A one-year case series of arthrocentesis with hyaluronic acid injections for temporomandibular joint osteoarthritis

Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols*

The aim of the present pilot investigation was to compare the effectiveness of six treatment protocols providing temporomandibular joint (TMJ) arthrocentesis with or without additional drugs to manage symptoms in patients with inflammatory-degenerative TMJ disease. A consecutive series of 72 patients with TMJ osteoarthritis (axis group IIIb) with pain lasting from more than 6 months were randomly assigned to one of the groups receiving the following treatment protocols: single-session two-needle arthrocentesis (A), single-session two-needle arthrocentesis plus corticosteroid (B), single-session two-needle arthrocentesis plus low molecular weight hyaluronic acid (HA) (C), single-session two-needle arthrocentesis plus high molecular weight HA (D), 5 weekly two-needle arthrocenteses plus low molecular weight HA (E) and 5 weekly single-needle arthrocenteses plus low molecular weight HA (F). At the 3-month follow-up, improvement with respect to mean baseline values was recorded in all the five treatment groups completing the protocol. No significant differences emerged between groups in any outcome variable. The protocol providing five sessions of two-needle arthrocenteses plus low molecular weight HA allowed achieving the highest improvement in almost all the outcome variables. Findings suggested that no statistically significant differences existed between the treatment groups. The clinical significance of these findings needs to be tested with future studies on larger samples with longer follow-up periods.

The effects of high molecular weight hyaluronic acid (Hylan G-F 20) on experimentally induced temporomandibular joint osteoartrosis: part II

The aim of this study was to determine the efficacy of Hylan G-F 20 on experimentally induced osteoarthritic changes in rabbit temporomandibular joint (TMJ). A 3mg/ml concentration of sodium mono iodoacetate (MIA) had been injected into both joints of 24 rabbits to create osteoartrosis. The study group was injected with Hylan G-F 20 in one joint and saline in the contralateral joint as a control (once a week for 3 weeks). Histological changes in articular cartilage, osteochondral junction, chondrocyte appearance and subchondral bone were determined at 4, 6, and 8 weeks. Regarding cartilage, there was a statistically significant difference between the two groups at 4 weeks. Degenerative bony changes to subchondral bone were significantly higher in the controls. No statistical difference was found in the study group at 6 weeks. A positive correlation was found between osteochondral junction and subchondral bone in the study group at 8 weeks. The changes in chondrocyte appearance were significantly decreased in the study group at all follow-up times. Intra-articular injection of Hylan G-F 20 decreased cartilage changes in early stage TMJ osteoartrosis and clustering of chondrocytes showed the chondroprotective effects of Hylan G-F 20 caused by hypertrophic responses.

Reoperative temporomandibular joint surgery

TMJ surgeries are not always successful. Many potential pitfalls can occur during any phase of the treatment and can lead to complications, less than desirable results, and short- or long-term failures. Unsatisfactory results can occur for multiple reasons, including misdiagnosis of the original pathologic condition, incorrect selection of surgical technique, technical failures, complications, systemic disease, and unrealistic expectations. This article focuses on the reoperation of the TMJ primarily in cases of internal derangement and discusses TMJ arthrocentesis, arthroscopy, modified condylotomy, and open joint procedures.

Predictive factors of hyaluronic acid injections short-term effectiveness for TMJ degenerative joint disease

