Abstract
The aim of the present study was to estimate the prevalence of temporomandibular joint (TMJ) symptoms and clinical findings in Albanian patients with rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis. The authors examined 124 consecutive hospitalized patients (88 with rheumatoid arthritis, 22 with systemic lupus erythematosus and 14 with systemic sclerosis) and 124 age- and gender-matched healthy controls using a questionnaire and an oro-facial clinical examination for assessing the presence of TMJ sounds, pain in the TMJ area, tenderness of masticatory muscles and limited mouth opening. Significantly more patients (67%) reported TMJ symptoms than controls (19%). A significantly higher proportion of patients (65%) exhibited clinical signs of temporomandibular dysfunction compared with controls (26%). The most frequent findings in rheumatoid arthritis were temporomandibular sounds and pain. Pain was found in a significantly higher proportion in patients with systemic lupus erythematosus compared with controls. Difficulty and limitation in mouth opening were observed in the majority of systemic sclerosis patients, and in only a minority of rheumatoid arthritis patients. This study supports the notion that TMJ examination should be encouraged in the rheumatology setting and clinicians should be able to provide pain management and patient support.
Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are amongst the main systemic rheumatic diseases. Their aetiology and pathogenesis is multifactorial and complex. It may involve genetic predisposition, immune system disturbances and environmental factors. Hormones may also play a role, as the diseases affect women more than men .
RA is characterized by symmetric, erosive synovitis, which may result in joint deformity and disability . Being a synovial joint, the temporomandibular joint (TMJ) is subject to the same disorders affecting other synovial joints, including RA. TMJ involvement in RA was first scientifically described in 1874 by G arrod . The frequency of its recognition in later studies ranges widely, from 5 to 86%, depending, in part, on diagnostic criteria, the population studied, and the means of TMJ assessment . The most common clinical findings are pain in the TMJ area and tenderness of the masticatory muscles, joint sounds and limited joint function .
SLE may display a broad spectrum of clinical manifestations with multiple end-organ involvement. It is well known that a great proportion of patients present with arthritis , but TMJ findings in SLE are given far less attention than in RA. J onsson et al. found that TMJ involvement was common in SLE . Although most studies of SLE arthritis in joints other than the TMJ have shown minimal radiographic evidence of bone erosion , erosion of the TMJ condyles similar to changes seen in RA patients was noted in 8 (11%) of the patients investigated by J onsson et al.
There are few case reports related to TMJ findings in SSc, indicating resorption of the condylar process . It is suggested that bone resorption is due to pressure ischaemia (from tight skin and muscle atrophy) and vascular ischaemia. It is likely that atrophic and fibrotic alterations of the synovia may also contribute to TMJ involvement in SSc.
The aim of the present study was to estimate the prevalence of symptoms and clinical findings related to TMJ in Albanian patients with RA, SLE and SSc and to compare the findings with those in age- and gender-matched healthy subjects.
Materials and methods
The patient group consisted of 124 consecutive hospitalized patients. 88 patients had RA, 22 had SLE, and 14 patients had SSc. All patients with RA met the American Rheumatism Association (ARA) revised criteria for the classification of RA , patients with SLE met the revised ARA criteria for the classification of SLE , and SSc patients fulfilled the ACR and L e R oy et al. criteria.
The controls were respondents to a cross-sectional general health survey, which was carried out on individuals randomly selected from the Tirana population register by the Albanian Institute of Statistics. Respondents consented to a home visit and the authors obtained data from 124 subjects, each being matched for age and gender with one of the patients, and with no history of previous immune system/autoimmune disorder, or history of immunosuppressive treatment.
Ethical approval was given by the Faculty of Medicine Committee, University of Tirana, and patients and controls were included during the period from May 2008 to June 2009.
A detailed medical history was taken from all patients and controls, which included RA, SLE and SSc history, duration of disease (defined as years since diagnosis), and complications, a list of other medical diagnoses, as well as medical treatment. Demographic details, years of education and urban versus rural residence were also recorded.
Examination of TMJ
The TMJ of the subjects was examined according to WHO criteria (1997). TMJ symptoms were recorded for all patients and controls by means of a questionnaire. The questions concerned TMJ sounds (including clicking and crepitation), pain during occlusion or mouth opening, unprovoked pain from the TMJ area, and difficulty in mouth opening. A single positive statement to any of the questions classified a subject as symptomatic. Patients were also asked if TMJ symptoms occurred in relation to their self-perceived disease severity, and if they had occurred once or periodically since the disease was diagnosed.
