- Email: [email protected]
Retrospective evaluation of the duration of arthrocentesis in the treatment of temporomandibular joint diseases
Journal Pre-proof Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of Temporomandibular Joint Diseases Mehmet Emrah Polat Saim Yanik Onur Odabasi
PII:
S2468-7855(20)30040-9
DOI:
https://doi.org/doi:10.1016/j.jormas.2020.02.006
Reference:
JORMAS 805
To appear in:
Journal of Stomatology oral and Maxillofacial Surgery
Received Date:
23 December 2019
Accepted Date:
18 February 2020
Please cite this article as: Mehmet Emrah PolatSaim YanikOnur Odabasi Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of Temporomandibular Joint Diseases (2020), doi: https://doi.org/10.1016/j.jormas.2020.02.006
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
*Title: Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of Temporomandibular Joint Diseases
*List of Autors 1)Corresponding outhor: Mehmet Emrah POLAT Orcid: 0000-0002-3249-1997 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Harran University, 63300, Sanlıurfa, TURKEY Mail: [email protected] 2)Contributing autor: Phd. Dr. Saim YANIK Orcid: 0000-0002-1229-2982
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Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Harran University, 63300, Sanlıurfa, TURKEY Mail: [email protected]
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3)Contributing autor: Phd. Dr. Onur ODABASI Orcid: 0000-0001-7771-048X
e-
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Yildirim Beyazit University, 060010, Ankara, TURKEY
Pr
Mail: [email protected]
Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of
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al
Temporomandibular Joint Diseases
ABSTRACT
Objective: This study investigated the duration of arthrocentesis in treatment of patients with different diagnoses of temporomandibular disorders. Methods: This retrospective study evaluated the duration of arthrocentesis used for 65 patients who were diagnosed with osteoarthritis (OA), disc displacement with reduction (DDWR), or disc displacement without reduction (DDWoR), in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders protocol. Results: Mean operation times were 18.13 min in OA patients, 19.02 min in DDWR patients, and 24.86 min in DDWoR patients; these significantly differed among groups (p<0.001). In addition, post hoc analyses revealed statistically significant differences in mean operation times between DDWoR and OA (p<0.05) and DDWoR and DDWR (p<0.05).
Page 1 of 12
Conclusion: The appropriate duration of arthrocentesis may vary among joint disorders, and the duration of arthrocentesis in DDWoR treatment is longer than that in DDWR and OA treatments. In addition there was no relationship between the age or gender and operation time of the patients.Changes in anatomic structures due to temporomandibular diseases are presumed to influence the duration of arthrocentesis treatment.
Keywords: TMJ, Treatment, Arthrocentesis
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INTRODUCTION
Temporomandibular disorders (TMD) are a group of functional and pathological disorders that affect the temporomandibular joint (TMJ), chewing muscles, and surrounding tissues.(1,2)
pr
Symptoms of TMD include pain, joint sounds (e.g., click or crepitus), limited mouth opening, and deviation of the mandible.(3) TMD is the second most common musculoskeletal disorder that causes
e-
pain and loss of function; the most common disorder of this type is chronic lower back pain.(4) Furthermore, TMD is the most common cause of non-odontogenic pain in the orofacial region and is
Pr
one of the most difficult conditions to treat. TMD often manifests as joint degeneration and disc displacement. (5)
al
Anxiety and depression are risk factors for TMD. The frequency of TMD is expected to increase due to these negative emotional conditions, which are increasingly experienced in the 21st
Jo ur n
century.(5) In fact, according to a report published in 2014, the annual cost of TMD treatment in the United States (excluding the cost of imaging) has doubled over the last decade and has reached $4 billion.(4) Therefore, effective, rapid, and economical treatment options are needed for patients with TMD.
