[The effect of sodium hyaluronate on the rabbit osteoarthrosis]

OBJECTIVE

To study the effect of high-molecular-weight sodium hyaluronate on rabbit osteoarthrosis, which was made by immobilizing the temporomandibular joint.

METHODS

18 common rabbits were equally divided into 2 experimental groups and 1 control group. After the rabbit temporomandibular joint were immobilized, 0.06 ml high-molecular-weight sodium hyaluronate were injected into the left TMJs while the same amount of physiological Saline into the right ones. The animals were terminated after 2 weeks and 4 weeks respectively. The whole bilateral TMJs were removed and histopathological and histochemical examinations were performed to evaluate the changes of articular cartilage and the content of glycansaminoglycan in articular cartilage.

RESULTS

There were severe osteoarthrotic changes in the right TMJs, whereas the changes in the left ones were slight. There was a significant difference between them (P < 0.01).

CONCLUSION

High-molecular-weight sodium hyaluronate can restrain the degenerative changes of the immobilized TMJs.

[Clinical study on chitosan in curing irreducible anterior disc displacement of tempormandibular joint]

OBJECTIVE

To evaluate the clinical efficacy of intra-articular injection with 2% chitosan as a treatment for irreducible anterior disc displacement of the TMJ.

METHODS

Total 30 patients with irreducible anterior disc displacement were divided into two groups according to quasi-randomizaion. The patients in test group received intra-articular injection with 1.0 ml of 2% chitosan into upper cavities of the suffered joints, in control group with 12.5 mg of prednisolone. The patients were followed up at the 1st day and 14th day after injection and the maximal mouth opening was measured.

RESULTS

The maximal mouth opening at 14th day was (36.73 +/- 4.69) mm in test group, with 11.73 mm increase from baseline; and (28.53 +/- 5.81) mm in control group, with 3.86 mm increase, respectively. The increase of maximal mouth opening in test group was significantly higher than that of control group (P < 0.05).

CONCLUSION

Chitosan is an effective biomaterial in curing irreducible anterior disc displacement of TMJs.

The prospective use of COX-2 inhibitors for the treatment of temporomandibular joint inflammatory disorders

Development of a new class of drugs designed to selectively inhibit the inducible cyclooxygenase isoenzyme, COX-2, was initially prescribed for individuals diagnosed with osteoarthritis or rheumatoid arthritis. Although these inflammatory disorders are more typically related to the joints of the knee, ankle, or hand, the temporomandibular joint (TMJ) plays a special role due to its involvement in our normal day-to-day activities of eating and communicating. The TMJ, unlike most of the other joints, contains some unique morphological characteristics that support various inflammatory disorders. An overview of these characteristics and the prospective use of the COX-2 inhibitors for temporomandibular joint inflammation are presented.

Long-term follow-up of intra-articular injections into the temporomandibular joint in patients with rheumatoid arthritis

A long-term (12 years) follow-up of treatment with intra-articular injections into the temporomandibular joint (TMJ) of steroid or non-steroid agents was performed in 21 patients with rheumatoid arthritis (RA) and symptomatic TMJs. The aim of the study was to compare symptoms, signs and radiological appearance of the TMJ initially and at the follow-up in this group of patients. Eleven patients were assigned to a steroid group and 10 patients to a non-steroid group. Initial and follow-up clinical and radiological examination procedures were the same. The radiological evaluation was based on a grading system using standard reference films. At follow-up, 14 patients reported no pain from the TMJ and positive changes in most clinical variables were found in both groups. Radiographic follow-up examination was performed on 12 patients. Initially, all but 4 of the 24 joints had structural bone changes. At follow-up, 2 joints had lower, 11 joints had unchanged and 11 joints had higher radiological grades. Two out of 5 and 3 out of 10 joints in the steroid and non-steroid group, respectively, showed progression of structural bone changes. Among 9 untreated joints, 6 had higher radiological grades and 3 were unchanged. In the 11 TMJs with higher radiological grades at follow-up, there was in most cases moderate progression of erosive changes. The results suggest that the long-term development of symptoms and signs from the TMJ in patients previously treated was good and the long-term progression of joint destruction was low for both steroid and non-steroid agents in this patient group with RA.

Therapeutic response of benzodiazepine, orphenadrine citrate and occlusal splint association in TMD pain

Loss of function, muscle inflammation, and pain are some of the signs and symptoms of temporomandibular dysfunction (TMD). Pharmacological strategies to minimize the clinical manifestation of these disorders often focus on blocking or inhibiting the pain-causing symptom. Resources such as muscle-relaxants, anxiety-relief drugs, and splint therapy are often used to reduce muscular hyperactivity related to TMD muscle pain. This study compares the effect of a randomly ordered association of occlusal splint therapy (S), nonsteroid anti-inflammatory with a muscle-relaxant drug (orphenadrine citrate) (O), and an anxiety-relief drug (benzodiazepine) (B), to ease painful TMD muscle symptoms. Clinical and anamnestic analyses were recorded in accordance with the Helkimo TMD index and applied before and after treatments. Twenty-one group two Helkimo TMD adult female patients were treated, all of whom were subjected to the three random therapeutic associations proposed: SBO, BOS, and OSB. The same operator applied the three specific associations over a period of 21 days in the proposed sequence, seven days for each therapy. The results show that all the groups presented the best results in terms of relief from pain after the therapeutic association (28.5% showed a decrease and 47.6% showed an absence of symptoms). No significant difference was observed among association therapeutic protocols.

Treatment of recurrent temporomandibular joint dislocation with intramuscular botulinum toxin injection

Recurrent dislocation of the mandibular condyle poses a difficult problem for affected patients. In the course of time, dislocations often become more frequent and more difficult to avoid. Even with good patient compliance, conservative treatment is often not sufficient. Operative procedures have also been described for the treatment of temporomandibular joint dislocation. However, these interventions are invasive, involving open arthrotomy with possible complications, and cannot safely guarantee a successful outcome. On the other hand, botulinum toxin injections into the lateral pterygoid muscles offer the option of a predictable and prolonged period without renewed dislocation. We present the results of this treatment carried out in 21 patients with recurrent temporomandibular joint dislocation. Four patients were treated following unsuccessful physical therapy and the use of occlusal splints. The remaining 17 patients were treated for a number of conditions resulting in dislocation, including some with senile dementia and mental impairment in whom compliance with conservative measures was poor or completely absent. Injections were given on a 3-month basis in order to have a sustained effect. Within the study period of 6 months to 3 years, only two of the 21 patients suffered further dislocation. There were no side effects recorded as a result of treatment.

Hyaluronate for temporomandibular joint disorders

BACKGROUND

Temporomandibular joint disorders (TMD) refer to a group of heterogeneous pain and dysfunction conditions involving the masticatory system, reducing life quality of the sufferers. Intra-articular injection of hyaluronate for TMD has been used for nearly two decades but the clinical effectiveness of the agent has not been summarized in the form of a systematic review.

OBJECTIVES

To assess the effectiveness of intra-articular injection of hyaluronate both alone and in combination with other remedies on temporomandibular joint disorders.

