Morbidity after temporomandibular joint arthrography is lower than after removal of lower third molars Per-Lennart Westesson,DDS, PhD,a and Lars Eriksson, DDS, PhD,b Malmii and Lund, Sweden UNIVERSITY
OF LUND,
SCHOOL OF DENTISTRY,
AND UNIVERSITY
HOSPITAL
The morbidity after temporomandibular joint arthrography was studied as the amount of pain, use of pain medicine, and disturbed sleep and was compared with the morbidity after removal of lower third molars. The morbidity was substantially higher after surgery than after arthrography. It was concluded that the morbidity after arthrography can be kept at a low level and that it should not restrict the indications for this examination. (ORAL SURC ORAL MED ORAL PATHOL 1990;70:2-4)
T
emporomandibular joint arthrography’ has been said to be a painful procedure associatedwith significant morbidity. **3This is not in accordance with our clinical experience, becausemost of our patients have had only minimal discomfort after arthrography. Similar findings have been suggested in a recent study.4 To assessmorbidity after temporomandibular joint arthrography, we registered pain, use of pain medicine, and frequency of sleep disturbance because of pain after arthrography and compared this with the morbidity after removal of a lower third molar. PATIENTS
AND METHODS
The patients consisted of 10 men (mean age, 26 years; range, 21 to 34 years) and 10 women, (mean age, 21 years; range, 20 to 44 years). The patients were selected as described previously536 from those referred to the Department of Oral Surgery, University Hospital of Lund, for removal of lower third molars. Thus persons with asymptomatic and clinically normal temporomandibular joints and masticatory muscles were asked to volunteer for unilateral temporomandibular joint arthrograms.
aDepartment of Oral Radiology, University of Lund, School of Dentistry, Malmii, Sweden. bDepartment of Oral Surgery, University Hospital, Lund, Sweden. 7/12/30723
2
Arthrography was performed in a standardized way as dual-space, double-contrast arthrotomography7 with injection of contrast medium (iohexol [Omnipaque], 300 mg iodine per milliliter) and air into both upper and lower joint spaces.All arthrograms were performed by one of us (P. L. W.). Reaspiration after arthrography was not performed. Removal of the lower third molars was performed by the other author (L. E.) in a standardized way, with a mucoperiosteal flap from the distal part of the lower first molar to the distal part of the lower third molar. Bone was removed lateral to the third molar, the tooth was separated and removed, and the mucoperiosteal flap was sutured. Degree of pain was registered by the patient on 100 mm visual analog scales with 0 and 10 as end points. Marking was performed once.a day, starting the day after arthrography/removal of the lower third molar and continuing until the pain disappeared. The distance from 0 to the patient’s mark was measured to the nearest millimeter. The total number of tablets taken for pain during the entire postoperative period was noted. The frequency of sleep disturbance caused by pain was registered. Arthrography was performed first and the lower third molar was removed after about 1 month. RESULTS
The day after arthrography 11 of the 20 patients had no pain, whereas all patients had symptoms after
Morbidity after TMJ arthrography
Volume 70 Number 1
Table I. Degree of pain after temporomandibular joint arthrography and after removal of a lower third molar (n = 20 patients) Time after arthrography and surgery, respectively Pays) 1 2 3 4 5
II. Number of patients who rated pain more than 10 mm on a 100 mm analog scale after temporomandibular joint arthrography and after removal of a lower third molar (n = 20 patients)
Table
Time after arthrography and surgery, respectively Pays) 2 1 1 1 0
22 17 13 12 10
3
1 2 3 4 5
No. of patients Arthrography 1 1 1 1 0
Surgery 14 14 10 9 5
Data are means on a 100 mm visual analog scale
removal of the lower third molar. The degree and frequency of pain were greater after surgery than after arthrography (Tables I and II). All patients used analgesics after removal of the tooth (mean, 10 tablets; range, one to 29 tablets) compared to none of the patients after arthrography. Five patients reported disturbed sleep becauseof pain after surgery, and none had this problem after arthrography. Three patients were absent from work 2 days each because of symptoms after removal of a lower third molar. This did not occur after arthrography. DISCUSSION
