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TEMPOROMANDIBULAR JOINT
Effectiveness of Dexamethasone Iontophoresis in Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis
Rina Mina, MDCincinnati Children’s Hospital Medical Center
TMJ and Rheumatology
TMJ
JIA
Myofascial pain
syndromes
Others
Isolated TMJ
arthritis
TMJ Involvement in JIA
• Prevalence: 25-80%• Frequently asymptomatic • Seen in all subtypes of JIA
JIA Subtype PrevalenceOligoarthritis 29-39%
Polyarthritis: RF positive 9-33%
Polyarthritis: RF negative 22-59%Systemic arthritis 2-67%Psoriatic arthritis 13-33%
Enthesitis-related arthritis 13-16%
TMJ damage
*Shaw. J Rheum, 2004
Risk factors for damage*
Longer disease duration
Younger age at onset
Decreased translation
Decreased mouth opening
*Inconsistent associations with subtypes, ANA +, HLA B27+
Gaps in TMJ
• Clinically important difference
• Role of MRI• Biology (? animal models)• Therapy
• New biologics• Surgery
Therapy
Therapy*
Medical: MTX (Ince 2000) and Biologics (Moen 2005)Physical therapy
Surgical
Steroid injection
*Best therapy is unknown
Study # pts Follow-up Results
Saurenmann 2008 21 42 days
MIO increased by 1.8 mmPain resolved in 5 patientsSynovial enhancement resolved in 6/36
Ringold2008
25 26 months
MIO increased by 6.6 mm1 skin atrophy
Tzaribahev2007
10 3 months
Synovial enhancement resolved in all, improvement asymmetric mouth opening
Arabshahi2005
23 6-12 months MIO increased by 5 mmPain resolved in 10/132 facial swelling
TMJ: Steroid Injection
Iontophoresis• Process whereby ions in solution
are transferred through intact skin via electrical potential using bipolar electrodes
• 1st done by LeDuc in 1908 when he demonstrated that ions could be driven across the skin by means of an electrical current
*Harris P. J Ortho & Sports PhysTher. 1982
Iontophoresis• Numerous applications of iontophoresis for
disorders of the skin, muscle, joints, dental procedures
• Utilized to achieve anesthesia for minor surgery
• Decrease inflammation in soft tissue & around joints• Drug administration: Lidocaine, Ketorolac,
Diclofenac, Dexamethasone
*Harris P. J Ortho & Sports PhysTher. 1982
Iontophoresis: Laboratory Studies
• Rhesus monkeys: radiolabeled dexamethasone sodium phosphate was iontophoresed into the tissue overlying the elbow, shoulder, hip, knee and ankle
• Results demonstrated that the dexa was transferred iontophoretically into all tissue underlying the electrode down to, and including, tendinous structures and cartilaginous tissues
* Petelenz TJ, et al. J Controlled Release.1992
Study Results Comments
Shiffman EL, et al. J OrofacialPain 1996
Dexamethasone and lidocaine ionto was effective in improving mandibular function, but not in reducing pain, in TMJ disc replacement without reduction
small size of the study;did not present p-values comparing the randomized groups for the pain and changes in mobility outcomes
Reid KJ, et al. Oral Surg Oral Med Oral Pathol 1994
Dexamethasone and lidocaine ionto did not improve self-reported pain measured by a VAS or mandibular range-of-motion compared to placebo.
