Bill Klaproth (Host): This is an AAOMS On the Go Podcast. I'm Bill Klaproth. And with me are Dr. Gary Bouloux and Dr. Joli Chou. They are here to discuss the position paper titled The Contemporary Management of TMJ Intra-articular Pain and Dysfunction recently published in the Journal of Oral and Maxillofacial Surgeons. Dr. Bouloux and Dr. Chou, welcome.

Gary Bouloux: Thank you for the invitation, Bill.

Host: You're welcome.

Joli Chou: Thank you. Honored to be here.

Host: Yes, always good to see you and talk with you. So, Dr. Bouloux, let me start with you. So, what led AAOMS to appoint a special committee on TMJ care?

Gary Bouloux: That's a very interesting story, Bill. In about 2017, the Food and Drug Administration, The National Academy of Science, Engineering and Medicine, got together with some patient advocacy groups and really began to bring to everyone's attention the lack of knowledge, access, and consistency in the treatment of patients with temporomandibular disorders, for want of a better word. That led to AAOMS leadership deciding that this might be the right time to put a committee together and develop some contemporary guidelines which reflect what we truly do and advocate more so for the patients.

Host: Yeah, that makes sense. Dr. Chou, anything to add?

Joli Chou: Yeah, I mean, for many years, there's not a lot of clarity regarding treatment algorithms or options for these patients or even diagnosis. And so, I think it's important and because of the Medical Device Epidemiology Network and the FDA and the National Academy of Sciences report, we just felt like it was time and that as oral and maxillofacial surgeons who treats a lot of these patients, that it's important that we can come up with some solutions and guidelines for our surgeons.

Host: Yeah, that seems to definitely make sense. And then, Dr. Chou, did the committee's recommendations challenge any long-held assumptions about TMJ disorders? Like, “yeah, we already know that.” So, did this challenge some of those long-held assumptions, particularly in terms of treatment approaches?

Joli Chou: So, I think the treatment approaches are certainly there. Every surgeon has a little bit different approach to how we treat these type of patients. But the main thing that is mentioned in this paper is that traditionally we tend to look at the temporomandibular joint disorder, especially the intra-articular or arthrogenous causes to be more anatomical and mechanical to be related to the position of the disc. And in this paper, we have shifted the focus a little bit. You certainly can have patients with displaced discs, but that is not symptomatic because we know from the past literature that we do have patients who have displaced disc that is not symptomatic. So it's more about inflammation, synovitis. So, the focus is more on the synovitis, the results of that synovitis, that inflammation of the tissue around the joint space, and then how that ends up with the symptoms and signs that that patient exhibits.

Host: Yeah. So, with this new understanding then, Dr. Bouloux, how does this updated information improve the diagnosis and treatment then of patients? What has this resulted in?

Gary Bouloux: I think it's brought clarity to the fact that when patients per history and examination present with intra-articular pain and dysfunction, that the causes for this are multifocal and include many things, as Joli's mentioned, that are typically unrelated to disc position. And because of that, it really lends itself to treatment in a more conservatively or minimally-invasive process, at least initially. So based on that, our recommendations have generally been, and continue to be, that we should treat patients with non-surgical approaches when humanly possible.

When this is not considered appropriate or has failed, we need to adopt a minimally invasive approach initially, which includes arthrocentesis or arthroscopy. And really, it's only when they have failed, and the diagnosis still remains intra-articular pain and dysfunction, that we then consider open approaches.

Host: Okay. That's really interesting. And then, Dr. Chou, then, for a surgeon listening to this, what are the key implications for that OMS putting it into everyday practice? What does that mean to them?

Joli Chou: As Gary had mentioned that this paper really recommends that, because of the pathiophysiology of what we think is causing the patient's signs and symptoms, that there are conservative therapies that can alleviate these signs and symptoms just as well as open surgery. I think this paper clarifies that and allows for surgeons who may not do open surgery or major surgery to provide these more minimally-invasive or conservative therapies in their practice. So, that would apply to, you know, surgeons who practice in major medical centers, in private practice. The implications is that you can certainly catch these patients in the earlier stages and provide adequate treatment.

Gary Bouloux: In addition to Joli's valid points, I think it also establishes for the surgeons across the U.S. that, given our recommendations, if you as an individual surgeon have not necessarily been educated or proficient in minimally invasive procedures, arthrocentesis or arthroscopy, despite that, there should be some effort to ensure that the patient is referred to someone who can perform those procedures.

