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Implication of general anaesthetic and sedation techniques in temporomandibular joint disorders – a systematic review
J Stomatol Oral Maxillofac Surg 118 (2017) 40–44
Available online at
ScienceDirect www.sciencedirect.com
Review
Implication of general anaesthetic and sedation techniques in temporomandibular joint disorders – a systematic review J. Talava´n-Serna a,*, J.M. Montiel-Company b, C. Bellot-Arcı´s b, J.M. Almerich-Silla b a b
Department of Anaesthesiology and Reanimation, Ontinyent General Hospital, Avda. Francisco Cerda`, 3, 46870 Valencia, Spain Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, C/Gasco´ Oliag No. 10, 46010 Valencia, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 September 2016 Accepted 12 December 2016 Available online 3 February 2017
The purpose of this study was to conduct a systematic review of the literature on temporomandibular joint damage directly related to general anaesthesia and sedation. We searched MEDLINE, SCOPUS and the COCHRANE Library for titles and abstracts containing terms related to the subject. The search delimiters were analytical and descriptive studies with abstracts in Spanish, German, English or French, with no time limit. The search was updated in January 2015. Of the 398 articles found, 89 were duplicates and only 28 were of interest. Of these, 23 (82.14%) were case and case series reports, 4 (14.28%) were longitudinal studies and 1 (3.57%) was a cross-sectional study. General anaesthesia and sedation are risk factors for temporomandibular joint damage because of the drop in muscle tone caused by the drugs employed and because of airway management manoeuvres involving the joint. Joint complications have been described with spontaneous ventilation as well as with ventilation assisted by a face or laryngeal mask and with intubation. They are more frequent in women and/or patients with previous temporomandibular problems. Proper assessment is required both before and after anaesthesia or sedation in order to foresee and avoid or minimize temporomandibular complications. The data should be treated with caution, as the evidence of case and case series reports is not of a high standard and the small number of analytical studies is not entirely comparable. General anaesthesia and sedation techniques can influence the onset of temporomandibular joint disorders. More studies are needed to provide better clinical evidence.
C 2016 Elsevier Masson SAS. All rights reserved.
Keywords: Mandibular Joint Sedation Anaesthesia Disorders
1. Introduction Many types of anaesthetic- and sedation-related temporomandibular joint (TMJ) damage or disorder have been described. They range from slight discomfort and joint sounds [1,2] to headaches and even to severe impairment of joint movement and malocclusion problems [3–5] that interfere seriously with stomatognathic system function. However, the ultimate aetiology of such events is largely unknown [6,7], although it has been suggested that factors related to anaesthetic techniques may be involved [4,8], since airway management entails mobilising the mouth and TMJ system [9,10] while the patient is unconscious and partially or totally unable to make defensive movements. While manoeuvring the joint, complications may arise. In the same way, loss of muscle tone due to the unconsciousness and muscular relaxation of a patient
* Corresponding author. Unidad Docente de Preventiva, Departamento de Estomatologı´a, Facultad de Medicina y Odontologı´a, Universidad de Valencia, C/ Gasco´ Oliag No. 10, 46010 Valencia, Spain. E-mail address: [email protected] (J. Talava´n-Serna). http://dx.doi.org/10.1016/j.jormas.2016.12.002 C 2016 Elsevier Masson SAS. All rights reserved. 2468-7855/
under general anaesthetic can predispose to greater joint mobilisation [11,12], which can lead to more complications than those already involved in mobilisation for airway control. Prior TMJ dysfunction or certain systemic conditions can favour the development of new onset TMJ problems or the exacerbation of existing manifestations when general anaesthetic techniques are applied to the patient [13,14]. Additionally, there is widespread unawareness of the different manifestations of TMJ damage that can appear after using anaesthetic techniques or in relation to the various airway control techniques [6,7]. In view of the foregoing, the aim of this study was to conduct a systematic review of the literature concerning damage to the temporomandibular joint directly related to different general anaesthesia and sedation methods, in order to acquire a better understanding of the factors involved. 2. Methods We reviewed the bibliography systematically in accordance with the PRISMA (Preferred Reporting Items for Systematic
J. Talava´n-Serna et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 40–44
Reviews and Meta-Analyses) recommendations [15] and the CONSORT criteria [16].
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the information given in the abstract was insufficient for definite inclusion or exclusion, they reviewed the full article before taking the final decision.
2.1. Study selection criteria 2.3. Data extraction The selection criteria for inclusion in the review were: articles, articles in press and reviews; studies conducted in adults. The types of study included were: systematic reviews and metaanalyses, randomised controlled trials (RCTs), cohort studies and case-control studies, both prospective and retrospective, and case and case series reports. All those that investigated the involvement of general anaesthetic and sedation techniques in temporomandibular joint disorders were accepted. 2.2. Search strategy and screening of articles To identify the relevant studies, irrespective of language and with no time limit, we conducted detailed electronic searches in the Medline, Scopus and Cochrane Library databases, updating them on 20 January 2015. The search equations were formed from the following terms: temporomandibular, temporomandibular joint, TMJ, temporomandibular disease, TMD, temporal, mandibular, intubation, laryngoscopy, laryngoscope, extubation, anaesthesia, anesthesia, anaesthetic, anesthetic, induction, dislocation, jaw, perioperative, laryngeal mask, LMA, joint, propofol, ketamine and midazolam, using all the possible combinations of these words. Two separate reviewers independently assessed the titles and abstracts of all the articles. If they disagreed they attempted to reach a consensus, failing which they consulted a third reviewer. If
The variables recorded for comparison of the studies were: author(s), publication year, demographic data (gender and age), sample size, study type and disorder described (Table 1). 3. Results The database search found 302 articles in Medline, 84 in Scopus and 12 in Cochrane Library Plus, totalling 398 articles. The 89 duplicates were excluded. A critical reading of the title and abstract led to excluding 279 articles that did not answer the research question, leaving a total of 30 articles. On reading the full text, a further 2 were excluded because they did not answer the research question, resulting in a total of 28 articles. Of these 28 articles, 23 were case and case series reports (Table 1), four were longitudinal studies and one was a cross-sectional study (Table 2). The case and case series reports assessed 28 patients: 19 female (67.8%) and 9 male (32.14%). By anaesthetic procedure, a general anaesthetic was applied in 27 cases (96.42%) and sedation techniques in one case (3.57%). By disorder, 21 patients presented dislocation of one or both condyles (75.0%), six patients (21.4%) had disc dislocation with locking and one case (3.5%) showed TMJ condyle resorption. The mean age was 40.89 years (female: 37.3, range 18–66 years, male: 48.5, range 22–81 years) (Table 1).
