A Young Patient with Temporomandibular Joint Osteoarthritis: Case Report

Abstract

This paper describes a case of a young patient who sought help because of pain in the right temporomandibular joint (TMJ). She also reported increasing of pain during chewing. Clinical examination revealed limited mouth opening with uncorrected deviation to the ipsilateral side. Palpation of the lateral pole of the right condyle discovered crepitus, and maximum assisted opening elicited a report of "familiar pain". The diagnosis of osteoarthritis of the TMJ (RDC / TMD criteria, Axis I, Group III) was confirmed by CBCT of TMJ. There is no "gold standard" for the management of TMD, but the need for TMD treatment has to be based on precise indications related to the presence of pain, limitation in function of the lower jaw and signs of degenerative joint disease. Conservative, reversible therapeutic procedures are considered as the first choice for TMD treatment and their task is to improve the function of the entire masticatory system. In this case patient was treated with the combination of physical therapy and stabilization splint, in order to reduce the pain and restore the normal function of the lower jaw. At 6 months’ follow-up symptoms have almost completely disappeared, while 3 years later, the patient still has no significant subjective symptoms. In the present case non-invasive therapy was sufficient to bring, otherwise recurrent nature of osteoarthritis, in complete remission and keep it like that for years.

INTRODUCTION

Osteoarthritis (OA) is a degenerative joint disease characterized by degeneration of cartilage, subchondral bone sclerosis and formation of osteophytes. Like all other joints in the body, osteoarthritis can affect the temporomandibular joint, where destructive bone changes cause pain and / or dysfunction of the joint during mandibular movements. The etiology and pathophysiology of OA are complex, and the role in the onset of OA is often attributed to a variety of local and systemic factors that generally act synergistically in the occurrence of a pathological condition. Therefore, OA is considered to be multifactorial disease (1). According to the current literature, the degenerative changes in the TMJ are believed to result from the imbalance between dynamic processes (joint loading during functional and parafunctional movements of the jaw) and ability of the TMJ to tolerate the same with the help of the flexibility of its specific structure, functional remodeling and tissue repair (2). Imbalance between dynamic processes and the ability of the joint to adapt can be caused by different stressors whose action begins at the molecular level. The accumulation of changes at the molecular level may result in macrochanges that sometimes manifest as functional disorders during clinical examinations (1).

Diagnosis of OA includes medical history, clinical functional analysis, and radiological methods. Unilateral pain in the joint and soft tissue around it which increases during mandibular movements, as well as crepitus, may often be present. Clinical examination is necessary to determine any deviation from the normal function of masticatory system. Clinical evaluation includes the assessment of pain during the palpation of masticatory muscles, joint palpation, detection of limitations and interferences during functional jaw movements, as well as assessment of occlusion. It is very important to note which of the movements cause pain and the occurrence of clicking sounds or crepitus (3). Research Diagnostic Criteria for Temporomandibular Disorders RDC / TMD, or its newer, improved version DC / TMD, enables standardization of the most common forms of TMD associated with muscles and joints (4). Since the clinical signs and symptoms are not always the clearest indication of the presence of degenerative joint disease, correct diagnosis is mandatory by critical clinical evaluation supported by imaging. Computerized tomography (CT) and cone-beam CT (CBCT) allow accurate visualization of bone structures and hard tissues. CBCT is a promising new method to visualize hard-tissue changes with a relatively low radiation dose. Magnetic resonance imaging (MRI) is of great importance in the diagnosis of dislocation of the disc (5). Conventional radiolographs, for instance a panoramic radiograph, can display advanced destruction of bone tissue in the form of flattening, however, is not sufficiently detailed method for evaluating the severity of OA. Imaging of an osteoarthritic joint typically shows osteophytes, erosion and subcortical pseudocyst (6). The diagnosis of osteoarthritis is still a challenge because of the weak association between severity of symptoms and radiographic evidence of destruction of the joint (7).

Treatment of TMJ OA can be divided into non-invasive treatment and invasive treatment that include surgery as well as application of various agents into the joint. Recently, we have witnessed the increasing popularity of invasive methods, regardless of scarce scientific evidence of their effectiveness (1). Non-invasive treatments include patient education about different relaxation techniques, physical therapy, interocclusal appliances, and other methods that help in alleviating symptoms. The most common and effective medications used for TMD management are NSAIDs, that have well pain-relieving properties. Stabilization splint is the treatment of choice for pain control in temporomandibular disorder (TMD) patients (2). The appliance changes the position of mandibular condyles and increases the vertical dimension, so these effects may lead to muscle relaxation and a reduction of pain of myofacial origin and TMJ arthralgia. Despite the impossibility of direct action on OA, stabilization splint can contribute to the reduction of the impact of various risk factors to the joint (8, 9).