Now, having said that, arthrocentesis is very straightforward, and every oral and maxillofacial surgeon should be able to perform that. Arthroscopy is a little bit more advanced and generally considered to be a fellowship-level training for the majority of us. But irrespective of your training, I think there's still an obligation to manage it non-surgically or minimally invasive, or refer it to someone who can, if you cannot.

Host: So based on these findings, this sounds like it's also really good news for the patient being that you're recommending these non-surgical, minimally-invasive treatment options right at the front from what you've learned.

Joli Chou: That's correct. I think one of the things about this paper too is that it clarifies a lot of the things that we were not sure about, but rather that it just kind of summarizes everything in a much more organized manner, in a stepwise fashion, in terms of diagnosis and treatment planning.

Gary Bouloux: In addition, I would say, from the outset, it's important to realize that even though these were guidelines prepared by colleagues who are familiar and proficient in surgery, it was not based on opinion. It was based on the literature and the level of literature that existed for each of the treatment modalities. So, I think it's as scientific as we can possibly get.

Host: So then, Dr. Bouloux, let me ask you this, what are the next steps then in TMJ research and care based on these findings and recommendations that are published in the paper? What are our next steps?

Gary Bouloux: You know, I think at the present time where some challenges lie is specifically with open surgery. As a predecessor to that comment, I would say that literature is very robust for arthrocentesis and arthroscopy given what the goals and aims would be for those particular procedures.

Total joint replacement also is generally amply supported by the literature. Where the elephant in the room is tends to be the arthroplasty, the open surgery that's not total joint. And the literature is really all over the place. And looking back at the last 40 or 50 years when research wasn't as robust and the requirements for publication weren't as robust, it sort of led to publications that maybe not as accurate, not as generalizable. So, I think for the moment, research really is what levels of arthroscopy, one, two or three, would be the most beneficial, and what role does open joint surgery have if it's not total joint replacement.

Host: So, you've taken all this information, you've really condensed it down, if you will, and presented these new findings in a much more concise, clear way that, if you follow these procedures, I mean, this will most likely produce results in this minimally invasive non-surgical way. You've kind of condensed it and clarified it. Would that be fair to say?

Joli Chou: Yes and no. Yes, it condensed it, making it more concise. Not necessarily just for minimally-invasive surgery, but now there's a pathway or an algorithm for people to sort of follow.

Host: This provides more of a roadmap, if you will.

Joli Chou: Yes.

Host: Got it. Okay. Thank you. Well, this has been really fascinating and congrats on this published article. Before we wrap up, I'd like to get final thoughts from each of you on this publication. Dr. Chou, let's start with you. Anything else you want to add?

Joli Chou: I am very thankful for the opportunity to work on the paper and that for the AAOMS organization to support the work that Dr. Bouloux and I do. As we know, the population of patients that has TMD, in my opinion, is large because that's my area of subspecialty within oral and maxillofacial surgery, but not a lot our members necessarily is involved in the, you know, treatment of these patients. So I'm really glad. I think it's an important issue. And so, I'm really glad that the association supports it. And hopefully, we'll continue to support it.

Host: Yeah. Nicely said. Dr. Bouloux, I'll wrap it up for us. Your final thoughts.

Gary Bouloux: The paper is a very good paper that really will shape the future of management of patients with temporomandibular disorders, particularly intra-articular pain and dysfunction, and the purpose of the paper really is to help residents in training, young faculty, and young private practice surgeons who are looking to have some guidelines that are evidence-based that can really help them in their career. It's less likely to influence those that have already been doing things for 30 years. But it certainly can make a difference over the next 5 or 10 years in shaping the way we approach intra-articular pain and dysfunction.

Host: And that's really important. So, congrats again on the paper. And thank you for your time today. I really appreciate this. Dr. Chou and Dr. Bouloux, thank you again.

Gary Bouloux: Thanks for your time.

Joli Chou: Thank you.

Host: Absolutely. Once again, that's Dr. Gary Boulou and Dr. Joli Chou.

For more information, you can visit AAOMS.org/PositionPapers to review the position paper, or visit AAOMS.org/JOMS, that's J-O-M-S, AAOMS.org/JOMS to read it in the journal, and I ask that you do that. It's a really good paper.

And if you found this podcast helpful, please share it on your social channels, and don't forget to subscribe. Thanks for listening.