|IMAGES IN RHEUMATOLOGY
|Year : 2016 | Volume
| Issue : 3 | Page : 174-176
Temporomandibular joint in rheumatoid arthritis: Clinicoradiological aspects
S Jayachandran, Priyanka Khobre
Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||11-Aug-2016|
Dr. Priyanka Khobre
Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Keywords: Cone-beam computed tomography, rheumatoid arthritis, temporomandibular joint
|How to cite this article:|
Jayachandran S, Khobre P. Temporomandibular joint in rheumatoid arthritis: Clinicoradiological aspects. Indian J Rheumatol 2016;11:174-6
A 60-year-old female reported to the Department of Oral Medicine and Radiology with chief complaint of pain at preauricular region of both sides since 2 months. The patient also gave history of stiffness on opening the mouth. The patient revealed history of rheumatoid arthritis (RA) since 1 year and was on analgesics, anti-inflammatory, and corticosteroids for the same. The patient was seropositive for rheumatoid factor and anti-citrullinated peptide antibodies. On examination, mouth opening was normal with interincisal distance of 42 mm and there was tenderness on palpation at temporomandibular joint (TMJ) region bilaterally. Crepitus was heard on left TMJ region during opening the mouth.
For precise evaluation of condyle, the patient was subjected to cone-beam computed tomography (CBCT) with Carestream CS 9300 of 8 by 8 fields of view and TMJ was examined in sagittal, coronal, axial, and three-dimensional reconstructed view. Sagittal view of right TMJ revealed posterior positioning of condyle in glenoid fossa with decrease width of joint space and extensive erosion posteriorly [Figure 1] while left TMJ showed prominent osteophyte from superior aspect of condyle with flattening of temporal component [Figure 2].
|Figure 1: Cone-beam computed tomography showing sagittal view of right temporomandibular joint|
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|Figure 2: Cone-beam computed tomography showing sagittal view of left temporomandibular joint|
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Coronal view of right TMJ showed surface erosion with reduced joint space and flattening on superolateral aspect of condyle and subchondral sclerosis evident on medial aspect [Figure 3] whereas left TMJ showed bony erosion by the pannus on superior aspect of condyle with subchondral cyst on medial aspect along with evidence of erosion of temporal component [Figure 4]. All these features were consistent of RA. Labial minor salivary gland biopsy was performed. Histopathology confirmed them as apparently normal minor salivary glands with multiple foci of chronic inflammatory infiltrate, the diagnostic feature of secondary Sjogren's syndrome (SS).
|Figure 3: Cone-beam computed tomography showing coronal view of right temporomandibular joint|
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|Figure 4: Cone-beam computed tomography showing coronal view of left temporomandibular joint|
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RA is a chronic condition which causes the destruction of articular surface and subarticular bone because of inflammation of synovial membrane. It is a systemic autoimmune disease of unknown cause.  RA has prevalence of 1% worldwide, with female predominance (3:1), and affects mainly between 35 and 55 years of age group.  TMJ complaints are usually present in almost 50% of the patients with RA.  Clinical symptoms are pain at preauricular region, morning stiffness of joint usually lasting for 30 min, sound and movement impairment.  Erosion of the components of TMJ can be seen in two-third of the patients suffering from RA.  CBCT is a remarkable imaging modality which can find out bony changes at TMJ, which includes flattening of condylar head, erosion of articular and subarticular bone, reduction in the width of joint space, pencil head deformation of condylar head, resorption, and subchondral cyst. , Reduced joint space is due to the destruction of disc by the pannus.  Magnetic resonance imaging (MRI) can document both osseous and soft tissue abnormalities of the TMJ in early stages of the disease. It is mainly useful for the evaluation of internal derangement of the TMJ.  In our case, CBCT best demonstrated the advanced bony changes of TMJ in RA. Hence, the patient was not subjected to MRI. Management of pain and inflammation is by the use of first-line drugs, such as aspirin and cortisone. Reducing disease progression and promote remission is by the use of second-line drugs (disease-modifying anti-rheumatic drugs), such as hydroxychloroquine and methotrexate.  Studies have shown that 4-31% of RA will be having SS.  Dry mouth in these patients can cause caries, ulceration, and periodontal problems. The patient was emphasized to maintain oral hygiene using tooth brushes and chlorhexidine mouth rinses and saliva substitutes to avoid oral complications. Hence, these patients require multidisciplinary approach with rheumatologist and oral medicine specialist in management of RA with SS to improve the quality of life.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]