A comparison of magnetic resonance imaging and cone beam computerized tomography in the evaluation of temporomandibular joint changes in rheumatoid arthritis patients

doi:10.21203/rs.3.rs-1432633/v1

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Research Article

A comparison of magnetic resonance imaging and cone beam computerized tomography in the evaluation of temporomandibular joint changes in rheumatoid arthritis patients

https://doi.org/10.21203/rs.3.rs-1432633/v1

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Objectives: This study aimed to determine the features of temporomandibular joint involvement in rheumatoid arthritis patients and to examine the association of radiographic changes with RA duration by comparing the diagnostic efficacy of cone-beam computerized tomography to magnetic resonance imaging in identifying changes of TMJs.

Methods: This case-control study was performed on 40 RA patients with 10 healthy adults (control cases). Clinical examination with CBCT and MRI as well as laboratory tests were done for participants. Independent and paired t-tests and correlation coefficient test were used for data analysis by SPSS program

Results: The frequency of TMJ involvement using CBCT and MRI techniques were 82.5% and 87.5% in RA patients and were 50% and 30% in control cases. The most frequently observed clinical symptom was facial pain (25%), and the slightest symptom was clicking (2.5%) during mouth opening. The commonest change in CBCT of RA patients was condylar head erosion (67.5%), and the less common change was articular eminence erosion (7.5%). The commonest changes in MRI of RA patients were an osseous change of condylar head (80%), and the minor change was effusion (10%), while in controls were an osseous change of condylar head (30%) and condylar head flattening (10%). There was a positive correlation between ESR, RF, and Anti-CCP and osseous TMJ changes, while CRP shows a negative correlation.

Conclusions: Osseous changes occur in TMJs of RA patients with no/mild symptoms, MRI can be used as efficient imaging modality for detecting changes in TMJ, and elevated ESR, RF and Anti-CCP may indicate the presence of osseous changes in RA patients.

Autoimmune disease

case-control study

CBCT

MRI

serological test

degenerative changes

Rheumatoid arthritis (RA) is a chronic, systematic, autoimmune, irreversible, inflammatory disorder of the joint throughout the body that characterized by swelling, tenderness, pain and destruction of the joint. The synovium is the key target of the disease process in rheumatoid arthritis (RA). It can be anticipated that examination of synovial tissue samples may provide insight into the pathogenesis of the disease and the mechanism of action of treatment.¹

The temporomandibular joint (TMJ) is a vital organ closely associated with masticatory and swallowing functions, and its damage severely reduces the quality of life. Generally, the TMJ pain complaints in patients with RA were recorded to be higher than 50%, the most frequent being bilateral involvement. However, it is rarely the first joint to be affected, thus, posing diagnostic challenges for the dentist.²

The frequently observed radiographic changes in RA are joint-space reduction and peripheral erosions, while in the progressive stage are extreme osteolysis and even total damage of the condyle. Although, osteophytes are not considered as a definite feature of RA but it might be seen, while ankylosis is very rare.³

The most commonly used imaging procedures for the assessment of the TMJ is MRI that has significant benefits than other techniques. MRI has the capacity to illustrate soft tissue alterations of the TMJ, but their investigative worth for the discovery of TMJ osseous defects is still debated.⁴ Recently, CBCT is extensively utilized to detect anomalies of the dental area, and its consistency for identifying early degenerative changes of the TMJ has been described widely.⁵

Up to date, the correlation between TMJ involvement in RA patients in Sulaimaniyah city has not been done using MRI and CBCT techniques accurately. Therefore, in this study, we aimed to determine the frequency and character of TMJ involvement in RA patients and compare the diagnostic efficacy of two imaging modalities (MRI and CBCT) for examination of TMJ radiographic procedures and finally, to find out the correlation between RA and clinical symptoms of TMJ.

Patients

Forty patients with RA (38 females and 2 males) who were diagnosed at Rheumatology and Rehabilitation Center, Sulaimaniyah Health Directorate, Sulaimaniyah city, Iraq by rheumatology specialist according to implement criteria described by the American College of Rheumatology/European League against Rheumatism for classification and assessing the severity of the disease [6] and were on medication for their RA; were involved in this study.

