Assessment of radiological changes involving the articular surface of the temporo-mandibular joint in patients with osteoarthritis and rheumatoid arthritis using CT Scan- a prospective clinico – radiological study
The cranio-mandibular articulation is a complex synovial system composed of two temporomandibular joints together with their articular ligaments & 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 masticatory function.
Temporomandibular disorders are an umbrella term under which multiple disorders are grouped.It designates the conditions that comprise complaints of the masticatory system involving the craniomandibular articulation and its musculature. This study is based on the group “inflammatory disorders of the joint” and specifically on patients with rheumatoid arthritis and osteoarthritis involving the temporomandibular joint.
Arthritis means any inflammatory condition of the joint.Osteoarthritis represents a degenerative and destructive process by which the bony particular surfaces of the condyle and fossa become altered. It is generally considered to be body’s response to increasing loading of a joint. Osseous changes involving the condyle and temporal bone occur as sequelae of disk displacement, frequently with long standing disk displacement without reduction.
On the other hand rheumatoid arthritis is an inflammation of the synovial membranes that extends into surrounding connective tissues and articular surfaces. With damage to the joint tissues several osseous changes can occur in the joint.
It can cause 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 TMJ. Since the time of introduction of Computed Tomography in 1970, it has evolved as an important diagnostic tool in the field in radiology. Its capacity to define osseous details without superimposition has made it superior to other imaging modalities like conventional radiology, conventional tomography and MRI. It is of great help in three dimensional imaging of the bony structures.The best application of CT of temporomandibular joint is a high resolution examination of osseous abnormalities.
This study was undertaken to evaluate osseous changes in TMJ secondary to osteoarthritis, and rheumatoid arthritis using CT scan.
Aims and Objectives:
The study was carried out to evaluate patients with osteoarthritis and rheumatoid arthritis affecting the temporomandibular joint clinically and radiologically using computed tomography and to compare their findings.
Materials and Methods:
The study was conducted on 20 patients with osteoarthritis and 20 patients with rheumatoid arthritis. The patients were selected from the OPD of the Dept. of Orthopedics & Dept. of Oral Medicine & Radiology, The CT scan images were obtained from the Department ofRadiology.
All the patients gave the informed consent prior being included into the study. For the selection of the patients (20 patients with osteoarthritis and 20 patients with rheumatoid arthritis), following criteria were considered.
1.Patients who were willing to participate in this study.
2.Patients who were diagnosed having osteoarthritis and rheumatoid arthritis
3.Patients who had symptoms of pain at the pre-auricular region during mandibular movements, joint sounds such as clicking or crepitus, limitation of mouth opening & presenting with deviation / deflection of mandible on opening or closing were included.
1.Patients who were not willing to participate in this study.
2.Patients with TMJ disorders, and not having osteoarthritis and rheumatoid arthritis.
3. Patients having TMJ ankylosis
4. Patients with known history of cervical spondylitis & other systemic diseases.
5. Pregnant patients
Patients were made to undergo complete medical examination by an Orthopedic Surgeon with detailed examination of the joints. Then they were subjected to detailed case history, examination & routine radiographs. A detailed examination of TMJ was carried out with reference to range of mouth opening, movements, tenderness of joint, clicking, crepitus, deviation & deflection and muscles of mastication.
Intra oral examination:
Detailed examination was done with special relevance to missing teeth, mobility of teeth, attrition, abrasions, dental occlusion suggestive of parafunctional habits and prosthetic rehabilitation if any in the oral cavity was also assessed.
Prior consent was obtained from each patient to undergo radiographic examination. Conventional radiographic examination was done using Orthopantomograph to screen the patients. CT scans showing both the TMJs were obtained for all 40 patients. The scans were carried out on SIEMENS SOMATUM EMOTION Spiral single slice scanner, Department of Radiology, Narayana Hospital at 120Kv & 200mA with acquisition time of 1 second. CT scanning was carried out in direct axial & reconstructed coronal & sagittal planes with contiguous slice thickness of 2mm using bone window.
All the CT scans were evaluated in detail by a Senior Radiologist. Each condyle and glenoid fossa were evaluated for changes like erosion, flattening, sclerosis, osteophyte formation, narrowing of joint space and subchondral cyst formation.
The CT scan findings of each TMJ were then subjected for statistical analysis. Statistical analysis was done using the SPSS version 17. The data has been considered to be a non-parametric data so non parametric tests Mann-Whitney U test and Wilcoxon have been applied. The value of statistical significance was taken at 0.05.
Results and Observations:
The present study was conducted on 40 patients, out of which 20 were of Osteoarthritis and 20 cases of Rheumatoid arthritis. The comparative evaluation of CT scan changes in the TMJs of these patients was carried out.
Mean age of the patients with osteoarthritis was 49 ±15yrs and in patients with rheumatoid arthritis 50 ±11yrs. The female to male ratio was 2:1. There was marked predilection for females in both groups. Bilateral TMJ involvement was predominantly seen among patients with RA.
In OA patients most common finding was narrowing of joint space (15 pts) (75%), followed by osteophytes on medial aspect (11 pts) (55%) and flattening ( 6 pts) (30%).
