Osteomyelitis of the temporomandibular joint in patients with malignant otitis externa

Malignant (invasive) otitis externa is an infection involving the external ear canal, often in elderly diabetic patients, which carries a high morbidity and mortality. It may involve widespread areas of soft tissue around the skull base, and in more advanced cases, may give rise to osteomyelitis and cranial neuropathy. We describe two patients who were treated for malignant otitis externa complicated by destructive osteomyelitis of the temporomandibular joint (TMJ). For both patients, diagnosis was made using magnetic resonance imaging (MRI), and repeat scans were employed during follow-up. Improved scan appearances mirrored improvements in clinical condition in both cases.

A computerized model for teaching various methods of positioning the condyles to centric relation

The entire masticatory system is within the realm of the dentist's responsibility, and therefore requires the dentist to have a working knowledge and understanding of the TMJs, neuromuscular system, and occlusion as well as the teeth and periodontal structures. This article presents how a computerized model can help dentists help their patients with TMJ disorders.

SAPHO syndrome of the temporomandibular joint associated with sudden deafness

We report a case of arthritis of the temporomandibular joint (TMJ) associated with sclerosing osteomyelitis of the mandible and temporal bone, causing deafness. The presence of a palmoplantar pustulosis established the diagnosis of SAPHO syndrome. SAPHO (an acronym referring to synovitis, acne, palmoplantar pustulosis, hyperostosis, and osteitis) syndrome is defined by the association of characteristic osteoarticular and dermatologic manifestations, with diffuse sclerosing osteomyelitis of the mandible being a part of this entity. We review the literature of SAPHO syndrome with mandibular manifestations and discuss the mechanisms of inflammatory spread from the TMJ to the cochlea. To our knowledge, this is the first description of skull base involvement in a patient with SAPHO syndrome leading to sudden deafness.

Comparison of radiography, scintigraphy and ultrasonography in the diagnosis of a case of temporomandibular joint arthropathy in a horse

Diagnosis of temporomandibular joint disease in the horse presents a challenge to the equine veterinarian. This case report illustrates a combined imaging approach using radiography, scintigraphy and ultrasonography in a horse with severe arthropathy of the left temporomandibular joint. Radiographs were inconclusive. Scintigraphy with Tc99m methylenediphosphonate localised, but failed to characterise the disease process; ultrasonography was the only imaging method which both localised and characterised the lesion. Ultrasonography proved to be a relatively cheap, technically easy to perform and non-invasive method for the assessment of the disease.

Destruction of the glenoid joint fossa by a tenosynovial giant-cell tumour of the skull base: a case report

A 63-year-old man is presented in whom a tenosynovial giant-cell tumour had destroyed the temporomandibular joint fossa and expanded intracranially. The lesion was not diagnosed for a period of at least two years. Treatment included wide resection including the surrounding bone, dura and condyle.

Horizontal condylar angulation and condyle position associated with adolescent TMJ disk status

The purpose of this research was to examine the relationship between horizontal condylar angulation and position and joint status in an adolescent population. Submentovertex (SMV) radiographs and MRI (magnetic resonance images) of 95 subjects (56 females and 39 males) between the ages of 10-17 years (mean age 13.3 years) were used for this study. Horizontal condylar angulation as well as A-P and transverse condyle position were determined in relation to a cranial base reference (a line formed between the two foramina spinosa) from SMV images. Joint status variables consisted of disk length and disk displacement measurements taken from medial, central and lateral sagittal MRI slices of each joint. Additional joint status variables were derived through a principal component analysis which was used to calculate a single disk length, disk displacement, and internal derangement variable for each joint. The results were: 1. No significant correlations (p = .05) were found between any of the joint status variables and horizontal condylar angulation; 2. Statistically significant correlations (r = .14 to .22, p = .05) were observed between certain joint status variables (anterior disk displacement in medial and central joint slices, disk displacement variable, and TMJ internal derangement variable) and transverse condyle position; and, 3. Statistically significant correlations (r = -.22 to .25; p = .05) were observed between condylar angulation and both A-P and transverse condyle position.