Table 1 Distribution of case and case series reports. Author (year) [reference]
n
Age
Gender (F/M)
Anaesthetic technique
When disorder occurred
TMJ disorder
Avidan (2002) [20]
1
26
F
S
CD
Bellman and Babu (1978) [11] Gambling and Ross (1988) [19] Gould and Banes (1995) [9]
1 1 2
18 30 34 24
F F F F
GA GA GA
Iguchi et al. (2004) [26] Knibbe et al. (1989) [3]
1 3
1
F F M M F
GA GA
Mareque-Bueno et al. (2013) [5]
43 27 31 81 52
Induction Diagnosis: Postoperative Induction (pre-intubation) Induction (pre-intubation) Induction (pre-intubation) in one case. Not specified in the other case Diagnosis: post-extubation (postoperative) Induction (pre-intubation) Not specified Diagnosis: postoperative
Michot et al. (2010) [24] Oofuvong (2005) [10] Patel (1979) [12] Pillai and Konia (2013) [22]
1 1 1 1
42 30 55 66
F F M F
GA GA GA GA
Quessard et al. (2008) [7]
1
49
M
GA
Rastogi et al. (1997) [4]
2 1
F M M
GA
Rattan and Arora (2006) [30]
36 35 22
Roze des Ordons and Townsend (2008) [29] Sia et al. (2008) [6]
1 2 1 1 1 1 1
F M F F M F F F
GA GA
Small et al. (2004) [28] Schwartz (2000) [8] Sosis and Lazar (1987) [25] Sriganesh et al. (2005) [14] Ting J. (2006) [21]
39 64 60 40 69 27 34 45
Unnikrishnan et al. (2006) [27] Wang et al. (2009) [23]
1 1
31 35
M F
GA GA.
GA
GA
GA GA GA GA GA
Not specified Diagnosis: postoperative (late) Eduction (removal of laryngeal mask) Induction of anaesthesia (intubation) Induction Not specified Diagnosis: postoperative Not specified Diagnosis: postoperative Not specified Diagnosis: post-extubation (postoperative) Not specified Diagnosis: post-ICU (late) Induction (pre-intubation) Induction (intubation/insertion of laryngeal mask) Induction of anaesthesia (pre-intubation) Postoperative Induction (intubation) Induction (intubation) Not specified Diagnosis: after removal of laryngeal mask (postoperative) Induction Extubation (eduction of anaesthesia)
F: female; M: male; GA: general anaesthesia; S: sedation; CD: condyle dislocation; DDL: disc dislocation and locking; CR: condylar resorption.
CD CD DDL
DDL DDL DDL CD CR CD CD CD CD CD CD CD DDL CD CD CD CD CD CD CD CD
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42 Table 2 Analytical articles. Author/year [reference]
n
Mean age (years)
Gender (F/M)
Anaesthetic technique
Results
Rodrigues et al. (2009) [2]
100
44
Martin et al. (2007) [1]
122
53.4
M: 34% F: 66% M: 43.3% F: 56.7%
GA with intubation GA with intubation
Lipp et al. (1987) [18]
100
–
Agro´ et al. (2015) [13]
68
42.2 (GA) 46.8 (LRA) 50.6
GA with intubation/LRA GA with intubation
Domino et al. (1999) [17]
4460 claims (27 TMJ-related)
8% disc displacement (female to male ratio 7:1) 19% joint sounds (female to male ratio 4:1) Advanced age, female gender and low interincisal distance are risk factors for TMJ pain Greater risk if prior TMJ disorder No relationship between intubation time and TMJ symptoms 66% of the patients who underwent general anaesthesia presented up to 35% reduction of maximum mouth opening 13% presented some type of TMJ dysfunction prior to surgery. Of these, 44% worsened after intubation 5% of patients developed new onset TMJ dysfunction Of the 27 claims, 11 were for joint dislocation and 16 for isolated pain 30% presented discomfort due to previous joint disorders
–
M: 58.8 F: 41.2 M: 85% F: 15%
GA
F: female; M: male; GA: general anaesthesia; LRA: locoregional anaesthesia.
