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Timing of Arthrocentesis in the Management of Temporomandibular Disorders: a Systematic Review and Meta-Analysis

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Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 Timing of Arthrocentesis in the Management of Temporomandibular Disorders: A Systematic Review and Meta-analysis Dion Tik Shun LI 1, Natalie Sui Miu WONG 1, Samantha Ka Yan LI2, Colman Patrick MCGRATH3, Yiu Yan LEUNG 1 1 Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong 2Faculty of Dentistry, The University of Hong Kong, Hong Kong 3Applied Oral Sciences & Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong Corresponding author Dr. Yiu Yan Leung Oral and Maxillofacial Surgery 34 Hospital Road, Hong Kong Tel: +852 28590511 Fax: +852 28575570 E-mail: [email protected] Funding: None Key words: temporomandibular joint disorders, arthrocentesis, TMJ, arthralgia, lavage 1 © 2020 by the author(s). Distributed under a Creative Commons CC BY license. Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 ABSTRACT The aim of this study was to assess the best timing to perform arthrocentesis in the management of temporomandibular disorders with regards to conservative treatment. A systematic search based on PRISMA guidelines, including a computer search with specific keywords, reference list search, and manual search was done. Relevant articles were selected after 3 search rounds for final review based on 6 predefined inclusion criteria, followed by a round of critical appraisal. Eleven publications, including 5 randomized controlled trials and 6 prospective clinical studies informed this review. The studies were divided into 3 groups based on the timing of arthrocentesis: 1). Arthrocentesis as the initial treatment, 2). Early arthrocentesis, and 3). Late arthrocentesis. Meta-analyses compared the efficacy of improvement in mouth opening and pain reduction in the 3 groups. The results were statistically significant and favoured early arthrocentesis, followed by late arthrocentesis in terms of both improvements in mouth opening and pain reduction. All 3 groups showed improvement in mouth opening and pain reduction. We conclude that early arthrocentesis may be able to produce the best clinical results, while arthrocentesis before attempting conservative treatment may produce less favourable outcomes. 2 Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 INTRODUCTION Temporomandibular disorders (TMDs) are a group of common facial pain conditions affecting 3.7-12% of the general population 1, 2, and is 5 times more prevalent in women 2. TMDs can be from the joint itself, the muscles of mastication, or a combination of both 3. Although up to two-thirds of these patients will seek treatment for TMDs, about 15% of them will develop into chronic disease 1. According to the National Institute of Dental and Craniofacial research, the estimated annual cost incurred in the United States related to TMDs is about $4 billion 1. Because of their high prevalence, tendency to develop into chronicity, and significant financial burden to the society, TMDs are no doubt a public health problem. The conventional approach to the management of most types of TMDs begins with conservative treatment, such as non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, soft diet, and occlusal splint etc. 4. Positive results are seen in between 75-90% of the patients with TMDs with conservative treatment 5. However, there remains a small proportion of patients that are refractory to conservative treatment. In general, as the duration of pain symptoms increase, patient response to intervention diminishes 6, 7, and they become difficult to treat. This phenomenon applies to TMDs as it has been concluded that patients with chronic temporomandibular joint (TMJ) pain respond less favourably than in patients where the pain is non-chronic in nature 8-10. Temporomandibular joint arthrocentesis was introduced as a minimally invasive treatment for severe, limited mouth opening in the early 1990s 11. It involves lavage of the superior joint space using 2 needles with an irrigation fluid such as normal saline, 3 Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 with or without additional medications injected into the joint. While arthrocentesis has been proposed to be a first-line treatment for closed-lock of the TMJ 12, different authors have also noted the effectiveness in the treatment of non-locking joints, and mechanisms have been proposed, such as removal of pathological joint fluid, and elimination of the negative pressure termed “the suction cup” effect 8, 13, 14. Being cost-effective and safe, with a success rate of over 80% 15, arthrocentesis