J Oral Maxillofac Surg

66:1804-1811, 2008

Targeted Assessment of the

Temporomandibular Joint in Patients
With Rheumatoid Arthritis
Ricardo V. Bessa-Nogueira, DDS, MSc,*
Belmiro Cavalcanti do Egito Vasconcelos, PhD,†
Angela P. Duarte, MD, PhD,‡ Paulo S.A. Góes, DDS, PhD,§ and
Tácio P. Bezerra, DDS储

Purpose: This observational study was done to identify the signs and symptoms of temporomandibular
joint (TMJ) involvement in patients with rheumatoid arthritis (RA) and to assess the association between
these and quantitative measurements for the evaluation of rheumatologic disease.
Patients and Methods: The sample comprised 61 patients suffering from RA whose signs and
symptoms of TMJ were recorded by means of a questionnaire (scale of limited mandibular function) and
clinical measurements (pain during jaw movement, limitation of maximal mouth opening, joint sounds,
tenderness on TMJ palpation, tenderness on masticatory muscle palpation). These findings were corre-
lated with the quantitative measurements for evaluating RA: duration of the disease, positivity for
rheumatoid factor, Health Assessment Questionnaire (HAQ) score, number of edematous and painful
joints, and overall assessment of functional status.
Results: In terms of overall figures, 70.5% of the patients presented with at least 1 sign or symptom,
49.2% had at least 1 symptom, and 54.1% had at least 1 sign. The variable pain on movement was
associated with the number of painful joints and the overall assessment findings (P ⬍ .05). Sound on
movement was positively associated with the number of edematous joints (P ⫽ .0291). The scale of
limited mandibular function was statistically significantly correlated with 4 quantitative measurements
(P ⫽ .0283 to .0448). The variable pain on palpation of the masticatory muscles was associated with the
number of painful joints (P ⫽ .0023). Pain on palpation of the TMJ was statistically significantly
associated with the HAQ score (P ⫽ .0344) and with the number of painful joints (P ⫽ .0006).
Conclusion: A significant percentage of the patients with RA have signs and symptoms of TMJ
involvement, and the scale of limited mandibular function proved to be an important measurement tool.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:1804-1811, 2008

Rheumatoid arthritis (RA) is a systemic inflammatory
disease that manifests itself predominately in the sy-
novial membrane of the joints in a symmetric fash-
ion.1,2 RA is associated with a wide range of manifes-
tations, from a temporarily limiting disease to a
progressive chronic alteration, and may exhibit an
overt extra-articular clinical involvement in various
organs. The heterogeneity of these manifestations is
determined by genetic and environmental factors that
control the progression and pattern of inflammation.1
World epidemiologic data reveal that 1% of the
population suffers from RA.3-5 The female:male ratio
is 2.5:1, and the disease most frequently occurs be-
tween ages 35 and 45 years.1 It is estimated that the
survival of RA sufferers is 20% lower than in the
general population, with mortality increasing in direct

*PhD Student, Oral and Maxillofacial Surgery, University of Per-
nambuco, Recife, Brazil.
†Senior Lecturer and Director of the MSc and PhD Programs,
Oral and Maxillofacial Surgery, University of Pernambuco, Recife,
Brazil.
‡Senior Lecturer, Department of Rheumatology, Federal Univer-
sity of Pernambuco, Recife, Brazil.
§Senior Lecturer, Preventive and Social Dentistry, University of
Pernambuco, Recife, Brazil.
储Senior Resident, Oral and Maxillofacial Surgery, University of
Pernambuco, Recife, Brazil.
Address correspondence and reprint requests to Dr Vasconce-
los: Department of Oral and Maxillofacial Surgery, University of
Pernambuco, 1650 Av General Newton Cavalcanti, 54753-220
Recife, PE, Brazil; e-mail: belmiro@pesquisador.cnpq.br
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6609-0005$34.00/0
doi:10.1016/j.joms.2007.08.037

