Dentomaxillofacial Radiology (2007) 36, 155159 q 2007 The British Institute of Radiology http:/ /dmfr.birjournals.

org

RESEARCH

Baseline clinical and radiographic features are associated with long-term (8 years) signs/symptoms for subjects with diseased temporomandibular joint
H Kurita*, S Uehara, C Zhao, Z Zhiyong, H Miyazawa, T Koike and K Kurashina
Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Matsumoto, Japan

Objectives: The purpose of this study was to determine the extent to which baseline clinical and radiographic features were associated with long-term outcomes in patients with temporomandibular joint disorder (TMJD). Methods: 49 patients with unilateral radiographically proven TMJD were available in this study. Self-reported long-term (mean 96.2 months) outcomes (current joint pain, maximum mouth opening and joint noise) after TMJD treatments were assessed by questionnaire. The impact of multiple initial clinical/radiographic ndings (gender, age at rst visit, time interval between rst visit and questionnaire survey, treatment method, disc displacement, disc morphology, disc mobility, condylar bony change and morphology of the articular eminence) on the long-term outcomes was assessed using stepwise multiple regression and logistic regression analysis. Results: Patient age at the rst visit was signicantly correlated with current joint pain. Disc mobility and morphology of the articular eminence were signicantly correlated with current range of maximal mouth opening. Conclusions: The results of this study suggest that patients who appeared symptomatic at a younger age or who initially had a xed disc were the most likely to have recurrent or persisting clinical signs/symptoms of TMJD after 8 years. Dentomaxillofacial Radiology (2007) 36, 155159. doi: 10.1259/dmfr/46387630 Keywords: long-term prognosis, temporomandibular joint (TMJ) disorder, radiological nding, predictor Temporomandibular joint (TMJ) disorder, which includes internal derangement and osteoarthritis/osteoarthrosis (OA), has a multifactorial nature that sometimes causes joint pain, joint sounds and/or difculty in mouth opening. TMJ disorder is thought to be a non-progressive and selflimiting disease. Previous studies have suggested that major signs and symptoms of TMJ disorder tended to decrease with time and that long-term (more than 2 years) outcome is favourable in most of the cases with or without intervention.1 11 It is thought that patients with TMJ disorders experience very little discomfort, if any, in the long run. However, it is also true that some patients have complained of persisting joint pain, restrictions in mouth opening or recurrence or are-up of TMJ symptomatology.8,10 Previously, Yatani et al studied the long-term
*Correspondence to: Hiroshi Kurita, DDS, PhD, Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 3908621, Japan; E-mail: hkurita@hsp.md.shinshu-u.ac.jp Received 20 January 2006; revised 8 May 2006; accepted 18 June 2006

results of treatments for temporomandibular disorders and reported that 12.3% of patients reported a lack of improvement of TMJ signs/symptoms.8 Several imaging studies have shown that radiographically visible degenerative changes to TMJ components occurred frequently in the joints with TMJ disorders.12 16 Radiographic changes may reect ongoing and/or past destructive or adaptive pathological changes of the TMJ hard and soft tissues. The presence of these changes may inuence the short- and long-term prognosis. However, little information has been published about the factors that inuence the longterm results of TMJ disorder. Therefore, the purpose of this study was to determine the extent to which baseline clinical and radiographic features were associated with long-term outcomes in patients with TMJ disorder. Materials and methods A questionnaire assessment of long-term results in signs/ symptoms concerning TMJ disorder was carried out for all 181 patients (148 women and 33 men, with a mean age of

