Internal derangement of temporomandibular joint: an evaluation of effect of corticosteroid injection compared with injection of sodium hyaluronate after arthrocentesis

State of the Art in Temporomandibular Joint Arthrocentesis-A Systematic Review

Temporomandibular joint disorders are a heterogenic group of clinical conditions, which impair physiological functioning of the masticatory system. Arthrocentesis of the temporomandibular joint has become a widely approved method for non-invasive treatment, bridging the gap between conservative and surgical approaches. Regardless of technique, treatment is based upon joint lavage and lysis of the inflammatory fibrous tissue adhesions, which, in turn, improves joint mobility and reduces pain and closed lock. Recently, approaches for intra-articular injections have been proposed as adjuvant or replacement therapy. The aim of this study was to assess the most efficient technique of arthrocentesis. A systematic search based on PRISMA guidelines, including a computer search with specific keywords, a reference list search and a manual search, was performed. Relevant articles were selected after three search rounds for final review. The studies pulled for the analysis presented information about the relevant predictors, including the technique of arthrocentesis (single- or two-needle method), fluid used for lavage (Ringer lactate or saline), volume of the fluid, application of the injectable, number of interventions, pain (VAS) and mouth opening scores (MMO) and follow-up. All cohorts showed improvement in mouth opening, but significant pain reduction was observed only in cohorts treated either by arthrocentesis alone or arthrocentesis followed by intra-articular injectables. Intra-articular injectables used alone failed to reduce pain post-operatively when compared to other cohorts. We concluded that both double-needle and single-puncture arthrocentesis techniques are equally efficient. Application of the adjuvant injectable did not improve the outcomes of arthrocentesis performed alone. The volume of the fluid used for joint lavage and its chemical composition were not significant in clinical outcomes. However, due to the lack of homogeneity in the study settings, a meta-analysis could not be applied and a systematic review was conducted. We still, however, state that there is a knowledge gap in the current literature regarding the use of injectables alone, as well as a longitudinal follow-up, which provides information about treatment efficiency. More high-quality and randomized controlled trials are required to shed light on this subject.

Hyaluronic Acid and Platelet-Rich Plasma Mixture Versus Hyaluronic Acid and Corticosteroid in the Treatment of Temporomandibular Joint Internal Derangement: A Comparative Randomized Study

Objectives

This study aimed to compare the effects of different intra-articular injections using a mixture of hyaluronic acid (HA) and platelet-rich plasma (PRP) versus hyaluronic acid and corticosteroid in the management of TMJ internal derangement with reduction.

Materials and Methods

Sixty patients were randomly divided into two equal groups. Group I was injected with hyaluronic acid and PRP, while group II was injected with hyaluronic acid and corticosteroid. Pain intensity according to the visual analogue scale, maximum inter-incisal opening (MIO), lateral movement, and joint sound were measured pre-operatively and at 1 week, 1 month, and 6 months post-operatively.

Results

MIO and lateral movements were improved in both groups, with a reduction in the number of patients suffering from clicking sounds along the follow-up periods with no significant difference between the studied groups. However, regarding pain, the group injected with HA and PRP achieved the best results after 6 months, while patients treated with HA and corticosteroids obtained the best results at the end of the 1st week.

Conclusion

Hyaluronic acid and platelet-rich plasma mixture performed better than hyaluronic acid and corticosteroid in the treatment of TMJ internal derangement with reduction at the long-term follow-up regarding pain intensity.

Temporomandibular joint arthrocentesis: a single-center experience and review of the literature

BACKGROUND

The aim of this paper was to report our experience and to review the literature of arthrocentesis focusing on protocols and results.

METHODS

Arthrocentesis with supplemental hyaluronic acid was performed in patients with TMDs between January 2017 and December 2020 at the Division of Maxillofacial Surgery. The maximum interincisal opening (MIO) and pain score were recorded preoperatively (T0), 2 months postoperatively (T1), and 6 months postoperatively (T2). A literature search was performed to analyze the same parameters in patients with TMDs. Patient demographic, characteristics and treatment protocols used were also recorded.