SEARCH STRATEGY

Intensive electronic and handsearches were carried out. The Oral Health Group's Trials Register (September 2001), The Cochrane Library CENTRAL database (Issue 3, 2001), MEDLINE (1966- May 2001), PubMed ( up to March 2002), EMBASE (1974 - August 2001), SIGLE (1980 - December 2001), CBMdisc (1983 - July 2001, in Chinese) and Chinese Medical Library were searched. All the Chinese professional journals in the oral health field were handsearched and conference proceedings consulted. There was no language restriction.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials (RCTs), with single or double blind, design testing the effectiveness of hyaluronate for patients with temporomandibular joint disorders.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, and three reviewers independently assessed the quality of included studies. The first authors of the selected articles were contacted for additional information.

MAIN RESULTS

Seven studies were included in the review. Three studies, including 109 patients with temporomandibular disorders, compared hyaluronate with placebo. Long term effects (three months or longer) are in favour of hyaluronate for the improvement of clinical signs/overall improvement of TMD (RR=1.71, 95%CI: 1.05, 2.77) from two of the studies (n=71). However, this conclusion was not stable enough at sensitivity analysis. Three studies provided data from 124 patients for the comparison of hyaluronate with glucocorticoids (one study also included a placebo group). Hyaluronate had the same short term and long term effects on the improvement of symptoms, clinical signs or overall conditions of the disorders as glucocorticoids. When comparing the effect of arthroscopy or arthrocentesis with and without hyaluronate, results were inconsistent. Hyaluronate had a potential in improving arthroscopic evaluation scores. Mild and transient adverse reactions such as discomfort or pain at the injection site were reported in the hyaluronate groups. No quality of life data were reported

REVIEWER'S CONCLUSIONS

There is insufficient, consistent evidence to either support or refute the use of hyaluronate for treating patients with TMD. Further high quality RCTs of hyaluronate need to be conducted before firm conclusions with regard to its effectiveness can be drawn.

Pharmacologic interventions in the treatment of temporomandibular disorders, atypical facial pain, and burning mouth syndrome. A qualitative systematic review

AIMS

To carry out a systematic review of the literature in order to assess the pain-relieving effect and safety of pharmacologic interventions in the treatment of chronic temporomandibular disorders (TMD), including rheumatoid arthritis (RA), as well as atypical facial pain (AFP), and burning mouth syndrome (BMS).

METHODS

Study selection was based on randomized clinical trials (RCTs). Inclusion criteria included studies on adult patients (> or = 18 years) with TMD, RA of the temporomandibular joint (TMJ), AFP, or BMS and a pain duration of > 3 months. Data sources included Medline, Cochrane Library, Embase, and Psych Litt.

RESULTS

Eleven studies with a total of 368 patients met the inclusion criteria. Four trials were on TMD patients, 2 on AFP, 1 on BMS, 1 on RA of the TMJ, and 3 on mixed groups of patients with TMD and AFP. Of the latter, amitriptyline was effective in 1 study and benzodiazepine in 2 studies; the effect in 1 of the benzodiazepine studies was improved when ibuprofen was also given. One study showed that intra-articular injection with glucocorticoid relieved the pain of RA of the TMJ. In 1 study, a combination of paracetamol, codeine, and doxylamine was effective in reducing TMD pain. No effective pharmacologic treatment was found for BMS. Only minor adverse effects were reported in the studies.

CONCLUSION

The common use of analgesics in TMD, AFP, and BMS is not supported by scientific evidence. More large RCTs are needed to determine which pharmacologic interventions are effective in TMD, AFP, and BMS.

Treatment of temporomandibular disorders with botulinum toxin

Temporomandibular disorder (TMD) is a collective term used to characterize a heterogeneous group of conditions involving the temporomandibular joint (TMJ) and its contiguous tissues. Although the pathologies behind TMDs have not been completely explained, the symptoms associated with these disorders are similar and are most commonly manifest as pain in the orofacial region. In preliminary studies, botulinum toxin has been used successfully to treat various pain syndromes, including TMDs. Because of the complex nature of TMDs and proximity of affected muscles to facial nerves, correct injection technique and appropriate dosing guidelines are very important for successful results. This article describes common TMDs and their treatment with botulinum toxin. Dosing guidelines and illustrations of affected muscles and target injection sites are provided.

Relief of tension-type headache symptoms in subjects with temporomandibular disorders treated with botulinum toxin-A

BACKGROUND

Temporomandibular disorder (TMD) and chronic tension headaches clinically coexist in many individuals. Generally considered as separate pathological entities, they have been clinically treated by different means.

OBJECTIVE

To determine the utility of treatment with botulinum toxin for patients with coexisting TMD and chronic tension type headache.

METHODS

In this open-label study of 60 subjects with chronic TMD, 46 subjects also met the diagnostic criteria for chronic tension headache. All 60 subjects were treated with 150 units of botulinum toxin-A injected into the masticatory muscles, specifically 50 units into each masseter and 25 units into each temporalis muscle.

RESULTS

Thirty-eight of 60 subjects (63%) reported a 50% improvement in their facial pain during the follow-up period. The subset of 46 subjects with chronic tension headache and TMD symptoms reported a 50% or greater improvement in headache pain as well. The number of headache free days also improved postinjection.

CONCLUSION

These results suggest that the masticatory muscles, specifically the temporalis, may be involved in the pathogenesis of this form of chronic tension headache found in association with TMD.

[Pharmacotherapy of orofacial pain]

OBJECTIVES

Pharmacotherapy of chronic orofacial pain is unsatisfactory. Here we set out to prepare a systematic review of randomized controlled clinical trials (RCTs) on pharmacotherapy of facial pain.

METHODS

The diagnostic groups "temporomandibular disorders" (TMDs), "atypical facial pain", and "trigeminal neuralgia" were included. RCTs published between 1966 and August 2001 were identified by Medline search, from review articles, and from the Cochrane and Bandolier databases. The quality of the trials was judged according to established criteria. Good or excellent pain reduction or >50% pain reduction were used as endpoints for successful treatment. Numbers needed to treat (NNTs) and their 95% confidence intervals were calculated where dichotomous data were available.

RESULTS

Twelve studies were identified for the TMDs, 11 for trigeminal neuralgia, four for atypical facial pain. Many studies had methodological problems and small numbers of patients. There was sufficient evidence of efficacy of carbamazepin in trigeminal neuralgia, also for baclofen and lamotrigine. In the TMD studies, there was evidence of a moderate effect of muscle relaxants/tranquilizers. Two studies of atypical facial pain showed a moderate effect of antidepressants.

CONCLUSIONS

Apart from studies in trigeminal neuralgia, there is little evidence of efficacy of pharmacotherapy in orofacial pain. High quality studies with sufficient numbers of patients using operational definitions of disease entities are warranted.

