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Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease?
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease? N. Thomas a,∗ , D.E. Harper b , S. Aronovich c a b c
St. John Providence Oral and Maxillofacial Surgery Department of Anesthesiology, University of Michigan, Ann Arbor, MI Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
Accepted 21 November 2017
Abstract Effusions are common among patients with disorders of the temporomandibular joint (TMJ), but publications are limited and results inconsistent about the correlation between them and important clinical variables, in particular severity of pain and degenerative disease. We organised a retrospective study of patients who presented for the evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Inclusion criteria were: patients who had pain that was primarily arthrogenous, and coexisting myogenous pain, who had had initial non-surgical treatment, and arthroscopy of the TMJ with or without intramuscular injection of onabotulinumtoxinA ® (Botox, Allegan, Weston, Fl, USA). The primary outcome variables were pain at rest as measured by visual analogue score (VAS) and the presence of degenerative disease of the joint. The secondary outcome variables included the position of the disc and whether it was perforated, signs of synovitis, maximal interincisal opening (MIO), and duration of symptoms. We studied 47 patients (94 TMJ) who met the inclusion criteria. We found no significant differences in pain at rest before or after arthroscopy, between patients with and without effusions, or in maximal MIO or duration of symptoms between the two groups. There was, however, a significant relation between effusions and degenerative joint disease. Effusions were also associated with a lower probability of the disc being in a normal position and a higher probability of anterior disc displacement without reduction. © 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Temporomandibular joint; TMJ; Effusion; Effusions; Degenerative joint disease; DJD; Disc position; Pain score; Temporomandibular disorders; TMD
Introduction Effusions are common in disorders of the temporomandibular joint (TMJ), and studies have shown that they are present in up to half of all joints with anterior disc displacement without reduction and up to 40% of joints with anterior disc ∗ Corresponding author at: St. John Providence, 11800 E. 12 Mile Rd., Warren, MI 48093. Tel.: +1 248 535 1370. E-mail address: [email protected] (N. Thomas).
displacement with reduction.1 However, there are few and inconsistent reports about the correlation between effusions and important clinical variables such as severity of pain and degenerative joint disease. An effusion of the TMJ is defined as excess intra-articular synovial fluid within the TMJ space. It is identified by hyperintensity within the joint space on a T2-weighted magnetic resonance image (MRI). Joint effusions are thought to indicate an inflammatory process, with several studies having shown increased concentrations of proteins and proinflam-
https://doi.org/10.1016/j.bjoms.2017.11.011 0266-4356/© 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
matory cytokines in the synovial fluid and tissue of joints with effusions.2 Occasionally an effusion of the TMJ may be found in conjunction with acute septic arthritis, gouty arthritis, pseudogout, metastatic joint effusion, and synovial chondromatosis.3–5 Recently, orthopaedic studies have shown a correlation between effusions of the knee joint and compartment-specific contributions to both weight-bearing and non-weight-bearing knee pain.6,7 In contrast, papers about the TMJ have found an inconsistent correlation between effusions and temporomandibular arthralgia. Khawaja et al examined 312 TMJ and found that effusions were not associated with arthralgia or with other clinical variables, with the exception of the position of the articular disc in the sagittal plane.8 Park et al found that effusions of the TMJ had no significant association with spontaneous facial pain, and no relation to pain on palpation of the masticatory muscles.9 In contrast to these findings, Bas et al found a significant correlation between pain scores measured on a visual analogue scale (VAS) and the presence of effusions on MRI. They also identified a significant positive correlation between increased width of the capsule and effusions on ultrasound imaging.10,11 The purpose of this study was to assess the correlation between TMJ effusions and relevant clinical and radiographic variables, specifically the presence of arthralgia in the TMJ, degenerative joint disease on MRI, and arthroscopic findings. We hypothesised that there is no difference in clinical and radiographic variables in patients with and without effusions of the TMJ. The specific aims of the study, therefore, were as follows: first, to compare the incidence and severity of arthralgia of the TMJ; secondly, to compare the presence of degenerative joint disease on MRI; thirdly, to compare secondary variables (including position and perforation of the disc, active maximal interincisal opening (MIO), and duration of symptoms); fourthly, to compare arthroscopic findings; and lastly to compare the outcomes of TMJ arthroscopy in those with and without effusions.
