Background/Purpose: Temporomandibular joint (TMJ) arthritis occurs in as much as 80% of children with juvenile idiopathic arthritis (JIA) and can result in substantial facial deformity. TMJ arthritis often responds poorly to systemic immunosuppressive therapy. Intra-articular corticosteroid injections (IACI) are of benefit in approximately 50% of JIA patients with TMJ arthritis, but repeated injections are often ineffective. Multiple studies have shown benefit of IA infliximab injections (IAII) in treating chronic arthritis, including to the TMJ in one case report, so we used IAII of the TMJs in JIA patients with TMJ arthritis refractory to both repeated IACI and to systemic arthritis therapy.

Methods: Chart review was performed for all children with JIA treated at a single center who received one or more IAII (5-10 mg/injection) to the TMJs. Outcomes assessed were maximal incisal opening (MIO) measurements and pre- and post-contrast magnetic resonance imaging (MRI) findings. Specifically, we compared pre- versus post-IACI and pre- versus post-IAII MRI studies for changes in the acute (synovial fluid, synovial enhancement, marrow edema) and chronic (synovial hypertrophy, condylar head flattening and erosions, disc displacement) findings associated with TMJ arthritis. Assessments of improved, unchanged, or worsened were made by two independent reviewers based upon the official reports, and adjudicated by a radiologist based upon the actual films in instances of disagreement. Institutional Review Board, and Hospital Pharmacy and Therapeutics Committee, approvals were obtained prior to reporting and treating, respectively.

Results: 24 children with JIA and treatment-refractory TMJ arthritis underwent bilateral IAII of the TMJs, of whom 23 had MRIs at all three timepoints (pre-IACI, post-IACI, post-IAII). 23 / 24 (96%) were on a biologic, with or without concurrent conventional disease-modifying agents; 1 child received methotrexate as monotherapy. Their MIOs (mean ± SEM; in mm) were unchanged before and after both IACI (44.0 ± 1.3 versus 44.6 ± 0.7, p = 0.813) and IAII (44.6 ± 0.7 vs 44.5 ± 0.9, p = 0.840.) However, MRIs revealed improved or halted progression of acute changes in 31 out of 46 TMJs (67%) and of chronic changes in 29 out of 46 TMJs (63%), compared to 15/46 (33%) and 19/46 (41%), respectively, with repeated use of IACI (p = 0.002 and 0.052, respectively). No side effects (infections, nerve damage, cosmetic alterations, prolonged discomfort) were noted after 7.4 person-years of follow-up among 22 patients.

Conclusion: IAII halted or reversed the progression of TMJ arthritis in the majority of JIA patients who were refractory to systemic arthritis therapy and repeated IACI TMJ injections. The IAII TMJ injections were safe in the short term. It remains unknown whether repeated injections of IAII will be of benefit to treatment refractory TMJ arthritis in children with JIA. Future studies will evaluate the efficacy of infliximab versus long-acting corticosteroid injections as initial therapy for TMJ arthritis in children with JIA.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/safety-and-efficacy-of-intra-articular-infliximab-therapy-for-treatment-resistant-temporomandibular-joint-arthritis-in-children/