1. Controversies in Oral Medicine
Dr. David Oliver
Specialist in Oral Medicine
BDSc (Melb), PGDipCD (Melb),
Doctorate of Clinical Dentistry (Melb)
Glen Iris, Dandenong

2. Controversies in Oral Medicine
1. What is the role of surgery in the management of TMD’s 2. Management of Potentially Malignant Lesions 3. Is Oral Lichen Planus a Potentially Malignant Condition? 4. Does Oral Lichen Planus require review?

3. Temporomandibular disorders
‘Temporomandibular disorders’ is a collective term embracing a number of clinical problems that involve the masticatory musculature, the TMJ and associated structures, or both (Jeffrey Okeson, 1996).
Pain, joint sounds and jaw dysfunction

8. American Academy of Orofacial Pain’s Classification of TMD’s
Masticatory muscle disorders
Myofascial Pain
Myositis
Myospasm
Myofibrotic contracture
Neoplasia
Local Myalgia

9. American Academy of Orofacial Pain’s Classification of TMD’s
Articular disorders
Congenital or developmental disorders
Disc derangement/displacement disorders
Temporomandibular dislocation
Inflammatory disorders – RA, psoriatic arthritis
Osteoarthritis (non-inflammatory disorders)
Ankylosis
Fracture

10. Articular disorders 1. Disc derangement/displacement disorders
Disc displacement with reduction
Disc displacement without reduction
2. Osteoarthritis (noninflammatory disorders)

12. Normal TMJ movement

13. Normal TMJ movement

14. Normal TMJ movement

15. Disc Displacement with Reduction

16. Disc Displacement without Reduction (‘closed lock’)

17. Management of Closed Locks of the TMJ
1. Conservative
Home treatments - jaw rest, home exercises
Physical therapy
Splint
2. Surgical
Arthrocentesis/Arthroscopy
Discectomy
Disc repositioning

18. TMJ Disc Displacement without Reduction Management

19. Arthroscopy

20. Arthroscopy

21. Arthroscopy

22. Arthroscopy

23. TMJ Disc Displacement without Reduction Management: A Systematic Review Al-Baghdadi, JDR, 2014
Electronic and manual searches up to November 1, 2013, were conducted for English-language, peer-reviewed, publications of randomized clinical trials comparing any form of conservative or surgical interventions for patients with clinical and/or radiologic diagnosis of acute or chronic DDwoR. Twenty studies involving 1,305 patients were included. Data analysis involved 21 comparisons between a variety of interventions

24. TMJ Disc Displacement without Reduction Management: A Systematic Review Al-Baghdadi, JDR, 2014
(1) non-invasive (conservative), including education, self-management, splint therapy, physiotherapy, and their combinations; (2) minimally invasive, including arthrocentesis; or (3) invasive (surgical), including arthroscopic and open joint surgeries.

25. TMJ Disc Displacement without Reduction Management: A Systematic Review Al-Baghdadi, JDR, 2014
Minimally invasive arthrocentesis and invasive arthroscopic and open joint surgical interventions did not, in general, demonstrate significant differences in
effects over non-invasive conservative interventions and could be associated with complications.
‘’Currently, there is insufficient evidence to support or refute the use of minimally invasive (arthrocentesis/arthroscopy) and invasive (open joint, discectomy) surgical interventions for DDwoR.’’

26. TMJ Disc Displacement without Reduction Management: A Systematic Review Al-Baghdadi, JDR, 2014
‘’The comparable therapeutic effects of reviewed interventions suggest using the simplest, least costly, and least invasive interventions for the initial management of DDwoR.’’

27. Arthroscopy vs. Conservative Treatments Schiffman et al, 2007
1. Self management (self-care/medication/education) and
2. combination of splint plus exercises (+ self-care/medication/education + CBT).
Arthroscopy did not demonstrate statistically significant
differences in effect over conservative interventions on all
measured outcomes over the short or long term

28. 1st line – self care, medication, education, exercises, CBT
TMJ Disc Displacement without Reduction Management: A Systematic Review Al-Baghdadi, JDR, 2014
1st line – self care, medication, education, exercises, CBT
2nd line – physiotherapy or splint
3rd line – arthroscopy
4th line – open joint surgery

29. Management of TMJ Osteoarthritis

30. Management of TMJ Osteoarthritis
1. Conservative
Home treatments - jaw rest, home exercises
Medications – intra-articular injections, oral NSAIDS
Physical therapy
Splint
2. Surgical
Arthrocentesis
Arthroscopy
Discectomy
Disc repositioning
Joint Replacement Surgery

