Minimally-invasive treatment for temporomandibular disorders : early arthrocentesis and extracorporeal shockwave therapy

Abstract

Temporomandibular disorders (TMD) are a common group of orofacial pain conditions in the maxillofacial region and may involve the temporomandibular joint (TMJ) and associated musculature. Treatment options for TMD are various depending on the diagnosis. Chapter 1 is a literature review which discusses the present thinking in the etiology and classification of TMD, followed by the diagnostic approach and the current trend which appears to favor minimally-invasive procedures, such as arthrocentesis. Chapter 2 of this thesis provides a review of the various surgical treatment options of the TMJ and includes discussions on open versus closed procedures. To investigate the best timing to perform arthrocentesis in the management of temporomandibular disorders with regard to conservative treatment, an integrated review and meta-analysis was performed and is reported in Chapter 3. After a systematic search and selection of relevant articles, eleven publications, including eight randomized controlled trials and three prospective clinical studies, were included. Meta-analysis suggested that arthrocentesis performed within 3 months of conservative treatment may produce beneficial results in terms of pain reduction and improvement of mouth opening (MO). However, it was concluded that there is a knowledge gap in the current literature regarding the preferable timing to perform TMJ arthrocentesis, which led to the superiority trial reported in Chapter 4. This superiority trial aimed to investigate the clinical outcomes of arthrocentesis as an early treatment, versus occlusal splint only, in the management of TMJ arthralgia. Ninety-five adult patients presented with TMJ arthralgia were recruited into the study and randomized into two groups: Group 1 received arthrocentesis as an early treatment and occlusal splint, whereas Group 2 received occlusal splint only. Seventy-four patients completed the 1-year follow up schedule and were included into the final analysis. In Group 1, pain intensity significantly decreased at 6 weeks and all subsequent time points compared to Group 2. For MO, significant improvement was observed in both groups during the course of treatment, yet a statistical significance was not seen between the two treatment groups. It was concluded that early arthrocentesis supported by occlusal splint is superior to occlusal splint alone in the treatment of TMJ arthralgia and could be discussed as an option for first-line treatment with patients allied to an occlusal splint. Chapter 5 reports a pilot study to investigate the feasibility and clinical outcomes of extracorporeal shockwave therapy (ESWT) in the treatment of TMD of myogenous origin (M-TMD). Forty-one adult patients presented with M-TMD were recruited into the study and randomized into two groups: Group 1 received ESWT treatment, whereas Group 2 received placebo treatment. Twenty-six patients completed 1-year follow up and were included into the final analysis. In both groups, reduction in pain and increase in MO were seen at post-treatment 1 year. Although more reduction in pain and increase in all MO in was seen Group 1, statistical significance was not detected. Yet this prospective pilot study provided preliminary evidence that ESWT is safe and potentially beneficial in the treatment of M-TMD.