The patient and control subjects underwent a routine oro-facial examination to detect signs of TMJ involvement. The examination included palpation of the masticatory muscles and TMJ. Tenderness was recorded whenever palpation produced a palpation reflex or when the patient reported subjective discomfort. The following masticatory muscles were palpated bilaterally: the posterior, middle and anterior part of the temporalis muscle, insertion and origin of the masseter muscle, body of the masseter muscle, lateral and medial pterygoid muscle. TMJ sounds on mandible movement, such as clicking (reciprocal or other) and crepitation, were assessed by palpation on each side separately. Maximum mouth opening (defined as the distance between the incisal edge of the central maxillary incisor that is most vertically oriented and the labioincisal edge of the opposing mandibular incisor during maximal opening, added the amount of vertical incisor overlap) was measured to the nearest millimetre with a ruler. Maximal mouth opening was considered reduced if it measured < 40 mm . A single positive finding classified a subject as having objective signs of TMJ dysfunction. Clinical examination included assessment of lateral or anterior open bite. The collection of TMJ data was conducted by a single examiner (A.A.) trained in the use of the assessment instruments used in the study.
Statistical analysis
Statistical analysis of the differences between the patient and the control group were carried out using the Mc Nemar test for paired samples. The level of significance was set at P < 0.05. The associations between variables were analysed using the χ 2 test. The data were analysed using the SPSS/PC software version 17.0 (SPSS Inc., Chicago, IL, USA).
Results
124 RA, SLE, and SSc patients and 124 control subjects were examined. 85% of patients and 85% of controls were female. In the patient group the mean age was 49.3 ± 10.0 (range 21–73) years for females and 52.7 ± 10.9 (range 25–70) years for males. The mean age of the control subjects was 50.1 ± 12.2 (range 21–77) years for females and 50.1 ± 12.6 (range 26–72) years for men. The mean duration of disease for the patient group was 9.1 ± 8.1 (range 0.3–37) years. The characteristics of each patient group and controls are shown in Table 1 .
| Rheumatoid arthritis ( n = 88) | Systemic lupus erythematosus ( n = 22) | Systemic sclerosis ( n = 14) | Controls ( n = 124) | |
|---|---|---|---|---|
| Gender (M/F) | 17/71 | 0/22 | 2/12 | 19/105 |
| Mean age (SD), years | 52.5 (8.5) | 40.2 (11.6) | 47.6 (8.3) | 50.0 (12.2) |
| Mean duration of disease (SD), years | 9.5 (8.2) | 6.6 (7.0) | 9.4 (8.1) | – |
| Medication (no. of subjects, %) | ||||
| Oral steroids | 72 (81.8) | 20 (90.9) | 12 (85.7) | – |
| NSAIDs | 66 (75.0) | 15 (68.2) | 9 (64.3) | 4 (3.2) |
| DMARDs | 61 (69.3) | 13 (59.1) | 4 (28.6) | – |
| Monotherapy | ||||
| MTX | 45 (51.1) | 1 (4.5) | 4 (28.6) | |
| HCQ | 6 (6.8) | 9 (40.9) | – | |
| Rituximab | 1 (1.1) | – | – | |
| Combination therapy | ||||
| MTX + HCQ | – | 3 (13.6) | – | |
| MTX + LFL | 3 (3.4) | – | – | |
| MTX + Rituximab | 4 (4.5) | – | – | |
| LFL + Rituximab | 1 (1.1) | – | – | |
| MTX + LFL + Rituximab | 1 (1.1) | – | – | |
Medical treatment in both groups
104 (84%) of the patients overall were treated with oral steroids, 90 (73%) with non-steroidal anti-inflammatory drugs (NSAIDs), 78 (63%) with disease-modifying anti-rheumatic drugs (DMARDs), either as monotherapy, or as combination therapy ( Table 1 ). The most frequent oral steroids and DMARDs given were methylprednisolone and methotrexate, respectively. 56 (45%) of the patients were treated with other drugs, including heart and vascular drugs, gastrointestinal drugs, or hypoglycaemic drugs.
