Referral to Maxillofacial Specialist for TMJ Involvement in JIA
Yes, you should refer a patient with Juvenile Idiopathic Arthritis (JIA) to a maxillofacial specialist when there is evidence of TMJ involvement, as optimal TMJ arthritis management requires an interdisciplinary approach and longitudinal evaluation into adulthood regardless of current TMJ disease activity. 1, 2
Diagnostic Indicators for TMJ Involvement
- Contrast-enhanced MRI is currently the best method to detect active TMJ arthritis and should be used to confirm diagnosis before referral 1
- Progressive deviation in mandibular morphology and facial profiles (e.g., mandibular asymmetry/retrognathia) should prompt referral to maxillofacial specialists 1
- Even asymptomatic TMJ involvement is common in JIA patients, with studies showing 40-90% of patients have TMJ involvement that can lead to significant facial deformity if left untreated 3
- TMJ abnormalities often persist into adulthood, with one study showing 55% of adult JIA patients had TMJ abnormalities on imaging and 76% had facial asymmetry 4
Specific Indications for Maxillofacial Referral
- Presence of dentofacial deformity, which occurs most frequently in patients who experience TMJ arthritis prior to reaching skeletal maturity 1
- TMJ dysfunction that doesn't respond to systemic therapy or conservative management 1, 5
- Need for specialized treatments such as intraarticular lavage, orthodontic intervention, or consideration of surgical options 1
- Development of mandibular growth disturbances, which can cause severe craniofacial abnormalities if not addressed early 6, 7
Interdisciplinary Management Benefits
- Maxillofacial specialists can provide dentofacial orthopedics and orthodontics that may improve facial development, occlusion, and function in skeletally immature patients (100% agreement in guidelines) 1
- Skeletal surgery may be indicated in both skeletally immature and mature patients with dentofacial deformities and controlled TMJ arthritis (97% agreement in guidelines) 1
- Early intervention by maxillofacial specialists can prevent irreversible deformities that may require more extensive treatment later 8, 7
- Standardized orofacial examination by specialists helps monitor changes over time and assess treatment response 1, 5
Timing of Referral
- Early referral is recommended as TMJ arthritis often develops asymptomatically but can lead to significant facial deformity 7, 3
- Regular screening of JIA patients for TMJ involvement should occur at least annually during childhood and adolescence 3
- Referral should not be delayed until symptoms appear, as structural damage can occur before clinical symptoms manifest 6, 4
Caution and Considerations
- Avoid delaying referral based solely on absence of symptoms, as TMJ involvement in JIA is frequently asymptomatic 6, 3
- Be aware that TMJ abnormalities and related morbidity remain common in adult patients with a history of JIA, suggesting the need for long-term follow-up 4
- Recognize that intraarticular glucocorticoid injections (which may be administered by maxillofacial specialists) are not recommended as first-line treatment in skeletally immature patients 1, 2
Remember that early detection and interdisciplinary management of TMJ involvement in JIA patients can significantly improve outcomes and prevent long-term facial deformities that may impact quality of life 7, 4.