Methods Study design/sample We designed a retrospective cohort study of all patients who presented for evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Patients had to have pain that was primarily arthrogenous together with coexisting myogenous pain, and to have had a preoperative MRI of the TMJ. They should also have had initial non-surgical treatment, and TMJ arthroscopy with or without an intramuscular injection of ® onabotulinumtoxinA (Botox , Allegan, Weston, Fl, USA). Patients who had other procedures on the TMJ, those with primary neuropathic pain, and those who did not have preoperative or postoperative outcomes of interest documented,
97
were excluded. All procedures were done by a single surgeon in the Department of Oral and Maxillofacial Surgery, and the study was exempted from the need for ethics approval by the institutional review board, and followed the guidelines stated in the Helsinki Declaration. Variables Personal, diagnostic, clinical, and operative data were collected, including sex, age, specific diagnosis of the TMJ being treated, the condition of the disc, number and type of previous operations, pain at rest on VAS (0–10), presence of degenerative joint disease on MRI, position of the disc on MRI, presence of perforation of the disc on MRI and on arthroscopy, duration of symptoms, and active MIO. The primary outcome variables recorded were pain at rest on VAS and the presence of degenerative joint disease. Secondary outcome variables recorded included the position of the disc on MRI, perforation of the disc on MRI, the presence of synovitis on arthroscopy, MIO, and duration of symptoms. Collection of data Physical examination was according to the criteria laid down in the Research Criteria for Temporomandibular Disorders. All measurements were made by the same observer both before and after the intervention. Pain scores were recorded on VAS (0–10, with 10 being the most severe). MIO was measured (mm) using a curvilinear ruler (TheraBite Jaw ROM Scale, Great Lakes Ortho, Tonawanda, NY, USA) between maxillary and mandibular central incisors on active opening. Effusions of the TMJ were identified on T2-weighed MRI and reported by the neuroradiologist. Degenerative joint disease and the position of the disc were assessed on proton density sequences of the MRI in both open and closed positions. Degenerative joint disease was diagnosed if there were signs of flattening, erosion, osteophytes, or the formation of subchondral cysts. The extent of the findings was used to classify severity as none, mild, moderate, or severe. Arthroscopic findings of synovitis of the TMJ were recorded in the same fashion, and fragmentation or perforation of the articular disc was also noted on arthroscopy. Surgical technique Single puncture arthroscopy as described by McCain and de la Rua (quoted by Zhuo and Cai12 ) was done with an outflow needle for joint lavage and diagnostic sweep. Intramuscular ® injections of onabotulinumtoxinA (Botox , Allegan, Weston, Fl) were given at sites of maximal tenderness within the masseter and temporalis muscles. Patients who complained of tenderness over the anterior ramus or coronoid were also given an injection of Depo-Medrol (methylprednisolone acetate, Henry Schein, Melville, NY, USA) at the insertion of the temporalis tendon using a total dose of 40 mg/side.
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N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
Table 1 Clinical condition before and after arthroscopy. Variable
With effusion
Without effusion
df
t
p value
Mean (SD) age (years) Duration of symptoms (years)
45 (13) 7.2 (9.5)
42 (18) 6.1 (8.4)
45 41
0.59 0.40
0.556 0.688
Pain at rest (VAS 0–10): Before After Change
6.7 (2.0) 3.8 (3.0) −2.9 (3.3)
6.0 (2.0) 3.3 (3.0) 02.7 (3.6)
34 34 34
1.0 0.49 −0.15
0.327 0.631 0.881
Active maximum incisal opening (mm): Before After Change
32.7 (6.2) 38.5 (7.0) 5.8 (5.8)
36.4 (8.2) 41.2 (6.8) 4.8 (6.6)
37 37 37
−1.50 −1.18 0.50
0.143 0.246 0.251
Statistical analysis Data were analysed with the help of IBM SPSS Statistics for Windows (version 24, IBM Corp, Armonk, NY, USA). Independent samples t tests were used to test the significance of differences among continuous variables (age, duration of symptoms, pain at rest, and MIO) between patients (or joints) with and without effusions. Paired-samples t tests were used to assess whether pain at rest and MIO changed significantly after the surgical intervention. To rule out the influence of confounding factors, including duration of symptoms and degrees of preoperative pain, we applied linear regression. The standardised residuals were then compared across groups to assess the significance of the associations between effusions and changes in the amount of pain. In the case of categorical variables, including degenerative joint disease, position of the disc, and perforation of the disc on arthroscopy, the Chi squared test was used to assess whether the presence of effusions was related. Probabilities of less than 0.05 were accepted as significant. All tests were two-tailed.
