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British Journal of Oral and Maxillofacial Surgery 51 (2013) 191198

Review

Management of the temporomandibular joint in rheumatoid disorders

A.J. Sidebottom , R. Salha
Maxillofacial Unit, Queens Medical Centre, Nottingham University Hospital, Derby Road, Nottingham NG7 2UH, United Kingdom Accepted 15 April 2012 Available online 1 June 2012

Abstract This article summarises the rheumatoid diseases that particularly affect the temporomandibular joint (TMJ): psoriatic arthropathy, ankylosing spondylitis, and rheumatoid arthritis. Management is by a joint approach between rheumatologists and maxillofacial surgeons with a specic interest in diseases of the TMJ who give early surgical advice. Steroid injections, whilst useful in the short term, are not useful for long term or repeated treatment, and may lead to collapse of the joint and development of a deformed anterior open bite. These disorders should be managed primarily using standard conservative regimens, and failure to respond should lead to diagnostic or therapeutic arthroscopy and appropriate surgical treatment. When ankylosis develops or the joint collapses, a replacement joint should be considered and patients should be referred to an appropriately trained surgeon. 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: TMJ; Temporomandibular joint; Rheumatoid arthritis; Psoriasis; Psoriatic arthropathy; Ankylosing spondylitis; TMJ replacement; TMJ arthroscopy; TMJ surgery

Introduction We consider surgical management of the common rheumatological disorders that affect the temporomandibular joint (TMJ). Rheumatologists should manage the disease and advise on the adjustment of medical treatment to enable safe and effective surgery. Intra-articular steroids are not a panacea for management, and the TMJ seems to be sensitive to loss of cartilage because of the cartilage structure (brocartilage).

plaques topped by silvery scales. It has an unknown aetiology although there is a family history in one third of patients, it affects both sexes equally, and occurs in 12% of the population.1 It may begin at any age, is unusual in children under 8 years of age, and has two peaks of onset: in the second to third, and sixth decades.

Psoriatic arthropathy Psoriatic arthropathy is an inammatory seronegative arthritis that affects 58% of patients with psoriasis.2 It may also occur independently in 0.010.2% of the population.2,3 First observed in 1818, the relation between arthritis and psoriasis was described in 1860, and was claried in 195636 ; there are 5 main categories (Table 1). Whilst skin lesions of psoriasis have their peak onset in the third decade, it is usually diagnosed 10 years later.7 The aetiology is thought to be multifactorial with a strong genetic component, and there is a clear association with HLA-B27 (which may explain

Psoriasis Psoriasis is a chronic, papulosquamous, inammatory skin disease characterised by well-demarcated erythematous
Corresponding author. Tel.: +44 115 9249924x65895; fax: +44 115 8493386. E-mail addresses: Andrew.sidebottom@nuh.nhs.uk, ajsidebottom@doctors.org.uk (A.J. Sidebottom).

0266-4356/$ see front matter 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjoms.2012.04.271

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Table 1 Different types of psoriatic arthritis and joints affected. Type Classic or asymmetrical Rheumatoid-like Arthritis mutilans Monoarthritis Ankylosing spondylitis Joints affected Distal interphalangeal joints of hands and feet Symmetrical polyarthritis Phalanges, metacarpals, metatarsals Spine

ankylosing spondylitis-type symptoms) (Fig. 1). In a genetically predisposed person certain environmental factors for example, trauma, infectious agents, or stress, can lead to an immune imbalance with a reduction in T-suppressor cells, and excessive production of immunoglobulin against epithelial or synovial tissues. Formation of immune complexes which release inammatory mediators and chemotactic factors ensure continued activation of lymphocytes.3,8 The joints involved are typically asymmetrical and commonly involve the distal interphalangeal joints of the ngers.9 Other affected joints include the knees, elbows, shoulders, ankles, spine, and toes.5 In 70% of cases 12 joints are affected, in the remainder more than 3 joints are involved.5 Common symptoms are stiffness and pain in the joints.10 Remission occurs in 8% of cases.11

Fig. 2. Restricted mouth opening caused by ankylosis of the TMJ in psoriatic arthropathy.

