Recently, there has been increased recognition of the importance of the clinical examination of the TMJ in children with JIA. Along with the ankle, wrist, hip, and sacroiliac joint, the TMJ is considered a key risk factor for poor outcomes in JIA and thus the presence of TMJ arthritis is conditionally recommended to guide treatment decisions [17]. Recommendations for the management of orofacial manifestations of JIA [18] have highlighted the critical role of a standardized clinical TMJ examination.

We therefore used the TMJaw brief standardized orofacial examination to develop a novel educational module to teach TMJ examination. In our study, both the original article and the module were shown to be effective in improving learners’ knowledge of the TMJ examination in a sample of pediatric rheumatology fellows. The module was superior in teaching objective measurements of oral aperture.

Accurate assessment of mouth opening has important clinical implications for children with JIA. Limited mouth opening [19] and mandibular deviation at maximal mouth opening [10, 20] have been shown to be predictive of active TMJ inflammation in JIA. Assessment of mouth opening capacity is the most common outcome used to assess TMJ arthritis in clinical studies [14].

There is a paucity of data regarding evidence-based pharmacologic treatment in patients with JIA and TMJ involvement. To our knowledge, there is no prospective study in the biologic era which addresses or provides specific guidance on TMJ arthritis management in JIA. TMJ outcomes are not routinely evaluated in clinical trials for JIA. Of 224 clinical trials involving JIA, only six studies reported on TMJ status [21]. While standardized terminology to describe TMJ arthritis in JIA exists [13], it is still not widely used. This lack of consistent assessment and description can lead to discrepancies and difficulty comparing research studies, which may impede meaningful advancement in understanding of TMJ involvement in JIA. The question of optimal management of TMJ arthritis can only be addressed with use of standardized TMJ examination and inclusion of TMJ outcomes in prospective, controlled trials of patients with juvenile arthritis.

We herein describe the first e-learning module that teaches JIA TMJ examination best practices. The e-module can be completed within 25-minutes and uses interactive techniques and adult learning theory to teach the five key TMJ examination domains, using the STOMPS mnemonic as a guide. Fellows using the e-learning module rated their enjoyment of the model as a 7.7/10, which significantly exceeded fellows’ enjoyment of the article as a means of learning the TMJ physical examination.

It is important to note that both groups improved significantly in their post-test knowledge levels and confidence after reviewing the materials, meaning that the article and the e-module were both effective learning tools. The e-module was superior for teaching fellows to perform measurement techniques, which is the most complex of the physical examination techniques included in the TMJ protocol. It is also notable that the fellows assigned the e-learning module enjoyed the learning experience more than those who used the article alone to prepare for the OSCE. In a real-world setting, where trainees would not be expected to perform an OSCE following an assigned curriculum, fellows may be more likely to complete an enjoyable e-learning self-study module than they would be to spend the same amount of time reading an article.

Although the learning materials were made available to the trainees 2 weeks prior to the OSCE, most participants viewed the module the day of the OSCE. Fellows using the 25 min-module, with access to the article, self-reported spending an average of 35.5 min preparing for the OSCE, which is comparable to the article group, which reported spending 34.1 min using the article to prepare. It is difficult to ascertain whether the participants in the module group accessed the article and duration spent in the module.

Unfortunately, after 3 months, less than half of all participants reported consistently performing the full TMJ examination protocol in practice, and there was no difference between the groups. One participant in the module group reported never performing the TMJ exam for follow up patients. While there was improvement in rates of performing this examination, barriers likely still exist but were not specifically assessed in this study. In a large multinational JIA registry, the TMJ was measured quantitatively in 8% of visits [22], compared with 27–45% of the learners who completed this study, so there is reason to believe that a structured curriculum in TMJ examination may lead to increased dedicated examination of these joints.

In terms of study weaknesses, the p values of the two groups were just shy of statistical significance, and a larger sample size may have led to more significant results. Unfortunately, while the study was powered for the pre/post-test, it was not possible to fully power the OSCE. While we are able to confirm that each participant assigned to the module did access the module, we are unable to ascertain the duration that the participants spent on the study materials and which material was used as their primary source. We did not measure inter-rater variability for the OSCE; however, all evaluators received the same training on scoring procedures and were blinded to trainees’ study groups. It is also important to note that an OSCE inherently forces observation in a simulated environment, which is an assessment of what one can do, rather than what one does in an authentic clinical setting. Nevertheless, OSCE exam scores have been shown to correlate with clinical evaluations in pediatric residents [23], and the ability to effectively examine the TMJ will enable a trainee to get more effective data if/when wanting to assess for disease activity. We note that video monitoring could have provided more objective scoring of the trainees and allowed specific feedback to further improve trainees’ skills and satisfaction with the training. Finally, sustained impact could have been assessed by performing a follow up OSCE. However, this was not logistically feasible to coordinate.

There were several strengths to this study. With expert collaboration, we developed a novel learning tool to teach a new standardized physical exam of the TMJ in JIA. The tool includes helpful video demonstrations, didactics, interactive questions, and a mnemonic to provide organization to the performance of the physical examination. To evaluate our tool, we conducted a randomized, blinded, in-person assessment of clinical skills among a target group of learners. All the subjects completed all the study activities including the follow-up survey 3 months later. While the article was also helpful in teaching many of the examination skills, the module was more effective in teaching the quantitative measurements.