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