Treatment pathway for arthritis in the jaw with Mr Komath, Consultant Maxillofacial Surgeon, London.

Typical treatment pathway

For the majority of patients with such ailments, the treatment pathway begins with a thorough examination of the jaw joints, a medical history and a clinical assessment to eliminate any other causes of the pain or dysfunction being experienced. A CBCT is taken of the jaw, followed by an MRI scan in both the open and closed bite position to show dynamic movement of the joint. This would also demonstrate the presence or absence of inflammatory changes within the jaw joint, including inflammation within the synovium, whether there is free movement or restriction of the cartilage disc, large perforations of the disc, bone changes like bone spurs also called osteophytes, or inflammation within the marrow of the jaw joint.

These modern imaging modalities afford an unprecedented level of detail during the assessment stages and are integral to an accurate diagnosis. In some cases, they may also be accompanied by a bone scan to better examine abnormal growth. This initial assessment would determine the level of jaw joint degeneration, likely according to the Wilkes classification of TMD severity.

A patient would usually begin treatment in the form of specialist TMD physiotherapy, which can be very effective, sometimes in conjunction with acupuncture. Where the jaw joint is not arthritic, TMD may be also be treated with physiotherapy and botulinum toxin injections. Should the problems impact the joint alone, then a mandibular anterior repositioning splint may be indicated, which would be followed shortly thereafter by an arthroscopy procedure – as a day case. This involves accessing the jaw joint through two 1.9mm ports, washing out the joint, repairing it, repositioning the articular disc and/or co-ablating/cauterising any inflamed tissue. Once the disc is secured in the correct position, the joint is filled with platelet rich plasma (PRP) or bone marrow aspirate concentrate (BMAC), and the patient goes home the same day.

Post operatively, the patient would commonly use the splint provided immediately and commence physiotherapy within weeks after the surgery to aid recovery. This treatment sequence is effective in up to 85% of patients in controlling symptoms and restoring function. However, there are limits to what can be achieved with keyhole surgery and this is not always the end of the treatment pathway for the patient.

Case presentation

A female patient was referred to me with stage 4 arthritis in her jaw. She had already undergone one surgery several years prior to seeing me, but had experienced a relapse of symptoms and was in an incredible amount of pain every day. Though the arthritis had developed on the right side of her jaw, her pain occurred mostly in the left.

She presented for this round of treatment with terrible pain and diet scores, as well as severely restricted mouth opening. She had reported painful clicking of the jaw many times a day, which in turn was causing headaches. The patient was also unable to eat properly as chewing was painful and her malocclusion meant that she could not bite the teeth together.

A full assessment and treatment plan were completed, and the patient provided informed consent to proceed with a level II arthroscopy.

Treatment ensued as described above to access the jaw joint in a minimally invasively way. The joint was washed out and inflamed tissue co-ablated, before PRP was packed into the wound to aid healing. Due to the severity of the arthritis in the jaw, this patient was advised that further intervention would likely be required.

The gold standard treatment for end stage arthritis is replacement of the jaw joint. However, as this is a more invasive and comprehensive procedure, the goal is always to delay such a step with temporarily improved jaw function and quality of life until further intervention is absolutely necessary – hence focusing on the keyhole jaw joint surgery, splints, analgesics and physiotherapy for as long as possible. Jaw joint replacement surgery is offered only once everything else has been tried – at this point it is the patient’s decision whether to move onto comprehensive surgery. If their pain is too high or function too low, they will often move forward to this stage of treatment. It’s important to realise that this can impact patients of all age groups as well; I have treated 26 to 80-year-olds in this way.

The patient is currently still recovering from surgery. She has improved quality of life compared to before treatment, with significantly reduced discomfort and no more painful clicking of the jaw which she previously felt so often. However, her mouth opening remains small and this has come to affect her ability to chew she awaits physiotherapy following surgery.

Diagnosis for GDPs

There are many diagnostic pointers for GDPs to look out for when it comes TMD, no matter what the cause may be. These would include closed lock joint, crepitus or changes in bite. Regarding early symptoms of disease in the jaw, preauricular tenderness may be a sign of synovitis, which can occur in association with arthritis and may lead to jaw joint degeneration over time. Patients with end stage disease will often report feeling like their jaw “doesn’t fit” as their bite changes significantly.

Wherever TMD is suspected, patients should be referred for specialist assessment as early as possible. The case presented here demonstrates the surgical treatment pathway available to those in significant pain or with minimal function, but this should not, and usually is not, the starting point.