Controversial Aspects of Diagnostics and Therapy of Arthritis of the Temporomandibular Joint in Rheumatoid and Juvenile Idiopathic Arthritis—An Analysis of Evidence- and Consensus-Based Recommendations Based on an Interdisciplinary Guideline Project

Abstract

Introduction: Due to potentially severe sequelae (impaired growth, condylar resorption, and ankylosis) early diagnosis of chronic rheumatic arthritis of the temporomandibular joint (TMJ) and timely onset of therapy are essential. Aim: Owing to very limited evidence the aim of the study was to identify and discuss controversial topics in the guideline development to promote further focused research. Methods: Through a systematic literature search, 394 out of 3771 publications were included in a German interdisciplinary guideline draft. Two workgroups (1: oral and maxillofacial surgery, 2: interdisciplinary) voted on 77 recommendations/statements, in 2 independent anonymized and blinded consensus phases (Delphi process). Results: The voting results were relatively homogenous, except for a greater proportion of abstentions amongst the interdisciplinary group (p < 0.001). Eighty-four percent of recommendations/statements were approved in the first round, 89% with strong consensus. Fourteen recommendations/statements (18.2%) required a prolonged consensus phase and further discussion. Discussion: Contrast-enhanced MRI was confirmed as the method of choice for the diagnosis of TMJ arthritis. Intraarticular corticosteroid injection is to be limited to therapy-refractory cases and single injection only. In adults, alloplastic joint replacement is preferable to autologous replacement. In children/adolescents, autologous reconstruction may be performed lacking viable alternatives. Alloplastic options are currently still considered experimental.

Frequency and Pattern of Presentation of Different Types of TMJ Ankylosis in Patients Presenting to Nisthar Institute of Dentistry, Multan

“…Mouth opening and re-ankylosis restriction are the two most frequent problems that might develop after surgery for the treatment of TMJA [27,28]. Other consequences include facial nerve injury,mal occlusion, and restriction in mouth opening.…”

Controversial Aspects of Diagnostics and Therapy of Idiopathic Condylar Resorption: An Analysis of Evidence- and Consensus-Based Recommendations Based on an Interdisciplinary Guideline Project

“…However, according to the relevant recommendations of a recently published consensus and evidence-based S3 guideline on inflammatory diseases of the temporomandibular joint (cf. S3 guideline "Inflammatory diseases of the temporomandibular joint: Juvenile idiopathic arthritis (JIA) and rheumatoid arthritis (RA) of the temporomandibular joint", register number 007/061), the previous recommendation on serological diagnostics was rediscussed and reevaluated within the guideline group, based on this newly available higher level of evidence [21]. After detailed research, the recommendation developed is to primarily perform contrast-enhanced MR diagnostics of the temporomandibular joint in order to substantiate or rule out an autoimmune or rheumatoid disease as causative, and to perform serological diagnostics only if results are unclear (LoE 4/k+, B).…”

“…Another main limitation of this study relates to the Delphi process. As already analysed by Schmidt et al, this method, while offering the advantage of great flexibility to the members of the guideline group, is very time-consuming [21]. At the same time, the Delphi process also offers the additional great advantage of the anonymity with which voting results and comments can be evaluated.…”

“…Based on the systematic literature search, and following the identical methodology as in previous AWMF guidelines [20,21], an initial draft guideline was compiled by the steering group (M.R. and A.N.)…”

“…The initial literature search was performed in May 2021; the sources were again updated in August 2022, with a final update before submission to the AWMF in February 2023. Due to the limited evidence base (no/only few systematic studies in the literature of grades 1, 2 and 3, primary sources, especially evidence levels 4 and 5), case-control studies with evidence level 4 (e.g., case series) and 5 (case reports) were also included in the guideline [21,22].…”