|Year : 2018 | Volume
| Issue : 3 | Page : 173-177
The relationship between the temporomandibular joint radiographic changes and the duration of rheumatoid arthritis
Walid S Salem1, Ahmed Bakry2
1 Department of Oral and Maxillofacial Radiology, Beni Suef University, Beni Suef, Egypt; Department of Maxillofacial Surgery and Diagnostic Science, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
2 Department of Oral and Maxillofacial Radiology, Almenia University, Almenia, Egypt
|Date of Submission||17-Jan-2018|
|Date of Acceptance||02-Apr-2018|
|Date of Web Publication||10-Oct-2018|
Walid S Salem
2 Omar Zafan Street, Nasr City, Cairo, Egypt
Source of Support: None, Conflict of Interest: None
Rheumatoid arthritis (RA) is a systemic disease affecting many body joint. In the later stage of RA it affects the temporomandibular joint (TMJ). The extent of TMJ association is by all accounts correlated with the seriousness of RA. There is a contentions with respect to the correlation between the duration of RA and temporomandibular joint dysfunction. The aim of this study was to determine if there is a relation between the RA duration and the radiographic finding in the TMJ.
Patients and methods
A total of 36 patients range in age between 45 and 55 years, were divided into three groups, group 1: 12 patients with RA for at least 10 years and are on a regular treatment and follow-up, group 2: 12 patients with RA recently discovered and less than 5 years diseased, group 3: 12 normal patients (control group) and the radiographic bony changes are recorded in each group as well as the space between the condyle and the glenoid fossa.
In group 1 and group 2 all the cases have at least one of the bone involvement, while in the control group only 50% of the cases complaining from at least one of the bone involvement which is mainly condyle erosion. Regarding the space between the condyle and the glenoid fossa in group 1 show more reduced space than the other groups, followed by group 2.
The present study revealed the RA duration increase damaging effect on the condyle and articular eminence even if the patient is under treatment. The RA also leads to anterior displacement of the condyle and this percentage increase with the RA duration.
Keywords: condyle position, rheumatoid arthritis, temporomandibular joint
|How to cite this article:|
Salem WS, Bakry A. The relationship between the temporomandibular joint radiographic changes and the duration of rheumatoid arthritis. Tanta Dent J 2018;15:173-7
|How to cite this URL:|
Salem WS, Bakry A. The relationship between the temporomandibular joint radiographic changes and the duration of rheumatoid arthritis. Tanta Dent J [serial online] 2018 [cited 2018 Dec 9];15:173-7. Available from: http://www.tmj.eg.net/text.asp?2018/15/3/173/243075
| Introduction|| |
Rheumatoid arthritis (RA) considered as a systemic disease, may affect many of the body joints. When the temporomandibular joints (TMJs) is affected with RA, it may produce pain in the tempromandibular joint during opening and closing, difficulties in opening the mouth due to joint stiffness, and anterior open bite ,. The masticatory movement may be hampered in severe cases of the joint disorders .
In the later stages of the RA, the disease affects the TMJ. Larheim et al.  stated that the TMJ is involved in half the patients suffering from RA, while another study by Ogus  recorded a higher percentage of TMJ involvement, as he found a 61% of the cases have this clinical problem in a selected sample of RA patients. Although the clinical and radiographical features of TMJ involvement in RA were described by some investigators ,,, the histopathological features have yet to be clearly defined .
The prevalence of TMJ involvement reported in RA patients has a big range starting from 4.7% and reach 88% ,,. This huge range may be due to many factors as: (a) methods of patient selection, (b) the techniques used for the diagnosis as well as the diagnostic criteria for temporomandibular joint dysfunction (TMD), (c) in many cases the patients is overlooked by a rheumatologists, this mainly takes place when the chief complain is concentrated on other joints. Since delaying the treatment for the TMD may lead to severe complication and disabilities, the early diagnosis, and the appropriate management, is warranted . But unfortunately RA affecting the TMJ presents as a diagnostic challenge to the dentist in the initial stages of disease course . It requires a comprehensive clinical examination with radiological evaluation.