Fig. 1. Association between effusion of the temporomandibular joint and degenerative joint disease.
Results Fifty-seven patients who had arthroscopies of the TMJ between 2011 and 2014 were identified, of whom 47 (94 TMJ) had data about effusions and met the inclusion criteria. There were 26 TMJ with effusions on MRI and 68 without. Effusions were present in nine TMJ on the left and 17 on the right; seven patients had bilateral effusions, two had unilateral effusions on the left, and 10 on the right. There were no significant differences in outcome between patients with bilateral and unilateral effusions (all p > 0.10). The primary outcome variables were pain at rest on VAS (0–10) and the presence of degenerative joint disease on MRI, and the results are shown in Table 1. With respect to degenerative joint disease, there was a significant relation between effusions and degenerative bone disease (2 (3) = 11.79, p = 0.008; Fig. 1). Secondary outcome variables included MIO, position of the disc on MRI, the presence of synovitis and perforation of the disc on arthroscopy, and duration of symptoms. We found
Fig. 2. Comparison with the position of the disc.
a significant relation between effusions and the position of the disc (2 (3) = 13.11, p = 0.004; Fig. 2). Specifically, effusions were associated with a lower probability of the disc being in the normal position and a higher probability of anterior disc displacement without reduction or perforation of the disc on MRI (Table 2). There was no significant relation between effusions on MRI and arthroscopic findings.
N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100 Table 2 Relation between effusion of the temporomandibular joint (TMJ) and the state of the disc. Variable Position of TMJ disc: Normal Displaced (with reduction) Displaced (without reduction) Perforated or missing Total
Effusion
No effusion
Total
3.8 (1) 34.6 (9)
29.4 (20) 36.8 (25)
22.3 (21) 36.2 (34)
30.8 (8)
26.5 (18)
27.7 (26)
30.8 (8) 100 (26)
7.4 (5) 100 (68)
13.8 (13) −(94)
Note: Numbers in parentheses are numbers of patients in each category.
Discussion The purpose of this study was to assess the correlation between effusions of the TMJ and relevant clinical variables, specifically the presence of arthralgia and degenerative joint disease. We hypothesised that there is no difference in clinical variables in patients with and without effusions of the TMJ. The specific aims of the study, therefore, were to compare the presence of arthralgia measured by pain scores at rest on VAS (0–10); to compare the presence of degenerative joint disease as seen on MRI; and to compare secondary clinical variables (including position and perforation of the disc, the presence of synovitis, active MIO, and duration of symptoms). We found no relation between effusions of the joint and the clinical variables such as severity of pain and MIO, and the presence of an effusion did not predict a better response to arthroscopy than no effusion. Taken in isolation, therefore, the presence of an effusion identified on a T2-weighed MRI does not constitute an absolute indication for intervention. Instead, decisions about treatment should be based on a combination of factors deduced from the patient’s history, physical examination, and diagnostic imaging. As seen in orthopaedic studies of effusions of the knee joint, pain may be compartment specific and multifactorial,13 and the same can be said for pain in the TMJ. The quantification of joint effusion is difficult, both on MRI and ultrasound, so the reliability and validity of these measurements are questionable and may lead to false assessments of pain. Haley et al found a large number of false positive and false negative results with effusions of the TMJ shown on MRI and reports of pain in the TMJ. They found that palpation of the TMJ was more accurate in diagnosing pain.14 The quantification of synovitis is subject to similar concerns, as shown by previous studies that found a link between effusion and synovitis, whereas this study found no such correlation, but the trend was towards an association between effusions and severe synovitis.15 We did, however, identify a significant association between effusion of the TMJ and degenerative joint disease of increasing severity, as well as progressive abnormalities of the articular disc. In the setting of inflammatory arthri-