Regeneration of defects in the articular cartilage in rabbit temporomandibular joints by bone morphogenetic protein-2

The purpose of this study was to investigate the therapeutic use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in internally deranged temporomandibular joints (TMJ). Defects (2 mm in diameter) were created in the surface of the condylar head. Lyophilized rhBMP-2 with collagen as the carrier was implanted in the defects in different doses: rhBMP-2 15 microg (n = 5); rhBMP-2 3 microg (n = 5); rhBMP-2 0.6 microg (n = 5). In the two control groups, the defects were either filled with collagen alone (n = 5) or left untreated (n = 5). Three weeks postoperatively the sites of defects were examined under light microscopy. In the 15 micromg and the 3 microg groups, new cartilage had filled the defects; endochondral ossification was also found deep within the defect. In the 0.6 microg group, fibrous tissue was proliferating in most areas of the defect, although cartilage was also found in some parts. In the two control groups, there was either soft tissue repair only or no evidence of tissue repair. These findings suggest that BMP-2 could stimulate the repair of defects in the articular cartilage of the mandibular condyle head during the 3 weeks postoperatively. To observe the progress of endochondral ossification in more detail, it may be necessary to extend the experiment for a longer period of time. However, this study supports the contention that BMP-2 may be useful in the regeneration of cartilage in TMJ disease.

[Photophoresis of methyluracil ointment in the complex treatment of temporomandibular pain syndrome]

The authors recommend to expand laser radiation zones, i.e. to expose to infra-red laser radiation not only the trigger points and the temporomandibular joint but also paravertebral area, in the treatment of patients with temporomandibular painful dysfunctional syndrome (TMPDS). Experimental and clinical data have shown that photophoresis of 10% methyluracilic onitment is more effective than laser therapy in mild and moderate TMPDS.

Treatment of patients with arthrosis of the temporomandibular joint by infiltration of sodium hyaluronate: a preliminary study

Patients with degenerative disease of the temporomandibular joint (TMJ) who did not respond to conservative medical therapy (splint therapy, selected grinding or physiotherapy) can be treated by arthrocentesis, which is associated with intra-articular injections of sodium hyaluronate (Hyalgan). In this study, we treated ten dysfunctional patients with degenerative joint disease (DJD) who had been diagnosed clinically and had had the diagnosis confirmed by MRI. All subjects presented impaired mouth opening, joint pain at rest and on movement and impaired masticatory efficiency. We performed one cycle of five infiltrations with joint arthrocentesis and the injection of sodium hyaluronate at weekly intervals. The following parameters were assessed before and after infiltration and at follow-up after 6 months: mouth opening (with a mean of between 36.5 mm and 41.9 mm); sideways movements (to the right 4.9 mm to 8.9 mm and to the left 4.7 mm to 9.2 mm); pain at rest (VAS=1.8 to 0.5) and on movement (VAS=7.8 to 1.1); masticatory efficiency (VAS=5.7 to 8.6); subjective judgement of the functional TMJ limitation level (from 2.8 to 0.8); judgement of efficacy (from 2.4 to 3.2); judgement of tolerability to the therapy (from 2.0 to 3.1). The therapeutic benefits observed can be attributed both to joint arthrocentesis and to the characteristics of sodium hyaluronate itself. All the parameters considered revealed a statistically significant positive variation that persisted over time ( P<0.05). The results obtained by this minimally invasive, fast and easy technique proved to be valid and lasting. This infiltration technique using sodium hyaluronate looks very promising for patients affected by symptomatic DJD who do not respond to conservative medical therapy, reflecting similarly encouraging findings in the orthopaedic treatment of degenerative knee pathology.

Temporomandibular disorders in children and adolescents: a survey of dentists' attitudes, routine and experience

The aim of this study was to survey the experience and routine of, attitudes toward, and need for specialist resources in the treatment of temporomandibular disorders (TMD) in children and adolescents among public dentists. A questionnaire study was conducted in three counties in Sweden: Ostergötland, Västmanland, and Göteborg. The questionnaire was sent to 286 Public Dental Service dentists. It contained questions on demographic issues, quality assurance, clinical experience and expertise, attitudes, and the need for specialist resources. Eighty-seven per cent (250) of the dentists answered the questionnaire. The dentists in the three areas reported good routine and safety in occlusal splint treatments (74%-81%), occlusal equilibration (28%-55%), jaw exercise (25%-29%), and medication treatments (3%-55%). Good experience concerning diagnostics and therapy decision was reported by 25%-50% of the dentists. A significantly greater portion of the dentists in Västmanland had attended courses in TMD compared with the two other counties (p = 0.001). Registrations of quality variables such as verbal and/or written case histories with questions on facial pain and tension-type headache (1%-39%) and measurements of jaw openings were performed less frequently in the three counties (0%-5%). Fifty-five per cent of the dentists had a positive attitude toward the care of children and adolescents with TMD. A large need for specialist resources with the possibility to send referrals or to consult was reported by 98%-100% of the respondents, to participate in continuing education by 97%-98%, and to do auscultation by 61%-82%. In conclusion, many of the dentists lacked routines for making diagnoses, deciding therapy, and judging treatment results. Good routines were reported only in occlusal splint therapy. The majority of the dentists had a positive attitude toward the care of children and adolescents with TMD-related symptoms. The majority of the dentists reported a great need for TMD specialists.he

Therapeutic uses of non-steroidal anti-inflammatory drugs in dentistry

The non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of drugs for the management of acute and chronic pain in dentistry. Their therapeutic efficacy and toxicity are well-documented and provide evidence that NSAIDs generally provide an acceptable therapeutic ratio of pain relief with fewer adverse effects than the opioid-mild analgesic combination drugs that they have largely replaced for most dental applications. The great many studies done with the oral surgery model of acute pain indicate that a single dose of an NSAID is more effective than combinations of aspirin or acetaminophen plus an opioid, with fewer side-effects, thus making it preferable for ambulatory patients. The combination of an NSAID with an opioid generally results in marginal analgesic activity but with an increased incidence of side-effects, which limits its use to patients in whom the NSAID alone results in inadequate analgesia. The selective COX-2 inhibitors hold promise for clinical efficacy with less toxicity from chronic administration and may prove advantageous for the relief of chronic orofacial pain. The use of repeated doses of NSAIDs for chronic orofacial pain should be re-evaluated in light of a lack of documented efficacy and the potential for serious gastrointestinal and renal toxicity with repeated dosing.

[Treatment of temporo-mandibular joint closed-lock using intra-articular injection of mepivacaine with immediate resolution durable in time (six months follow-up)]

BACKGROUND

The purpose of this study was to assess the value of intra-articular fluid injection under pressure, as a technique suggested for temporo-mandibular joint (TMJ) closed-lock treatment, and to determine if there is a persisting lock resolution in time.

METHODS

Twelve patients were studied at our centre, with a diagnosis of TMJ closed-lock, not amenable with conventional therapies. All patients underwent a MRI scan, confirming the presence of anteriorly displaced disk. This technique is based on intra-articular injection of anaesthetic (mepivacaine cloridrate) under pressure, using the so called pumping technique, that allows an inferior distraction of the condyle. The study has a six months follow-up. After closed-lock resolution all patients underwent physiotherapy with guided mouth opening, for one month.

