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JIDA_FebMarch2008 30/01/2008 16:12 Page 1 Volume 54 Number 1 February/March 2008 Journal of the Irish Dental AssociationIris Cumainn Déadach na hÉireann Oral care in juvenile
JIDA_FebMarch2008 30/01/2008 16:14 Page 29 Journal of the Irish Dental Association Oral health and orthodontic
considerations in children with juvenile
idiopathic arthritis: review of the
literature and report of a case
Abstract: Juvenile idiopathic arthritis (JIA) is a severe disease of childhood, which
comprises a diverse group of distinct clinical entities of unclear aetiology. Some
abnormality of the immune system is present in all JIA cases. In its most severe
clinical form, JIA may show localised and/or systemic complications, including
functional impairment of the affected sites. This may result in variable growth and
developmental anomalies. In many JIA cases, where the temporomandibular joint
(TMJ) is affected, mandibular growth may be restricted, thus leading to the
development of mandibular hypoplasia and/or retrognathism. As a result, it is not
uncommon for JIA patients to present with skeletal Class II and open bite
malocclusions. Furthermore, in JIA cases with unilateral TMJ involvement, craniofacial
asymmetry may occur. In such cases, early orthodontic intervention facilitates both
the skeletal and the occlusal rehabilitation.
Increased prevalence of dental caries and periodontal disease in JIA cases may be
attributed to a combination of aetiological factors, including difficulties in executing
good oral hygiene, unfavourable dietary practices and side effects from the long-term
administration of medication. In addition, an association between periodontal disease
and JIA has been reported based on their similar pattern of clinical disregulation of
the inflammatory process. This paper presents a brief description of JIA, with special
reference to dental health and orthodontic treatment considerations. In addition, a
case is presented where the appropriate orthodontic intervention led to the
establishment of a normally functioning, as well as an aesthetically pleasing,
occlusion.
KEY WORDS: juvenile idiopathic arthritis, craniofacial growth, TMJ, oral health, malocclusion,
Journal of the Irish Dental Association 2008; 54: 29-36 Introduction to juvenile
remains unclear, although it appears to be multifactorial, involving infectious, genetic Philippos N Synodinos
Juvenile idiopathic arthritis (JIA) is a major and endocrine factors.8-12 connective tissue disease and one of the The clinical course of JIA usually involves Athens, Greece.
most common chronic illnesses of several sequential long or short periods of childhood.1 Essentially, it is an early-onset flare-ups and remissions.13-14 It may affect form of arthritis affecting one or more joints.
any joint in the body and, in its most severe JIA manifests before the age of 16 and form, it may be accompanied by systemic Athens, Greece.
remains active for more than six weeks.2 Its complications of the cardiovascular system, incidence is estimated at around 1-2:10,000 the urinary system and the eyes.14 Systemic and its prevalence at 1:1,000.3-6 The or local disturbances of growth may be diagnostic criteria of JIA are reported in Table
observed in JIA patients,13,14 depending on Dublin Dental School & Hospital, 1.7 In general, three major types of JIA are
which joints are affected. This may be related recognised: oligoarthritic; polyarthritic; and, to either the disease or to the medication.15 systemic. These three types are briefly Most JIA cases require chronic administration outlined in Table 2.2 The exact cause of JIA
of multi-drug medication, including non- Volume 54 (1) : February/March 2008 29 JIDA_FebMarch2008 30/01/2008 16:14 Page 30 Journal of the Irish Dental Association TABLE 1: Diagnostic criteria and types of juvenile
TABLE 2: Characteristics of the three major types of
juvenile rheumatoid arthritis.2
■ Age at onset younger than 16 years; ■ arthritis in one or more joints (defined as swelling or effusion, or Relative frequency the presence of two or more of the following signs: limitation of Number of joints range of motion; tenderness or pain on motion; and, increased ■ duration of disease >6 weeks; ■ type of onset of disease during the first six months (polyarthritic when five or more joints are affected; oligoarthritic when less Seropositivity – than five joints are affected; systemic when intermittent fever is rheumatoid factor present and other systems of the body are involved; psoriatic; Seropositivity – enthesitis related; and, other), and antinuclear antibodies ■ exclusion of other forms of juvenile arthritis.
