Full text of DOI:10.1038/sj.bdj.4800381a

RESEARCH
TMD disorders
The value of patient feedback in the audit
of TMJ arthroscopy
1
2
D. R. P. Godden, and J. M. Robertson,
AimThis study assessed the patients’ and clinicians’ perception
of the outcome of temporomandibular joint arthroscopy.
Method All patients who underwent TMJ arthroscopy for both
diagnostic and therapeutic purposes over a 6-year period were
sent a questionnaire that asked about various symptoms
attributable to the TMJ. Additionally a review of the clinical notes
was performed.
Results 83 patients underwent arthroscopy to 127
temporomandibular joints. The mean follow up was 3.6 years.
55% of patients assessed their jaw function as being effective, jaw
ovial fluid may account for many of the symptoms and may explain
why arthrocentesis or arthroscopic wash out work. Despite con-
19
tinuing research into the efficacy of arthroscopy and despite the fact
that there is a wealth of information from the clinician’s view, there
is little detail focused on the patients’ perception of its success. The
aim of this study was to evaluate the success of arthroscopy by
means of both a patient questionnaire and a retrospective clinical
notes review. In addition, a comparison was made between the
patients who were found to have an irreducibly displaced meniscus
and those who had evidence of degenerative change only, to investi-
movement, pain control, and overall satisfaction were satisfactory gate which group did best.
in 37%, 57%, and 48% of cases respectively. The clinicians’
assessment revealed that 45% of patients had no joint tenderness,
Method
74% of patients were able to open to > 35 mm and 74% of patients This study was set in the Oral Surgery Department at Peterborough
were free of any joint noise. 66% of patients were prepared to
undergo a second procedure if indicated.
ConclusionOverall, 50% of patients seemed to view
arthroscopy favourably although many patients still felt that jaw
opening was restricted. The outcome was not related to the
District Hospital. All patients who underwent arthroscopy to the
TMJ between 1991 and 1996 were sent a questionnaire during 1997.
The format of this is described by Fridrich et al. It subjectively eval-
uated the perceptions of pain, joint noise, jaw mobility and func-
tion. It asked the patients whether they considered their surgery a
3
position and reducibility of the disc at surgery and other variables success and whether they were prepared to undergo surgery again if
may be responsible. The disparity between the clinical evaluation
and the patients’ perception of effectiveness emphasises the
importance of patient feedback.
required. The questions were in the form of a visual analogue scale
(VAS). To facilitate an assessment of the success of surgery, patients
have been placed into bands according to the score on the visual
analogue scale. The definition of success or failure is very much an
arbitrary judgement. We have chosen success if the score was within
nternal derangement of the temporomandibular joint (TMJ) is a 75% of normal and failure if the patient scored within 25% of
common problem in dental practice. The role of surgery in its grossly abnormal. Patients who scored the VAS between these values
I
management is controversial and the indications are relative rather are described as borderline.
1
than absolute. Similarly the definition of success in surgery of the
The clinical notes review recorded the presence of joint tender-
2
TMJ is difficult to quantify, although guidelines are available. The ness, the degree of mouth opening and the presence of joint noise.
use of an arthroscopic approach to the TMJ has become widely used In addition, the arthroscopic findings were recorded and these were
in the management of TMJ disorders. It provides minimally inva- compared with the patients’ perception of outcome.
sive access to the joint and while initially it was used as a diagnostic
Prior to arthroscopy all patients had received a period of conserv-
tool, more recently with the refinement of instrumentation it has ative management including, where indicated, the use of analgesics,
been used therapeutically and success rates following treatment tricyclic antidepressants and bite raising appliances. Arthroscopy
3–16
range from 50–100%.
Patients with painful limited opening was carried out when there was a significant degree of pain, hypo-
(closed lock) generally fare better than those with normal open- mobility, or joint noise. Dual port arthroscopy followed by lysis and
3,5,7,10,16
ing.
The reason for this is not clear, simple lavage and lysis lavage and instrument sweep of the superior joint space was per-
of the superior joint space without formal disc repositioning is suc- formed. Intra-articular triamcinalone was infused at the end of the
cessful, and consequently the importance of disc position has been procedure where significant synovial inflammation was found.
8,9,17,18
questioned.
Kircos has shown disc displacement in 30% of Patients were discharged with instructions to maintain a soft diet
18
asymptomatic volunteers following MR scanning. The identifica- for 1 week and to encourage active mouth opening with exercises
tion of the various chemical mediators of inflammation in the syn- after 24 hours.
Statistical analysis was performed using SPSS statistics package
on PC, statistical significance was determined at the 5% level.