RA patients shows both radiographic and clinical involvement of TMJ ,,,,,,. The condylar erosions have been reported as a typical radiographic feature of this entity . Radiographic examination is of great value for detecting changes in the osseous and soft tissue components. In case of mild osseous changes which is not demonstrated by conventional radiographs can be clearly seen by advanced imaging modalities as cone beam computed tomography (CBCT) and computed tomography (CT) . However, CT is more expensive and the patient is subjected to higher radiation dose. CBCT is therefore widely used .
The extent of TMJ association is by all accounts correlated with the seriousness of RA. The level of rheumatoid factor, C-reactive protein, erythrocyte sedimentation rate, thrombocyte count, and plasma tumor necrosis factor-α have all been noted to correspond with the seriousness of TMD ,,.
In the reports of Yoshida et al.  and Yamakawa et al. , TMD seriousness compared to Steinbrocker's staging of the joints of RA patients. In clinical practice, we may distinguish extreme TMD by evaluating RA involvement. On the off chance that we can figure out what the most vital prescient variables are, at that point enhanced clinical practice might be encouraged.
On the other hand, there is a contentions with respect to the correlation between the duration of RA and TMD. In an early study done by Mayne and Hatch , TMJ pain positively correlated with RA duration. Moreover, Ogus  noted TMJ association all the more as often as possible in patients with greater than or equal to 5 years' span of RA. However, a more recent report by Goupille et al.  discredited this connection. Further investigations are required to determine this issue, this was our aim in this study.
| Patients and Methods|| |
All patients are informed about the purpose and steps of this research and written consents are signed according to the ethics committee of faculty of Dentistry, Menia University. A total of 36 patients were selected from the out-patient clinic in the university hospital in Menia University from the rheumatoid clinic. The patient age range between 45 and 55 years.
The patients were divided into three groups:
- Group 1: 12 patients with RA for at least 10 years and are on a regular treatment and follow-up
- Group 2: 12 patients with RA recently discovered and less than 5 years diseased
- Group 3: 12 normal patients (control group).
CBCT images were performed with a Soredex Scanora 3D unit (Sordex, Tuusula, Finland). For the CBCT imaging the following settings were used 120 kV; 5 mA; Field of view (FOV) 130 × 145 mm (3D XL) standard resolution; orientation landscape; exposure time 4.5 s; voxel dimension 0.35 mm with the patient in a seated position.
The CBCT were evaluated for the following hard tissue changes:
- Erosion in the condyle or articular eminence in localized areas or in the entire mediolateral extension of the joint as shown in [Figure 1] (erosion was defined as: area of decreased density of the cortical bone and the adjacent subcortical bone)
- Flattening of the condyle or articular eminence (flattening was defined as: flat bony contour deviating from the convex form)
- Sclerosis of the condyle or articular eminence in a localized area or in the entire mediolateral extension of the joint (sclerosis was defined as: area with increased density of the cortical bone extending into the subcortical bone)
- Osteophytes as shown in [Figure 2] (defined as: marginal bony outgrowth on the condyle).
The radiographic condylar position in the lateral, central, and medial parts of the joint were measured and subjectively assessed from the sagittal cuts.
The condylar position was subjectively assessed in centric occlusion. From the sagittal cuts, the joint space was measured at the subjectively narrowest locations anteriorly, superiorly, and posteriorly between the condyle and the glenoid fossa as shown in [Figure 3]. On the basis of findings by Hansson et al. , the joint space was classified as:
- Reduced (<1.5 mm)
- Normal (between 1.5 and 4.0 mm)
- Increased (>4.0 mm).