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30.2 ^ 18.9 years) who had undergone MRI of TMJ during the period between July 1991 and December 2000. In this period, the patients who had symptomatic closed lock and those who were suspected to have reducible disc displacement with signs/symptoms other than joint clicking were encouraged to undergo MR examination. The radiological examinations were carried out within a few weeks of the rst visit. The patients were assessed for disc displacement, disc morphology, mobility of the disc, OA change of the condyle and morphology of the articular eminence using MRI and conventional radiography. MRI was performed as described by Kurita et al.17 Disc displacement was dened as previously reported.17,18 Disc morphology was claried in the closed-mouth projection in the sagittal plane and categorized as either normal (biconcave), biplanar, convex, folded, or amorphous.19,20 The mobility of the disc was determined in the closed- and open-mouth projection in the sagittal plane. The disc was classied as mobile if the disc changed its position relative to the glenoid fossa and the articular eminence. Lack of change in the position was classied as xed.18 OA change of the condyle was considered to be present if erosive and/or proliferative changes, including attening, spurring or eburnation, were found in the sagittal MR images of TMJ.14 The morphology of the articular eminence was classied into two types, the box/sigmoid type and the attened/deformed type, according to the criteria reported previously.17 Each image was evaluated separately by a trained radiologist and one of the authors (HK). Any disagreements were discussed until consensus was reached. A questionnaire assessment of patient-based clinical signs/symptoms of TMJ disorder was carried out by mail. The patients were asked for their current condition concerning the degree of joint pain, range of maximal mouth opening and presence or absence of joint noise. The degree of joint pain was scored using a visual analogue scale (VAS; no pain: 0; to severe pain: 100). To accurately assess the range of mouth opening, a triangular section of cardboard was enclosed with the questionnaire together with instructions on how to place the card vertically to measure the interincisal distance (Figure 1). The patients were also asked for presence or absence of current joint noise. The relationships between the results of the questionnaire survey and baseline clinical ndings (gender, age at rst visit, treatment method and time interval between the rst visit and questionnaire survey) as well as radiographic ndings (disc displacement, disc morphology, mobility of disc, OA change of the condyle and morphology of the articular eminence) were analysed. Stepwise multiple regression analysis was employed to analyse relationships between either current VAS quantitative joint pain or a range of maximal mouth opening and the multiple baseline clinical/radiographic variables. A stepwise logistic regression model was employed to analyse the relationship between current joint noise and the multiple baseline clinical/radiological variables. Scores for multivariate analyses are summarized in Table 1. Analyses were performed using computer software (StatView 5.0, SAS Institute Inc., NC). All P-values less than 0.05 were considered statistically signicant.
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Figure 1 Method to assess the range of mouth opening in mail questionnaire. A triangular section of cardboard was enclosed with the questionnaire together with instructions on how to place the card vertically to measure the interincisal distance

Results Out of 181 subjects who were mailed the questionnaire, 59 patients (32.6%) responded. Since it is difcult to identify the symptomatic side in patients with bilateral joint disorders, 10 patients with bilateral disorders were
Table 1 Summary of the distribution of clinical and radiological variables and given scores for multivariate analyses Variables Gender Male Female Age at rst visit (years) Treatment method Non surgical Surgical Time interval between rst visit and questionnaire survey (months) Disc displacement No displacement Reducible displacement Permanent displacement Disc morphology Biconcave Biplanar/biconvex Folded/amorphous Mobility of disc Mobile Fixed OA change of the condyle No change Erosive change Proliferative change Morphology of the articular eminence Box/sigmoid type Flattened/deformed type OA, osteoarthritic/osteoarthrotic Number of cases 6 43 42 7 Score for analysis 1 2 14 62 0 1 42 145

7 9 33 10 22 17 38 11 18 13 18 33 16

0 1 2 0 1 2 0 1 0 1 2 0 1

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Table 2 Results of the questionnaire survey on current sign/symptoms of TMJ disorders Joint pain No (VAS 0) Mild (VAS , 20) Moderate to severe (VAS $ 20) Maximum mouth opening Equal or more than 35 mm Less than 35 mm Unknown (missing data) Joint noise Absence Presence 24 patients (49.0%) 16 (32.6) 9 (18.4) 45 (91.8) 3 (6.1) 1 (2.0) 11 (22.4) 38 (77.6)