The limitations and difficulties in assessingsubjective morbidity are recognized. For this reason, we performed the assessmentof morbidity after arthrography on a group of patients in whom also a lower third molar was going to be removed. In this way we could compare the morbidity after the two procedures within the same person and document the morbidity after temporomandibular joint arthrography in relation to a more well-known procedure. A drawback of this design is the use of persons with asymptomatic joints. Patients with temporomandibular joint disorders might behave differently. Arthrography has long been accepted as a tool for diagnosis of internal structures of joints of the body in general, but temporomandibular joint arthrography has only recently gained acceptance.Some of the reluctance to use temporomandibular joint arthrography can be traced to a general opinion that this examination is painful and may cause substantial discomfort and morbidity.2 Our study does not support this general opinion and suggests that the morbidity after temporomandibular joint arthrography can be kept at a low level. This is also in accordance with suggestions in o;her recent studies.8,9 The lower morbidity found in recent series compared with the older reports2 may be the result of
refined techniques for cannulation of the joint compartments with an image intensifierlO I ’ and improved contrast materials. The use of an image intensifier greatly facilitates joint puncture and also permits visualization of the injection phase. Thus overdistension, which might be one source of pain after arthrography, can be avoided. The influence of iodine content and type of contrast medium on pain has previously been pointed out.‘, 3 A higher iodine concentration has usually been associated with more pain after the examination, whereas a lower concentration reduces the quality of the resulting radiographs. Omnipaque medium, used in our study, is a nonionic watersoluble iodine contrast medium that to some degree overcomesthese disadvantages. This type of nonionic contrast medium has a low toxicityI and lower osmolality than the previously used monomeric ionic contrast medium.13 In experimental studies on arthrography of the knee in rabbits, this type of contrast medium has caused less joint effusion than other contrast media and it was concluded that it seemsto be superior for arthrography.14 In conclusion, this study demonstrated that the morbidity after temporomandibular joint arthrography can be kept at such a low level that it should not restrict the indications for this examination. Supported by the Swedish Medical Research Council (project No. 6751) and the Torsten and Ragnar Siiderbergs Foundations, Stockholm, Sweden. Nyegaard & Co A/S, Oslo, Norway, is acknowledged for providing the contrast medium used in this investigation. REFERENCES 1. Norgaard F. Temporomandibular arthrography. Thesis. Copenhagen: Munksgaard, 1947:42-5. 2. Campbell W. Clinical radiological investigations of the mandibular joints. Br J Radio1 1965;38:401-21.
4
Westessonand Eriksson
3. Toiler PA. Opaque arthrography of the temporomandibular joint. Int J Oral Surg 1974;3:17-28. 4. Lydiatt D, Kaplan P, Tu H, Sleder P. Morbidity associated with temporomandibular joint arthrography in clinically normal joints. J Oral Maxillofac Surg 1986;44:8- 10. 5. Westesson P-L, Eriksson L, Kurita K. Temporomandibular joint: variation of normal arthrographic anatomy. ORAL SURG ORAL MED ORAL PATHOL 1990;69:5 14-9. of a 6. Westesson P-L, Eriksson L, Kurita K. Reliability negative clinical temporomandibular joint examinationprevalence of disk displacement in asymptomatic temporomandibular joints. ORAL SURG ORAL MED ORAL PATHOL 1989;68:551-4. of the 7. Westesson P-L. Double-contrast arthrotomography temporomandibular joint: introduction of an arthrographic technique for visualization of the disc and articular surfaces. J Oral Maxillofac Surg 1983;41: 162-72. 8. Blaschke DD, Solberg WK, Sanders B. Arthrography of the temporomandibular joint: review of current status. J Am Dent Assoc 1980;100:388-95. 9. Katzberg RW, Dolwick MF, Helms CA, et al. Arthrotomography of the temporomandibular joint. AJR 1980;134:9951003. 10. Lynch TP, Chase DC. Arthrography in the evaluation of the temporomandibular joint. Radiology 1978;126:667-72.
