Skip to main content

Main menu

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • 50th Volume Reprints
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • Privacy/GDPR Policy
    • Accessibility
  • Contact Us
  • JRheum Supplements
  • Services

User menu

  • My Cart
  • Log In

Search

  • Advanced search
The Journal of Rheumatology
  • JRheum Supplements
  • Services
  • My Cart
  • Log In
The Journal of Rheumatology

Advanced Search

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • 50th Volume Reprints
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • Privacy/GDPR Policy
    • Accessibility
  • Contact Us
  • Follow Jrheum on BlueSky
  • Follow jrheum on Twitter
  • Visit jrheum on Facebook
  • Follow jrheum on LinkedIn
  • Follow jrheum on YouTube
  • Follow jrheum on Instagram
  • Follow jrheum on RSS
Research ArticlePediatric Rheumatology

Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies

Peter Stoustrup, Marinka Twilt, Lynn Spiegel, Kasper Dahl Kristensen, Bernd Koos, Thomas Klit Pedersen, Annelise Küseler, Randy Q. Cron, Shelly Abramowicz, Carlalberta Verna, Timo Peltomäki, Per Alstergren, Ross Petty, Sarah Ringold, Sven Erik Nørholt, Rotraud K. Saurenmann and Troels Herlin on behalf of the euroTMjoint Research Network
The Journal of Rheumatology March 2017, 44 (3) 326-333; DOI: https://doi.org/10.3899/jrheum.160796
Peter Stoustrup
From the Section of Orthodontics, and the Department of Oral and Maxillofacial Surgery, and the Department of Pediatrics, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Pediatrics, Division of Rheumatology, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta; Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; the Specialist Oral Health Center for Western Norway, Rogaland, Stavanger, Norway; Department of Orthodontics, University of Rostock, Rostock, Germany; Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama; Oral and Maxillofacial Surgery and Pediatrics, Emory University, and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA; Clinic for Orthodontics and Pediatric Dentistry, University Center for Dental Medicine, University of Basel, Basel, Switzerland; Field of Dentistry, School of Medicine, University of Tampere and Oral and Maxillofacial Unit, Tampere University Hospital, Tampere, Finland; Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Scandinavian Center for Orofacial Neurosciences, Malmö, Sweden; Division of Pediatric Rheumatology, Department of Pediatrics, BC Children’s Hospital, Vancouver, British Columbia, Canada; Seattle Children’s Hospital; Seattle, Washington, USA; Cantonal Hospital Wintherthur, University of Zürich, Zürich, Switzerland.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: pstoustrup@odont.au.dk
Marinka Twilt
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lynn Spiegel
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kasper Dahl Kristensen
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bernd Koos
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Thomas Klit Pedersen
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Annelise Küseler
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Randy Q. Cron
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shelly Abramowicz
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Carlalberta Verna
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Timo Peltomäki
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Per Alstergren
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ross Petty
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sarah Ringold
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sven Erik Nørholt
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rotraud K. Saurenmann
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Troels Herlin
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Supplemental
  • Info & Metrics
  • References
  • PDF
PreviousNext
Loading

Abstract

Objective. To develop international consensus-based recommendations for the orofacial examination of patients with juvenile idiopathic arthritis (JIA), for use in clinical practice and research.

Methods. Using a sequential phased approach, a multidisciplinary task force developed and evaluated a set of recommendations for the orofacial examination of patients with JIA. Phase 1: A Delphi survey was conducted among 40 expert physicians and dentists with the aim of identifying and ranking the importance of items for inclusion. Phase 2: The task force developed consensus about the domains and items to be included in the recommendations. Phase 3: A systematic literature review was performed to assess the evidence supporting the consensus-based recommendations. Phase 4: An independent group of orofacial and JIA experts were invited to assess the content validity of the task force’s recommendations.

Results. Five recommendations were developed to assess the following 5 domains: medical history, orofacial symptoms, muscle and temporomandibular joint function, orofacial function, and dentofacial growth. After application of data search criteria, 56 articles were included in the systematic review. The level of evidence for the 5 recommendations was derived primarily from descriptive studies, such as cross-sectional and case-control studies.

Conclusion. Five recommendations are proposed for the orofacial examination of patients with JIA to improve the clinical practice and aid standardized data collection for future studies. The task force has formulated a future research program based on the proposed recommendations.

Key Indexing Terms:
  • JUVENILE IDIOPATHIC ARTHRITIS
  • OROFACIAL EXAMINATION
  • TEMPOROMANDIBULAR JOINT

Temporomandibular joint (TMJ) inflammation and deformation are seen in a substantial number of patients with juvenile idiopathic arthritis (JIA). The reported prevalence of TMJ arthritis in JIA reaches 87% depending on the diagnostic criteria and methodology used1,2,3. TMJ inflammation may interfere with optimal joint function and may cause abnormal clinical symptoms, findings, and dysmorphic alterations in dentofacial growth and development4–10,11–15. Therefore, routine orofacial examinations constitute an important part of the general clinical assessment of patients with JIA, to ensure diagnosis of TMJ arthritis, evaluate treatment options, assess response to therapy, and provide ongoing monitoring of a patient with existing TMJ arthritis.

Within the past decade, increased attention has been paid to the consequences of TMJ arthritis in patients diagnosed with JIA. However, no standardized criteria for history-related items and functional clinical orofacial outcome measures have been established. Therefore, there are significant discrepancies in how clinical orofacial examinations are conducted. Recent systematic literature reviews have confirmed the need for standardized guidelines for the clinical orofacial examination to provide the opportunity for future interstudy comparisons16,17.

The observed interstudy discrepancy in clinical orofacial examinations may be explained in part by differences in the professional training of the medical and dental practitioners conducting the studies. Specialists, including rheumatologists, maxillofacial surgeons, orthodontists, and orofacial pain specialists, use diverse methods and examination tools to perform orofacial examinations. Many of these techniques have not been validated in patients with JIA. Further, many published studies are retrospective, and extract nonstandardized clinical data from charts, which may lead to biased conclusions. The objective of our present work is to develop international, interdisciplinary, consensus-based, and evidence-based recommendations for domains of importance, reflecting the minimum standard of care during routine clinical orofacial evaluations performed by rheumatologists and dentists. These domains may also be used as outcome measures in future clinical studies involving orofacial assessment in patients with JIA.

