The paper entitled “Effects of four treatment strategies for temporomandibular joint closed lock” by Schiffman et al., published in the International Journal of Oral and Maxillofacial Surgery (IJOMS) in February 2014, is based on a previous study from the same group entitled “Randomized effectiveness study of four therapeutic strategies for TMJ closed lock”, which was published in the Journal of Dental Research (JDR) in 2007. However, in their 2014 IJOMS paper, the authors only employed the 1993 International Association of Oral and Maxillofacial Surgeons (IAOMS) criteria for successful temporomandibular joint (TMJ) surgery when assessing the outcomes of the four treatments.
I recognize that the treatment outcomes in the four groups of medical management, rehabilitation, arthroscopy, and arthroplasty were comparable in their two papers. I also agree with their conclusion stressing the importance and necessity of appropriate non-surgical treatment prior to any surgical intervention. However, the comment “immediate relief using any of these treatment strategies does not occur often, and all treatment strategies result in similar improvement over time” is somewhat counter to my experience, and is inconsistent with their 2007 report.
The original data from the JDR 2007 report revealed that a repeated-measures analysis of the Symptom Severity Index (SSI) demonstrated group differences. The groups differed in time trend ( P = 0.03): arthroplasty achieved its full effect by 3 months, while the other three groups improved throughout the 60-month follow-up. Their results indicated that arthroplasty reduced pain more rapidly. Further, the data-adjusted analyses of SSI showed that arthroplasty was superior to medical management at the 6-month follow-up ( P = 0.02). Hence, these data attest to the advantage of surgical intervention, not only in time scale, but also in good pain control.
There was an interesting description in the JDR 2007 article referring to the fact that the four groups differed in prescription medication use at 3 months ( P = 0.001). The number of participants requiring prescription analgesics more than once weekly was reported to be 17/28 (61%) in the medical management group, but 2/21 (10%) in the rehabilitation group, 9/22 (23%) in the arthroscopy group, and 1/19 (5%) in the arthroplasty group. The number requiring muscle relaxants in the medical management group was reported to be 8/28 (29%) vs. 2/21 (10%), 0/22, and 0/19, respectively, in the other three groups. Unfortunately, in the 2014 paper, this information was not reported because they used the IAOMS 1993 criteria. It is important that the time and medication requirements presented in their JDR 2007 paper be considered in the conclusions made in their IJOMS 2014 paper, and if not, the omission justified.
It is agreed that non-surgical management is appropriate as the initial treatment for patients with closed lock, but sometimes these patients need an extended treatment time scale. Treatment objectives should include not only the achievement of long-term acceptable pain relief and functional outcomes, but also a shorter duration of the initial short-term pain and dysfunction and an improvement in the patient’s quality of life.
The results of a recent evidence-based randomized clinical trial (RCT) on arthrocentesis as the initial treatment for TMJ arthropathy have been reported. The study clearly showed arthrocentesis to more rapidly reduce pain and functional impairment than conventional non-surgical treatment.
Arthrocentesis and arthroscopy are both minimally invasive procedures; the early application of these surgical interventions for the appropriate diagnosis may prevent the waste of time and resources associated with inappropriate non-surgical treatments.