steroidal anti-inflammatory, steroidal, disease-modifying anti- rheumatic, and immunosuppressive drugs. The main objective of such ■ hyperdivergent facial type, increased mandibular plane angle, and treatment is to restore and maintain quality of life for patients, while decreased posterior facial height;21,22,33,39,40-42,44,45 alleviating pain and controlling inflammation, thereby preventing or ■ facial asymmetry in cases with unilateral TMJ involvement;20 and, minimising joint destruction and deformity.16 ■ decreased overbite, open bite or open bite Despite treatment, an effective permanent change in the clinical course of the disease may not be achieved until adolescence where, in The unfavourable craniofacial growth pattern observed in many JIA up to 70-85% of cases, a spontaneous remission is observed.17 patients is usually regarded either as primary or secondary. Primary Additionally, prolonged administration of medication may inflict unfavourable growth pattern is attributed to the disturbed growth of severe side effects because of its toxicity, especially with regard to the affected mandibular condyles,18,19,22,39,46,48,49 while secondary is skeletal growth and development. During active phases of the disease, attributed to the children's impaired oral function21,45 and/or ossification at the epiphyses is accelerated, followed by premature medication-related somatic growth retardation.20,40 closure of the epiphyseal growth plates in later stages. This may Clinical examination may not be considered as an accurate method of eventually result in retardation of skeletal growth and joint diagnosing TMJ involvement in JIA patients.18,19,30,47,49,50 Therefore, the dysfunction.2 In many JIA cases where the temporomandibular joints application of an appropriate TMJ imaging method is often (TMJs) are affected by the disease, growth of the mandible is indicated.51-53 Techniques used include panoramic radiography (PR), restricted, resulting in severe functional and aesthetic problems of the tomography, arthrography, fluoroscopy, computerised tomography, craniofacial complex.18-23 Complications due to the disease itself, as magnetic resonance imaging (MRI), and radionuclide imaging.54-56 well as its treatment, may affect oral health, as evidenced by the There is almost universal agreement that the examination of the reported increased prevalence of caries and periodontal disease in osseous surfaces of the TMJ is facilitated by the application of JIA patients.24-26 tomography rather than plain film techniques.57-61 Fine bone details can be visualised without projection limitations, while the real shape TMJ involvement in JIA cases
and size of anatomical structures is displayed.62,63 In contrast, imaging The reported prevalence of TMJ involvement in patients with JIA varies of soft tissues of the TMJ is investigated in most cases by the use of between 50% and 87%.27-34 In many such cases, temporomandibular MRI, which is non-invasive and does not result in the patient being joint dysfunction (TMD) is observed, presenting with restricted exposed to ionising radiation.64,65 mandibular movements, and reduced and/or painful functional or resting activity of the masticatory muscles. Furthermore, the Dental health considerations in JIA patients
underlying pattern and direction of dentofacial growth may be Although TMJ involvement in JIA is well described, only a few studies disturbed.21,22,27,28,30,35-38 As a result, TMJ involvement in JIA patients is report its potential adverse effects on dental health. Several factors often associated with the development of certain craniofacial and related to JIA may unfavourably affect oral health. TMJ-related dental features including: dentofacial abnormalities may be considered as contributing factors in ■ decreased mandibular length;18,19,22,39-42 the aetiology of oral diseases. TMD accompanied by impaired ■ Class II division 1 malocclusion, mostly due to mandibular masticatory function and functional impairment of upper limbs may 30 Volume 54 (1) : February/March 2008 JIDA_FebMarch2008 30/01/2008 16:16 Page 31 Journal of the Irish Dental Association affect toothbrushing competence.66-68 Dietary practices such as the addressed by orthodontic/orthopaedic treatment with consumption of softer, more sugary foods in frequent small amounts, functional appliances.22 sweets given as consolation, the use of oral medication containing It is not ubiquitously accepted that orthodontic treatment should be sugar43,69-71 and factors related to psychological issues delaying instigated early in all cases presenting malocclusions warranting optimal dental care,26,72 all adversely affect oral health.