MATERIALS AND METHODS

Our study was conducted by members of the euroTMjoint network. The euroTMjoint group was founded in Oslo, Norway, in 2010 to establish an international, multidisciplinary research network to study TMJ arthritis in JIA. Today, the network is a multinational, independent, open research group representing a substantial number of the research groups who have published within this area18.

This current work was initiated in 2012, when an international expert task force was established. The group consisted of 3 pediatric rheumatologists, 3 orthodontists, and 2 orofacial pain specialists. The members represent 6 international centers from Europe and North America.

Establishment of provisional recommendations for the clinical orofacial examination

Based on a systematic literature search16 and expert-based consensus on clinical orofacial examination guidelines, the members of the task force identified and proposed 20 clinical outcome variables for the assessment of patient symptoms, and 12 clinical outcome variables for the assessment of TMJ arthritis-related signs. The primary goal was to recommend domains to monitor patients with existing TMJ arthritis, and to identify outcome variables within those domains to assess response of TMJ arthritis to therapy.

All members on the euroTMjoint mailing list (n = 83) were invited to participate in an online Delphi survey with the aim of rating the importance of each of the proposed outcome variables. The participants were encouraged to suggest additional outcome variables during each Delphi survey round, leading to 2 additional outcome variables for assessment of TMJ arthritis-related signs: effect of pain on orofacial function, and assessment of occlusion in the sagittal plane. The results from the first poll were summarized and were provided to the participants for the next iteration. The importance of each of the proposed outcome variables was assessed twice based on a numerical scale (0 = not important, 10 = of utmost importance). All proposed outcome variables were subcategorized based on their ratings of importance: “high importance” (score ≥ 8), “moderate importance” (6 ≤ score < 8), “low importance” (score < 6). The results of the Delphi survey were used as a guide to structure the discussions during the consensus meetings.

The task force was composed of 8 members who met for consensus meetings on 2 occasions: in April 2013 in Aarhus, Denmark, and in April 2014 in Tampere, Finland. Based on the outcome of the Delphi survey, the members established 5 general provisional recommendations by nominal group technique regarding monitoring patients with JIA who have TMJ arthritis.

Literature review

A second literature review was conducted to assess the strength and content validity of each of the 5 recommendations. We included all publications that dealt with diagnosis and monitoring of patients with JIA and TMJ arthritis. Four research questions (RQ) were established and applied to each of the 5 provisional recommendations.

The recommendations for monitoring patients with JIA who have TMJ arthritis were the following: (RQ1) What is the general validity of the recommendation? (RQ2) What is the level of evidence of the recommendation?

The recommendations for diagnosing TMJ arthritis were the following: (RQ3) What is the diagnostic validity of the recommendation? (RQ4) What is the level of evidence of the recommendation with respect to diagnostic validity?

The systematic literature search of relevant articles was performed on June 26, 2014. Two independent reviewers (PS and MT) screened titles and abstracts of the identified citations. Potentially relevant articles were reviewed in full text using predetermined inclusion and exclusion criteria (Supplementary Material 1, search strategy, and Supplementary Material 2, data extraction criteria, available with the online version of this article). The level of evidence (RQ2 and RQ4) was graded for each of the final recommendations in accordance with the quality of the included studies19.

Final recommendations and level of evidence

Following the literature review, 12 experts within the field of TMJ arthritis in JIA were invited to assess the strength and content validity of the recommendations. Experts were identified based upon the following principles: clinical expertise, research activity, educational background, and general contribution to the field of TMJ arthritis in JIA. The identified group of experts consisted of pediatric rheumatologists (n = 4), orthodontists (n = 5), maxillofacial surgeons (n = 2), and orofacial pain specialist (n = 1). The invited experts were asked to assess the general validity and the diagnostic validity for each of the 5 recommendations by examining the results of the literature review and scoring the perceived strength of the recommendation (SOR) for each of the 5 provisional recommendations using a 0–10 numerical scale (0 = do not recommend, 10 = highly recommend). In addition, they were invited to comment on the provisional recommendations and the literature review with suggestions for improvements in clarity or addressing redundancies. A final set of recommendations was proposed based on the consensus of the task force and invited experts. Ethical approval was not required for any parts of the study.

RESULTS

Forty members on the euroTMjoint mailing list participated in the Delphi study (48% response rate). The professional backgrounds of participants were orthodontists (17/40, 42.5%), orofacial pain specialists (11/40, 27.5%), pediatric rheumatologists (9/40, 22.5%), maxillofacial surgeons (2/40, 5%), and a radiologist (1/40, 2.5%). The participants’ self-assessed median score of expertise in clinical TMJ examination was 8 (interquartile range 7–9) based on a numerical scale (0 = minimal experience, 10 = very experienced). The results of the Delphi survey revealed 17 outcome variables that were rated to be of “high” importance (median ≥ 8; Table 1); 10 were symptom-related and 7 were related to clinical findings. The residual outcome variables rated as “moderate” and “low” importance are presented in Supplementary Material 3 (available with the online version of this article).

View this table:
  • View inline
  • View popup
Table 1.

Clinical outcome variables rated of “high importance” in the Delphi survey (median ≥ 8, on a numerical scale, 0 = not important, 10 = of utmost importance); presented together with second-round median scores and 25th/75th percentiles. First-round Delphi scores are reported in brackets.

The literature search resulted in 1144 citations, of which 495 were duplicates. After removal of duplicates, a total of 649 unique citations were included in the title and abstract screening process, which left 84 articles for full text review after exclusion of 565 unique citations (for search details, see Supplementary Material 4, available with the online version of this article). During the full-text review, 29 articles were excluded, leaving 55 articles for inclusion. An additional hand search of relevant articles identified 1 article, resulting in a total of 56 articles complying with the search criteria for research questions 1 and 2. The evidence from these articles was used to answer research questions 1 and 2 for each of the 5 recommendations. After applying data search criteria for the third and fourth research questions, 27 articles were included (Supplementary Material 4). Studies presenting with the highest level of evidence were given more consideration when answering the research questions. The number of articles identified for each of the recommendations is listed in Table 2 (for list of articles, see Supplementary Material 5).

View this table:
  • View inline
  • View popup
Table 2.

Recommendations for the clinical orofacial examination of patients with juvenile idiopathic arthritis (JIA).

