Shelly Abramowicz

Alterations in Diversity of the Oral Microbiome in Pediatric Inflammatory Bowel Disease

Background: Oral pathology is a commonly reported extraintestinal manifestation of Crohns disease (CD). The host–microbe interaction has been implicated in the pathogenesis of inflammatory bowel disease (IBD) in genetically susceptible hosts, yet limited information exists about oral microbes in IBD. We hypothesize that the microbiology of the oral cavity may differ in patients with IBD. Our laboratory has developed a 16S rRNA‐based technique known as the Human Oral Microbe Identification Microarray (HOMIM) to study the oral microbiome of children and young adults with IBD. Methods: Tongue and buccal mucosal brushings from healthy controls, CD, and ulcerative colitis (UC) patients were analyzed using HOMIM. Shannon Diversity Index (SDI) and Principal Component Analysis (PCA) were employed to compare population and phylum‐level changes among our study groups. Results: In all, 114 unique subjects from the Childrens Hospital Boston were enrolled. Tongue samples from patients with CD showed a significant decrease in overall microbial diversity as compared with the same location in healthy controls (P = 0.015) with significant changes seen in Fusobacteria (P < 0.0002) and Firmicutes (P = 0.022). Tongue samples from patients with UC did not show a significant change in overall microbial diversity as compared with healthy controls (P = 0.418). Conclusions: As detected by HOMIM, we found a significant decrease in overall diversity in the oral microbiome of pediatric CD. Considering the proposed microbe–host interaction in IBD, the ease of visualization and direct oral mucosal sampling of the oral cavity, further study of the oral microbiome in IBD is of potential diagnostic and prognostic value. (Inflamm Bowel Dis 2011;)

Magnetic Resonance Imaging of Temporomandibular Joints in Children With Arthritis

PURPOSE The aim of the present study was to describe the gadolinium-enhanced magnetic resonance imaging (MRI) features of temporomandibular joints (TMJs) in children with arthritis. These findings would facilitate the early diagnosis of disease and/or relapse. MATERIALS AND METHODS In the present retrospective study, 2 pediatric radiologists reviewed consecutive MRI scans of the TMJs of children with a definitive diagnosis of juvenile idiopathic arthritis (JIA), including oligoarthritis, polyarthritis, and juvenile psoriatic arthritis. For each MRI scan, specific criteria were evaluated, including the condylar head, condylar fossa, articular eminence, disk shape and position, joint effusion, synovium, intra-articular space, and jaw motion. RESULTS A total of 48 patients with mean age of 11.2 years who had been diagnosed with JIA were reviewed. The most common abnormal findings (in order of frequency) were erosion of the condylar head (n = 38), synovial enhancement (n = 35), articular surface flattening (n = 20), abnormalities in jaw motion (n = 26), intra-articular space enhancement (n = 20), subchondral sclerosis of articular eminence (n = 12), joint effusion (n = 9), deformed/displaced disk in the open or closed position (n = 9), bone marrow edema (n = 8), sclerosis of fossa (n = 3), sclerosis of head (n = 3), and the presence of osteophytes (n = 1). Comparing each category of MRI findings, no significant gender differences were found. CONCLUSIONS Children with JIA who have undergone MRI of their TMJs typically present with more than 1 abnormal radiographic finding consistent with synovitis. Although the presence or absence of each MRI finding did not differ among the arthritis types, bilateral synovial enhancement and bilateral condylar head articular surface flattening were more common in JIA than in juvenile psoriatic arthritis. These findings suggest that MRI should play an important role in the diagnosis and assessment of TMJ involvement in children with JIA.

Contemporary Imaging of the Temporomandibular Joint

This article discusses imaging techniques for visualization of the temporomandibular joint. Conventional plain film modalities are discussed briefly, with an emphasis on the more contemporary modalities, such as CT with cone-beam technology, MRI, and nuclear imaging, including single-photon emission computed tomography, and positron emission tomography. Indications, advantages, and limitations are discussed. As advancements in this area continue, our understanding of this complex joint and its pathology will follow, which will lead to more defined imaging indications and ultimately, to improved treatment outcomes.

Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation.

