Arthrocentesis As Initial Treatment For TMD's
Arthrocentesis As Initial Treatment For TMD's
Arthrocentesis As Initial Treatment For TMD's
a r t i c l e i n f o a b s t r a c t
Article history: Objective: To determine the effectiveness of arthrocentesis compared to conservative treatment as initial
Paper received 23 January 2013 treatment with regard to temporomandibular joint pain and mandibular movement.
Accepted 17 July 2013 Patients and methods: In this randomized controlled trial, 80 patients with arthralgia of the TMJ (clas-
sified according to the Research Diagnostic Criteria for Temporomandibular Disorders) were randomly
Keywords: assigned to one of the two treatment groups. One group received arthrocentesis as initial treatment
TMD
(n ¼ 40), the other group received conventional treatment including soft diet, physical treatment and
Arthralgia
occlusal splint therapy (n ¼ 40). Follow-up was after 3, 12 and 26 weeks post treatment. Prior to
Lavage
Initial therapy
treatment, and at every follow-up assessment, pain intensity was measured (VAS 0e100 mm at rest, and
Pain VAS 0e100 mm during movement) and maximum mouth opening (MMO) (mm interincisor distance).
RCT Furthermore patients were asked to fill out several surveys concerning the impact of mandibular
impairment on their daily life, and psychosocial aspects.
Results: After 26 weeks, the TMJ pain (mm VAS at rest, and mm VAS during movement) had declined
comparably in both groups (arthrocentesis n ¼ 36; conservative treatment n ¼ 36) and MMO (mm
interincisor distance) had slightly improved. GEE models showed significant differences between
arthrocentesis as initial treatment and conservative treatment, indicating that the arthrocentesis group
improved more rapidly with regard to TMJ pain (VAS at rest p ¼ 0.008; regression coefficient b ¼ 8.90
(95% confidence interval 15.50, 2.31), VAS during movement p ¼ 0.003; regression coefficient b ¼
10.76 (95% confidence interval 17.75, 3.77)) and MMO (p ¼ 0.045; regression coefficient b ¼ 2.70
(95% confidence interval 5.35, 0.06)) compared to conservative treatment.
Conclusions: Arthrocentesis as initial treatment reduces pain and functional impairment more rapidly
compared to conservative treatment. However, after 26 weeks, both treatment modalities achieved
comparable outcomes.
Trial registration number: www.trialregister.nl: NTR1505.
Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2013.07.010
Please cite this article in press as: Vos LM, et al., Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized
controlled trial, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.010
2 L.M. Vos et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e6
2.1. Study design Fig. 1. Flow chart of the enrolment procedure and treatment arms.
Please cite this article in press as: Vos LM, et al., Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized
controlled trial, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.010
L.M. Vos et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e6 3
Patients assigned to
conservative treatment
group, n=40
Continuation soft diet, Additional physical Additional splint Additional splint and
n=36 therapyb, n=7 therapyc, n=15 physical therapyb,c, n=2
a
Explication of the pathology was provided in order to enhance patient’s understanding and thereby improve compliance.
b
Physical therapy was performed once a week and included ‘joint play’, stretching and dry needling of triggerpoints.
c
Splint therapy consisted of an intra oral hard acrylic splint which patients were instructed to use during the night, and one or two
hours during the day to get used to the unusual jaw position.
Please cite this article in press as: Vos LM, et al., Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized
controlled trial, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.010
4 L.M. Vos et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e6
3. Results
Please cite this article in press as: Vos LM, et al., Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized
controlled trial, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.010
L.M. Vos et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e6 5
Table 2
Regression coefficients and P-values as derived from GEE analysis.
b ¼ regression coefficient.
CI ¼ confidence interval.
These findings are consistent with currently available evidence used for TMJ evaluation, such as Magnetic Resonance Imaging
that arthrocentesis is an efficient and effective treatment modality, (MRI) and Cone-Beam Computed Tomography (CBCT). However, in
although these studies did not investigate arthrocentesis as initial order to detect the relatively small intra-articular bony changes,
treatment (Monje-Gil et al., 2012; Al-Belasy and Dolwick, 2007). CBCT may not be accurate since its precision is limited by the voxel
With regard to the effectiveness of the conservative treatment size. Furthermore, MRI is mainly used for evaluation of the soft
approach, the results of this study confirm that in particular TMJ tissues (Roh et al., 2012).
pain improves over time (de Souza et al., 2012). However, conser- Contemporary therapeutic strategy consists of initially conser-
vative treatment, and in particular splint therapy, may be more vative treatment, which is followed by minimally invasive tech-
effective when combined with arthrocentesis (Machon et al., 2011). niques like arthrocentesis, when patients are non-responsive to this
The relatively rapid improvement after arthrocentesis compared approach and the arthropathy appears to be persistent. In this study
to conservative treatment may be explained by the immediate arthrocentesis was used as initial therapy. Since the results of this
removal of pro-inflammatory interleukins, matrix degrading en- study indicate that arthrocentesis as initial treatment reduces pain
zymes, reactive cytokines and degeneration products, giving the and functional impairment more rapidly than non-invasive therapy
joint a head start in the recuperation process. However, favourable with low morbidity, the statement that non-invasive treatment
substances like hyaluronic acid and lubricin may be removed from should be used as initial treatment because it would be less
the joint space as well by the lavage therapy (Laskin, 2009). harmful, is at least doubtful.
Furthermore, arthrocentesis is less dependent on patient compli-
ance compared to conservative treatment since the treatment 5. Conclusion
consists of a one-time lavage of the joint that is performed by the
treating physician. Possibly, this may have contributed to the rapid Arthrocentesis, as initial treatment, reduces pain and functional
improvement after arthrocentesis as well. impairment more rapidly compared to conventional initial therapy.
Strengths of this study were the randomized allocation to the Progression of the reduction of TMJ pain and functional impairment
different treatment groups, the blinded follow-up observations and seems to be most explicit relatively short after arthrocentesis as
analyses, a sufficient sample size, and the extended psychosocial initial treatment, whereas progression after conservative treatment
patient profiling by means of several validated questionnaires. The seems to develop more gradually. Over time, both treatment mo-
main weaknesses of this study were the generalizability, and the dalities appear to be equally effective.
relatively large number of patients lost to follow-up.
The generalizability of this trial may be limited due to the in-
Conflict of interest statement
clusion procedure. Patients were selected using intra-articular
The authors declare no potential conflicts of interest with
anaesthesia, which excluded patients with mainly myogenous
respect to the authorship and/or publication of this paper.
symptoms. Therefore, the results of this study may be representa-
tive for a select group of TMD patients, since TMD patients usually
present mixed, arthrogenous and myogenous, symptoms (Kim Acknowledgements
et al., 2012a).
In this trial, the number of patients lost to follow-up was This paper was supported by the Department of Oral and
equally distributed among the two treatment groups. Therefore, Maxillofacial Surgery of the University Medical Center Groningen.
association of patient compliance and treatment group is unlikely.
However data about reasons for loss to follow-up were not Appendix A. Supplementary data
collected. Since the number of patients lost to follow-up increases
with time and in both groups symptoms tend to decrease over Supplementary data related to this article can be found at
time, possibly compliance is associated more with the severity of http://dx.doi.org/10.1016/j.jcms.2013.07.010.
the symptoms.
At baseline and at 26 weeks, X-ray examinations were per-
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Please cite this article in press as: Vos LM, et al., Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized
controlled trial, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.010