Patients were allocated into 2 groups based on their chronicity of RA. The 1st batch (A) includes 20 diagnosed patients that had RA for 1–5 years with a mean age of 49.1 ± 9.48 years, and 2nd batch (B) includes 20 diagnosed patients that had RA for 6–10 years with a mean age of 52.15 ± 11.37 years. On the other hand, ten healthy females with a mean age of 37.5 ± 6.187 years were included as a control group (C) (Table 1).

Table 1

Age distribution of study participants.
Group	No.	Age
Group	No.	Minimum	Maximum	Mean	SD
A	20	31	66	49.1	9.48
B	20	30	74	52.15	11.37
C	10	30	47	37.5	6.18

A: First group of RA patients, B: Second group of RA patients, and C: Control group.

Inclusion criteria

Patients diagnosed with RA, those without any other systemic diseases, chronic infection or heavy medication, and those willing to participate were included in this study from March 2020 until March 2021.

Exclusion criteria

Patients with psoriatic arthritis, osteoarthritis, history of juvenile RA, taking medication for other systemic diseases (hypertension, diabetes mellitus, hypercholestraemia, and cancer), pregnant women, patients not willing to participate and those contraindicated to MRI such as those having bullets, metallic objects, pacemaker, insulin pump biotimulator, neurostimulator, cochlear implant, intracranial aneurismal clips and hearing aids.

Clinical examination

Clinical examination was carried out by an oral medicine specialist who followed the Research Diagnostic Criteria (RDC). Symptoms of pain over the face (facial, Jaw, and muscle) and joints were reported, joint sounds (clicking during jaw opening and closing) were recorded, and maximal mouth opening, right/left lateral jaw excursion, and jaw protrusion was measured.

Laboratory tests

Erythrocyte Sedimentation Rate (ESR),³ Creatinine Reactive Protein (CRP),⁷ Rheumatoid Factor (RF),⁸ and Anti-Cyclic Citrullinated Peptide (anti-CCP) amounts⁹ were determined for participants using standard kits from high quality licensed companies.

Imaging

The imaging process was performed by two expert radiologists to find changes and abnormalities in TMJs.¹⁰

CBCT examination

CBCT examination was performed 360º of rotation with the participant’s closed mouth in an occlusal situation with the selected field of view (8.5 cm x 8.5 cm) and 98 kV, 10 mA and 14 seconds exposure time using Sirona 3D machine (Galileos Comfort, Germany). Later on, contiguous sectional images in 3 directions including sagittal section (vertical to the long axis of the condylar head), coronal section (parallel to the long axis of the condylar head), and axial (horizontal) section were done in a Multiplanar Reconstruction (MPR) with a slice thickness of 1 mm using CBCT software Sidex XG (Gallileos viewer).

MRI examination

MRI examination was performed using 1.5 Tesla GE machine (made in USA) that had a head coil with 14 slices, 3.0 mm slice thickness, 1.0 mm inter-slice gap, and FOV of 150*1.2. Scout images (an axial, coronal, and sagittal) were taken at the beginning to localize and plan the sequences. On the axial cuts, a slice was selected on which the condyles of both sides were well depicted. On the sagittal scout, axial cuts were planned parallel to the orbitomeatal line at the level of the auditory canal, and sagittal cuts were perpendicular on the parasagittal plane (long horizontal axis of each condyle), and the condyles were included inside the planned slices. T1 and T2 coronal and sagittal sections and PD sagittal sections were taken separately for right and left TMJs.

Radiographic measurement

A condylar length or AP dimension (linear distance between posterior and anterior mandible condyles in the sagittal plane) (Fig. 1A), a condylar width or ML dimension (linear distance between medial and lateral mandible condyles in the coronal plane) (Fig. 1B,) and a condylar height (perpendicular linear distance from superior mandible condyle to tangent constructed between the most inferior point of coronoid sigmoid notch perpendicular to the tangent of the posterior surface of ramus in the sagittal plane) (Fig. 1C) were measured.

