Management of Orofacial Manifestations of Juvenile Idiopathic Arthritis: Interdisciplinary Consensus‐Based Recommendations

Abstract

Involvement of the temporomandibular joint (TMJ) is common in juvenile idiopathic arthritis (JIA). TMJ arthritis can lead to orofacial symptoms, orofacial dysfunction, and dentofacial deformity with negative impact on quality of life. Management involves interdisciplinary collaboration. No current recommendations exist to guide clinical management. We undertook this study to develop consensus-based interdisciplinary recommendations for management of orofacial manifestations of JIA, and to create a future research agenda related to management of TMJ arthritis in children with JIA. Recommendations were developed using online surveying of relevant stakeholders, systematic literature review, evidence-informed generation of recommendations during 2 consensus meetings, and Delphi study iterations involving external experts. The process included disciplines involved in the care of orofacial manifestations of JIA: pediatric rheumatology, radiology, orthodontics, oral and maxillofacial surgery, orofacial pain specialists, and pediatric dentistry. Recommendations were accepted if agreement was >80% during a final Delphi study. Three overarching management principles and 12 recommendations for interdisciplinary management of orofacial manifestations of JIA were outlined. The 12 recommendations pertained to diagnosis (n = 4), treatment of TMJ arthritis (active TMJ inflammation) (n = 2), treatment of TMJ dysfunction and symptoms (n = 3), treatment of arthritis-related dentofacial deformity (n = 2), and other aspects related to JIA (n = 1). Additionally, a future interdisciplinary research agenda was developed. These are the first interdisciplinary recommendations to guide clinical management of TMJ JIA. The 3 overarching principles and 12 recommendations fill an important gap in current clinical practice. They emphasize the importance of an interdisciplinary approach to diagnosis and management of orofacial manifestations of JIA.

Reliability and measurement error of anterior maximum voluntary bite force in children with juvenile idiopathic arthritis and healthy children

“…The SDC in our study indicated that values above 11.4N in children with JIA might be a clinical relevant change over time. In further studies the founded SDC can be useful for longitudinal monitoring of the AMVBF in children with JIA, as this is suggest as an optimal management in patients with JIA [13]. Wide ranges of LoA were found in both children with JIA and in healthy children.…”

“…To appraise such a reduction, it is necessary to gain more insight in the reliability and smallest detectable change (SDC) of the maximum bite force in children with JIA and in healthy children. Monitoring the TMJ in a longitudinal evaluation is advised as an optimal management in patients with JIA [13]. Clinicians may interpret changes over time regarding bite force easier than absolute values.…”

Challenges in treating juvenile idiopathic arthritis

“…Recent advances have focused on clinical and imaging monitoring of orofacial health in JIA, with attention to early diagnosis and intervention to prevent or mitigate the complications of TMJ arthritis in JIA [16–18,19 ▪ ,20–22]. Another recent development is the publication of interdisciplinary, consensus-based, standardization of terminology and method of assessment of TMJ involvement [2,23,24 ▪▪ ]. The proposal of terminology provides an important platform for communication across healthcare providers involved in JIA-associated TMJ arthritis management and research.…”

“…The proposal of terminology provides an important platform for communication across healthcare providers involved in JIA-associated TMJ arthritis management and research. For the last 5 years, efforts have been combined which led to the publication of the first interdisciplinary consensus-based guidelines for management of TMJ arthritis and the related orofacial manifestation in JIA in 2023 [24 ▪▪ ]. In addition to specific recommendations for the diagnosis, management, and treatment of orofacial manifestations of JIA, these recommendations also come with a clear recognition of the need for a multidisciplinary approach to care, involving rheumatologists, pediatric dentists, orthodontists, oral surgeons, specialized radiologists, and physical therapists, among others.…”

“…In addition to specific recommendations for the diagnosis, management, and treatment of orofacial manifestations of JIA, these recommendations also come with a clear recognition of the need for a multidisciplinary approach to care, involving rheumatologists, pediatric dentists, orthodontists, oral surgeons, specialized radiologists, and physical therapists, among others. The objectives of the combined efforts are early identification of TMJ involvement, which can facilitate prompt initiation of relevant and timely treatment from a broad range of healthcare providers to prevent or mitigate the various aspects of JIA-related complications [24 ▪▪ ].…”