Results from the literature review and suggestions from the invited group of TMJ experts led to minor changes in the 5 provisional recommendations. The 5 final consensus-based recommendations are listed in Table 2 together with the SOR and the associated level of evidence. A brief summary of the supporting evidence for each of the final recommendations is available below. A more detailed description of the supporting evidence for each of the 5 recommendations is available in Supplementary Material 6 (available with the online version of this article).

  • Recommendation 1. The medical history should include sex, age at time of examination, JIA category, disease duration, previous/current medications, previous/current orthodontic treatment, and disease activity.

The majority of all eligible articles included background information1,6,7,8,12,13,14,20–58. The information varied among the studies. The most consistently included items were age at time of examination, JIA category, and disease duration. Information about medication or disease activity level was not consistently reported across the literature. A number of studies identified various demographic, clinical, and radiologic factors associated with the presence and severity of TMJ arthritis (Supplementary Material 5, available with the online version of this article). The task force therefore considers it important to standardize the medical history, and correlate this data with the orofacial examination findings. The level of evidence and strength of recommendation 1 is available in Table 2.

Recommendation 1 does not include imaging results in the medical history, because it is beyond the scope of this work to include recommendations on imaging modalities. However, the task force considers it important to assess clinical findings in the context of previous/current TMJ imaging results.

  • Recommendation 2. The patient should be asked about the presence of orofacial symptoms. This should include location, intensity, frequency, character, and situations in which the symptoms occur.

Forty of the eligible articles included some type of assessment of orofacial symptoms6,8,9,12,13,14,20,21,23–26,32–45, 47,52,54–65. Extrapolated evidence from the literature indicates a significantly higher prevalence of orofacial symptoms in patients with JIA compared with non-JIA controls. Newly diagnosed patients with JIA and TMJ involvement are often asymptomatic but the prevalence of orofacial symptoms increases significantly with disease duration and age of the patient (Supplementary Material 6, available with the online version of this article). The level of evidence and strength of recommendation 2 is available in Table 2.

Orofacial symptoms such as pain are traditionally used as an important outcome measure in studies, even though pain is a poor predictor of the presence of TMJ arthritis. Nevertheless, the task force agreed on the importance of addressing orofacial symptoms in the clinical orofacial examination of patients with JIA because of a high reported prevalence of symptoms, and because there is a substantial effect of orofacial symptoms on daily activities reported in the literature33. However, in longitudinal studies including orofacial pain assessments, it is important to recognize that pain reporting based on visual analog scales (VAS) is limited by reproducibility issues. This means that minor longitudinal changes in pain scores (< 10–14 mm on a VAS) cannot reliably be distinguished from random error within the assessment procedure13. In addition, it is important to recognize that orofacial signs and symptoms are regular findings in a nonarthritic adolescent population, with reported prevalence of 4%–7%66,67,68. The task force plans to develop a questionnaire to assess symptoms in JIA to achieve standardized collection of the important items represented in recommendation 2.

  • Recommendation 3. The clinical examination of orofacial signs should include palpation of the TMJ (lateral pole) and masticatory muscles (masseter and temporalis muscles); assessment of pain on palpation, TMJ pain on mandibular movement, and assessment of joint sounds (listening or auscultation).

More than half of the included studies (n = 37) that assessed the presence of clinical signs included palpation of the TMJ and masticatory muscles6,7,12,14,20,21,22,23,26,27,29–37, 39,40,41,42,44,45,46,47,52,54–59,61,62,64,65. Extrapolated evidence from case-control studies shows that tenderness on palpation, crepitation, and clicking are observed with significantly more frequency in patients with JIA compared to healthy controls (Supplementary Material 6, available with the online version of this article). The level of evidence and strength of recommendation 3 is available in Table 2.

Despite the intermediate predictive value of orofacial palpation for TMJ inflammation, the task force agrees on the inclusion of these items because they provide useful information on the mechanical function of the TMJ, the function of the masticatory muscles, and interplay between the osseous parts and articular disc within the TMJ. Pain on palpation of the orofacial regions and presence of TMJ sounds are also common findings in patients with temporomandibular dysfunction (TMD). In fact, there can be a significant overlap in symptoms and clinical findings in patients with other TMD and JIA patients with TMJ arthritis69. It is therefore important for the clinician to recognize that findings of TMJ clicking and palpation-induced tenderness are not necessarily causally related to the joint inflammation seen in JIA and can occur in patients without JIA.

  • Recommendation 4. The clinical examination of orofacial function should include assessment of temporomandibular joint function; e.g., maximal mouth opening, mouth opening deviation, protrusion, laterotrusion, and condylar translation during opening.

Fifty of the eligible articles included assessment of the TMJ function and mobility1,6,7,8,12,14,20,21,22,23,25,26,27, 29–40,42,43,44,46–65. The most consistently reported clinical outcome variables across the included literature were mouth opening capacity and mouth opening deviation. Based on the current literature, assessment of TMJ function seems to be extremely important. The evidence from a substantial number of the included articles indicates an increased prevalence of reduced TMJ function in patients with TMJ arthritis compared with healthy controls (Supplementary Material 6, available with the online version of this article). The level of evidence and strength of recommendation 4 is available in Table 2.

Diagnosis of TMJ arthritis based on TMJ function alone has poor sensitivity. Comparison of single measures of orofacial function to normative values are of limited diagnostic usefulness because of great variation in the normative values of TMJ function70. However, assessment of TMJ function traditionally constitutes an important outcome measure in longitudinal observational studies, or in studies dealing with intervention. Studies have typically used mouth opening capacity as an indirect outcome variable reflecting the current “functional status” of the TMJ, with increased posttreatment mouth opening capacities interpreted as a treatment-induced improvement in TMJ function. The task force finds the evaluation of TMJ function to be very important in the routine assessment of patients with JIA, as long as the variation within the assessment methods in the longitudinal assessment is factored into the interpretation of results, and conclusions drawn53. It remains unclear whether there is any diagnostic value in longitudinal assessment of orofacial function.

  • Recommendation 5. The clinical examination should include assessment of facial morphology and symmetry; mandibular sagittal position (convexity of the facial profile); and lower face asymmetry in the frontal plane.

For clarification purposes, the convexity of facial profile is defined as retrusion of the lower jaw in relation to the upper jaw. Lower face symmetry in the frontal plane is defined as the position of the mandible in relation to the vertical facial midline and the horizontal pupillary line.