Affected patients can be treated with a wide range of treatment options, ranging from
noninvasive methods to open surgery.(6) Arthrocentesis is a minimally invasive treatment modality that is recommended for patients who do not respond to conservative treatment (e.g., pharmacotherapy, physical therapy, or splint therapy).(7) In this technique, the upper joint cavity is irrigated, which leads to reduced pain by removal of inflammatory mediators and increased joint movements by release of disc adhesions.(8,9) The success rates of arthrocentesis in disc displacements and treatment of osteoarthritis are 83–84% and 68–81%, respectively.(10)
Page 2 of 12
Arthrocentesis was originally described by Nitzan (11) as a “simple, less invasive, inexpensive and high effective procedure.” In one randomized controlled study, arthrocentesis was more economical than conventional methods for the treatment of TMD-related pain; moreover, arthrocentesis was proposed as a suitable primary treatment option considering its effectiveness and low cost.(12) In this study, we evaluated and compared the operation times of patients who were diagnosed with osteoarthritis (OA), disc displacement with reduction (DDWR), or disc displacement
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without reduction (DDWoR), which are the most common indications for arthrocentesis.(13)
MATERIALS AND METHODS
This was a retrospective study of 65 patients who underwent arthrocentesis at Harran
pr
University Hospital from 2017 to 2019. The ethics committee of the Harran University Faculty of Medicine approved the study protocol (19/09/16). Conservative treatment (i.e., medical treatment,
e-
occlusal splint, and/or physiotherapy) was administered to patients diagnosed with OA, DDWR, or DDWoR (axis I groups IIIb/IIa/IIb/IIc), in accordance with the Research Diagnostic Criteria for
Pr
Temporomandibular Disorders protocol (RDC/TMD). Arthrocentesis was performed for patients whose symptoms did not resolve despite treatment for at least 6 months. Both panoramic and cone beam computed tomography images were used for diagnosis of
al
OA. Cortical surface erosion, joint surface flattening, subchondral bone cyst (Ely cyst) formation, osteophyte formation, and condyle and/or articular eminence sclerosis were considered diagnostic
Jo ur n
criteria.(1,2) Disk displacements were diagnosed by magnetic resonance imaging. Distinctions between reduction and non-reduction disc displacement were made based on clinical findings. The presence of a clicking sound during opening and closing of the mouth, disappearance of
the clicking sound during protrusion of the mandible, and absence of pain were sufficient for a diagnosis of DDWR. A history of significantly limited mouth opening, <35 mm maximum assisted mouth opening, ≤4 mm increase in mouth opening with passive stretching relative to the distance between incisors in maximum assisted opening, <7 mm contralateral movement of the mandible, and deviation towards the affected side during mouth opening were sufficient for a diagnosis of DDWoR. Inclusion criteria were diagnosis of OA, DDWR, or DDWoR based on clinical and radiographic evaluation; completion of the arthrocentesis procedure without complications; availability of patient information and postoperative follow-up data; and persistent symptoms
Page 3 of 12
despite conservative treatment for at least 6 months. Exclusion criteria were absence of any inflammatory, hematological, neurological, or connective tissue disease; no history of temporomandibular joint surgery or arthrocentesis; and no history of malignant tumor of the head and neck. The sample size was calculated based on 90% power to detect a clinically meaningful difference in maximal incisal opening of 0.4 cm, at a significance level of 0.05. Power analyses showed that 15 patients per group were required. All patients in this study underwent arthrocentesis following the same protocol. The treatment site was prepared with sterile drapes and wiped with antiseptic solution. A buffer
oo f
moistened with sterile saline solution was placed at the entrance of the external auditory canal to prevent irrigation fluid from entering the ear. Joint anesthesia was induced by blocking the auriculotemporal nerve with 4% articaine (1:100.000; Ultracaine, DS Fort) containing adrenaline.
pr
Then the entry points of the needles were marked on the skin. Line A was drawn from the middle of the tragus to the outer cantus. The posterior insertion point (A) was placed 10 mm from the midpoint
e-
of the tragus, 2 mm below the line. The anterior point (B) was placed 20 mm anterior to the midpoint of the tragus, 10 mm below the line. Point A was used to insert fluid into the upper joint space to
Pr
increase hydraulic pressure. Two 18-gauge needles were placed at points A and B to wash the joint space. Lactated Ringer’s solution (150 mL) was used for arthrocentesis. Patients were prescribed
months postoperatively.
al
antibiotics, analgesics, and muscle relaxants for 2 weeks postoperatively and followed up at 6
Jo ur n
One staff member recorded the time (in seconds) from the contact of the first 18-gauge needle with the skin until the completion of arthrocentesis and removal of the last needle, indicating the diagnosis for each patient. In this study, statistical data analysis applications were performed with R Project software. Shapiro-Wilk test was used for the normality tests for the duration of operation between sex and disease groups. In all hypothesis tests, test statistics and significance values are given together.
RESULTS The duration of arthrocentesis was evaluated in 65 patients (13 men, 52 women). The study consist of three diagnose groups. The distributions of patients according to sex and patient diagnose groups are shown in Table 1. No complications were encountered in any patient. Mean operation
Page 4 of 12
times were 423.79 (±66.77) seconds in OA patients, 459.92 (±56.67) seconds in DWR patients, and 609.00 (±106.88) seconds in DDWoR patients; these significantly differed among groups (p<0.001). Table 1 presents the results of frequency analysis and normality test for the duration of the operation according to the gender and patient groups of the patients. In addition, normality tests were performed for operation time and age variables. 20% of the participants were male and 80% were female. According to patient groups, 29.2% of the participants were in the first group, 36.9% were in the second group and 33.8% were in the third group. According to the significance values of the test statistics, the operation times in terms of gender groups are not normally distributed (p <0.05). However, the duration of operation on the
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basis of patient groups was consistent with the normal distribution (p> 0.05). When examined on a variable basis; operation time and age values are not normally distributed.
pr
Mann-Whitney test was used to compare the operation time between sex groups according to normality findings. In addition, variance analysis (ANOVA) was used to test the differences
e-
between the patient groups according to operation times. Nonparametric Spearman correlation analysis was used to test the relationship between operation time and age variables. Arithmetic
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mean, standard deviation, minimum and maximum values were obtained for all statistical tests. In addition to the mean and standard deviation for non-parametric tests, the median and interquartile range measurements, which are statistically more suitable for the assumption of normality, are also
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given.