Of the analytical studies, [17] examined the ASA Closed Claims Project, which records the data from 35 health insurers in the USA, to identify anaesthesia-related claims and collect information on airway lesions associated with general anaesthesia, the patients’ clinical manifestations and airway characteristics and the type of surgery. Agro` et al. [13] examined clinical manifestations in 68 patients before and after tracheal intubation in order to assess TMJ disorders and/or dysfunctions. Similarly, Martin et al. [1] conducted a study in 122 patients who had undergone tracheal intubation in relation to different types of surgery. They assessed pre- and postoperative TMJ-related clinical manifestations in order to investigate the risk factors associated with TMJ dysfunction following intubation. Lipp et al. [18] described a controlled prospective study in which 50 patients underwent surgery with general anaesthesia and orotracheal intubation and another 50 with locoregional anaesthesia (control group), and all were examined postoperatively to assess possible intubation-related TMJ damage. Rodrigues et al. [2] conducted a prospective study of 100 patients with no previous TMJ disorder, assessing disturbances to this joint following tracheal intubation for different types of surgery. They recorded the patients’ clinical and demographic variables postoperatively in order to study new onset development of joint disorders following intubation. 4. Discussion It would appear to have been established that forcing mouth opening can cause TMJ complications [3,19–22], the most frequent in this joint being anterior dislocation [10,22,23], although the TMJ accounts for only 3% of joint dislocations in the entire body [22]. However, there is little information on the incidence of this peri-anaesthesia complication [4,7,24]. The symptoms of TMJ dislocation can range from a serious acute clinical picture with severe pre-auricular pain and inability to close the mouth to a subacute picture of less obvious pain and partial mouth closure, but both are associated with difficulty in speaking and present a depression in the pre-auricular area on palpation [22]. In contrast, subluxation involves spontaneous reduction of the joint [8]. Several authors [3,7,8,10,11,14,22,25] mentioned TMJ condyle (sub)luxations related to orotracheal intubation manoeuvres under general anaesthetic with hypnotic and neuromuscular blocking drugs. In these cases, the mere drop in muscle tone and loss of defensive reflexes caused by general anaesthesia, together with laryngoscope traction for intubation, were sufficient for this phenomenon to occur [10–12,21,26,27]. Patel et al. [12] and Avidan et al. [20] referred to cases of TMJ dislocation following the induction of anaesthesia before invasive airway control had been effected: a few spontaneous actions (such
as yawning) were enough to dislocate the condyle. In the same way, Unnikrishnan et al. [27] described a case of condyle dislocation associated with yawning during the induction of anaesthesia in a tracheostomy tube wearer. In these cases, moreover, neuromuscular blocking drugs had not yet been administered. Similarly, Gambling et al. [19] published an analogous case of condyle dislocation after anaesthesia had been induced with hypnotic and neuromuscular blocking drugs but prior to intubation manoeuvres. As in the previous cases, joint reduction under sedation was required after this early diagnosis of condyle subluxation. Other manoeuvres associated with invasive airway management which do not require excessive opening, such as intubation with a fibrescope or lighted stylet, have also been described as possible joint dislocation triggers. Rastogi et al. [4] described a case of TMJ condyle dislocation following intubation with a fibrescope and the administration of general anaesthesia with neuromuscular blocking drugs. The same authors also reported a case of condyle dislocation in a patient with orotracheal intubation with a lighted stylet following induction of anaesthesia with hypnotic and neuromuscular blocking drugs. Direct laryngoscopy manoeuvres had not been performed in either of these two cases, but their mouths were sufficiently open to carry out the airway management procedure. Following the intervention, their respective joints were repositioned under sedation. Although most dislocations occur during intubation manoeuvres while inducing anaesthesia, Wang et al. [23] reported a case of condyle dislocation in a 35-year-old patient in relation to excessive oral opening during orotracheal extubation. Cases of mandibular dislocation during laryngeal mask insertion have also begun to be reported, even in patients with no previous history of TMJ disorders [6,21,24]. The reason is that head tilt and chin lift manoeuvres tend to be used to position these airways, causing passive wide opening of the mouth, which together with the low muscle tone induced by the general anaesthesia predisposes to joint dislocation [6]. Other studies report disc dislocation with locking but no condyle dislocation. Gould et al. [9] described two such cases. In one, the jaw locked even before laryngoscopy manoeuvres had begun. Small et al. [28] and Roze des Ordons et al. [29] described similar cases. In the case reported by Small et al. [28], the disk dislocation reduced spontaneously. In these cases, difficult airway management situations arose that required special intubation techniques. Knibbe et al. [3] and Iguchi et al. [26] also reported cases of disk displacement with locking. Cases of condyle resorption in which malocclusion and facial deviation developed several months after performing difficult