ORAL SURG ORAL MED ORAL PATHOL July 1990 1 I. Wilkes CH. Arthrography of the temporomandibular joint in patients with the TMJ pain-dysfunction syndrome. Minn Med 1978;61:645-52. 12. Gonsette RE. Biological tolerance of the central nervous system to metrizamide. Acta Radio1 [Suppl] (Stockh) 1973; (suppl):25-44. 13. Johansen JG. Experimental and clinical investigations of a non-ionic water-soluble contrast media (Amipaque). With special reference to application into body cavities and gastrointestinal tract. Thesis. Oslo: Universitv of Oslo. 1979:1-l 8. 14. Johanscn JG. Berner A. Arthrography’with Amipaque (metrizamide) and other contrast media. A roentgenographic and histologic evaluation in rabbits. Invest Radio1 1976;l 1:53440. Reprint requests to: Dr. Per-Lennart Westesson Department of Radiology University of Rochester School of Medicine and Dentistry Box 648 Rochester. NY 14642
OF LUND,
SCHOOL OF DENTISTRY,
AND UNIVERSITY
HOSPITAL
The morbidity after temporomandibular joint arthrography was studied as the amount of pain, use of pain medicine, and disturbed sleep and was compared with the morbidity after removal of lower third molars. The morbidity was substantially higher after surgery than after arthrography. It was concluded that the morbidity after arthrography can be kept at a low level and that it should not restrict the indications for this examination. (ORAL SURC ORAL MED ORAL PATHOL 1990;70:2-4)
T
emporomandibular joint arthrography’ has been said to be a painful procedure associatedwith significant morbidity. **3This is not in accordance with our clinical experience, becausemost of our patients have had only minimal discomfort after arthrography. Similar findings have been suggested in a recent study.4 To assessmorbidity after temporomandibular joint arthrography, we registered pain, use of pain medicine, and frequency of sleep disturbance because of pain after arthrography and compared this with the morbidity after removal of a lower third molar. PATIENTS
AND METHODS
The patients consisted of 10 men (mean age, 26 years; range, 21 to 34 years) and 10 women, (mean age, 21 years; range, 20 to 44 years). The patients were selected as described previously536 from those referred to the Department of Oral Surgery, University Hospital of Lund, for removal of lower third molars. Thus persons with asymptomatic and clinically normal temporomandibular joints and masticatory muscles were asked to volunteer for unilateral temporomandibular joint arthrograms.
aDepartment of Oral Radiology, University of Lund, School of Dentistry, Malmii, Sweden. bDepartment of Oral Surgery, University Hospital, Lund, Sweden. 7/12/30723
2
Arthrography was performed in a standardized way as dual-space, double-contrast arthrotomography7 with injection of contrast medium (iohexol [Omnipaque], 300 mg iodine per milliliter) and air into both upper and lower joint spaces.All arthrograms were performed by one of us (P. L. W.). Reaspiration after arthrography was not performed. Removal of the lower third molars was performed by the other author (L. E.) in a standardized way, with a mucoperiosteal flap from the distal part of the lower first molar to the distal part of the lower third molar. Bone was removed lateral to the third molar, the tooth was separated and removed, and the mucoperiosteal flap was sutured. Degree of pain was registered by the patient on 100 mm visual analog scales with 0 and 10 as end points. Marking was performed once.a day, starting the day after arthrography/removal of the lower third molar and continuing until the pain disappeared. The distance from 0 to the patient’s mark was measured to the nearest millimeter. The total number of tablets taken for pain during the entire postoperative period was noted. The frequency of sleep disturbance caused by pain was registered. Arthrography was performed first and the lower third molar was removed after about 1 month. RESULTS
The day after arthrography 11 of the 20 patients had no pain, whereas all patients had symptoms after
Morbidity after TMJ arthrography
Volume 70 Number 1
Table I. Degree of pain after temporomandibular joint arthrography and after removal of a lower third molar (n = 20 patients) Time after arthrography and surgery, respectively Pays) 1 2 3 4 5
II. Number of patients who rated pain more than 10 mm on a 100 mm analog scale after temporomandibular joint arthrography and after removal of a lower third molar (n = 20 patients)
Table
Time after arthrography and surgery, respectively Pays) 2 1 1 1 0
22 17 13 12 10
3
1 2 3 4 5
No. of patients Arthrography 1 1 1 1 0
Surgery 14 14 10 9 5
Data are means on a 100 mm visual analog scale
removal of the lower third molar. The degree and frequency of pain were greater after surgery than after arthrography (Tables I and II). All patients used analgesics after removal of the tooth (mean, 10 tablets; range, one to 29 tablets) compared to none of the patients after arthrography. Five patients reported disturbed sleep becauseof pain after surgery, and none had this problem after arthrography. Three patients were absent from work 2 days each because of symptoms after removal of a lower third molar. This did not occur after arthrography. DISCUSSION