Radiographic change finding

CBCT

The corrected sagittal and coronal sections of CBCT were examined for the occurrence of condylar head erosion, articular eminence erosion, condylar head flattening, sclerosis, subchondral cyst and osteophyte formation (Fig. 2).

MRI

The MRI of each patient was examined for the presence of the osseous change of condyle, articular eminence erosion, condylar head flattening, joint effusion, and synovial proliferation (Figure 3).

Statistical analysis

The collected data were analyzed using IBM SPSS statistics (Statistical Package for Social Sciences), version 26.0 (Chicago, USA). Numerical data were tested for normality of their distribution using Shapiro-Wilk test. Qualitative data were presented as number and percentage. Quantitative data were presented as mean and standard deviation. Student t-test used for parametric data; Independent t-test used for comparison between groups Pearson correlation coefficient were used to determine correlations between variables. Statistically significant data was considered when probability values of less than 0.05 (p < 0.05) were obtained.

Clinical finding

In RA patients, the jaw lock was absent in group A while 2 cases (10%) of group B had jaw lock. Three cases (15%) of group A and 7 cases (35%) of group B complained of facial pain. Moreover, 3 patients (15%) in group A felt jaw pain on the right side and 2 patients (10%) on the left side. Whereas 5 cases (25%) in group B felt jaw pain on the right side and 6 cases (30%) on the left side. However, in group B, only 1 case (5%) had clicking during mouth opening, and 1 case (5%) had pain during right lateral jaw excursion (Table 2).

Laboratory result

The ESR was positive in 15 (75%) and 17 (85%) cases of group A and B, respectively, without significant difference (P = 0.695). The RF was positive in 16 cases (80%) of group A and 10 cases (50%) of group B with no significant difference (P = 0.096). Similarly, the CRP was positive in 17 cases (85%) of group A and 18 cases (90%) of group B without significant difference (P = 1.000). The Anti-CCP was positive in 15 cases (75%) and 13 cases (65%) of groups A and B, respectively, with no significant difference (P = 0.731) (Table 3).

Table 2

Frequency of symptoms of TMJs of RA and control cases.
Group	Jaw Lock	Pain Face	Jaw Pain		Muscle Pain	Joint Pain	Joint Click Open	Joint Click Close	Right Lateral Excursion		Left Lateral Excursion		Protrusion
Group	Jaw Lock	Pain Face	RT	LT	Muscle Pain	Joint Pain	Joint Click Open	Joint Click Close	Muscle Pain	Joint Pain	Muscle Pain	Joint Pain	Muscle Pain	Joint Pain
A	0	15 (3)	15 (3)	10 (2)	0	0	0	0	0	0	0	0	0	0
B	10 (2)	35 (7)	25 (5)	30 (6)	0	0	5 (1)	0	5 (1)	5 (1)	0	0	0	0
Total	5 (2)	25 (10)	20 (8)	20 (8)	0	0	2.5 (1)	0	2.5 (1)	2.5 (1)	0	0	0	0
C	0	0	0	0	0	0	0	0	0	0	0	0	0	0

Table 3

Number and frequency of participants with positive laboratory test results.
Test	Group A		Group B		P-value
Test	No.	%	No.	%	P-value
ESR	15	75	17	85	0.695
RF	16	80	10	50	0.096
CRP	17	85	18	90	1.000
Anti-CCP	15	75	13	65	0.731

Radiological assessment

The frequency of TMJ involvement in RA patients using CBCT and MRI were 82.5% and 87.5%, respectively and in the control group were 50% and 30%, respectively (Fig. 4).

Regarding the mean of maximum unassisted mouth opening in RA and control groups, significant differences between both groups (P = 0.008) were seen that was 39 mm in the RA group and was 44.5 mm in the control group. Similarly, a significant difference (P = 0.012) in the mean of maximum assisted mouth opening was observed between both RA and control groups (39.5 mm in group A and 39.8 mm in group B, with 44.8 mm in the control group) (Table 4).

