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Jemds.com Review Article TMJ Arthritis Subhashini Ramasubbu1, Shivangi Gaur2, Abdul Wahab P.U.3, Madhulaxmi Marimuthu4 1, 2, 3, 4 Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Velappanchavadi, Chennai, Tamil Nadu, India. ABSTRACT BACKGROUND Temporomandibular Joint (TMJ) arthritis affects the joint and the surrounding Corresponding Author: musculature. Like any other joints, causes of temporomandibular joint arthritis could Dr. Subhashini Ramasubbu. Department of Oral and Maxillofacial be rheumatoid arthritis, osteo arthritis, or psoriatic arthritis. Severity of the disease Surgery, Saveetha differs from each other ranging from mild to severe. In case of temporomandibular Dental College and Hospitals, Saveetha joint trauma, it may lead to degeneration of the joint which may result in ankylosis of Institute of Medical and Technical Sciences, the joint if it is left untreated. In case of inflammatory arthropathies, even after the Saveetha University, No 162, Poonamallee treatment, inflammation of the joint still persists. To suppress the inflammation, High Road, Velappanchavadi, Chennai, patients can be prescribed immunosuppressive treatment. Long term use of Tamil Nadu, India. immunosuppressants is deleterious and may lead to failure of organs. One more E-mail: [email protected] adverse effect of immunosuppressive drugs is that it makes the patient prone for DOI: 10.14260/jemds/2020/690 infections if the patient undergoes surgery. Symptoms of temporomandibular joint arthritis include pain on involved side, restricted mouth opening, and difficulty in How to Cite This Article: eating. Origin of pain may be from the joint itself or from the muscles attached to it or Ramasubbu S, Gaur S, Abdul Wahab PU, et from both. The patient will complain of mild to severe pain. The objective of this study al. TMJ arthritis. J Evolution Med Dent Sci is to assess TMJ arthritis in those with above said inflammatory arthropathies. This 2020;9(42):3152-3158, DOI: article is to highlight the peculiarities of TMJ arthritis secondary to those 10.14260/jemds/2020/690 inflammatory arthropathies and how to best manage these ailments, which should guide when referral to a specialist TMJ surgeon is appropriate. The aim of this review Submission 18-07-2020, Peer Review 12-09-2020, is to discuss about the various causes of TMJ arthritis, etiopathogenesis, clinical Acceptance 18-09-2020, features, investigations and the management of temporomandibular joint Arthritis. Published 19-10-2020. KEY WORDS Copyright © 2020 Subhashini Ramasubbu Temporomandibular Joint Arthritis, Rheumatoid Arthritis, Psoriatic Arthritis, et al. This is an open access article Osteoarthritis, Ankylosing Spondylitis distributed under Creative Commons Attribution License [Attribution 4.0 International (CC BY 4.0)] J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 42 / Oct. 19, 2020 Page 3152 Jemds.com Review Article BACKGROUND 3. Restricted movement 4. Fatigue Temporomandibular Joint arthritis affects the joint and the 5. Fever surrounding musculature. Like any other joint, causes of 6. Loss of weight temporomandibular joint arthritis could be rheumatoid 7. Mild joint discomfort to severe pain arthritis, osteo arthritis or psoriatic arthritis. The aim of this 8. In chronic stage, it can cause cartilage loss, erosion and review is to discuss about the various causes of TMJ arthritis, generalized weakness. aetiopathogenesis, clinical features, investigations and the 9. Deformity management of temporomandibular joint arthritis. 10. Destruction of joint 11. Loss of function RHEUMATOID ARTHRITIS TMJ Symptoms 1. Pain in preauricular region Rheumatoid arthritis is an autoimmune, inflammatory 2. Swelling disorder causing inflammation in and around the joint, 3. Crepitus resulting in deformity and loss of function1. It is a chronic 4. Impairment of the function painful condition involving almost all joints, causing erosion 5. Occlusal derangement of the joints and the presentation is usually symmetric. It 6. Sometimes in advanced stage, they may be anterior open usually involves peripheral joints. Involvement of TMJ is rare bite and it is the last joint to get involved by the disease. 