Phase II therapy for a chronic pain patient: a clinical report

One of the roadblocks to success in treating temporomandibular joint dysfunction (TMD) patients is an accurate diagnosis. The terms "TMJ" or "TMD" are not specific enough to provide definitive treatment. Initially the disorder must be classified as a muscular or an internal derangement problem. Once accomplished, the further diagnostic breakdown of the problem will prepare the patient and the doctor for the scope of treatment necessary and the prognosis. This lack of a specific diagnosis can lead to inappropriate treatment and inadequate communication among clinical dentists, academia and patients. Our patients and the profession will continue to suffer until a single diagnostic system is universally agreed upon and utilized.

Clinical update--the teeth and the maxillary sinus: the mutual impact of clinical procedures, disease conditions and their treatment implications. Part 3. But doctor, my ear hurts

Temporomandibular disorders (TMD) can present as an array of symptoms that can mimic both odontogenic and ear, nose, and throat (ENT) disorders. Dentists need to be alert to the possibility of primary ENT disorders in patients who present with TMD symptoms, as should ENT physicians be familiar with the clinical presentation of TMD, especially in those patients who present with ENT symptoms but no sign of ENT disease.

Reconsideration of the TMJ condylar position during internal derangement: comparison between condylar position on tomogram and degree of disk displacement on MRI

The objective of this study was to investigate condylar position during different degrees of disk displacement. The degree of disk displacement was evaluated on 1.5 Tesla high-field sagittal MR images of 76 joints (48 patients; mean age 19.4 years) and was classified into three grades (1 to 3). To establish condylar position, the anterior, superior and posterior joint spaces were measured on corrected tomograms. The possible relationship between condylar position, indicated by the width of joint space and successive degree of disk displacement, was compared by a one-way factorial ANOVA (p < 0.05). The anterior joint space was significantly larger in grades 1, 2, and 3 disk displacements than in grade 0 pointing to a dorsal condylar position. The posterior joint space was significantly smaller in grades 1 and 2 compared with grade 0. When the degree of the disk displacement becomes severe (i.e., grade 3 disk displacement), the posterior joint space tends to increase to a similar distance as in a normal healthy joint pointing to a more normal condylar position.

Dental side effects of an oral device to treat snoring and obstructive sleep apnea

STUDY OBJECTIVES

Snoring and obstructive sleep apnea (OSA) are common and related conditions--with major social and health implications--which can be treated successfully with dental devices that reposition the mandible. Despite wide use, side effects of these devices have not yet been systematically evaluated. The purpose of the study was to evaluate side effects of a mandibular advancement splint (MAS) previously described by the authors.

DESIGN

Questionnaire survey and dental examination of a consecutive case series of patients treated with the MAS SETTING: Dental outpatient clinic

PATIENTS

Attempts were made to contact all 191 patients treated over a 5-year period. All had snored loudly and habitually with or without OSA prior to treatment.

MEASUREMENTS AND RESULTS

Of 191 patients treated, 132 agreed to complete the questionnaire. All were scheduled to attend for dental examination and 106 underwent examination. Of the 132 interviewed, patient and partner report indicated that the device was well tolerated and controlled snoring satisfactorily in 100 after 31 +/- 18 (mean +/- SD) months of use. Dental side effects were reported in 107 patients, although these were mostly minor, and only 10 patients ceased using the device because of them. Side effects included excess salivation (in 40), xerostomia (in 30), temporomandibular joint pain (in 35), dental discomfort (in 35), myofacial discomfort (in 33) and bite changes (in 16). Of 106 patients examined, 30 had increased maximal opening and 76 had no change compared with pretreatment records. Temporomandibular joint noises were found in 9 patients, and occlusal changes (12 m mylar strip and wax bite, relative to pretreatment) in 15. None of these effects could be related to degree of opening or protrusion produced by the MAS.

CONCLUSION

Dental side effects occur in a significant proportion of patients using the MAS. In most cases these are minor and their importance must be balanced against the efficacy of the MAS in treating snoring and OSA.

Magnetic resonance imaging and clinical assessment of temporomandibular joint pathology in ankylosing spondylitis

OBJECTIVE

To evaluate temporomandibular joint (TMJ) articular disc position and osseous degenerative changes using magnetic resonance imaging (MRI) as well as clinical symptoms of temporomandibular disorders in patients with ankylosing spondylitis (AS).

METHODS

A sample of 43 patients with AS (38 males, age 45.9+/-10.7 years) and 16 controls (all male, age 41.3+/-6.3 years) were studied. All subjects completed a self-administered questionnaire and underwent clinical examination and MRI survey. Recorded variables included disease characteristics, subjective neck and TMJ disorder symptoms, and axial mobility measurements. MRI variables included TMJ disc position and severity of osseous degenerative change.