Table 4

Mean and standard deviation of mouth opening of the participants.
Group	Unassisted Opening				Maximum Unassisted Opening			Maximum Assisted Opening
Group	Mean		SD	P-value	Mean	SD	P-value	Mean	SD	P-value
A	39	8.97		0.289	39	8.97	0.289	39.5	10.11	0.179
B	39	6.03		0.289	39	6.03	0.289	39.8	6.22	0.179
C	44.5	1.9		0.008	44.5	1.9	0.008	44.8	1.99	0.012

Additionally, the mean of right lateral jaw excursion was 5.85 mm in group A, 5.4 mm in group B, and 9.5 mm in group C with a significant difference (P = 0.002) between RA patients and control cases. Moreover, the mean left lateral jaw excursion was 5.5 mm in group A, 5.75 mm in group B, and 7.2 mm in group C without significant difference (P = 0.952) between RA patients and control cases. On the other hand, the mean of mandibular protrusion was 2.05 mm in group A, 3.2 mm in group B, and 5.1 mm in group C with no significant difference (P = 0.444) between RA patients and control cases (Table 5).

Table 5

Mean and standard deviation of lateral excursion and protrusion of mandible of participants.
Group	Right Lateral Excursion			Left Lateral Excursion			Protrusion
Group	Mean	SD	P-value	Mean	SD	P-value	Mean	SD	P-value
A	5.85	2.96	0.719	5.5	3.51	0.783	2.05	1.7	0.663
B	5.40	3.56	0.719	5.75	3.66	0.783	3.2	1.47	0.663
C	9.5	0.7	0.002	7.2	3.61	0.952	5.1	1.59	0.444

Furthermore, the mean of condylar length in group A was 6.84 ± 0.91 mm, and in group B was 6.93 ± 1.27 mm with no significant difference between them (P = 0.202). The mean of condylar width in group A was 17.23 ± 1.74 mm, and in group B was 16.31 ± 2.21 mm with no significant difference between them (P = 0.633). The mean of condylar height was 18.25 ± 2.01 mm and 17.79 ± 1.94 mm in groups A and B, respectively, with no significant difference between them (P = 0.915). In control cases; the mean of condylar length was 7.61 ± 0.71 mm, the mean of condylar width was 16.53 ± 1.71 mm, and the mean of condylar height was 21.14 ± 1.51 mm without significant difference between control cases and patients (P = 0.215, 0.844, and 0.219, respectively) (Table 6).

Table 6

Mean and standard deviation of condylar measurements on CBCT.
Group	Condylar Length/mm			Condylar Width/mm			Condylar Height/mm
Group	Mean	SD	P-value	Mean	SD	P-value	Mean	SD	P-value
A	6.84	0.91	0.202	17.23	1.74	0.633	18.25	2.01	0.915
B	6.93	1.27	0.202	16.31	2.21	0.633	17.79	1.94	0.915
C	7.61	0.71	0.215	16.53	1.71	0.844	21.14	1.51	0.219

Radiographic finding on CBCT

In RA patients, the frequency of condylar head erosion was 70% in group A and 65% in group B, with no significant difference (P = 0.516). The frequency of articular eminence erosion was 5% in group A and 10% in group B, with a significant difference (P = 0.032). The frequency of condylar head flattening was 55% in group A and 75% in group B, with no significant difference (P = 0.834). The frequency of condylar sclerosis was 15% in both groups A and B, with no significant difference (P = 0.245). The frequency of subchondral cyst was 30% and 5% in groups A and B, respectively, with a significant difference (P = 0.000), and there was no osteophyte in both groups. On the other hand, the only observed radiographic change in group C was the flattening of condylar head (50%) with no significant difference with RA patients (P = 0.803) (Table 7).

