Does glucosamine, chondroitin sulfate, and methylsulfonylmethane supplementation improve the outcome of temporomandibular joint osteoarthritis management with arthrocentesis plus intraarticular hyaluronic acid injection. A randomized clinical trial

Analysis of the Use of Sample Size and Effect Size Calculations in a Temporomandibular Disorders Randomised Controlled Trial-Short Narrative Review

BACKGROUND/OBJECTIVES

Temporomandibular disorder (TMD) is the term used to describe a pathology (dysfunction and pain) in the masticatory muscles and temporomandibular joint (TMJ). There is an apparent upward trend in the publication of dental research and a need to continually improve the quality of research. Therefore, this study was conducted to analyse the use of sample size and effect size calculations in a TMD randomised controlled trial.

METHODS

The period was restricted to the full 5 years, i.e., papers published in 2019, 2020, 2021, 2022, and 2023. The filter article type-"Randomized Controlled Trial" was used. The studies were graded on a two-level scale: 0-1. In the case of 1, sample size (SS) and effect size (ES) were calculated.

RESULTS

In the entire study sample, SS was used in 58% of studies, while ES was used in 15% of studies.

CONCLUSIONS

Quality should improve as research increases. One factor that influences quality is the level of statistics. SS and ES calculations provide a basis for understanding the results obtained by the authors. Access to formulas, online calculators and software facilitates these analyses. High-quality trials provide a solid foundation for medical progress, fostering the development of personalized therapies that provide more precise and effective treatment and increase patients' chances of recovery. Improving the quality of TMD research, and medical research in general, helps to increase public confidence in medical advances and raises the standard of patient care.

Effects of Glucosamine in the Temporomandibular Joint Osteoarthritis: A Review

Osteoarthritis in the temporomandibular joint (TMJ) is a chronic disease characterized by irreversible damage to articular surfaces, including inflammation, loss of articular cartilage, and subchondral bone alterations, which would be radiographically evident only in later stages. Symptomatic slow-acting so-called nutraceutical drugs have been proposed as a treatment for osteoarthritis in comparison to non-steroidal anti-inflammatory drugs (NSAID) because of their appreciable safety profile even in long-term intake. Glucosamine, being one among them, proved highly efficient in knee osteoarthritis. However, its application in TMJ osteoarthritis dates back only to 2001 and is still inconclusive in its efficiency even with systematic reviews, in restoring the structural and functional aspects of damaged TMJ. Glucosamine, being a natural compound and also a contributor to building the matrix of articular cartilage, can be utilized effectively for TMJ osteoarthritis as an adjunct along with other conventional treatment modalities available till now, which also have moderate prognosis in most of the clinical scenarios. This review summarizes data relating to the mechanism of osteoarthritis and its management using glucosamine formulations. The beneficial effects of glucosamine on the pathophysiology of TMJ osteoarthritis are possibly due to its contribution to hyaluronic acid regulation and in establishing a proper balance between anabolism/catabolism in the articular tissues.

Conservative and minimally invasive approaches to control idiopathic condylar resorption: a scoping review

Idiopathic condylar resorption (ICR) is an uncommon disease with multiple names that challenges orthodontic and surgical treatments. The aim of this study was to investigate the existing conservative and minimally invasive approaches to controlling ICR. A scoping literature review was conducted. Inclusion criteria were young patients with degenerative joint disease based on the Research Diagnostic Criteria for Temporomandibular Disorders or Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocols, or ICR based on the DC/TMD expanded taxonomy protocol. Six electronic databases and the grey literature were searched, without restriction on year or language. Two reviewers independently performed the study selection and data extraction. Ten studies were selected from the 13,953 records identified. The total sample size was 424 patients; the female-to-male ratio was 7:1 and the mean age of the patients was 25.7 years. The main primary outcomes were pain, mandibular dysfunction, and condylar resorption. There is no guarantee of definitive success in the early management of ICR, despite the promising approaches studied, and there is no specific protocol to be followed. Therefore, close post-surgical follow-up is still required. This study highlights the need to standardize the nomenclature and diagnostic criteria, and assess the status of condylar activity/severity in future research.

