Intra-articular steroid injection for temporomandibular joint arthritis in juvenile idiopathic arthritis: A systematic review on efficacy and safety

Abstract

Objective

To determine the current level of evidence for the use of intra-articular corticosteroid injections (IACI) against temporomandibular joint (TMJ) arthritis in patients with juvenile idiopathic arthritis (JIA) with a particular focus on clinical and radiological improvements and safety profile.

Methods

A comprehensive electronic search strategy was performed in all major medical databases in February 2012. Studies were selected independently by two reviewers in accordance with a pre-specified protocol and a risk of bias assessment for all included studies.

Results

Ninety-four unique citations were identified of which seven remained after the inclusion criteria were applied and all of these were assessed to have a high risk of bias. The current limited level of evidence suggests potential beneficial properties of IACI in patients with TMJ arthritis-related symptoms and/or MRI-verified signs of TMJ inflammation. Currently, no scientific evidence substantiates the effect of IACI in terms of (I) improving maximal mouth opening capacity significantly, (II) reducing radiological disease progression, (III) normalising/improving mandibular growth, and (IV) increasing efficacy upon repeated injections.

Conclusion

The current level of evidence allows only very limited conclusions on the effect of IACI therapy in patients with TMJ arthritis. Knowledge on the long-term impact of IACI on mandibular growth is not available. Future studies designed in accordance with evidence-based standards are needed to allow a more general conclusion on efficacy and safety of this treatment modality in patients with TMJ arthritis.

Introduction

Temporomandibular joint (TMJ) inflammation is seen in a substantial part of patients with juvenile idiopathic arthritis (JIA) [1], [2], [3], [4]. TMJ arthritis may cause reduced and asymmetric mandibular and craniofacial growth, unstable occlusion, disturbed TMJ and masticatory function which, in turn, cause asymmetric loading of joints and muscles, orofacial symptoms, and a compromised aesthetic appearance [5], [6], [7], [8], [9], [10], [11], [12], [13]. It is difficult to diagnose TMJ arthritis because TMJ pain and functional impairment have limited sensitivity as predictors of TMJ inflammation, and patients with TMJ arthritis may have no clinical signs of inflammation (e.g. joint swelling is very rare) [3], [4], [12].

Intervention against TMJ arthritis in patients with JIA specifically aims to (1) maintain optimal joint function and reduce any orofacial symptoms, (2) avoid permanent damage to the cartilaginous and osseous components of the TMJ and (3) reduce unfavourable mandibular and craniofacial growth alterations [14]. To meet these aims, optimal TMJ arthritis management must therefore satisfy two important aspects: (1) reduction of TMJ inflammation and (2) reduction of craniofacial growth disturbances with normalisation of mandibular growth [14], [15], [16]. Avoidance of mandibular and craniofacial growth disturbances is a primary aim in TMJ arthritis management in children since the magnitude of the treatment involves substantial and clinically challenging orthopaedic and possibly surgical interventions that proceed over a long period which requires excellent patient cooperation [16], [17].

In patients with JIA and TMJ arthritis, the anti-inflammatory therapy described in the literature has consisted mainly of intra-articular corticosteroid injection (IACI). Symptomatic relief, functional improvements and reduction in TMJ inflammation as assessed by magnetic resonance imaging (MRI) have been reported following IACI therapy in patients with TMJ arthritis [4], [18], [19], [20], [21]. This has made IACI a popular therapy against TMJ arthritis in patients with JIA [22]. However, concerns have been raised that this beneficial, short-term effect of IACI on TMJ inflammation in children may be accompanied by long-term side-effects on mandibular growth. Data from animal studies have supported these concerns by showing that IACI inhibits the inflammation but also has a detrimental impact on mandibular growth [23], [24], [25]. To understand the underlying construct of this concern, a specific and unique feature of the TMJ needs to be addressed. In contrast to other joints, the TMJ has an intra-articular growth site responsible for a substantial part of the total mandibular vertical growth [26]. To inject corticosteroids into the TMJ, which is in close contact with this important mandibular growth site, could cause corticosteroid-induced craniofacial growth suppression since corticosteroids have a negative impact on bone and cartilage formation [27], [28], [29].

Evidence-based practice aims to apply the best available evidence gained from scientific research to clinical decision-making. The objective of this systematic review was to determine the current level of evidence for the use of IACI against TMJ arthritis in patients with JIA with particular focus on clinical and radiological improvements and safety profile.