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orotracheal intubations have also been described. These could be related to infectious, autoimmune, endocrine, cardiovascular, metabolic or traumatic factors [5]. Consequently, it could be argued that temporomandibular dysfunction following laryngoscopy and intubation or the insertion of a laryngeal mask does not imply failings in these techniques, as the structure of the TMJ and the wide range of movements it can perform [23] make this joint quite susceptible to instability and it may even dislocate when no external force has been applied [25,27]. At all events, spontaneous dislocation of the temporomandibular joint and TMJ disorders arising as a result of general anaesthesia have not yet been clarified sufficiently [6] and probably have a multifactorial origin. It would be advisable to assess TMJ status preoperatively in order to plan the intubation accordingly [1–4,7,10,13,28], as recommended by the American Society of Anesthesiology [22], and to proceed cautiously [6] during induction and intubation, checking the occlusion in the event of any suspicion of joint dislocation [30]. The patient should also be warned of the risk of such complications, which could even be triggered de novo following airway manipulation in the context of general anaesthesia [2–4]. In severe cases, postponement of surgery might even be considered until the TMJ disorder has been resolved [3]. It would also be advisable for the anaesthetist to be conscious of these complications [19], to be as careful as possible [6], to check during the application of anaesthesia and perianaesthetically that TMJ disorders are absent, and to be able to diagnose and treat them [3,7,10,14,25,30], especially in the case of dislocation, where delayed diagnosis can lead to greater difficulty in correcting the problem [6,20]. Diagnosing TMJ complications in patients with intubation can be complex, owing to communication difficulties as a result of the general anaesthesia, analgesic medication prescribed perioperatively, which can mask TMJ pain, and a lack of familiarity with joint dislocation among healthcare staff [22]. As a result, the condition is often not diagnosed until the patient recovers full consciousness and is able to communicate the feeling of pain and the inability to move the mouth [4,6,23]. Prolonged unconsciousness, such as may occur in intensive care patients, can therefore entail a considerable delay in diagnosis. For instance, Rattan and Arora [30] describe the case of a 22-year-old man whose prolonged orotracheal intubation was followed by late diagnosis of TMJ condyle dislocation, which required surgical reduction as closed reduction was no longer possible. On occasion, the diagnosis may be still tardier, even occurring weeks or months after the patient’s postoperative discharge [3]. According to Martin et al. [1], the patient’s ability to open the mouth preoperatively is correlated with the Mallampati score, although the latter is not a good predictor of TMJ dysfunction. They also consider that low interincisal distance, female gender and increasing age are correlated with TMJ pain following intubation and that previously experience of TMJ symptoms is the best predictive factor for post-intubation symptoms, even up to two weeks after this procedure. A greater or lesser duration of intubation appears not to be related to TMJ symptoms [1]. It seems to have been established that TMJ dysfunction can be aggravated by intubation manoeuvres. For instance, Agro` et al. [13] reported that up to 13% of the population presents symptoms, which suggest TMJ dysfunction prior to general anaesthesia, and the symptoms of 44% of these worsened following intubation. Moreover, up to 5% of patients developed new onset TMJ dysfunction. In the prospective study conducted by Gould et al. [9], 35 of the 15 patients who underwent intubation presented TMJ disorders, albeit temporary, and two cases presented disc displacement with locking. Lipp et al. [18] reported up to 66% of
43
minor TMJ incidents following intubation in a series of 50 patients. Domino et al. [17] found that 10% of the claims for airway trauma (27 out of 266) were for TMJ damage, in all cases associated with ordinary tracheal intubation in ASA I–II patients. Out of this total, 85% of the claims were made by women and 96% by persons aged under 60 years. Of the 27 TMJ trauma claims, 11 were for joint dislocation and 16 were for pain. 30% of the cases had a previous history of TMJ disorders. Certain conditions, such as some autoimmune diseases that affect joints; diseases that cause hyperlaxity and fragile connective tissues; malocclusion problems; retrognathism; algodystrophic TMJ syndromes; a previous history of joint dislocation favoured by flatness of the articular eminence; muscle hypotonia; or even psychogenic factors, can favour TMJ disorder development in the course of airway control manoeuvres during anaesthesia, as the loss of muscle tone is combined with forced manoeuvres with a susceptible joint [4,6–8,13,14,19,22,23,25,27,28]. However, it would also appear that not achieving adequate neuromuscular relaxation could make laryngoscopy manoeuvres more difficult and oblige the anaesthetist to increase the force applied to the adjacent tissues and to the TMJ itself, predisposing this joint to greater damage [9]. Moreover, slow induction of general anaesthesia is also a risk factor for TMJ disorders [7,24] as it makes it necessary to extend the duration of airway control manoeuvres, which are one of the risk factors for joint disorders. In the same way, a difficult airway adds to the difficulties and using more aggressive manoeuvres increases the risk of joint dislocation [3,8,28]. The main limitation of this review is that few studies have been published on TMJ disorders related to general anaesthetic and sedation techniques and most of those published are case or case series reports of isolated instances encountered while applying these procedures. This means that the evidence they provide is of a low standard. A higher standard of evidence was provided by some authors [1,2,13,17,18], although the fact that their number is very small and the variables analysed by each of them were highly disparate makes them difficult to analyse with a view to arriving at definite conclusions. Despite the few studies found, we may conclude that intubation can cause TMJ disorders, although their percentage is small. The most frequent is condyle dislocation followed by disc locking. A record of TMJ problems is a risk factor for postoperative joint complications. More studies of higher evidence quality need to be conducted on TMJ disorders in relation to general anaesthetic and sedation procedures. Contributions Conception and design of study: J. Talava´n-Serna, J.M. MontielCompany. Acquisition of data: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis, J.M. Almerich-Silla. Analysis and/or interpretation of data: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis. Drafting the manuscript: J. Talava´n-Serna, J.M. MontielCompany, C. Bellot-Arcis. Revising the manuscript critically for important intellectual content: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis. Approval of the version of the manuscript to be published: J. Talava´n-Serna, J.M. Montiel-Company C. Bellot-Arcis, J.M. Almerich-Silla. Disclosure of interest The authors declare that they have no competing interest.