Effectiveness of double-puncture temporomandibular joint arthrocentesis with viscosupplementation in different categories of severity - a prospective study

This 3-year prospective study evaluated the efficacy of temporomandibular joint (TMJ) arthrocentesis with viscosupplementation in different severity stages based on the Dimitroulis classification (categories 2-4 were included). TMJ arthrocentesis was performed under local anaesthesia, and the protocol consisted of a double-puncture technique with lavage of ≥150 cc Ringer Lactate plus viscosupplementation. Incobotulinum toxin A was administered 10-15 days preoperatively in patients with concomitant masticatory myalgia. The primary outcome was TMJ pain, assessed by visual analogue scale (VAS, 0-10), and the secondary outcomes were the maximum mouth opening (MMO, mm) and myalgia degree (0-3). All outcomes were assessed on the intervention day (T0) and after the procedure (T1) (minimum 1 month and then 3 months, 6 months, 1 year and every year since). A total of 108 patients were enrolled (mean age of 43.1 ± 18.9 years); 86 (80%) were women and 22 (20%) were men. Preoperative pain was 4.02 ± 3.12 (mean ± SD), MMO was 38.10 ± 9.56 (mean ± SD) and myalgia degree was 1.80 ± 1.18 (mean ± SD). After an average of 215.4 days (31-1253 days), a statistically significant improvement of pain (P < 0.0001), MMO (P = 0.005) and myalgia degree (P < 0.0001) was observed. The overall successful outcome of TMJ arthrocentesis with viscosupplementation was 76%. The authors observed increased arthrocentesis effectiveness and success rate with viscosupplementation in Dimitroulis category 2 (88.6%) compared to 3-4 (71.4%). An association was found between arthrocentesis with viscosupplementation failure and painful myalgia (ρ = 0.477; P < 0.0001). Thirteen patients (12%) underwent a second TMJ intervention after finalising the present trial. With a low complication rate, TMJ arthrocentesis with viscosupplementation led to an overall benefit for all the included patients. This study reinforces the important role of minimally invasive TMJ arthrocentesis as a first treatment option, with better results in the early stages compared to more severe stages.

Current Clinical Research Directions on Temporomandibular Joint Intra-Articular Injections: A Mapping Review

This mapping review aims to identify and discuss current research directions on intracavitary temporomandibular joints (TMJs) injections. The inclusion criteria allowed studies published in the last full six years, based on patients diagnosed with temporomandibular joint disorders (TMDs), treated by TMJ intra-articular injections. Medical databases covered by the Association for Computing Machinery, Bielefeld Academic Search Engine, PubMed, and Elsevier Scopus engines were searched. The results were visualized with tables, charts, and diagrams. Of the 2712 records identified following the selection process, 152 reports were qualified for review. From January 2017, viscosupplementation with hyaluronic acid (HA) was the best-documented injectable administered into TMJ cavities. However, a significant growing trend was observed in the number of primary studies on centrifuged blood preparations administrations that surpassed the previously leading HA from 2021.

Oral Glucosamine in the Treatment of Temporomandibular Joint Osteoarthritis: A Systematic Review

Temporomandibular disorders (TMDs) occur frequently within the general population and are the most common non-dental cause of orofacial pain. Temporomandibular joint osteoarthritis (TMJ OA) is a degenerative joint disease (DJD). There have been several different methods of treatment of TMJ OA listed, including pharmacotherapy among others. Due to its anti-aging, antioxidative, bacteriostatic, anti-inflammatory, immuno-stimulating, pro-anabolic and anti-catabolic properties, oral glucosamine seems to be a potentially very effective agent in the treatment of TMJ OA. The aim of this review was to critically assess the efficacy of oral glucosamine in the treatment of TMJ OA on the basis of the literature. PubMed and Scopus databases were analyzed with the keywords: (temporomandibular joints) AND ((disorders) OR (osteoarthritis)) AND (treatment) AND (glucosamine). After the screening of 50 results, eight studies have been included in this review. Oral glucosamine is one of the symptomatic slow-acting drugs for osteoarthritis. There is not enough scientific evidence to unambiguously confirm the clinical effectiveness of glucosamine supplements in the treatment of TMJ OA on the basis of the literature. The most important aspect affecting the clinical efficacy of oral glucosamine in the treatment of TMJ OA was the total administration time. Administration of oral glucosamine for a longer period of time, i.e., 3 months, led to a significant reduction in TMJ pain and a significant increase in maximum mouth opening. It also resulted in long-term anti-inflammatory effects within the TMJs. Further long-term, randomized, double-blind studies, with a unified methodology, ought to be performed to draw the general recommendations for the use of oral glucosamine in the treatment of TMJ OA.

