Management of dysfunction of the temporomandibular joint guidelines approved by the BAOMS and NICE
Posted on 8th June 2017 at 19:05
The British Association of Oral and Maxillofacial Surgeons (BAOMS) national guidelines about the management of conditions of the temporomandibular joint (TMJ) have been approved by the National Institute for Health and Care Excellence (NICE). Its purpose is to be an useful tool available for surgeons and other medical colleagues, so they can also assist in the management of what might develop into a condition of chronic pain. The use of TMJ multidisciplinary teams should be encouraged to allow all treatment options for management to be discussed appropriately in selected cases, rather than unnecessarily progressing to surgical intervention. In this review we will cover the range of clinical situations of the TMJ and what are the treatment options available in each case according to the NICE and BAOMS guidelines.
An updated review of the guidelines was made in 2017 by S.Rajapakse, N.Ahmed, A.J.Sidebottom from the Maxillofacial Surgery Department, Queens Medical Centre, Derby Road, Nottingham.
CLINICAL SITUATION #1
- Painless click with no restriction opening or dietary function: This case needs no treatment.
Clinical Situation #2
- Patients with small limited mouth opening, visual analogue pain scale >5/10 and a restriction diet score <5/10. The clinician must look for contributing factors (unilateral chewing, malocclusion, oral habits). Initial management of a patient with Temporomandibular dysfunction is usually non-operative. An indication for a soft pain free diet, application heat/cold and massages to masticatory muscles can be very helpful at the beginning. Topical NSAIDs can produce a good clinical result as systemic ones, such as 1g paracetamol four times per day (qds) or 400mg of ibuprofen three times per day (tds). A soft lower occlusal splint can also be designed. so a lower soft splint is a simple and useful first stage. Bite splints, were shown to be more effective than doing nothing.
Physiotherapy has been used for this group of patients, and evidence suggests that in a carefully selected group it may be beneficial. The diagnostic dilemma is whether the pain is myofascial, joint related, or a combination of both. As these patients often present with pain and restricted mouth opening, a comprehensive history and examination are essential. Myofascial pain is indicated by the presence of trigger points during assessment of the muscles of mastication. Infiltration of trigger points with local anaesthesia has been shown to reduce pain.
Arthrocentesis and arthroscopy of the TMJ should be considered as firts-line management. A Cochrane review suggested that pain was more likely to be reduced both at 6 and 12 months after arthroscopy compared with an open operation.
Clinical Situation #3 "Emergencies"
Affected patients tend to be younger and present with an acute severe restriction of opening or after injury. In roughly 90% the symptoms will resolve without further progression if they are dealt early otherwise they run the risk of a fibrosed joint if left untreated. Some cases that aren't related to trauma, can be easily treated with local anaesthetic and performing an arthrocentesis. This will improve mouth opening and give pain relief.
The guidelines refers that surgical treatment of the TMJ have decreased in favor of non surgical treatments, but, there are still some indications for it;
Recurrent dislocation, is a common reason for a patient to assist to A&E, in some cases these patients have recurrent dislocations, for years. This is a pure indication for surgeons to choose an open intervention. Options include eminectomy or augmentation of the eminence. In elderly patients can be offered the option to infiltrate autologous blood inside the joint space and surrounding tissues.
Acute pain with no response of non-surgical treatments, when all resources have been exhausted, and the patient keeps suffering acute pain >5/10, and limited mouth opening below 32mm. A discectomy or meniscopex can be performed. Discectomy is perfomed for a deformed or perforated disc. A reduction of the disc can be done when there is gross displacement of the disc.
Prosthetic total joint replacement: Clinical indications under which replacement of the joint should be considered:
• Dietary score of <5/10 (liquid scores 0, full diet scores 10).
• Restriction of mouth opening (<35mm).
• Occlusal collapse (anterior open bite or retrusion).
• Excessive condylar resorption and loss of height of vertical ramus.
• Painscore >5/10 on visual analogues cale (combined with any of the others).
• Reduced quality of life score(this gives an idea of pain and functional disability, and permit some assessment of outcome).
• Clinical diagnosis confirmed by computed tomography.
Where patients meet the criteria for total replacement of the TMJ, it would be considered prudent to liaise, discuss, and refer patients for early specialist management.
NICE Interventional Procedure Guidance 500 - Total Prosthetic Replacement of the Temporomandibular Joint; 2014. Available at URL: https://www.nice.org.uk/guidance/ipg329 (last accessed 1 June 2016).
S. Rajapakse, N. Ahmed, A.J. Sidebottom. Current thinking about the management of dysfunction of the temporomandibular joint: a review. British Journal of Oral and Maxillofacial Surgery Volume 55, Issue 4, May 2017, Pages 351–356.
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