1804
BESSA-NOGUEIRA ET AL
proportion to the severity of the disease. Survival in
the subgroup of RA patients with involvement in
more than 30 joints is 40% to 45% after 5 years, a
figure corresponding to the survival of patients with
coronary disease.2
The progression of RA leads to an incapacity for
performing daily routine and professional activities,
which has a significant negative socioeconomic im-
pact on both patient and society as a whole. Early
diagnosis and immediate treatment are fundamental
for controlling the activity of the disease, with the aim
of preventing functional incapacity and irreversible
joint lesions.1,2,5,6
Pain is an important determinant of the impact of
RA, because it leads to limited joint movement and is
associated with the onset of fatigue, asthenia, and
morning stiffness. In general, the treatment of RA
aims to improve joint function and stagnation of joint
damage and to prevent progression of the functional
incapacity and associated morbidity factors.1,2,5,6
The involvement of the temporomandibular joint
(TMJ) in patients with RA has been reported begin-
ning with the introduction of the term by Garrod in
1859.7 The literature demonstrates the importance of
routinely assessing TMJ function to allow early detec-
tion of signs and symptoms of involvement and
prompt intervention in cases requiring treatment.8
The likelihood of patients with RA developing TMJ
involvement is correlated with the severity and dura-
tion of the systemic disease.8-15 Epidemiologic studies
have shown a frequency of TMJ involvement in RA
ranging from 4.7% to 84%.11,12,14,15 This wide varia-
tion may be explained by differences in the popula-
tions studied or in the selection criteria used, or by
inappropriate examination of the TMJ and adjacent
musculature in patients with TMJ involvement.8,11,12
The most common signs and symptoms of TMJ
involvement are joint pain, edema, crepitation, and
limited movement, all of which are associated with
jaw stiffness on mouth opening.14 The most common
radiographic findings are erosion and flattening of the
head of the mandible and articular fossa and reduc-
tion of the joint spaces,16 usually noticed 5 to 10 years
after the onset of symptoms.15
Research studies have demonstrated a correlation
between the limitation of mouth opening and the
severity of RA.15 But this reduction in jaw movement
may present as an early or a late sign, sometimes
giving a false impression of TMJ involvement.7 Such a
limitation may be caused by pain, the presence of
fibrous adhesions, or a more severe degeneration of
the TMJ.13,15,17,18 Thus, the measurement of maximal
mouth opening as the sole assessment parameter does
not appear to be reliable for analyzing TMJ function in
patients with RA.18 A targeted assessment of TMJ
involvement in RA should include 2 fundamental ele-
1805
ments: 1) an understanding of anatomic and physio-
logical variables important for the diagnosis and 2)
the patient’s perception of his or her own limita-
tion.19
The present study was an observational investiga-
tion aimed at identifying the signs and symptoms of
TMJ involvement in patients with RA and assessing
their association with quantitative measurements for
the assessment of RA.
Patients and Methods
The study population comprised patients of both
genders and various social backgrounds suffering
from RA undergoing treatment at the Department of
Rheumatology, Pernambuco Federal University Hos-
pital, between December 2003 and December 2004.
The following inclusion criteria were adopted: a diag-
nosis of RA according to the American College of
Rheumatology’s 1987 criteria, no previous treatment
of any kind for TMJ involvement, and a sufficient
number of teeth (or tooth prostheses) for obtaining
quantitative measurements of jaw movement. Any
patient not wishing to participate in the study was
excluded. In compliance with resolutions on ethics in
research involving humans, the project was approved
by the University of Pernambuco’s Ethics in Research
Committee.
The initial sample comprised 70 patients. Because 9
of these lacked the required number of teeth for
verification of the data, the final sample comprised 61
patients (55 females and 6 males) ranging in age from
24 to 76 years (mean, 44 years, 7 months).
The collection of data concerning RA was con-
ducted by a single examiner (R.V.B.N.) trained in the
use of the assessment instruments used in the study.
In the patient interview, data were collected on the
duration of RA, positivity for rheumatoid factor,
Health Assessment Questionnaire (HAQ) score, num-
ber of edematous and painful joints, overall assess-
ment of the disease by the patient, and functional
status. The HAQ is a self-assessment instrument
through which patients assess the condition of their
joints. It comprises 20 questions related to difficulty
in performing daily activities and permits 4 possible
answers: 0, no difficulty at all; 1, some difficulty; 2,
great difficulty; and 3, incapacity. The scores of the
answers are grouped and calculated, with a mean
score obtained to define the patient’s HAQ. The pa-
tient’s final score is rated on a scale of 0 to 3, with 0
indicating full ability to perform activities and 3 indi-
cating total incapacity.20
An overall assessment of the severity of the pa-
tient’s signs and symptoms of RA was done using a
visual analog scale. The assessment of functional sta-
tus comprised 4 Classes (I to IV) that expressed the
1806 TMJ ASSESSMENT IN RHEUMATOID ARTHRITIS

