|Year : 2017 | Volume
| Issue : 1 | Page : 24-29
Assessment of radiological changes involving the articular surface of the temporomandibular joint in patients with osteoarthritis and rheumatoid arthritis using computed tomography scan: A prospective clinico-radiological study
Krishnaveni Buduru1, Rajendra Patil2, Kannan Natarajan3, Suneetha Pentyala4, B Anand Babu1, Dalsingh Vankudoth5, Abhishek Singh Nayyar6
1 Department of Oral Medicine and Radiology, KLR's Lenora Institute of Dental Sciences, Rajahmundry, India
2 Department of Oral Medicine and Radiology, Kothiwal Dental College, Moradabad, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
4 Department of General Radiology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
5 Department of Oral and Maxillofacial Surgery, KLR's Lenora Institute of Dental Sciences, Rajahmundry, India
6 Department of Oral Medicine and Radiology, Saraswati-Dhanwantari Dental College and Hospital and Post Graduate Research Institute, Parbhani, Maharashtra, India
|Date of Web Publication||16-Jun-2017|
Abhishek Singh Nayyar
44, Behind Singla Nursing Home, New Friends' Colony, Model Town, Panipat - 132 103, Haryana
Source of Support: None, Conflict of Interest: None
Background and Objective: The purpose of the present study was to assess the radiological changes involving the articular surfaces of temporomandibular joints (TMJs) in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) using computed tomography (CT) scans. Materials and Methods: A total of 20 patients with OA and 20 patients with RA were subjected to a detailed examination, routine radiography, and CT imaging of the TMJs. CT scanning was carried out for the direct axial view and reconstructed to coronal and sagittal planes with contiguous slice thickness of 2 mm using bone window. All the images were evaluated for the presence of osteophytes, flattening of the articular surfaces, sclerosis, and narrowing of the joint space and subjected to statistical analysis. Results: The female to male ratio of the study group for OA and RA was 2:1, respectively. Of all the CT findings, namely, osteophytes, flattening of the articular surfaces, sclerosis, and narrowing of the joint space, statistically significant values (P = 0.056) for osteophytes were obtained. Flattening and narrowing of joint space were seen in both types of arthritides, however, a relatively higher percentage of such patients was seen in RA group. Conclusion: OA and RA of the TMJ are the two most commonly seen conditions which can impair the functional capacity of the entire masticatory system. Their in-depth clinical and radiological evaluation is a must to assess the disease activity. Likewise, CT is a valuable tool in assessing osseous abnormalities and should be used in cases where osseous involvement of the TMJs is suspected.
Keywords: Computed tomography scan of temporomandibular joint, osteoarthritis, osteophytes, rheumatoid arthritis, sclerosis of temporomandibular joint
|How to cite this article:|
Buduru K, Patil R, Natarajan K, Pentyala S, Babu B A, Vankudoth D, Nayyar AS. Assessment of radiological changes involving the articular surface of the temporomandibular joint in patients with osteoarthritis and rheumatoid arthritis using computed tomography scan: A prospective clinico-radiological study. Arch Med Health Sci 2017;5:24-9
|How to cite this URL:|
Buduru K, Patil R, Natarajan K, Pentyala S, Babu B A, Vankudoth D, Nayyar AS. Assessment of radiological changes involving the articular surface of the temporomandibular joint in patients with osteoarthritis and rheumatoid arthritis using computed tomography scan: A prospective clinico-radiological study. Arch Med Health Sci [serial online] 2017 [cited 2017 Oct 19];5:24-9. Available from: http://www.amhsjournal.org/text.asp?2017/5/1/24/208205
| Introduction|| |
The craniomandibular articulation is a complex synovial system composed of two temporomandibular joints (TMJs) together with their articular ligaments and masticatory muscles. It is structurally the most complex synovial system in the body. The articulation is subject to ills that afflict other synovial joints as well as to few that relate specifically to the masticatory function. Temporomandibular disorders constitute a term under which multiple disorders are grouped. Temporomandibular disorders include conditions that comprise complaints of the masticatory system involving the craniomandibular articulation and its musculature. The present study is based on the group “inflammatory disorders of the joint,” specifically, on patients with osteoarthritis (OA) and rheumatoid arthritis (RA) involving the TMJs. Arthritis means any inflammatory condition of the joint. OA represents a degenerative and destructive process by which the bony articular surfaces of the condyle and fossa become altered. It is generally considered to be the body's response to increasing loading of a joint. Osseous changes involving the condyle and temporal bone occur as sequelae of disk displacements, frequently, with long-standing disk displacements without reduction. On the other hand, RA is an inflammation of the synovial membranes that extends into the surrounding connective tissues and articular surfaces. With damage to the joint tissues, several osseous changes occur in the joint causing destruction of the temporomandibular articular surfaces, if not evaluated and treated in time. Early intervention can reduce the severity of the disease. There are many imaging modalities available to view TMJs. Since the time of introduction of computed tomography (CT) in the 1970s, it has evolved as an important diagnostic tool in the field in radiology. Its capacity to define osseous details without overlapping and superimpositions has made it superior to other imaging modalities including conventional radiology, conventional tomography and even, magnetic resonance imaging. It is of great help in three dimensional imaging of the bony structures. The best application of CT in TMJ imaging is a high-resolution examination of the osseous abnormalities which no other imaging modalities can achieve. This study was undertaken to evaluate the osseous changes in TMJs in patients with OA and RA both clinically and and radiologically using CT scans and to compare their findings.