1
Specialist Registrar, Department of Oral and Maxillofacial Surgery,
Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA;
2
Consultant, Department of Oral & Maxillofacial Surgery, Peterborough District
Results
Hospital, Thorpe Road, Peterborough PE3 6DA
During the study period a total of 110 patients underwent
arthroscopy. Ten patients could not be contacted by post because
Correspondence to: Mr D R P Godden, 3 Oak Coppice, Bolton BL1 5JD
REFEREED PAPER
of change of address. Of the remaining 100 patients, 83 patients
responded to the questionnaire. There were 68 female and 15 male
Received 19.04.99; accepted 13.10.99
© British Dental Journal 2000; 188: 37–39
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 1, JANUARY 8 2000
37

RESEARCH
TMD disorders
Number of patients
10
8
6
4
2
0
Fig. 1 Patient satisfaction —
‘rate your level of
satisfaction with the
operation’ n = 80, three
patients failed to score their
satisfaction with the surgery,
mean = 59.7, 0 = total failure,
100 = complete success
Patient operation satisfaction
patients. The mean age at surgery was 34.7 years (range 17–75
years). The mean follow-up period from surgery to questionnaire
was 3.6 years. Thirty-nine patients underwent unilateral
arthroscopy; 44 patients had a bilateral procedure, a total of 127
joints were arthroscoped. Five patients (6%) required subsequent
re-arthroscopy. The median conservative management period
prior to surgery was 5.5 months.
The responses received from the patients were clustered in the
middle and toward the satisfactory end of the scale, creating a
bimodal distribution for all the parameters recorded. This is shown
by the overall satisfaction response in Figure 1. Fifty-five per cent of
patients rated jaw function as being effective; jaw movement, pain
control, and overall satisfaction were in the satisfactory range for
37%, 57% and 48% of cases respectively (Table 1).
Table 1 VAS scores for all patients
Mean VAS scores
Success
Failure
Borderline
†
Pain
28.7
47 (57%)
43 (52%)
31 (37%)
46 (55%)
4 (5%)
32 (39%)
32 (39%)
47 (57%)
35 (42%)
25 (31%)
‡
Noise
34.3
8 (10%)
5 (6%)
2 (2%)
α
Movement
Function
Satisfaction*
36.5
β
27.4
γ
59.7
38 (48%) 17 (21%)
†
‡
n = 83, *n = 80, 0 = no pain, 100 = severe pain; 0 = no noise, 100 = extremely
α
β
loud noise; 0 = no restriction, 100 = extreme restriction; 0 = no restriction to
γ
chewing, 100 = liquid diet, unable to chew solids; 0 = total failure,
100 = complete success
Table 2 Mean VAS scores according to disc position
When the patients were asked if they were prepared to undergo
further arthroscopy again if warranted, 55 patients (66%) said yes,
8 patients (10%) said no and the remainder (24%) did not know.
At surgery 38 patients were found to have irreducible disc dis-
placement and 24 patients had degenerative changes. Degenerative
change includes adhesions, fibrillation, and chondromalacia. The
remaining 21 patients (25%) had normal or mixed findings during
a bilateral procedure. There was no statistical difference in the VAS
responses for any of the parameters measured between the two
groups (Mann-Whitney U Test, P > 0.05) (Table 2).
Degenerative change Irreducible disc
P-value*
mean value
mean value
Pain
31
39
36
30
58
26
31
32
21
63
0.36
0.23
0.50
0.14
0.52
Noise
Movement
Function
Satisfaction
†
†
*Mann Whitney U test, n = 83, n = 80
The clinical notes review revealed that following arthroscopy
there was an improvement in all the parameters recorded. The
absence of joint noise improved from 22% to 74%, 45% were free of
joint tenderness and 73% of patients could open to > 35 mm fol-
lowing arthroscopy (Table 3).
Table 3 Clinical evaluation pre- and post-arthroscopy
Pre-arthroscopy
Post-arthroscopy
Joint tenderness
Nil
7 (8%)
63 (76%)
13 (16%)
37 (45%)
38 (46%)
8 (10%)
Discussion
Mild
The success of arthroscopy is difficult to quantify accurately. The cri-
Severe
2
teria have been examined by Goss. The absence of pain is an ideal
Jaw opening > 35 mm
42 (51%)
61 (73%)
criterion, but a satisfactory outcome may be achieved if the pain is
significantly reduced in both intensity and frequency. The range of
opening should be 35 mm or more. While this is still restricted, it
correlates well with a subjective feeling of well-being. The absence of
joint sounds is an ideal criterion, however, it is frequently surgically
unobtainable. Joint sounds are so common in the population that
they can be considered a normal finding. Finally the patient should
Jaw noise
Nil
18 (22%)
58 (70%)
7 (8%)
61 (74%)
15 (18%)
7 (8%)
Soft
Loud
n = 83
38
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RESEARCH
TMD disorders
be able to achieve full jaw function without any restrictions. When mental evidence that degenerative changes can be induced by
21
the measures of pain and jaw function are used, success ranges from diagnostic arthroscopy, and because there is evidence that the
3,5–16
50%–100%.