Table 1. DISTRIBUTION OF PATIENTS ACCORDING

factor, 55.7% were positive and 44.3% negative. The
TO THE VARIABLES PAIN AND NOISE ON HAQ assessment, 32.8% had a score of up to 1 and
MOVEMENT AND LIMITATION OF MAXIMAL MOUTH 67.2% had a score of 1 to 3 (37.7% between 1 and 2
OPENING
and 29.5% between 2 and 3). Of note, 42.6% of the
Signs and Symptoms % patients had 1 or more edematous joints, 45.9% had
more than 5 painful joints, and 42.6% had an overall
Absence 29.5 score of 51 to 100. With regard to the variable func-
Presence 70.5
Total 100.0 tional status, the lowest percentage (11.5%) corre-
Pain during jaw movements 16.4 sponded to patients in Class IV and the highest
Limitation of maximal mouth opening 0.0 (37.7%) corresponded to those in Class III. The per-
Joint sound 18.0 centages for Classes I and II were 21.3% and 29.5%,
Pain ⫹ sound 21.3 respectively.
Pain ⫹ limitation 4.9
Sound ⫹ limitation 3.3 The TMJ examination revealed that 49.2% of the
Pain ⫹ sound ⫹ limitation 6.6 patients had pain during jaw movement and 50.8%
Total 70.5 had no pain. Maximal mouth opening ranged from
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis.
23.40 mm to 67.16 mm, with a mean of 48.56 mm
J Oral Maxillofac Surg 2008. (standard deviation, 9.39 mm), and 14.8% of the pa-
tients had a limitation of maximal mouth opening
(⬍40 mm). The distribution of the maximal mouth
patient’s capacity to perform particular activities: opening measurements was found to be normal using
Class I, able to perform common everyday activities; the Shapiro-Wilk test (P ⫽ .6310). Approximately half
Class II, able to perform activities relating to personal (49.2%) of the sample presented with joint sounds, of
hygiene and at work, but limited with regard to rec- which 19.7% were clicks and 29.5% were crepita-
reational activities; Class III, able to perform only tions. The distribution of these 3 variables (pain, lim-
activities relating to personal hygiene; and Class IV, itation of maximal mouth opening, and joint sounds)
limited in all activities.21 is given in Table 1, which shows that 70.5% of the
In the TMJ assessment, the following signs and patients had at least 1 sign or symptom in the TMJ,
symptoms were recorded: pain during jaw move- 49.2% had at least 1 symptom, and 54.1% had at least
ment, limitation of maximal mouth opening (interin- 1 sign. Palpation of the TMJ and masticatory muscu-
cisal distance ⬍40 mm), joint sounds, tenderness on lature revealed pain in 44.3% and 24.6% of the pa-
TMJ palpation, tenderness on masticatory muscle pal- tients, respectively, with symmetrical involvement in
pation, and scale of limited mandibular function (ie, 29%.
assessment of the impact of the TMJ involvement on Table 2 shows the impact of TMJ symptomatology
everyday activities related to the stomatognathic sys- in the performance of habitual activities. Use of the
tem).6,8,22
The data obtained were organized using the Excel
spreadsheet (Microsoft, Richmond, WA). SAS version
Table 2. IMPACT OF TMJ SYMPTOMATOLOGY ON
11 for Windows (SAS Institute, Cary, NC) was used for THE PERFORMANCE OF HABITUAL ACTIVITIES,
the descriptive and inferential statistical analysis. The USING THE SCALE OF LIMITATION OF MANDIBULAR
descriptive analysis of the data was made by means of FUNCTION (N ⴝ 61)
absolute and percentage frequencies for the nominal %
variables or those categorized. For the inferential anal- Habitual Activities Yes No
ysis, Pearson’s ␹2 test of independence or Fisher’s
exact test was used when the conditions for using the Eating solid food 50.8 49.2
␹2 test did not prevail. The level of significance Chewing 39.3 60.7
Yawning (frequent mouth opening when
adopted in interpreting the statistical tests was 5% sleepy) 34.4 65.6
(P ⫽ .05). Doing physical exercise or gymnastics 34.4 65.6
Smiling or laughing 24.6 75.4
Cleaning teeth or face 19.7 80.3
Results Maintaining a normal expression with no
appearance of pain or sadness 16.7 83.3
The duration of RA ranged from 9 months to 65 Swallowing 13.1 86.9
years, with a mean of 12 years (standard deviation, 11 Talking 13.1 86.9
years, 3 months). Of the total group, 32.8% had RA of Drinking 11.5 88.5
up to 5 years’ duration, 24.6% had RA of 5 to 10 years’ Eating soft food 8.2 91.8
duration, and 42.6% had RA of more than 10 years’ Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis.
duration. With regard to positivity for rheumatoid J Oral Maxillofac Surg 2008.
BESSA-NOGUEIRA ET AL 1807