Assessment of the facial morphology and symmetry was included in 24 of the eligible studies1,14,21–24,26,33–35,37, 39,41,44,45,47,48,51,54,57,60–63,65. Extrapolated evidence from the literature indicates that facial asymmetry based on clinical examination is more prevalent in patients with JIA compared to healthy controls. Cross-sectional studies also reported a significantly higher prevalence of convex profiles in patients with JIA compared to controls (Supplementary Material 6, available with the online version of this article). The level of evidence and strength of recommendation 5 is available in Table 2.

Orofacial growth alterations and the development of dentofacial asymmetry are some of the primary complications in patients with JIA and TMJ involvement. The task force therefore agreed on the importance of regular clinical orofacial assessments for changes in facial symmetry and patient profile, although changes in dentofacial morphology is the outcome of longterm rather than short-term TMJ arthritis. The task force also recognizes that the presence of a convex profile and/or facial asymmetry is also a naturally occurring characteristic in a non-diseased population.

Combining the clinical outcome variables

Several papers reported the use of standardized clinical orofacial assessment tools such as the Research Diagnostic Criteria for Temporomandibular Disorders71, the Craniomandibular Index72,73, and the Helkimo Index74. These criteria and indices were originally developed for diagnosis and assessment of dysfunction severity in the TMD patient population. Thus, they were not specifically intended or validated for the clinical orofacial examination in children and adolescents with JIA. In 2014, new diagnostic criteria for temporomandibular disorders were published69; however, to date these criteria have not been applied to the JIA population.

In studies dealing with JIA, the diagnostic value of the combination of clinical outcome measures was reported in few studies, but none were associated with more than a moderate diagnostic value of predicting TMJ inflammation2,22,37,51. Therefore, the task force did not consider it warranted to include combinations of outcome variables in the recommendations at this point.

Future research

The literature currently uses the term “TMJ involvement” without a standardized distinction between synovial inflammation and deformity of the joint. We will address this issue in our future work. Table 3 outlines our multiphased research program to develop, validate, and implement “evidence-based criteria” for the orofacial examination in patients with JIA.

View this table:
  • View inline
  • View popup
Table 3.

Future research agenda as defined by the task force.

DISCUSSION

These recommendations have been developed with the intention of standardizing and improving the clinical orofacial examination in JIA for clinical practice and for research studies. This is the first set of orofacial examination recommendations that exclusively applies to patients with JIA. The current recommendations do not include information on patient perception of disability or depression scores. The association between clinical orofacial findings and psychosocial aspects therefore constitutes a future research focus in patients with JIA.

Although extrapolated evidence from the literature clearly demonstrates a relationship between signs/symptoms and TMJ arthritis, these clinical findings are of insufficient magnitude to reliably predict the presence of TMJ inflammation. TMJ arthritis cannot be diagnosed by medical history and physical examination alone. Imaging and radiological techniques such as contrast-enhanced magnetic resonance imaging and cone-beam computerized tomography are required to rule out other causes of asymmetry or dysmorphic dentofacial development, and to help determine whether there is active inflammation or chronic structural changes caused by previous inflammation. This, however, should not undermine the importance of the clinical orofacial examination. Although the medical history and physical examination have limitations in diagnosing TMJ arthritis, they do play an important role in the longitudinal quantification of patient discomfort, orofacial dysfunction, and dysmorphic mandibular development. The regular clinical orofacial examination is therefore a critical part of the clinical assessment of patients with JIA because it documents the morbidity of TMJ arthritis regarding altered TMJ functions and dentofacial growth disturbances.

The level of evidence for all 5 recommendations was low, which underscores the lack of data from rigorous trials. The current literature revealed that insufficient description of outcome variables was a common finding during the review process. This highlights the importance of developing standardized outcome measures. It is our hope that the current recommendations will become part of standard clinical care, and will improve the quality of future studies. The authors recognize that revisions of these recommendations will be ongoing as our understanding of the pathophysiology of TMJ arthritis improves.

ONLINE SUPPLEMENT

Supplementary material accompanies the online version of this article.

Acknowledgment

We acknowledge the work of Michel Steenks, Willemijn van Bruggen, and Lukas Müller during the consensus process. We thank research librarian Janne Lytoft, PhD, for her help with this project.

  • Accepted for publication November 16, 2016.