Table 7

Frequency of radiographic changes by CBCT.
Group	Condylar Erosion			Articular Eminence Erosion			Osteophyte		Sclerosis			Subchondral Cyst			Flattening
Group	No.	%	P-value	No.	%	P-value	No.	%	No.	%	P-value	No.	%	P-value	No.	%	P-value
A	14	70	0.516	1	5	0.032	0	0	3	15	0.245	6	30	≤ 0.01	11	55	0.834
B	13	65	0.516	2	10	0.032	0	0	3	15	0.245	1	5	≤ 0.01	15	75	0.834
Total	27	67.5		3	7.5		0	0	6	15		7	17.5		26	65
C	0	0	≤ 0.01	0	0	≤ 0.01	0	0	0	0	≤ 0.01	0	0	≤ 0.01	5	50	0.803

Radiographic finding on MRI

In RA patients, the frequency of condylar head erosion was 75% in group A and 85% in group B. The frequency of articular eminence erosion was 20% in group A and 30% in group B with no significant difference (P = 0.122 and 0.174, respectively). The condylar head flattening was 30% and 20% in groups A and B, respectively, without significant difference (P = 0.367). Moreover, there is no significant difference (P = 0.423) in the frequency of synovial proliferation in groups A and B (20%). In comparison, the frequency of effusion was 15% in group A and 5% in group B, with a significant difference (P = 0.017). In group C, the most frequent radiographic change was the osseous condylar head (30%) followed by condylar head flattening (10%) with a significant difference with patients (P = 0.000 and 0.001, respectively) (Table 8).

Table 8

Frequency of radiographic changes by MRI in participants.
Group	Osseous Condyle			Osseous Articular Eminence			Synovial Proliferation			Effusion			Condylar Flattening
Group	No.	%	P-value	No.	%	P-value	No.	%	P-value	No.	%	P-value	No.	%	P-value
A	15	75	0.122	4	20	0.174	4	20	0.423	3	15	0.017	6	30	0.367
B	17	85	0.122	6	30	0.174	4	20	0.423	1	5	0.017	4	20	0.367
Total	32	80		10	25		8	20		4	10		10	25
C	3	30	0.234	0	0	≤ 0.01	0	0	≤ 0.01	0	0	≤ 0.01	1	10	0.001

Comparison between CBCT and MRI outcomes

Sensitivity and specificity tests were done to compare the diagnostic ability of CBCT and MRI in detecting osseous abnormalities of TMJs, and we revealed that the MRI had a sensitivity of 75% and specificity of 84% than CBCT test (Fig. 5).

This study was done to assess TMJ changes in RA patients and their relative to disease chronicity and comparing the diagnostic effectiveness of CBCT and MRI in detecting radiographic changes of TMJs. There is no international radiographic classification or scoring measurements to evaluate TMJ changes in RA patients.¹¹ Therefore, we aimed to find TMJ changes as dimensional condylar changes and radiographic osteoarthritic features.

In our study, the frequency of TMJ involvement in RA patients was 85%, while it was reported to vary from 2–86% in other studies.^12–14 Such differences might be due to the different types of examination, patient selection criteria, the use of diagnostic techniques and the inclusion criteria. Based on the results of some other studies, same damaging pathway as found in other joints also seen in TMJ involvement which believed to be is straightly related to the severity and extent of RA.¹⁵ These findings are not confirmed by our study and some other studies.¹⁶

Clinical findings

In our RA patients, 25% of patients had facial pain followed by jaw pain (20%), then clicking during mouth opening (2.5%), and muscle pain and joint pain during a right lateral excursion of the mandible (2.5%). TMJ pain was found in 65%, muscle pain in 42%, and joint sound in 51% of RA patients in a study done in Iran.¹⁶ Such differences might be related to examination methods of TMJs, variation in the number of included cases, types and frequency of drug intake in RA patients and inclusion of cases with TMD.