Psoriatic arthropathy of the TMJ Involvement of the TMJ in psoriatic arthropathy was considered rare with less than 40 cases reported since 1965,1220 but recent evidence shows that one third of patients with psoriasis have signs or symptoms, or both, of dysfunction,5,9,11 whereas up to half the patients with psoriatic arthropathy have TMJ symptoms, and up to 90% have signs of dysfunction.9,21 Typical ndings include noises in the joint, pain on function, morning stiffness, crepitus, and muscle tenderness.5,9,11 As the disease progresses pain is replaced by limited movement (Fig. 2) because of an increased tendency towards brosis. Crepitus is found later in the disease and is associated with structural changes in the joint. Involvement of

Fig. 1. Symptoms of psoriatic arthropathy similar to ankylosing spondylitis.

the TMJ is more common and more severe in patients with psoriatic arthropathy than in those with uncomplicated psoriasis and healthy individuals.5 There is no difference between the sexes in the incidence or severity of TMJ symptoms.9 The duration of the disease, severity of symptoms, and number of somatic joints affected are the main risk factors for involvement of the TMJ.5,9 No relation exists between the severity of the skin symptoms and involvement of the joint.5,9 Diagnosis is difcult because symptoms, radiographic ndings, and laboratory markers are not specic. There are three prerequisites for a diagnosis of psoriatic arthropathy of the TMJ: psoriasis, erosive polyarthritis, and negative rheumatoid factor serology.22 Despite these requirements, diagnosis is difcult because psoriatic skin lesions may not be present or easily identiable, and it occurs independently in only 0.010.2% of the population.2,3 Symptoms in the joint may precede the skin lesions, psoriatic arthropathy can manifest as a monoarthritis rather than polyarthritis, and rheumatoid factor is present in 5% of healthy people. If psoriatic arthropathy of the TMJ is suspected, careful examination of the scalp, nails, and umbilicus may aid diagnosis.23 Positive signs include pitting of the nails and onycholysis (separation of the distal edge of the nail from the nail bed), which is seen in 85% of patients with psoriatic arthropathy compared with 20% of those with uncomplicated psoriasis; eye symptoms (including conjunctivitis, iritis, and uveitis); and the Koebner phenomenon, in which psoriatic lesions develop in areas of skin subjected to trauma. Radiographic features of the disease24 include erosion of the condylar head (resulting from subchondral osteolysis) (Fig. 3) with osteoporotic lesions (healing after inammation), formation of osteophytes, narrowing of the joint space, attening of the condylar head, and subchondral sclerosis in

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Fig. 3. Orthopantogram showing loss of the condylar head in psoriatic arthropathy.

later chronic disease.7,11,25 However, these features are not specic and do not differentiate psoriatic arthropathy from other arthritic conditions or degenerative disease.7 There may be a time lag between the appearance of symptoms and radiographic changes, so the absence of radiographic features does not exclude the possibility of disease.11 Also, radiographic features, particularly erosions, can be found in the absence of signs or symptoms, possibly because of the remissive nature of the disease or because erosions do not cause tenderness and pain later in its progression. Erosions correlate with TMJ symptoms and with most signs of psoriatic arthropathy,11 but it is important that management is based on the control of symptoms and rehabilitation, not on the radiograph. Radiographic collapse may be present without evidence of occlusal changes, pain, or restricted opening.26,27 Late presentation can be with collapse of the joint and loss of ramal height or ankylosis (Fig. 4), the latter particularly in cases with symptoms similar to B27 ankylosing spondylitis. Early cases from the senior authors practice that have failed standard conservative measures have had the symptoms resolved satisfactorily by the judicious use of arthroscopy and arthrocentesis. Four late cases responded well to the joint being replaced (Sidebottom AJ. Prospective 5-year outcome of custom made total TMJ replacement.

In: Paper presented at BAOMS annual scientic meeting. Manchester; May 2010).

Ankylosing spondylitis Ankylosing spondylitis, also known as Bechterew disease, is an inammatory seronegative progressive disorder of the back.28 It mainly affects young male adults and has an incidence in white people of 12%.28,29 It tends to involve the brocartilagenous structures, most commonly the sacroiliac joints and the intervertebral discs. Other structures affected include the pubic symphysis, and the sternomanubrial and sternoclavicular joints. There is a higher incidence of peripheral joints being involved in patients with onset of disease before the age of 20 years.29,30 The pathogenesis is thought to involve synovial proliferation over the articular cartilage with subsequent loss of cartilage, and penetration of granulation tissue into the underlying bone.29 Clinical features include increasing pain and morning stiffness in the lower back, and a progressive loss of spinal movement. Later signs include loss of lumbar lordosis, increased kyphosis, and reduction in chest expansion with xed exion of the hips and knees.28,31 Progression to complete spinal and thoracic rigidity is common (Fig. 1).