RESULTS

This retrospective analysis enrolled 45 patients. Twenty-two patients (20 females, 2 males) with mean age of 37.13 years with internal derangement were included in study group A. Study group B included 23 patients with degenerative joint disease (19 females and 4 males) with mean age of 55.73 years. The outcomes trend of MIO and pain during the follow-up period showed a gradual improvement. Fifty articles meeting the proposed scientific criteria were selected for the literature revision. A range of clinical and procedural variables were analyzed by grouping the studies into two broad categories based on the diagnosis of TMD.

CONCLUSIONS

Based on our experience and on the basis of the most accredited scientific studies in the literature, intra-articular injections of HA are beneficial for the improvement of the pain and/or functional symptoms of TMDs.

Does intra-articular injection of tenoxicam after arthrocentesis heal outcomes of temporomandibular joint osteoarthritis? A randomized clinical trial

BACKGROUND

Temporomandibular joint osteoarthritis (TMJ-OA) is a degenerative disease and manifests itself with pain and limitation of movement in the jaws. Arthrocentesis alone or in combination with intraarticular injections is one of the most commonly used treatment methods in these patients. The aim of the study is to examine the effectiveness of arthrocentesis plus tenoxicam injection and to compare it with arthrocentesis alone in patients with TMJ-OA.

METHODS

Thirty patients with TMJ-OA who were treated randomly with either arthrocentesis plus tenoxicam injection (TX group) or arthrocentesis alone (control group) were examined. Maximum mouth opening (MMO), visual analog scale (VAS) pain values, and joint sounds were the outcome variables, which were evaluated at pre-treatment and at 1, 4, 12, and 24 weeks after treatment. Statistical significance was set at p < 0.05.

RESULTS

The gender distribution and mean age were not significantly different between the two groups. Pain values (p < 0.001), MMO (p < 0.001), and joint sounds (p < 0.001) improved significantly in both groups. However, there was no significant difference between the groups in terms of outcome variables [pain (p = 0.085), MMO (p = 0.174), joint sounds (p = 0.131)].

CONCLUSIONS

Arthrocentesis plus tenoxicam injection showed no better outcomes in terms of MMO, pain, and joint sounds compared with arthrocentesis alone in patients with TMJ-OA.

TRIAL REGISTRATION

Injection of Tenoxicam Versus Arthrocentesis Alone in the Treatment of Temporomandibular Joint Osteoarthritis, NCT05497570. Registered 11 May 2022. Retrospectively registered, https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S000CD7A&selectaction=Edit&uid=U0006FC4&ts=6&cx=f3anuq.

Disc-condyle relationship alterations following stabilization splint therapy or arthrocentesis plus hyaluronic acid injection in patients with anterior disc displacement: a retrospective cohort study

OBJECTIVE

The objective of this study was to quantitatively evaluate the efficacy of stabilization splint (SS) therapy or arthrocentesis plus hyaluronic acid (HA) injection in the treatment of anterior disc displacement (ADD) through magnetic resonance imaging (MRI).

METHODS

99 subjects were collected in this study. 46 subjects received SS treatment (SS group), 53 subjects received arthrocentesis plus HA injection (HA group). Joints with anterior disc displacement with reduction (ADDwR) and anterior disc displacement without reduction (ADDwoR) were compared separately. MRI before the beginning of the treatment and after a set of treatment were used for measurement. Disc-condyle relationship and positions of condyles and discs were determined by disc-condyle angles and X-Y coordinates.

RESULTS

The disc-condyle angles decreased significantly in the SS group (P < .0001). Whereas no significant change was found in the HA group. Substantial anteroinferior condyle movement was detected in the SS group, slight anterior movement of condyles was discovered in the HA group. Anterior shift of discs position was observed in HA group and joints with ADDwoR in the SS group.

CONCLUSIONS

SS was effective in improving the disc-condyle relationship in ADD subjects, while significant improvement of disc-condyle relationship cannot be achieved through arthrocentesis plus HA injection.

Validity of IL-6 and Arthrocentesis in the Cause and Management of Internal Derangement of TMJ

Purpose

The aim of this clinical study was to evaluate the level of Interleukine-6 (IL-6), pre and post arthrocentesis to validate it as a biomarker in the Internal Derangement (ID) of TMJ.