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tis, increasing permeability of the synovial lining may be a mechanism that explains this trend. As previous studies have linked effusions of the TMJ to a proinflammatory process, it is noteworthy that this study found a clinically relevant relation between effusions and degenerative joint disease, and the position of the disc and whether it was perforated. A study of 508 joints found that joints with anterior displacement with reduction showed a 2.01 odds ratio for degenerative changes and a 2.85 odds ratio for joint effusions compared with joints with discs in a normal position, while joints with anterior displacement without reduction had an odds ratio of 4.43 for degenerative changes and 4.61 for joint effusions.11 These trends corroborate the finding that effusions are associated with degenerative changes and the position of the disc, specifically anterior displacement without reduction. Khawaja et al recently found an association between effusions and the position of the temporomandibular disc in the coronal and sagittal planes,8 so it is reasonable to conclude that the disc is likely to be displaced at the same time as there is an increase in inflammatory mediators and a joint effusion, which may eventually result in degenerative joint disease. In a recent study 124 adolescent patients with unilateral anterior displacement without reduction were followed with serial MRI taken 14 months apart. These TMJ had a significantly higher incidence of condylar degeneration and effusion than the opposite joint in which the articular disc was in the normal position. Despite a lack of intervention, the followup images showed a considerable reduction in both effusion and progressive deformation of the disc.14 Like us, Haley et al14 showed that TMJ effusion is associated with progressive degenerative joint disease and articular disc disorder. However, the presence of effusion in patients with long-standing temporomandibular disorders seems to be a transient phenomenon the clinical relevance of which is not clear. Our study had several limitations. An effusion was considered to be present if it was identified based on the radiology report, and there was a lack of standardisation as many different radiologists read the MRI studies, which increasing the risk of type 1 and type 2 errors. The fact that the study was retrospective increases the risk of bias and inaccurate data, and the sample was small for analysis of subgroups (for example, the number of effusions in patients with perforated discs). The sample also included patients with TMJ arthralgia and myofascial pain, and they had adjunctive procedures that potentially confounded the association between effusion and pain. Finally, this study acknowledges that some MRI scans might have been taken while patients were taking anti-inflammatory drugs, and it is not known what effect that might have on the presence of effusions in the TMJ.
Conclusion In this study we examined the relation between effusions of the TMJ and clinical variables including pain scores and
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N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
degenerative joint changes. Effusions were found to be significantly associated with degenerative joint disease and the condition of the disc, but not with pain score, mouth opening, or arthroscopic findings. An effusion of the TMJ seen on MRI before arthroscopy was not associated with a better postoperative outcome. Future efforts should be made to elucidate the incidence of effusions of the TMJ in patients without symptoms, and randomised controlled trials designed with larger samples to further clarify the relations between effusions of the TMJ and relevant clinical outcomes.
Ethics statement/confirmation of patients’ permission The University Institutional Review Board exempted the paper from the need for ethics approval. Patients’ permission was not required.
Conflict of interest We have no conflicts of interest.
References 1. Westesson PL, Brooks SL. Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. Am J Roentgenol 1992;159:559–63. 2. Kaneyama K, Segami N, Sun W, et al. Levels of soluble cytokine factors in temporomandibular joint effusions seen on magnetic resonance images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:411–8. 3. Al-Khalisy HM, Nikiforov I, Mansoora Q, et al. Septic arthritis in the temporomandibular joint. N Am J Med Sci 2015;7:480–2.
