Title: Calcium pyrophosphate dihydrate deposition disease (Cppd, or pseudo gout) Of the temper mandibular joint: An unusual condition
Introduction/Aims: Calcium pyrophosphate dihydrate crystal deposition disease (CPPD) or pseudogout, is is a form of arthritis that causes pain, stiffness, tenderness, redness, warmth and swelling in some joints. It can result from abnormal formation of CPPD crystals in cartilage or synovial fluid, which can lead to episodes that mimic rheumatoid arthritis. It is well known that the temperomandibular joint (TMJ) may be affected by conditions such as psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis. But interestingly, and unusually, there have been a few reported of cases of pseudogout in the TMJ.
Materials and Methods: An 84-year-old female presented to the Oral Medicine department with a 6-day history of pain of sudden onset in the right side of her face which had focused down to the area overlying the right TMJ and parotid gland. She denied any other joint symptoms, fever, weight loss or sweats. She was aware of some redness overlying the tragus of the ear and limitation of opening which necessitated soft diet. She had found no relief from Paracetamol but some benefit from Ibuprofen. Examination revealed some tenderness and oedema overlying the right TMJ and parotid gland. This was associated with deflection and redness of the earlobe and loss of normal facial contour.
Results/Statistics: Blood tests showed a raised ferritin, CRP and ESR. The right parotid gland was completely healthy on ultrasound scan (USS) but there was significant swelling of right TMJ including increased vascularity. CBCT demonstrated some loose bodies within the joint and some features in the premandibular space. MRI showed the appearances to be consistent with an inflammatory arthropathy. Further investigations and follow-up to come.
Conclusions/Clinical Relevance: TMJ issues are rarely a result of pseudogout and this should be considered as a differential diagnosis. It can be treated either conservatively or, if severe, with surgery.
Audience Takes Away Notes:
- The audience will be able to identify clinical signs and symptoms related to pseudogout in the TMJ
- The audience will learn which investigations are required to conclude a diagnosis of pseudogout in the TMJ and why
- The audience will be able to examine temporomandibular joints on panoramic films
- The audience will become aware of other medical conditions which may increase the risk of a patient developing pseudogout, e.g. hyperparathyroidism, joint pain/arthritis
- The audience will learn the differential diagnosis for preauricular pain, swelling and limited mouth-opening along with the more obvious temporomandibular joint dysfunction or parotitis
- The audience will know when to refer in for a joint aspirate or to a rheumatologist if suspicious
- By providing this information, the awareness of pseudogout of the TMJ will increase