Table 2 shows the Mann-Whitney test results and descriptive statistics applied between the
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sex groups in terms of operation times. Figure 1 shows the box graph of operation times according to gender groups. According to the test results, there was no statistically significant difference between the sex groups in terms of the operation time (p> 0.05).
Table 3 shows the ANOVA test results and descriptive statistics performed between the patient groups in terms of the duration of the operation. Graph 2 shows the box graph of the operation times for the patient groups. As a result of Levene test, it was determined that the variances were not homogeneous among the patient groups and variance analysis was performed
Page 5 of 12
according to Welch statistics. According to the test results, there was a statistically significant difference between the patient groups according to the operation time (p <0.05). In order to examine the differences between the patient groups, Tamhane test was used in cases where the variances were not distributed homogeneously. As a result of the Tamhane multiple comparison test, it was found that the operation time of the 3rd group patients was statistically significantly higher than the patients in the 1st and 2nd groups. Table 4 shows the Spearman correlation test results and descriptive statistics applied to test the relationship between operation time and age variables. The negative Spearman correlation coefficient indicates an inverse relationship between age and operation time. However, according to
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the correlation analysis findings, there was no statistically significant relationship between the age
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and operation time of the patients (p> 0.05).
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DISCUSSION
Arthrocentesis, which is effective for the treatment of TMD, is also a practical approach in terms of the time required for treatment. The duration of arthrocentesis may vary among joint
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disorders; in particular, it takes more time in patients with DDWoR than in patients DWR or OA. To the best of our knowledge, this comparison has not been previously performed.
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TMD is a group of musculoskeletal disorders caused by trauma, parafunctional habits,
functional overload, hormonal changes, psychosocial factors, occlusal changes, and/or anatomical characteristics.(14-16) In addition, autoimmune disorders, fibromyalgia, sleep apnea, and psychiatric problems may contribute to chronic and persistent TMD.(17) Symptoms associated with TMD include reduced mouth opening, pain in the joint and chewing muscles, headache, earache, and joint sounds and deviation during mouth opening and closing.(5-17) These symptoms may cause mild pain or may exhibit sufficient severity to interfere with the patient’s daily activities.(1) Information regarding the prevalence of TMD varies throughout the literature due to differences in diagnostic criteria, classification systems, populations, and examination methods among studies.(5) In a study that evaluated adolescents, the reported prevalence of TMD was 34.9%; the most common symptoms were head and neck pain (20.9%), joint sounds (18.5%), and joint pain (14%).(18) In an electronic survey-based study conducted in Brazil, 37.5% of respondents reported at
Page 6 of 12
least one TMD symptom.(19) The reported prevalences of at least one symptom associated with TMD were 41.3% and 68.6% in two separate studies of college students. (20,21) According to a review of 17 separate epidemiological studies that evaluated different populations and age groups, 41% of the included 10,579 people had at least one TMD symptom (minimum prevalence, 14%(22); maximum prevalence, 80%(23).(24) Talaat et al.(5) investigated the prevalence of TMD based on RDC/TMD criteria, and found that the most common diagnoses were DDWR (40.92%), myofascial pain (17.54%), DDWoR with limited mouth opening (15.69%), myofascial pain with limited mouth opening (9.23%), osteoarthritis (11.69%), and DDWoR without limited mouth opening (4.62%). The treatment of TMD is divided into three main categories: noninvasive, minimally
oo f
invasive, and invasive. Although the choice of treatment may vary according to differences in diagnosis and severity, it is generally accepted that noninvasive conservative treatments should be attempted first. When TMD does not respond to conservative treatments, the least invasive method
pr
should be chosen; more invasive options should be implemented when less invasive methods fail.(1) Conservative treatments include ancillary measures (e.g., jaw exercise and/or soft diet), occlusal
e-
splints, complementary medicine, pharmacotherapy (e.g., nonsteroidal anti-inflammatory drugs, benzodiazepines, and/or muscle relaxants), and physical therapy. A long-term study showed that
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conservative treatments reduced symptoms in 50–90% of patients.(7,17) Minimally invasive surgery is the first-line treatment modality when conservative treatment fails.(25) Among the current minimally invasive treatments, arthrocentesis is a simpler and less invasive procedure than
al
arthroscopy (26); notably, arthrocentesis was first applied by Nitzan (11) in 1991 for the treatment of closed locking. Arthrocentesis aims to reduce the levels of inflammatory mediators that cause