Ankylosing spondylitis of the TMJ The TMJ has been reported to be involved in 22% of cases of ankylosing spondylitis.29 Clinical symptoms are not specic to the disease and most patients have no pain or discomfort in the joint.29 Clinical signs include noises in the joint, tenderness on muscle palpation (particularly the lateral pterygoids), muscular hypertrophy (particularly the masseters), and restricted mouth opening.29,32 Of the 12 case reports of TMJ ankylosis in patients with the disease, 5 were bilateral.31 Signs and symptoms appear less often and are less severe than those of rheumatoid or psoriatic arthritis.32 Bilateral total joint replacement in two patients with severe ankylosis that

Fig. 4. Ankylosis in ankylosing psoriatic arthropathy.

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caused opening of less than 20 mm gave a pain-free resolution and opening of more than 30 mm (Sidebottom AJ. Prospective 5-year outcome of custom made total TMJ replacement. In: Paper presented at BAOMS annual scientic meeting. Manchester; May 2010).

Rheumatoid arthritis Rheumatoid arthritis is a systemic, symmetrical, peripheral, inammatory polyarthropathy caused by erosive synovitis, the end result of which is deformity and instability of the joints.33 It affects 1% of the population, is most common in women, and usually begins in the third and fourth decades.34 Survival is estimated to be 20% lower than in the general population.34 The aetiology is multifactorial and results in an autoimmune mechanism with inammatory and destructive features.28 The pathogenesis involves synovial proliferation over the surface of the cartilage, which produces a tumourlike mass (pannus)28 that destroys the articular cartilage and underlying bone, and causes erosions. Clinical features include pain, stiffness, and swelling of the small joints of the hands and feet, which is worst in the morning and improves during the day. The disease is polyarticular, and most commonly affects the hands, feet, wrists, elbows, shoulders, cervical spine, knees, and feet. The lumbar spine is spared. Extra-articular manifestations may involve the eyes, lungs, heart, nervous system, kidneys, and blood vessels.

Fig. 5. Right condylar collapse in rheumatoid arthritis with appearance that suggests left condylar hyperplasia.

Rheumatoid arthritis of the TMJ The TMJ is a synovial joint and can be affected by rheumatoid arthritis. Its involvement in the disease was rst described in 1874,33 and the incidence of its involvement ranges from 5% to 86%, depending on the population studied, diagnostic criteria, and the means of assessment.3234 Bessa-Nogueira et al. found that 70% of patients with rheumatoid arthritis presented with at least one sign or symptom.34 Involvement of the TMJ correlates with the severity and duration of the systemic disease,3436 and a patient who experiences pain

on palpation of peripheral joints is likely to have tenderness on palpation of the TMJ.34 Clinical ndings include sounds, pain, stiffness in the joint, and limited movement.34,35 Ankylosis is an uncommon late nding, and may be bilateral.37,38 Juvenile onset can lead to changes in facial appearance suggestive of contralateral condylar hyperplasia (Fig. 5) with occlusal cant and unilateral loss of ramal height. In severe bilateral cases, loss of condylar height results in retrognathia, loss of ramal height, and anterior open bite (Figs. 6 and 7).33,39 Severe cases may have associated episodes of upper airway obstruction (sleep apnoea), particularly when supine.33,40 In one study, 66% of patients with rheumatoid arthritis in the TMJ had severe cervical arthritis, and a half of patients with rheumatoid arthritis in the cervical spine had severe arthritis in the TMJ.41 The surgical team should be aware of these potentially fatal associations, particularly slippage of C1 on C2. Stability of the cervical spine should be decided preoperatively for all patients having general anaesthesia, and if necessary the opinion of a spinal surgeon should be sought. Muscle tenderness and pain in the TMJ are suggestive of active disease.33 Restricted mouth opening is common but non-specic in rheumatoid arthritis, and there may be a number of causes that include pain, brous adhesions,

Fig. 6. Three-dimensional model showing downward and backward rotation of the mandible after collapse of the joints in rheumatoid disease.