Material and Methods

This study included 30 patients (20 females and 10 males) of Temporo-Mandibular Dysfunction (TMD) with Disc displacement without reduction (DDwoR) Wilkes stage III, who were refractory to conservative management. Arthrocentesis was performed as a therapeutic modality. Synovial fluid aspirates were obtained prior to arthrocentesis and post arthrocentesis with 300 ml of Ringer Lactate solution into the superior joint compartment for the assessment of level of IL-6. The clinical parameters used for correlating the level of IL-6 were degree of pain (VAS I), chewing ability (VAS II), Maximal Mouth Opening (MMO) in both pre and post op phase with the follow-up period of 01 day, 01 week, 01 month, 03 month and 06 month and the results were compared. ELISA was performed to analyze the levels of IL-6 in the aspirates. The clinical parameters and the level of IL-6 were recorded and analyzed statistically.

Results

The study showed ID of TMJ (Wilkes stage III) s are more prevalent in females especially in the fourth decades of life with the mean age of 38.4 years. The post operative assessment in terms of pain, maximum mouth opening, lateral movements of the mandible and the levels of IL-6 were found to be statistically significant with a P value <0.01.

Conclusion

This study validates the role of IL-6 as a definitive biomarker for the pathogenesis of ID of TMJ Wilkes stage III and arthrocentesis proved to be a minimally invasive therapeutic modality for its management.

Evaluation of Auditory Changes in Patients Undergoing Temporomandibular Joint Discectomy

PURPOSE

Discectomy is 1 of the preferred TMJ surgical procedure for the treatment of internal derangements when conservative and minimally invasive treatments have failed. The purpose of the current study is to investigate whether a TMJ discectomy operation influences auditory function and clinical variables.

MATERIALS AND METHODS

This prospective study was composed of patients who underwent a TMJ discectomy operation between 2016 and 2020. Auditory function was evaluated with pure tone audiometry, tympanometry, and acoustic reflex tests at preoperatively (T₀), postoperative first week (T₁), first month (T₂), and third month (T₃). Clinical parameters including maximum mouth opening (MMO) and TMJ pain were also evaluated at T₀, T₁, T₂, T₃, and sixth month (T₄).

RESULTS

The study consisted of 17 patients (5 males, 12 females) with a mean age of 42.65. A significant reduction in VAS pain scores and MMO values compared to baseline values was achieved in all follow up periods (P^T0-T1= .001; P^T0-T2/T3/T4 < .001). In pure tone audiometry, a significant increase in T₁-T₀ comparisons at 1000 Hz, 2000 Hz, 6000 Hz, 8000 Hz frequencies, and pure tone average (P = .008; P = .005; P = .012; P = .002; P = .001) was observed. In T₃-T₀ comparisons, a statistically significant decrease was observed in pure tone thresholds at 125 Hz and 8000 Hz frequencies (P = .008; P = .01). There was no statistically significant difference in middle ear pressure and compliance values at T₁, T₂, and T₃ compared to T₀ (P ˃ .05). Type C tympanogram was seen in 3 patients at T₁ and in 1 patient at T₂. Acoustic reflex tests were positive in all patients.

CONCLUSIONS

Although mild changes occurred in auditory tests in the early postoperative period, TMJ discectomy procedure has no permanent effect on auditory function.

Management of Internal Disc Derangement Using Normal Saline and Sodium Hyaluronate: A Comparative Study

Background:

Arthrocentesis of the temporomandibular joint (TMJ) is the unadorned form of surgical therapy which comprises of lavage of inflammatory enzymes and mediators and improve joint mobility and eliminate pain by pressure of the lavage solution in the upper compartment of TMJ.

Objectives:

The current study was conducted to assess and compare the effectiveness of arthrocentesis with normal saline alone and in conjunction with sodium hyaluronate (SH) injection in the treatment of internal derangement of the TMJ.

Methodology:

Sixty patients with internal derangement of the TMJ were randomly divided into two equal groups; Group 1 was performed with normal saline and Group 2 with normal saline followed by 1 ml of SH. The patients were followed up after 1 week to check for any postoperative complications and 1, 2, and 3 months for subsequent sessions and changes in subjective and objective variables.