Table 3. ASSESSMENT OF PAIN ON MOVEMENT ACCORDING TO THE METHOD OF RA ASSESSMENT

Pain on Movement
Yes No Total
Study Variable n % n % n % P*

Number of painful joints

More than 5 18 64.3 10 35.7 28 100.0 .0297†
Up to 5 12 36.4 21 63.6 33 100.0
Total group 30 49.2 31 50.8 61 100.0
Overall assessment
51 to 100 17 65.4 9 34.6 26 100.0 .0291†
0 to 50 13 37.1 22 62.9 35 100.0
Group total 30 49.2 31 50.8 61 100.0
*Significant association at a level of 5%.
†Using Pearson’s ␹2 test.
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis. J Oral Maxillofac Surg 2008.

variable limitation of mandibular function revealed
the presence of at least 1 of its items in 63.9% of the
patients and the absence of all of the items in the
remaining 36.1%. The variation ranged from 8.2% to
50.8%, with the most frequently seen items being
eating hard food (50.8%), chewing (39.3%), yawning
(34.4%), and smiling or laughing (24.6%).
The dependent and independent variables were
assessed inferentially in all of the associations. Tables
3 to 7 present only the results that exhibited statisti-
cally significant P values.
Discussion
Performing a targeted assessment of the TMJ in
patients with RA requires special care owing to the
fact that a large percentage of these patients have
symptomatology. In terms of overall figures, 70.5% of
the patients presented with at least 1 sign or symp-
tom, 49.2% had at least 1 symptom, and 54.1% had at
least 1 sign. These findings are in agreement with
other published studies showing that 33% to 66% of
the patients with RA have some sign or symptom of
TMJ involvement; however, analysis of our patients’
signs and symptoms demonstrated higher frequen-
cies. This difference is due to differences in the clas-
sification and assessment of the signs and symptoms
in the various studies.7-11,13,17,23-25 Analysis of the age
distribution of the patients showed that most (52.5%)
were between 24 and 45 years old, a finding similar to
that reported by Goronzy and Weyand.1
The main features of the patients with RA in the
sample were disease duration of more than 10 years
(42.6%) and a positive rheumatoid factor (55.7%).
These findings reflect the quantitative nature of the
assessment of RA; that is, 67.2% of the patients had an
HAQ score of 1 to 3; slightly less than 50% had 1 or
more edematous joints (42.6%), more than 5 painful
joints (45.9%), and an overall assessment ranging from
51 to 100 (42.6%); and 37.7% of the patients were
able to perform activities relating to personal hygiene,
with limitations for all other activities (Class III). The
explanation for these findings, according to Laurindo
and Torigoe,5 is that more than 50% of the affected
individuals, after suffering from the disease for 10
years, have difficulty performing their professional
activities, and with the disease progression become
unable to perform even their everyday activities, with