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Fig. 7. Collapse of the joint leading to development of deformed anterior open bite.

internal derangement, inammation, muscular contraction, or severe degeneration of the joint. Objective differences in mouth opening are not different from those of the general population,33 and may be because the TMJ contains more resistant brocartilage than hyaline cartilage which is found in other peripheral joints. Compared with psoriatic arthropathy and ankylosing spondylitis, the signs and symptoms of rheumatoid arthritis are more frequent and more severe.32 Crepitus, which is an important sign of joint destruction is more common and may persist even when other signs and symptoms have disappeared.32,33 Patients who have medical treatment such as corticosteroid or disease-modifying antirheumatic drugs have less crepitation as the drugs can reduce or prevent damage to the joint.34 Radiographic changes are found more often in rheumatoid arthritis than in psoriatic arthritis and ankylosing spondylitis.32,33,42 Typical radiographic changes include cortical erosions, subcortical cysts, attening of the condylar head and articular eminence, subcortical sclerosis, and narrowing of the joint space,35,42,43 although they are not pathognomonic of rheumatoid arthritis.

muscle, disrupted occlusion, and restricted range of movement (less than 35 mm opening). The rst aim of management is to relieve pain. Initial conservative measures include reassurance, jaw rest, physiotherapy, non-steroidal anti-inammatory drugs (NSAIDs),44 and occlusal splints. Around 80% of patients will have their symptoms resolved by conservative measures alone.45 In many patients with rheumatoid disorders, the TMJ is not involved, and it should be managed assuming that this is the case until involvement is conrmed by the use of radiographs or arthroscopy. Physiotherapy is not harmful and is reversible. There is no good evidence of long term benet, but it can be used in the short term to manage restricted opening or after arthroscopy or open surgery. NSAIDs are indicated for pain secondary to inammation, and topical use provides the same benets as systemic use, but with fewer side effects.44 They should be used 4 times a day for 4 weeks.44,46 Cochrane analysis shows that no particular design of bite splint is advantageous, therefore a simple lower soft splint provides a safe and cheap alternative.47 Joint pain can be conrmed and temporarily relieved by injection of local anaesthetic into the joint space, and pain relief suggests that arthroscopy will provide a therapeutic and diagnostic aid. Synovitis that does not improve 46 weeks after arthroscopic arthrocentesis (which it commonly does) may benet from intra-articular steroids. Myofascial pain and spasm can be relieved by needling with long-acting local anaesthetic such as bupivacaine, or by botulinum injections into the masseter and temporalis muscles. This causes localised paralysis of the muscles for up to 6 months and has been shown to be effective in 80% of patients.48,49 More traditional methods of management include the use of low-dose tricyclic medication.

Arthroscopy and arthrocentesis First described in 1975,50 arthroscopy has a low risk of long term degenerative change, and patients can potentially be treated as day cases using local anaesthetics, particularly with the newer 1.2 mm scopes. Disadvantages include limited access and restricted view of the lower joint space. Restricted mouth opening is usually secondary to problems in the upper joint space, particularly anchored disc phenomenon and synovitis, where arthrocentesis is particularly benecial.45,51 Degenerative disorders tend to affect the lower joint space most often, and access usually requires an open procedure. There is no evidence that arthroscopy gives therapeutic benet over arthrocentesis, but arthroscopy is essential for the appropriate diagnosis and management of rheumatological disorders (Fig. 8). Visualised arthrocentesis using the OnPoint 1.2 mm Scope System (Biomet Microxation, Jacksonville, USA) is less traumatic and easier to use than standard 1.9 mm scopes, and provides the operator with a

Management of disorders of the TMJ in rheumatological diseases The critical symptoms of disorders of the TMJ are noises in the joint, pain, limited mouth opening, and locking. Pain can originate from the joint itself or from the associated muscles of mastication. Clinical signs are tenderness of the joint and

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Fig. 9. Specimen of rheumatoid joint destruction.

Fig. 8. Arthroscopic appearance of synovitis.

can remodel the surface of the joint and relieve pain, but there is a risk that the joint will collapse further with loss of condylar height.

clinical diagnosis of the presence of synovitis or erosion of the joint surface. Less than 10% of patients progress to arthroscopy; around 80% are cured by this procedure whilst 10% require subsequent open joint surgery.45,52 The outcome is less favourable in rheumatoid diseases, although there have been no denitive studies with large enough numbers. Arthroscopy is difcult, if not impossible, in ankylosing conditions.