All the measurement were performed using the OnDemand 3D software (Cybermed Inc., Seoul, Republic of Korea).
| Results|| |
For each patient we took two readings (right and left) so we got 24 reading for each group. In group 1, all the cases have at least one of the bones involvement, and group 2, 75% have at least one of the bones involvement while in the control group only 50% of the cases complaining from at least one of the bones involvement which is mainly condyle erosion. The frequency of the bony changes was illustrated in [Chart 1] and [Chart 2].
From the previous charts, it was clear that group 1 patients show all the types of bony changes, and group 2 show most of the changes while group 3 did not show most of the changes, just the condyle erosion and eminence flattening.
Regarding the space between the condyle and the glenoid fossa in group 1 we found reduced space in 50, 16.67, and 16.67% in the anterior (the condyle positioned anteriorly), superior (the condyle positioned in centric position) and posterior joint space (the condyle positioned posteriorly), respectively, and no increased joint space in the three areas. Group 2 has different results as the reduced space percentage was: 33.33, 8.33, and 66.67% in the anterior, superior, and posterior joint space, respectively, and in the same group there is increase in the superior joint space by 8.33%. While group 3 shows a lower percentages in the reduced space (4.17, 4.17, and 0% in the anterior, superior, and posterior joint space, respectively) and no increased in any one of the spaces. The summary of the records are shown in [Chart 3].
| Discussion|| |
When comparing the results between the three groups, group 1 has the highest percentage (100%) of skeletal changes in the condyle and the articular eminence, followed by group 2 (75%) and the least percentage was found in group 3, this results is higher than the previous studies ,,,,.
Larheim et al.  evaluated patients with RA of comparable age and sex distribution and detected radiographic hard tissue changes in 55% of them while Oynther et al.  detected the bony changes in 71%. The different in our results specially for group 1 may be due to the long duration of this group as the patients of this group complaining from RA for more than 10 years. Second reason to explain the difference in results that we used CBCT which is more accurate in evaluating minute skeletal changes .
Also Larheim et al.  classification of the skeletal changes were based on the degree of bone destruction (erosion) dividing them into: mild erosion, moderate erosion, or severe erosion, without recording any other changes (flattening, sclerosis, or osteophytes). While in our study we used a more detailed radiographic classification.
In our study the selected classification for the radiographic finding was based on the previous studies. In previous radiographic investigations of patients with TMJ internal derangement and osteoarthritis, sclerosis and flattening of the eminence , as well as osteophytes  have been the most common hard tissue changes. Cholitgul et al.  when compare the radiographic finding regarded erosions as reliable evidence, whereas sclerosis was viewed as unreliable. On the other hand, tomographic findings of sclerosis were frequently associated with arthroscopic features of degenerative changes in patients with TMJ internal derangement and osteoarthritis .
Regarding the condyle position (the joint space), in group 1 the condyle is anteriorly in (50%) followed by group 2 (33.33%) then group 1 (4.17%) this results is going with Syrjainen  who reported that the condylar position was mainly anterior in patients with RA with panoramic radiography. But in group 2 the results is not the same as it is mainly centric 66.67% followed by anterior displacement 33.33%. The difference may be due to the limitations of panoramic radiography with respect to TMJ abnormalities.
Oynther et al.  used the conventional tomography to locate the condylar position in RA and found that the position is anterior and concentric in the same frequencies. Which is not the same as group 1 or group 2 results, but Oynther et al.  did not mention the RA duration, but if we add the two groups together we will found that the result (anterior 42% and centric 49%) of the present study will be almost similar to Oynther et al. .
Reduced joint space was more frequent more than increased joint space this can be explained as the RA primarily affects the synovium with an in growth of soft tissue that obstruct the joint space. In an arthroscopic study, Holmlund et al.  found much higher frequencies of fibrosis and adhesions in patients with RA compared with patients with chronic locking and osteoarthritis.
| Conclusion|| |
The present study revealed the RA duration increase damaging effect on the condyle and articular eminence (erosion, flattening, sclerosis, and osteophytes) even if the patient is under treatment. The RA also leads to anterior displacement of the condyle and this percentage increase with the RA duration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]