Microbiological investigation of retrodiscal tissues from patients with advanced internal derangement of the temporomandibular joint

Abstract

The aim of this study was to investigate the presence of bacteria in samples of retrodiscal tissues taken from patients suffering from advanced internal derangement of the temporomandibular joint (TMJ). 12 fresh retrodiscal tissue samples were taken from 12 consecutive patients who underwent unilateral TMJ discectomy for advanced TMJ internal derangement (Wilkes stage IV). The retrodiscal tissue samples were stained and cultured for the presence of micro-organisms in microbiology laboratories. No evidence of bacteria or other micro-organisms was found in any of the tissue specimens procured from the TMJ. This study failed to identify the presence of bacteria or other micro-organisms in fresh retrodiscal tissue specimens of the TMJ in patients with advanced TMJ internal derangement.

Temporomandibular joint internal derangement (TMJ-ID) is characterised by mechanical interference within the joint, often caused by disc displacement, which may result in pain and dysfunction in the TMJ. Clinical presentation may include pain during jaw movement, joint noises such as clicking or crepitus and limited mouth opening. While conservative management such as splint therapy, physiotherapy and anti-inflammatory medications are employed for early to moderate cases of TMJ-ID, in more advanced cases, TMJ arthroscopy or open surgery may be indicated with surgical removal of the articular disc reserved for recalcitrant cases that fail to respond to lesser measures.

The pathophysiology of TMJ-ID is often related to the stretching of the retrodiscal tissues resulting in disc displacement. Acute or chronic repetitive trauma is said to be the cause of retrodiscal damage, but what is uncertain is whether there is any other underlying factor that may contribute or exacerbate the stretching of the retrodiscal tissues that results in disc displacement. In other words, is the damage in TMJ-ID purely a mechanical injury or is there perhaps a microbial invasion that may be a factor in the inflammation, destruction and degeneration of the retrodiscal tissues that results in disc displacement? A search conducted on PubMed found no published studies that have looked at the presence of microbes within the articular tissues of joints diagnosed with advanced TMJ internal derangement. The aim of this study was to investigate the presence of bacteria and other micro-organisms in fresh samples of retrodiscal tissues taken from patients suffering from advanced TMJ internal derangement.

Materials and methods

12 consecutive patients who were diagnosed with Wilkes stage IV Internal Derangement and underwent TMJ discectomy participated in the study. All patients had at least 6 months of failed conservative management which included splint therapy, physiotherapy and medications before being referred to the second author for surgical management. The basis for referral was intolerable pain well localised to the joint combined with radiological evidence from magnetic resonance imaging (MRI) which showed non-reducing disc displacement and severe disc deformity but with condylar disease that was salvageable. Patients with a history of infective or reactive arthritis, idiopathic condylar resorption and autoimmune connective tissue diseases were excluded from this study.

No ethics approval was required because all tissue excised from TMJ discectomies are routinely sent off for histopathology. The only difference in the cases which form part of this study is that a small part of the retrodiscal attachment was sent off to microbiology as a fresh specimen in a separate container from the rest of the disc specimen and its surrounding attachments which went to histopathology. In their written consent for surgery all patients were informed that in addition to the routine histopathology, part of their tissue specimen would be sent to microbiology for additional examination. Patients were generally grateful for the additional laboratory investigation.

The TMJ was approached via a standard preauricular incision and dissection with the patient under naso-endotracheal general anaesthesia. As it was beyond salvage, the whole articular disc and its surrounding attachments were excised. A portion of retrodiscal tissue attached to the posterior edge of the excised disc was removed and placed as a fresh specimen in a sterile plastic container. The rest of the disc specimen was placed in another container filled with formalin for histopathology. Following debridement of the surrounding fossa, eminence and condylar head, an interpositional dermis fat graft harvested from the lower abdomen was placed in the resultant joint cavity to fill the defect. The joint capsule was repaired carefully and the incision was closed in layers with interrupted sutures.

