Oral Health in Children and Adolescents With Juvenile Idiopathic Arthritis

A Systematic Review and Meta-analysis

Marit S. Skeie; Elisabeth G. Gil; Lena Cetrelli; Annika Rosén; Johannes Fischer; Anne Nordrehaug Åstrøm; Keijo Luukko; Xieqi Shi; Astrid J. Feuerherm; Abhijit Sen; Paula Frid; Marite Rygg; Athanasia Bletsa


BMC Oral Health. 2019;19(285) 

In This Article


Juvenile idiopathic arthritis (JIA) is a common chronic rheumatic condition, affecting around 1 in 1000 children under the age of 16 years.[1,2] The incidence and prevalence of JIA varies across different studies globally, but by pooling data from several studies, it is estimated that around 60,000 children below 16 years are affected in Europe, with an estimated incidence of around 7000 new cases each year.[3] The incidence in the Nordic countries including Norway is among the highest in the world.[4] JIA comprises a group of distinct clinical entities of unknown aetiology, characterized by joint inflammation with symptoms persisting for more than six weeks and onset before 16 years of age.[5] Currently, it is classified according to the International League of Associations of Rheumatology (ILAR) as systemic arthritis, polyarthritis (Rheumatoid factor (RF) negative or positive), oligoarthritis (persistent or extended), enthesitis-related arthritis, psoriatic arthritis and undifferentiated arthritis.[5]

Long-term inflammation and use of anti-inflammatory drugs, such as corticosteroids, may cause disturbances in growth and pubertal development, overall bone maturation, and eventually the development of osteopenia with low bone mineral content and low mineral density. These consequences are found to be associated with the duration of active JIA and severity[6] and are more frequent in individuals with early-onset JIA.[7]

Overload of bacteria is considered as a possible trigger of rheumatic arthritis (RA) in adults.[8] This means that the oral cavity, one of the most bacteria colonised parts of the body and hosting nearly 800 species of bacteria,[9] should be kept free from oral diseases. When the oral microbiota[10] shifts from balance to imbalance (dysbiosis), e.g. during rapid caries development, bacteria might pass through exposed dentine, pulp or periapical bone to the bloodstream.[11] In case of plaque accumulation at gingival margins or during ongoing gingivitis or periodontitis, bacteria might pass the blood stream through periodontal pockets, or through the oral mucosa directly if there is oral mucositis or ulcer. In patients with RA, dysbiosis has been detected in the gut and oral microbiomes (dental and saliva microbiome) and has been found to be correlated with clinical measures of RA status and to be altered compared with healthy individuals.[12]

Individuals with JIA may be subjected to unfavourable underlying oral health determinants. If JIA reduces functional ability of the upper limbs, effective tooth brushing and plaque removal will be difficult. Plaque removal might also be impeded in children with JIA with restriction in mouth opening.[13] When JIA is accompanied by impaired masticatory function, consumption of softer and more sugary foods in small amounts might be more convenient.[14] Frequent and long-term intake of liquid oral medication with sugary or acidic content has previously been reported in children with JIA,[15] but today sugar-free alternatives exist,[16] and there is reason to believe that such intake is more rare. Knowledge of intra-oral adverse effects and frequency of side effects of modern long-term administration of anti-rheumatic drugs, is hitherto scarce.

Temporomandibular disorder (TMD) is an umbrella term including Temporomandibular joint (TMJ) involvement as well as localized pain in the masticatory muscles, decreased mouth opening and chewing ability, pain associated with mandibular movement during eating, chewing or yawning, and comorbidities such as earache and headache.[7] A high proportion of children with JIA might have involvement of the TMJ during disease course.[17] The consequences of local inflammation in the TMJs may involve local growth disturbances and as a consequence impaired mandibular growth.[18] Development of malocclusion and facial deformities such as micro- or retrognathia, are later scenarios associated with established permanent sequelae in the TMJ.[7] To identify TMJ arthritis early enough to prevent permanent growth disturbances and joint damage, it is important to recognize all clinical symptoms associated with JIA involvement. A challenge is that TMJ arthritis might evolve without or with TMD symptoms, especially in the youngest children who are unable to communicate and localize their pain adequately.[7] Thus, early detection of TMD by imaging signs of inflammation in the joints is essential.

In 2016, the key part of Vision 2020[19] was approved, including an upgraded definition of oral health which is estimated to be multifaceted and to include different attributes of oral health. The new definition not only includes disease and condition status, but also underlying determinants, moderating factors, overall health and well-being. Thus, the ability to speak, smile, smell, taste, touch, chew, swallow and express emotions, functioning without feeling pain or discomfort, are integrated components in oral health. Children and adolescents with TMJ arthritis, may experience reductions in one, some or all these abilities, resulting in both reduced quality of life (QoL)[20] and reduced oral health-related quality of life (OHRQoL).[21] For the group of children and adolescents with JIA, documentation of reduced OHRQoL due to oral diseases restricted to the oral cavity, e.g. dental caries, dental erosion, and not including jaw symptoms, is sparse.

Whether children and adolescents with JIA have a heavier burden of oral conditions and as a consequence, experience reduced OHRQoL, is not clearly established. For this reason, the aims of this systematic review were to gain reliable information on the following research questions;

  1. Is oral health and oral health-related quality of life poorer among children and adolescents with JIA than among their healthy peers?

  2. Does the activity and severity of JIA have any impact on the prevalence of oral and TMJ diseases or oral conditions?