RESULTS

Mandibular function (maximal mouth opening) increased on average of 20.2 mm after treatment, and of 21.1 mm six months later (p=0.00000; with p<0.005). Pain decreased on average from VAS=6.75 to VAS=0.3 (p=0.00001; with p<0.005). The masticatory efficiency improved from VAS=5.25 to VAS=8.75 (p=0.002; p<0.005). Functional TMJ limitation level is significantly increased (p=0.002; p<0.005). Also, patient's efficacy judgement (mean value 3.58= good) and tolerability judgement (mean value 2.92=good) indicate that this therapy is well accepted.

CONCLUSIONS

This technique is easy to perform, well tolerated and does not need specific instruments: it permits the resolution of TMJ closed-lock, decreases the pain and improves masticatory efficiency. All these effects persist in time. Subjects with recent closed-lock have an immediate and complete functional recovery while patients with chronic closed-lock do not.

[Comparative study on effects of sodium hyaluronate and prednisolone injections on experimental temporomandibular joint osteoarthritis of rabbits]

OBJECTIVE

To assess the treatment effect of sodium hyaluronate (HA) on experimental temporomandibular joint (TMJ) osteoarthritis of rabbits in comparison with prednisolone (PS).

METHODS

The upper compartments of both TMJs of 12 Japanese White Ear Rabbits were injected with 0.2 ml of 1.6% papain, 3 days after the right TMJs were injected again with same amount of papain to induce osteoarthritis with different severity levels. Except 1 rabbit was died accidentally. After one week from final injection of papain, the upper compartments of both TMJs of 6 rabbits were injected with HA 1.3 mg, 5 rabbits with PS 1.6 mg weekly for 4 times. At 3, 5 and 7 weeks after the final injection, the rabbits were sacrificed and the TMJs were pathologically examined.

RESULTS

The TMJs receiving PS showed predominant structural disorganization, and the right TMJs had much severe pathology. The manifestations were fibrillation, thinner or flaking of the articular cartilage of the temporal part of the joint, and the articular surface was covered with fibrous tissue. Whereas the TMJs receiving HA injections demonstrated limited changes of cartilage, less fibrillation, only local loss of cartilage on outside layer of the surface. In vicinity of the defect area, cluster of the chondrocytes appeared. Pathological scores of the TMJs receiving HA were significantly less than those of the TMJs revieving PS.

CONCLUSION

The results suggest that hyaluronate have effect of cartilaginous reparation and protection for the osteoarthritis of rabbit. While prednisolone has no help or worsened for articular cartilage reparation.

[Randomized controlled trial of sodium hyaluronate for degenerative disorders of the temporomandibular joint]

OBJECTIVE

To assess the effect of sodium hyaluronate (HA) for degenerative disorders of the temporomandibular joint (TMJ).

METHODS

A prospective randomized controlled clinical trial was conducted. The experimental group received injections in the upper compartments of the involved TMJs with 1% HA 6 mg, whereas the control group received prednisolone (PS) 12.5 mg once a week. Three to four injections were as one course. Before and one week after the treatment courses, clinical symptoms, amount of interleukin-6 (IL-6) and total protein of synovial fluid were measured and compared.

RESULTS

Sixty-seven patients were included and 4 out of them were dropped out. There were 12 males and 51 females, among them, 14 cases with synovitis, 21 with anterior disc displacement without reduction and 28 with osteoarthritis of the TMJ. Thirty-five patients allocated in HA group and 28 in PS group. Both drugs could relieve the clinical symptoms of TMJ degenerative disorders. In HA group, marked improvement rate was 51.43% and failure rate was 2.86%, whereas marked improvement rate 39.29% and failure rate 17.86% in PS group. The declined levels of IL-6 in synovial fluid was notably greater in HA group than those in PS group.

CONCLUSION

Intra-articular injection of HA is effective and safe to treat TMJ degenerative disorders with mild adverse reactions, better in terms of effective rate and declined level of IL-6 than PS.

Intra-articular morphine as analgesic in temporomandibular joint arthralgia/osteoarthritis

The aim of this study was to determine the analgesic efficacy of a single dose intra-articular injection (i.a.) of morphine in 53 patients with unilateral arthralgia/osteoarthritis of the temporomandibular joint (TMJ). This randomized, double-blind, parallel group, multicenter study included a screening visit, a treatment visit, and a follow-up visit 1 week after treatment. Recordings of visual analog scales (VAS) pain intensity scores at maximum mouth opening (main efficacy variable) and at jaw rest were made directly before a 1-ml i.a. injection into one TMJ of either 1.0mg morphine-HCl, 0.1mg morphine-HCl, or saline (placebo). The pain intensity was also recorded at the follow-up and in a diary 3 days before and 5 days after the injection. The VAS pain score at maximum mouth opening was considerably reduced 1-10h after injection but without significant differences between groups. At the follow-up, the median VAS pain score at maximal mouth opening was significantly lower in the 0.1-mg morphine group than in the 1.0-mg morphine group (P<0.043) or the saline group (P<0.021). A significant increase in pain pressure threshold over the affected joint was seen in the 0.1-mg morphine group compared with the saline group at the follow-up but not 1 and 2h post-injection. The incidence of adverse events was small and did not differ between the treatment groups. In conclusion, one i.a. injection of 0.1mg morphine significantly increased the pain pressure threshold and mouth opening ability, but evidence for the analgesic property of the locally applied opioid was inconclusive. No dose-effect relation and no significant short-term analgesic property were seen. Although statistically significant, the magnitude of the reduced VAS pain intensity score was not clinically relevant at the 1-week follow-up.

Drug discovery and target validation

Recent drug discovery has been driven largely by a genomics-based approach. This revolution in pharmaceutics is based on localized expression of either a novel gene or homologue of a known gene found in cDNA libraries made from normal versus diseased tissue. The choice and quality of cDNA library is critical for the success of this approach. Expression is normally verified at the cellular level by either immunocytochemistry or in situ hybridization. Activity of the recombinant protein in secondary cell-based assays allows highthroughput screens to be formulated to identify small-molecule effectors of this protein. More recently, a proteomics approach has also been incorporated into this process. This technology directly measures proteins whose expression is localized in disease tissue as the basis for cell-based screens to look for either activators or inhibitors, of this activity. The majority of screens are designed to look for inhibitors. Activity of small-molecules found by screening gives rise to pharmacokinetic studies and verification of activity in animal models of the disease. Structure-activity relationship (SAR) optimization of these small-molecules allows for suitable oral bioavailability and pharmacokinetics, resulting in compounds progressing from discovery to development. Based on these strategies, we have developed inhibitors of osteoclast-mediated bone resorption and are currently screening for bone anabolic agents. In addition, we have also developed small-molecule caspase inhibitors which prevent chondrocyte apoptosis and retain cell function in an attempt to find therapeutic agents to either prevent or treat osteoarthritis. These agents may well have utility in the treatment of temporomandibular joint diseases.

Modulation of the inflammatory response in the rat TMJ with increasing doses of complete Freund's adjuvant

OBJECTIVES

Acute inflammation stresses the physiological system, which must respond in order to reestablish homeostasis. The purpose of this study was to determine whether bilateral temporomandibular joint (TMJ) injections of different doses of Complete Freund's Adjuvant (CFA) produced dose-dependent changes in biologic markers of acute inflammation. The ability to establish an animal model with varying degrees of joint inflammation would allow evaluation of agents or conditions that could modulate the severity of the disease.