Jo ur n
chronic pain through irrigation of the upper joint cavity; moreover, it aims to release the articular disc through removal of adhesions between the disc and mandibular fossa by hydraulic pressure.(8,27) Biochemical and pressure changes in synovial fluid content, rather than physical displacement of the disc, may be the causative factor in TMD; this awareness has increased the importance of arthrocentesis.(28) Indeed, despite incomplete repositioning of the disc, some studies have shown that the pain associated with TMD is reduced by 80–90% after arthrocentesis.(29) Thus, the success of the procedure is considered independent of positional and morphological changes in the disc.(30) Although arthrocentesis was first used for the treatment of DDWoR, it is now applied with high success rates for the treatment of DDWR and OA.(1) A literature review reported that the mean success rate of arthrocentesis in DDWoR treatment was 83.2% (minimum rate, 63.2% (31); maximum rate, 100%(32,33) for 1,141 joints among 19 studies.(30) When DD and DWR were evaluated together, the success rate was 83.5%. Another review indicated that the success rate of
Page 7 of 12
arthrocentesis for the treatment of TMJ OA ranged from 68% to 81% among multiple studies.(30) Saline solution or lactated Ringer’s solution, in volumes ranging from 50 to 500 mL, are useful for lavage of the joint cavity.(30) Although a precise and standard lavage volume has not yet been determined, a previous study demonstrated that at least 100 mL lactated Ringer’s solution should be used to eliminate therapeutic proteins and specific proteinases in synovial fluid.(34) Another study reported that the results obtained from patients who had undergone lavage with >150 mL were not better than those of patients who had undergone lavage with 130–150 mL; thus, they concluded that a lavage volume of 150 mL was sufficient.(35) Based on these findings, we evaluated the duration of arthrocentesis using 150 mL lactated
oo f
Ringer’s solution (the presumed minimum effective amount). We observed the longest mean duration of arthrocentesis in the DDWoR group (609.00±106.88 seconds) and noted a statistically significant difference in the duration of the procedure between the DDWoR and DDWR groups, as
pr
well as between the DDWoR and OA groups. Three different mechanisms may be at play. First, in patients with DDWoR, the condyle cannot perform translation movement(36) because the mouth
e-
opening is restricted and the joint cavity is narrower than in patients with DDWR or OA, due to its inability to move away from the glenoid fossa. Therefore, additional time is needed to place needles
Pr
in the correct positions. Second, adhesions between the disc and temporal bone are more common in patients with DDWoR than in patients with DDWR or OA.(37) As the circulating lactated Ringer’s solution passes through these adhesions, it encounters resistance, which slows the movement of
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liquid. Third, the superior joint cavity becomes narrower and more crescent-shaped in patients with DDWoR than in patients with DDWR or OA, as the condyle cannot perform translation movement. In
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this situation, the surface-to-volume ratio increases, thus increasing the volume of liquid interacting with the surface; this increases the adhesion effect and reduces the flow of liquid. There were no statistically significant differences in duration of arthrocentesis between
patients with OA and those with DDWR. However, arthrocentesis tended to be performed more rapidly in patients with OA. In OA, articular cartilage and bone structures exhibit degeneration because of forces that exceed the adaptive capacity;(10) this resorption may cause considerable enlargement of the glenoid fossa.(38) Presumably, the enlarged joint space reduces the resistance to fluid movement and shortens the duration of arthrocentesis in patients with OA.
CONCLUSION These findings should be confirmed in studies with larger numbers of patients. In addition there was no relationship between the age or gender and operation time of the patients.
Page 8 of 12
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The English in this document has been checked by at least two professional editors, both native
Jo ur n
al
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http://www.textcheck.com/certificate/lB0bi7
e-
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speakers of English. For a certificate, please see:
Page 9 of 12
Operation time (seconds)
Male
Female
Jo ur n
al
Pr
e-
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Graph 1: Box graph of operation times for gender groups
Page 10 of 12
Operation Time (sec) 700 600 500 400
OA
DDWR
oo f
300
DDWoR
Group
n (%)
Statistic
p
Male
13 (%20)
0.903
0.146
Female
52 (%80)
0.938
0.009
OA
19 (%29.2)
0.955
0.473
DDWR
24 (%36.9)
0.958
0.406
DDWoR
22 (%33.8)
0.937
0.170
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Variable
al
Pr
e-
pr
Graph 2: Box graph of operation times for patient groups
Gender
Patient group
Table 1: Normality test results
Gender
±σ
M ± IQR
Min
Max
Statistic
p
Page 11 of 12
Male Female
525.23 ± 131.84 493.46 ± 107.12
515 ± 131 461.50 ± 102.25
362 264
758 760
384.500
0.450
: Arithmetic mean, σ: Standart deviation, M: Median, IQR: Interquartile Range
Table 2: Mann-Whitney test results for gender groups.