The limitations and difficulties in assessingsubjective morbidity are recognized. For this reason, we performed the assessmentof morbidity after arthrography on a group of patients in whom also a lower third molar was going to be removed. In this way we could compare the morbidity after the two procedures within the same person and document the morbidity after temporomandibular joint arthrography in relation to a more well-known procedure. A drawback of this design is the use of persons with asymptomatic joints. Patients with temporomandibular joint disorders might behave differently. Arthrography has long been accepted as a tool for diagnosis of internal structures of joints of the body in general, but temporomandibular joint arthrography has only recently gained acceptance.Some of the reluctance to use temporomandibular joint arthrography can be traced to a general opinion that this examination is painful and may cause substantial discomfort and morbidity.2 Our study does not support this general opinion and suggests that the morbidity after temporomandibular joint arthrography can be kept at a low level. This is also in accordance with suggestions in o;her recent studies.8,9 The lower morbidity found in recent series compared with the older reports2 may be the result of
refined techniques for cannulation of the joint compartments with an image intensifierlO I ’ and improved contrast materials. The use of an image intensifier greatly facilitates joint puncture and also permits visualization of the injection phase. Thus overdistension, which might be one source of pain after arthrography, can be avoided. The influence of iodine content and type of contrast medium on pain has previously been pointed out.‘, 3 A higher iodine concentration has usually been associated with more pain after the examination, whereas a lower concentration reduces the quality of the resulting radiographs. Omnipaque medium, used in our study, is a nonionic watersoluble iodine contrast medium that to some degree overcomesthese disadvantages. This type of nonionic contrast medium has a low toxicityI and lower osmolality than the previously used monomeric ionic contrast medium.13 In experimental studies on arthrography of the knee in rabbits, this type of contrast medium has caused less joint effusion than other contrast media and it was concluded that it seemsto be superior for arthrography.14 In conclusion, this study demonstrated that the morbidity after temporomandibular joint arthrography can be kept at such a low level that it should not restrict the indications for this examination. Supported by the Swedish Medical Research Council (project No. 6751) and the Torsten and Ragnar Siiderbergs Foundations, Stockholm, Sweden. Nyegaard & Co A/S, Oslo, Norway, is acknowledged for providing the contrast medium used in this investigation. REFERENCES 1. Norgaard F. Temporomandibular arthrography. Thesis. Copenhagen: Munksgaard, 1947:42-5. 2. Campbell W. Clinical radiological investigations of the mandibular joints. Br J Radio1 1965;38:401-21.
4
Westessonand Eriksson
3. Toiler PA. Opaque arthrography of the temporomandibular joint. Int J Oral Surg 1974;3:17-28. 4. Lydiatt D, Kaplan P, Tu H, Sleder P. Morbidity associated with temporomandibular joint arthrography in clinically normal joints. J Oral Maxillofac Surg 1986;44:8- 10. 5. Westesson P-L, Eriksson L, Kurita K. Temporomandibular joint: variation of normal arthrographic anatomy. ORAL SURG ORAL MED ORAL PATHOL 1990;69:5 14-9. of a 6. Westesson P-L, Eriksson L, Kurita K. Reliability negative clinical temporomandibular joint examinationprevalence of disk displacement in asymptomatic temporomandibular joints. ORAL SURG ORAL MED ORAL PATHOL 1989;68:551-4. of the 7. Westesson P-L. Double-contrast arthrotomography temporomandibular joint: introduction of an arthrographic technique for visualization of the disc and articular surfaces. J Oral Maxillofac Surg 1983;41: 162-72. 8. Blaschke DD, Solberg WK, Sanders B. Arthrography of the temporomandibular joint: review of current status. J Am Dent Assoc 1980;100:388-95. 9. Katzberg RW, Dolwick MF, Helms CA, et al. Arthrotomography of the temporomandibular joint. AJR 1980;134:9951003. 10. Lynch TP, Chase DC. Arthrography in the evaluation of the temporomandibular joint. Radiology 1978;126:667-72.
ORAL SURG ORAL MED ORAL PATHOL July 1990 1 I. Wilkes CH. Arthrography of the temporomandibular joint in patients with the TMJ pain-dysfunction syndrome. Minn Med 1978;61:645-52. 12. Gonsette RE. Biological tolerance of the central nervous system to metrizamide. Acta Radio1 [Suppl] (Stockh) 1973; (suppl):25-44. 13. Johansen JG. Experimental and clinical investigations of a non-ionic water-soluble contrast media (Amipaque). With special reference to application into body cavities and gastrointestinal tract. Thesis. Oslo: Universitv of Oslo. 1979:1-l 8. 14. Johanscn JG. Berner A. Arthrography’with Amipaque (metrizamide) and other contrast media. A roentgenographic and histologic evaluation in rabbits. Invest Radio1 1976;l 1:53440. Reprint requests to: Dr. Per-Lennart Westesson Department of Radiology University of Rochester School of Medicine and Dentistry Box 648 Rochester. NY 14642