Minimally invasive procedures include methods that comprise application of corticosteroids, local anesthetics, plasma rich growth factors (PRGF) (10, 11) into the joint, as well as artrocentesis (removal of inflammatory exudate) in combination with hyaluronic acid injections. Invasive or surgical therapy plays a small but important role in the treatment of OA, particularly in patients who do not respond to less invasive therapies. The real proof of the effectiveness of invasive methods in the treatment of TMJ is very scarce (12).

A large number of studies have reported a relationship between the frequency and progression of osteoarthritis and age. This is because of the cumulative exposure of temporomandibular joint to a number of biological changes associated with aging. Aging increases the level of calcium in the articular disk and therefore it becomes stronger, but less elastic and less able to handle overload (2, 13). However, severe cases of osteoarthritis may be found in a much younger population, particularly women of around 35 years of age. A majority of those patients reported macrotrauma in the medical history (2, 14, 15). In addition, it is considered that the female reproductive hormones play a special role in the development of OA, especially estrogen, which influences the catabolism of cartilage-fibrous tissue of the joint (16).

The aim of this study was to review the goals and possibilities of conservative treatment of OA as well as to show how severe cases of OA can also be found in younger population. This contributes to the description of osteoarthritis as etiologically and pathophysiologicaly not quite clear condition which initiation is complex and depends on many external and internal risk factors. We report on a young, 21-year-old woman with signs and symptoms of degenerative changes of TMJ.

CASE REPORT:

The 21-year-old patient was referred to the Department of Prosthodontics, School of Dental medicine at the University of Zagreb in 2013 because of pain in front and in the right TMJ, which increased during mandibular movements. Medical history revealed that 3 months ago, the patient was involved in a traffic accident where she suffered a strong blow to the head. Since then difficulties while opening and pain during the normal functional movements and mastication were present.

Clinical diagnostics

Palpation of the masticatory muscles did not provoke pain, but palpation of the lateral pole and provocation tests (opening and protrusive movements) produce report of “familiar pain”. Crepitus of the right TMJ was detected with palpation.

During clinical examination limitation in mouth opening was found, with unassisted opening of 22 mm. The application of mild force in the direction of the mouth opening failed to increase the opening of more than 2 mm (Figure 1). During mouth opening, uncorrected deviation to the right side was present.

Figure 1.

– Patient is pointing the area of pain during limited mouth opening.

Patient reported pain in the right TMJ during left lateral excursion. Left lateral movement. was 8 mm, while the right lateral movement was 11 mm, and was carried out without pain. The amount of protrusion was 6 mm (Figure 2). Opening and protrusion provoked a report of "familiar pain." Patient self-assessed the level of pain using visual-analog scale (VAS = 0-10) as VAS = 7. During lateral movements crepitus in the right TMJ was detected.

Figure 2.

– The protrusion of 6 mm.

Dental status

Clinical examination and analysis of panoramic radiograph revealed that the patient's teeth were treated previously and were without prosthodontic restorations. In the transversal plane there was a 3 mm displacement of the medial line. Interdental spacing was present. The teeth 18, 28, 48 were erupting, while the tooth 38 was missing. Vertical overbite and horizontal overjet amounted to 4 mm.

Panoramic radiograph showed flattening of the right condyle (Figure 3 a and b). Since panoramic radiograph has limited display options of the degree and severity of bone destruction, the diagnosis of osteoarthritis of the TMJ (RDC / TMD criteria, Axis I, Group III) was confirmed by recording TMJ CBCT. On a three-dimensional view of the right joint (CBCT), taken in closed and open mouth positions, it was evident that during the opening the condyle did not reach to the articular eminence indicating joint hypomobility that was clinically manifested as limited range of mouth opening (Figure 4). This indicated the possibility of the disc dislocation. However, by using CBCT technology it is not possible to estimate the position of the articular disc (12, 17, 18). Therefore it was not possible to confirm the disc dislocation as the cause of joint hypomobility.

Figure 3a.

– Panoramic radiograph showing flattening of the right condyle.

Figure 3b.

– Enlarged view of the joint affected by osteoarthritis.

Figure 4.

– Osteoarthritic changes of the TMJ on CBCT.

Treatment

The patient was instructed to restrict the jaw movement to within painless limits. Instructions were provided for physical therapy to be employed during the day. The treatment protocol consisted of a self–administered exercises: passive muscle stretching (patient was encouraged to open on a straight opening pathway by looking in the mirror), and assisted muscle stretching (patient was instructed to apply gentle force to the elevator muscles with the fingers, in order to increase the amount of mouth opening) (Figure 5). After 2 weeks patient reported significant relaxation of masticatory musculature. Stabilization splint is fabricated in the therapeutic centric relation position with increase of the vertical dimension of occlusion of 2 mm. Patient was instructed to wear a splint during night (Figure 6).

Figure 5.

– One of the treatment protocol considering self-administered exercises was assisted muscle stretching. Patient was instructed to apply gentle force to the elevator muscles with the fingers, in order to increase the amount of mouth opening.