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Acknowledgements Mary Georgina Hardinge translated the manuscript into English. References [1] Martin MD, Wilson KJ, Ross BK, Souter K. Intubation risk factors for temporomandibular joint/facial pain. Anesth Prog 2007;54:109–14. [2] Rodrigues ET, Suazo IC, Guimaraes AS. Temporomandibular joint sounds and disc dislocation incidence after orotracheal intubation. J Clin Cosm Investig Dent 2009;8:71–3. [3] Knibbe MA, Carter BJ, Frokjer GM. Postanesthetic temporomandibular joint dysfunction. Anesth Prog 1989;36:21–5. [4] Rastogi NK, Vakharia N, Hung OR. Perioperative anterior dislocation of the temporomandibular joint. Anesth Analg 1997;84:924–6. [5] Mareque-Bueno J, Ferna´ndez-Barriales M, Morey-Mas MA, Herna´ndez-Alfaro F. Progressive mandibular midline deviation after difficult tracheal intubation. Anaesthesia 2013;68:770–2. [6] Sia SL, Chang YL, Lee TM, Lai YY. Temporomandibular joint dislocation after laryngeal mask airway insertion. Acta Anaesthesiol Taiwan 2008;46:82–5. [7] Quessard A, Barrie`re P, Levy F, Steib A, Dupeyron P. Luxation de l’articulation temporomandibulaire diagnostique´e au de´cours d’une anesthe´sie ge´ne´rale. Ann Fr Anesth Reanim 2008;27:846–9. [8] Schwartz AJ. Dislocation of the mandible: a case report. J Am Assoc Nurse Anesth 2000;68:507–13. [9] Gould DB, Banes CH. Iatrogenic disruptions of right temporomandibular joints during orotracheal intubation causing permanent closed lock of the jaw. Anesth Analg 1995;81:191–4. [10] Oofuvong M. Bilateral temporomandibular joint dislocations during induction of anesthesia and orotracheal intubation. J Med Assoc 2005;88:695–7. [11] Bellman MH, Babu KV. Jaw dislocation during anaesthesia. Anaesthesia 1978;33:844. [12] Patel A. Jaw dislocation during anaesthesia. Anaesthesia 1979;34:376. [13] Agro` F, Salvinelli F, Casale M, Antonelli S. Temporomandibular joint assessment in anaesthetic practice. Br J Anaesth 2003;90:707–8. [14] Sriganesh K, Farooq S, Byrappa V. Temporomandibular joint dislocation during tracheal intubation in a patient with Sjogren syndrome. J Neurosurg Anesthesiol 2015;27:82–3.
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Review
Implication of general anaesthetic and sedation techniques in temporomandibular joint disorders – a systematic review J. Talava´n-Serna a,*, J.M. Montiel-Company b, C. Bellot-Arcı´s b, J.M. Almerich-Silla b a b
Department of Anaesthesiology and Reanimation, Ontinyent General Hospital, Avda. Francisco Cerda`, 3, 46870 Valencia, Spain Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, C/Gasco´ Oliag No. 10, 46010 Valencia, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 September 2016 Accepted 12 December 2016 Available online 3 February 2017
The purpose of this study was to conduct a systematic review of the literature on temporomandibular joint damage directly related to general anaesthesia and sedation. We searched MEDLINE, SCOPUS and the COCHRANE Library for titles and abstracts containing terms related to the subject. The search delimiters were analytical and descriptive studies with abstracts in Spanish, German, English or French, with no time limit. The search was updated in January 2015. Of the 398 articles found, 89 were duplicates and only 28 were of interest. Of these, 23 (82.14%) were case and case series reports, 4 (14.28%) were longitudinal studies and 1 (3.57%) was a cross-sectional study. General anaesthesia and sedation are risk factors for temporomandibular joint damage because of the drop in muscle tone caused by the drugs employed and because of airway management manoeuvres involving the joint. Joint complications have been described with spontaneous ventilation as well as with ventilation assisted by a face or laryngeal mask and with intubation. They are more frequent in women and/or patients with previous temporomandibular problems. Proper assessment is required both before and after anaesthesia or sedation in order to foresee and avoid or minimize temporomandibular complications. The data should be treated with caution, as the evidence of case and case series reports is not of a high standard and the small number of analytical studies is not entirely comparable. General anaesthesia and sedation techniques can influence the onset of temporomandibular joint disorders. More studies are needed to provide better clinical evidence.
C 2016 Elsevier Masson SAS. All rights reserved.
Keywords: Mandibular Joint Sedation Anaesthesia Disorders
1. Introduction Many types of anaesthetic- and sedation-related temporomandibular joint (TMJ) damage or disorder have been described. They range from slight discomfort and joint sounds [1,2] to headaches and even to severe impairment of joint movement and malocclusion problems [3–5] that interfere seriously with stomatognathic system function. However, the ultimate aetiology of such events is largely unknown [6,7], although it has been suggested that factors related to anaesthetic techniques may be involved [4,8], since airway management entails mobilising the mouth and TMJ system [9,10] while the patient is unconscious and partially or totally unable to make defensive movements. While manoeuvring the joint, complications may arise. In the same way, loss of muscle tone due to the unconsciousness and muscular relaxation of a patient
* Corresponding author. Unidad Docente de Preventiva, Departamento de Estomatologı´a, Facultad de Medicina y Odontologı´a, Universidad de Valencia, C/ Gasco´ Oliag No. 10, 46010 Valencia, Spain. E-mail address: [email protected] (J. Talava´n-Serna). http://dx.doi.org/10.1016/j.jormas.2016.12.002 C 2016 Elsevier Masson SAS. All rights reserved. 2468-7855/
under general anaesthetic can predispose to greater joint mobilisation [11,12], which can lead to more complications than those already involved in mobilisation for airway control. Prior TMJ dysfunction or certain systemic conditions can favour the development of new onset TMJ problems or the exacerbation of existing manifestations when general anaesthetic techniques are applied to the patient [13,14]. Additionally, there is widespread unawareness of the different manifestations of TMJ damage that can appear after using anaesthetic techniques or in relation to the various airway control techniques [6,7]. In view of the foregoing, the aim of this study was to conduct a systematic review of the literature concerning damage to the temporomandibular joint directly related to different general anaesthesia and sedation methods, in order to acquire a better understanding of the factors involved. 2. Methods We reviewed the bibliography systematically in accordance with the PRISMA (Preferred Reporting Items for Systematic
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Reviews and Meta-Analyses) recommendations [15] and the CONSORT criteria [16].
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the information given in the abstract was insufficient for definite inclusion or exclusion, they reviewed the full article before taking the final decision.