30 (24%) of the control subjects were medically treated with drugs, mainly antihypertensives and beta-blockers, and 10 were using over-the-counter analgesics. Significantly more patients (77%) were using analgesic drugs than were the control subjects (8%), P = 0.000.
TMJ involvement
The proportion of symptomatic subjects was higher in the patient group (67%) than in the control group (19%), P = 0.000. The frequency distributions were significantly different for TMJ sounds ( P = 0.000), pain from the TMJ area and/or during mandibular movement ( P = 0.000), and difficulty in opening mouth ( P = 0.000). The most commonly reported symptom in patients was ‘TMJ sounds’, present in 60 (48%) patients overall, or in 72% of the subgroup classified as ‘symptomatic’, and ‘pain’ reported by 59 (48%) of the patients overall, or by 71% of the subgroup classified as ‘symptomatic’. 55% of the symptomatic patients reported more than one TMJ symptom, and one-quarter reported all three.
The breakdown of patients’ TMJ symptoms by type of disease is given in Table 2 . All three symptoms were reported by RA patients more often than by matched controls, especially TMJ sound, reported by half of RA patients. TMJ symptoms were also more prevalent in the SLE group than in matched controls, especially pain, but difference in the difficulty in mouth opening was not statistically significant. The majority of SSc patients reported pain and difficulty in mouth opening. Although half of the SSc patients reported TMJ sounds as well, no statistically significant difference was found with their matched controls. Crepitation was reported by only 5 RA patients and one patient with SLE.
| No. of RA patients (%) n = 88 | No. of SLE patients (%) n = 22 | No. of SSc patients (%) n = 14 | No. of controls (%) n = 124 | |
|---|---|---|---|---|
| Reported symptoms | ||||
| TMJ sounds | 45 (51.1) ** | 8 (36.4) * | 7 (50) | 18 (14.5%) |
| Pain | 36 (40.9) ** | 11 (50) * | 12 (85.7) * | 10 (8.1%) |
| Difficulty in opening mouth | 14 (15.9) * | 6 (27.3) | 12 (85.7) * | 3 (2.4%) |
| At least one symptom | 57 (64.8) ** | 13 (59.1) * | 13 (92.9) * | 24 (19.4) |
| Clinical findings | ||||
| TMJ sounds | 44 (50) ** | 8 (36.4) | 5 (35.7) | 27 (21.8%) |
| Pain | 24 (27.3) ** | 6 (27.3) * | 5 (35.7) | 2 (1.6%) |
| Reduced mouth opening | 7 (8) | 1 (4.5) | 11 (78.6) * | 6 (4.8%) |
| At least one clinical finding | 56 (63.6) ** | 11 (50) | 13 (92.9) * | 32 (25.8) |
| At least one symptom or clinical finding | 65 (73.9) ** | 14 (63.6) | 14 (100) * | 39 (31.5) |
* Statistically significant difference between patient and matched controls, P < 0.05.
** Statistically significant difference between patient and matched controls, P < 0.001.
A higher proportion of patients (65%) had objective signs of TMJ dysfunction compared with controls (26%), P = 0.000. All three TMJ signs were significantly found more in the patient group compared with controls; TMJ sounds ( P = 0.000), pain on palpation ( P = 0.000), and reduction in maximum mouth opening ( P = 0.007). The most common sign in patients was ‘TMJ sounds’, found in 57 (46%) of the patients overall, or in 71% of the subgroup classified as having objective signs of TMJ dysfunction. The majority of patients had only one sign, but 5 of them had all three.
The proportion of patients with at least one TMJ finding, either as a symptom, or as a clinical finding, was higher in the patients group (75%) than in controls (32%) ( P = 0.000).
The breakdown of patients TMJ signs by type of disease is given in Table 2 . Sounds occurred frequently in all three patients groups, but the difference between patients and controls was statistically significant only for the RA group. Crepitation was present in 12 (14%) of the RA patients, but was uncommon in the other study groups. The proportion of patients with pain in palpation was significantly higher in the RA and SLE groups compared with controls, but no difference was found between SSc patients and controls. Reduction in maximum mouth opening was found in a higher proportion in SSc patients than in controls, but no difference was found between RA or SLE patients and controls. One RA patient had developed anterior open bite, and panoramic radiography revealed erosion in both condyles.
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