DESIGN

The TMJs of three groups of male Sprague-Dawley rats were injected with CFA containing varying doses of Mycobacterium tuberculosis (MT). A group of non-injected and a group of saline injected rats were used as controls. Food intake, body weights, swelling and chromodacryorrhea were recorded daily. Interleukin-1 beta (IL-1 beta) and corticosterone levels were assayed and condylar cartilage thickness was measured 48 h after injections.

RESULTS

Twenty-four hours post-injection, bilateral TMJ swelling and chromodacryorrhea were significantly (P< 0.05) increased following 10 microg of MT and further increased with elevated MT dose. In the CFA groups food intake was attenuated (P< 0.01) 24 and 48 h post-injection and negatively correlated with dose at 24 h. Body weight was also negatively correlated with dose. TMJ retrodiscal tissues IL-1 beta was increased (P< 0.05) in a dose-dependent manner. CFA increased corticosterone (P< 0.05), but this elevation was not dose dependent. Condylar cartilage thickness was decreased in a dose-dependent manner.

CONCLUSIONS

These data suggest that an intermediate dose of CFA can be used to effect submaximal levels of TMJ inflammation that will allow experimental modulation in future studies.

Occlusal splints and temporomandibular disorders: why, when, how?

Occlusal splints are one form of treatment in the management of patients with a temporomandibular disorder. Appliances are often used in conjunction with other forms of treatment such as physiotherapy or medication. A variety of splints is described in the literature and the dentist must ensure that the splint prescribed is of a design that has a proven success rate for the specific diagnosis. General principles that apply to the provision of all splints are outlined in this paper.

Topical application of capsaicin for the treatment of localized pain in the temporomandibular joint area

AIMS

To determine the effectiveness of topical capsaicin cream application on localized pain in the temporomandibular joint (TMJ) area.

METHODS

A randomized, double-blind, placebo-controlled study was conducted on 30 patients suffering from unilateral pain in the TMJ area. Patients were randomly divided into experimental and placebo groups; they were instructed to apply 0.025% capsaicin cream or its vehicle to the painful TMJ area 4 times daily for 4 weeks. Subjective parameters of present pain, most severe pain, effect of pain on daily activities, and pain relief were assessed each week on a visual analog scale. Muscle and joint sensitivity to palpation on the painful and contralateral joints and maximal mouth opening (assisted/passive and non-assisted/active) were examined weekly by the same experienced examiner.

RESULTS

Capsaicin cream produced no statistically significant influence on measured variables when compared to placebo. Both experimental and placebo groups showed statistically significant improvement in most variables during the experiment.

CONCLUSION

The factor of time had a major effect in the non-specific improvement of the parameters assessed. The placebo effect played an important role in the treatment of patients with pain in the TMJ area.

A randomized double-blind clinical trial of the effect of chondroitin sulfate and glucosamine hydrochloride on temporomandibular joint disorders: a pilot study

Previous studies have shown chondroitin sulfate and glucosamine hydrochloride have beneficial effects on symptoms of osteoarthritis of the knee. Our aim was to study the effect of a daily dose of 1500 mg of glucosamine hydrochloride (GH) and 1200 mg of chondroitin sulfate (CS) taken for twelve weeks on subjects diagnosed with capsulitis, disk displacement, disk dislocation, or painful osteoarthritis of the temporomandibular joint (TMJ). Forty-five subjects were enrolled in the study and were randomly assigned to either an active medication group or a placebo group. Eleven subjects were lost from the study for various reasons, resulting in fourteen subjects remaining in the active medication group and twenty subjects remaining in the placebo group. Subjects taking CS-GH had improvements in their pain as measured by one index of the McGill Pain Questionnaire, in TMJ tenderness, in TMJ sounds, and in the number of daily over-the-counter medications needed. Subjects taking the placebo medication had improvements in their pains as measured by the visual analog scale and by four indices of the McGill Pain Questionnaire. Additional studies are required to evaluate the clinical effectiveness of CS-GH and to determine the exact mechanism by which CS-GH affects the articular cartilage of synovial joints.

Immediate effects of the serotonin antagonist granisetron on temporomandibular joint pain in patients with systemic inflammatory disorders

The aim of this study was to investigate if the 5-HT3 antagonist granisetron reduces temporomandibular joint (TMJ) pain in patients with systemic inflammatory joint disorders. Sixteen patients with systemic inflammatory joint disease with pain localized over the TMJ region and tenderness to digital palpation of the TMJ were included. The current resting pain (VASRest) and the pain during maximum mouth opening (VAS(MVM)) of the TMJs were assessed with a 100 mm visual analogue scale. An electronic pressure algometer was used to estimate the pressure pain threshold (PPT) over the lateral aspect of the TMJ. Venous blood was collected for measurement of the plasma and serum levels of 5-HT, erythrocyte sedimentation rate, rheumatoid factor and C-reactive protein. The selective 5-HT3 receptor antagonist granisetron or saline were injected into the posterior part of the upper TMJ compartment in a randomized double-blind manner. The patients in the granisetron group had lower VASRest than the patients in the saline group after 10 min. In the granisetron group, VASRest was decreased after 10 min, while VAS(MVM) was decreased and PPT increased after 20 min. In the saline group, VAS(MVM) was decreased after 20 min. In conclusion, granisetron has an immediate, short-lasting and specific pain reducing effect in TMJ inflammatory arthritis. The 5-HT3 receptor may therefore be involved in the mediation of TMJ pain in systemic inflammatory joint disorders.

Botulinum toxin: new treatment for temporomandibular disorders

BACKGROUND

Temporomandibular disorders (TMDs) affect the face and jaws, and cause chronic pain and dysfunction in many people. As in other conditions involving the musculoskeletal system, controlling the myogenous component is an integral part of treatment. In this study, we evaluated subjective and objective responses to treatment with botulinum toxin A (BTX-A) in a group of 46 patients with TMDs.

METHODS

46 subjects with TMD were enrolled in this uncontrolled study and treated with BTX-A 150U. Both masseter muscles were injected with 50 U each and both temporalis muscles with 25 U each under electromyographic guidance. Subjects were assessed at two-week intervals for eight weeks. Outcome measures included subjective assessment of pain by visual analogue scale (VAS), measurement of mean maximum voluntary contraction (MVC), interincisal oral opening, tenderness to palpation, and a functional index based on multiple VAS. Medians of the data were taken for each outcome measure at each time point and subjected to Duncan's multiple range test.

RESULTS

There were significant (P<0.05) differences in all median outcome measures between the pre-treatment assessment and the four follow-up assessments except for MVC. Although MVC was significantly reduced midway through the study, it had returned to pretreatment values by the final two assessments. All other outcome measures remained significantly different from the pretreatment findings. Paired correlation of variables including age, sex, diagnosis, depression index, and time of onset showed no significant differences.

