the
detection of acute and chronic TMJ changes in a cohort
of children with new-onset JIA.
PATIENTS AND METHODS
Protection of human subjects. The protocol for the
conduct of this study was reviewed and approved by the
Children’s Hospital of Philadelphia Committee for the Protection of Human Subjects.
Patients. Any child (ⱕ17 years of age) with a diagnosis
of JIA was eligible for participation in this study. Children with
cardiac pacemakers, metal implants or clips, or dental braces
were excluded. Forty-six patients with newly diagnosed JIA,
ages 1–17 years, who attended the pediatric rheumatology
clinic at Children’s Hospital of Philadelphia were prospectively
enrolled between January 2005 and April 2007. For 3 of these
patients, who were between the ages of 16 years and 17 years,
the diagnosis did not meet the formal definition of JIA
(required age at diagnosis ⬍16 years), but they were nevertheless included in the analysis.
A total of 131 new diagnoses of JIA were made at the
Children’s Hospital of Philadelphia during the recruitment
period; however, not all providers actively recruited patients
for enrollment. New patients are randomly assigned to attending physicians, and those patients who were enrolled were
recruited irrespective of jaw symptoms or dysfunction. Of the
46 recruited patients, 2 were ineligible for the study because
they subsequently received alternate diagnoses (1 inflammatory bowel disease, 1 pigmented villonodular synovitis), 2 were
excluded from analysis because of sedation problems and
incomplete imaging evaluation, and the families of 10 patients
decided against participation after consent had been provided.
Data collection. Prior to imaging, jaw pain and dysfunction in each patient were assessed with a parental questionnaire and a physical examination by the physician. Overall
JIA activity and disability were assessed with parent’s and
physician’s visual analog scales (range 0–100 mm), the Childhood Health Assessment Questionnaire (C-HAQ) (scale 0–3)
(17), and a physical examination. The examination was performed by 1 of 2 physicians (PFW or BA) and consisted of
evaluation of anterior translation, clicking, crepitus, pain with
palpation and opening, asymmetric opening, micrognathia,
and the MIO. Objective values for the MIO were obtained
from direct measurements, using the Therabite Measuring
Scale (Atos Medical, Milwaukee, WI); normal values for the
MIO were obtained from a previously published study in which
the MIO was determined in normal healthy children up to age
18 years (18). Accurate measurement of the MIO is difficult in
children between the ages of 5 years and 7 years, due to the loss
of deciduous teeth; only 3 patients in this study were in that age
range, and none had missing deciduous teeth at the time of
evaluation. The mean MIO was not significantly different
between the patients who underwent a physical examination by
either of the 2 physicians. Although corticosteroid injections
were not part of the study protocol, a large proportion of the
patients received intraarticular injections of corticosteroid for
active TMJ arthritis; the majority of these patients underwent
a repeat MIO measurement after injection.
Imaging examination. All patients were screened with
MRI and US of the TMJ within 8 weeks of diagnosis. MRI was
performed on a 1.5T scanner utilizing a high-resolution surface
coil. At the onset of the study, axial T1-weighted images were
obtained at the level of the TMJs to determine the orientation
of the mandibular condyles. The MRI evaluation included
coronal T1- and T2-weighted images, sagittal T1-weighted and
dual-echo T2-weighted images, and, following intravenous
administration of gadolinium contrast material, sagittal and
coronal fat-saturated T1-weighted images. All MR images of
each TMJ were obtained with the patient in a closed-mouth
position. A focused US evaluation of the TMJs was performed
using a 12.5-MHz linear array transducer, and all evaluations
DETECTION OF TMJ ARTHRITIS BY MRI VERSUS US
Figure 1. Chronic and acute changes in the temporomandibular joints
(TMJs) of patients with juvenile idiopathic arthritis, as detected by
magnetic resonance imaging (MRI). Chronic changes in the TMJs are
shown on T1-weighted sagittal MR images (A and B), involving
condylar flattening (A), condylar erosions (arrows in A and B), and
anterior disk displacement (B). Acute changes in the TMJs are shown
on fat-saturated T2-weighted MR images (C and D), involving joint
effusions in the anterior superior, inferior, and posterior superior
compartments (arrows in C and D) and condylar erosions. C ⫽
condyle.
were interpreted by a single radiologist (AJ) who is experienced in pediatric US. The US images were obtained in the
coronal and axial planes, with the patient in either an openmouth or closed-mouth position.