Min
Max
264 333 421
516 566 760
Levene test Statistic p 9.259
<0.001
ANOVA test Statistic p 23.127
<0.001
oo f
Patient ±σ group OA 423.79 ± 66.77a DDWR 459.92 ± 56.67a DDWoR 609.00±106.88b : Arithmetic mean, σ: Standart deviation
M ± IQR 470 ± 121 24 ± 17
al
Variable ±σ Time 499.82 ± 112.10 Age 30.34 ± 13.58
Pr
e-
pr
Table 3: ANOVA test results for patient groups
Min 264 15
Max 760 67
Statistic
p
0.744
-0.041
: Arithmetic mean, σ: Standart deviation, M: Median, IQR: Interquartile Range
Jo ur n
Table 4: Spearman correlation analysis results
Page 12 of 12
PII:
S2468-7855(20)30040-9
DOI:
https://doi.org/doi:10.1016/j.jormas.2020.02.006
Reference:
JORMAS 805
To appear in:
Journal of Stomatology oral and Maxillofacial Surgery
Received Date:
23 December 2019
Accepted Date:
18 February 2020
Please cite this article as: Mehmet Emrah PolatSaim YanikOnur Odabasi Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of Temporomandibular Joint Diseases (2020), doi: https://doi.org/10.1016/j.jormas.2020.02.006
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
*Title: Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of Temporomandibular Joint Diseases
*List of Autors 1)Corresponding outhor: Mehmet Emrah POLAT Orcid: 0000-0002-3249-1997 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Harran University, 63300, Sanlıurfa, TURKEY Mail: [email protected] 2)Contributing autor: Phd. Dr. Saim YANIK Orcid: 0000-0002-1229-2982
oo f
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Harran University, 63300, Sanlıurfa, TURKEY Mail: [email protected]
pr
3)Contributing autor: Phd. Dr. Onur ODABASI Orcid: 0000-0001-7771-048X
e-
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Yildirim Beyazit University, 060010, Ankara, TURKEY
Pr
Mail: [email protected]
Retrospective Evaluation of the Duration of Arthrocentesis in the Treatment of
Jo ur n
al
Temporomandibular Joint Diseases
ABSTRACT
Objective: This study investigated the duration of arthrocentesis in treatment of patients with different diagnoses of temporomandibular disorders. Methods: This retrospective study evaluated the duration of arthrocentesis used for 65 patients who were diagnosed with osteoarthritis (OA), disc displacement with reduction (DDWR), or disc displacement without reduction (DDWoR), in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders protocol. Results: Mean operation times were 18.13 min in OA patients, 19.02 min in DDWR patients, and 24.86 min in DDWoR patients; these significantly differed among groups (p<0.001). In addition, post hoc analyses revealed statistically significant differences in mean operation times between DDWoR and OA (p<0.05) and DDWoR and DDWR (p<0.05).
Page 1 of 12
Conclusion: The appropriate duration of arthrocentesis may vary among joint disorders, and the duration of arthrocentesis in DDWoR treatment is longer than that in DDWR and OA treatments. In addition there was no relationship between the age or gender and operation time of the patients.Changes in anatomic structures due to temporomandibular diseases are presumed to influence the duration of arthrocentesis treatment.
Keywords: TMJ, Treatment, Arthrocentesis
oo f
INTRODUCTION
Temporomandibular disorders (TMD) are a group of functional and pathological disorders that affect the temporomandibular joint (TMJ), chewing muscles, and surrounding tissues.(1,2)
pr
Symptoms of TMD include pain, joint sounds (e.g., click or crepitus), limited mouth opening, and deviation of the mandible.(3) TMD is the second most common musculoskeletal disorder that causes
e-
pain and loss of function; the most common disorder of this type is chronic lower back pain.(4) Furthermore, TMD is the most common cause of non-odontogenic pain in the orofacial region and is
Pr
one of the most difficult conditions to treat. TMD often manifests as joint degeneration and disc displacement. (5)
al
Anxiety and depression are risk factors for TMD. The frequency of TMD is expected to increase due to these negative emotional conditions, which are increasingly experienced in the 21st
Jo ur n
century.(5) In fact, according to a report published in 2014, the annual cost of TMD treatment in the United States (excluding the cost of imaging) has doubled over the last decade and has reached $4 billion.(4) Therefore, effective, rapid, and economical treatment options are needed for patients with TMD.