Table 4. ASSESSMENT OF SOUND ON MOVEMENT ACCORDING TO THE METHOD OF RA ASSESSMENT

Occurrence of Sound on Movement

Yes No Total
Study Variable n % n % n % P*

Number of edematous joints

More than 1 17 65.4 9 24.6 26 100.0 .0291†
Up to 1 13 37.1 22 62.9 35 100.0
Total group 30 49.2 31 50.8 61 100.0
*Significant association at a level of 5%.
†Using Pearson’s ␹2 test.
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis. J Oral Maxillofac Surg 2008.
1808 TMJ ASSESSMENT IN RHEUMATOID ARTHRITIS

Table 5. ASSESSMENT OF THE SCALE OF LIMITATION OF MANDIBULAR FUNCTION ACCORDING TO THE METHOD
OF RA ASSESSMENT

Scale of Limitation of Mandibular Function

1 or More None Total
Study Variable n % n % n % P*

Rhematoid factor
Positive 18 52.9 16 47.1 34 100.0 .0448†
Negative 21 77.8 6 22.2 27 100.0
Total group 39 63.9 22 36.1 61 100.0
HAQ
1 to 3 30 73.2 11 26.8 41 100.0 .0315†
0 to 1 9 45.0 11 55.0 20 100.0
Total group 39 63.9 22 36.1 61 100.0
Number of painful joints
More than 5 22 78.6 6 21.4 28 100.0 .0283†
Up to 5 17 51.5 16 48.5 33 100.0
Total group 39 63.9 22 36.1 61 100.0
Functional status
Class I 4 30.8 9 69.2 13 100.0 .0406‡
Class II 12 66.7 6 33.3 18 100.0
Class III 17 73.9 6 26.1 23 100.0
Class IV 6 85.7 1 14.3 7 100.0
Total group 39 63.9 22 36.1 61 100.0
*Significant association at a level of 5.0%.
†Using Pearson’s ␹2 test.
‡Using Fisher’s exact test.
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis. J Oral Maxillofac Surg 2008.

a resulting significant socioeconomic impact on both
the patients and society as a whole. Note that 60% to
90% of patients with RA develop the progressive form
of the disease after 10 years26; in these cases, the
relationship between inflammation and incapacity,
which was previously directly proportional to time,
comes to reflect the effect of the destruction of joints
caused by the disease.27
From the standpoint of the signs and symptoms of
TMJ involvement, a coherence and harmony can be
seen in the distribution of the data collected, in which
49.2% of patients experienced pain on TMJ move-
ment. Ogus,23 in a study of 62 patients with RA, found
that 36% had pain on movement. In a series of 123
patients with RA, Tegelberg and Kopp13 found that
54% had pain on movement.
A small fraction of the patients had limited mandib-
ular movement (14.8%), in agreement with previously
reported findings.7,10-13,17,23-25 Nevertheless, there is
no uniformity regarding the normal patterns of move-
ment. Many of the previous studies followed what
was proposed by Agerberg:28 maximal mouth open-