For detection by MRI, chronic TMJ arthritis was
defined as condylar changes or erosions demonstrated on
T1-weighted images (Figures 1A and B). Acute TMJ arthritis
was defined as effusions or synovial thickening demonstrated
on fat-saturated T2-weighted MR images (Figures 1 C and D).
Synovial enhancement on MRI was not included as a criterion
for acute arthritis, because experience from our institution has
shown that normal healthy children (those without any identifiable TMJ disorder) have various degrees of TMJ enhancement on fat-saturated T1-weighted images following intravenous injection of contrast material (Weiss PF, et al:
unpublished data). In addition, in one study of adult subjects,
MR images from asymptomatic volunteers and from subjects
with TMJ dysfunction were evaluated for evidence of TMJ
effusions and condyle marrow alterations, with the results
showing that marked effusions and condylar abnormalities
were not detected in any of the asymptomatic volunteers (19).
For detection by US, chronic TMJ arthritis was defined
as condylar changes or erosions demonstrated on multiplanar
imaging, in either an open-mouth or closed-mouth view. Acute
TMJ arthritis was defined as fluid collection in either joint,
1191
detected on multiplanar US imaging in either an open-mouth
or closed-mouth view. Radiologists at our institution have not
routinely performed TMJ ultrasonography in normal healthy
children; however, several investigators have previously reported US findings in the TMJs of normal healthy subjects
(20–22).
All results of MRI studies were read by an experienced
neuroradiologist (LB), and 8 of the MRI studies were also read
by a second neuroradiologist (DZ), to evaluate for interobserver agreement. Results of all US studies were read by an
experienced ultrasonographer (AJ). Children younger than
age 8 years were sedated intravenously for the MRI, using a
combination of intravenous midazolam hydrochloride (0.1–0.3
mg/kg), fentanyl citrate (1–3 mg/kg), and pentobarbital sodium
(2–4 mg/kg), as previously described (23).
Treatment of active TMJ arthritis was not part of the
study protocol. Patients with active TMJ arthritis were either
referred for injection or followed up for symptoms, depending
on the routine practice of the patient’s attending physician.
Twenty-one of 24 patients with active TMJ arthritis underwent
TMJ injection(s). The corticosteroid injections were performed by 1 of 4 experienced pediatric interventional radiologists, using either a 22-gauge or a 25-gauge needle, under
computed tomography guidance as previously described (23).
Once the position of the needle within the joint was confirmed,
0.5 cc (10 mg) of triamcinolone hexacetonide (Aristospan-20;
SAB-Pharma, Lake Forest, IL) was injected. All patients were
sedated with the same agents as used for MRI.
Statistical analysis. Stata (version 9.2; StataCorp, College Station, TX) was used for all statistical analyses. Cohen’s
kappa coefficients were used to compare interrater agreement
for MRI interpretation and for agreement between MRI and
US findings of acute and chronic TMJ arthritis (24). Cohen’s
kappa coefficient is the preferred measure of agreement, as
compared with simple percent agreement, since the kappa
statistic accounts for agreement that may occur by chance. A
kappa value of 1 denotes perfect observed agreement, and a
kappa value of 0 indicates a lack of agreement other than by
chance.
RESULTS
Demographic and clinical characteristics.
Thirty-two patients were enrolled in the study. The
frequency of JIA subtype, distributions of age and sex,
and serologic findings, as shown in Table 1, were consistent with those observed in studies of larger JIA
populations (25).