31. Management of TMJ Osteoarthritis
Long term studies have revealed that the prognosis of TMJ OA when treated with conservative measures is satisfactory for the majority of patients (de Leeuw et al 1994, 1995, 1996)
Surgery should not be recommended unless non surgical means have failed (Kopp 1985, Milam and Schmitz 1995, Nitzan 2003, Kurita at al 2004 and 2006, Martinez Blanco et al 2004, Tanaka 2005)
(one exception may be where there is displacement of the mandible and significant malocclusion)

32. Management of TMJ Osteoarthritis
What if conservative management fails and patient’s S/S persist?
Intolerable symptoms – pain, difficulty eating, severe trismus, malocclusion, etc
Surgical
Arthrocentesis
Arthroscopy
Discectomy
Disc repositioning
Joint Replacement Surgery

33. Management of TMJ Osteoarthritis
A new surgical classification for temporomandibular joint disorders (Dimitroulis 2013) Category 1 – TMJ normal Category 2 – TMJ minor changes Category 3 – TMJ moderate changes Category 4 – TMJ severe changes Category 5 – TMJ catastrophic changes

34. Management of TMJ Osteoarthritis
A new surgical classification for temporomandibular joint disorders (Dimitroulis 2013) Category 1 – TMJ normal – NO OA Category 2 – TMJ minor changes – NO OA Category 3 – TMJ moderate changes – NO OA Category 4 – TMJ severe changes – MILD OA Category 5 – TMJ catastrophic changes – MODERATE TO SEVERE OA * Disc pathology likely to be present in category 2 - 5

35. Temporomandibular joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery (Briek, Dimitroulis, et al 2016)
The purpose of this study was to evaluate the medium to long-term outcomes of TMJ arthroscopic lysis and lavage and determine factors associated with progression to open surgery
A total of 167 patients and 216 joints underwent arthroscopy with a mean follow up of 6.9 years. 
There was a statistically significant rate of progression to open surgery depending on the classification at the time of arthroscopy, with all patients with category 4 and 5 disease progressing to open surgery
Open joint surgery included arthroplasty, discectomy, rib graft or TJR with prosthesis

36. Practical effect of this?
Temporomandibular joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery (Briek, Dimitroulis, et al 2016)
Practical effect of this?
For a lot of our patients with category 4 or 5 joints (osteoarthitis with likely disc pathology), arthroscopy and arthrocentesis are being by-passed in favour of open joint surgery - SE’s, costs, absence from work
Category 5 joints are exceedingly progressing straight to TJR surgery

37. Management of TMJ Osteoarthritis
The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints (Nitzan and Price, 2001)
The purpose of this retrospective study was to determine the efficacy of arthrocentesis in restoring the functional capacity of osteoarthritic temporomandibular joints (TMJ)
Of the 38 TMJs treated with arthrocentesis, 26 joints reacted favourably to the treatment
Follow up – mean was 21 months
Arthrocentesis is a safe and rapid procedure that in many instances results in the osteoarthritic TMJs returning to a healthy functional state

38. Management of TMJ Osteoarthritis
Temporomandibular joint arthrocentesis for the treatment of osteoarthritis (Leibur et al, 2015)
The aim of the study was to determine the effectiveness of arthrocentesis with regard to TMJ pain intensity and mandibular movement
23 consecutive patients with a diagnosis of TMJ osteoarthritis after non effective conservative treatment were treated with arthrocentesis
After 6 months MIO improved significantly and pain according to VAS had substantially decreased
Arthrocentesis with this technique for the treatment of TMJ osteoarthritis offer favourable results with regard to increasing MIO, reducing pain and dysfunction

39. Surgical management of TMJ Osteoarthritis
Conclusions
Indicated if TMJ OA symptoms do not respond to conservative treatment
Why the difference in results?
(Briek et al VERSUS Leibur et al/Nitzan et al)
- Arthroscopy vs Arthrocentesis?
- Mean follow up periods
Briek et al – 6.9 yrs; Leibur et al – 6 months; Nitzan et al – 21 months
What is the long term prognosis of open joint surgeries for management of TMJ OA
What is the long term prognosis of arthrocentesis for management of TMJ OA – are beneficial effects seen beyond 21 months?
What level of procedure is the patient willing to tolerate?

40. Surgical management of TMJ Osteoarthritis
Conclusions continued....
Still a lack of evidence to provide guidelines on how best to manage TMJ OA surgically
Less invasive surgical therapy (arthrocentesis) for TMJ OA should be considered prior to open joint surgery
Arthroplasty and Discectomy for TMJ OA should be considered prior to TJR surgery

41. Oral Potentially Malignant Disorders
“clinical presentations that carry a risk of cancer development in the oral cavity, whether in a clinically definable precursor lesion or in clinically normal mucosa’’ (WHO, 2017)

42. Leukoplakia
“white plaques of questionable risk, once other specific conditions and other OPMDs have been ruled out.”