CONCLUSIONS

BTX-A injections produced significant improvements in pain, function, mouth opening, and tenderness to palpation. MVC initially diminished then returned to the initial values. Although the study was uncontrolled, the results strongly suggest that BTX-A reduces severity of symptoms and improves functional abilities for patients with TMD and that these extend beyond its muscle-relaxing effects.

Amitriptyline treatment of chronic pain in patients with temporomandibular disorders

Randomized clinical trials of amitriptyline will require data from pilot studies to be used for sample size estimates, but such data are lacking. This study investigated the 6-week and 1-year effectiveness of low dose amitriptyline (10-30 mg) for the treatment of patients with chronic temporomandibular disorder (TMD) pain. Based on clinical examination, patients were divided into two groups: myofascial and mixed (myofascial and temporomandibular joint disorders). Baseline pain was assessed by a Visual Analogue Scale (VAS) for pain intensity and by the McGill Pain Questionnaire (MPQ). Depression was assessed by the Beck Depression Inventory (BDI) short form. Patient assessment of global treatment effectiveness was obtained after 6 weeks and 1 year of treatment by using a five-point ordinal scale: (1) worse, (2) unchanged, (3) minimally improved, (4) moderately improved, (5) markedly improved. The results showed a significant reduction for all pain scores after 6 weeks and 1 year post-treatment. The depression scores changed in depressed but not in non-depressed patients. Global treatment effectiveness showed significant improvement 6 weeks and 1 year post-treatment. However, pain and global treatment effectiveness were less improved at 1 year than at 6 weeks.

[Treatment of recurrent luxation of the temporomandibular joint with botulinum toxin]

We report the case of a 70-year-old man who suffered recurrent dislocations of the temporomandibular joint secondary to severe Parkinson syndrome. The patient was given repeated injections of botulinum toxin. After 3 injections over a 9-month period, no further dislocation occurred. Botulinum toxin may be an alternative to surgery.

Effect of methotrexate on the temporomandibular joint and facial morphology in juvenile rheumatoid arthritis patients

Juvenile rheumatoid arthritis is a disease characterized by chronic inflammation in one or more joints; it affects children and adolescents up to 18 years of age. This disease may cause significant skeletal joint destruction, and the temporomandibular joint, like other joints, may become severely affected resulting in aberrant mandibular growth, abnormal dentofacial development, and/or altered orofacial muscle function. Methotrexate is the most common remittive agent used in juvenile rheumatoid arthritis to modify the course of inflammatory destruction of peripheral joints. The purpose of this study was: (1) to evaluate the effect of methotrexate therapy on the prevalence of temporomandibular joint lesions and aberration in craniofacial development in children afflicted with juvenile rheumatoid arthritis; (2) to further examine the relationship between the temporomandibular joint/cephalometric findings and rheumatologic data (ie, age at onset, duration of disease); and (3) to evaluate further pauciarticular- and polyarticular-onset disease in juvenile rheumatoid arthritis and the prevalence of temporomandibular joint lesions and facial dysmorphology. The following information was obtained from 45 patients with juvenile rheumatoid arthritis: (1) routine rheumatologic clinical examination data; (2) anamnestic temporomandibular joint evaluation data; (3) clinical temporomandibular joint examination data; (4) lateral cephalometric measurement data; (5) posteroanterior cephalometric measurement data; and (6) individually corrected axial tomographic data. The results demonstrated the following: (1) radiographic evidence of condylar degeneration was apparent in 63% of all patients with juvenile rheumatoid arthritis with pauciarticular patients showing less temporomandibular involvement than polyarticular patients; (2) polyarticular juvenile rheumatoid arthritis patients receiving methotrexate showed less severe temporomandibular joint involvement than the polyarticular patients not receiving methotrexate; (3) the craniofacial structure was affected to a greater extent in the polyarticular form of the disease; (4) the craniomandibular index scores were significantly greater in the polyarticular group; (5) vertical height asymmetry and chin deviation were noted in more than 50% of the patients; and (6) there was a correlation between the severity of condylar lesions and cephalometric findings (ie, mandibular retroposition, posterior rotation, smaller ramus and mandibular dimensions) and the onset and duration of the disease. In conclusion, under the conditions of this study, methotrexate therapy was effective in minimizing temporomandibular joint destruction and craniofacial dysmorphology in juvenile rheumatoid arthritis patients with the polyarticular form of the disease.

Temporomandibular joint osteoarthrosis. Histopathological study of the effects of intra-articular injection of triamcinolone acetonide

OBJECTIVES

The aim of this study was to investigate the histopathological changes of human temporomandibular joint osteoarthrosis following intra-articular injection of triamcinolone acetonide, and compare the results to these of control group.

METHODS

One hundred and forty nine patients who complained of temporomandibular joint dysfunction underwent non-surgical treatment for at least 6 months. Twenty three patients had high condylectomy as a treatment. Forty four patients received two intra-articular injections of triamcinolone acetonide. Histological study was carried out on 44 specimens from 41 patients, the histological changes were recorded for each specimen.

RESULTS

Patients who received temporomandibular intra-articular injection of triamcinolone acetonide showed damage to the fibrous layer (100%), to the cartilage (64%) and to the bone (42%). In those cases treated by condylectomy there were changes in the fibrous layer (100%), in the cartilaginous layer (68%) and to the bony layer (32%). Analysis of the results showed that the changes seen in the steroid (triamcinolone acetonide) group were more obvious than the changes in the non-steroid group.

CONCLUSION

The result of this study indicated that intra-articular injection of steroid (triamcinolone acetonide) into human osteoarthritic temporomandibular joints acts as a lytic agent.

Profile of TMD and Bruxer compared to TMD and nonbruxer patients regarding chief complaint, previous consultations, modes of therapy, and chronicity

This comparative study by groups assesses the profiles of TMD (temporomandibular dysfunction) and bruxism patients and TMD-nonbruxing patients regarding chief complaint, previous medical and dental consultations, duration of the chief complaint, previous medication, and use of splints. The sample consisted of a group of 340 TMD patients, 275 of whom were bruxers and 65 who were nonbruxers. Both patients and controls were consecutive referrals over a period of five years. The group of TMD and Bruxer was classified according to the degree of severity. One hundred eight (108), 84, and 83 patients demonstrated mild, moderate, and severe bruxism respectively. Information gathered included a set of questionnaires, history of signs and symptoms, and a clinical examination. The most common chief complaints in TMD bruxers and nonbruxers were facial, temporomandibular joint, headache and/or cervical pain, and joint noises. It was observed that the need for medical and dental consultations increased with the severity of bruxism. It was also apparent in this study that the need for medication (analgesics, muscle relaxants, and antidepressants), increased with the severity of bruxism. Moderate and severe subgroups of bruxers used significantly more splints compared to mild bruxers and to TMD-nonbruxer patients. Both groups of TMD + bruxism and TMD - nonbruxism sought medical and dental consultations with dentists (clinicians and specialists) neurologists, and otolaryngologists more frequently compared to other medical professionals. Since the need for health services increased with the severity of bruxism, this study urges the need to include a protocol or questionnaire to assess the severity of bruxing behavior in TMD patients in order to use a customized method of treatment/management. This study also reinforces the point of view that different subgroups of TMD and bruxism do exist and suggests a differentiated therapeutic approach. They show previously confirmed findings that pain is the major complaint of TMD and bruxer patients.