Baseline and subjective symptoms. C-HAQ
scores, used for the assessment of disease activity and
disability, were low, with a median C-HAQ score of 0.3
(range 0–2) among the 32 patients with JIA. For overall
disease severity, the median scores on the parent’s and
physician’s visual analog scales were 41 mm (range
0–100) and 25 mm (range 0–67), respectively. Disease
severity according to sex and JIA subtype is shown in
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WEISS ET AL
Table 1. Characteristics of the new-onset juvenile idiopathic anthritis (JIA) study population at diagnosis*
Characteristic
Sex
Female
Male
JIA subtype
Oligoarticular
Polyarticular, RF⫹
Polyarticular, RF⫺
Systemic
Psoriatic
ERA
Other
Positive serologic findings†
ANA (n ⫽ 30)
RF (n ⫽ 29)
CCP (n ⫽ 22)
HLA–B27 (n ⫽ 17)
Overall disease severity
No. (%)
of patients
Age, median
(range) years
Duration of
symptoms,
median (range)
months
25 (78)
7 (22)
8.4 (1.9–17.2)
9.9 (1.5–13.8)
3 (0.8–18)
3 (0.5–12)
3 (1–46)
2 (1–32)
0.1 (0–1.5)
0.4 (0–2)
10 (0–61)
28 (0–67)
11 (34)
3 (9)
7 (22)
1 (3)
4 (13)
5 (16)
1 (3)
4.3 (2–14.6)
12.6 (8.4–16.5)
7.3 (1.5–13.3)
3.4
12.9 (9.9–14.6)
13.9 (2.9–17.2)
16.9
3 (0.5–8)
3 (3–8)
3 (1–12)
3
11.5 (1.5–18)
6 (2.5–7)
6
1 (1–4)
15 (4–25)
7 (1–46)
3
4 (1–32)
2 (1–2)
9
0 (0–1.6)
1.3 (0–1.6)
0.6 (0.3–2)
1.37
1 (0–1.5)
0.1 (0–0.9)
1.9
12 (0–31)
52 (0–66)
48 (11–61)
56
61 (0–67)
25 (0–49)
66
Number of joints
with active disease,
median (range)
C-HAQ
score, median
(range)
Physician
VAS, median
(range) mm
15 (50)
3 (10)
4 (18)
3 (18)
* C-HAQ ⫽ Childhood Health Assessment Questionnaire; VAS ⫽ visual analog scale; RF ⫽ rheumatoid factor; ERA ⫽ enthesitis-related arthritis;
ANA ⫽ antinuclear antibody; CCP ⫽ anti–cyclic citrullinated peptide.
† Serologic testing was not performed on all patients; results are reflective of those in whom serologic findings were known.
Table 1. TMJ symptoms were absent in 25 patients
(81%) (Table 2). In the 6 patients with TMJ symptoms,
Table 2. Jaw symptoms and physical examination findings of acute
or chronic temporomandibular joint (TMJ) disease at diagnosis of
juvenile idiopathic arthritis*
Finding
Subjective symptoms†
None
Any
Clicking
Locking
Pain at rest
Pain with chewing
Physical examination‡
Normal
Abnormal (any)
MIO below normal
Clicking
Tenderness to palpation
Tenderness with opening
Absent translation
Asymmetric opening
Micrognathia
Acute
TMJ
disease,
no. (%)
Chronic
TMJ
disease,
no. (%)
25 (81)
6 (19)
4 (13)
1 (3)
0 (0)
5 (16)
17 (68)
6 (100)
16 (64)
6 (100)
19 (59)
13 (41)
7 (22)
2 (6)
4 (13)
4 (13)
2 (6)
6 (19)
0
15 (79)
9 (69)
No. (%)
of patients
11 (58)
11 (85)
* Acute and chronic changes were defined by magnetic resonance
imaging results. MIO ⫽ maximal incisal opening.
† n ⫽ 31.
‡ n ⫽ 32.
clicking and pain with chewing were the most common
(Table 2).