is now a standard procedure not only for closed lock of the TMJ, but also for TMJ arthralgia of a non-locking nature when the outcomes of conservative treatment are unsatisfactory. However, how long should conservative treatment be attempted before moving on to the next step in the treatment algorithm when results are unsatisfactory remains a question to be answered. Unfortunately, some patients are shunted between conservative treatment options for an extended period of time without observable progress, while early minimally invasive treatment, such as arthrocentesis, may have the potential to provide timely symptomatic relief as well as functional improvement. This early clinical benefit may prevent the development of chronic pain and psychological deterioration in some of the patients with TMDs. As said earlier, the difficulty of treating pain symptoms increases with the duration of those pain symptoms experienced by the patients. Therefore, the importance of understanding when to performing TMJ arthrocentesis cannot be overstated. However, there is no consensus in the literature regarding the timing of arthrocentesis with regards to conservative treatment at present. The aim of this systematic review and meta-analysis was to determine whether timing of arthrocentesis, with regards to conservative management, has any effects on the treatment outcomes in patients with temporomandibular disorders. 4 Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 METHODS Eligibility criteria The following PICOTS criteria were applied: ‘P’ (population): adult human patients with pain due to arthrogenic, with or without myogenic TMDs. A clear clinical diagnosis or specific signs and symptoms of TMDs should be mentioned. ‘I’ (intervention): arthrocentesis, or lysis and lavage, with or without intra-articular injections, either as initial treatment (no prior treatment for TMDs), or as treatment after failure of conservative treatment. ‘C’ (comparisons): control or conservative treatment only including occlusal splint, or compared to arthrocentesis with intra-articular injections, or compared to arthrocentesis with different intra-articular injections, or compared to arthrocentesis on patients with different diagnoses of TMDs ‘O’ (outcomes): the primary outcome is pain intensity, measured by visual analogue scale (VAS) or numerical rating scale (NRS). The secondary outcome is maximum mouth opening in millimetres. ‘T’ (time): all studies should have a follow up period of at least 2 weeks. For those studies with arthrocentesis as treatment after failure of conservative treatment, the duration of conservative treatment should be mentioned. ‘S’ (study design): randomized controlled trial or controlled clinical trial or prospective clinical trial. The following studies were excluded: studies not in English, full text not available, animal or cadaver studies, studies not related to TMDs or where there is no mention of specific 5 Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 6 August 2020 doi:10.20944/preprints202008.0155.v1 diagnoses or signs and symptoms, studies not using arthrocentesis as intervention, studies that included less than 30 patients undergoing arthrocentesis, studies not using pain and jaw function as outcomes, non-clinical studies, retrospective studies, technical notes, case reports and case series. Information sources and search strategy This systematic review and meta-analysis was conducted according to the PRISMA statement 16. In the first round, a comprehensive electronic search in Pubmed, Cochrane Library, EMBASE (Ovid) and Scopus was updated to March 19, 2020. The following search terms were used: (“Temporomandibular Joint” OR “Temporomandibular Joint Disorders” OR “Temporomandibular Joint Dysfunction Syndrome” OR “Myofascial Pain Syndromes” OR “Craniomandibular Disorders” OR TMJ OR TMD or CMD) AND (Arthrocentesis OR “Temporomandibular Joint Arthrocentesis” OR lysis OR lavage). No restrictions on publication date, language, or status of publication were imposed. The abstracts of the articles from the computer search were reviewed for eligibility. Full texts of potentially eligible studies relevant to the treatment of TMDs by arthrocentesis were obtained and included in the second round. In the second round, manual search was performed in 3 relevant international journals: International Journal of Oral and Maxillofacial Surgery, the Journal of Oral and Maxillofacial Surgery, and the Journal of Craniomaxillofacial Surgery. In addition, reference lists of all included studies from the first round and from the manual search were searched for relevant articles relating to management of TMDs with arthrocentesis.
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