In the current study, the mean of unassisted opening and maximum unassisted opening of mouth were close to each other in RA (39.03 mm) and control (44.5 mm) groups. In contrast, the mean of maximum assisted mouth opening in RA patients was 39.65 mm and 44.8 mm in the control group, which was higher than the results found by Ardic et al., 2006,¹⁷ who reported unassisted opening to be 37.5 mm in RA and 39.1 mm in control groups, however, they reported higher range of assisted opening (44.3 mm in RA and 45.2 mm in control groups).

Additionally, we found that the mean of right lateral jaw excursion was 5.63 mm in RA and 9.5 mm in control groups, while the mean of left lateral jaw excursion was 5.63 mm and 7.2 mm in RA and control groups. These findings were lower than the results of a study that reported right excursion of 6.7 mm and 8.7 mm in RA and control groups, respectively and left excursion of 6.9 mm and 7.9 mm in RA control groups, respectively.¹⁷ Most studies show a decreased range of motion in RA patients, which might be caused by reduced joint space, sclerosis, or changed condylar positioned as an adaptive procedure.

Laboratory investigation

In our study, we investigated four laboratory tests of RA (ESR, RF, CRP and Anti-CCP) to find any correlation between them and radiographic changes of TMJs. There was a positive correlation between ESR, RF, Anti-CCP with radiographic changes detected on TMJs. Regarding our ESR and FR outcomes, they were agreed with a study done in Iran.¹⁶ However, our results for the relation between RF and Anti-CCP with radiographic changes are controversial to a study done in Egypt. ¹¹

CBCT finding

In our RA patients, the most common osseous change was condylar head erosion (67.5%) which was higher than the results of other studies^{18 19} who reported 13.3% and 50%, respectively, and close to the result found by Gheita et al., 2012 ²⁰ (62.5%) but lower than those found by other studies²¹,²² who reported 72% and 85%, respectively. We detected flattening in both RA and control groups (65% and 50%, respectively) which was close to the results of a study conducted in Egypt ²³ who found 89.3% and 50%, respectively and higher than the results of Voog et al., 2004 who found 30% flattening in RA patients. ¹⁹

Moreover, we found subchondral cyst only in the RA group (17.5%), which was higher than the outcomes of Deoghare and Degwekar, 2010²² (10%) but was lower than some other researches^{18–20, 23} who reported 32.1%, 23.3%, 30%, and 20.83%, respectively. Furthermore, we found sclerosis in the RA patients (15%), which was much lower than the results reported by other studies^{19, 20, 23} who reported 64.3%, 75%, and 41.67%, respectively.

MRI finding

In our RA patients, the frequency of osseous change of condyle (erosion) was 80% which was in agreement with results found by other studies^{24, 25} who reported 80% and 83.3%, respectively but higher than Abdel Aziz and Esha, 2017²⁶ (52.5%), and lower than the result of a study conducted in Japan²⁷ who found erosion in 96% of RA cases. On the other hand, the frequency of articular eminence erosion was 25% which was higher than the results reported by other studies^{25, 27} who found 9.5% and 8.2%, respectively, but lower than the reported result²⁶ (50%). Whereas, the condylar head flattening was seen in 25%, higher than the results found by Abdel Aziz and Esha, 2017, Hirahara et al., 2017 (15% and 16.6%, respectively). ^{25, 26}

In our patients, synovial proliferation was found in 20%, which is different from the results of other studies^{25, 27}, who reported 100% and 85.7%, respectively. The frequency of effusion was 10% which was much lower than the results reported by other studies^{24, 25, 27} who reported 67.5%, 30.9%, and 33%, respectively. Consequently, the mean condylar length was 6.88 mm in RA patients and 7.61 mm in control cases, which was lower than the results of Youssef et al., 2020 who found 8.66 mm in RA and 8.27 mm in control groups¹¹. Our results for control cases were close to the results of a study done in Malaysia¹⁰ (7.50 mm in Malays and 7.20 mm in Chinese). The mean of condylar width was 16.77 mm in RA patients and 16.53 mm in control cases which were slightly lower than the results reported by other researchers^{10, 11} who found 17.89 mm in RA/17.99 mm in controls and 17.18 mm in Malays and 17.80 mm in Chinese, respectively but was higher than the results reported by Manja and Rajaduray, 2019²⁸ who found 11.67 mm in patients with clicking and 11.18 mm in patients without clicking.