This study attempted to identify baseline predictors of positive outcome of arthrocenteses plus hyaluronic acid injections in degenerative temporomandibular joint disease (TMJ DJD). Ninety (n=90) consecutive patients with Research Diagnostic Criteria for Temporomandibular Disorders TMJ osteoarthritis (RDC/TMD 1.0 Axis I Group IIIb) underwent a cycle of five arthrocenteses with injections of 1mL hyaluronic acid and were followed up for 3months. Eight potential predictors of positive treatment outcome (sex, age, pain duration, baseline pain at chewing, presence of uni- or bilateral arthritis, presence of other concurrent RDC/TMD diagnoses, type of intervention and tolerability of treatment) were included in a logistic regression model to identify baseline predictors of treatment effectiveness. At follow-up, 85·6% of patients improved with respect to baseline VAS values, and 64·4% had a 50% or more decrease (positive outcomes). Correlation with positive outcomes existed only for unilateral osteoarthritis, and the logistic regression identified the side of arthritis (unilateral/bilateral) as the only predictor of positive treatment outcome (P=0·032). The achievement of any treatment improvement was predicted by high baseline pain levels (P=0·016). The regression models explained only 7·7-15% of the variance in the outcome variable. The attempts to find predictors of positive treatment outcome with HA injections for TMJ degenerative joint disease have been successful only in part. The search for other outcome predictors is likely to benefit from the assessment of psychosocial features associated with TMJ disorders.

Short-term effects of arthrocentesis plus viscosupplementation in the management of signs and symptoms of painful TMJ disc displacement with reduction. A pilot study

AIM

To provide data on the short-term effect of a cycle of five weekly arthrocenteses plus hyaluronic acid injections in the management of signs and symptoms of painful disc displacements.

METHODS

Thirty-one consecutive patients (25 females, six males; mean age 42.4) with a combined diagnosis of disc displacement with reduction and arthralgia according to the Research Diagnostic Criteria for Temporomandibular Disorders underwent a cycle of five arthrocenteses with injections (one per week) of 1 ml hyaluronic acid. A number of subjective and objective clinical parameters were assessed at the time of the diagnosis (baseline), at each appointment during the treatment, at the end of the treatment, and three follow-up appointments (1 week, 1 month, and 3 months).

RESULTS

At the end of the treatment period, marked improvements with respect to baseline values were recorded in all the outcomes variables, and they were maintained over the 3-month follow-up span. Significant changes were shown in subjective outcome variables, viz., masticatory efficiency, maximum pain levels, functional limitation, perceived efficacy, and objective clinical parameters, viz., jaw range of motion on different movements. Tolerability of treatment was acceptable since the first intervention and was moderately improved over time.

CONCLUSIONS

A cycle of five weekly hyaluronic acid injections performed immediately following arthrocentesis is effective to improve signs and symptoms in patients with painful temporomandibular joint disc displacement with reduction and to maintain them over a 3-month follow-up.

Effects of intra-articular administration of sodium hyaluronate on plasminogen activator system in temporomandibular joints with osteoarthritis

OBJECTIVE

The aim of this study was to investigate the effect of intra-articular sodium hyaluronate (SH) injections on the main components of plasminogen activator (PA) system in the synovial fluid of temporomandibular joint (TMJ) osteoarthritis (OA).

STUDY DESIGN

Forty patients diagnosed with TMJ OA and 20 healthy control subjects were included in this study. Synovial fluid was collected in the OA group and the healthy group at baseline. The OA patients were randomly divided into 2 groups (20 patients for each group): One group received 5 injections of SH, and the other received 5 injections of physiologic saline solution in the upper joint space at weekly intervals. Synovial fluid was collected before and after treatment. Urokinase-type PA (uPA), soluble uPA receptor (suPAR) and PA inhibitor 1 (PAI-1) levels in synovial fluid were quantified by enzyme-linked immunosorbent assay.

RESULTS

The OA patients had significantly higher uPA activity and levels of uPA (median 80.01 ng/L), suPAR (median 7.54 ng/L), and PAI-1 (median 54.9 ng/mL) than the healthy control subjects (median 20.47 ng/L uPA, 2.34 ng/L suPAR, and 19.9 ng/mL PAI-1; (P < .05). The uPA activity and levels of uPA, suPAR, and PAI-1 were significantly decreased after SH injections in TMJs of OA patients (P < .05), and there was no difference after saline injection. Visual analog pain score reduction correlated with changes in uPA and uPAR levels as well as uPA activity.

CONCLUSION

The effects of SH on PA system provide new insight into a possible underlying mechanism by which SH alleviates pain of patients with TMJ OA.