REFERENCES

  1. 1.↵
    1. Cannizzaro E,
    2. Schroeder S,
    3. Muller LM,
    4. Kellenberger CJ,
    5. Saurenmann RK
    . Temporomandibular joint involvement in children with juvenile idiopathic arthritis. J Rheumatol 2011;38:510–5.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Koos B,
    2. Twilt M,
    3. Kyank U,
    4. Fischer-Brandies H,
    5. Gassling V,
    6. Tzaribachev N
    . Reliability of clinical symptoms in diagnosing temporomandibular joint arthritis in juvenile idiopathic arthritis. J Rheumatol 2014;41:1871–7.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Kuseler A,
    2. Pedersen TK,
    3. Herlin T,
    4. Gelineck J
    . Contrast enhanced magnetic resonance imaging as a method to diagnose early inflammatory changes in the temporomandibular joint in children with juvenile chronic arthritis. J Rheumatol 1998;25:1406–12.
    OpenUrlPubMed
  4. 4.↵
    1. Arvidsson LZ,
    2. Fjeld MG,
    3. Smith HJ,
    4. Flato B,
    5. Ogaard B,
    6. Larheim TA
    . Craniofacial growth disturbance is related to temporomandibular joint abnormality in patients with juvenile idiopathic arthritis, but normal facial profile was also found at the 27-year follow-up. Scand J Rheumatol 2010;39:373–9.
    OpenUrlCrossRefPubMed
  5. 5.
    1. Arvidsson LZ,
    2. Flato B,
    3. Larheim TA
    . Radiographic TMJ abnormalities in patients with juvenile idiopathic arthritis followed for 27 years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:114–23.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Bakke M,
    2. Zak M,
    3. Jensen BL,
    4. Pedersen FK,
    5. Kreiborg S
    . Orofacial pain, jaw function, and temporomandibular disorders in women with a history of juvenile chronic arthritis or persistent juvenile chronic arthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:406–14.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Billiau AD,
    2. Hu Y,
    3. Verdonck A,
    4. Carels C,
    5. Wouters C
    . Temporomandibular joint arthritis in juvenile idiopathic arthritis: prevalence, clinical and radiological signs, and relation to dentofacial morphology. J Rheumatol 2007;34:1925–33.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Cedstromer AL,
    2. Andlin-Sobocki A,
    3. Berntson L,
    4. Hedenberg-Magnusson B,
    5. Dahlstrom L
    . Temporomandibular signs, symptoms, joint alterations and disease activity in juvenile idiopathic arthritis — an observational study. Pediatr Rheumatol Online J 2013;11:37.
    OpenUrl
  9. 9.↵
    1. Engstrom AL,
    2. Wanman A,
    3. Johansson A,
    4. Keshishian P,
    5. Forsberg M
    . Juvenile arthritis and development of symptoms of temporomandibular disorders: a 15-year prospective cohort study. J Orofac Pain 2007;21:120–6.
    OpenUrlPubMed
  10. 10.↵
    1. Fjeld MG,
    2. Arvidsson LZ,
    3. Stabrun AE,
    4. Birkeland K,
    5. Larheim TA,
    6. Ogaard B
    . Average craniofacial development from 6 to 35 years of age in a mixed group of patients with juvenile idiopathic arthritis. Acta Odontol Scand 2009;67:153–60.
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. Kjellberg H
    . Juvenile chronic arthritis. Dentofacial morphology, growth, mandibular function and orthodontic treatment. Swed Dent J Suppl 1995;109:1–56.
    OpenUrlPubMed
  12. 12.↵
    1. Kuseler A,
    2. Pedersen TK,
    3. Gelineck J,
    4. Herlin T
    . A 2 year followup study of enhanced magnetic resonance imaging and clinical examination of the temporomandibular joint in children with juvenile idiopathic arthritis. J Rheumatol 2005;32:162–9.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Stoustrup P,
    2. Kristensen KD,
    3. Verna C,
    4. Kuseler A,
    5. Herlin T,
    6. Pedersen TK
    . Orofacial symptoms related to temporomandibular joint arthritis in juvenile idiopathic arthritis: smallest detectable difference in self-reported pain intensity. J Rheumatol 2012;39:2352–8.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Twilt M,
    2. Mobers SM,
    3. Arends LR,
    4. ten Cate R,
    5. Suijlekom-Smit L
    . Temporomandibular involvement in juvenile idiopathic arthritis. J Rheumatol 2004;31:1418–22.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Twilt M,
    2. Schulten AJ,
    3. Nicolaas P,
    4. Dulger A,
    5. Suijlekom-Smit LW
    . Facioskeletal changes in children with juvenile idiopathic arthritis. Ann Rheum Dis 2006;65:823–5.
    OpenUrlAbstract/FREE Full Text
  16. 16.↵
    1. Kristensen KD,
    2. Stoustrup P,
    3. Kuseler A,
    4. Pedersen TK,
    5. Twilt M,
    6. Herlin T
    . Clinical predictors of temporomandibular joint arthritis in juvenile idiopathic arthritis: a systematic literature review. Semin Arthritis Rheum 2016;45:717–32.
    OpenUrl
  17. 17.↵
    1. Stoustrup P,
    2. Kristensen KD,
    3. Verna C,
    4. Kuseler A,
    5. Pedersen TK,
    6. Herlin T
    . Intra-articular steroid injection for temporomandibular joint arthritis in juvenile idiopathic arthritis: a systematic review on efficacy and safety. Semin Arthritis Rheum 2013;43:63–70.
    OpenUrlCrossRefPubMed
  18. 18.↵
    Review studies on TMJ arthritis in JIA patients recruiting through euroTMjoint. [Internet. Accessed November 16, 2016.] Available from: www.eurotmj.com
  19. 19.↵
    1. Shekelle PG,
    2. Woolf SH,
    3. Eccles M,
    4. Grimshaw J
    . Clinical guidelines: developing guidelines. BMJ 1999;318:593–6.
    OpenUrlFREE Full Text
  20. 20.↵
    1. Abdul-Aziez OA,
    2. Saber NZ,
    3. El-Bakry SA,
    4. Mohammad AA,
    5. Abdel-Maksud SS,
    6. Ali Y
    . Serum S100A12 and temporomandibular joint magnetic resonance imaging in juvenile idiopathic arthritis Egyptian patients: a case control study. Pak J Biol Sci 2010;13:101–13.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Abramowicz S,
    2. Kim S,
    3. Susarla HK,
    4. Kaban LB
    . Differentiating arthritic from myofascial pain in children with juvenile idiopathic arthritis: preliminary report. J Oral Maxillofac Surg 2013;71:493–6.
    OpenUrl
  22. 22.↵
    1. Abramowicz S,
    2. Susarla HK,
    3. Kim S,
    4. Kaban LB
    . Physical findings associated with active temporomandibular joint inflammation in children with juvenile idiopathic arthritis. J Oral Maxillofac Surg 2013;71:1683–7.
    OpenUrlCrossRefPubMed
  23. 23.↵
    1. Ahmed N,
    2. Bloch-Zupan A,
    3. Murray KJ,
    4. Calvert M,
    5. Roberts GJ,
    6. Lucas VS
    . Oral health of children with juvenile idiopathic arthritis. J Rheumatol 2004;31:1639–43.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. Arabshahi B,
    2. Dewitt EM,
    3. Cahill AM,
    4. Kaye RD,
    5. Baskin KM,
    6. Towbin RB,
    7. et al.