Results:

The increase in mouth opening from preoperative to 3 months' postoperatively was 4.9 mm for Group 1 and 6.43 mm for Group 2. The change in the pain score (visual analogue scale scale) in Group 1 from the preoperative session to 3 months' follow-up was 7.23–4.1 and in Group 2 was 7.36–3.7. The difference in clicking/popping in Group 1 from preoperative session to 3 months' follow-up was 2.43–1 and in Group 2 was 2.4–0.53.

Conclusion:

Patients refractory to conservative treatment showed promising results with arthrocentesis with SH than arthrocentesis alone in treatment of TMJ internal derangement.

Treatment of Temporomandibular Joint Arthritis with Triamcinolone Acetonide and Hyaluronic Acid Injection: An Observational Study

Temporomandibular joint (TMJ) arthritis is a common cause of orofacial pain with distressing symptoms. The patients most commonly females are often anxious and worried due to the typical gritty sound produced during chewing moments. In other cases there is pain followed by decreased mouth opening. Currently the treatment is not standardised though the clinicians are treating these disorders either by oral medications; splintage or by injections. Though local injection of Triamcinolone acetonide and Hyaluronic acid is an innovative therapy yet it is elusive of much research. The main aim of the present study is to evaluate the efficacy of with Triamcinolone acetonide and Hyaluronic acid in treating temporomandibular joint arthritis. The present study is a prospective non randomized clinical trial of 100 patients in a tertiary referral centre. The patients diagnosed with temporomandibular joint arthritis were treated with local infiltration of 40 mg triamcinolone acetonide along with 20 mg of hyaluronic acid; one injection every week for 4 weeks. The pre-treatment and post-treatment data was compared using student paired t test and Mann-Whitney U test. Majority of the patients showed relief in symptoms like pain (87/96) and clicking sounds (81/88) and the difference was statistically significant (p < 0.05). Though other symptoms like restrictive mouth opening; discomfort on lateral and medial movement were also relieved in 9/15 patients and 21/23 patients respectively however the difference was not statistically significant. We highly recommend the use of Triamcinolone acetonide and hyaluronic acid injection in TMJ arthritis as it helps in relieving pain and clicking of sound in majority of the patients. The treatment is an out-patient department procedure with almost no side effects in most of the patients. The cost effectiveness of the treatment is another benefit.

Is Single-Puncture TMJ Arthrocentesis Superior to the Double-Puncture Technique for the Improvement of Outcomes in Patients With TMDs?

PURPOSE

Arthrocentesis is a common treatment for temporomandibular joint disorders. Although modifications of the standard double-puncture technique have been described, no consensus has been reached regarding which is the best. The aim of the present study was to compare the outcomes of the single- and double-puncture arthrocentesis techniques (SPT and DPT, respectively).

MATERIALS AND METHODS

A systematic review following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. Two independent reviewers conducted electronic searches in the MEDLINE/PubMed, Cochrane Library, and Scopus databases for relevant studies reported up to January 2019. Studies comparing type I SPT (only 1 cannula) or type II SPT (2 soldered cannulas) to conventional DPT were considered. Data regarding the maximal mouth opening (MMO), joint pain, and operative time were extracted for the meta-analysis. In the case of statistically significant heterogeneity (P < .10), a random effects model was used to assess the significance of the treatment effects. Otherwise, a fixed effects model was used. The included randomized controlled trials (RCTs) were assessed for methodologic quality using the Cochrane Collaboration tool.

RESULTS

Nine studies were included for qualitative synthesis. Two were suitable for quantitative synthesis per outcome. The meta-analysis did not find any differences between SPT and DPT in relation to the MMO. However, in relation to joint pain, the results slightly favored the use of DPT. No differences in operative time were found between type I SPT and DPT (P = .49).

CONCLUSIONS

The present study found no differences between the SPT and DPT in relation to the MMO, and no difference was found in operative time between the DPT and type I SPT. Because of the heterogeneity between studies, it might be interesting to conduct more homogeneous RCTs to elucidate which technique results in better clinical outcomes.