Affected patients can be treated with a wide range of treatment options, ranging from
noninvasive methods to open surgery.(6) Arthrocentesis is a minimally invasive treatment modality that is recommended for patients who do not respond to conservative treatment (e.g., pharmacotherapy, physical therapy, or splint therapy).(7) In this technique, the upper joint cavity is irrigated, which leads to reduced pain by removal of inflammatory mediators and increased joint movements by release of disc adhesions.(8,9) The success rates of arthrocentesis in disc displacements and treatment of osteoarthritis are 83–84% and 68–81%, respectively.(10)
Page 2 of 12
Arthrocentesis was originally described by Nitzan (11) as a “simple, less invasive, inexpensive and high effective procedure.” In one randomized controlled study, arthrocentesis was more economical than conventional methods for the treatment of TMD-related pain; moreover, arthrocentesis was proposed as a suitable primary treatment option considering its effectiveness and low cost.(12) In this study, we evaluated and compared the operation times of patients who were diagnosed with osteoarthritis (OA), disc displacement with reduction (DDWR), or disc displacement
oo f
without reduction (DDWoR), which are the most common indications for arthrocentesis.(13)
MATERIALS AND METHODS
This was a retrospective study of 65 patients who underwent arthrocentesis at Harran
pr
University Hospital from 2017 to 2019. The ethics committee of the Harran University Faculty of Medicine approved the study protocol (19/09/16). Conservative treatment (i.e., medical treatment,
e-
occlusal splint, and/or physiotherapy) was administered to patients diagnosed with OA, DDWR, or DDWoR (axis I groups IIIb/IIa/IIb/IIc), in accordance with the Research Diagnostic Criteria for
Pr
Temporomandibular Disorders protocol (RDC/TMD). Arthrocentesis was performed for patients whose symptoms did not resolve despite treatment for at least 6 months. Both panoramic and cone beam computed tomography images were used for diagnosis of
al
OA. Cortical surface erosion, joint surface flattening, subchondral bone cyst (Ely cyst) formation, osteophyte formation, and condyle and/or articular eminence sclerosis were considered diagnostic
Jo ur n
criteria.(1,2) Disk displacements were diagnosed by magnetic resonance imaging. Distinctions between reduction and non-reduction disc displacement were made based on clinical findings. The presence of a clicking sound during opening and closing of the mouth, disappearance of
the clicking sound during protrusion of the mandible, and absence of pain were sufficient for a diagnosis of DDWR. A history of significantly limited mouth opening, <35 mm maximum assisted mouth opening, ≤4 mm increase in mouth opening with passive stretching relative to the distance between incisors in maximum assisted opening, <7 mm contralateral movement of the mandible, and deviation towards the affected side during mouth opening were sufficient for a diagnosis of DDWoR. Inclusion criteria were diagnosis of OA, DDWR, or DDWoR based on clinical and radiographic evaluation; completion of the arthrocentesis procedure without complications; availability of patient information and postoperative follow-up data; and persistent symptoms
Page 3 of 12
despite conservative treatment for at least 6 months. Exclusion criteria were absence of any inflammatory, hematological, neurological, or connective tissue disease; no history of temporomandibular joint surgery or arthrocentesis; and no history of malignant tumor of the head and neck. The sample size was calculated based on 90% power to detect a clinically meaningful difference in maximal incisal opening of 0.4 cm, at a significance level of 0.05. Power analyses showed that 15 patients per group were required. All patients in this study underwent arthrocentesis following the same protocol. The treatment site was prepared with sterile drapes and wiped with antiseptic solution. A buffer
oo f
moistened with sterile saline solution was placed at the entrance of the external auditory canal to prevent irrigation fluid from entering the ear. Joint anesthesia was induced by blocking the auriculotemporal nerve with 4% articaine (1:100.000; Ultracaine, DS Fort) containing adrenaline.
pr
Then the entry points of the needles were marked on the skin. Line A was drawn from the middle of the tragus to the outer cantus. The posterior insertion point (A) was placed 10 mm from the midpoint
e-
of the tragus, 2 mm below the line. The anterior point (B) was placed 20 mm anterior to the midpoint of the tragus, 10 mm below the line. Point A was used to insert fluid into the upper joint space to
Pr
increase hydraulic pressure. Two 18-gauge needles were placed at points A and B to wash the joint space. Lactated Ringer’s solution (150 mL) was used for arthrocentesis. Patients were prescribed
months postoperatively.
al
antibiotics, analgesics, and muscle relaxants for 2 weeks postoperatively and followed up at 6
Jo ur n
One staff member recorded the time (in seconds) from the contact of the first 18-gauge needle with the skin until the completion of arthrocentesis and removal of the last needle, indicating the diagnosis for each patient. In this study, statistical data analysis applications were performed with R Project software. Shapiro-Wilk test was used for the normality tests for the duration of operation between sex and disease groups. In all hypothesis tests, test statistics and significance values are given together.
RESULTS The duration of arthrocentesis was evaluated in 65 patients (13 men, 52 women). The study consist of three diagnose groups. The distributions of patients according to sex and patient diagnose groups are shown in Table 1. No complications were encountered in any patient. Mean operation
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times were 423.79 (±66.77) seconds in OA patients, 459.92 (±56.67) seconds in DWR patients, and 609.00 (±106.88) seconds in DDWoR patients; these significantly differed among groups (p<0.001). Table 1 presents the results of frequency analysis and normality test for the duration of the operation according to the gender and patient groups of the patients. In addition, normality tests were performed for operation time and age variables. 20% of the participants were male and 80% were female. According to patient groups, 29.2% of the participants were in the first group, 36.9% were in the second group and 33.8% were in the third group. According to the significance values of the test statistics, the operation times in terms of gender groups are not normally distributed (p <0.05). However, the duration of operation on the
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basis of patient groups was consistent with the normal distribution (p> 0.05). When examined on a variable basis; operation time and age values are not normally distributed.