Joint replacement surgery When symptoms are caused by failure of the joint the nal treatment for all degenerative, ankylotic, and collapsed joints is total replacement. Collapse presents with a deranged occlusion, and failure causes lack of function (ability to eat), restricted mouth opening, and pain. The surface of the joint is often destroyed by erosion (Fig. 9). Use of costochondral grafts has largely been replaced by total joint replacement as the outcomes from the latter are more predictable.53,54 Total replacement of the TMJ was developed during the 19th century, and current prostheses have been modied from those produced by Christensen in the 60s. Two prostheses are licensed in the UK with 1520 years of follow up. Hemiarthroplasty is not recommended in rheumatoid diseases. The Christensen prosthesis was modied from acrylic on cobaltchrome (used until 1999) to metal-on-metal cobaltchrome alloy, but around 10% developed a foreign body reaction, possibly because of a material allergy.54 Follow up on the former type of prosthesis showed good outcomes until the acrylic wore out and it is currently withdrawn from the market. TMJ Concepts custom-made prostheses (TMJ Concepts, Ventura, USA) are created using CAD-CAM (computer-aided design and manufacture) models from a three-dimensional computed tomogram (CT), and offer 90% success rates for up to 17 years in terms of improved opening, diet, and pain.55 They are made from high molecular weight polyethylene and cobaltchrome alloy, and costs for inpatients are similar to total knee replacements (only a 2day stay). They are xed to the base of the skull and ramus of the mandible (Fig. 10). The condylar component head may be hardened titanium in patients with an allergy to the cobaltchromium alloy. The Biomet prosthesis is similar, but also has a stock prosthesis.

Open joint surgery Unresponsive TMJ problems were formerly managed with open operations. Many cases were successful, but the indiscriminate use of operation is now becoming apparent. A proportion of these patients develop secondary degenerative disease or prolonged dysaesthetic pain that is recalcitrant to many analgesics. Arthroscopy deals with many cases associated with pain and restriction, but the persistence of noises alone does not necessitate operation. Synovectomy is a difcult procedure to dene in the TMJ, and the medial anatomy makes it a complex and risky procedure because of the presence of branches of the trigeminal nerve and branches of the terminal carotid artery and jugular vein. Discectomy is indicated for grossly deranged and damaged discs that cannot be repaired because of perforation or lack of mobility. It may be supplemented with interpositional grafts, but there is no sound evidence of benet (temporalis interpositional grafts may restrict opening because of scarring) and the joint can be allowed to remodel and form a neo disc with brous tissue. Simple repeated arthrocentesis in a functional joint with the judicious use of steroid as indicated by synovitis diagnosed arthroscopically is often enough to keep the patient comfortable. It can also be benecial when a disc is torn as it can relieve symptoms, so reliance on magnetic resonance (MRI) ndings to proceed to open operation before conrming with arthroscopy, should be used with caution. A condylar shave

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replacement. All patients in the UK should be entered on the BAOMS approved national database, which will enable long term outcomes to be assessed and allow the different prostheses to be analysed for comparative suitability. It will assist particularly in the analysis of less common diagnoses such as rheumatoid disorders, and outcomes can be assessed from the whole of the UK.

Conict of interest The authors have no conict of interest.

References
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Fig. 10. TMJ Concepts total joint replacement in place and postoperative radiograph.

Replacement of the joint corrects the occlusion immediately (stable advancement and lengthening of the ramus may also be achieved), mouth opening improves over the rst months, and diet improves over one year. The outcomes of the authors patients at one year (including 4 with psoriatic arthropathy, 1 with ankylosing spondylitis, and 9 with rheumatoid arthritis with good outcomes) show pain relief and dietary improvement of 90%, and a mean improvement in mouth opening of 11 mm (Sidebottom AJ. Prospective 5-year outcome of custom made total TMJ replacement. In: Paper presented at BAOMS annual scientic meeting. Manchester; May 2010). Longer term follow up shows that these outcomes are maintained. In one patient with rheumatoid arthritis with marked collapse and an associated 11 mm anterior open bite which was closed during bilateral joint replacement, the joint dislocated postoperatively because of shortening of the temporalis and lack of stability of the anterior joint. It responded to light elastics for one week. Since then, use of light elastics for one week after closure of an anterior open bite, or after coronoidectomy has prevented it. Total joint replacement is the nal stage of TMJ management and there are strict guidelines from the National Institute for Health and Clinical Excellence (NICE).56,57 Around 100 joints are replaced each year in the UK, which requires only a few surgeons to carry out the complex procedure. Outcomes are less satisfactory in multiply-operated joints so it is important that patients are referred early to an appropriately trained surgeon to nd out whether a lesser procedure is acceptable or whether it will compromise the ultimate outcome of joint

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