| Materials and Methods|| |
The study was conducted on a total of 40 patients, 20 patients with OA and 20 patients with RA. The patients were selected from the outpatient department with a known history of OA and RA. The CT scan images were obtained from the Department of Radiology. The permission to conduct the present study was obtained from the Institutional Ethics Committee. All the patients gave informed consent before being included in the study. For the selection of the patients, following criteria were considered.
- Patients who were willing to participate in the study
- Patients who were diagnosed with OA and RA
- Patients who had symptoms of pain at the preauricular region, especially during mandibular movements, joint sounds such as clicking or popping and/or crepitus, limitation of mouth opening and patients who presented with deviation/deflection of the mandible on opening.
- Patients who were not willing to participate in the study
- Patients with TMJ disorders with causes that could not directly be correlated to OA and RA
- Patients having TMJ ankylosis
- Patients with known history of cervical spondylitis and other systemic diseases that could have led to confounding of a clear-cut etiology apart from OA and RA
- Pregnant females.
Patients were made to undergo complete medical examination by an orthopedic surgeon with a detailed examination of the joints. Then they were subjected to a detailed case history, clinical examination, and routine radiography. A detailed examination of the TMJs was then carried out with reference to range of mouth opening, movements, tenderness of joint, clicking, popping, crepitus, deviation, and deflection of the mandible during opening and any sign including hypertrophy and/or tenderness in relation to muscles of mastication.
A detailed intraoral examination was then carried out with special relevance to missing teeth, mobility of teeth, attrition, abrasions, occlusion suggestive of parafunctional habits and prosthetic rehabilitation, if any.
A written informed consent was obtained from all the patients before their inclusion into the study with special mention of radiographic examination. Conventional radiographic examination was done using orthopantomograph to screen the patients. CT scans showing both the TMJs were obtained for all the 40 patients. The scans were carried out on Siemens SOMATOM Emotion Spiral Single Slice Scanner in the Department of Radiology at 120 KVp and 200 mA settings with acquisition time of 1 s. CT scanning was carried out in direct axial sections and coronal and sagittal planes were reconstructed with contiguous slice thickness of 2 mm using bone window. All scans were then evaluated by a senior radiologist. Each condyle and glenoid fossa were evaluated for changes including flattening, sclerosis, narrowing of joint space, osteophytes, erosions, and subchondral cyst formations.
The findings of the study were subjected to statistical analysis. Statistical analysis was done using SPSS version 17 (SPSS version 14: SPSS Inc., 233 South Wackier Drive, 11th Floor, Chicago, USA). The data were considered to be a nonparametric data, so, nonparametric tests such as Mann–Whitney U-test and Wilcoxon test were applied for statistical analysis. The value of statistical significance was taken at 0.05.
| Results|| |
The present study was conducted on 40 patients, out of which 20 patients were known cases of OA whereas the remaining 20 were known cases of RA. The comparative evaluation of CT scan changes in the TMJs of these patients was carried out. The mean age of the patients with OA was calculated as 49 ± 15 years while in patients with RA, the mean age calculated came out to be 50 ± 11 years [Table 1] and [Graph 1]. The female to male ratio was 2:1. There was marked predilection for females in both groups [Table 2] and [Graph 2]. Bilateral TMJ involvement was predominantly seen among patients with RA [Table 3] and [Graph 3]. In OA, the most common finding was narrowing of the joint space, (15 patients) (75%), [Figure 1] and [Graph 4] followed by osteophytes on medial aspect, (11 patients) (55%) [Figure 2]a,[Figure 2]b,[Figure 2]c and [Graph 5] and flattening of the articular surfaces, (6 patients) (30%) [Figure 3] and [Graph 6]. In RA patients also, the most common finding was narrowing of the joint space, (17 patients) (85%) [Graph 4] followed by flattening of the articular surfaces, (8 patients) (40%) [Graph 6] and osteophytes, (5 patients) (25%) [Graph 5]. Subchondral sclerosis was seen exclusively in a single RA patient, (1 patient) (5%) [Figure 4]a, [Figure 4]b and [Graph 7]. CT findings were similar in both OA and RA cases except subchondral sclerosis [Table 4]. Other changes including subcondylar cyst formations and condylar erosions were not present. On comparison of the CT findings of OA and RA, the presence of osteophytes alone was found to be statistically significant (P = 0.056). Although other findings were seen in both groups, the results were found to be statistically insignificant.
