22 September 2014

NICE Approves Jaw Replacement Surgery, in 500th IP

NICE has recommended the use of jaw replacement surgery for people who have pain and difficulty opening their mouth and are unable to eat a normal diet.

Temporomandibular joint disorders are problems that affect the joint between the lower jaw and the base of the skull. TJDs are relatively common and can occur in approximately 20-30 per cent of the adult population. Symptoms may occur at any age but are more common in women and in early adulthood.

Temporomandibular joint disease can be caused by inflammatory and degenerative arthritis, trauma and complications of surgery.

First line treatment involves the use of lifestyle changes such as eating soft foods and avoiding chewing gum, the use of mouth guards, non-steroidal anti-inflammatory drugs and physiotherapy.

However, if these measures do not help then total prosthetic replacement of the temporomandibular joint should now be considered for patients.

Previously, NICE was only able to recommend the procedure under special arrangements for clinical governance, consent and audit or research because of a lack of evidence on long-term efficacy and on safety.

With the patient under anaesthetic, a cut is made in front of the ear and behind or below the lower jaw. The diseased parts of the joint are replaced with artificial joints, which can be made from various materials. Part of the lower jaw is sometimes removed to allow more movement after surgery.

Patient selection should be carried out in specialist units by a team with regular practice and specific expertise in the conservative and surgical management of temporomandibular joint problems, and should include consideration of all relevant medical and surgical options. The British Association of Oral and Maxillofacial Surgeons (BAOMS) has produced guidelines on patient selection.

The procedure should be carried out only by clinicians with specific training and experience in total prosthetic replacement of the temporomandibular joint.

Professor Bruce Campbell, Chair of the Interventional Procedures Advisory Committee at NICE, said: “Total prosthetic replacement of the temporomandibular joint is only intended for people who are experiencing extreme pain or disability. It is one of a number of surgical options, which specialists will always discuss in detail with people who might need this operation.

“We are pleased to be able to recommend normal arrangements for this procedure. When we originally looked at this prosthetic replacement of the temporomandibular joint in 2009 there was not enough evidence for us to advise that it worked well enough and was safe enough. At the time, we encouraged clinicians to collect more data to provide us with further evidence of the procedure’s long-term safety and effectiveness. We’re pleased that specialists took notice of our recommendation and recorded this information – this has directly led to NICE revising its guidance.”

The latest recommendations are set out in the 500th piece of interventional procedures guidance published by NICE. Interventional procedures guidance provides recommendations on a wide range of treatments, and some diagnostic tests, to ensure that they are introduced into the NHS in a responsible way.  These include all kinds of surgical operations, procedures done through the arteries and veins and procedures done using ultrasound or X-rays.

Interventional procedures guidance aims to support healthcare professionals who are in the process of introducing new procedures, and protect patient safety. Many of the procedures we examine are new, but we also investigate more established procedures if there is any uncertainty about how safe they are or how well they work.