RESULTS

TMJ disorder symptoms of headache duration and frequency, TMJ pain duration and frequency, and painful jaw movement were more frequent in patients with AS (p < 0.05). Significant differences were also observed in MRI indices for disc displacement (AS, 0.89; controls, 0.36; p = 0.005) and degenerative changes (AS, 0.55; controls, 0.06; p = 0.01). A total of 50 (62%) joints in the AS group had disc displacement compared to 11 (34%) joints in the controls. A total of 16 (20%) joints in the AS group had degenerative change compared to 2 (6%) joints in the controls.

CONCLUSION

TMJ internal derangement, degenerative changes, and subjective pain complaints are frequent in patients with AS. Physicians should be aware of potential TMJ involvement in these patients, which may require specific assessment and therapy.

Temporomandibular disorders: evidence for significant overlap with psychopathology

Data were analyzed for 277 acute and chronic temporomandibular disorder (TMD) patients to determine if there was a relationship between psychological and physical diagnoses. A significant (p < .01) relationship existed among the following: combined past or current mood disorder-personality disorder and muscle disorder; combined current mood, anxiety, or substance use disorder-personality disorder and muscle disorder; and combined current anxiety disorder-personality disorder and muscle disorder. This study further confirmed other research that has found that significant psychopathology exists in TMD. More important, this psychopathology appears to be linked primarily to muscle disorders, as opposed to disc or joint disorders, within the rubric of TMD.

False localization of TMJ sounds to side is an important source of error in TMD diagnosis

The results of the study indicate that the head tissues act as a band pass filter that is far from flat. Instead there seems to be strong frequency variations in attenuation of transmitted sounds. The sounds are subject to phase shift and time delay, which can be used to decide from which TMJ the sound comes. Bilateral electronic recording with high sampling rate (>> 44 kHz) is needed to accurately and consistently identify the origin of a TMJ sound. Further studies on autopsy specimens and large subject groups are motivated.

Temporomandibular disorders--an overview

Temporomandibular disorders (TMD) have been an area of increased clinical and scientific inquiry in dentistry. This is due to increased patient awareness and desire for treatment as well as scientific advances in the fields of epidemiology, neurobiology and diagnostic imaging. This article sets out to introduce this disorder and describes its aetiology and management.

Synovial fluid sampling from the temporomandibular joint: sample quality criteria and levels of interleukin-1 beta and serotonin

The aims of this study were to compare two sets of quality criteria (SQC A and B) with respect to synovial fluid (SF) sampling and to present temporomandibular joint (TMJ) SF levels of IL-1 beta and 5-HT. The study comprised 310 TMJ SF samples from 12 healthy individuals (HI) and 59 patients with TMJ inflammatory disorders. Ten HI and 37 patients were selected for investigation of TMJ SF levels and samples were obtained by a push-and-pull method with quantification by vitamin B12. The SQC comprised aspirate weight (AW), dilution factor (DF), blood contamination and hemolysis. IL-1 beta and 5-HT levels did not differ between the samples that satisfied SQC A or B. The proportion of samples that satisfied SQC A was higher than for SQC B. Patients with polyarthritides had significantly higher TMJ SF concentrations of 5-HT and IL-1 beta than HL. In conclusion, there is a recovery of TMJ SF of 0.1-0.2 g with the method used and the criteria set with the highest success rate do not differ from the other one with respect to SF levels of IL-1 beta and 5-HT. This set of sample quality criteria comprised no hemolysis, no or only minor blood contamination, AW > 0.5 g and DF < 0.98. The higher SF levels in the diseased TMJ (polyarthritides) compared to the healthy joint with respect to 5-HT and IL-1 beta is of clinical diagnostic relevance and the presence of 5-HT or IL-1 beta in TMJ SF seems to indicate a pathological joint condition probably of an inflammatory nature.

Position paper regarding diagnosis, management, and treatment of temporomandibular disorders. The American Equilibration Society

The following position paper regarding diagnosis, management, and treatment of temporomandibular disorders (TMD) was authored by Dr Peter Dawson on behalf of the American Equilibration Society for presentation to the National Institutes of Health, Technology Conference on Management of Temporomandibular Disorders, given April 29 through May 1, 1996, in Bethesda, Md.

