J Korean Assoc Oral Maxillofac Surg.  2020 Jun;46(3):174-182. 10.5125/jkaoms.2020.46.3.174.

Efficacy of arthrocentesis and lavage for treatment of post-traumatic arthritis in temporomandibular joints

• Park JY
• Lee JH

• KMID: 2504303
• DOI: http://doi.org/10.5125/jkaoms.2020.46.3.174

Abstract

Objectives
Joint injuries frequently lead to progressive joint degeneration that causes articular disc derangement, joint inflammation, and osteoarthritis. Such arthropathies that arise after trauma are defined as post-traumatic arthritis (PTA). Although PTA is well recognized in knee and elbow joints, PTA in the temporomandibular joint (TMJ) has not been clearly defined. Interestingly, patients experiencing head and neck trauma without direct jaw fracture have displayed TMJ disease symptoms; however, definitive diagnosis and treatment options are not available. This study will analyze clinical aspects of PTA in TMJ and their treatment outcomes after joint arthrocentesis and lavage.
Materials and Methods
Twenty patients with history of trauma to the head and neck especially without jaw fracture were retrospectively studied. Those patients developed TMJ disease symptoms and were diagnosed by computed tomography or magnetic resonance imaging. To decrease TMJ discomfort, arthrocentesis and lavage with or without conservative therapy were applied, and efficacy was evaluated by amount of mouth opening and pain scale. Statistical differences between pre- and post-treatment values were evaluated by Wilcoxon signed-rank test.
Results
Patient age varied widely between 20 and 80 years, and causes of trauma were diverse. Duration of disease onset was measured as 508 posttrauma days, and 85% of the patients sought clinic visit within 2 years after trauma. In addition, 85% of the patients showed TMJ disc derangement without reduction, and osteoarthritis was accompanied at the traumatized side or at both sides in 40% of the patients. After arthrocentesis or lavage, maximal mouth opening was significantly increased (28-44 mm on average, P<0.001) and pain scale was dramatically decreased (7.8-3.5 of 10, P<0.001); however, concomitant conservative therapy showed no difference in treatment outcome.
Conclusion
The results of this study clarify the disease identity of PTA in TMJ and suggest early diagnosis and treatment options to manage PTA in TMJ.

Keyword

Temporomandibular joint disc; Synovial fluid; Joint diseases; Post-traumatic headache; Osteoarthritis

Figure

• 

  Fig. 1 Clinical aspects of post-traumatic arthritis in temporomandibular joint. A. Age distribution of the 20 patients. Mean age was 48.7 years (thick bar in the middle) with standard error of 4.6 years (left panel). The age distribution passed the normality test (α>0.05) by the one-sample Kolmogorov–Smirnov test (P>0.1), and the normal distribution is shown in a QQ plot on the right panel. B. Sex distribution of the patients (male=9, female=11). C. The causes of trauma of the 20 patients were diverse, as comprising traffic accident (n=6), assault (n=3), hit by materials (n=3), and fall down (n=8).

• 

  Fig. 2 Onset of post-traumatic arthritis (PTA) in temporomandibular joint (TMJ). A. When a PTA patient reports to a clinic with TMJ discomfort, the time since initial trauma should be measured. Days after trauma was calculated as the duration between initial trauma and the patient’s first visit to the clinic and is was marked with a triangle in the bar graph. The average “days after trauma” was 508 days, with a standard error of 112 days. B. The bar graphs show the number of PTA patients reporting to the TMJ clinic during the 1st (n=8), 2nd (n=9), or 3rd (n=3) year after initial trauma. In total, 85.0% of the patients (17 of 20) sought help within 2 years after trauma.

• 

  Fig. 3 Diagnosis of temporomandibular joint (TMJ) arthritis in post-traumatic arthritis patients by computed tomography or magnetic resonance imaging (MRI). TMJ MRI showed TMJ disc derangement without reduction (DD w/o reduction) in 85% of the patients (17 of 20), 5 of whom showed derangement at both sides. Eight patients suffered degenerative joint disease (DJD) such as osteoarthritis at the traumatized side of the TMJ, 2 of which had osteoarthritis at both sides. Only 2 patients were diagnosed with disc derangement with reduction (DD w/ reduction).

• 

  Fig. 4 Treatment efficacy of temporomandibular joint arthrocentesis and lavage in post-traumatic arthritis patients. A. All patients received joint arthrocentesis or lavage with (n=8) or without (n=12) conservative therapy. B. After arthrocentesis or lavage, improvement of maximal mouth opening (MMO) was statistically significant (28-44 mm in average, ***P<0.001, left panel). The dot plot shows amount of MMO at pre- or post-treatment visit. Thick black bar shows the average and standard error of 20 patients. Pre- and post-lavage MMOs in the same patient were connected as paired data (right panel). C. Pain scale was dramatically reduced from 7.8 to 3.5 of 10 (***P<0.001). The dot plot shows the pain scale at pre- or post-treatment visit. Thick black bar shows average and standard error of 20 patients. The pain scales at pre- and post-lavage in the same patient were connected as paired data (right panel). Differences in treatment outcomes before and after treatments were assessed using the Wilcoxon signed rank test. All reported P-values were based on two-sided tests, and statistical significance was shown as ***P<0.001.

• 

  Fig. 5 Recommended treatment protocol for post-traumatic arthritis in temporomandibular joint. A. Maximal mouth opening (MMO, mm) over treatment days, where day “0” is the first visit at the clinic. The red dotted line represents 40 mm of mouth opening. B. MMO over treatment numbers. The x-axis is the number of patients’ visits. The red dotted line represents 40 mm of mouth opening. Each dot represents one patient’s visit and each identical figure represents one patient. C. Comparison of pre- and post-treatment MMO (left panel) and pain scale (right panel) between the two groups: lavage only group versus lavage with concomitant conservative therapy group. Bar graphs show average changes in MMO with standard errors. Changes in MMO and pain scales were compared between the two groups by Mann–Whitney test. (NS: not significant)

Reference

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