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


The aim of this systematic review was to investigate the relationship between oral health measures and OHRQoL among children and adolescents with JIA compared with peers without JIA. The present systematic review and meta-analysis includes mostly studies with cross-sectional design and the overall qualitative assessment of these studies was found to be low. As a wealth of information was reported, interpretation of the data needed a clear and thorough reporting of methodology, quality and bias.[82] Table 1 and Table 2 constituted the quality evidence basis when answering the research questions of the article. For dental caries, also caries meta-analysis (a quantitative method to combine data) was feasible.

Reviews published more than a decade ago have concluded that oral health in children with JIA is poor.[13,14] However, the articles examined in these reviews were from the 1970s and the 1980s. Conclusions from this review based on more recent research on the caries situation among children and adolescents with JIA, have not been easy to draw. Due to insufficient sample size in the study of Santos et al.,[29] the statistically lower dmft value among children with JIA compared with healthy peers, is not compact. The opposite conclusion drawn by Welbury et al.,[31] showing a higher mean dmft among 0–11-year-olds with JIA and a higher D component among 12–17-year-olds with JIA, is probably a more reliable finding due to higher sample sizes and a calibrated examiner. Nevertheless, as the total sample included many subgroups, the exact number in the two subgroups reported was not reassuring; the youngest subgroup of both individuals with and without JIA included 46 individuals, the older subgroup 32. Additionally, bitewing radiographs were not included in the caries examination, which actually meant an underscoring of approximal caries lesions and of total caries experience.[83] However, as both cases and controls were examined without bitewing radiographs, it was not necessary to take into account any bias in the comparison.

Although the present review evaluated eight articles with caries as subject, we could not conclude that caries was more prevalent among children and adolescents with JIA than among healthy peers. The findings from this meta-analysis on dental caries suggest no significant mean difference in dmft or DMFT between JIA affected individuals and not. One of the explanations for a possible improved caries status in individuals with JIA during the later years, might be the development of a more effective overall treatment of JIA.[84] Another explanation is the increased focus on oral health in JIA, including the development of other sweeteners and sugar alternatives used in medicines e.g. in NSAID mixtures.[16]

The finding that plaque, gingivitis and periodontitis were more common among children and adolescents with JIA than among those without JIA, constituted a consistent trait in the present review. The fact that so many studies drew this conclusion increased the quality of evidence supporting this result. Unfortunately, it was not possible to perform meta-analysis due to inconsistency of outcome definitions for periodontitis across the studies.

The present review lacked studies with focus on erosive wear, a condition which in later years has been reported to be as commonly distributed as caries in some groups of adolescents.[85,86] Only one study reported on enamel defects,[22] but it had very small sample size, so reliable information about the prevalence of this oral condition is still lacking. To the question of whether dental maturation was more advanced among patients with JIA than among healthy peers, there was no clear answer. The OPG radiographs in the study of Lethinen et al.,[24] dating from the late 1960s to the early 1980s, were therefore too old to represent today's patients, and the study of Ley et al.[87] instead of matched controls, compared the findings in children with JIA with normative values obtained from healthy Canadian, German and Dutch children. Conclusively, for dental erosive wear, enamel defects and dental maturation, there is no scientific evidence to answer the posed research questions.

Concerning TMJ arthritis and TMJ involvement, the present review consolidated the literature reporting these conditions to be more common in children and adolescents with JIA than in healthy counterparts.[88] However, not all the five included articles that described this topic had sufficient sample size to give reliable results,[22,35–38] but a higher frequency of surface flattening of the condylar head in children with JIA versus those without JIA, seemed to be a valid radiological feature, reported by Shwaikh et al..[35] Furthermore, TMD and structural TMJ changes were found to be more prevalent in children with JIA than in healthy peers,[38] and when comparing OHRQoL in the two groups, these were poorest among the children with JIA.[38] This was not a surprising result, taking into account that oral health definition includes all functioning without feeling pain or discomfort.

In order to answer the research question, whether OHRQoL only due to oral diseases/conditions restricted to the oral cavity is more common among those with JIA than those without, more studies related to this topic are needed. Only one study was included in the review concerning this topic: Santos et al.[29] documented that oral health status had little or no effect on well-being among both individuals with JIA and those without JIA.

To be able to respond to the second research question, whether the activity and severity of JIA had any impact on the prevalence of oral and TMJ diseases or oral conditions, larger sample sizes are needed before reliable answers can be given.

Strengths and Limitations

The strength when comparing children and adolescents with JIA with those without JIA, is that the overall oral health outcomes were taken into account and discussed elaborately. Another strength of the study was the adoption of PRISMA protocol[41] and the use of modified Newcastle-Ottawa Scale to comprehensively evaluate and assess the methodological quality of the selected studies.[75] Additionally, meta-analysis was performed for studies focusing on dental caries as an outcome. However, the present. systematic review was not without limitations. Firstly, majority of the included studies were cross-sectional in nature which is tied to high risk of bias. Secondly, due to inadequate studies and inconsistency of outcome definitions, only meta-analyses regarding dental caries, not regarding other oral diseases or conditions, could be performed. Thirdly, as grey literature was excluded in the present systematic review, the comprehensiveness of the search might have been reduced and therefore should be considered as a limitation of the review.[89]