2.1. Study selection criteria 2.3. Data extraction The selection criteria for inclusion in the review were: articles, articles in press and reviews; studies conducted in adults. The types of study included were: systematic reviews and metaanalyses, randomised controlled trials (RCTs), cohort studies and case-control studies, both prospective and retrospective, and case and case series reports. All those that investigated the involvement of general anaesthetic and sedation techniques in temporomandibular joint disorders were accepted. 2.2. Search strategy and screening of articles To identify the relevant studies, irrespective of language and with no time limit, we conducted detailed electronic searches in the Medline, Scopus and Cochrane Library databases, updating them on 20 January 2015. The search equations were formed from the following terms: temporomandibular, temporomandibular joint, TMJ, temporomandibular disease, TMD, temporal, mandibular, intubation, laryngoscopy, laryngoscope, extubation, anaesthesia, anesthesia, anaesthetic, anesthetic, induction, dislocation, jaw, perioperative, laryngeal mask, LMA, joint, propofol, ketamine and midazolam, using all the possible combinations of these words. Two separate reviewers independently assessed the titles and abstracts of all the articles. If they disagreed they attempted to reach a consensus, failing which they consulted a third reviewer. If
The variables recorded for comparison of the studies were: author(s), publication year, demographic data (gender and age), sample size, study type and disorder described (Table 1). 3. Results The database search found 302 articles in Medline, 84 in Scopus and 12 in Cochrane Library Plus, totalling 398 articles. The 89 duplicates were excluded. A critical reading of the title and abstract led to excluding 279 articles that did not answer the research question, leaving a total of 30 articles. On reading the full text, a further 2 were excluded because they did not answer the research question, resulting in a total of 28 articles. Of these 28 articles, 23 were case and case series reports (Table 1), four were longitudinal studies and one was a cross-sectional study (Table 2). The case and case series reports assessed 28 patients: 19 female (67.8%) and 9 male (32.14%). By anaesthetic procedure, a general anaesthetic was applied in 27 cases (96.42%) and sedation techniques in one case (3.57%). By disorder, 21 patients presented dislocation of one or both condyles (75.0%), six patients (21.4%) had disc dislocation with locking and one case (3.5%) showed TMJ condyle resorption. The mean age was 40.89 years (female: 37.3, range 18–66 years, male: 48.5, range 22–81 years) (Table 1).
Table 1 Distribution of case and case series reports. Author (year) [reference]
n
Age
Gender (F/M)
Anaesthetic technique
When disorder occurred
TMJ disorder
Avidan (2002) [20]
1
26
F
S
CD
Bellman and Babu (1978) [11] Gambling and Ross (1988) [19] Gould and Banes (1995) [9]
1 1 2
18 30 34 24
F F F F
GA GA GA
Iguchi et al. (2004) [26] Knibbe et al. (1989) [3]
1 3
1
F F M M F
GA GA
Mareque-Bueno et al. (2013) [5]
43 27 31 81 52
Induction Diagnosis: Postoperative Induction (pre-intubation) Induction (pre-intubation) Induction (pre-intubation) in one case. Not specified in the other case Diagnosis: post-extubation (postoperative) Induction (pre-intubation) Not specified Diagnosis: postoperative
Michot et al. (2010) [24] Oofuvong (2005) [10] Patel (1979) [12] Pillai and Konia (2013) [22]
1 1 1 1
42 30 55 66
F F M F
GA GA GA GA
Quessard et al. (2008) [7]
1
49
M
GA
Rastogi et al. (1997) [4]
2 1
F M M
GA
Rattan and Arora (2006) [30]
36 35 22
Roze des Ordons and Townsend (2008) [29] Sia et al. (2008) [6]
1 2 1 1 1 1 1
F M F F M F F F
GA GA
Small et al. (2004) [28] Schwartz (2000) [8] Sosis and Lazar (1987) [25] Sriganesh et al. (2005) [14] Ting J. (2006) [21]
39 64 60 40 69 27 34 45
Unnikrishnan et al. (2006) [27] Wang et al. (2009) [23]
1 1
31 35
M F
GA GA.
GA
GA
GA GA GA GA GA
Not specified Diagnosis: postoperative (late) Eduction (removal of laryngeal mask) Induction of anaesthesia (intubation) Induction Not specified Diagnosis: postoperative Not specified Diagnosis: postoperative Not specified Diagnosis: post-extubation (postoperative) Not specified Diagnosis: post-ICU (late) Induction (pre-intubation) Induction (intubation/insertion of laryngeal mask) Induction of anaesthesia (pre-intubation) Postoperative Induction (intubation) Induction (intubation) Not specified Diagnosis: after removal of laryngeal mask (postoperative) Induction Extubation (eduction of anaesthesia)
F: female; M: male; GA: general anaesthesia; S: sedation; CD: condyle dislocation; DDL: disc dislocation and locking; CR: condylar resorption.
CD CD DDL
DDL DDL DDL CD CR CD CD CD CD CD CD CD DDL CD CD CD CD CD CD CD CD
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42 Table 2 Analytical articles. Author/year [reference]
n
Mean age (years)
Gender (F/M)
Anaesthetic technique
Results
Rodrigues et al. (2009) [2]
100
44
Martin et al. (2007) [1]
122
53.4
M: 34% F: 66% M: 43.3% F: 56.7%
GA with intubation GA with intubation
Lipp et al. (1987) [18]
100
–
Agro´ et al. (2015) [13]
68
42.2 (GA) 46.8 (LRA) 50.6
GA with intubation/LRA GA with intubation
Domino et al. (1999) [17]
4460 claims (27 TMJ-related)
8% disc displacement (female to male ratio 7:1) 19% joint sounds (female to male ratio 4:1) Advanced age, female gender and low interincisal distance are risk factors for TMJ pain Greater risk if prior TMJ disorder No relationship between intubation time and TMJ symptoms 66% of the patients who underwent general anaesthesia presented up to 35% reduction of maximum mouth opening 13% presented some type of TMJ dysfunction prior to surgery. Of these, 44% worsened after intubation 5% of patients developed new onset TMJ dysfunction Of the 27 claims, 11 were for joint dislocation and 16 for isolated pain 30% presented discomfort due to previous joint disorders
–
M: 58.8 F: 41.2 M: 85% F: 15%
GA
F: female; M: male; GA: general anaesthesia; LRA: locoregional anaesthesia.
