Rheumatoid arthritis (synonyms: Arthritis; Chronic polyarthritis; Polyarthritis chronica progressiva; Polyarthritis rheumatica; Primary chronic polyarthritis; Primary chronic polyarthritis; Rheumatoid arthritis; pcP; ICD-10: M06.- – Other chronic polyarthritis) is a chronic inflammatory multisystem disease that usually manifests as synovitis (inflammation of the synovial membrane). It is also referred to as primary chronic polyarthritis (PcP). Only rheumatoid arthritis of the temporomandibular joints is described below.
Symptoms – Complaints
In the context of temporomandibular joint arthritis (ICD:10 – K 07.6 – Diseases of the temporomandibular joint; temporomandibular arthralgia), destruction of the temporomandibular joint head occurs. As a result, retrognathia (mandibular recession) combined with a frontal open bite develops. The ability to move the mandible is painfully restricted, and ankylosis (joint stiffness – ICD:10 – M24.68 Ankylosis of a joint, other [neck, head, ribs, trunk, skull, spine]) may occur in the course of the disease. Friction sounds may also be heard due to the changes in the joint. Only one of the temporomandibular joints may be affected, but usually the symptoms are present on both sides. The pain of temporomandibular joint arthritis is constant and increases with movement of the lower jaw. Radiation of the pain into the neck and/or masticatory muscles is possible. Sometimes other joints besides the temporomandibular joint are affected by rheumatoid arthritis. In children, facial growth may be impeded by the disease.
Pathogenesis (disease development) – etiology (causes)
In rheumatoid arthritis, there is immigration of inflammatory cells – macrophages and T lymphocytes – into the synovial membrane (inner lining of the joint capsule) and release of proinflammatory (inflammation-promoting) cytokines such as interleukin-1b and TNF-α – tumor necrosis factor alpha – which contribute significantly to joint destruction. It is not yet scientifically clear which causes are responsible for this chronic inflammatory process. It is assumed that it may be an autoimmune disease. In some cases, a genetic predisposition (disposition) with HLA-DR4 expression can be demonstrated. Rheumatoid arthritis is also thought to be a response of the body to infection with an as yet unidentified pathogen-mycoplasma, Epstein-Barr virus (EBV), cytomegalovirus (CMV), parvovirus, and rubellavirus are suspected.Because rheumatoid arthritis occurs throughout the world, it has been hypothesized that the infectious agent should also be present worldwide.
Consequential Diseases
Ankylosis (joint stiffness) may occur in the temporomandibular joints.
Diagnostics
To make a diagnosis, a thorough pain history must be taken. Likewise, the temporomandibular joint and surrounding muscles are examined by palpation (palpation) to determine any hardening or painfully tight muscles. The temporomandibular joint can be listened to in order to detect any friction noises that may be present. Diagnostics also include taking an x-ray of the head or the temporomandibular joint. If necessary, a computer tomography (cranial CT; cCT) or a magnetic resonance imaging (cranial MRI; cMRI) can be performed to confirm the diagnosis. Radiologic findings include a narrowed joint space and changes in the condyle (temporomandibular joint head). These include erosive changes or flattening of the condyle to its complete resolution.
Therapy
After diagnosis, depending on the extent of the disease, an initial attempt is made to treat purely conservatively. Antirheumatic drug therapy is always performed in collaboration with a rheumatologist. Intra-articular injections can be performed with various drugs. These include the combination of dexamethasone with lidocaine for more inflammatory symptoms and hyaluronic acid, which alleviates more arthritic symptoms. Physical therapy and physiotherapy are also used to treat rheumatoid arthritis of the temporomandibular joints. Among other things, mouth opening and movement exercises are performed here. To relieve the jaw joint, so-called bite splints can be made and used. In severe cases – when ankylosis occurs – surgical treatment may be necessary.However, this is only performed when the disease has gone into remission. After surgical resolution of ankylosis, reankylosis of the joint occurs in five to eight percent of cases.