A sterile environment was used at all times. The retrodiscal tissue specimens were placed in dry sterile plastic pathology specimen containers and transported to either one of two independent laboratories for microbiological and histological examination. The fresh dry specimens were processed in under 2 h of being procured and cultured for aerobes and anaerobes in a number of different enrichment mediums. A haematoxylin and eosin (H–E) Gram stain was performed immediately to assess for bacteria, tissue cells, polymorphs and mycotic elements. The standard protocols for culture mediums at both laboratories are given in Table 1 . If a specimen is identified additional media are used ( Table 1 ).

Table 1
Standard protocols for culture mediums at both laboratories.
Media Atmosphere Time for reading Temperature
Blood agar (BA) CO 2 24 and 48 h 35 °C
Chocolate agar (CA) CO 2 24 and 48 h 35 °C
Anaerobic agar (AA) pre-reduced AnO 2 48 h 35 °C
Thioglycollate broth (THIO) O 2 7 days 35 °C
Additional media is used f specimen is identified
Purulent specimen
Saponin lysed BA (SAP) CO 2 24 and 48 h 35 °C
• Intracellular organisms seen in polymorphs on Gram stain
Saponin lysed BA (SAP) CO 2 24 and 48 h 35 °C
• Gram negative bacilli seen on Gram stain
MacConkey agar (MC) O 2 24 h 35 °C
• Gram negative bacilli mixed with Gram positive organisms
Blood nalidixic acid colistin agar (BNC) CO 2 24 and 48 h 35 °C
• Fungi
Sabourauds agar (F) O 2 7 days 30 °C
• Actinomyces
Nalidixic acid Tween agar (NAT) + MTZ5 disc AnO 2 7 days 35 °C

Specimens were reported after 48 h as most pathogens grow within this time frame but the mediums are also reviewed at 7 days. If there is growth in the enrichment broth a Gram stain and culture onto solid media is carried out to determine the morphology of the organism in question so that appropriate sensitivity testing can take place. The standard protocols as described are the same as those used to examine specimens from other joints in the body including the hip and knee.

Results

The microbiological investigations are summarised in Table 2 . Fresh retrodiscal tissue samples were taken from 12 consecutive patients who underwent unilateral TMJ disectomy for advanced TMJ internal derangement by the second author. The average age of the patients was 41 years (range 22–65 years), with females outnumbering males 6:1. All were unilateral with 7 right side and 5 left side joints from which specimens were procured. All 12 specimens submitted for Gram staining with H–E were negative for micro-organisms including fungi. Polymorphs, markers for inflammation, were not identified in any of the stained tissue specimens. No micro-organisms were grown in the culture media of any of the 12 specimens after 7 days.

Table 2
Summary of microbiological investigations.
Specimen Age of patient (years) Gender Side specimen was taken Microscopy results Culture
1 35 Female Right TMJ Nil organisms
Nil polymorphs
No growth
2 39 Female Left TMJ Nil organisms
Nil polymorphs
No growth
3 39 Female Left TMJ Nil organisms
Nil polymorphs
No growth
4 33 Female Left TMJ Nil organisms
Nil polymorphs
No growth
5 56 Female Right TMJ Nil organisms
Nil polymorphs
No growth
6 34 Female Left TMJ Nil organisms
Nil polymorphs
No growth
7 55 Female Right TMJ Nil organisms
Nil polymorphs
No growth
8 41 Female Left TMJ Nil organisms
Nil polymorphs
No growth
9 34 Female Right TMJ Nil organisms
Nil polymorphs
No growth
10 35 Male Right TMJ Nil organisms
Nil polymorphs
No growth
11 22 Female Right TMJ Nil organisms
Nil polymorphs
No growth
12 64 Male Right TMJ Nil organisms
Nil polymorphs
No growth
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Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Microbiological investigation of retrodiscal tissues from patients with advanced internal derangement of the temporomandibular joint
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