Of the analytical studies, [17] examined the ASA Closed Claims Project, which records the data from 35 health insurers in the USA, to identify anaesthesia-related claims and collect information on airway lesions associated with general anaesthesia, the patients’ clinical manifestations and airway characteristics and the type of surgery. Agro` et al. [13] examined clinical manifestations in 68 patients before and after tracheal intubation in order to assess TMJ disorders and/or dysfunctions. Similarly, Martin et al. [1] conducted a study in 122 patients who had undergone tracheal intubation in relation to different types of surgery. They assessed pre- and postoperative TMJ-related clinical manifestations in order to investigate the risk factors associated with TMJ dysfunction following intubation. Lipp et al. [18] described a controlled prospective study in which 50 patients underwent surgery with general anaesthesia and orotracheal intubation and another 50 with locoregional anaesthesia (control group), and all were examined postoperatively to assess possible intubation-related TMJ damage. Rodrigues et al. [2] conducted a prospective study of 100 patients with no previous TMJ disorder, assessing disturbances to this joint following tracheal intubation for different types of surgery. They recorded the patients’ clinical and demographic variables postoperatively in order to study new onset development of joint disorders following intubation. 4. Discussion It would appear to have been established that forcing mouth opening can cause TMJ complications [3,19–22], the most frequent in this joint being anterior dislocation [10,22,23], although the TMJ accounts for only 3% of joint dislocations in the entire body [22]. However, there is little information on the incidence of this peri-anaesthesia complication [4,7,24]. The symptoms of TMJ dislocation can range from a serious acute clinical picture with severe pre-auricular pain and inability to close the mouth to a subacute picture of less obvious pain and partial mouth closure, but both are associated with difficulty in speaking and present a depression in the pre-auricular area on palpation [22]. In contrast, subluxation involves spontaneous reduction of the joint [8]. Several authors [3,7,8,10,11,14,22,25] mentioned TMJ condyle (sub)luxations related to orotracheal intubation manoeuvres under general anaesthetic with hypnotic and neuromuscular blocking drugs. In these cases, the mere drop in muscle tone and loss of defensive reflexes caused by general anaesthesia, together with laryngoscope traction for intubation, were sufficient for this phenomenon to occur [10–12,21,26,27]. Patel et al. [12] and Avidan et al. [20] referred to cases of TMJ dislocation following the induction of anaesthesia before invasive airway control had been effected: a few spontaneous actions (such
as yawning) were enough to dislocate the condyle. In the same way, Unnikrishnan et al. [27] described a case of condyle dislocation associated with yawning during the induction of anaesthesia in a tracheostomy tube wearer. In these cases, moreover, neuromuscular blocking drugs had not yet been administered. Similarly, Gambling et al. [19] published an analogous case of condyle dislocation after anaesthesia had been induced with hypnotic and neuromuscular blocking drugs but prior to intubation manoeuvres. As in the previous cases, joint reduction under sedation was required after this early diagnosis of condyle subluxation. Other manoeuvres associated with invasive airway management which do not require excessive opening, such as intubation with a fibrescope or lighted stylet, have also been described as possible joint dislocation triggers. Rastogi et al. [4] described a case of TMJ condyle dislocation following intubation with a fibrescope and the administration of general anaesthesia with neuromuscular blocking drugs. The same authors also reported a case of condyle dislocation in a patient with orotracheal intubation with a lighted stylet following induction of anaesthesia with hypnotic and neuromuscular blocking drugs. Direct laryngoscopy manoeuvres had not been performed in either of these two cases, but their mouths were sufficiently open to carry out the airway management procedure. Following the intervention, their respective joints were repositioned under sedation. Although most dislocations occur during intubation manoeuvres while inducing anaesthesia, Wang et al. [23] reported a case of condyle dislocation in a 35-year-old patient in relation to excessive oral opening during orotracheal extubation. Cases of mandibular dislocation during laryngeal mask insertion have also begun to be reported, even in patients with no previous history of TMJ disorders [6,21,24]. The reason is that head tilt and chin lift manoeuvres tend to be used to position these airways, causing passive wide opening of the mouth, which together with the low muscle tone induced by the general anaesthesia predisposes to joint dislocation [6]. Other studies report disc dislocation with locking but no condyle dislocation. Gould et al. [9] described two such cases. In one, the jaw locked even before laryngoscopy manoeuvres had begun. Small et al. [28] and Roze des Ordons et al. [29] described similar cases. In the case reported by Small et al. [28], the disk dislocation reduced spontaneously. In these cases, difficult airway management situations arose that required special intubation techniques. Knibbe et al. [3] and Iguchi et al. [26] also reported cases of disk displacement with locking. Cases of condyle resorption in which malocclusion and facial deviation developed several months after performing difficult