4. Teng GG, Nair R, Saag KG. Pathophysiology, clinical presentation and treatment of gout. Drugs 2006;66:1547–63. 5. MacMullan P, McCarthy G. Treatment and management of pseudogout: insights for the clinician. Ther Adv Musculoskelet Dis 2012;4:121–31. 6. Lo G, McAlindon T, Niu J, et al. Bone marrow lesions and joint effusion are strongly and independently associated with weight-bearing pain in knee osteoarthritis: data from the osteoarthritis initiative. Osteoarthr Cartil 2009;17:1562–9. 7. Wang X, Jin X, Han W, et al. Cross-sectional and longitudinal associations between knee joint effusion synovitis and knee pain in older adults. J Rheumatol 2016;43:121–30. 8. Khawaja SN, Crow H, Mahmoud RF, et al. Is there an association between temporomandibular joint effusion and arthralgia/. J Oral Maxillofac Surg 2017;75:268–75. 9. Park HN, Kim KA, Koh KJ. Relationship between pain and effusion on magnetic resonance imaging in temporomandibular disorder patients. Imaging Sci Dent 2014;44:293–9. 10. Bas B, Yılmaz N, Gökce E, et al. Ultrasound assessment of increased capsular width in temporomandibular joint internal derangements: relationship with joint pain and magnetic resonance grading of joint effusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:112–7. 11. Roh HS, Kim W, Kim YK, et al. Relationships between disk displacement, joint effusion, and degenerative changes of the TMJ in TMD patients based on MRI findings. J Craniomaxillofac Surg 2012;40:283–6. 12. Zhuo Z, Cai X. Results of radiological follow-up of untreated anterior disc displacement without reduction in adolescents. Br J Oral Maxillofac Surg 2016;54:203–7. 13. Wang X, Jin X, Han W, et al. Cross-sectional and longitudinal associations between knee joint effusion synovitis and knee pain in older adults. J Rheumatol 2015;43:121–30. 14. Haley DP, Schiffman EL, Lindgren BR, et al. The relationship between clinical and MRI findings in patients with unilateral temporomandibular joint pain. J Am Dent Assoc 2001;132:476–81. 15. Segami N, Nishimura M, Kaneyama K, et al. Does joint effusion on T2 magnetic resonance images reflect synovitis? Comparison of arthroscopic findings in internal derangements of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:341–5.
ScienceDirect British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease? N. Thomas a,∗ , D.E. Harper b , S. Aronovich c a b c
St. John Providence Oral and Maxillofacial Surgery Department of Anesthesiology, University of Michigan, Ann Arbor, MI Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
Accepted 21 November 2017
Abstract Effusions are common among patients with disorders of the temporomandibular joint (TMJ), but publications are limited and results inconsistent about the correlation between them and important clinical variables, in particular severity of pain and degenerative disease. We organised a retrospective study of patients who presented for the evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Inclusion criteria were: patients who had pain that was primarily arthrogenous, and coexisting myogenous pain, who had had initial non-surgical treatment, and arthroscopy of the TMJ with or without intramuscular injection of onabotulinumtoxinA ® (Botox, Allegan, Weston, Fl, USA). The primary outcome variables were pain at rest as measured by visual analogue score (VAS) and the presence of degenerative disease of the joint. The secondary outcome variables included the position of the disc and whether it was perforated, signs of synovitis, maximal interincisal opening (MIO), and duration of symptoms. We studied 47 patients (94 TMJ) who met the inclusion criteria. We found no significant differences in pain at rest before or after arthroscopy, between patients with and without effusions, or in maximal MIO or duration of symptoms between the two groups. There was, however, a significant relation between effusions and degenerative joint disease. Effusions were also associated with a lower probability of the disc being in a normal position and a higher probability of anterior disc displacement without reduction. © 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Temporomandibular joint; TMJ; Effusion; Effusions; Degenerative joint disease; DJD; Disc position; Pain score; Temporomandibular disorders; TMD
Introduction Effusions are common in disorders of the temporomandibular joint (TMJ), and studies have shown that they are present in up to half of all joints with anterior disc displacement without reduction and up to 40% of joints with anterior disc ∗ Corresponding author at: St. John Providence, 11800 E. 12 Mile Rd., Warren, MI 48093. Tel.: +1 248 535 1370. E-mail address: [email protected] (N. Thomas).