Evaluation of the efficiency of hyaluronic acid, PRP and I-PRF intra-articular injections in the treatment of internal derangement of the temporomandibular joint: A prospective study

This study aimed to evaluate the clinical effects of hyaluronic acid (HA), platelet-rich plasma (PRP), and platelet-rich fibrin (I-PRF) injections in the internal derangement of the temporomandibular joint. Adult patients who had failed to respond to nonsurgical treatment were were included in the study. The patients were divided into three treatment groups according to the given substance: 1) HA administration three times in a row on a weekly basis, 2) a single dose of PRP, or 3) a single dose of I-PRF. Clinical assessment was performed preoperatively and 6 and 12 months after the treatment, including maximal mouth opening (MMO) and pain level (Visual Analog Scale). Low and high molecular weight (HA_L, HA_H) hyaluronic acid forms were also compared. 68 adult patients, with a total of 109 joints were included in the study. The mean age was 53 ± 16 years. The statistical analysis showed a significant improvement in MMO in the HA group (p < 0.01). The pain level significantly decreased in all treatment groups (p_HA,PRP,I-PRF<0.01). Comparing HA_L and HA_H forms, no significant difference was found in the evaluation of MMO and VAS values. Within the limitations of the study it seems that due to the similar effects of HA and the autologous blood substances, the platelet concentrates should be preferred in the intra-articular treatment in order to reduce the risk of possible adverse effects.

EFFECTIVENESS OF INTRA-ARTICULAR INJECTIONS OF SODIUM HYALURONATE, CORTICOSTEROIDS, PLATELET-RICH PLASMA ON TEMPOROMANDIBULAR JOINT OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

OBJECTIVE

To compare the efficacy of Intra-articular injections of corticosteroids (CCS), hyaluronic acid (HA), and platelet-rich plasma (PRP) on temporomandibular joint osteoarthritis.

METHODS

Studies were identified from PubMed, Embase and Cochrane Central Register of Controlled Trials, ClinicalTrials.gov with date up to January 15, 2022. Randomized controlled trials included were the studies of patients with temporomandibular joint osteoarthritis who had intra-articular treatment with CCS, HA, PRP, placebo and follow-up assessing temporomandibular joint function in target outcome variables. The primary outcome was temporomandibular joint pain. The secondary outcomes were maximal mouth opening (mm), and lateral movement to the affected side (mm). This study is registered with PROSPERO, number CRD42021270914.

RESULTS

Nine randomized controlled trials involving 316 patients were included. For primary pain outcome, no significance was detected when CCS, HA and PRP were compared with placebo by both short- (3-6 months) and long-term (>12 months) follow-up. Relatively, the top ranking of which was PRP in the long-term (Mean Difference, -0.23 [95% CI, -2.49 to 2.04]). In addition, these injectables did not significantly outperform placebo by evaluating secondary functional outcomes (maximal mouth opening and lateral movement) with the same follow-up. Subgroup analyses showed that the effect of CCS on subgroups with more than 70% women was statistically less effective compared with placebo (Mean Difference, 1.73 [95% CI, 0.37-3.09]).

CONCLUSION

Evidence suggested that intra-articular pharmacological injections of CCS, HA, and PRP had no effect on improving temporomandibular joint pain and functional outcomes compared with placebo injection.