    Utility of corticosteroid injection for temporomandibular arthritis in children with juvenile idiopathic arthritis. Arthritis Rheum 2005;52:3563–9.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Argyropoulou MI,
    2. Margariti PN,
    3. Karali A,
    4. Astrakas L,
    5. Alfandaki S,
    6. Kosta P,
    7. et al.
    Temporomandibular joint involvement in juvenile idiopathic arthritis: clinical predictors of magnetic resonance imaging signs. Eur Radiol 2009;19:693–700.
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Hanna VE,
    2. Rider SF,
    3. Moore TL,
    4. Wilson VK,
    5. Osborn TG,
    6. Rotskoff KS,
    7. et al.
    Effects of systemic onset juvenile rheumatoid arthritis on facial morphology and temporomandibular joint form and function. J Rheumatol 1996;23:155–8.
    OpenUrlPubMed
  27. 27.↵
    1. Hu Y,
    2. Billiau AD,
    3. Verdonck A,
    4. Wouters C,
    5. Carels C
    . Variation in dentofacial morphology and occlusion in juvenile idiopathic arthritis subjects: a case-control study. Eur J Orthod 2009;31:51–8.
    OpenUrlAbstract/FREE Full Text
  28. 28.
    1. Hu YS,
    2. Schneiderman ED
    . The temporomandibular joint in juvenile rheumatoid arthritis: I. Computed tomographic findings. Pediatr Dent 1995;17:46–53.
    OpenUrlPubMed
  29. 29.↵
    1. Ince DO,
    2. Ince A,
    3. Moore TL
    . Effect of methotrexate on the temporomandibular joint and facial morphology in juvenile rheumatoid arthritis patients. Am J Orthod Dentofacial Orthop 2000;118:75–83.
    OpenUrlCrossRefPubMed
  30. 30.
    1. Jank S,
    2. Haase S,
    3. Strobl H,
    4. Michels H,
    5. Hafner R,
    6. Missmann M,
    7. et al.
    Sonographic investigation of the temporomandibular joint in patients with juvenile idiopathic arthritis: a pilot study. Arthritis Rheum 2007;57:213–8.
    OpenUrlCrossRefPubMed
  31. 31.
    1. Karhulahti T,
    2. Ronning O,
    3. Jamsa T
    . Mandibular condyle lesions, jaw movements, and occlusal status in 15-year-old children with juvenile rheumatoid arthritis. Scand J Dent Res 1990;98:17–26.
    OpenUrlPubMed
  32. 32.↵
    1. Larheim TA,
    2. Hoyeraal HM,
    3. Stabrun AE,
    4. Haanaes HR
    . The temporomandibular joint in juvenile rheumatoid arthritis. Radiographic changes related to clinical and laboratory parameters in 100 children. Scand J Rheumatol 1982;11:5–12.
    OpenUrlPubMed
  33. 33.↵
    1. Leksell E,
    2. Ernberg M,
    3. Magnusson B,
    4. Hedenberg-Magnusson B
    . Orofacial pain and dysfunction in children with juvenile idiopathic arthritis: a case-control study. Scand J Rheumatol 2012;41:375–8.
    OpenUrlPubMed
  34. 34.
    1. Mandall NA,
    2. Gray R,
    3. O’Brien KD,
    4. Baildam E,
    5. Macfarlane TV,
    6. Davidson J,
    7. et al.
    Juvenile idiopathic arthritis (JIA): a screening study to measure class II skeletal pattern, TMJ PDS and use of systemic corticosteroids. J Orthod 2010;37:6–15.
    OpenUrlAbstract/FREE Full Text
  35. 35.↵
    1. Mericle PM,
    2. Wilson VK,
    3. Moore TL,
    4. Hanna VE,
    5. Osborn TG,
    6. Rotskoff KS,
    7. et al.
    Effects of polyarticular and pauciarticular onset juvenile rheumatoid arthritis on facial and mandibular growth. J Rheumatol 1996;23:159–65.
    OpenUrlPubMed
  36. 36.
    1. Mina R,
    2. Melson P,
    3. Powell S,
    4. Rao M,
    5. Hinze C,
    6. Passo M,
    7. et al.
    Effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis. Arthritis Care Res 2011;63:1511–6.
    OpenUrl
  37. 37.↵
    1. Muller L,
    2. Kellenberger CJ,
    3. Cannizzaro E,
    4. Ettlin D,
    5. Schraner T,
    6. Bolt IB,
    7. et al.
    Early diagnosis of temporomandibular joint involvement in juvenile idiopathic arthritis: a pilot study comparing clinical examination and ultrasound to magnetic resonance imaging. Rheumatology 2009;48:680–5.
    OpenUrlAbstract/FREE Full Text
  38. 38.
    1. Mussler A,
    2. Allozy B,
    3. Landau H,
    4. Kallinich T,
    5. Trauzeddel R,
    6. Schroder RJ
    . Comparison of magnetic resonance imaging signs and clinical findings in follow-up examinations in children and juveniles with temporomandibular joint involvement in juvenile idiopathic arthritis. Rofo 2010;182:36–44.
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Norholt SE,
    2. Pedersen TK,
    3. Herlin T
    . Functional changes following distraction osteogenesis treatment of asymmetric mandibular growth deviation in unilateral juvenile idiopathic arthritis: a prospective study with long-term follow-up. Int J Oral Maxillofac Surg 2013;42:329–36.
    OpenUrl
  40. 40.↵
    1. Olsen-Bergem H,
    2. Bjornland T
    . A cohort study of patients with juvenile idiopathic arthritis and arthritis of the temporomandibular joint: outcome of arthrocentesis with and without the use of steroids. Int J Oral Maxillofac Surg 2014;43:990–5.
    OpenUrl
  41. 41.↵
    1. Olson L,
    2. Eckerdal O,
    3. Hallonsten AL,
    4. Helkimo M,
    5. Koch G,
    6. Gare BA
    . Craniomandibular function in juvenile chronic arthritis. A clinical and radiographic study. Swed Dent Journal 1991;15:71-83.
    OpenUrl
  42. 42.↵
    1. Pedersen TK,
    2. Kuseler A,
    3. Gelineck J,
    4. Herlin T
    . A prospective study of magnetic resonance and radiographic imaging in relation to symptoms and clinical findings of the temporomandibular joint in children with juvenile idiopathic arthritis. J Rheumatol 2008;35:1668–75.
    OpenUrlAbstract/FREE Full Text
  43. 43.↵
    1. Ringold S,
    2. Thapa M,
    3. Shaw EA,
    4. Wallace CA
    . Heterotopic ossification of the temporomandibular joint in juvenile idiopathic arthritis. J Rheumatol 2011;38:1423–8.
    OpenUrlAbstract/FREE Full Text
  44. 44.↵
    1. Ringold S,
    2. Torgerson TR,
    3. Egbert MA,
    4. Wallace CA
    . Intraarticular corticosteroid injections of the temporomandibular joint in juvenile idiopathic arthritis. J Rheumatol 2008;35:1157–64.
    OpenUrlAbstract/FREE Full Text
  45. 45.↵
    1. Ronchezel MV,
    2. Hilario MO,
    3. Goldenberg J,
    4. Lederman HM,
    5. Faltin K Jr,
    6. de Azevedo MF,
    7. et al.
    Temporomandibular joint and mandibular growth alterations in patients with juvenile rheumatoid arthritis. J Rheumatol 1995;22:1956–61.
    OpenUrlPubMed
  46. 46.↵
    1. Ronning O,
    2. Valiaho ML,
    3. Laaksonen AL
    . The involvement of the temporomandibular joint in juvenile rheumatoid arthritis. Scand J Rheumatol 1974;3:89–96.
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Savioli C,
    2. Silva CA,
    3. Ching LH,
    4. Campos LM,
    5. Prado EF,
    6. Siqueira JT
    . Dental and facial characteristics of patients with juvenile idiopathic arthritis. Rev Hosp Clin Fac Med Sao Paulo 2004;59:93–8.
    OpenUrlPubMed
  48. 48.↵
    1. Stabrun AE,
    2. Larheim TA,
    3. Hoyeraal HM