PURPOSE Many different surgical techniques for the treatment of chronic recurrent temporomandibular joint (TMJ) dislocation have been described. This article discusses a technique of autologous blood injection to the TMJ for treatment of chronic recurrent TMJ dislocation. MATERIALS AND METHODS Twenty-five patients diagnosed with chronic recurrent TMJ dislocation were treated by bilateral injections of autologous blood into the upper joint space and around the TMJ capsules bilaterally. RESULTS Eighty percent had a successful outcome and required no further treatment at their 1-year follow-up. CONCLUSION This procedure has proven to be safe, simple, and cost effective for the treatment of chronic recurrent TMJ dislocation.

20-Year Follow-Up Study of Disc Repositioning Surgery for Temporomandibular Joint Internal Derangement

PURPOSE The purpose of this study was to assess the outcomes of temporomandibular joint (TMJ) disc repositioning as a surgical treatment for TMJ internal derangement (ID). MATERIALS AND METHODS By retrospective chart review, all patients who had TMJ disc repositioning for treatment of TMJ ID from 1984 to 1990 were identified. Attempts were made to locate these patients, and they were sent a TMJ questionnaire. The questionnaire provided subjective (pain and diet consistency) and objective (mandibular function) data. RESULTS The chart review yielded 153 patients. Complete TMJ questionnaires were obtained from 18 patients (36 joints). Analysis of data showed a reduction in pain scores, an improvement in diet consistency, and an increase in mandibular range of motion. The majority (94%) reported an improvement in quality of life. CONCLUSIONS Outcome data presented show that TMJ disc repositioning is an effective and successful surgical treatment for TMJ ID. This success has been maintained for 20 years in this specific patient population.

Physical findings associated with active temporomandibular joint inflammation in children with juvenile idiopathic arthritis.

PURPOSE To identify the physical findings associated with active temporomandibular joint (TMJ) inflammation (ie, synovitis) in children with juvenile idiopathic arthritis (JIA). PATIENTS AND METHODS This was a retrospective study of children with JIA evaluated at Boston Childrens Hospital. The patients were included if they had a confirmed diagnosis of JIA and had undergone a TMJ magnetic resonance imaging (MRI) study with contrast. Medical records and imaging studies were reviewed to document the demographic, physical (ie, facial asymmetry, joint noises, maximal incisal opening, deviation on opening, occlusal cant), and MRI findings. The outcome variable was TMJ synovitis on the MRI study. Descriptive and bivariate statistics were computed. Multiple regression models were used to identify associations (P ≤ .05, significance). RESULTS A total of 51 patients with JIA were evaluated during the study period. Of these, 43 patients (33 girls) with a mean age of 11.4 years met the inclusion criteria. MRI demonstrated TMJ synovitis in 27 patients. The age-adjusted limited maximal incisal opening (MIO) and deviation on opening were the only physical findings significantly associated with synovitis on MRI (P = .003 and P = .043, respectively). Using these parameters as predictors of synovitis, a limited MIO and deviation on opening had a high specificity (86% and 94%, respectively). Patients with a limited MIO were 6.7 times more likely to have synovitis than those with a normal MIO. All patients with a limited MIO and deviation on opening had TMJ synovitis on the MRI scan. CONCLUSIONS The results of this study indicate that, in children with JIA, limited MIO and deviation on opening can be used to predict the presence of TMJ synovitis. Documentation of these parameters should be an essential part of the clinical examination and longitudinal follow-up of children with JIA.

Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management

The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.

Total alloplastic temporomandibular joint reconstruction using Biomet stock prostheses: the University of Florida experience.

The purpose of this study was to report the subjective and objective outcomes of temporomandibular joint (TMJ) replacement with Biomet stock prostheses at a single institution in Florida. In this retrospective study, patients who underwent TMJ replacement using a Biomet stock prosthesis from 2005 to 2012 were analyzed. Subjective (pain, diet) and objective (maximal incisal opening) information was obtained. In addition, a quality of life measure was obtained pre- and postoperatively. Significance was set at <0.01. Thirty-six patients (26 bilateral, 6 left, and 4 right) who underwent TMJ replacement using a Biomet stock prosthesis were eligible for the study. Maximal incisal opening improved from 26.1mm preoperatively to a mean of 34.4mm postoperatively. The pain score decreased from 7.9 preoperatively to a mean of 3.8 postoperatively. Diet restriction decreased from 6.8 preoperatively to a mean of 3.5 postoperatively. Quality of life improved from a median of 4 preoperatively to a postoperative median of 2. Four implants were removed/replaced because of heterotopic bone formation, infection, and/or loose hardware. Follow-up ranged from 6 to 83 months. Overall, TMJ reconstruction using the Biomet stock joint is effective and safe in this patient population.