Different Treatments in Patients with Temporomandibular Joint Disorders: A Comparative Randomized Study

BACKGROUND AND OBJECTIVES

Temporomandibular joint disorders (TMJDs) are associated with pain and reduced jaw mobility. The aim of this study was to compare the outcome of patients with TMJ arthralgia when submitted to four different treatment modalities, in some cases using intra-articular injections of substances with anti-inflammatory properties and in others, a more conservative approach consisting only of a bite splint. Materials and Methods: The sample was made up of 80 patients, randomly distributed into 4 groups of 20 patients each. Each patient was given a nocturnal bite splint. One of the groups was treated with the bite splint only, while each patient in the other 3 was injected with betamethasone, sodium hyaluronate, or platelet-rich plasma in addition to using the bite splint. Two variables were assessed, namely pain intensity between 0 to 10 according to the visual analogue scale and maximum pain-free mouth opening in mm. The patients were evaluated at four different points: at the beginning of the treatment, as well as one week, one month and six months after initiation.

RESULTS

The results showed that maximum pain-free mouth opening improved in all the groups that made up the sample, with either a reduction in pain severity or with no pain. However, the group injected with platelet-rich plasma yielded the best results after six months, while patients treated with sodium hyaluronate or betamethasone obtained the best results at the end of the first week.

CONCLUSIONS

We concluded that all the treatments used caused a reduction in pain and increased pain-free mouth opening. The splint combined with the platelet-rich plasma injection achieved long-term success.

Retrospective evaluation of the duration of arthrocentesis in the treatment of temporomandibular joint diseases

OBJECTIVE

This study investigated the duration of arthrocentesis in treatment of patients with different diagnoses of temporomandibular disorders.

METHODS

This retrospective study evaluated the duration of arthrocentesis used for 65 patients who were diagnosed with osteoarthritis (OA), disc displacement with reduction (DDWR), or disc displacement without reduction (DDWoR), in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders protocol.

RESULTS

Mean operation times were 423.79 (± 66.77) seconds in OA patients, 459.92 (± 56.67) seconds in DDWR patients, and 609.00 (± 106.88) seconds in DDWoR patients; these significantly differed among groups (P < 0.001). In addition, post hoc analyses revealed statistically significant differences in mean operation times between DDWoR and OA (P<0.05) and DDWoR and DDWR (P<0.05).

CONCLUSION

The appropriate duration of arthrocentesis may vary among joint disorders, and the duration of arthrocentesis in DDWoR treatment is longer than that in DDWR and OA treatments. In addition there was no relationship between the age or gender and operation time of the patients. Changes in anatomic structures due to temporomandibular diseases are presumed to influence the duration of arthrocentesis treatment.

Comparison of efficacy of sodium hyaluronate and normal saline arthrocentesis in the management of internal derangement of temporomandibular joints - A prospective study

Purpose:

The aim of the present study was to evaluate the efficacy of arthrocentesis with and without sodium hyaluronate (SH) injection in the treatment of patients with temporomandibular joint (TMJ) internal derangement.

Materials and Methods:

The study consisted of 20 patients with chief complaints of limited mouth opening, TMJ pain, and jaw deviation. Patients with disc displacement with reduction and closed lock were randomly divided into two groups. In Group 1, only arthrocentesis was performed, and in Group 2, arthrocentesis plus intra-articular injection of SH was performed. Arthrocentesis was performed under aseptic conditions using normal saline. Clinical evaluation was done for maximum mouth opening (MMO), TMJ pain, and jaw deviation before the procedure and 1 week, 2 weeks, 1 month, and 3 months following arthrocentesis.

Results:

The mean visual analog scale (VAS) score change was statistically significant in Group 1 and Group 2 for within the group analysis. There was statistically significant difference in VAS score between Group 1 and Group 2 at all time intervals postoperatively. The increase in MMO from preoperative to 3 months postoperatively was statistically significant for within the group analysis. There was a reduction in mandibular deviation in both Group 1 and Group 2, but the difference was not statistically significant. There was no statistically significant difference in deviation between the two groups.

Conclusion:

Arthrocentesis with SH is superior to arthrocentesis alone in treating patients suffering with TMJ internal derangement, who are refractory to conservative treatment.