In RA patients also most common finding was narrowing of joint space similar to OA (17pts) (85%) followed by flattening (8 pts) (40%), osteophytes (5 pts) (25%). Subchondral sclerosis was seen exclusively in RA patient (1 pt) (5%).
CT findings were similar in both OA & RA cases except the subchondral sclerosis. Other changes like condylar erosions and sub-condylar cysts were not seen.
On comparison of CT findings of OA and RA, the presence of osteophytes ( p = 0.056) alone were statistically signaificant. Although other findings were seen in both groups, they were statistically insignificant.
Osteoarthritis (OA) is a degenerative, non-inflammatory joint disease characterized by destruction of articular cartilage and formation of new bone at the joint surfaces and margins. OA affects the synovial joints, though it can affect any joint, it is more common in the weight bearing joints like the hip, knee, spine etc. Occurrence of OA may be related to the adaptive capacity of the articular cartilage with regard to joint loading throughout life. Loading of joint beyond its capacity may lead to tissue breakdown of the cartilage and eventually result in osteoarthritis.
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Rheumatoid arthritis (RA) is the most common inflammatory disease of the joints. It is a immune mediated systemic disease of young and middle aged adults characterized by proliferative and destructive changes in synovial membrane, articular and periarticular structures. Eventually, joints are destroyed, fibrosed or ankylosed. It is a wide spread vasculitis of the small arterioles. RA can affect any joint in the body. It involves the peripheral joints more often and very rarely affects the larger joints.
OA and RA both have different etiopathogenesis but affect the TM Joints similarly, clinically and radiologically.
CT scan is of course, the most suitable modality for detection of alteration in hard tissue such as osseous changes of the condyle and temporal component in patients with temporomandibular joint pain and dysfunction. Studies indicate that accuracy of computed tomography for depicting the osseous changes is upto 87%.
In this study, most commonly affected age group by TMJ arthritis is 41-60 years. The mean age for the patients with TMJ osteoarthritis was 49 years. This finding is similar toTroller P A, whoconcluded that OA of mandibular condyle occurs after 42 years of age. In a radiographic study of TMJ in young patients, Wiberg B & Wanman Aindicated OA occurs as aresult 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 50 years and that is close to the findings by ArdicF et al in their study, based on clinical and radiological evaluation of 33 patients with RA, found the mean age to be 46 years (range 18-76).VoogU et.al.in their study on 20 patients reported that the mean age was found to be 41 years.
Gynther G, Tronje G. in their radiographic study on rheumatoid arthritis found the mean age of occurrence of the disease was to be 44 years. The mean age of the patients in our study is slightly on the higher side.
OA and RA have always been seen affecting females more than males, which was confirmed by the findings of this study (2:1). Various studies byWiber B & Wanman A, ArdicF et.al,Gynther G & Tronje G, have proved that females might be predisposed to dysfunctional remodeling of the TMJ and this female preponderance for dysfunctional remodeling of the TMJ suggests a potential role of sex hormones (ie, estrogen, prolactin) as modulators of this response.
OA involves a few joints whereas RA involves multiple joints. TM joint being one of the joint to be involved.
In general OA involves joints unilaterally and RA usually involves joints bilaterally.In contrast, present study showed 50% of TMJs involved bilaterally in OA. This finding is similar toWiber B & Wanman A55% of temporomandibular joints were involved bilaterally in RA. This finding was similar findings byGoupille P, Fouquet B, Holmlund A, Gynther G, Reinholt F.
In OA group the most common CT finding was narrowing of joint space (75%), followed by osteophyte formation (55%), and flattening (35%).
Gynther G. and Tronje Gin their study on generalized OA, found flattening of condylar surface in 40% of cases, sclerosis in 35% of cases and osteophyte formation in 55% of joints. Of all these findings, only osteophyte formation is similar to our study. Flattening of condylar surface was found slightly on lower side in our study.
In RA group, abnormal findings were found in 90% of CT scans. Predominant CT finding was narrowing of joint space (85%) followed by flattening (40%), osteophyte formation (25%) and sclerosis (5%).
R. Celiker, Y Gokce-Kutsal, and M. Eryilmaz, the most frequent pathological changes in their study were osteophyte formation (70%), reduced joint space (70%) and erosion (60%). In contrast, our study showed narrowing of joint space (85%) slightly on higher side. Only 5% had sclerosis of joint. This finding was towards the lower side when compared toVoog U. et. al. and ArdicF.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 predominant finding in OA. Although, other findings like narrowing of joint space, flattening seen commonly in both groups but higher percentage was seen in RA group.
Osteoarthritis and rheumatoid arthritis of the TM joint are two 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 that can help to plan the treatment modality and also to monitor the therapeutic response.
Therefore, we recommend thorough clinical and radiological (CT scan) assessment of TMJs in all the patients above 40yrs of age, who are suffering with generalized joint pains to help in treatment plan and assess progress of disease.
(1) The patients gave the informed consent prior to being included into the study;
(2) The study was authorized by the local ethical committee and was performed in accordance with the Ethical standards of the 1964 Declaration of Helsinki as revised in 2000.
“Conflict of interest: None”
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