displacement with reduction.1 However, there are few and inconsistent reports about the correlation between effusions and important clinical variables such as severity of pain and degenerative joint disease. An effusion of the TMJ is defined as excess intra-articular synovial fluid within the TMJ space. It is identified by hyperintensity within the joint space on a T2-weighted magnetic resonance image (MRI). Joint effusions are thought to indicate an inflammatory process, with several studies having shown increased concentrations of proteins and proinflam-
https://doi.org/10.1016/j.bjoms.2017.11.011 0266-4356/© 2017 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
matory cytokines in the synovial fluid and tissue of joints with effusions.2 Occasionally an effusion of the TMJ may be found in conjunction with acute septic arthritis, gouty arthritis, pseudogout, metastatic joint effusion, and synovial chondromatosis.3–5 Recently, orthopaedic studies have shown a correlation between effusions of the knee joint and compartment-specific contributions to both weight-bearing and non-weight-bearing knee pain.6,7 In contrast, papers about the TMJ have found an inconsistent correlation between effusions and temporomandibular arthralgia. Khawaja et al examined 312 TMJ and found that effusions were not associated with arthralgia or with other clinical variables, with the exception of the position of the articular disc in the sagittal plane.8 Park et al found that effusions of the TMJ had no significant association with spontaneous facial pain, and no relation to pain on palpation of the masticatory muscles.9 In contrast to these findings, Bas et al found a significant correlation between pain scores measured on a visual analogue scale (VAS) and the presence of effusions on MRI. They also identified a significant positive correlation between increased width of the capsule and effusions on ultrasound imaging.10,11 The purpose of this study was to assess the correlation between TMJ effusions and relevant clinical and radiographic variables, specifically the presence of arthralgia in the TMJ, degenerative joint disease on MRI, and arthroscopic findings. We hypothesised that there is no difference in clinical and radiographic variables in patients with and without effusions of the TMJ. The specific aims of the study, therefore, were as follows: first, to compare the incidence and severity of arthralgia of the TMJ; secondly, to compare the presence of degenerative joint disease on MRI; thirdly, to compare secondary variables (including position and perforation of the disc, active maximal interincisal opening (MIO), and duration of symptoms); fourthly, to compare arthroscopic findings; and lastly to compare the outcomes of TMJ arthroscopy in those with and without effusions.
Methods Study design/sample We designed a retrospective cohort study of all patients who presented for evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Patients had to have pain that was primarily arthrogenous together with coexisting myogenous pain, and to have had a preoperative MRI of the TMJ. They should also have had initial non-surgical treatment, and TMJ arthroscopy with or without an intramuscular injection of ® onabotulinumtoxinA (Botox , Allegan, Weston, Fl, USA). Patients who had other procedures on the TMJ, those with primary neuropathic pain, and those who did not have preoperative or postoperative outcomes of interest documented,
97
were excluded. All procedures were done by a single surgeon in the Department of Oral and Maxillofacial Surgery, and the study was exempted from the need for ethics approval by the institutional review board, and followed the guidelines stated in the Helsinki Declaration. Variables Personal, diagnostic, clinical, and operative data were collected, including sex, age, specific diagnosis of the TMJ being treated, the condition of the disc, number and type of previous operations, pain at rest on VAS (0–10), presence of degenerative joint disease on MRI, position of the disc on MRI, presence of perforation of the disc on MRI and on arthroscopy, duration of symptoms, and active MIO. The primary outcome variables recorded were pain at rest on VAS and the presence of degenerative joint disease. Secondary outcome variables recorded included the position of the disc on MRI, perforation of the disc on MRI, the presence of synovitis on arthroscopy, MIO, and duration of symptoms. Collection of data Physical examination was according to the criteria laid down in the Research Criteria for Temporomandibular Disorders. All measurements were made by the same observer both before and after the intervention. Pain scores were recorded on VAS (0–10, with 10 being the most severe). MIO was measured (mm) using a curvilinear ruler (TheraBite Jaw ROM Scale, Great Lakes Ortho, Tonawanda, NY, USA) between maxillary and mandibular central incisors on active opening. Effusions of the TMJ were identified on T2-weighed MRI and reported by the neuroradiologist. Degenerative joint disease and the position of the disc were assessed on proton density sequences of the MRI in both open and closed positions. Degenerative joint disease was diagnosed if there were signs of flattening, erosion, osteophytes, or the formation of subchondral cysts. The extent of the findings was used to classify severity as none, mild, moderate, or severe. Arthroscopic findings of synovitis of the TMJ were recorded in the same fashion, and fragmentation or perforation of the articular disc was also noted on arthroscopy. Surgical technique Single puncture arthroscopy as described by McCain and de la Rua (quoted by Zhuo and Cai12 ) was done with an outflow needle for joint lavage and diagnostic sweep. Intramuscular ® injections of onabotulinumtoxinA (Botox , Allegan, Weston, Fl) were given at sites of maximal tenderness within the masseter and temporalis muscles. Patients who complained of tenderness over the anterior ramus or coronoid were also given an injection of Depo-Medrol (methylprednisolone acetate, Henry Schein, Melville, NY, USA) at the insertion of the temporalis tendon using a total dose of 40 mg/side.