Evaluation of success criteria for temporomandibular joint arthrocentesis

Objectives

The aim of this study was to use four sets of success criteria to evaluate the outcomes of arthrocentesis treatment with hyaluronic acid injection in patients with internal derangement (ID) of the temporomandibular joint (TMJ).

Materials and Methods

The study included 40 patients diagnosed with unilateral Wilkes stage III TMJ dysfunction. Clinical parameters, including maximum mouth opening (MMO) and pain during function, were evaluated preoperatively, 6 months, and 1 year after TMJ arthrocentesis. Outcomes were assessed and compared using four sets of success criteria from the following: the American Association of Oral and Maxillofacial Surgeons (AAOMS; MMO ≥35 mm and visual analogue scale [VAS] score ≤3), Murakami et al.'s criteria (MMO >38 mm and VAS score <2), Emshoff and Rudisch criteria (MMO ≥35 mm and >50% pain reduction), and patient self-reports (self-evaluation of treatment as successful or unsuccessful).

Results

Significant improvements in MMO and pain reduction during function were observed between the preoperative period and 6 months and 1 year postoperatively (P<0.01). The success rates of treatment determined using AAOMS (52.5%), Emshoff and Rudisch criteria (57.5%), and self-reported patient criteria (40.0%) were similar. Application of the Murakami et al. criteria reported the lowest success rate (12.5%).

Conclusion

The AAOMS and Emshoff and Rudisch criteria are consistent with patient expectations and can be used to assess treatment efficacy.

A comparison of the effects of Methylprednisolone Acetate, Sodium Hyaluronate and Tenoxicam in the treatment of non-reducing disc displacement of the temporomandibular joint

Background

This clinical study aimed to radiologically and clinically compare the effect of intra-articular injection of methylprednisolone, sodium hyaluronate or tenoxicam following arthrocentesis with that of arthrocentesis alone in patients with non-reducing disc displacement.

Material and Methods

A total of 44 patients radiographically diagnosed with non-reducing disc displacement of the temporomandibular joint (TMJ) were randomly divided into four treatment groups, as follows: Group 1, arthrocentesis alone; Group 2, arthrocentesis plus methylprednisolone acetate; Group 3, arthrocentesis plus sodium hyaluronate; Group 4, arthrocentesis plus tenoxicam. Maximum mouth opening (MMO), lateral movement, pain severity and tenderness of TMJ and muscles of mastication on palpation were measured before treatment and at 1 week and 1, 3 and 6 months after treatment. Disc position, presence or absence of disc reduction, level of effusion, joint movement and joint space were also evaluated using magnetic resonance imaging (MRI) before treatment and 6 months after treatment.

Results

No significant differences in treatment success were found among the four groups. MRI findings did not vary significantly among the groups, but pre- and post-operative MRI findings varied significantly within all four groups (p<0.001).

Conclusions

According to the data from this study, it may be concluded that either arthrocentesis alone or arthrocentesis with methylprednisolone acetate or sodium hyaluronate or tenoxicam intra-articular injections are similarly effective and promising methods in the treatment of TMJ with non-reducing disc displacement.

Key words:Non-reduction disc displacement, arthrocentesis, methylprednisolone, sodium hyaluronate, tenoxicam.

Is arthrocentesis of temporomandibular joint with corticosteroids beneficial? A systematic review

Background

Temporomandibular disorders (TMDs) are musculoskeletal conditions that can inhibit the normal function of temporomandibular joints (TMJs) and affect the patient’s quality of life, negatively. Arthrocentesis (AC) is a minimally invasive surgical procedure used for treating TMDs. The aim of present paper is to evaluate the advantages of administrating corticosteroid (CS) during AC by reviewing high quality released articles.

Material and Methods

Searching on Cochrane Library, Web of Science, Google Scholar, PubMed, ProQuest, and Scopus databases were performed with focusing on proper key words. Related titles and abstracts, up to December 2017, were screened and selected based on inclusion criteria. The full text of all randomized controlled trials (RCTs) was extensively read and subjected to quality assessments.