|Figure 1: Computed tomography findings in the study for narrowing of the joint space-axial view|
Click here to view
|Figure 2: (a) Computed tomography findings in the study for the presence of osteophyte-axial view. (b and c) Computed tomography findings in the study for the presence of osteophyte-coronal views|
Click here to view
|Figure 3: Computed tomography findings in the study for flattening of the articular surfaces-coronal view|
Click here to view
|Figure 4: (a) Computed tomography findings in the study for subchondral sclerosis-axial view. (b) Computed tomography findings in the study for subchondral sclerosis-coronal view|
Click here to view
|Table 4: Computed tomography findings in the study sample with statistical analysis|
Click here to view
| Discussion|| |
OA is a degenerative, noninflammatory joint disease process which is characterized by destruction of the articular cartilage and formation of new bone at the joint surfaces and margins. OA affects the synovial joints. Although it can affect any joint, it is more common in the weight-bearing joints such as the hip, knee, and spine. The occurrence of OA may be related to the adaptive capacity of the articular cartilages with regard to joint loading throughout the life. The loading of the joint beyond its capacity may lead to tissue breakdown of the cartilage and eventually, result in OA. RA, on the other hand, is the most common inflammatory disease of the joints. RA is an immune-mediated systemic disease of the young and middle-aged adults characterized by proliferative and destructive changes in the synovial membrane and the articular and the peri-articular structures. Eventually, joints are destroyed, fibrosed, or ankylosed. It is a widespread vasculitis of the small arterioles. RA can affect any joint in the body. However, it involves the peripheral joints more often and rarely affects the larger joints. OA and RA both have different etiopathogenesis but affect the TM Joints similarly, clinically and radiologically. CT is one of the preferred modality of imaging for detection of alteration in the hard tissues such as the osseous changes in the condyles and temporal components as well as the other articulating and nonarticulating surfaces in patients with TMJ diseases. Studies indicate that accuracy of CT for depicting the osseous changes is up to 87%. In this study, most commonly affected age group by TMJ disorders was 41–60 years. The mean age for the patients with TMJ OA was 49 ± 15 years, a finding which was similar to the observations made by Toller who found that OA of mandibular condyle manifests itself clinically after 42 years of age. In a radiographic study of TMJ in young patients, Wiberg and Wänman indicated OA occurs as a result of TMJ pathosis. These results suggest that the occurrence of TM joint OA is age related and not due to TMJ pathosis. In RA group, the mean age was found to be 50 ± 11 years, close to the findings of the study conducted by Ardic et al. In their study, based on clinical and radiological evaluation of 33 patients with RA, they found the mean age to be 46 years (range 18–76). Voog et al., in their study on 20 patients, reported that the mean age was 41 years. Gynther and Tronje, in their radiographic study on RA, found the mean age of occurrence of the disease to be 44 years. The mean age of the patients in our study was although slightly on the higher end. OA and RA have always been seen affecting females more commonly than males which was confirmed in our study again with a female to male ratio obtained of 2:1, respectively. Various studies by Wiberg and Wänman, Ardic et al. and Gynther and Tronje  have proved that females might be predisposed to dysfunctional remodeling of the TMJs. This female preponderance for dysfunctional remodeling of the TMJs suggests a potential role of sex hormones (i.e., estrogen, prolactin) as modulators of this response. OA involves a few joints whereas RA involves multiple joints with TM joints being one of the joints to be involved frequently. In general, OA involves joints unilaterally while RA usually involves joints bilaterally. In contrast, the present study showed 50% of TMJs involved bilaterally in OA. This finding was though in coherence with the study conducted by Wiberg and Wänman. 55% of TMJs were involved bilaterally in RA. This finding was similar to the findings of the study conducted by Goupille et al. and Holmlund et al. In OA group, the most common CT finding was narrowing of the joint space, (75%), followed by osteophyte formation, (55%), and flattening of the articular surfaces, (35%). Gynther and Tronje, in their study on generalized OA, found flattening of condylar surface in 40% of the cases, sclerosis in 35% of cases and osteophyte formation in 55% of them. Of all these findings, the finding of osteophyte formation was the only significant observation similar to our study. Flattening of the condylar surfaces was found slightly on lower side in our study. In RA group, abnormal findings were found in 90% of the patients with the predominant CT findings being narrowing of the joint space (85%), followed by flattening of the articular surfaces (40%), osteophyte formation (25%), and sclerosis, which was seen only in a single patient (5%). The most frequent pathological changes in the study conducted by Celiker et al. included osteophyte formation in 70% of the patients, reduced joint space in 70% and erosions in around 60% of the patients. In contrast, our study showed narrowing of the joint space in 85% of the patients which was slightly on the higher end. Only a single patient, 5%, was reported to have sclerosis of the joint. This finding was on lower side when compared to the findings of the studies conducted by Ardic et al. and Voog et al. In summary, the comparative analysis of OA and RA by CT scan findings showed statistically significant amount of osteophyte formations in TMJs and it was a predominant finding in OA. Other findings like narrowing of the joint space and flattening of the articular surfaces were also seen in both the groups but a relatively higher percentage was seen in relation to the RA group.