Table 6. ASSESSMENT OF PAIN ON TMJ PALPATION ACCORDING TO THE METHOD OF RA ASSESSMENT

Pain on TMJ Palpation

Yes No Total
Study Variable n % n % n % P*

HAQ
1 to 3 22 53.7 19 76.3 41 100.0 .0344†
0 to 1 5 25.0 15 75.0 20 100.0
Total group 27 44.3 34 55.7 61 100.0
Number of painful joints
More than 5 19 67.9 9 32.1 28 100.0 .0006†
Up to 5 8 24.2 25 75.8 33 100.0
Total group 27 44.3 34 55.7 61 100.0
*Significant association at a level of 5.0%.
†Using Pearson’s ␹2 test.
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis. J Oral Maxillofac Surg 2008.
BESSA-NOGUEIRA ET AL
Table 7. ASSESSMENT OF PAIN ON PALPATION OF THE MASTICATORY MUSCLES ACCORDING TO THE METHOD
OF RA ASSESSMENT
Pain on Palpation of the Masticatory Muscles
Yes
Study Variable n %
Number of painful joints
More than 5 12 42.9
Up to 5 3 9.1
Total group 15 24.6
*Significant association at a level of 5.0%.
†Using Peason’s ␹2 test.
Bessa-Nogueira et al. TMJ Assessment in Rheumatoid Arthritis. J Oral Maxillofac Surg 2008.
ing greater than 40 mm, right or left lateral move-
ments, and protrusion of the jaw greater than 7 mm.
Sound on TMJ movement was found in 49.2% of the
patients, with a click in 19.7% and crepitation in
29.5%. These findings are in agreement with those of
other studies,8,10,16,23,24 demonstrating that TMJ
sounds are a frequent finding and that the most com-
mon sound is crepitation. Akerman et al24 studied the
relationship between clinical and radiologic TMJ find-
ings in 101 patients with RA and found that 80% of the
TMJs that presented with crepitation also exhibited
radiographic evidence of erosion; thus, crepitation
can be considered a reliable predictive factor. How-
ever, crepitation revealed a low sensibility in detect-
ing joints with erosion, owing to the fact that half of
the joints with evidence of erosion presented with
either a click or no sound at all.
The analysis of palpation of the masticatory and
TMJ muscles revealed that two thirds of the patients
had no pain in the muscles, whereas 44.3% had pain
in the TMJ, with symmetrical involvement noted in
29%. Ettala-Ylitalo et al,12 in their analysis of 60 pa-
tients, noted that 53.3% had pain on palpation of the
muscles. On the other hand, Koh et al8 analyzed 80
patients and found that only 16.2% had involvement
of the musculature of mastication. Franks10 found that
40% of the patients examined had pain on TMJ palpa-
tion.
The analysis of limitation of mandibular function
demonstrated that the activities most affected were
eating hard food (50.8%), chewing (39.3%), and yawn-
ing (34.4%). This may be accounted for by the results
of Voog et al,6 who found a positive association be-
tween pain during maximal mouth opening and pain
on TMJ palpation, correlated with difficulties in per-
forming everyday activities such as yawning and
mouth opening. We found that 44.3% of our patients
experienced pain on maximal mouth opening and
TMJ palpation.
In interpreting the inferential results, we used 7 vari-
ables directly related to RA.26 To obtain the tables of
1809
No Total
n % n % P*
16 57.1 28 100.0 .0023†
30 90.9 33 100.0
46 75.4 61 100.0
results (Tables 3-7), we crossed these variables with 6
variables of TMJ analysis.22,29,30 Analysis of these tables
reveals an association between increased values of RA
measurement and a greater frequency of signs and
symptoms of TMJ involvement. The literature reports
that the likelihood of patients with RA developing symp-
toms in the TMJ is correlated with the severity and
duration of the systemic disease; in other words, the
more severe the involvement, the greater the likelihood
of it causing TMJ symptomatology.8-15
Among all of the associations, rheumatoid factor
was the only one that demonstrated divergent results;
that is, individuals who were negative for rheumatoid
factor reported a greater frequency of limited man-
dibular function (Table 5). The factor in question is an
indicator of the development of functional incapacity,
with the presence of extra-articular manifestations;
thus, a positive rheumatoid factor suggests a poorer