Results

After initial search, a total of 2067 articles were included into the study. Finally, 7 studies were reliable enough in methodology and randomization to be included into the study. All of the observed studies showed improvements in jaw functions and pain relief with no statistical differences in both AC and control groups. One study reported painless maximum incisal opening in CS group than the control group.

Conclusions

Based on available RCTs, the AC of TMJ with CS seems to result in similar findings to other therapeutic drugs, with no significant differences.

Key words:Arthrocentesis, corticosteroid, temporomandibular joints, temporomandibular joint disorders.

Analysis of synovial fluid visfatin level in temporomandibular joint disorders

Background: Biochemical analysis of synovial fluid (SF) is an important means of understanding the pathogenesis of temporomandibular disorder (TMD) and confirming diagnoses made using traditional methods. Objective: The aim of this study was to determine whether or not SF visfatin levels can serve as a biochemical marker in the diagnosis of TMD. Method: Sixty samples of SF were obtained from 60 patients with internal derangement (ID) or osteoarthritis (OA). Visfatin in the SF was examined by enzyme-linked immunosorbent assay (ELISA). Result: Visfatin levels showed positive correlations with TMD pain and ID stage and a negative correlation with maximum mouth opening. In addition, Visfatin levels in joints with OA changes in the condyle were significantly higher in comparison to joints with no OA changes. Conclusion: Within the limitations of this study, it can be concluded that visfatin may play a role in the pathogenesis of TMD.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short Term for Improving Function and Quality of Life After Arthrocentesis? Part 2

PURPOSE

Although arthrocentesis has been used for the management of patients with temporomandibular joint pain, the benefit of hyaluronic acid (HA) or corticosteroid (CS) remains uncertain. The purpose of this study was to assess the efficacy of HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis for changes in quality of life (QoL), jaw function (Jaw Function Limitation Scale [JFLS] score), and maximum incisal opening (MIO).

MATERIALS AND METHODS

This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then instillation of HA, CS, or LR. All patients were evaluated clinically at 1 and 3 months. The outcome variables were QoL, JFLS score, and MIO. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant.

RESULTS

One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for analysis of data at 1 month. An additional 51 were lost to follow-up at 3 months, leaving 51 patients for data analysis at this time point. There was no difference among groups for QoL Mental Health Composite score at 1 month (P = .70) or 3 months (P = .69). There was no difference among groups for JFLS score at 1 month (P = .71) or 3 months (P = .98). There was no difference among groups for MIO at 1 month (P = .47) or 3 months (P = .31). All groups showed within-group improvements in JFLS score and MIO at 1 and 3 months.

CONCLUSION

Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in improving jaw function and MIO at 1 and 3 months. QoL is not improved with arthrocentesis alone or in combination with CS or HA.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short-Term Reduction of Temporomandibular Joint Pain After Arthrocentesis? Part 1

PURPOSE

Arthrocentesis has been used for the management of patients with temporomandibular joint (TMJ) pain, with good success. The additional use of hyaluronic acid (HA) or corticosteroid (CS) remains controversial. The purpose of this study was to compare HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis.

MATERIALS AND METHODS

This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then the instillation of HA, CS, or LR. Patients were evaluated clinically at 1 and 3 months. The primary outcome variable was pain at 1 month (by visual analog scale). Secondary outcome variables were pain at 3 months and analgesic consumption. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant.

RESULTS

One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for the final analysis. The mean age of patients in the HA, CS, and LR groups was 39.6, 44.3, and 51.8 years, respectively (P = .02). There was no difference among groups in time to follow-up at 1 month (P = .11). The mean decrease in pain in the CS group was 19% for right-side procedures (P = .12) and 36% for left-side procedures (P = .02). The mean decrease in pain in the HA group was 31% for right-side procedures (P = .01) and 34% for left-side procedures (P = .01). The mean decrease in pain in the LR group was 43% for right-side procedures (P < .01) and 37% for left-side procedures (P < .01). There was no difference in pain decrease among groups (P = .55). There was no difference in the use of narcotic (P = .52) or nonsteroidal anti-inflammatory drugs (P = .71) among groups.

CONCLUSION

Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in decreasing TMJ pain.