small study; authors did not report numbers for these outcomes (they only reported statistical significance) heterogeneous sample (disk replacement with reduction; disk replacement without reduction and OA)
TMJ: Iontophoresis
Dexamethasone Iontophoresis: CCHMC Protocol• 8 to 12 sessions over 4-6 wks• Iontophoresis equipment :
bipolar electrodes, the drug delivery (negative electrode for dexamethasone) and the dispersive (receiving) electrode
• Drug delivery electrode: added 1.5 mL of dexamethasone sodium phosphate (6 mg)
• Active electrode adhered over TMJ treatment• Dispersive electrode adhered over the trapezius or biceps
muscle (same side)• Electrical current initiated at 1mA for the first minute of
treatment then increased slowly total current-dosage ~ 40 mA
Methods
• Retrospective analysis of charts of JIA patients who underwent the procedure “dexamethasone iontophoresis” from 1997 to 2010 using the billing database of the Division of Occupational (OT) and Physical Therapy (PT) in Cincinnati Children’s Hospital Medical Center
• Chart abstraction: RM, PM, SP• Excluded: charts with only 1 data point,
diagnosis other than JIA
Methods
• Primary endpoint: maximal incisor opening
• Secondary endpoint: pain, clicking, labs, imaging, adverse /side effects
• Statistics: paired t-test, anova, mixed effects modeling
Predictors (covariates)
• Baseline measurements• Number of sessions• Patient age• JIA subtype• Joint count• Concomitant medications• Presence of side-effects• TMJ-disease duration• JIA duration
*Labs and imaging only in select number of patients
Number of patients 25
Age: median ± IQR (range) 13 ± 8.5 years (2-21 years)Gender : Female/ Male 21 (84%)/ 4 (16%)Race: Caucasian/ African-American/ Asian 23 (92%)/ 1 (4%)/ 1 (4%)JIA subtype: Oligo extended 1 (4%)Oligo persistent 8 (32%)Poly RF negative 11 (44%)Poly RF positive 2 (8%)Psoriatic 1 (4%)Enthesitis-related 2 (8%)
Results: Patient Characteristics
Results: Patient Characteristics
Number of joints: median ± IQR 6 ± 9 (2-16)ESR: median ± IQR 5 ± 7MRI 10 patients, only 2 pairedUveitis 5 (20%)Duration JIA: median ± IQR (range) 24 ± 39 mos (4-84 mos)Duration of TMJ disease: median ± IQR (range) 3 ± 12.5 mos (1-24 mos)Medications: number(%): NSAIDS 19 (76%)Methotrexate 9 (36%)Etanercept 2 (8%)Infliximab 1 (4%)Adalimumab 4 (16%)Prednisone 1 (4%)
Results
Side of Iontophoresis treatment: number (%)Bilateral 14 (56%)Right number 6 (24%)Left number 5 (20)Number of sessions: median ± IQR (range) 8 ± 2 (2-14)
Results: Primary Endpoints
TMJ range of motion
Number ofmeasurements
Baseline measurement: mean ± SD (range)(mm)
Final measurement: mean ± SD (range)(mm)
p-value
Maximal incisor opening 25
35.9 ± 10.1(20-55)
39.6 ± 7.2(26-55) 0.0002
PredictorsIncisor opening
Univariate Multivariate
Baseline measurements X XNumber of sessions X XPatient age
JIA subtype
Joint count XUse of methotrexate XUse of biologics
Use of NSAIDS
Use of prednisone
TMJ-disease duration
JIA duration
Predictors of Final Maximal Incisor Opening
Results: Maximal Incisor Opening
0
10
20
30
40
50
60
Pre-treatmentPost-treatment
mm
Patients
PredictorsChange in maximal incisor opening
Increased (n=17)
Decreased (n=2)
Same (n=6)
Baseline measurements (mm)median (range)
32 (20-45) 38.5 (27-50) 50 (36-55)
Number of sessionsmedian (range)
8 (5-14) 9 (7-11) 8 (2-10)
Patient age median (range) 11.5 10 15
JIA subtype All except PsA Oligopersistent,ERA
Oligopersistent, Poly, PsA
Joint count median (range) 7 (2-13) 9 (2-16) 2 (2-6)
Use of methotrexate (n) 5 (29%) 0 3 (50%)
Use of biologics (n) 6 (35%) 0 1 (17%)
Use of prednisone (n) 1 (6%) 0 0
TMJ-disease duration in mosmedian (range)
3 (2-24) 1.5 (1-2) 5 (3-24)
JIA duration median (range) 26 (5-84) 28.5 (4-53) 24 (11-24)
Secondary endpoints:number(%)
PresentPre-treatment
AbsentPost-treatment
TMJ pain 13 10 (77)%Clicking* 7 1 (14%)
Side effects: number(%)Site erythema (transient) 20 (80%)Blistering 1 (4%)Metallic taste 1 (4%)
Results: Secondary Endpoints
Conclusion
• Dexamethasone iontophoresis appears to be effective in the management of TMJ-involvement in JIA.
• Baseline TMJ measurements and number of sessions are associated with the final maximal incisor opening of JIA patients who underwent dexamethasone iontophoresis for TMJ-involvement.
• Prospective controlled-studies evaluating some protocol parameters are needed.
Limitation
• Retrospective• Imaging and lab effects• Effects of physical therapy
Acknowledgments
• Hermine Brunner• Maorapelli Rao• Paula Melson• Stephanie Powell• CCHMC Rheumatology
Vielen Dank
For questions, please e-mail:
rina.mina@cchmc.org
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