How things can go wrong

I was once again nervously awaiting for Mr. C.. He entered the consultation room smiling, and very kindly asked how I was feeling. "Not so good, I'm afraid..."

I explained all the new symptoms I had during the past month, since the right TMJ arthrocentesis. Limited mouth opening (max. 23mm/0.9inch), inability to chew anything solid, more pronounced lower jaw shift to the right side, and the pain. Severe pain. "Please, help me cope with the pain..."

He thought for a few moments before speaking. I took a deep breath and prepared myself for it.

One of two things had happened with the arthrocentesis: either I was taking a little more time than usual to recover from the procedure, or things had gone wrong. In the light of my symptoms, he was inclined to believe it was the second case.

Before the arthrocentesis, I was told that there was the chance that this surgery wouldn't help me. Mr. C. explained me that the success rate of an arthrocentesis depends on whether it is the adequate procedure to be done for a certain kind of TMJ disorder. The diagnosis of a TMJ disorder is based on MRI scans and the ability of the surgeon to interpret them. Also, the visualisation of the TMJ (bone and soft tissues) depends on the quality of the scan, which in turn is conditioned by the capability of the patient to be absolutely still during the twenty to thirty minutes that takes to do the scan (believe me - this is mission impossible...). Considering all these variables, one can only be sure of the state of a TMJ during a more invasive surgery, in which the joint is exposed. Although he was certain of my diagnosis before the arthrocentesis (anterior disc displacement with reduction), he wasn't able to tell me how damaged my disc and the surrounding tissues were. These are just too small to be visualised (the entire disc is usually < 2cm/0.8inch).

In his experience as a surgeon, the arthrocentesis procedure proved to be helpful for some people, as there was some pain and discomfort relief, especially in cases of jaw locking. However in other cases this procedure didn't show any improvements whatsoever. 

As I mentioned before, he suggested the arthrocentesis as a way to "buy some more time before a bigger surgery". He never assured me that the arthrocentesis would help me; he made it quite clear that there was the possibility of not having any positive results. But maybe I could be one of the cases where the arthrocentesis would actually help. And it was based on these arguments that I decided to do it. I didn't have anything to loose - it was either I would feel better or my TMJ condition would remain the same. Or so we thought...

Back in the consultation room, I was struggling to understand how could've things gone wrong. This was totally unexpected. "What do you mean, things went wrong?"

The limited mouth opening and the severe pain were signs that there might have been significant changes in the position of the disc inside the joint. It appeared to Mr. C. that the disc had slipped out of its normal position above the condyle permanently, as the TMJ was flushed. In other words, the fluid injection inside the joint pushed the disc forward, forcing it to remain in that position. The limited mouth opening could be a sign that the disc was acting like a barrier for the condyle to move forward, preventing mouth opening. The pain was consequence of highly innervated soft tissues being crushed between joint bones.

But it was still too early to assume that this was what actually happened. As he said right in the beginning, it could be that I was taking more time than usual to recover. So he would see me again a month later - if I didn't show any improvements, another MRI scan would be scheduled to check the TMJ. I was given an anti-inflammatory to be taken with paracetamol to control the pain. I was so overwhelmed with all this that I didn't even complain about the fact that paracetamol was not enough to reduce the pain.

I just went straight to the reception to arrange my next appointment. As if I didn't receive enough bad news already, I was told that the earliest appointment with Mr. C. would be two months later. Despite all my objections, Mr. C. said it would be okay to wait two months to be seen again. "It's okay for him, not for me! I am the one in pain!"

September went by, and so went October. During these two months the pain increased considerably. Paracetamol with the anti-inflammatory was useless. Co-codamol in doses of 6mg codeine/1000mg paracetamol every four hours was not enough. My GP (general practitioner/family doctor) prescribed me a stronger form of co-codamol: 30mg codeine/500mg paracetamol pills. I was taking two pills (60mg codeine/1000mg paracetamol) every four hours, and I felt much better. With this dosage of co-codamol, the general pain was reduced to a "comfortable pain", which is a manageable amount of pain. However, the bursts of severe pain (mostly associated with muscle spasms) were becoming more frequent and the co-codamol didn't help much.

Nothing changed with regards to eating - I was still on a soft/liquid diet. But by this point, the word soup would make my stomach revolve in disgust. I was loosing weight fast, although at the time I didn't see it as a bad thing since I was a bit overweight before the arthrocentesis.

Strong pain medication also comes with a price - it costs your stomach and bowels.

Gastritis is one of the most common side effects, and I have it. I used to be nauseated most of the time, and frequently vomiting. With a limited mouth opening, vomiting is usually done through the small mouth aperture and nose. Vomiting is bad enough; but through the nose is beyond unpleasant. Not to mention when food gets blocked inside it and you can't breath properly. I am now taking more medication to prevent stomach upsets.

I am constipated all the time, being highly dependent of laxatives. However, once I decided to take a week off the laxatives, and I ended up in the hospital with a bowel blockage and a bleeding anus. If you're laughing, you're lucky and I envy you - it means you never had to go through this and you have no idea of the suffering agony. Needless to say, from then onwards I never missed my daily laxatives.

Being in constant pain makes me feel tired and weak all the time. I do my best to work on my PhD, but the maximum I can do is around four hours a day. These are considered good days, and are becoming more and more rare as the time passes by. I am not making much progress (if any...) in my research - the thing I loved doing the most. It is extremely frustrating. I feel useless and depressed most of the time. I try to fight against it, but I'm too weak. It is exhausting.

I can't have a normal sleeping routine. I sleep only when all my energy has been drained out. I can be in bed with the lights off for hours and hours, but I'll be awake, alone with my pain. It doesn't help that I can't find  a comfortable position to rest or sleep. When I am finally exhausted, usually between 05:00-07:00am, I fall asleep. So I take the mornings off.

In the beginning of November 2011, I had my second oral-maxillofacial surgery consultation after the arthrocentesis. It was quite short, as it was only to get the papers to do another MRI scan. But this time I was lucky - on the day I called to schedule it, there was a cancellation and so I had the scan done a couple of hours later.

The day after I phoned the surgery reception to arrange an appointment with Mr. C., to discuss the results of the new MRI scan. But, as it happened before, I was told that the earliest appointment would be two months later, early February 2012.

Two months more waiting. Two months more without knowing the status of my right TMJ. Two months more of pain and suffer. Two months. A lot of things can happen in two months. And a lot did...