Objective signs of TMJ arthritis. Nineteen patients (59%) had normal findings on jaw examination,
including an MIO in the normal range (Table 2). In
contrast, 7 (22%) of the 32 patients had an MIO that was
below the normal range for age-matched normal healthy
subjects (17), and 6 (19%) had asymmetric jaw opening.
Baseline medications. At the time of JIA diagnosis, the majority of patients were receiving nonsteroidal
antiinflammatory agents for symptomatic relief; none of
the patients were receiving disease-modifying agents. At
the time of imaging evaluation, treatment consisted of
Table 3. Agreement between magnetic resonance imaging (MRI)
and ultrasound (US) for the detection of acute or chronic temporomandibular joint arthritis in patients with new-onset juvenile idiopathic arthritis
Acute changes
Unilateral
Bilateral
Chronic changes
Unilateral
Bilateral
MRI,
no. (%)
of patients
US,
no. (%)
of patients
24 (75)
4 (17)
20 (83)
22 (69)
7 (32)
15 (68)
0
0
0
9 (28)
5 (56)
4 (44)
Agreement,
%
Kappa
23
0.00
50
0.12
DETECTION OF TMJ ARTHRITIS BY MRI VERSUS US
nonsteroidal antiinflammatory agents (15 of 32 patients), methotrexate (12 of 32 patients, with a median
treatment duration of 22.5 days [range 9–54 days]), and
etanercept (3 of 32 patients, with a median treatment
duration of 12 days [range 9–20 days]).
Imaging findings. Acute TMJ arthritis was found
in 24 patients (75%) by MRI, with the majority of these
patients (20 [83%]) having bilateral disease. Acute TMJ
arthritis was not found in any of the patients by US.
Chronic TMJ arthritis was found in 22 patients (69%) by
MRI and in 9 (28%) by US (Table 3). Findings of both
acute and chronic disease were obtained in 17 patients
(53%) by MRI.
In comparing MRI and US findings, the 2 techniques had only 23% agreement and a kappa coefficient
of 0 for the detection of acute TMJ arthritis, indicating
that the agreement between techniques was no more
than what would be expected by chance (Table 3). For
the detection of chronic TMJ changes, findings from the
2 imaging techniques displayed 50% agreement and a
kappa value of 0.12.
All MR images were read by the same experienced pediatric neuroradiologist, and 8 (25%) of the
randomly selected images were read by a second pediatric radiologist to evaluate for interobserver agreement.
For any findings of acute or chronic disease obtained by
MRI, there was 100% agreement and a kappa coefficient of 1.0 between the 2 radiologists. For detection of
specific signs, the degree of agreement was lower; specifically, for effusion there was 75% agreement (␬ ⫽
0.38), and for synovial thickening there was 62.5%
agreement (␬ ⫽ 0.33).
Utility of reported symptoms and examinationdetected abnormalities for imaging-defined acute TMJ
arthritis. Table 4 shows the sensitivity, specificity, positive predictive value, and negative predictive value for
the reported TMJ symptoms and for having abnormal
physical examination findings in the detection of TMJ
Table 4. Sensitivity, specificity, positive predictive, and negative
predictive values of symptoms and abnormal physical examination
findings for the detection of acute temporomandibular joint arthritis in
new-onset juvenile idiopathic arthritis*
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Symptoms
Abnormal physical
examination findings
26 (10–48)
100 (63–100)
100 (54–100)
32 (15–54)
38 (19–59)
50 (16–84)
69 (39–91)
21 (6–46)
* Values are the percent (95% confidence interval).
1193
Figure 2. Change in the maximal incisal opening (MIO) from pre– to
post–corticosteroid injection in patients with juvenile idiopathic arthritis (JIA), by age category. Bars show the mean ⫾ SEM MIO in patients
with JIA as compared with that in normal healthy subjects (see ref. 18).
disease. TMJ symptoms were highly specific, but not
sensitive, for acute TMJ arthritis. Physical examination
findings were not predictive of either acute or chronic
TMJ arthritis.