prognosis of RA. However, rheumatoid factor does
not have the power to predict which joints will be
most or least affected.31,32 On the other hand, the
number of painful joints was the variable that most
frequently demonstrated a statistically significant as-
sociation with the dependent variables of the study
(Tables 3, 5, 6, and 7).
The variable pain on movement showed a statisti-
cally significant association with the number of pain-
ful joints and with the overall assessment findings
(Table 3). This association leads us to believe that
there is a strong likelihood that the patient, in report-
ing pain in other body joints, will also refer to pain on
TMJ movement.
The frequency of limited maximal mouth opening
was similar to that found in most of the previous
reports reviewed.7,10-13,17,23-25 According to Stegenga
et al,19 maximal mouth opening is one of the most
frequently used variables in clinical trials. Nonethe-
less, it fails to make a differential diagnosis, because
the limitation may exist for numerous reasons, includ-
ing intra-articular and muscular factors. Restriction of
intra-articular movements may be caused by obstruc-
1810
tion of the movement of translation of the head of the
mandible by anterior disk displacement, by a reduced
capacity for extension of the capsular ligament, by the
formation of fibrous adhesions, or by shortening of
the elevator muscles, owing to contraction, inflamma-
tion, or contracture of the musculature itself.
The scale of limitation of the mandibular function
was the variable most commonly associated with the
quantitative assessment of RA, with a statistically sig-
nificant correlation obtained with 4 of the variables
directly related to the disease (Table 5). The associa-
tion of this finding with the HAQ score and functional
status is evidence that as RA increasingly impairs the
patient’s daily activities, there is an increasing likeli-
hood of involvement of the activities of the stomatog-
nathic system (eg, eating hard food, chewing, yawn-
ing), and that questionnaires that address the subject
are valuable tools in assessing a patient with RA.6,20
The variable pain on palpation of the masticatory
muscles showed a statistically significant correlation
with the number of painful joints (Table 7). This
finding is at odds with the findings of Ettala-Ylitalo et
al.12 This disparity may be explained by the fact that
those authors used Steinbroker’s 1949 classification
system to assess the patients, and so may not have
counted the number of painful joints.
Pain on TMJ palpation was significantly associ-
ated with the HAQ and the number of painful
joints. This finding demonstrates a strong likelihood
that a patient experiencing pain on palpation of
other joints of the body also will experience pain
on TMJ palpation.
Because the present study is an observational one,
it cannot determine the temporal sequence of events
and thus is unable to provide a reliable characteriza-
tion of the cause-and-effect relationship. The lack of
comparison between the findings in our patients with
RA and findings in individuals without RA limits the
power of this study’s conclusions.
In conclusion, our findings demonstrate that a sig-
nificant proportion of patients suffering from RA also
exhibit signs and symptoms of TMJ involvement.
Among the quantitative measurements for assessing
RA, the number of painful joints was the one in which
a significant association was noted most frequently,
but this should not be considered the only important
factor in assessing the association of signs and symp-
toms of TMJ involvement in RA. Pain and noise on
TMJ movement, pain on palpation of the masticatory
muscles and the TMJ, and limitation of mandibular
function are related to quantitative measurements of
RA. The verification of the impact on mandibular
function by means of a questionnaire is an important
aspect to the assessment of a patient suffering from
RA with TMJ symptomatology.
TMJ ASSESSMENT IN RHEUMATOID ARTHRITIS
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