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Mann-Whitney test was used to compare the operation time between sex groups according to normality findings. In addition, variance analysis (ANOVA) was used to test the differences
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between the patient groups according to operation times. Nonparametric Spearman correlation analysis was used to test the relationship between operation time and age variables. Arithmetic
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mean, standard deviation, minimum and maximum values were obtained for all statistical tests. In addition to the mean and standard deviation for non-parametric tests, the median and interquartile range measurements, which are statistically more suitable for the assumption of normality, are also
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given.
Table 2 shows the Mann-Whitney test results and descriptive statistics applied between the
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sex groups in terms of operation times. Figure 1 shows the box graph of operation times according to gender groups. According to the test results, there was no statistically significant difference between the sex groups in terms of the operation time (p> 0.05).
Table 3 shows the ANOVA test results and descriptive statistics performed between the patient groups in terms of the duration of the operation. Graph 2 shows the box graph of the operation times for the patient groups. As a result of Levene test, it was determined that the variances were not homogeneous among the patient groups and variance analysis was performed
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according to Welch statistics. According to the test results, there was a statistically significant difference between the patient groups according to the operation time (p <0.05). In order to examine the differences between the patient groups, Tamhane test was used in cases where the variances were not distributed homogeneously. As a result of the Tamhane multiple comparison test, it was found that the operation time of the 3rd group patients was statistically significantly higher than the patients in the 1st and 2nd groups. Table 4 shows the Spearman correlation test results and descriptive statistics applied to test the relationship between operation time and age variables. The negative Spearman correlation coefficient indicates an inverse relationship between age and operation time. However, according to
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the correlation analysis findings, there was no statistically significant relationship between the age
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and operation time of the patients (p> 0.05).
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DISCUSSION
Arthrocentesis, which is effective for the treatment of TMD, is also a practical approach in terms of the time required for treatment. The duration of arthrocentesis may vary among joint
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disorders; in particular, it takes more time in patients with DDWoR than in patients DWR or OA. To the best of our knowledge, this comparison has not been previously performed.
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TMD is a group of musculoskeletal disorders caused by trauma, parafunctional habits,
functional overload, hormonal changes, psychosocial factors, occlusal changes, and/or anatomical characteristics.(14-16) In addition, autoimmune disorders, fibromyalgia, sleep apnea, and psychiatric problems may contribute to chronic and persistent TMD.(17) Symptoms associated with TMD include reduced mouth opening, pain in the joint and chewing muscles, headache, earache, and joint sounds and deviation during mouth opening and closing.(5-17) These symptoms may cause mild pain or may exhibit sufficient severity to interfere with the patient’s daily activities.(1) Information regarding the prevalence of TMD varies throughout the literature due to differences in diagnostic criteria, classification systems, populations, and examination methods among studies.(5) In a study that evaluated adolescents, the reported prevalence of TMD was 34.9%; the most common symptoms were head and neck pain (20.9%), joint sounds (18.5%), and joint pain (14%).(18) In an electronic survey-based study conducted in Brazil, 37.5% of respondents reported at
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least one TMD symptom.(19) The reported prevalences of at least one symptom associated with TMD were 41.3% and 68.6% in two separate studies of college students. (20,21) According to a review of 17 separate epidemiological studies that evaluated different populations and age groups, 41% of the included 10,579 people had at least one TMD symptom (minimum prevalence, 14%(22); maximum prevalence, 80%(23).(24) Talaat et al.(5) investigated the prevalence of TMD based on RDC/TMD criteria, and found that the most common diagnoses were DDWR (40.92%), myofascial pain (17.54%), DDWoR with limited mouth opening (15.69%), myofascial pain with limited mouth opening (9.23%), osteoarthritis (11.69%), and DDWoR without limited mouth opening (4.62%). The treatment of TMD is divided into three main categories: noninvasive, minimally
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invasive, and invasive. Although the choice of treatment may vary according to differences in diagnosis and severity, it is generally accepted that noninvasive conservative treatments should be attempted first. When TMD does not respond to conservative treatments, the least invasive method
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should be chosen; more invasive options should be implemented when less invasive methods fail.(1) Conservative treatments include ancillary measures (e.g., jaw exercise and/or soft diet), occlusal
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splints, complementary medicine, pharmacotherapy (e.g., nonsteroidal anti-inflammatory drugs, benzodiazepines, and/or muscle relaxants), and physical therapy. A long-term study showed that
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conservative treatments reduced symptoms in 50–90% of patients.(7,17) Minimally invasive surgery is the first-line treatment modality when conservative treatment fails.(25) Among the current minimally invasive treatments, arthrocentesis is a simpler and less invasive procedure than