43. Dysplasia

44. Management of oral dysplastic lesions
Controversial
Options
Wait and see
Surgical removal – scalpel, laser,
Medical management

45. Management of oral dysplasia
Does removal of lesions containing dysplasia help to prevent malignant transformation?

46. Does removal of OED help prevent malignant transformation
The World Workshop on Oral Medicine IV met in 2005 and a group of experts reviewed the literature regarding the management of OED from 1966 till 2006 The article published by the expert group concluded ‘Because of the lack of RCTs, no evidence-based recommendations can be provided for specific surgical interventions of dysplastic oral lesions.’

47. Does removal of PML’s help prevent malignant transformation
Post 2006, several studies have further addressed this topic. None however were large, prospective, RCT’s Balasundaram J Oral Pathol Med 2014 “Unfortunately, the majority of evidence is based on observational and retrospective data, as yet no good quality RCTs are available. For this reason, there are no universally agreed guidelines for the treatment of oral PMDs’’

48. OED Lesions – MONITOR vs REMOVE
Factors to consider
no universally agreed guidelines for the treatment of OED lesions
OED lesions can recur post surgical removal
Oral cancer can occur in areas in which OED lesions were previously removed
Excision and re-excision may be an indefinite process leading to significant morbidity for the patient
5–10% of leukoplakias contain carcinoma which was not initially noted on diagnostic biopsy but only afterwards on surgical excision

49. OED Lesions – MONITOR vs REMOVE
Dysplastic
Non dysplastic

50. Does removal of PML’s help prevent malignant transformation
Can we fine tune our management of PML’s in the future?
Large, prospective, RCT’s - does removal of PML’s help prevent malignant transformation?
More accurate markers to determine which PML’s will progress and which ones won’t

51. Is Oral Lichen Planus a Potentially Malignant Condition?

52. Is Oral Lichen Planus a Potentially Malignant Condition?
Malignant transformation of oral lichen planus and oral lichenoid lesions: A meta-analysis of patient data (Aghbari et al 2017)
A small subset of OLP patients (1.1%) develop OSCC
A higher incidence of malignant transformation was found among smokers, alcoholics, and HCV-infected patients

53. Is Oral Lichen Planus a Potentially Malignant Condition
Does this prove causation? Several mechanisms of carcinogenicity have been proposed, but not proven

54. 1. Mignogna et al 2001 vs Lo Muzio et al 1998
ORAL LICHEN PLANUS AND MALIGNANT TRANSFORMATION: IS A RECALL OF PATIENTS JUSTIFIED?
1. Mignogna et al 2001 vs Lo Muzio et al 1998
(same clinic in Italy)
Mignogna et al - at least 3 reviews per year
Lo Muzio et al – 1 review per year
Of the oral cancers diagnosed, Lo Muzio (1 year review) detected a greater proportion of advanced cancers than Mignogna et al - at least 3 reviews per year
HOWEVER, the number of recurrences and mortalities did not differ significantly between the 2 studies ????????

55. ORAL LICHEN PLANUS AND MALIGNANT TRANSFORMATION: IS A RECALL OF PATIENTS JUSTIFIED?
Mignogna et al 2001 vs Lo Muzio et al (same clinic in Italy) cont.....
‘’ Consequently, these studies indicate that
12 month follow ups detect more advanced disease than 3 month reviews
but more frequent follow-ups do not automatically lead to an improved prognosis for OLP patients with oral cancer.’’
Given progressive nature of oral cancer, can deduce that some form of review is beneficial as early diagnosis is crucial in improving prognosis

56. Of the SCC’s they detected 95% were early stage – 5 yr survival 97%
ORAL LICHEN PLANUS AND MALIGNANT TRANSFORMATION: IS A RECALL OF PATIENTS JUSTIFIED?
2. Mignogna et al 2006
12 month reviews
Of the SCC’s they detected
95% were early stage – 5 yr survival 97%
5% were advanced stage - 5 yr survival 50%

57. ORAL LICHEN PLANUS AND MALIGNANT TRANSFORMATION: IS A RECALL OF PATIENTS JUSTIFIED?
Conclusions
Regular review is justified and likely to be helpful for the majority of OLP patients
Is 3 month review better than 12 month review? – not according to these studies, but logic would suggest otherwise
Consider the financial burden if in a public health system
Consider practicality for elderly and those in remote areas
GDP or Oral Medicine Specialist? – both