Response to TMJ corticosteroid injection. Although not part of the study protocol, computed tomography–guided injections of corticosteroid were administered as part of routine care to 21 of the 24 patients
with acute TMJ arthritis. In 16 of these 21 patients, the
MIO was measured again at followup, after corticosteroid injection (median followup 2.4 months postinjection, range 1.4–7.3 months). Nine (56%) of 16 patients
showed improvement in the MIO, with 5 (56%) of the 9
showing an increase in MIO of at least 0.5 cm. Among
the 9 responders, 5 (56%) had been asymptomatic and
had normal findings on jaw examination. Changes in the
MIO from pre– to post–corticosteroid injection are
shown by age category in Figure 2. In all categories
except the youngest age range, the MIO in all patients
was in the normal range after injection.
As part of the routine followup evaluation, 5 of
21 patients who underwent TMJ injection(s) with corticosteroid were evaluated with a repeat MRI of the TMJs
within 6 months postinjection. At this followup time
point, 5 of 6 patients had MRI evidence of decreased
joint effusions and/or decreased synovial thickening; the
sixth patient had stable findings. Of the 5 patients with
improvement on MRI, 2 had an improved MIO, 1 had
no change in MIO, and 1 had a decreased MIO after
injection. The sixth patient, whose MRI findings were
1194
WEISS ET AL
stable, also had no change in the MIO after injection. No
interval improvement in condylar changes or in erosions
were noted with any of the evaluations.
DISCUSSION
The present study is the first to investigate the
prevalence of MRI findings of acute and chronic TMJ
arthritis in patients with JIA, detected at the time of
diagnosis, and to directly compare MRI with US for
detection of TMJ disease. TMJ arthritis as diagnosed by
MRI was present in the majority of patients with newonset JIA. Seventy-five percent of our subjects had acute
TMJ arthritis at the time of diagnosis of JIA, which is at
the higher end of previously reported ranges of 17–87%
(4,6,14). This prevalence at the time of JIA diagnosis
indicates that the TMJ is one of the most commonly
involved joints in children with JIA. Among those patients with TMJ arthritis, 83% had bilateral acute disease, a prevalence that is higher than the 53% reported
in a recent study (6). Furthermore, 69% of patients with
newly diagnosed JIA were demonstrated by MRI to have
chronic TMJ arthritis, which is higher than the 55%
reported in a study that used US to assess chronic
destructive changes (14). More than half of the patients
in our cohort had both acute and chronic findings
diagnosed by MRI. Of the patients with acute TMJ
arthritis, the majority were asymptomatic and had normal jaw examination findings.
In addition, although treatment and followup of
response were not part of the study, we have obtained
data to suggest that corticosteroid injection is beneficial
for acute disease, even in those patients who are asymptomatic. Among patients with acute disease who received corticosteroid injections and who underwent subsequent MIO measurements, the MIO improved in
most, with half of the patients showing improvement of
at least 0.5 cm. Even among patients with the greatest
response, 4 of the 8 were asymptomatic and had normal
jaw examination findings. Further studies are warranted
to evaluate the response to corticosteroid injection.
Given the limited ability to follow up TMJ arthritis by
clinical examination and MIO measurements, future
studies should assess the response using repeat imaging
evaluations shortly after TMJ injection.
Our results suggest that MRI and US findings are
not well correlated, and that MRI has greater sensitivity
for the detection of TMJ disease. The majority of recent
studies utilizing high-resolution US for detection of TMJ
disease in JIA have been from European centers that
have considerable experience with US techniques
(14,15,26). In the United States, ultrasonography is
frequently used to identify synovial thickening and effusions in joints other than the TMJs, but experience with
this technique in assessing the TMJs is limited. Given
the bony anatomy and small size of the TMJs, it may be
more difficult to master techniques and to adequately
visualize effusions and synovial thickening. As experience with TMJ ultrasonography grows, the utility of the
technique may increase, particularly given the lower
costs and less invasive nature of such studies.
