Francesco Chiappelli Ph.D
There is insufficient evidence to support or to refute the use of arthrocentesis and lavage over control interventions for treating patients with temporomandibular joint disorders (TMDs).
The evidence to date, two studies at high risk of bias, does not allow us to conclude that arthrocentesis and lavage is better or worse than the control interventions in reducing pain associated with TMDs.
In adults with TMDs derived from internal derangements (e.g., clicking, popping, grating), is arthrocentesis and lavage more effective than a control interventions, or no treatment/placebo in relieving pain?
The authors searched five databases and conducted hand-searches of the oral health literature. There were no language restrictions. Two reviewers independently extracted the data. The review included randomized controlled trials as well as quasi-randomized clinical trials. Three reviewers independently assessed the risk of bias of the included trials. Authors of the trials were contacted as needed. Estimates of an intervention’s effect were expressed as risk ratios with 95 percent confidence intervals (CI95). For studies making similar comparisons, the authors pooled the data and conducted a random effects model meta-analysis.
The authors obtained two trials, which included 81 patients with TMDs derived from internal derangements, to compare arthrocentesis with arthroscopy. The studies had a risk of bias ranging from unclear to high risk. The authors found a statistically significant difference in maximum incisal opening (weighted mean difference: -5.28, 95 percent CI95: 7.10 to -3.46) favoring arthroscopy. Both groups reported mild and transient discomfort or pain at the injection site. The authors found no statistically significant difference for pain between the interventions and did not report data on quality of life. One study had a greater than 30% loss-to-follow-up at 12 months and 79% at 24 months.
The evidence is insufficient to support or to refute the benefits and risks of arthrocentesis and lavage for reducing pain in patients with TMDs, compared to controlled interventions.
Source of Funding:
Internal sources: Chinese Cochrane Center, China; West China College of Stomatology, Sichuan University, China. External sources: Project of Development of Systematic Review supported by Chinese Medical Board of New York (Grant: 98-680), USA; Cochrane Oral Health Group, UK.
Importance and Context:
TMDs are important oral health problems affecting 1 in 4 to 1 in 3 adults at some point in their lives. The prevalence of TMDs in pre-menopausal women compared to aged-matched men (by a factor of 2:1 to 3:1) makes these disorders an important women's health issue. Because of pain and potential oral and systemic sequelae, TMDs seriously affect a patient’s quality of life. The standard therapy, arthroscopy, has significant risks (e.g., perforation, synovitis), and it is important to find a less-invasive and more cost-effective way to manage TMDs.
Strengths and Weaknesses of the Systematic Review:
The search of the available literature, data extraction, assessment of the risk of bias, and data analysis are strengths of the review. Weaknesses of the review include over-reaching conclusions based on the results of the systematic review.
Strengths and Weaknesses of the Evidence:
The search process included randomized and quasi-randomized clinical trials. The review analysis included only two studies that had small sample sizes. In addition, the studies had manifest methodological flaws. For example, neither study detailed how the randomization sequence of allocation concealment was generated. Further, the authors did not completely report blinded outcome assessment, but this may not have been possible given that the primary outcome of pain relief was patient-reported. Lastly, the evidence was weak because TMD symptoms can often not be quantitatively expressed by means of validated instruments.
Implications for Dental Practice:
The protocol of arthrocentesis and lavage typically has mild side-effects (e.g., minimal, transient swelling and local sensitivity), is simpler to perform, and costs substantially less than arthroscopy. But, the evidence is lacking to support or to refute the benefits and risks of arthrocentesis and lavage for reducing pain in patients with TMDs, compared to control interventions, in dental practices in the developed world or in developing areas, as proposed by the authors.