Temporomandibular joint osteoarthritis: an open label trial of 76 patients treated with arthrocentesis plus hyaluronic acid injections

This study is an open-label trial on a sample of 76 consecutive patients with temporomandibular joint (TMJ) osteoarthritis treated with a cycle of five weekly arthrocenteses plus hyaluronic acid injections. Patients had a diagnosis of osteoarthritis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD Axis I Group IIIb). They underwent a cycle of five arthrocenteses with injections (1 per week) of 1ml hyaluronic acid and four follow-up assessments after the end of the treatment (at 1 week, 1 month, 3 months, 6 months). At each appointment, several subjective and objective outcome variables were assessed to test the efficacy of the treatment protocol. Marked improvements were reported for all variables during the treatment phase. The improvements were maintained over the 6-month follow-up period. The p-value of the multivariate permutation test for the efficacy of the treatment over time (with Tippett's combination) was 0.001, and significant changes at the end of the follow-up period were detected for almost all the outcome variables. Data from this study lend further support to the usefulness of serial hyaluronic acid injections performed after arthrocentesis for the treatment of TMJ osteoarthritis and for the maintenance of improvements over a 6-month follow-up period.

Emerging intra-articular drug delivery systems for the temporomandibular joint

Temporomandibular joint (TMJ) disorders are a heterogeneous group of diseases that cause progressive joint degeneration leading to chronic pain and reduced quality of life. Both effective pain reduction and restoration of TMJ function remain unmet challenges. Intra-articular injections of corticosteroids and hyaluronic acid are currently used to treat chronic pain, but these methods require multiple injections that increase the risk of iatrogenic joint damage and other complications. The small and emerging field of TMJ tissue engineering aims to reduce pain and disability through novel strategies that induce joint tissue regeneration. Development of methods for sustained, intra-articular release of growth factors and other pro-regenerative signals will be critical for the success of TMJ tissue engineering strategies. This review discusses methods of intra-articular drug delivery to the TMJ, as well as emerging injectable controlled release systems with potential to improve TMJ drug delivery, to encourage further research in the development of sustained release systems for both long-term pain management and to enhance tissue engineering strategies for TMJ regeneration.

Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique

Arthrocentesis is a method of flushing out the temporomandibular joint (TMJ) that is currently performed by providing a double access to the joint space. Several studies have shown that arthrocentesis of the upper compartment of the TMJ may be a highly effective method to restore normal maximal mouth opening and functioning. Nonetheless, the classical 2-needle technique has some limits, such as the low tolerability and difficulty in performing it in the presence of intra-articular adherences. The adoption of a single-needle for both fluid injection and aspiration might have some advantages with respect to the traditional 2-needle approach in terms of time of execution, tolerability, and retention of medication. These potential advantages have to be assessed with future randomized and controlled clinical trials.

Injection of sodium hyaluronate compared to a corticosteroid in the treatment of patients with temporomandibular joint osteoarthritis: a CT evaluation

OBJECTIVE

Osseous changes in the temporomandibular joint (TMJ) were evaluated using computed tomography (CT) examinations before and after TMJ injections of sodium hyaluronate or a corticosteroid in patients with osteoarthritis (OA).

STUDY DESIGN

Forty patients were randomly allocated into 2 groups for 2 intra-articular injections with either sodium hyaluronate or a corticosteroid. Bilateral TMJ examinations with high resolution CT were obtained in 36 patients before and 6 months after treatment. Treated and contralateral TMJs were evaluated for the presence of osteoarthritic osseous abnormalities by 2 reviewers independently.

RESULTS

Progression, regression, and no changes of osseous abnormalities were demonstrated in 13, 9, and 14 TMJs, respectively, 6 months after treatment. There was no significant difference between the groups.

CONCLUSIONS

Progression/regression and no changes of osteoarthritic abnormalities were observed on CT examinations in both the treated and the contralateral TMJs after treatment with intra-articular injection with sodium hyaluronate or corticosteroid.