    . Temporomandibular joint involvement in juvenile rheumatoid arthritis. Clinical diagnostic criteria. Scand J Rheumatol 1989;18:197–204.
    OpenUrlCrossRefPubMed
  49. 49.
    1. Stoll ML,
    2. Good J,
    3. Sharpe T,
    4. Beukelman T,
    5. Young D,
    6. Waite PD,
    7. et al.
    Intra-articular corticosteroid injections to the temporomandibular joints are safe and appear to be effective therapy in children with juvenile idiopathic arthritis. J Oral Maxillofac Surg 2012;70:1802–7.
    OpenUrlCrossRefPubMed
  50. 50.
    1. Stoll ML,
    2. Morlandt AB,
    3. Teerawattanapong S,
    4. Young D,
    5. Waite PD,
    6. Cron RQ
    . Safety and efficacy of intra-articular infliximab therapy for treatment-resistant temporomandibular joint arthritis in children: a retrospective study. Rheumatology 2013;52:554–9.
    OpenUrlAbstract/FREE Full Text
  51. 51.↵
    1. Stoll ML,
    2. Sharpe T,
    3. Beukelman T,
    4. Good J,
    5. Young D,
    6. Cron RQ
    . Risk factors for temporomandibular joint arthritis in children with juvenile idiopathic arthritis. J Rheumatol 2012;39:1880–7.
    OpenUrlAbstract/FREE Full Text
  52. 52.↵
    1. Stoustrup P,
    2. Kristensen KD,
    3. Kuseler A,
    4. Verna C,
    5. Herlin T,
    6. Pedersen TK
    . Management of temporomandibular joint arthritis-related orofacial symptoms in juvenile idiopathic arthritis by the use of a stabilization splint. Scand J Rheumatol 2014;43:137–45.
    OpenUrl
  53. 53.↵
    1. Stoustrup P,
    2. Verna C,
    3. Kristensen KD,
    4. Kuseler A,
    5. Herlin T,
    6. Pedersen TK
    . Smallest detectable differences in clinical functional temporomandibular joint examination variables in juvenile idiopathic arthritis. Orthod Craniofac Res 2013;16:137–45.
    OpenUrlCrossRefPubMed
  54. 54.↵
    1. Svensson B,
    2. Adell R,
    3. Kopp S
    . Temporomandibular disorders in juvenile chronic arthritis patients. A clinical study. Swed Dent J 2000;24:83–92.
    OpenUrlPubMed
  55. 55.
    1. Svensson B,
    2. Larsson A,
    3. Adell R
    . The mandibular condyle in juvenile chronic arthritis patients with mandibular hypoplasia: a clinical and histological study. Int J Oral Maxillofac Surg 2001;30:300–5.
    OpenUrlCrossRefPubMed
  56. 56.
    1. Twilt M,
    2. Schulten AJ,
    3. Verschure F,
    4. Wisse L,
    5. Prahl-Andersen B,
    6. Suijlekom-Smit LW
    . Long-term followup of temporomandibular joint involvement in juvenile idiopathic arthritis. Arthritis Rheum 2008;59:546–52.
    OpenUrlCrossRefPubMed
  57. 57.↵
    1. Weiss PF,
    2. Arabshahi B,
    3. Johnson A,
    4. Bilaniuk LT,
    5. Zarnow D,
    6. Cahill AM,
    7. et al.
    High prevalence of temporomandibular joint arthritis at disease onset in children with juvenile idiopathic arthritis, as detected by magnetic resonance imaging but not by ultrasound. Arthritis Rheum 2008;58:1189–96.
    OpenUrlCrossRefPubMed
  58. 58.↵
    1. Wenneberg B,
    2. Kjellberg H,
    3. Kiliaridis S
    . Bite force and temporomandibular disorder in juvenile chronic arthritis. J Oral Rehabil 1995;22:633–41.
    OpenUrlCrossRefPubMed
  59. 59.↵
    1. Lima Ferraz Junior AM,
    2. Devito KL,
    3. Guimaraes JP
    . Temporomandibular disorder in patients with juvenile idiopathic arthritis: clinical evaluation and correlation with the findings of cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e51–7.
    OpenUrlPubMed
  60. 60.↵
    1. Cahill AM,
    2. Baskin KM,
    3. Kaye RD,
    4. Arabshahi B,
    5. Cron RQ,
    6. Dewitt EM,
    7. et al.
    CT-guided percutaneous steroid injection for management of inflammatory arthropathy of the temporomandibular joint in children. AJR Am J Roentgenol 2007;188:182–6.
    OpenUrlCrossRefPubMed
  61. 61.↵
    1. Davis MA,
    2. Castillo M
    . MRI evaluation of the temporomandibular joints in juvenile rheumatoid arthritis: a retrospective review. Neuroradiol J 2011;24:928–32.
    OpenUrlAbstract/FREE Full Text
  62. 62.↵
    1. Grosfeld O,
    2. Czarnecka B,
    3. Drecka-Kuzan K,
    4. Szymanska-Jagiello W,
    5. Zyszko A
    . Clinical investigations of the temporomandibular joint in children and adolescents with rheumatoid arthritis. Scand J Rheumatol 1973;2:145–9.
    OpenUrlPubMed
  63. 63.↵
    1. Habibi S,
    2. Ellis J,
    3. Strike H,
    4. Ramanan AV
    . Safety and efficacy of US-guided CS injection into temporomandibular joints in children with active JIA. Rheumatology 2011;51:874–7.
    OpenUrl
  64. 64.↵
    1. Harper RP,
    2. Brown CM,
    3. Triplett MM,
    4. Villasenor A,
    5. Gatchel RJ
    . Masticatory function in patients with juvenile rheumatoid arthritis. Pediatr Dent 2000;22:200–6.
    OpenUrlPubMed
  65. 65.↵
    1. Hu YS,
    2. Schneiderman ED,
    3. Harper RP
    . The temporomandibular joint in juvenile rheumatoid arthritis: Part II. Relationship between computed tomographic and clinical findings. Pediatr Dent 1996;18:312–9.
    OpenUrlPubMed
  66. 66.↵
    1. Kohler AA,
    2. Helkimo AN,
    3. Magnusson T,
    4. Hugoson A
    . Prevalence of symptoms and signs indicative of temporomandibular disorders in children and adolescents. A cross-sectional epidemiological investigation covering two decades. Eur Arch Paediatr Dent 2009;10 Suppl 1:16–25.
    OpenUrlCrossRefPubMed
  67. 67.↵
    1. List T,
    2. Wahlund K,
    3. Wenneberg B,
    4. Dworkin SF
    . TMD in children and adolescents: prevalence of pain, gender differences, and perceived treatment need. J Orofac Pain 1999;13:9–20.
    OpenUrlPubMed
  68. 68.↵
    1. Nilsson IM,
    2. List T,
    3. Drangsholt M
    . Prevalence of temporomandibular pain and subsequent dental treatment in Swedish adolescents. J Orofac Pain 2005;19:144–50.
    OpenUrlPubMed
  69. 69.↵
    1. Schiffman E,
    2. Ohrbach R,
    3. Truelove E,
    4. Look J,
    5. Anderson G,
    6. Goulet JP,
    7. et al.
    Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6–27.
    OpenUrlCrossRefPubMed
  70. 70.↵
    1. Müller L,
    2. van Waes H,
    3. Langerweger C,
    4. Molinari L,
    5. Saurenmann RK
    . Maximal mouth opening capacity: percentiles for healthy children 4–17 years of age. Pediatr Rheumatol Online J 2013;11:17.
    OpenUrlCrossRefPubMed
  71. 71.↵
    1. Dworkin SF,
    2. LeResche L
    . Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–55.
    OpenUrlPubMed
  72. 72.↵
    1. Fricton JR,
    2. Schiffman EL
    . Reliability of a craniomandibular index. J Dent Res 1986;65:1359–64.
    OpenUrlAbstract/FREE Full Text
  73. 73.↵
    1. Fricton JR,
    2. Schiffman EL
    . The craniomandibular index: validity. J Prosthet Dent 1987;58:222–8.
    OpenUrlCrossRefPubMed
  74. 74.↵
    1. Helkimo M
    . Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swed Dent J 1974;67:101–21.
    OpenUrl
PreviousNext
Back to top