Clinical predictability of temporomandibular joint disc displacement

Single items from a typical clinical examination have proved disappointing in their predictive value for temporomandibular joint (TMJ) disc displacement. Only one criterion (the 12 o'clock) is used to diagnose normal disc position. According to this criterion, the posterior band of the disc should be located at the top of the condyle, at the 12 o'clock position. The purpose of this study was to determine which signs and symptoms provide a valid prediction of the condition of the joint based on 4 magnetic resonance imaging (MRI) criteria used to define normal disc position. Sagittal MRI and clinical findings of 137 temporomandibular disorder patients and 23 normal asymptomatic volunteers were used. Three calibrated and blinded observers interpreted the images. Disc position with the mouth closed was evaluated based on 4 MRI criteria: 12, 11, 10 o'clock, and the intermediate zone. Disc position with the mouth open was determined based on one criterion. It was considered normal if the intermediate zone of the disc was located between the condyle and the articular eminence. Joints were classified as normal or as having disc displacement with or without reduction. The sensitivity and specificity of multiple clinical parameters for predicting the condition of the joint established by each of these 4 gold-standard MRI criteria were then determined. Regarding disc displacement with reduction, significant differences were observed in the sensitivity and specificity of all of the clinical parameters used to predict the imaging diagnosis established by each of the criteria. Concerning disc displacement without reduction, no significant differences were observed. The intermediate zone criterion was the criterion that most accurately reflected the condition of the joint. The clinical predictability of the disorder diagnosed according to this criterion suggests that clinical findings alone are too often nonspecific as predictors of the imaging stage of disc displacement. However, we found that combining the most sensitive clinical items to predict the disorder and using an overall criterion for positivity to interpret the results led to an impressive increase in the specificity of the combination, enabling false-positive diagnoses to be excluded.

Craniomandibular disorders--comparative investigations with clinical examination and electronic axiography

An essential problem in the diagnosis of craniomandibular disorders is still the evaluation of the type and severity of the TMJ diseases. For a differential classification of TMJ diseases, we developed an electronic axiography system which facilitates a recording of lower jaw movements. It works 3-dimensionally and relates to the joints. The measuring system, which was internationally patented, is based on a linear resistive foil for the sagittal plane and an inductive gauge for the horizontal plane. The aim of this pilot study was to evaluate the usefulness of our electronic axiography system in obtaining a differential diagnosis of craniomandibular disorders. We examined 30 patients (60 joints) with complaints in the TMJ area (pain and TMJ sounds). Clinical examinations yielded only uncertain indications of TMJ disease. With the help of electronic axiography we could differentiate the TMJ diseases into microtrauma and macrotrauma. Both forms may show a loss of function and an audible TMJ clicking. 23 joints had a macrotrauma (disk displacement with reduction, 20 times; disk displacement without reduction, 3 times). In 8 joints, a microtrauma was found. 3 joints showed a subluxation. In 4 uncertain cases, the diagnosis was confirmed with the help of magnetic resonance imaging (MRI). All patients with a diagnosed arthrogenic disorder received adequate treatment with reposition splints. Our initial results show that 3-dimensional electronic axiography can be a good aid in further characterization of craniomandibular disorders and permits an effective therapy.

Treatment of TMJ static disk with arthroscopic lysis and lavage: a comparison between MRI arthroscopic findings and clinical results

Arthroscopic surgery using the lysis and lavage technique was performed on 30 temporomandibular joints (TMJs) of 26 patients with the clinical and radiological (pseudodynamic Magnetic Resonance Imaging) diagnosis of static disk (SD). Parameters of condylar movement, position of the disk in relation to the condyle in open and closed mouth positions and mobility of the articular disk were evaluated both clinically and radiologically using pseudodynamic Magnetic Resonance Imaging (MRI) before and after surgery. Subjective parameters of pain and functional limitation were also evaluated clinically. The results showed that all the clinical and radiological parameters analyzed improved significantly in all the patients included in the study. In view of the results, the authors concluded that SD should be added to the existing categories of TMJ internal derangements. Pseudodynamic MRI is the diagnostic technique of choice in these cases and arthroscopic surgery with lysis and lavage followed by active physical therapy is an effective treatment modality in this type of pathology.