Suppurative Arthritis of the Temporomandibular Joint Associated With Bisphosphonate: A Case Report

Septic arthritis of the temporomandibular joint in adults: Systematic review

BACKGROUND

Septic arthritis of the temporomandibular joint (SATMJ) is acute or chronic bacterial or fungal infection involving temporomandibular joint (TMJ) space. It is a disease with high mortality in whole body joints, and about three-fourths of survivors have residual malfunctioning of the affected joint.

OBJECTIVE

The aim of this review was to search systematically, evaluate and then summarize scientific literature about etiology, signs and symptoms, diagnosis, treatment and prognosis of the SATMJ in adults.

METHODS

After registration at PROSPERO this systematic review was conducted and reported according to the PRISMA checklist. The following databases were systematically searched: MEDLINE, EBSCO, The Cochrane Central Register of Controlled Trials (Central), SCIndex, Scopus, Google Scholar and Registry of clinical studies with human participants.

RESULTS

In total 37 studies with 91 patients were included in the review. Dominant signs and symptoms of SATMJ were pain and trismus, while fever was infrequent. The most frequent isolates from the TMJ were Staphylococcus aureus and Streptococci; however, less than 20% of patients had data about susceptibility of the isolates to antibiotics. Combination of third generation cephalosporin and metronidazole was the most frequently prescribed empirically, and antibiotics especially active against S. aureus (glycopeptides and anti-staphylococcal beta-lactams) were under-prescribed. Administration of antibiotics was prolonged (median over 30 days), although two weeks are sufficient treatment for SATMJ if right choice of antibiotics was made. There was high rate of repeated surgical interventions (53.5%), which were linked to higher risk of long-term functional defects.

CONCLUSIONS

The SATMJ is serious infection that requires early empiric administration of antibiotics with good coverage of Gram-positive bacteria, and subsequent correction of antibiotic therapy according to susceptibility of isolates. Appropriate antibiotic therapy decreases risk of long-term functional disorders.

Zoledronate promotes ECM degradation and apoptosis via Wnt/β-catenin

This study examined the potential mechanism of zoledronate on interleukin (IL)-1β-induced temporomandibular joint osteoarthritis (TMJOA) chondrocytes, using IL-1β-induced rabbit immortalized mandibular condylar chondrocytes cultured with zoledronate. Cell viability, apoptosis, mRNA, and protein expression of relevant genes involved in extracellular matrix (ECM) degradation, apoptosis, and Wnt/β-catenin signaling were examined. The involvement of the Wnt/β-catenin signaling was examined using Wnt/β-catenin inhibitor (2-(4-(trifluoromethyl)phenyl)-7,8-dihydro-5H-thiopyrano[4,3-d]pyrimidin-4-ol (XAV-939)) and activator lithium chloride (LiCl). Aggrecan and type II collagen were downregulated by zoledronate, especially with 100 nM for 48 h (p < 0.01), consistently with the upregulation of A disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS-4) (p < 0.001), matrix metalloprotease-9 (MMP-9) (p < 0.01), caspase-3 (p < 0.001) and downregulation of proliferating cell nuclear antigen (PCNA) (p < 0.01). The apoptotic rate increased from 34.1% to 45.7% with 100 nM zoledronate for 48 h (p < 0.01). The effects of zoledronate on ADAMTs4 (p < 0.001), MMP-9 (p < 0.001), caspase-3 (p < 0.001), and PCNA (p < 0.01) were reversed by XAV-939, while LiCl increased caspase-3 expression (p < 0.01). In conclusion, zoledronate enhances IL-1β-induced ECM degradation and cell apoptosis in TMJOA chondrocytes. Wnt/β-catenin signaling might be involved in this process, but additional studies are necessary to determine the exact involvement of Wnt/β-catenin signaling in chondrocytes after zoledronate treatment.

Acute septic arthritis of the temporomandibular joint derived from otitis media: a report and review of the English and Japanese literature

Septic arthritis of the temporomandibular joint (SATMJ) is an extremely rare disease with characteristic features of preauricular pain, swelling, redness, and malocclusion. The present report describes a case of SATMJ derived from otitis media, which resulted in a good outcome. We also reviewed the English and Japanese literature with special interest in etiology. It is generally agreed that contiguous or distant infection and trauma are common etiological factors of SATMJ. So far, these etiological factors are mainly discussed based on hypotheses rather than sufficient evidence. Therefore, in many past cases, accurate causes were not identified. To our knowledge, our case is the third report of SATMJ following otitis media. In addition, this is the first case in which the pathogenic bacterium responsible for the otitis media was the definite cause of the SATMJ. Cases of SATMJ are sometimes misdiagnosed with otitis media, and SATMJ derived from otitis media is extremely rare. Dentists and otolaryngologists should collaborate for the management of this disease as needed.

Septic Arthritis of the Temporomandibular Joint--Unusual Presentations

This report describes 2 patients whose septic arthritis of the temporomandibular joint (SATMJ) presented atypically, resulting in treatment delay and complications. A 49-year-old man developed left-side facial allodynia, which was first treated unsuccessfully as trigeminal neuralgia. On day 21, the patient sustained facial trauma from a fall and presented to the emergency department (ED). Maxillofacial contrast-enhanced computed tomographic (CT) scan was suggestive of parotiditis, SATMJ, or hemarthrosis. His condition did not improve with empiric antibiotic treatment. On day 30, contrast-enhanced magnetic resonance imaging (MRI) confirmed SATMJ. Incision and drainage yielded 6 mL of pus and produced clinical improvement. Cultures grew methicillin-resistant Staphylococcus aureus, which was treated with amoxicillin plus clavulanate and sulfamethoxazole plus trimethoprim for 30 days. On day 59, the patient still had slight preauricular pain and CT-proved TMJ osteoarthritic changes. A 56-year-old woman developed right-side facial pain after a crown procedure on her right mandibular second molar. Oral prednisone (and clindamycin) produced partial relief. Her primary physician suspected temporal arteritis, but its biopsy result on day 11 was normal. Gradually, the patient developed trismus and malocclusion refractory to various medicines. On day 49, she presented to the ED. A contrast-enhanced maxillofacial CT scan suggested SATMJ. Incision and drainage yielded 30 mL of pus and produced clinical improvement. During days 50 to 57, the patient received intravenous ampicillin plus sulbactam and metronidazole. However, preauricular tenderness and drainage from the surgical incision persisted. On day 55, CT scan showed a residual abscess. Secondary debridement yielded 5 mL of pus. Culture grew coagulase-negative S aureus. On day 141, the patient still had slight preauricular pain and TMJ osteoarthritic changes on MRI. In these cases, the SATMJ diagnosis was delayed owing to the mildness of local and systemic manifestations, the possibility of confounding conditions, and the rarity of SATMJ. Contrast-enhanced CT and MRI facilitated the diagnosis. Abscess drainage alleviated the symptoms. Postinfectious osteoarthritis developed possibly from treatment delay. SATMJ should be considered in all patients with enigmatic preauricular pain, trismus, or malocclusion.