Occlusion, prosthodontic treatment, and temporomandibular disorders: a review

The purpose of this article is to review the literature on the relationship between occlusal discrepancies and temporomandibular disorders (TMD) and to summarize the guidelines of treating TMD by prosthetic rehabilitation. To date, the relationship between occlusal condition and TMD has not been confirmed, although there is a current trend toward making a weak correlation between occlusal interference and TMD. Furthermore, several types of occlusal discrepancies have been considered as variable features of the norm. But unstable occlusion in the intercuspal position may cause TMD. In cases of restored dentition, the problem is probably different and iatrogenic TMD are not rare. Namely, malformed occlusal surfaces, defects in anterior guidance, occlusal curvature, and vertical dimension may lead to some TMD trouble. According to these recent concepts the treatment modalities of TMD have been changed. Conservative treatments such as counseling, behavioral modification, physical therapy, pharmacotherapy, and interocclusal appliances should be the first choice, and treatments that lead to drastic changes of occlusion are not recommended.

The use of botulinum toxin for the treatment of temporomandibular disorders: preliminary findings

PURPOSE

The aim of this study was to evaluate the response of patients with temporomandibular disorders to Botulinum toxin A (BTX-A) therapy.

METHODS

The 15 subjects enrolled in this uncontrolled study were diagnostically categorized and treated with 150 units of BTX-A. Both masseter muscles received 50 units each under eletromyographic (EMG) guidance. Similarly, both temporalis muscles were injected with 25 units each. Subjects were assessed at 2-week intervals for 8 weeks. Outcome measures included subjective pain by visual analog scale (VAS), measurement of bite force, interincisal opening, tenderness to palpation, and a functional index based on multiple VAS.

RESULTS

All mean outcome measures, with the exception of bite force, showed a significant (P = .05) difference between the preinjection assessment and the four follow-up assessments. No side effects were reported.

CONCLUSIONS

BTX-A injections produced a statistically significant improvement in four of five measured outcomes, specifically pain, function, mouth opening, and tenderness. No statistically significant changes were found in mean maximum voluntary contraction or in paired correlation of factors such as age, sex, diagnosis, depression index, or time of onset.

Comparison of clinical profiles and treatment outcomes of an elderly and a younger temporomandibular patient group

STATEMENT OF PROBLEM

Older temporomandibular disorder patients with more general complications and health problems may have a different clinical profile and be likely to react less favorably to conservative treatment.

PURPOSE

This retrospective study compared the clinical profiles of a young (20 to 30 years) and an older (50 to 70 years) group of patients with pain and dysfunction in the temporomandibular region and to analyze treatment outcomes.

METHODS

Clinical profiles and treatment outcomes were studied with a standardized protocol and the Helkimo Pain and Dysfunction Index up to 1 year after initial examination.

RESULTS

Younger and older patients with temporomandibular disorder differed only in pain intensity at initial examination, but the outcome of conservation treatment was equally successful.

CONCLUSION

Conservative treatment resulted in a significant alleviation of pain and dysfunction in almost 85% of patients. Both the younger and the older patient groups benefitted from this treatment protocol and therefore can be treated in the same fashion.

[Pathologic study on synovial fluid after intra-articular corticosteroid therapy in temporomandibular joint disorders]

OBJECTIVE

To study what happens after intra-articular injection of corticosteroid.

METHODS

Synovial fluid after intra-articular corticosteroid therapy in temporomandibular joint disorders (TMD) was studied by hematoxylin-eosin, PAS, and Atcian blue staining.

RESULTS

The results were that broken synovial membrane and articular cartilage, lots of synovial lining cells, macrophagocytes, inflammatory cells and free cartilage matrix could be found in the lavage fluid.

CONCLUSION

The results suggest that drug synovectomy may be one mechanism about intra-articular corticosteroid therapy in TMD, and this therapy could lead to progressive degradation and destruction of the articular cartilage. Arthrocentesis and lavage are needed three to five days after this therapy.

The effect of intra-articular irrigation injection therapy on osteoarthrosis of the temporomandibular joint

OBJECTIVE

To investigate the effect of intra-articular irrigation-injection therapy in treating osteoarthrosis of the temporomandibular joint.

MATERIALS AND METHODS

Thirty-seven patients (the test group) received intra-articular irrigation injection; 26 patients (the control group) received intra-articular injection of steroid. The synovial fluid, aspirated from five subjects of the test group before and after the therapy, was assayed to determine the tumor necrosis factor.

RESULTS

Clinical evaluations were performed 3 months after the therapy. Thirteen subjects in the test group fell into the "excellent" category, 19 into the "good" category, and five into the "no effect" category; in the control group, eight subjects fell into the "excellent" category; nine into the "good" category, and nine into the "no effect" category. The category difference in total effectiveness between the test group and the control group is statistically significant (X2 = 3.9340 P < 0.05). TNF in synovial fluid also showed statistically significant differences before and after treatment (T = 2.8825, P < 0.05).

CONCLUSIONS

Intra-articular irrigation injection is an effective therapy method for treating osteoarthrosis and is superior to intra-articular injection of steroid.

Clinical aspects of orthodontic treatment for children with juvenile chronic arthritis

Growth abnormalities as a consequence of temporomandibular joint arthritis in children with juvenile chronic arthritis are difficult and complicated problems to treat. The diagnosis of the inflammatory condition in the joint is difficult but important to the success of the interceptive treatment. The diagnostic problems, treatment objectives, and treatment suggestions are discussed in this article.

The potential role of doxycycline in the treatment of osteoarthritis of the temporomandibular joint

Collagenase and gelatinase are matrix metalloproteinases (MMPs) which play an important role in tissue destruction in arthritic joints. Studies have demonstrated that tetracyclines can inhibit MMPs and prevent tissue destruction independent of their antimicrobial activity. The purpose of this pilot study is to assess the potential therapeutic role of Doxycycline in patients with advanced osteoarthritis of the temporomandibular joint (TMJ). This ongoing investigation includes patients with a diagnosis of osteoarthritis of the TMJ based on clinical and diagnostic imaging findings, symptoms (localized TMJ pain, limited mobility, dysfunction) for a minimum of 36 months, and failure of previous non-surgical and surgical modalities to alleviate the symptoms. A synovial fluid sample is collected by a saline injection and aspiration technique, followed by diagnostic arthroscopy. Patients are placed on Doxycycline 50 mg BID for three months and then undergo repeat diagnostic arthroscopy and synovial fluid collection. The samples are stored at -80 degrees C. Collagenase activity is determined by a combination of SDS-polyacrylamide gel electrophoresis and fluorography and calculated based on the percentage of collagen alpha chains that are degraded into alphaA breakdown products. Three patients have completed the three-month course of Doxycycline thus far, and 5 joints with osteoarthritis have been analyzed. All patients were female (mean age = 35, mean duration of symptoms = 132 months) and had undergone previous bilateral arthroscopies. One patient had undergone unilateral arthroplasty. The mean collagenase activity showed 55% collagen lysis prior to Doxycycline treatment and 19% after three months of therapy. The mean gelatinase activity was 28% prior to Doxycycline treatment and 7% after three months of therapy. The mean interincisal opening was 33 mm initially and 41 mm after three months of Doxycycline. Subjectively, two of the three patients reported significant improvement in their overall symptoms, which they had not experienced over the previous three years. One patient did not experience any change in symptoms, in spite of a marked reduction in collagenase activity from 86.4% to 9.6%. Because of the very small numbers of patients enrolled in this pilot study so far, no statistically significant differences could be appreciated. However, the dramatic reduction in collagenase activity in these patients, with a long history of TMJ symptoms from osteoarthritis, suggests the potential promising role of Doxycycline in the management of osteoarthritis, and further investigation is warranted.

