Arthritic Conditions Affecting the Temporomandibular Joint L. G. Mercuri and S. Abramowicz Abstract Keywords Arthritis is the most common inflammatory Temporomandibular joint • Arthritis • Osteoar- joint disease in children and adults. It has mul- thritis • Degenerative joint disease • TMJ tifactorial etiology resulting in joint degenera- reconstruction • TMJ replacement • Rheuma- tion and loss of function. Using a management toid arthritis • Juvenile idiopathic arthritis • classification scheme based on clinical signs, Arthrocentesis • Arthroscopy • Orthognathic symptoms, and imaging, this chapter will pre- surgery • Synovectomy sent an evidence-based discussion for the man- agement of arthritic conditions affecting the Contents temporomandibular joint (TMJ). The common Introduction .......................................... 1 and significant signs and symptoms of TMJ General Principles ................................... 2 arthritic conditions are pain, loss of joint func- tion, joint instability, mandibular dysfunction, Signs and Symptoms of Arthritis ................... 4 and facial deformity due to loss of posterior Diagnosis .............................................. 5 mandibular vertical dimension as pathologic Low-Inflammatory Arthritis .......................... 5 osteolysis decreases the height of the condyle. High-Inflammatory Arthritis .......................... 5 Juvenile Idiopathic Arthritis .......................... 8 Medical management can ameliorate early- Condylar Resorption .................................. 9 stage disease. Progressive disease may require the employment of invasive procedures, Management of TMJ Arthritic Conditions ........ 12 Noninvasive Modalities ............................... 14 whereas in end-stage disease, joint replace- Minimally Invasive Procedures ....................... 19 ment is typically required. Surgery ................................................ 25 Conclusion and Future Directions .................. 30 Cross-References ..................................... 31 References ............................................ 31 L.G. Mercuri (*) Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA Clinical Consultant TMJ Concepts, Ventura, CA, USA Introduction e-mail: [email protected] S. Abramowicz Worldwide statistics indicate that the incidence of Oral and Maxillofacial Surgery and Pediatrics, Emory arthritis is 3.2%. Arthritis affects females more University and Children’s Healthcare of Atlanta, Atlanta, than males (2.7:1) and can lead to joint destruc- GA, USA tion, deformity, and disability in 10–15% of e-mail: [email protected] # Springer International Publishing AG 2017 1 C.S. Farah et al. (eds.), Contemporary Oral Medicine, https://doi.org/10.1007/978-3-319-28100-1_32-1 2 L.G. Mercuri and S. Abramowicz patients. Arthritic conditions are the second most pathology (e.g., arthritis or osteoarthrosis) or frequent cause of outpatient complaints among extra-articular factors (e.g., joint hypermobility patients with chronic diseases (Rodrigo and or sensitization, peripheral or central) (Michelotti Gershwin 2001). By 2030, an estimated 67 million et al. 2016). Americans aged 18 years or older are projected to have diagnosed arthritis (Hootman and Helmick 2006). Approximately 1 in 250 children under the General Principles age of 18 have some form of arthritis or rheumatic condition; this represents approximately 294,000 TMJ arthritic conditions can be classified as children in the United States (Sacks et al. 2007). low-inflammatory or high-inflammatory types Arthritis has many causes; however, the com- (Table 1) (Mercuri 2006). Table 2 describes the mon result is the degeneration of the affected joint basic clinical, laboratory, and imaging character- surfaces resulting in loss of joint function. The istics of each of these conditions. cause of the arthritic condition determines the Low-inflammatory arthritic conditions are pur- clinical characteristics and rate of degeneration ported to begin in the matrix of the articular surface of the joint surfaces. of the joint, with the subcondylar bone and capsule The prevalence of significant temporomandib- becoming secondarily involved. The two classic ular joint (TMJ) arthritis resulting in joint degen- types of low-inflammatory arthritis are: first, degen- eration, dysfunction, and/or joint pain is erative joint disease, or primary osteoarthritis (OA), unknown. Previous studies have provided esti- produced by intrinsic degeneration of articular car- mates that the incidence of TMJ arthritic condi- tilage typically the result of age-related functional tions ranges from 1% to 84% of the general loading; and second post-traumatic arthritis. population (Westesson and Rohlin 1984). Even though these low-inflammatory