Table 4 Results of the stepwise multivariate analyses of the relationship between current sign/symptoms of TMJ disorders and clinical/radiographic ndings at rst visit Coefcient Standard error P-value VAS quantitative joint pain vs Age at rst visit 2 0.48 Maximum mouth opening (mm) vs Mobility of the disc 2 5.00 Morphology of the articular 3.33 eminence Joint noise (presence) vs Time interval between rst 0.03 visit and questionnaire survey Disc displacement 2 0.79 0.12 1.89 1.66 0.01 0.60 , 0.01 , 0.01 , 0.05 0.07 0.18

excluded and 49 patients who had been diagnosed with TMD in a unilateral joint were consequently analysed in this study; 43 were women and 6 were men. The mean age at the rst visit was 37.2 (SD 16.1) years, with a range of 14 62 years. The patients had undergone one or more treatment modalities, including a stabilization-type occlusal appliance in 30 patients, medication in 18 patients, a disc-repositioning type occlusal appliance in 11 patients, a disc-recapturing type occlusal appliance in 9 patients and arthroscopic surgery in 7 patients. Distributions of baseline clinical and radiographic ndings are summarized in Table 1. Of these, 34 patients were consequently satised with the result of the treatments (no or mild joint pain, mouth opening of more than 35 mm and a normal diet) and 6 patients were not. Another nine patients were lost to follow-up and their treatment results were unknown. The results of the questionnaire survey of current signs/symptoms of TMJ disorder are summarized in Table 2. The average interval between the rst visit and the time of the questionnaire survey was 96.2 (SD 27.3) months with a range of 42 145 months. 9 patients (18.4%) reported current moderate to severe joint pain (VAS $ 20), 3 patients (6.1%) reported restricted maximal mouth opening of less than 35 mm and 38 patients (77.6%) reported the presence of current joint noise. The relationship between the results of initial treatments and the results of the questionnaire survey of current signs/symptoms of TMJ disorder is shown in Table 3. In the patients who had been judged as successful with the initial treatments, six patients reported current joint pain and one patient reported a restricted mouth opening capacity. On the other hand, in the patients who had been judged as unsuccessful, only one patient reported current joint pain. The results of stepwise multivariate analyses are shown in Table 4. Patient age at rst visit was a signicant independent predictor for current joint pain. Patient age
Table 3

TMJ, temperomandibular joint; VAS, visual analogue scale

was a negative predictor and patients who appeared symptomatic at a younger age were likely to be complicated with current joint pain. Either mobility of the disc or morphology of the articular eminence was a signicant predictor for the current maximal mouth opening range. The patients who had a xed disc reported a smaller degree of maximal mouth opening, while the patients who had a attened/deformed type of articular eminence had a wider range of maximal mouth opening. On the other hand, there was no signicant relationship between current joint noise and the baseline clinical/radiographic ndings.

Discussion This study was carried out to analyse clinical and radiographic predictors for long-term outcome in signs/ symptoms of patients with TMJ disorder. This study included patients who had their TMJ examined with MR imaging. In our hospital, MR examination was intended for patients who were clinically suspected of having internal derangement of their affected TMJ and who had moderate to severe joint dysfunctions. The patients who had mild joint dysfunction (mild pain and/or mild restriction in mouth opening) and who had no symptoms other than joint clicking were not scanned and were therefore not included in this study. The results of this follow-up study show the long-term results of patients with TMJ disorder that produced moderate to severe joint dysfunction. It must be noted that some patients continued to complain of recurrent or persisting joint pain and limited mouth opening capacity.8,10 In the results of this study, 18.4% of patients reported current moderate to severe joint

Comparison between the results of initial treatments and of the questionnaire survey of current signs/symptoms of TMJ disorders Result of initial treatments Successful (34 patients) Unsuccessful (6 patients) 1 patient (16.7%) 0 5 patients (83.3%) Dropped out (9 patients) 2 patients (22.2%) 0 9 patients (100%)

Current signs/symptoms Moderate to severe joint pain (VAS $ 20) Restricted mouth opening (, 35 mm) Joint noise

6 patients (17.6%) 3 patients (8.8%) 24 patients (70.6%)