Effect of intra-articular versus systemic anti-inflammatory drugs in a rabbit model of temporomandibular joint inflammation

PURPOSE

In an attempt to better understand the time course of inflammatory mediator production or release in inflammatory joint disease, a rabbit model of acute temporomandibular joint (TMJ) inflammation was established. This model was used to evaluate the effects of specific anti-inflammatory agents administered either systemically (intraperitoneal, IP) or locally (intra-articular, IA) on the modulation of in vivo tissue levels of two prototypic inflammatory mediators, prostaglandin E2 (PGE2) and bradykinin (BK).

MATERIALS AND METHODS

An experimental model of inflammation was created by administering carrageenan (carra) into one joint and an equivalent volume of saline (control) into the contralateral joint of 42 male New Zealand White rabbits. The development of hyperthermia was assessed by placement of a microthermister probe into the joint space. The inflammatory mediators, immunoreactive PGE2 (iPGE2) and BK (iBK), were recovered with microdialysis probes, and samples were assayed in conjunction with specific pharmacologic interventions. In the first part of the study, the time course for the release or production of iBK and iPGE2 was determined. In the second part, the effects of IP versus IA administration of dexamethasone and a nonsteroidal anti-inflammatory drug, ketorolac tromethamine, were compared. Dexamethasone and ketorolac were administered at 3 hours and 1 hour, respectively, before the peak release of the inflammatory mediators.

RESULTS

The onset of IA hyperthermia, an index of inflammation, was evident by 90 minutes post-carra and reached a maximum of 1.2 degrees C above core temperature by 150 minutes post-carra. Intra-articular levels of iPGE2 and iBK peaked at 240 minutes (3.35+/-1.9 nmol/L) and 270 minutes (0.45+/-0.29 nmol/L), respectively, after the induction of inflammation in the superior joint space. iBK levels within the superior joint space were significantly decreased by dexamethasone and ketorolac. Ketorolac (50 microg) decreased iBK and iPGE2 levels when given IA or IP. With dexamethasone (3 mg), the levels of iBK were significantly reduced, and iPGE2 levels were not changed.

CONCLUSIONS

This study shows that the rabbit model of TMJ inflammation, with concurrent collection of iBK and iPGE2 via microdialysis, is a reproducible and reliable method to investigate the time course of inflammatory mediator release and their modulation by either the local or systemic administration of anti-inflammatory medications.

The effects of glucosamine and chondroitin sulfate on osteoarthritis of the TMJ: a preliminary report of 50 patients

The signs and symptoms of osteoarthritis are common complaints seen in patients suffering with chronic temporomandibular disorders (TMD), specifically, internal derangements with a diagnosis of osteoarthritis. With or without the complaints of pain and swelling, joint noises are bothersome and annoying to both the patient and at times, to those seated close to the patient during mealtime. In fact, many patients are driven to seek care by family members because of his or her TMJ noises. For years in veterinarian medicine, glucosamine and chondroitin sulfates have been used to treat symptoms of osteoarthritis. Recently, the use of these two supplements has been recommended for human beings as well. Reports of decreased joint noises, pain and swelling after the administration of therapeutic doses of these supplements have sparked an interest in their possible use in the treatment of osteoarthritis.

Necrosis of the articular tubercle after repeated injections of sodium hyaluronate in the temporomandibular joint. A case report

A case of partial bone necrosis of the articular tubercle of the temporomandibular joint is presented. It was probably caused by repeated injections of sodium hyaluronate in the joint. A sequestrectomy was performed under general anesthesia, and the postoperative course was uneventful.

Triazolam improves sleep but fails to alter pain in TMD patients

Patients with chronic orofacial pain often report disturbances in sleep, leading to the hypothesis that nocturnal motor hyperactivity of the muscles of mastication may contribute to the nociceptive process. This hypothesis was tested in a controlled study to evaluate the relationship between sleep stages, patient self-report of pain in the orofacial region, and nocturnal masticatory muscle activity. Twenty subjects participating in a two-period, within-subject, crossover study received triazolam or placebo for 4 nights. Sleep, pain, and mandibular range of motion were assessed at baseline, following the first period, and again following the second period; a 3-day washout period separated the two treatments. Subjective report of sleep quality was significantly improved following triazolam in comparison to placebo as measured by category scales for sleep quality, restfulness, and sleep compared to usual. The amount of time spent in stage-2 sleep was also significantly increased by triazolam. No improvement was seen in pain as measured by palpation with an algometer, in scales for sensory intensity and the affective component of pain, or in daily pain diaries. Mean facial muscle electromyographic activity for 30-second epochs averaged over the entire period of sleep did not reveal any differences in muscle activity across the three conditions. These data indicate that improvements in sleep quality and alterations in sleep architecture do not affect nocturnal facial muscle activity or subsequent pain report in temporomandibular patients, thereby failing to support the hypothesized relationship between sleep disturbances and chronic orofacial pain.

Substance P-associated increase of intra-articular temperature and pain threshold in the arthritic TMJ

Neuropeptides are considered mediators and modulators of inflammatory joint disease. Substance P (SP) has been proposed as a mediator of pain, and its vasoactive properties are well documented. In this study, the presence of SP-like immunoreactivity in the synovial fluid was correlated to intra-articular temperature (IAT) and pain from the arthritic temporomandibular joint (TMJ) 3 to 5 weeks after one intra-articular injection of glucocorticosteroids. Eighteen TMJs were investigated for IAT and the presence of SP-like immunoreactivity in the synovial fluid in 12 patients with systemic inflammatory joint disease. After arthrocentesis, the aspirates were analyzed for SP-like immunoreactivity by means of competitive radio immunoassay. A visual analogue scale and an algometer determining the pressure pain threshold and tolerance level assessed arthritic pain and hyperalgesia in the TMJ. Our results indicate that SP-like immunoreactivity is associated with IAT and that increased concentrations of joint fluid SP-like immunoreactivity correspond to increased pain threshold and tolerance and a concomitantly decreased visual analogue scale. These findings suggest that SP is implicated in the vascular and nociceptive response of the arthritic joint and that SP, possibly assisted by the antinociceptive effect of local corticosteroids, has a modulatory role in arthritic pain and hyperalgesia.