Figure 6.

– Stabilization splint fabricated in physiological, centric relation position enabled relief of the masticatory system and helped in relaxation of muscles acting as deprogrammer of the neuromuscular system; uniform contacts of teeth in the centric relation position with increase of the vertical dimension of occlusion of 2 mm were present.

After- care

Follow up appointments were carried out at 1st, 3rd and 6th month of wearing the splint. At follow-up appointment after 6 months of regular wearing the splint the patient reported improvement of symptoms. Unassisted opening amounted to 35 mm while assisted opening amounted to 41 mm (Figure 7 a and b). Lateral movements were symmetrical (Figure 8 a and b). Occasional pain was still present only during chewing hard food (VAS = 2). Palpation of the lateral condyle pole was not painful.

Figure 7a.

– After 6 months unassisted opening amounted to 35 mm.

Figure 7b.

– After 6 months assisted opening amounted to 41 mm.

Figure 8.

– a & b Symmetrical lateral movements.

At a 3-year recall appointment, in November 2016, the patient reported that by regular wearing a splint at night, pain occurs very rarely and only during chewing gum. However, if a splint is worn only occasionally, the headaches begun as well as difficulties while chewing hard food. Clinical examination showed mild uncorrected deviation during the opening, and the crepitus was still felt in the right joint.

DISCUSSION

Osteoarthritis of the temporomandibular joint entails different variations in the pathophysiology, epidemiology, and progression of the disorder as well as signs and symptoms. It is important to mention that progression from the onset of symptoms and signs to clinically significant joint destruction may take years, but it can also happen very quickly (2). Because of the diverse range of incidence and manifestations, OA remains a condition whose diagnosis and treatment are the subject of discussion and research. Some methods, which include the application of corticosteroids, hyaluronic acid or the PRGF in the area of TMJ, at first glance offer rapid improvement of symptoms.

The question that arises is whether invasive methods can achieve better results than conservative therapeutic approaches (non-invasive methods) as well as how much are such therapeutic methods supported by scientific evidence of actual efficacy.

We presented young patient with severe osteoarthritic changes accompanied by pain and limited mouth opening that emerged after macrotrauma. The primary therapeutic goal was to resolve the pain and to increase the range of motion. Patient was treated with the combination of physical therapy and stabilization splint At 6 months follow up patient reported improvement of symptoms. At a 3-year recall appointment the patient still had no significant symptoms. Clinical examination revealed crepitus in the right TMJ and mild uncorrected deviation during the opening, however, such a finding is not a problem for normal functioning of the patient.

When thinking of other therapeutic methods such as the application of various therapeutic agents in the area of the joint, it can be seen that research presented e.g. application of PRGF in the joint did not give significantly different results compared to conservative, non-invasive methods. After PRGF application, Giacomello et al. an increase of 9.38 mm in the range of mouth opening after 6 months was found (10). Patient presented in our study, presented the increase in the range of, mouth opening of 13 mm. Regardless of the success of the methods comprising application of the PRGF in the joint, the question arises, whether those improvement would be permanent and whether it makes sense to use invasive methods and penetrate the joint area if calm state and function improvement can be achieved through less invasive methods. It is evident from the case of a young patient, presented in our study, that complete absence of pain was also managed by conservative methods, and the range of motion is almost completely recovered and was no longer a problem to the patient.

It is also important to note that the 21-year-old patient had experienced macrotrauma which might be the trigger for the development of symptoms. Since this was a whiplash injury, symptoms could be the result of the muscles in reactive spasm, and osteoarthritis could be an incidental finding that does not present problems to the patient other than crepitus. Crepitus is the only distinctive criterion of clinical analysis for the diagnosis of osteoarthritis, and it's a direct result of the friction between the bone surfaces (3). The incidence of crepitus in older adolescents and young adults is 12.5%, as stated Solberg et al. (19). Given the fact that patient also presented a mouth limited opening, it could be suspected the disc displacement precede osteoarthritis (1). However, to confirm a diagnosis of disc displacement without reduction a positive MRI is required (17).

CONCLUSION

We report on a 21-year-old woman with osteoarthritis of TMJ with a 3-year follow-up. Based on the case of a presented patient, we can conclude that OA of TMJ, in some cases, responds well to the non-invasive therapy. The task of the clinician is to identify the symptoms, relieve the pain in order to help the patient to achieve normal everyday life and slow the progression of osteoarthritis. The authors concluded that conservative treatment including counseling, exercises, occlusal splint therapy etc. should be considered as a first choice therapy, and in most cases the only therapy, for TMD pain because of their low risk of side effects.

When thinking about treatment of TMD invasive methods should be considered only in small percentage of patients that do not respond to less invasive therapy.

Symptomatic forms of osteoarthritis can also occur in younger age groups.