Are Panoramic Radiographs Predictive of Temporomandibular Joint Synovitis in Children With Juvenile Idiopathic Arthritis

PURPOSE To identify specific panoramic radiographic findings associated with temporomandibular joint (TMJ) synovitis in children with juvenile idiopathic arthritis (JIA). MATERIALS AND METHODS This was a retrospective study of children with JIA evaluated at Boston Childrens Hospital. Patients were included if they had a confirmed diagnosis of JIA, a panoramic radiograph, and a contemporaneous TMJ magnetic resonance imaging (MRI) study with contrast. Medical records and imaging studies were reviewed to document demographic, panoramic (accentuated antegonial notch, short ramus and condyle unit [RCU] length, and abnormal condyle morphology: decreased condyle anteroposterior or superoinferior dimension) and MRI findings. The outcome variable was the presence or absence of TMJ synovitis on MRI. Descriptive and bivariate statistics and logistic regression models were used to identify associations (significant at P ≤ .05). RESULTS Thirty patients (21 girls) with a mean age of 11.1 years (range, 5 to 16 yr) met the inclusion criteria. Of these, 15 patients had MRI scans positive for synovitis (bilateral in 18 joints in 9 patients and unilateral in 6 joints in 6 patients). The remaining 15 patients did not have evidence of synovitis on MRI. In the synovitis group, 18 of 24 joints (75%) showed abnormal panoramic findings (abnormal condyle morphology in 18 joints, accentuated antegonial notch in 9 joints, or short RCU length in 5 joints). In the nonsynovitis group, 15 of 36 joints (42%) showed abnormal panoramic findings (abnormal condyle morphology in 12 joints, accentuated antegonial notch in 6 joints, or short RCU length in 4 joints). Abnormal condyle morphology and accentuated antegonial notching on panoramic radiographs were found to be significantly correlated with synovitis (P = .0005 and .044, respectively). In a logistic regression model, abnormal condyle morphology was significantly associated with an increase in likelihood of TMJ synovitis versus those joints with normal condyle morphology (P = .007). Joints with abnormal condyle morphology and accentuated antegonial notching were 7.5 times as likely to have synovitis (P = .009) versus those joints without abnormal panoramic findings. CONCLUSION Results of this preliminary study indicate that in this sample of children with JIA, the combination of abnormal condyle morphology and accentuated antegonial notching on a panoramic radiograph correlates with TMJ synovitis on MRI.

Validation of the GILLS score for tongue-lip adhesion in Robin sequence patients.

BackgroundThe GILLS score consists of gastroesophageal reflux disease, preoperative intubation, late surgical intervention, low birth weight, and syndromic diagnosis. The purpose of this study was to test the validity of the GILLS score in predicting success of tongue-lip adhesion (TLA) in managing Robin sequence. Materials and MethodsInfants with Robin sequence were included in the study if they had a TLA for airway compromise subsequent to formulation of the GILLS scoring system, that is, they were not included in the original GILLS analysis. The patients were prospectively considered based on the presence of the 5 factors that constitute the GILLS score. A score of ⩽2 predicts success of TLA. ResultsTwenty patients met the inclusion criteria. Tongue-lip adhesion managed the compromised airway in 18 (90%) of 20 patients. Overall, the GILLS score had a sensitivity of 83%, specificity of 50%, positive predictive value of 94%, and negative predictive value of 25%. ConclusionsThe GILLS score accurately predicts a successful outcome for TLA in infants with Robin sequence. For infants with a score of 2 or less, TLA is the procedure of choice. Infants with a GILLS score of 3 or greater were 5 times more likely to fail TLA than those with a score of 2 or less. In these patients, other methods of managing the airway should be considered.