Arthritis of the Temporomandibular Joint (TMJ)

Infectious arthritis

Infection of the temporomandibular joint (TMJ) may result from direct extension of adjacent infection or hematogenous spread of bloodborne organisms (see Acute Infectious Arthritis). The joint area is inflamed, and jaw movement is limited and painful. Local signs of infection with or without systemic infection suggest the diagnosis. Radiographs may be negative in the early stages but may show bone destruction later. If suppurative arthritis is suspected, the joint is aspirated to confirm the diagnosis and to identify the causative organism. Diagnosis must be made rapidly to prevent permanent joint damage.

Treatment includes antibiotics, proper hydration, pain control, and motion restriction. A broad-spectrum antibiotic should be administered until a specific bacteriologic diagnosis can be made on the basis of culture and sensitivity testing (1). For methicillin-resistant Staphylococcus aureus (MRSA) infections of the oral structures, IV vancomycin is the antibiotic of choice. Suppurative infections are aspirated or incised and drained. Once the infection is controlled, passive jaw-opening exercises help prevent scarring and limitation of motion.(MRSA) infections of the oral structures, IV vancomycin is the antibiotic of choice. Suppurative infections are aspirated or incised and drained. Once the infection is controlled, passive jaw-opening exercises help prevent scarring and limitation of motion.

Traumatic arthritis

Rarely, acute injury (eg, due to difficult tooth extraction or endotracheal intubation) may lead to arthritis of the TMJ. Pain, tenderness, and limitation of mandibular motion occur. Diagnosis is based primarily on history. Radiographs are negative except when intra-articular edema or hemorrhage widens the joint space. Treatment includes oral glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), application of heat, a pain free diet, and restriction of jaw movement.

Osteoarthritis

The TMJ may be affected by osteoarthritis (degenerative joint disease), usually in patients > 50 years. Occasionally, patients complain of stiffness, a grating sound on jaw movement, or mild pain. Crepitus may result from disc degeneration or perforation, causing bone to grate on bone. Joint involvement is generally bilateral. Radiographs, conventional CT, or cone beam CT may show condylar flattening, lipping, spurring, or erosions and/or subchondral cysts due to excessive loading of the joint. Treatment is symptomatic. An oral appliance (occlusal splint [mouth guard]) worn during sleep (and possibly while awake) may help alleviate pain and reduce grating sounds. NSAIDs may provide pain relief.

Secondary degenerative arthritis

Secondary degenerative arthritis of the TMJ usually develops in patients with a systemic rheumatic disease (eg, rheumatoid arthritis, juvenile idiopathic arthritis) or those with a history of trauma, internal derangement (eg, disc or anatomical anomalies. It is characterized by limited opening of the mouth, unilateral pain during jaw movement, joint tenderness, and crepitus.

Unilateral joint involvement helps distinguish secondary degenerative arthritis from primary osteoarthritis. Diagnosis is based on radiographs or cone beam CT, which, as in osteoarthritis, generally show condylar flattening, lipping, spurring, or erosion on the affected side.

Treatment is conservative, although arthroplasty or high condylectomy may be necessary. An oral appliance may be of benefit for symptom relief. The appliance is worn constantly, except during meals, oral hygiene, and appliance cleaning. When symptoms improve, the length of time that the appliance is worn each day is gradually reduced. Intra-articular injection of glucocorticoids may relieve symptoms but may accelerate cartilage loss and joint space narrowing if repeated often (2).

Rheumatoid arthritis

The TMJ may be affected in adults and children with rheumatoid arthritis, but it is usually among those with more severe disease (3). Pain, swelling, and limited movement are the most common findings. In children, destruction of the condyle results in mandibular growth disturbance and facial deformity. Ankylosis may follow. Radiographs of the TMJ are usually negative in early stages but often show late-stage bone destruction, which may result in an anterior open-bite malocclusion. The diagnosis is suggested by TMJ inflammation associated with polyarthritis and is confirmed by other findings typical of active rheumatoid arthritis (eg, polyarthritis).

Treatment is similar to that of rheumatoid arthritis in other joints. In the acute stage, NSAIDs may be given for analgesia, and jaw function should be restricted. An oral appliance worn during sleep is often helpful. When symptoms subside, mild jaw exercises help prevent excessive loss of mandibular motion. Surgery is necessary if ankylosis develops but should not be performed until the condition is quiescent.

References

1. 1. Omiunu A, Talmor G, Nguyen B, et al. Septic Arthritis of the Temporomandibular Joint: A Systematic Review. J Oral Maxillofac Surg. 2021;79(6):1214-1229. doi:10.1016/j.joms.2021.01.004

2. 2. Derwich M, Mitus-Kenig M, Pawlowska E. Mechanisms of Action and Efficacy of Hyaluronic Acid, Corticosteroids and Platelet-Rich Plasma in the Treatment of Temporomandibular Joint Osteoarthritis-A Systematic Review. Int J Mol Sci. 2021;22(14):7405. Published 2021 Jul 9. doi:10.3390/ijms22147405

3. 3. Hysa E, Lercara A, Cere A, et al. Temporomandibular disorders in immune-mediated rheumatic diseases of the adult: A systematic review. Semin Arthritis Rheum. 2023;61:152215. doi:10.1016/j.semarthrit.2023.152215