arthritic Changes consistent with degenerative TMJ dis- conditions often involve the TMJ, these seldom ease are found in approximately 70% of the require invasive surgical intervention provided patients who undergo arthroscopy for TMJ disor- they are managed appropriately in the early stages ders; however, degenerative changes are clinically (Henderson et al. 2015; Tanaka et al. 2008; Wang diagnosed in less than 10% of patients (Israel et al. et al. 2012). Patients with low-inflammatory type 1991). Examination of the TMJ at autopsy reveals have been shown to have low leukocyte counts in degenerative changes in at least 40% of speci- the synovial fluid and laboratory findings consis- mens. However, estimates of the number of indi- tent with low-level inflammatory activity (e.g., viduals in the United States seeking treatment for erythrocyte sedimentation rate [ESR] and TMJ pain or dysfunction are substantially lower at C-reactive protein [CRP]), and the affected joint 1.9–3.4% (Westesson and Rohlin 1984). shows focal degeneration on imaging (Fig. 1) The diagnostic criteria used to differentiate (Mercuri 2006). between “arthritis” and the biologically different “ ” osteoarthrosis is not effective due to their shared Table 1 Classification of TMJ arthritic conditions multiple clinical signs and symptoms (Michelotti (Mercuri 2006) et al. 2016). There are discrepancies in estimates Low- Osteoarthritis (degenerative joint of the prevalence of each of these conditions inflammatory disease) because the association between pain, dysfunc- disorders Post-traumatic arthritis tion, and joint morphology is complex. Gross High- Infectious arthritis fl morphologic abnormalities can be present in the in ammatory Rheumatoid (ARA and JIA) disorders Metabolic absence of TMJ pain and dysfunction (Pereira (Gouty arthritis, psoriatic et al. 1994). Furthermore, the distinction between arthritis, lupus, ankylosing the diagnoses of “arthralgia” and “arthritis” is spondylitis, Reiter’s syndrome, difficult since the signs and symptoms overlap. arthritis associated with ulcerative colitis) “Arthralgia” may be due to intra-articular Arthritic Conditions Affecting the Temporomandibular Joint 3 Table 2 The basic clinical, laboratory and imaging characteristics of low and high inflammatory TMJ arthritic conditions TMJ findings Low-inflammatory High-inflammatory Pain Localized Diffuse TMJ involvement Unilateral or bilateral Bilateral Clicking Rare Absent Crepitation Present Rare Rheumatoid factor Rare Present ESR Often normal Elevated CPP Normal Elevated CRP May be elevated Elevated Imaging Erosive and exophytic Erosive Asymmetric bone loss Symmetric bone loss ESR erythrocyte sedimentation rate, CPP cyclic citrullinated peptide antibody, CRP C-reactive protein a b AE EAC LAT c EAC Fig. 1 Sagittal (a), coronal (b) and axial (a) reconstruc- articular surface flattening and sclerosis (open black arrow) tions of the left TMJ from a multi-detector CT scan dem- with a small anterior osteophyte (white arrows). Where onstrating articular surface remodelling and early, low- EAC= external auditory canal and LAT = lateral. (Images inflammatory, osteoarthritis. There is joint-space narrowing courtesy of Clinical Associate Professor Andy Whyte, which is most marked anterolaterally (dotted black arrows), Perth Radiological Clinic, Perth WA, Australia) 4 L.G. Mercuri and S. Abramowicz Fig. 2 Patient with JIA demonstrates open bite deformity of high-inflammatory arthritis due to diffuse degeneration of the involved joints High-inflammatory arthritic conditions primar- ily involve both the synovial cells and bones of the Signs and Symptoms of Arthritis joint. The classic type of high-inflammatory arthritis is rheumatoid arthritis (RA). Other types The most common symptom of TMJ arthritic of high-inflammatory arthritic conditions include conditions is pain. The pain arises from the soft metabolic arthritic diseases such as gout (Oliveira tissues around the affected joint that are under et al. 2014), pseudogout (Laviv et al. 2015), pso- tension, as well as the masticatory muscles that fl riatic arthritis (Crincoli et al. 2015), lupus are in re ex protective co-contraction because of ’ erythematosus (Jordan and D’Cruz 2016), anky- Hilton s Law. This orthopedic principle states that losing spondylitis (Arora et al. 2013), infectious the neural supply innervating a joint is the same as arthritis (Gayle et al. 2013), Reiter’s disease that innervating the muscles that move that joint (Mansour et al. 2013), and the arthritis associated and the overlying skin (Hébert-Blouin et al. with ulcerative colitis (Sarlos et al. 2014). 2014). This law provides for the protection of an Although these arthritic disorders may be his- injured or pathologically affected joint by causing