Caution has to be exercised in any interpretation, natural history of this disorder is that of spontaneous improve-
22
as these studies often contain only small patient numbers, have lim- ment with time, it would be prudent to restrict arthroscopy to
ited follow up, and use differing criteria for success. those patients who benefit most. This study has attempted to eval-
With experience in the use of arthroscopy it has become apparent uate the patients’ attitude to the effectiveness of arthroscopy. It has
that patients with painful limited opening (closed lock) do better shown that there is a disparity between the patients’ perceived
when compared with patients who are able to achieve wider open- benefit and the clinician’s evaluation. On the face of it, disc posi-
3,5,7,9,10,15,16
ing.
The reason for this is not clear. The therapeutic tion did not influence outcome. To discover who benefits most,
success of arthroscopy may be caused by the removal of disc adhe- further investigation with a control group consisting of patients
sions, manipulation of the mandible during the procedure, joint who are managed conservatively is warranted.
wash out or the use of intracapsular steroid injection at the end of
15
1
2
3
Dolwick M F, Dimitroulis G. Is there a role for temporomandibular joint
surgery? Br J Oral Maxillofac Surg 1994; 32: 307-313.
surgery. Equally successful outcomes can be achieved by simple
3
arthrocentesis of the joint.
Goss A N. Towards an international consensus on temporomandibular
joint surgery. Int J Oral Maxillofac Surg 1993; 22: 78-81.
Fridrich K L, Wise J M, Zeitler D L. Prospective comparison of arthroscopy
and arthrocentesis for temporomandibular joint disorders. J Oral
Maxillofoc Surg 1996; 54: 816-820.
In the analysis of these results it is apparent that for all parameters
there was a bimodal distribution, suggesting that there are two
groups of patients within the sample. There is a fairly consistent
group of patients who did well in all the parameters recorded, and a
second group who tended to cluster in the middle. The reason for
this is not clear. It is recognised that respondents tend to score VAS
scales in the middle of the scale and avoid extremes. This would
introduce an element of bias. The distribution pattern did not seem
to be influenced by the reducibility of the disc. Other variables
which may influence outcome but which have not been studied here
include the degree of trauma on entry to the joint, age of the patient,
and psychiatric status. These variables may introduce flaws into the
methodology. The response rate for the questionnaire was high at
83%, and the sample size of 100 patients was adequate.
Analysis of the results reveals that while the clinical assessment
showed that 73% of patients were able to open to greater than
35 mm, the questionnaire found that only 37% rated jaw movement
as in the satisfactory range, suggesting that 35 mm is not enough.
In addition the clinical review indicated that 90% of patients had no
or only mild joint tenderness yet only 57% recorded that they had
satisfactory pain control on self-assessment. This highlights the fact
that there is a disparity between the impression of the clinician and
the perception of the patient. The routine use of a VAS in clinical prac-
tice would facilitate more accurate feedback, and their use in clinical
trials reduces the degree of subjectivity in assessment. Of the parame-
ters investigated nearly two-thirds of patients felt dissatisfied with the
degree of mandibular movement while pain, joint noise and overall
function were considered satisfactory in around one half of cases.
The direct comparison of these results with other studies should
be exercised with caution since like groups were not used. The
patients in this study received arthroscopy for diagnostic purposes
as well as for the therapeutic management of closed lock, they were
a much more mixed group than many of the other trials which
tend to restrict their investigation to the management of closed
lock patients alone. Despite the above, the questionnaire indicates
that around one half of patients perceive arthroscopy favourably
and two-thirds were prepared to undergo the procedure again.
Disc position did not influence outcome and this is in contradis-
tinction to other studies. One reason for this, as suggested by
4
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9
Nitzan et al. may be that disc position is not as crucial as previ-
ously thought. Of the parameters recorded, jaw movement gave
the most disappointing result.
The long-term effects of arthroscopy on the TMJ are not known.
It is speculated that arthroscopy of the TMJ may be similar to
arthroscopy of other joints such as the knee where there is an ini-
20
tial benefit but which is not long lasting. Because there is experi-
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