prompt intervention.22,84 The reluctance of many practitioners to treat In JIA cases, an increased prevalence of dental caries24,25,73,74 and a skeletal Class II malocclusions of JIA patients with functional appliances higher risk for periodontal disease have been reported.75,76 while the disease remains active is due to the supported risk of flare- Interestingly, some common clinical and pathogenic features of up in the articular surfaces of the TMJs, resulting in a net bone loss in periodontitis and rheumatoid arthritis have been recognised.77,78 This the condylar growth centre.85 Whether justified or not, such delayed implies a possible association between the two diseases that may intervention would result in excluding any orthopaedic effect from share a common underlying disregulation of the inflammatory orthodontic treatment, since full remission of JIA does not occur until response.77 Alternatively, the reported higher prevalence of adolescence. Thus, in the majority of cases, the only choices periodontal disease may be considered as secondary to the overall remaining for such cases would be treating them in late adolescence, higher plaque accumulation recorded in JIA patients,79 or to the long- orthodontically-induced occlusal camouflaging of the underlying term administration of medication resulting in immunosuppression, skeletal discrepancy or, even, in extreme cases, the application of a xerostomia, stomatitis and gingival overgrowth.80 Whatever its cause, combination of orthodontic treatment and orthognathic poor oral health is considered to be potentially detrimental for the surgery.21,86,86-89 In the latter cases, costochondral grafting may be systemic condition of JIA cases because untreated dental caries and/or applied to serve as replacement for the completely destroyed periodontal disease, combined with poor oral hygiene, may increase condylar head.90,91 the risk for systemic infection, especially if the patient is taking In contrast to postponing treatment until cessation of growth, early immunosuppressive drugs such as methotrexate.26 treatment with functional orthodontic appliances aims to achieve and In all JIA cases, intensive prophylactic and therapeutic measures are maintain occlusal balance, and rehabilitate and preserve TMJ function, required to prevent or reduce the potential damage to the dental and while allowing for uninhibited mandibular growth.28,32,43,67 There is periodontal tissues. Regular dental and orthodontic examination, evidence that if functional conditions are created, growth has the case-specific oral hygiene instructions, topical and systemic use of potential to normalise.92 Close monitoring of the reaction of the fluoride, appropriate dietary modification, and prescription of sugar- condylar growth centre to functional stimuli is of utmost importance free medicines are of prime importance for maintaining optimal to decrease the risk of possible undesirable side effects. After the dental health in patients with JIA.26,72 As immunosuppression is a normalisation of craniofacial growth pattern, the application of fixed common side effect of several anti-rheumatic drugs, it may be wise to orthodontic appliances facilitates in finishing the orthodontically apply antibiotic prophylaxis before dental management of certain induced occlusal rehabilitation. In JIA cases presenting non-skeletal JIA patients.
malocclusions, timely application of fixed orthodontic appliances only In addition to advice on prevention, and treatment for dental diseases, is indicated. In any JIA case warranting some kind of orthodontic dentists should also provide information to the patient and their treatment, it must be noted that the administered medication may family regarding JIA's possible consequences for oral health. It is not interfere with bone physiology, adversely affecting bone turnover, uncommon for lay people parenting JIA patients to be totally unaware thereby restraining orthodontic tooth movements. In all cases, light of the effects of JIA on oral health.81 orthodontic forces should be applied to eliminate the risk of side effects such as apical root resorption, while facilitating optimal Orthodontic treatment considerations in JIA patients
tooth movement.23 There is extensive documentation regarding the impact that TMJ involvement may have on the pattern of craniofacial growth in JIA Case report
patients, resulting in the development of certain malocclusions.19- A female patient, aged 10 years and six months, presenting 22,31,29 Accordingly, case-specific objectives of orthodontic treatment polyarthritic JIA (involving at its onset both knees and several joints of in JIA patients should be assessed, always keeping in mind that the the hands), diagnosed at the age of two at the Paedo- principal objectives in the management of the systemic disease are Rheumatological Department of the Paediatric Clinic "Aglaia relief of pain and discomfort, avoidance of permanent joint damage Kyriakou" of Athens, was referred for orthodontic consultation with and preserving an acceptable level of quality of life.23 In any JIA case, special emphasis placed towards a comprehensive evaluation of the the indicated orthodontic treatment can be applied on the condition TMJ physiology. At the patient's initial admittance, the disease was in that TMJ inflammation caused by the systemic disease is controlled by remission using medication that included methotrexate in proper medical care.82,83 In cases where limitation of any mandibular combination with certain corticosteroids. Her medical history revealed movement is observed, the application of a properly designed occlusal a penicillin allergy. The physical examination did not show any splint is indicated to alleviate TMD symptomatology and, while clinically significant aberrations from normal height and weight unloading the joints, to re-establish normal masticatory physiology.28 percentiles. Her extra-oral examination showed symmetrical Subsequently, mandibular retrognathism/hypoplasia is typically craniofacial features along with normal proportions of her anterior Volume 54 (1) : February/March 2008 31

JIDA_FebMarch2008 30/01/2008 16:17 Page 32 Journal of the Irish Dental Association FIGURE 1: The anterior facial view of the patient at rest and smiling at FIGURE 3: The profile view of the patient and the lateral cephalometric her initial admittance. radiography at her initial admittance. FIGURE 2: The posteroanterior cephalometric radiography did not reveal FIGURE 4: The anterior and lateral view of the patient's occlusion before any significant asymmetry of any craniofacial structure. the initiation of orthodontic treatment. lower facial height (Figure 1). These were also evidenced by the
not show any signs and symptoms of TMJ dysfunction and no evaluation of the posteroanterior cephalometric radiograph (Figure
restriction was observed in her range of movements. The examination 2). In contrast, her profile view was concave; however, at rest position
of the panoramic and the corrected sagittal tomography revealed some interference of the lips was evident in addition to some tension some flattening and erosive lesions on both condylar articular surfaces of the genial muscle (Figure 3). Overall, her prominent ears affected
(Figures 5 and 6). The study of the lateral cephalometric radiograph
her facial aesthetics unfavourably and the aesthetics of her smile were showed a hyperdivergent facial growth type presenting skeletal Class impaired by the malaligned anterior teeth (Figure 1).