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arthroscopy (26); notably, arthrocentesis was first applied by Nitzan (11) in 1991 for the treatment of closed locking. Arthrocentesis aims to reduce the levels of inflammatory mediators that cause
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chronic pain through irrigation of the upper joint cavity; moreover, it aims to release the articular disc through removal of adhesions between the disc and mandibular fossa by hydraulic pressure.(8,27) Biochemical and pressure changes in synovial fluid content, rather than physical displacement of the disc, may be the causative factor in TMD; this awareness has increased the importance of arthrocentesis.(28) Indeed, despite incomplete repositioning of the disc, some studies have shown that the pain associated with TMD is reduced by 80–90% after arthrocentesis.(29) Thus, the success of the procedure is considered independent of positional and morphological changes in the disc.(30) Although arthrocentesis was first used for the treatment of DDWoR, it is now applied with high success rates for the treatment of DDWR and OA.(1) A literature review reported that the mean success rate of arthrocentesis in DDWoR treatment was 83.2% (minimum rate, 63.2% (31); maximum rate, 100%(32,33) for 1,141 joints among 19 studies.(30) When DD and DWR were evaluated together, the success rate was 83.5%. Another review indicated that the success rate of
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arthrocentesis for the treatment of TMJ OA ranged from 68% to 81% among multiple studies.(30) Saline solution or lactated Ringer’s solution, in volumes ranging from 50 to 500 mL, are useful for lavage of the joint cavity.(30) Although a precise and standard lavage volume has not yet been determined, a previous study demonstrated that at least 100 mL lactated Ringer’s solution should be used to eliminate therapeutic proteins and specific proteinases in synovial fluid.(34) Another study reported that the results obtained from patients who had undergone lavage with >150 mL were not better than those of patients who had undergone lavage with 130–150 mL; thus, they concluded that a lavage volume of 150 mL was sufficient.(35) Based on these findings, we evaluated the duration of arthrocentesis using 150 mL lactated
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Ringer’s solution (the presumed minimum effective amount). We observed the longest mean duration of arthrocentesis in the DDWoR group (609.00±106.88 seconds) and noted a statistically significant difference in the duration of the procedure between the DDWoR and DDWR groups, as
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well as between the DDWoR and OA groups. Three different mechanisms may be at play. First, in patients with DDWoR, the condyle cannot perform translation movement(36) because the mouth
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opening is restricted and the joint cavity is narrower than in patients with DDWR or OA, due to its inability to move away from the glenoid fossa. Therefore, additional time is needed to place needles
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in the correct positions. Second, adhesions between the disc and temporal bone are more common in patients with DDWoR than in patients with DDWR or OA.(37) As the circulating lactated Ringer’s solution passes through these adhesions, it encounters resistance, which slows the movement of
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liquid. Third, the superior joint cavity becomes narrower and more crescent-shaped in patients with DDWoR than in patients with DDWR or OA, as the condyle cannot perform translation movement. In
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this situation, the surface-to-volume ratio increases, thus increasing the volume of liquid interacting with the surface; this increases the adhesion effect and reduces the flow of liquid. There were no statistically significant differences in duration of arthrocentesis between
patients with OA and those with DDWR. However, arthrocentesis tended to be performed more rapidly in patients with OA. In OA, articular cartilage and bone structures exhibit degeneration because of forces that exceed the adaptive capacity;(10) this resorption may cause considerable enlargement of the glenoid fossa.(38) Presumably, the enlarged joint space reduces the resistance to fluid movement and shortens the duration of arthrocentesis in patients with OA.
CONCLUSION These findings should be confirmed in studies with larger numbers of patients. In addition there was no relationship between the age or gender and operation time of the patients.
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Operation time (seconds)
Male
Female
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Graph 1: Box graph of operation times for gender groups
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Operation Time (sec) 700 600 500 400
OA
DDWR
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300
DDWoR
Group
n (%)
Statistic
p
Male
13 (%20)
0.903
0.146
Female
52 (%80)
0.938
0.009
OA
19 (%29.2)
0.955
0.473
DDWR
24 (%36.9)
0.958
0.406
DDWoR
22 (%33.8)
0.937
0.170
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Variable
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Graph 2: Box graph of operation times for patient groups
Gender
Patient group
Table 1: Normality test results
Gender
±σ
M ± IQR
Min
Max
Statistic
p
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Male Female
525.23 ± 131.84 493.46 ± 107.12
515 ± 131 461.50 ± 102.25
362 264
758 760
384.500
0.450
: Arithmetic mean, σ: Standart deviation, M: Median, IQR: Interquartile Range
Table 2: Mann-Whitney test results for gender groups.
Min
Max
264 333 421
516 566 760
Levene test Statistic p 9.259
<0.001
ANOVA test Statistic p 23.127
<0.001
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Patient ±σ group OA 423.79 ± 66.77a DDWR 459.92 ± 56.67a DDWoR 609.00±106.88b : Arithmetic mean, σ: Standart deviation
M ± IQR 470 ± 121 24 ± 17
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Variable ±σ Time 499.82 ± 112.10 Age 30.34 ± 13.58
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Table 3: ANOVA test results for patient groups
Min 264 15
Max 760 67
Statistic
p
0.744
-0.041
: Arithmetic mean, σ: Standart deviation, M: Median, IQR: Interquartile Range
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Table 4: Spearman correlation analysis results
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