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N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100
Table 1 Clinical condition before and after arthroscopy. Variable
With effusion
Without effusion
df
t
p value
Mean (SD) age (years) Duration of symptoms (years)
45 (13) 7.2 (9.5)
42 (18) 6.1 (8.4)
45 41
0.59 0.40
0.556 0.688
Pain at rest (VAS 0–10): Before After Change
6.7 (2.0) 3.8 (3.0) −2.9 (3.3)
6.0 (2.0) 3.3 (3.0) 02.7 (3.6)
34 34 34
1.0 0.49 −0.15
0.327 0.631 0.881
Active maximum incisal opening (mm): Before After Change
32.7 (6.2) 38.5 (7.0) 5.8 (5.8)
36.4 (8.2) 41.2 (6.8) 4.8 (6.6)
37 37 37
−1.50 −1.18 0.50
0.143 0.246 0.251
Statistical analysis Data were analysed with the help of IBM SPSS Statistics for Windows (version 24, IBM Corp, Armonk, NY, USA). Independent samples t tests were used to test the significance of differences among continuous variables (age, duration of symptoms, pain at rest, and MIO) between patients (or joints) with and without effusions. Paired-samples t tests were used to assess whether pain at rest and MIO changed significantly after the surgical intervention. To rule out the influence of confounding factors, including duration of symptoms and degrees of preoperative pain, we applied linear regression. The standardised residuals were then compared across groups to assess the significance of the associations between effusions and changes in the amount of pain. In the case of categorical variables, including degenerative joint disease, position of the disc, and perforation of the disc on arthroscopy, the Chi squared test was used to assess whether the presence of effusions was related. Probabilities of less than 0.05 were accepted as significant. All tests were two-tailed.
Fig. 1. Association between effusion of the temporomandibular joint and degenerative joint disease.
Results Fifty-seven patients who had arthroscopies of the TMJ between 2011 and 2014 were identified, of whom 47 (94 TMJ) had data about effusions and met the inclusion criteria. There were 26 TMJ with effusions on MRI and 68 without. Effusions were present in nine TMJ on the left and 17 on the right; seven patients had bilateral effusions, two had unilateral effusions on the left, and 10 on the right. There were no significant differences in outcome between patients with bilateral and unilateral effusions (all p > 0.10). The primary outcome variables were pain at rest on VAS (0–10) and the presence of degenerative joint disease on MRI, and the results are shown in Table 1. With respect to degenerative joint disease, there was a significant relation between effusions and degenerative bone disease (2 (3) = 11.79, p = 0.008; Fig. 1). Secondary outcome variables included MIO, position of the disc on MRI, the presence of synovitis and perforation of the disc on arthroscopy, and duration of symptoms. We found
Fig. 2. Comparison with the position of the disc.
a significant relation between effusions and the position of the disc (2 (3) = 13.11, p = 0.004; Fig. 2). Specifically, effusions were associated with a lower probability of the disc being in the normal position and a higher probability of anterior disc displacement without reduction or perforation of the disc on MRI (Table 2). There was no significant relation between effusions on MRI and arthroscopic findings.
N. Thomas et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 96–100 Table 2 Relation between effusion of the temporomandibular joint (TMJ) and the state of the disc. Variable Position of TMJ disc: Normal Displaced (with reduction) Displaced (without reduction) Perforated or missing Total
Effusion
No effusion
Total
3.8 (1) 34.6 (9)
29.4 (20) 36.8 (25)
22.3 (21) 36.2 (34)
30.8 (8)
26.5 (18)
27.7 (26)
30.8 (8) 100 (26)
7.4 (5) 100 (68)
13.8 (13) −(94)
Note: Numbers in parentheses are numbers of patients in each category.