II division 1 malocclusion, mostly due to the posteriorly and The intra-oral examination revealed a late mixed dentition stage. She downward rotated direction of mandibular growth. An increase of the had a Class II division 1 malocclusion with bilateral posterior crossbite, lower to the total anterior facial height ratio was noted, in addition to severe anterior crowding of both arches, a reduced overbite and an a clinically significant decrease of the posterior to anterior facial height increased overjet (Figure 4). No dental pathology was observed with
ratio. These observations implied that mandibular growth was the exception of some plaque-induced gingival inflammation impaired, probably as a result of the condylar growth centres having restricted mostly to the crowded areas. The clinical TMJ evaluation did been affected by JIA.
32 Volume 54 (1) : February/March 2008

JIDA_FebMarch2008 30/01/2008 16:17 Page 33 Journal of the Irish Dental Association FIGURE 5: The initial panoramic radiograph of the patient. FIGURE 8: The anterior facial view of the patient at rest and smilingafter the completion of her orthodontic treatment. The severe dental crowding, in conjunction with the patient's unfavourable facial growth pattern and the incompetent lips, determined the orthodontic treatment plan, comprising the extraction of all four first premolars. The case was assessed as one requiring maximum anchorage, which initially involved a palatal bar connecting the banded upper first permanent molars, followed by a high-pull headgear. Full-mouth fixed orthodontic appliances were sequentially applied for a total period of two years and six months. On successive appointments, specific emphasis was placed on the importance of the patient maintaining optimal dental hygiene. After the completion of treatment the appliances were removed and the FIGURE 6: The tomographical views of the patient's TMJs (corrected by retention protocol followed. A Hawley-type retainer was used for the the use of submental-vertex radiograph). upper arch and a fixed lingual retainer on the lower anterior teeth.
Overall, the post orthodontic extra-oral and intra-oral clinical examination of the patient was quite satisfactory with regard to the occlusal and aesthetic dental and facial characteristics. No dental pathology was observed regarding the development of either carious (or even white spot) lesions or periodontal complications. The gingival contour of all teeth was firm and lacking severe inflammatory signs (no bleeding on probing, periodontal sulcus depth less than 3mm) although some localised plaque accumulation was evident. The occlusal view of both dental arches was normal and co-ordinated with each other, and their midlines coincided (Figure 7). Overall, an
aesthetically pleasing smile was accomplished by the proper alignment of the upper anterior teeth (Figure 8). The post-treatment
profile line of the patient had become almost orthognathic, although reminiscent of its former concave form (Figure 9). Even more
important was the fact that the vertical dimension of the craniofacial growth was controlled. The patient's lips were in contact at rest position, although the upper lip was flatter and the nose a bit more prominent. The post-treatment panoramic radiograph did not reveal any clinically significant apical root resorption, interproximal dental surfaces caries, or loss of periodontal support. The mesiodistal axial FIGURE 7: The anterior and lateral view of the patient's occlusion after inclination of maxillary left lateral incisor and canine did not appear the removal of fixed orthodontic appliances. ideal as viewed in the panoramic radiograph; however, it was Volume 54 (1) : February/March 2008 33 JIDA_FebMarch2008 30/01/2008 16:17 Page 34 Journal of the Irish Dental Association satisfactory on an intra-oral view. A further concern was the direction of eruption of the lower third molars, which warranted some attention in future recall visits (Figure 10).
The post-treatment lateral cephalometric study, although still determining a Class II skeletal relationship, revealed a reduction of initial values of respective variables. In addition, improved ratios of lower anterior to total anterior facial height, and posterior to anterior facial height, were noted. The interincisal angle was almost normalised owing to the favourable uprighting of upper incisors and some labial inclination of the lower incisors (Figure 11).
Finally, but most importantly, no signs or symptoms of TMJ dysfunction were recorded throughout orthodontic treatment.
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36 Volume 54 (1) : February/March 2008

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