In this issue

The Journal of Rheumatology
Vol. 44, Issue 3
1 Mar 2017
  • Table of Contents
  • Table of Contents (PDF)
  • Index by Author
  • Editorial Board (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about The Journal of Rheumatology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies
(Your Name) has forwarded a page to you from The Journal of Rheumatology
(Your Name) thought you would like to see this page from the The Journal of Rheumatology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies
Peter Stoustrup, Marinka Twilt, Lynn Spiegel, Kasper Dahl Kristensen, Bernd Koos, Thomas Klit Pedersen, Annelise Küseler, Randy Q. Cron, Shelly Abramowicz, Carlalberta Verna, Timo Peltomäki, Per Alstergren, Ross Petty, Sarah Ringold, Sven Erik Nørholt, Rotraud K. Saurenmann, Troels Herlin
The Journal of Rheumatology Mar 2017, 44 (3) 326-333; DOI: 10.3899/jrheum.160796

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

 Request Permissions

Share
Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies
Peter Stoustrup, Marinka Twilt, Lynn Spiegel, Kasper Dahl Kristensen, Bernd Koos, Thomas Klit Pedersen, Annelise Küseler, Randy Q. Cron, Shelly Abramowicz, Carlalberta Verna, Timo Peltomäki, Per Alstergren, Ross Petty, Sarah Ringold, Sven Erik Nørholt, Rotraud K. Saurenmann, Troels Herlin
The Journal of Rheumatology Mar 2017, 44 (3) 326-333; DOI: 10.3899/jrheum.160796
del.icio.us logo Twitter logo Facebook logo  logo Mendeley logo
  • Tweet Widget
  •  logo
Bookmark this article

Jump to section

  • Article
    • Abstract
    • MATERIALS AND METHODS
    • RESULTS
    • DISCUSSION
    • ONLINE SUPPLEMENT
    • Acknowledgment
    • REFERENCES
  • Figures & Data
  • Supplemental
  • Info & Metrics
  • References
  • PDF

Keywords

JUVENILE IDIOPATHIC ARTHRITIS
OROFACIAL EXAMINATION
TEMPOROMANDIBULAR JOINT

Related Articles

Cited By...

More in this TOC Section

  • Correlation Between Interferon Response Gene Score and Disease Activity in Juvenile Dermatomyositis
  • Pediatric Rheumatology Care in the Canadian Context: A Qualitative Analysis of Care Providers
  • Effects of Biologics on Temporomandibular Joint Inflammation in Juvenile Idiopathic Arthritis
Show more Pediatric Rheumatology

Similar Articles

Keywords

  • JUVENILE IDIOPATHIC ARTHRITIS
  • OROFACIAL EXAMINATION
  • temporomandibular joint

Content

  • First Release
  • Current
  • Archives
  • Collections
  • Audiovisual Rheum
  • COVID-19 and Rheumatology

Resources

  • Guide for Authors
  • Submit Manuscript
  • Author Payment
  • Reviewers
  • Advertisers
  • Classified Ads
  • Reprints and Translations
  • Permissions
  • Meetings
  • FAQ
  • Policies

Subscribers

  • Subscription Information
  • Purchase Subscription
  • Your Account
  • Terms and Conditions

More

  • About Us
  • Contact Us
  • My Alerts
  • My Folders
  • Privacy/GDPR Policy
  • RSS Feeds
The Journal of Rheumatology
The content of this site is intended for health care professionals.
Copyright © 2025 by The Journal of Rheumatology Publishing Co. Ltd.
Print ISSN: 0315-162X; Online ISSN: 1499-2752
Powered by HighWire