| Conclusion|| |
OA and RA of the TMJ are the two most commonly seen conditions which can impair the functional capacity of the entire masticatory system. Their in-depth clinical and radiological evaluation is a must to assess the disease activity and to help plan the treatment modality and monitor the therapeutic response. Likewise, CT is a valuable tool in assessing osseous abnormalities and should be used in cases where osseous involvement of the TMJs is suspected. Therefore, we recommend a thorough clinical and radiological (CT scan) assessment of TMJs in all patients above 40 years of age who are suffering with generalized joint pains to assess the progress of disease as well as to help in treatment planning.
Authors would like to thank all the patients who contributed in the study without whom this study would not have been feasible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bell W. Defining the problem in temporomandibular disorders: Classification, diagnosis and management. 3rd
ed. Chicago: Year Book Medical Publication; 1995. p. 3-12.
Okeson JP. Etiology and identification of functional disturbances in masticatory system in management of temporomandibular disorders and occlusion. 5th
ed. New York, NY, USA: Mosby Publication; 2003. p. 147-364.
Jablonski S. Jabolonsli's Dictionary of Dentistry. 1st
ed. New Delhi: AITBS Publication; 2002. p. 75.
de Bont LG, van der Kuijl B, Stegenga B, Vencken LM, Boering G. Computed tomography in differential diagnosis of temporomandibular joint disorders. Int J Oral Maxillofac Surg 1993;22:200-9.
Zarb G, Carlsson G, Sessle B, Mohl N. Clinical manifestations of Temporomandibular joint and masticatory muscle disorders in temporomandibular joint and masticatory muscle disorders. 1st
ed. Copenhagen: Mosby Publication; 1994. p. 221-386.
Ebner J. Textbook of Orthopedics. 4th
ed. New Delhi: Jaypee Publication; 2010. p. 581-3.
Ebner J. Textbook of Orthopedics. 4th
ed. New Delhi: Jaypee Publication; 2010. p. 674-5.
Westesson PL. Reliability and validity of imaging diagnosis of temporomandibular joint disorder. Adv Dent Res 1993;7:137-51.
Toller PA. Osteoarthrosis of the mandibular condyle. Br Dent J 1973;134:223-31.
Wiberg B, Wänman A. Signs of osteoarthrosis of the temporomandibular joints in young patients: A clinical and radiographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:158-64.
Ardic F, Gokharman D, Atsu S, Guner S, Yilmaz M, Yorgancioglu R. The comprehensive evaluation of temporomandibular disorders seen in rheumatoid arthritis. Aust Dent J 2006;51:23-8.
Voog U, Alstergren P, Eliasson S, Leibur E, Kallikorm R, Kopp S. Inflammatory mediators and radiographic changes in temporomandibular joints of patients with rheumatoid arthritis. Acta Odontol Scand 2003;61:57-64.
Gynther GW, Tronje G. Comparison of arthroscopy and radiography in patients with temporomandibular joint symptoms and generalized arthritis. Dentomaxillofac Radiol 1998;27:107-12.
Arnett GW, Tamborello JA. Progressive class II development- female idiopathic condylar resorption. In: West RA, editor. Oral and Maxillofacial Clinics of North America. Philadelphia, PA: WB Saunders; 1990. p. 699-716.
Abubaker O. Differential diagnosis of arthritis of the temporomandibular joint. Oral and Maxillofacial Clinics of North America. Vol. 7. Philadelphia, PA: WB Saunders; 1995. p. 1-21.
Goupille P, Fouquet B, Cotty P, Goga D, Valat JP. Direct coronal computed tomography of the temporomandibular joint in patients with rheumatoid arthritis. Br J Radiol 1992;65:955-60.
Holmlund AB, Gynther G, Reinholt FP. Rheumatoid arthritis and disk derangement of the temporomandibular joint. A comparative arthroscopic study. Oral Surg Oral Med Oral Pathol 1992;73:273-7.
Celiker R, Gökçe-Kutsal Y, Eryilmaz M. Temporomandibular joint involvement in rheumatoid arthritis. Relationship with disease activity. Scand J Rheumatol 1995;24:22-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]