Comparison of local and general anaesthesia for arthrocentesis of the temporomandibular joint

Arthrocentesis of the temporomandibular joint is an effective treatment for some disorders, and is usually done under local anaesthesia. We know of few studies that have compared the ease of arthrocentesis and its outcomes under local or general anaesthesia, so we studied 32 patients (n=16 in each group). Postoperative oedema and pain, maximum mouth opening, duration of arthrocentesis, and ease of operation were assessed to compare the relative effectiveness of the two types of anaesthetic. Scores for duration of arthrocentesis (p=0.003) and ease of procedure (0.004) differed significantly, while the other results were similar in the two groups. We noticed some superior outcomes when the procedure was done under general anaesthesia, but because of its limitations, selection of patients becomes more important.

Does Injection of Corticosteroid After Arthrocentesis Improve Outcomes of Temporomandibular Joint Osteoarthritis? A Randomized Clinical Trial

PURPOSE

The purpose of this study is to answer the following clinical question: Among patients with temporomandibular joint (TMJ) osteoarthritis (OA), do those undergoing arthrocentesis and corticosteroid (CS) injection, when compared with those undergoing arthrocentesis alone, have better outcomes in terms of range of motion and clinical symptoms?

MATERIALS AND METHODS

A randomized clinical trial in adult patients with TMJ OA referred to our clinic between May 2012 and September 2013 was implemented. The sample was composed of 24 consecutive patients with TMJ OA treated randomly with either arthrocentesis alone (control group) or arthrocentesis plus CS injection (CS group). The outcome variables were visual analog scale evaluations (ie, masticatory efficiency, joint sounds, and pain complaints), maximal interincisal opening, and mandibular motions. The outcome variables were recorded at baseline and at 12 months postoperatively. The Mann-Whitney U test was used for intergroup comparison. The paired t test and Wilcoxon signed rank test were used for intragroup comparisons.

RESULTS

The sample was composed of 32 joints in 24 patients with TMJ OA (15 joints in 12 patients with a mean age of 35.08 ± 14.84 years comprising the control group and 17 joints in 12 adult patients with a mean age of 32.58 ± 9.58 years comprising the CS group). Pain complaints and joint sounds showed statistically significant decreases (P < .01) in both groups, whereas painless interincisal opening showed a statistically significant increase (P < .001) in only the CS group. After estimation of differences between the follow-up and baseline outcomes, the mean change in the primary outcome variables showed no statistically significant differences between the 2 groups (P > .05).

CONCLUSIONS

These findings suggest that arthrocentesis plus intra-articular CS injection produced no better outcomes in terms of range of motion and clinical symptoms in patients with TMJ OA, as compared with those undergoing arthrocentesis alone.

Comparison Between Betamethasone and Sodium Hyaluronate Combination with Betamethasone Alone After Arthrocentesis in the Treatment of Internal Derangement of TMJ-Using Single Puncture Technique: A Preliminary Study

PURPOSE

This study was designed to compare the intra-articular injection of betamethasone and sodium hyaluronate (combination) with betamethasone alone after arthrocentesis using single puncture technique into the upper joint space in the treatment of temporomandibular joint internal derangements.

MATERIALS AND METHODS

Fourteen patients with internal derangement were randomly selected and divided into 2 groups (7 in each group). Arthrocentesis with single puncture technique of the upper joint space was then performed using ringer lactate under local anesthesia, followed by injection of either betamethasone and sodium hyaluronate combination or betamethasone alone into the joint. Clinical data was collected in the form of pain (visual analog scale), maximum mouth opening, and clicking sound before and after treatment up to 6 months.

RESULTS

At the follow up of 6 months, there was statistically significant decrease in intensity of pain and increase in mouth opening was seen in betamethasone and sodium hyaluronate combination group compared to betamethasone alone group. Although there was statistically significant difference between the two groups when clicking was evaluated in the initial time interval (2nd post op day), on follow up of up to 6 months there was no statistically significant difference in clicking.

CONCLUSION

Although patients benefitted from both techniques, arthrocentesis with intra-articular injection of betamethasone and sodium hyaluronate combination is superior to arthrocentesis with betamethasone injection alone.