Discussion The purpose of this study was to assess the correlation between effusions of the TMJ and relevant clinical variables, specifically the presence of arthralgia and degenerative joint disease. We hypothesised that there is no difference in clinical variables in patients with and without effusions of the TMJ. The specific aims of the study, therefore, were to compare the presence of arthralgia measured by pain scores at rest on VAS (0–10); to compare the presence of degenerative joint disease as seen on MRI; and to compare secondary clinical variables (including position and perforation of the disc, the presence of synovitis, active MIO, and duration of symptoms). We found no relation between effusions of the joint and the clinical variables such as severity of pain and MIO, and the presence of an effusion did not predict a better response to arthroscopy than no effusion. Taken in isolation, therefore, the presence of an effusion identified on a T2-weighed MRI does not constitute an absolute indication for intervention. Instead, decisions about treatment should be based on a combination of factors deduced from the patient’s history, physical examination, and diagnostic imaging. As seen in orthopaedic studies of effusions of the knee joint, pain may be compartment specific and multifactorial,13 and the same can be said for pain in the TMJ. The quantification of joint effusion is difficult, both on MRI and ultrasound, so the reliability and validity of these measurements are questionable and may lead to false assessments of pain. Haley et al found a large number of false positive and false negative results with effusions of the TMJ shown on MRI and reports of pain in the TMJ. They found that palpation of the TMJ was more accurate in diagnosing pain.14 The quantification of synovitis is subject to similar concerns, as shown by previous studies that found a link between effusion and synovitis, whereas this study found no such correlation, but the trend was towards an association between effusions and severe synovitis.15 We did, however, identify a significant association between effusion of the TMJ and degenerative joint disease of increasing severity, as well as progressive abnormalities of the articular disc. In the setting of inflammatory arthri-
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tis, increasing permeability of the synovial lining may be a mechanism that explains this trend. As previous studies have linked effusions of the TMJ to a proinflammatory process, it is noteworthy that this study found a clinically relevant relation between effusions and degenerative joint disease, and the position of the disc and whether it was perforated. A study of 508 joints found that joints with anterior displacement with reduction showed a 2.01 odds ratio for degenerative changes and a 2.85 odds ratio for joint effusions compared with joints with discs in a normal position, while joints with anterior displacement without reduction had an odds ratio of 4.43 for degenerative changes and 4.61 for joint effusions.11 These trends corroborate the finding that effusions are associated with degenerative changes and the position of the disc, specifically anterior displacement without reduction. Khawaja et al recently found an association between effusions and the position of the temporomandibular disc in the coronal and sagittal planes,8 so it is reasonable to conclude that the disc is likely to be displaced at the same time as there is an increase in inflammatory mediators and a joint effusion, which may eventually result in degenerative joint disease. In a recent study 124 adolescent patients with unilateral anterior displacement without reduction were followed with serial MRI taken 14 months apart. These TMJ had a significantly higher incidence of condylar degeneration and effusion than the opposite joint in which the articular disc was in the normal position. Despite a lack of intervention, the followup images showed a considerable reduction in both effusion and progressive deformation of the disc.14 Like us, Haley et al14 showed that TMJ effusion is associated with progressive degenerative joint disease and articular disc disorder. However, the presence of effusion in patients with long-standing temporomandibular disorders seems to be a transient phenomenon the clinical relevance of which is not clear. Our study had several limitations. An effusion was considered to be present if it was identified based on the radiology report, and there was a lack of standardisation as many different radiologists read the MRI studies, which increasing the risk of type 1 and type 2 errors. The fact that the study was retrospective increases the risk of bias and inaccurate data, and the sample was small for analysis of subgroups (for example, the number of effusions in patients with perforated discs). The sample also included patients with TMJ arthralgia and myofascial pain, and they had adjunctive procedures that potentially confounded the association between effusion and pain. Finally, this study acknowledges that some MRI scans might have been taken while patients were taking anti-inflammatory drugs, and it is not known what effect that might have on the presence of effusions in the TMJ.
Conclusion In this study we examined the relation between effusions of the TMJ and clinical variables including pain scores and
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degenerative joint changes. Effusions were found to be significantly associated with degenerative joint disease and the condition of the disc, but not with pain score, mouth opening, or arthroscopic findings. An effusion of the TMJ seen on MRI before arthroscopy was not associated with a better postoperative outcome. Future efforts should be made to elucidate the incidence of effusions of the TMJ in patients without symptoms, and randomised controlled trials designed with larger samples to further clarify the relations between effusions of the TMJ and relevant clinical outcomes.
Ethics statement/confirmation of patients’ permission The University Institutional Review Board exempted the paper from the need for ethics approval. Patients’ permission was not required.
Conflict of interest We have no conflicts of interest.
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