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


A systematic electronic literature search in the five main databases, Medline Ovid, Embase, CINAHL, SweMed+ and Cochrane Library, took place during the period 24.11.2017–01.12.2017. The search was later updated 25 Nov 2018. The search consisted of a combination of free text words and subject headings (i.e. MeSH, Emtree). In addition, manual searches in the reference lists of included articles were conducted. The details of search terms used for the different databases are presented in Additional file Table 1: S1.

Inclusion and Exclusion Criteria

This review primarily reports articles restricted to peer-reviewed journal articles published in English, German, Norwegian, Swedish or Danish during the period 1998 through 25 Nov 2018 covering children and adolescents' age groups. Randomised controlled trials (RCTs), controlled clinical trials (CTs), cohort studies, cross-sectional studies or case-control studies were included. The exclusion criteria were systematic reviews, meta-analyses, case reports, conference publications and grey literature. Grey literature was excluded as this type can vary considerably and often be affected by low standard of quality, review and production. In addition, studies lacking comparing groups (i.e. groups without JIA) were excluded for the analyses purpose. Lastly, as another systematic review is planned, articles mainly addressing saliva variables and orthodontic considerations in children and adolescents with JIA, were excluded.

Search Strategy

PRISMA[41] was followed as a guide for reporting this systematic review and meta-analysis. The levels followed in the literature search were as follows: 1) title and authors, 2) abstracts, and 3) full text. For abstracts decided to be within the scope of interest, full-text articles were read. Two reviewers (MSS and AB) independently evaluated studies for inclusion, and studies were selected after reading abstracts, and selected full-text articles. When abstract selection was not straightforward and the reviewers were in doubt, full-text articles were re-read by both reviewers and resolved by discussion. A flow diagram is presented as Additional file 5: Figure. S1.

Figure S1.

PRISMA flow diagram of review


Oral health and OHRQoL were assessed among children and adolescents with JIA and among those without JIA, and these examination data constituted the outcomes. Any outcome measures with information outside the scope of this review, but within included articles, are not mentioned. An overview of key information from the final evaluation is shown in Table 1 and Table 2 in a similar way as a previous systematic review.[74]

Qualitative Assessment

Central themes and topics from the PICOS (participants, interventions, comparators, and study design) approach were only to some extent extracted in Table 1 and Table 2 as an intervention was not the focus. The characteristics considered important for the evaluation of reliability and validity, were study design, level of control matching, exclusion criteria, non-respondents, sample size, calibration procedures, number of examiners, documentation of JIA history (activity assessment, laboratory evaluation, medication), applied imaging type, and oral health diagnostic tools. MSS conducted the data extraction and checked by AB for accuracy. Assessment of risk of bias was performed based on an adapted version of the Newcastle – Ottawa Scale (NOS),[75] which was further modified in support of this systematic review (Additional file 2: Table S2). Scoring was performed by two authors (MSS and AB), but in case of discrepancies, a third author (AS) was consulted. The range of the scores was from 0 to 10 (low risk of bias = overall scores were 9–10, medium risk of bias = 6–8, high risk of bias = 0–5). Summarized scores of each study are presented in Additional file 3: Table S3.

Statistical Analysis

It was not possible to perform meta-analysis of oral health outcomes regarding oral hygiene (dental plaque and calculus accumulation), periodontal disease (gingivitis included), enamel defects, tooth calcification (dental maturation) disorders, TMJ arthritis, TMJ involvement, TMD, oral ulcerations, and OHRQoL. The reasons include inadequate sample size, poor study quality, use of inconsistent definitions of outcomes (e.g. periodontitis assessment) or studies that failed to report number of children and adolescents with JIA. Nevertheless, meta-analyses for dental caries was performed. Two separate meta-analyses were conducted using continuous outcomes: dmft score (decayed/missed/filled primary teeth) and DMFT score (decayed/missed/filled permanent teeth). We used random-effect model[76] to calculate pooled mean differences between dmft/DMFT scores of children and adolescents with JIA and those without JIA. The articles that did not report dmft or DMFT score or standard deviation were excluded from this meta-analysis. The heterogeneity between the studies were quantitatively assessed by the Q-test and I2 statistics.[77] I2 is the proportion of total variation explained by between-study variation. I2-values of 0, 25, 50% and ≥ 75% indicates no, low, moderate and high heterogeneity, respectively. Publication bias was assessed by inspection of funnel plots for asymmetry and using Egger's test[78] and Begg-Mazumdar test.[79]

A two tailed p < 0.05 was considered statistically significant. Statistical analyses were performed using Stata, version 15.0 software (StataCorp, Texas, USA).