TMJ Arthritis Warning for Repeat Steroid Injections in Juvenile Arthritis

Repetitive intraarticular corticosteroid injections to the temporomandibular joint (TMJ) do not prevent progressive osseous deformation nor normalize mandibular growth in children with juvenile idiopathic arthritis (JIA), although they do improve inflammatory activity, according to a new commentary. The authors, Peter Stroustrup and Marinka Twilt from Aarhus University Hospital in Aarhus, Denmark, raise concerns that this treatment could reduce mandibular growth in children with TMJ arthritis. The Danish researchers reviewed a study from earlier this year led by Nina Lochbühler MD, pediatric radiology fellow, Department of Diagnostic Imaging, and Children’s Research Center, University Children’s Hospital in Zurich, Switzerland. The Swiss study had investigated the consequences of the repeated use of intraarticular corticosteroid injections for treatment of TMJ arthritis in patients with JIA. The Danish researchers noted that the Swiss study is the first human study to assess the mandibular development under the influence of intra-articular corticosteroid injections. The retrospective Swiss study included 33 patients, median age 5.2 years, who received repeated triamcinolone hexacetonid for an existing TMJ inflammation. The researchers evaluated inflammatory activity on consecutive magnetic resonance imaging scans, and assessed mandibular development and changes in intra-articular osseous deformities over 5 years. The results showed steroid injections had an anti-inflammatory effect in TMJ inflammation. As expected, correct intra-articular steroid application led to a greater reduction in inflammation than injections incorrectly placed into the periarticular soft tissue, noted the Danish researchers.[[{"type":"media","view_mode":"media_crop","fid":"42051","attributes":{"alt":"©thailoei92/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_3735547615215","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4517","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":" ","typeof":"foaf:Image"}}]] However, repeated injections did not prevent the development of osseous deformities or restore mandibular growth. Patients who received the highest cumulative doses of intra-articular steroids had significantly more pronounced joint destruction and mandibular growth reduction than those who received lower cumulative intra-articular dose due to incorrect periarticular injections. The Danish researchers noted that intra-articular calcifications were observed in 21% of TMJs that received steroid injections. They suggested that the existing dentofacial growth potential is “a decisive factor in the treatment plan for patients with TMJ arthritis.” They added that “treatments need to take into account a unique property of the TMJ-the intra-articular mandibular growth site.” Optimal treatment of TMJ arthritis must be interdisciplinary, they stated, with the anti-inflammatory treatment provided by the rheumatologist supplemented with nonsurgical dentofacial orthopaedic treatment by orthodontists and surgical distraction by maxillofacial surgeons.  The Danish researchers believe the Swiss study shows the beneficial short-term anti-inflammatory effects of intraarticular corticosteroid injections could be outweighed by long-term adverse effects on mandibular growth in juvenile idiopathic arthritis patients. 

References:

Lochbühler N, Saurenmann RK, et al. "Magnetic Resonance Imaging Assessment of Temporomandibular Joint Involvement and Mandibular Growth Following Corticosteroid Injection in Juvenile Idiopathic Arthritis,"The Journal of Rheumatology. Published online before print June 1, 2015, doi: 10.3899/jrheum.141502

Peter Stoustrup, Marinka Twilt. "Therapy: Intra-articular steroids for TMJ arthritis-caution needed,"Nature Reviews Rheumatology. doi:10.1038/nrrheum.2015.97. Published online 14 July 2015