Consequently, in this study, the mean of condylar height was 18.02 mm in RA patients and 21.14 mm in control cases which were close to results found by Manja and Rajaduray, 2019²⁸, who found 18.9 mm in patients with clicking and 22.81 mm in patients without clicking) and by Al-koshab et al., 2015 (17.0 mm in Malays and 18.37 mm in Chinese). ¹⁰ Our results were much higher than Youssef et al., 2020 (4.3 mm in RA and 4.87 mm in control cases). ¹¹ These drastic differences might be related to the height measurement method that is almost done from the most superior point of the condylar head down to the line of measuring the ML dimension of the condyle. The only decreased measurement was in the condylar height of RA patients concerning control cases that indicate bone changes in the upper condylar surface with fewer or no damage in the other sides.

Comparison of CBCT and MRI

Many researchers stated the high capacity and superiority of CBCT in evaluating osseous changes of the TMJ than other imaging modalities. ²⁹ Due to the great consistency of CBCT established by previous researches, we reflected CBCT a gold standard in estimating osseous damages compared to MRI.

However, the investigative capability of MRI to find osseous alterations of the TMJ using cadaver samples had been evaluated. This study demonstrated that the MRI had 75% sensitivity and 84% specificity in detecting osseous abnormalities. In this regard, evaluation of 106 TMJs was done by CBCT, and MRI and low sensitivity (30–82%) with high specificity (84–90%) of MRI for detecting osseous abnormalities were seen³⁰ as well as a study on 20 TMJs was done and sensitivity of 25–90.9% with a specificity of 70.8–97.2% were found²⁶. Generally, the low sensitivity of MRI in detecting osseous abnormalities might be due to the restricted resolution of MRI, and the slice thickness of MRI, as mainly ≥ 3 mm is used, which might be too profuse to identify indirect osseous damages. ³¹ Additionally, fibrous tissues within TMJ and the connection of the lateral pterygoid muscle nearby the articular surface of the condyle, which can be explained as either an osseous anomaly or as a disc. They may result in false-positive or -negative findings. ³² Finally, when identifying osseous deformities in the articular fossa and eminence, complications sometimes rise by the magnetic susceptibility artefacts. ^{33, 34}

Osseous changes such as erosion are associated with TMJs affection in RA patients that might occur with no/mild clinical signs. Thus, TMJ imaging must be done for RA patients to avoid severe complications even if there are no clinical signs. MRI can be used as an excellent diagnostic imaging modality compared to CBCT due to its high sensitivity and specificity in detecting osseous changes of the TMJs. In addition, elevated levels of ESR, RF, and Anti-CCP might expect RA and TMJ changes.

Ethics approval and consent to participate

All experiments in this study were performed in accordance with relevant guidelines and regulations belong to declaration of Helsinki for using of human tissues. Additionally, our study protocol was approved by the Ethical committee of College of Dentistry, University of Sulaimani, Republic of Iraq with No. 07/21072020-COD-UOS. Furthermore, informed written consent was obtained from all subjects.

Consent for publication

Not applicable.

Availability of data and materials

Available upon request.

Competing interest

The authors declare that there is no conflict of interest to this research study.

Funding

There was no any company or institution supporting this research economically, all funds were paid by authors themselves.

Author's contributions

RAJ: Conceptualization, data collection and analysis, writing the original manuscript; KMA: Visualization, supervision, validity, manuscript edition and correction; SMA: Resources, supervision, study registration and administration.

Acknowledgements

Authors are appreciating the help and assistant from the healthcare staffs from Rheumatology and Rehabilitation Center, Sulaimaniyah Health Directorate, Sulaimaniyah city, Iraq.

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No competing interests reported.

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A comparison of magnetic resonance imaging and cone beam computerized tomography in the evaluation of temporomandibular joint changes in rheumatoid arthritis patients

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