Bernd Koos1, Marinka Twilt2, Ullrike Kyank2, Helge Fischer-Brandies2, Volker Gassling2, Nikolay Tzaribachev2. 1. From the Department of Orthodontics, and the Department of Oral and Maxillofacial Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany; Hospital for Sick Children, University of Toronto, Division of Rheumatology, Toronto, Ontario, Canada; University Medical Center, Children's Hospital, Rostock; Pediatric Rheumatology Research Institute (PRI), Bad Bramstedt, Germany.B. Koos, DMD, Department of Orthodontics, University Medical Center Schleswig-Holstein; M. Twilt, MD, PhD, Hospital for Sick Children, University of Toronto, Division of Rheumatology; U. Kyank, MD, University Medical Center, Children's Hospital; H. Fischer-Brandies, DMD, PhD, Department of Orthodontics, University Medical Center Schleswig-Holstein; V. Gassling, MD, DMD, Department of Oral and Maxillofacial Surgery, University Medical Center Schleswig-Holstein; N. Tzaribachev, MD, PRI. koos-b@kfo-zmk.uni-kiel.de. 2. From the Department of Orthodontics, and the Department of Oral and Maxillofacial Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany; Hospital for Sick Children, University of Toronto, Division of Rheumatology, Toronto, Ontario, Canada; University Medical Center, Children's Hospital, Rostock; Pediatric Rheumatology Research Institute (PRI), Bad Bramstedt, Germany.B. Koos, DMD, Department of Orthodontics, University Medical Center Schleswig-Holstein; M. Twilt, MD, PhD, Hospital for Sick Children, University of Toronto, Division of Rheumatology; U. Kyank, MD, University Medical Center, Children's Hospital; H. Fischer-Brandies, DMD, PhD, Department of Orthodontics, University Medical Center Schleswig-Holstein; V. Gassling, MD, DMD, Department of Oral and Maxillofacial Surgery, University Medical Center Schleswig-Holstein; N. Tzaribachev, MD, PRI.
Abstract
OBJECTIVE: Temporomandibular joint (TMJ) arthritis, commonly considered oligoarthritic/asymptomatic, occurs frequently in children with juvenile idiopathic arthritis (JIA), and gadolinium-enhanced magnetic resonance imaging (Gd-MRI) has proved to be a sensitive diagnostic tool in this context. We compared the reliability of clinical examinations to Gd-MRI results in diagnosing the condition. METHODS: Patients with JIA (134 consecutive) underwent routine clinical and Gd-MRI examinations. The clinical items examined were clicking, tenderness (TMJ/adjacent muscles), and mouth-opening capacity. Blinded MRI reading focused on inflammation (synovitis/hypertrophy). After statistical power analysis, the clinical findings for 134 healthy controls were included. Contingency analysis was used to determine the sensitivity, specificity, and frequency of clinical symptoms (JIA/healthy controls); Cohen's κ was used to establish the interrater reliability. RESULTS: Statistically significant differences were observed between JIA and healthy control groups with regard to the concise screening items (power analysis > 0.95), whereas no differences in mouth-opening capacity were noted. In 80% of the patients with JIA, Gd-MRI revealed signs of TMJ arthritis, with positive correlations between concise screening items and Gd-MRI results. The average specificity was 0.81, but the sensitivity was low, at 0.42. Combining items led to a marked increase in the sensitivity (0.73). There was a high rate of both false-negative and false-positive results (corresponding to clinical underdiagnosis or overdiagnosis of TMJ arthritis). CONCLUSION: Despite a relatively high specificity, clinical examination alone does not seem sufficiently sensitive to adequately detect TMJ arthritis. Thus, a relatively high number of cases will be missed or overdiagnosed, potentially leading to undertreatment or overtreatment. Gd-MRI may support correct diagnosis, thereby helping to prevent undertreatment or overtreatment.
OBJECTIVE: Temporomandibular joint (TMJ) arthritis, commonly considered oligoarthritic/asymptomatic, occurs frequently in children with juvenile idiopathic arthritis (JIA), and gadolinium-enhanced magnetic resonance imaging (Gd-MRI) has proved to be a sensitive diagnostic tool in this context. We compared the reliability of clinical examinations to Gd-MRI results in diagnosing the condition. METHODS:Patients with JIA (134 consecutive) underwent routine clinical and Gd-MRI examinations. The clinical items examined were clicking, tenderness (TMJ/adjacent muscles), and mouth-opening capacity. Blinded MRI reading focused on inflammation (synovitis/hypertrophy). After statistical power analysis, the clinical findings for 134 healthy controls were included. Contingency analysis was used to determine the sensitivity, specificity, and frequency of clinical symptoms (JIA/healthy controls); Cohen's κ was used to establish the interrater reliability. RESULTS: Statistically significant differences were observed between JIA and healthy control groups with regard to the concise screening items (power analysis > 0.95), whereas no differences in mouth-opening capacity were noted. In 80% of the patients with JIA, Gd-MRI revealed signs of TMJ arthritis, with positive correlations between concise screening items and Gd-MRI results. The average specificity was 0.81, but the sensitivity was low, at 0.42. Combining items led to a marked increase in the sensitivity (0.73). There was a high rate of both false-negative and false-positive results (corresponding to clinical underdiagnosis or overdiagnosis of TMJ arthritis). CONCLUSION: Despite a relatively high specificity, clinical examination alone does not seem sufficiently sensitive to adequately detect TMJ arthritis. Thus, a relatively high number of cases will be missed or overdiagnosed, potentially leading to undertreatment or overtreatment. Gd-MRI may support correct diagnosis, thereby helping to prevent undertreatment or overtreatment.
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