In accordance with the results from prior studies,
we found that subjective symptoms and abnormalities on
physical examination were unreliable predictors of acute
and chronic TMJ arthritis as detected by MRI. Among
the patients with acute TMJ arthritis, 71% were asymptomatic, and 63% had normal jaw examination findings.
The positive predictive value of symptoms was high
(100%), indicating that if a patient reports symptoms of
jaw pain or dysfunction, he or she is very likely to have
active TMJ disease. The sensitivity of symptoms, however, was very low (26%), making it a poor screening
tool for detection of acute TMJ disease. Similarly,
abnormalities on jaw examination had a high positive
predictive value (69%) and low sensitivity (38%). In
addition, the negative predictive values for both symptoms and physical examination findings were low (32%
and 21%, respectively), indicating that a lack of symptoms and a lack of abnormalities on examination did not
preclude the presence of TMJ disease. Furthermore, a
beneficial response to treatment among asymptomatic
patients with normal jaw examination findings suggests
that the history review and physical examination are not
sufficient to screen for TMJ disease.
Given the results of 2 recent longitudinal studies
showing that the prevalences of TMJ dysfunction and
pain were increased in adult patients with a history of
JIA, the implications of early treatment of acute TMJ
arthritis may be substantial (7,8). One group of investigators reported a high prevalence of TMJ involvement
(67%) in women by an average of 26 years after diagnosis of oligoarticular or polyarticular JIA (8). In addition, detection of active TMJ disease by MRI in asymptomatic patients may be a predictor of arthritis
extension; a recent study demonstrated that MRI findings of a clinically unaffected knee distinguished between patients with persistent monarthritis and those in
whom extended arthritis developed (27). However, this
theory would apply only to the small subset of patients
DETECTION OF TMJ ARTHRITIS BY MRI VERSUS US
with acute, and not chronic, TMJ arthritis detected by
MRI.
Given the high prevalence of TMJ disease at the
time of JIA diagnosis, and given that TMJ disease is
often undetectable by jaw examination and history review, universal screening with MRI for TMJ arthritis at
the time that JIA is diagnosed should be considered.
Several questions regarding effective treatment and ongoing disease surveillance, however, remain unanswered, especially since children with JIA-associated
TMJ arthritis may be undergoing treatment for their JIA
with both methotrexate and a tumor necrosis factor
inhibitor (10). Specifically, the following issues should be
considered. 1) Should children of all ages who have
acute TMJ arthritis be treated with intraarticular corticosteroid injections? 2) Should patients with only chronic
TMJ disease be similarly treated? 3) Should the treatment of TMJ arthritis vary depending on the concurrent
systemic treatment of JIA? 4) Should a child with
arthritis in 2 TMJs and 3 other joints with active disease
be classified as having polyarticular arthritis? 5) How
often and with what techniques should physicians screen
for activity and resolution of TMJ disease? As the
awareness of the frequency and severity of TMJ disease
in children with JIA increases, we will need to improve
our ability to screen, diagnosis, treat, and monitor TMJ
arthritis.
1195
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
ACKNOWLEDGMENTS
We thank Dr. David D. Sherry and Dr. Esi Morgan
DeWitt for critical review of the manuscript.
15.
AUTHOR CONTRIBUTIONS
16.
Dr. Weiss 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. Weiss, Arabshahi, Feudtner, Cron.
Acquisition of data. Weiss, Arabshahi.
Analysis and interpretation of data. Weiss, Johnson, Bilaniuk,
Zarnow, Cahill, Feudtner, Cron.
Manuscript preparation. Weiss, Johnson, Feudtner, Cron.
Statistical analysis. Weiss, Feudtner.
17.
18.
19.
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detected, high, joint, disease, children, onset, idiopathic, temporomandibular, magnetic, imagine, arthritis, juvenile, resonance, prevalence, ultrasound
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