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orotracheal intubations have also been described. These could be related to infectious, autoimmune, endocrine, cardiovascular, metabolic or traumatic factors [5]. Consequently, it could be argued that temporomandibular dysfunction following laryngoscopy and intubation or the insertion of a laryngeal mask does not imply failings in these techniques, as the structure of the TMJ and the wide range of movements it can perform [23] make this joint quite susceptible to instability and it may even dislocate when no external force has been applied [25,27]. At all events, spontaneous dislocation of the temporomandibular joint and TMJ disorders arising as a result of general anaesthesia have not yet been clarified sufficiently [6] and probably have a multifactorial origin. It would be advisable to assess TMJ status preoperatively in order to plan the intubation accordingly [1–4,7,10,13,28], as recommended by the American Society of Anesthesiology [22], and to proceed cautiously [6] during induction and intubation, checking the occlusion in the event of any suspicion of joint dislocation [30]. The patient should also be warned of the risk of such complications, which could even be triggered de novo following airway manipulation in the context of general anaesthesia [2–4]. In severe cases, postponement of surgery might even be considered until the TMJ disorder has been resolved [3]. It would also be advisable for the anaesthetist to be conscious of these complications [19], to be as careful as possible [6], to check during the application of anaesthesia and perianaesthetically that TMJ disorders are absent, and to be able to diagnose and treat them [3,7,10,14,25,30], especially in the case of dislocation, where delayed diagnosis can lead to greater difficulty in correcting the problem [6,20]. Diagnosing TMJ complications in patients with intubation can be complex, owing to communication difficulties as a result of the general anaesthesia, analgesic medication prescribed perioperatively, which can mask TMJ pain, and a lack of familiarity with joint dislocation among healthcare staff [22]. As a result, the condition is often not diagnosed until the patient recovers full consciousness and is able to communicate the feeling of pain and the inability to move the mouth [4,6,23]. Prolonged unconsciousness, such as may occur in intensive care patients, can therefore entail a considerable delay in diagnosis. For instance, Rattan and Arora [30] describe the case of a 22-year-old man whose prolonged orotracheal intubation was followed by late diagnosis of TMJ condyle dislocation, which required surgical reduction as closed reduction was no longer possible. On occasion, the diagnosis may be still tardier, even occurring weeks or months after the patient’s postoperative discharge [3]. According to Martin et al. [1], the patient’s ability to open the mouth preoperatively is correlated with the Mallampati score, although the latter is not a good predictor of TMJ dysfunction. They also consider that low interincisal distance, female gender and increasing age are correlated with TMJ pain following intubation and that previously experience of TMJ symptoms is the best predictive factor for post-intubation symptoms, even up to two weeks after this procedure. A greater or lesser duration of intubation appears not to be related to TMJ symptoms [1]. It seems to have been established that TMJ dysfunction can be aggravated by intubation manoeuvres. For instance, Agro` et al. [13] reported that up to 13% of the population presents symptoms, which suggest TMJ dysfunction prior to general anaesthesia, and the symptoms of 44% of these worsened following intubation. Moreover, up to 5% of patients developed new onset TMJ dysfunction. In the prospective study conducted by Gould et al. [9], 35 of the 15 patients who underwent intubation presented TMJ disorders, albeit temporary, and two cases presented disc displacement with locking. Lipp et al. [18] reported up to 66% of
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minor TMJ incidents following intubation in a series of 50 patients. Domino et al. [17] found that 10% of the claims for airway trauma (27 out of 266) were for TMJ damage, in all cases associated with ordinary tracheal intubation in ASA I–II patients. Out of this total, 85% of the claims were made by women and 96% by persons aged under 60 years. Of the 27 TMJ trauma claims, 11 were for joint dislocation and 16 were for pain. 30% of the cases had a previous history of TMJ disorders. Certain conditions, such as some autoimmune diseases that affect joints; diseases that cause hyperlaxity and fragile connective tissues; malocclusion problems; retrognathism; algodystrophic TMJ syndromes; a previous history of joint dislocation favoured by flatness of the articular eminence; muscle hypotonia; or even psychogenic factors, can favour TMJ disorder development in the course of airway control manoeuvres during anaesthesia, as the loss of muscle tone is combined with forced manoeuvres with a susceptible joint [4,6–8,13,14,19,22,23,25,27,28]. However, it would also appear that not achieving adequate neuromuscular relaxation could make laryngoscopy manoeuvres more difficult and oblige the anaesthetist to increase the force applied to the adjacent tissues and to the TMJ itself, predisposing this joint to greater damage [9]. Moreover, slow induction of general anaesthesia is also a risk factor for TMJ disorders [7,24] as it makes it necessary to extend the duration of airway control manoeuvres, which are one of the risk factors for joint disorders. In the same way, a difficult airway adds to the difficulties and using more aggressive manoeuvres increases the risk of joint dislocation [3,8,28]. The main limitation of this review is that few studies have been published on TMJ disorders related to general anaesthetic and sedation techniques and most of those published are case or case series reports of isolated instances encountered while applying these procedures. This means that the evidence they provide is of a low standard. A higher standard of evidence was provided by some authors [1,2,13,17,18], although the fact that their number is very small and the variables analysed by each of them were highly disparate makes them difficult to analyse with a view to arriving at definite conclusions. Despite the few studies found, we may conclude that intubation can cause TMJ disorders, although their percentage is small. The most frequent is condyle dislocation followed by disc locking. A record of TMJ problems is a risk factor for postoperative joint complications. More studies of higher evidence quality need to be conducted on TMJ disorders in relation to general anaesthetic and sedation procedures. Contributions Conception and design of study: J. Talava´n-Serna, J.M. MontielCompany. Acquisition of data: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis, J.M. Almerich-Silla. Analysis and/or interpretation of data: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis. Drafting the manuscript: J. Talava´n-Serna, J.M. MontielCompany, C. Bellot-Arcis. Revising the manuscript critically for important intellectual content: J. Talava´n-Serna, J.M. Montiel-Company, C. Bellot-Arcis. Approval of the version of the manuscript to be published: J. Talava´n-Serna, J.M. Montiel-Company C. Bellot-Arcis, J.M. Almerich-Silla. Disclosure of interest The authors declare that they have no competing interest.
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