TMJ, temperomandibular joint; VAS, visual analogue scale

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pain, 6.1% of patients reported a restricted maximal mouth opening of less than 35 mm and 77.6% of patients reported the presence of current joint noise. At the end of the initial treatment, six patients were dissatised with the results of their treatment. However, in the questionnaire survey, all six patients reported to have good mouth opening capacity and only one patient reported to have current joint pain. This result suggested that most of the current signs/symptoms revealed by the questionnaire survey recurred after remission of the initial signs/symptoms of the TMD disorders. Yatani et al studied long-term results of treatments for temporomandibular disorders and reported that 12.3% of patients reported a lack of improvement in TMD signs/symptoms.8 The rate in the aforementioned study was similar to the current results, except for the higher prevalence of current joint noise. This population cannot be disregarded. The results of multivariate analysis showed that age at the patients rst visit was signicantly correlated with the long-term result of joint pain. Patient age was a negative predictor and patients who appeared symptomatic at a younger age had a poorer long-term result. The reasons why young patients had a higher risk for recurrent or persisting symptoms remain unclear. Some investigators reported a signicant correlation between the patients age and radiographically evident degenerative changes.21,22 Therefore, the pathological conditions might be different between young and old patients. On the other hand, some researchers have reported a signicant difference in complaints of craniomandibular disorder symptoms between the age groups.23,24 Most of the older patients did not complain of mild disorders.23 It was also reported that there was a relative decline by age in the prevalence of symptoms.24 At least, the results of this study suggested that patients who appeared symptomatic at a younger age were likely to have recurrent or persisting clinical signs/symptoms of TMJ disorders.
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It was also shown that patients who had a xed TMJ disc had a smaller degree of maximal mouth opening in the long-course of the TMJ disorder. Restricted mobility of the disc is considered one of the aetiologies for the signs/symptoms of TMJ disorders.18 Fixation of the disc to the articular fossa is thought to render the condyle incapable of sliding, resulting in restricted maximal mouth opening. It was unclear whether the disc was still xed at the time of questionnaire survey. If this condition was not resolved, it is easy to speculate that restriction of mouth opening capacity would remain. The pathological conditions that produce disc xation (i.e. synovitis or brosis of the synovial membrane) might also be responsible for a recurrent or persisting reduction in mouth opening capacity. On the other hand, patients who had attened articular eminence had a larger degree of maximal mouth opening in long-term TMJ disorder. It was reported that attening of the articular eminence, which was sometimes produced surgically, was related to an increase in rotation and a translatory movement of the condylar head.25 Steepness of the articular eminence was positively correlated with condyle translation in the joints with permanent disc displacement.26 Some researchers have reported that the articular eminence becomes attened with advancing stages of internal derangement.17,27 These results suggested that patients with attened eminence had a good prognosis for maximal mouth opening capacity. In conclusion, the results of this study suggest that patients who appeared symptomatic at a younger age or who initially had a xed disc were the most likely to have recurrent or persisting clinical signs/symptoms of TMJD after 8 years. This study suffered the limitations of a small sample size and relatively low return rate of the mailed questionnaire. Further studies with larger samples and an objective survey are therefore necessary.

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22. Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S. Tempromandibular internal derangement: correlation of MRI ndings with clinical symptoms of pain and joint sounds in patients with bruxing behavior. Dentomaxillofac Radiol 2003; 32: 304 310. 23. Okimoto K, Matsuo K, Moroi H, Terada Y. Factors correlated with craniomandibular disorders in young and older adults. Int J Prosthodont 1996; 9: 171 178. 24. Koidis PT, Zari A, Grigoriadou E, Gares P. Effect of age and sex on craniomandibular disorders. J Prosthet Dent 1993; 69: 93 101. 25. Williamson RA, McNamara D, McAuliffe W. True eminectomy for internal derangement of the temporomandibular joint. Br J Oral Maxillifac Surg 2000; 38: 554 560. 26. Gokalp H, Turkkahraman H, Bzeizi N. Correlation between eminence steepness and condylar disc movements in temporomandibular joints with internal derangements on magnetic resonance imaging. Eur J Orthod 2001; 23: 579 584. 27. Ren YF, Isberg A, Westesson P-L. Steepness of the articular eminence in the temporomandibular joint. Omographic comparison between asymptomatic volunteers with normal disk position and patients with disk displacement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80: 258 266.

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