7. Stiffness of the joint Rheumatoid arthritis is prevalent worldwide with a 8. In children, it may affect growth of the mandible, percentage of 1 percent. Women are most commonly affected eventually leads to facial deformity and ankylosis with than men with a ratio of 3:1. The age distribution is between occlusal deformity. Patient is unaware of the relationship 35 and 50 years. Percentage of involvement of TMJ is 2 – 88 between TMJ and arthritis4,9 %.2-4 But majority of studies shows TMJ involvement in 50 % of rheumatoid arthritis patients5-7 If it involves the joint, pain is the major problem, later it leads to inflammation, which in Diagnosis turn causes restricted movement, stiffness of the joint and Diagnosis is based on patient’s clinical history, clinical muscle spasm.8 findings, radiographs, blood investigations. Multidisciplinary approach is needed.10 Aetiopathogenesis Aetiology and pathogenesis of the disease are multifactorial. Investigations It involves macrophages, T cells, B cells, chondrocytes, 1. Routine blood investigation fibroblasts and dendritic cell. Combined genetic and 2. ESR, CRP immunological factors are associated with the disease. There 3. Rheumatoid factor are genes and epigenetic modification in the development of 4. ANA is a frequent finding in RA patients disease. Environmental factors like cigarette smoking, 5. Citrulline Antibody tests (done in dreadful cases) pollutants like silica, some bacterial and viral infection are 6. OPG also equally important. In the initial stage, there are 7. MRI disturbance in protein modification, followed by APC 8. CT (Antigen Presenting Cell) and Fibroblast-Like Synoviocytes 9. TMJ Tomogram (FLS) activation. Very rarely trauma to the joint or any acute 10. Arthrography injury mat trigger the disease. 11. CBCT Regarding rheumatoid arthritis, there won’t be any Classification of Rheumatoid Arthritis Based on changes in early stage of disease. The findings may vary from Radiographic Changes 19 - 86 %. In chronic stage or in severe stage there will be Classification is based on radiographic changes. Larsen flattening of condylar head, erosion of the joint, reduced joint classified into 6 grades space, spiked or pencil head deformity of condyle and in some 1. Normal cases sub cortical cysts. 2. Slight narrowing of joint space 3. Early abnormality, slight narrowing of joint space, slight erosion Management 4. Moderate disturbance, joint space eroded and reduced Medical Therapy - Aim of the therapy is to relieve pain. It can 5. Destruction is severe. Eroded, reduced joint space, resolve symptoms in 80 % of the patients.11 Therapy includes deformity is seen reassurance, soft diet, physiotherapy, NSAID’s12 & occlusal 6. Mutilating, disappearance of joint space, bony deformity splints. Effective management includes DMARD’s (Disease Modifying Anti-Rheumatoid Drugs). They are second line of drugs. They are methotrexate and HCQ. These drugs prevent General Symptoms of Rheumatoid Arthritis further progression of the disease. Newer DMARD’s are 1. Swollen Joint Leflunomide, Etanercept, Infliximab, Rituximab and 2. Pain J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 42 / Oct. 19, 2020 Page 3153 Jemds.com Review Article Abatacept. Though physiotherapy has no long-term benefits, situation where the anatomy is destroyed. Relative it is not harmful. Topical NSAID’s (Nonsteroidal Anti- indications are condylar fracture, AVN, tumours requiring Inflammatory Drug) is as effective as oral preparation and resection, congenital anomalies like hemifacial microsomia. should be taken 4 times a day for 4 weeks and it has fewer The custom-made prosthesis is designed by computer side effects.13-15 Low dose tricyclic antidepressants can be aided systems, and it is designed using stereolithographic given for myofascial pain.16 Occlusal splints should be worn models. Stereolithographic models can be obtained through at night. It permits masticatory muscle rest, reduces 3-D computed tomography. myofascial pain, it reduces load on TMJ as well.17 Benefits of DMARD’s are, TMJ is treated simultaneously with other joints by suppression of inflammation.18-23 In the management of Other Treatment Modes - In one study patient with RA arthritis, the choice of NSAID remains confusing and (Rheumatoid Arthritis) who has anterior open bite, controversial. orthodontic approach was done to improve occlusal and articular condition, promoting functional mandibular adaptation, reconstructing occlusion, which leads to condylar Local Anesthesia and Steroid Injection - Pain can be adaptive remodeling. For assessing myogenous temporarily controlled by LA (lignocaine 1 % or 2 %) temporomandibular disorders, thermography is also used.28 infiltration into joint space. Site of injection is 10 mm along and 2 mm below the line joining tragus and lateral canthus of eye. Bupivacaine 0.5 % can be injected for reducing PSORIATIC ARTHRITIS myofascial pain and spasm. When it is injected in temporalis muscle, localized muscle paralysis occurs for up to 6 months and reduced pain, which was measured by VAS (Visual Psoriatic arthritis is an inflammatory condition which Analogue Scale) in 79 % patients24 presents in psoriasis patients even
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