Chondroitin sulfate microspheres anchored with drug-loaded liposomes play a dual antioxidant role in the treatment of osteoarthritis

Reactive oxygen species (ROS) play a critical role in the pathogenesis of osteoarthritis. The injection of a single antioxidant drug is characterized by low drug utilization and short residence time in the articular cavity, limiting the therapeutic effect of antioxidant drugs on osteoarthritis. Currently, the drug circulation half-life can be extended using delivery vehicles such as liposomes and microspheres, which are widely used to treat diseases. In addition, the composite carriers of liposomes and hydrogel microspheres can combine the advantages of different material forms and show stronger plasticity and flexibility than traditional single carriers, which are expected to become new local drug delivery systems. Chondroitin sulfate, a sulfated glycosaminoglycan commonly found in native cartilage, has good antioxidant properties and degradability and is used to develop an injectable chondroitin sulfate hydrogel by covalent modification with photo-cross-linkable methacryloyl groups (ChsMA). Herein, ChsMA microgels anchored with liquiritin (LQ)-loaded liposomes (ChsMA@Lipo) were developed to delay the progression of osteoarthritis by dual antioxidation. On the one hand, the antioxidant drug LQ wrapped in ChsMA@Lipo microgels exhibits significant sustained-release kinetics due to the double obstruction of the lipid membrane and the hydrogel matrix network. On the other hand, ChsMA can eliminate ROS through degradation into chondroitin sulfate monomers by enzymes in vivo. Therefore, ChsMA@Lipo, as a degradable and dual antioxidant drug delivery platform, is a promising option for osteoarthritis treatment. STATEMENT OF SIGNIFICANCE: Compared with the traditional single carrier, the composite carriers of hydrogel microspheres and liposome can complement the advantages of different materials, which shows stronger plasticity and flexibility, and is expected to become a new and efficient drug delivery system. ChsMA@Lipo not only attenuates IL-1β-induced ECM degradation in chondrocytes but also inhibits the M1 macrophages polarization and the inflammasome activation. The obtained ChsMA@Lipo alleviates the progression of osteoarthritis in vivo, which is promising for osteoarthritis treatment.

Injectable platelet-rich fibrin as treatment for temporomandibular joint osteoarthritis: A randomized controlled clinical trial

The purpose of this study was to assess the treatment outcomes of intraarticular injection of injectable platelet-rich fibrin (i-PRF) after arthrocentesis in patients with temporomandibular joint osteoarthritis (TMJ-OA). Patients were randomly assigned to one of two treatment groups: those who received intraarticular injection of i-PRF after arthrocentesis procedure - the i-PRF group; and those who underwent the arthrocentesis procedure alone - the control group. The primary outcome variable was pain, the level of which was measured preoperatively and at 1, 2, 3, 6, and 12 months postoperatively. The secondary outcome variables included maximum mouth opening (MMO), and lateral and protrusive movements. Of the total of 36 patients, 18 were analyzed in the i-PRF group and 18 in the control group. There were significant differences between the groups in terms of pain levels and measurements of MMO, lateral movement, and protrusive movement over the 12 months of follow-up (p < 0.001). Significant increases in pain levels and decreases in measurements of MMO, lateral movement, and protrusive movement were observed in the control group from the 6th to 12th month postoperatively (p < 0.001). In contrast, no significant differences were found in both pain levels and measurements of MMO, lateral, and protrusive movements for the i-PRF group from the 2nd to the 12th month postoperatively. Within the limitations of the study it seems that intraarticular injection of i-PRF after arthrocentesis should be preferred whenever appropriate because when reducing pain intensity and improving functional jaw movement is the priority.

Long term oral health related quality of life after TMJ arthrocentesis with hyaluronic acid. A retrospective cohort study

The purpose of the study was to assess the long-term oral health-related quality of life (oQoL) in patients with temporomandibular joint (TMJ) internal derangement (ID) after TMJ arthrocentesis plus hyaluronic acid (HA). Patients were analysed at different follow-up times using an analytical observational design. The Oral Health Impact Profile-14 (OHIP-14) score was evaluated according to age, sex, disc position, presence of degenerative joint disease (DJD), joint pain, maximum mouth opening and follow-up time. A total of 60 participants were enrolled, 88% female, with a mean age of 38 years (SD = 13.48). In an average follow-up of 25.02 months (SD = 5.32), the OHIP-14 total score decreased 8.67 (95% confidence interval [CI]: -11.21 to -6.11) after the intervention (Cohen's d = 1.22; 95% CI = 0.81 to 1.64). All OHIP-14 domain scores decreased (p < 0.05) except for the Functional limitation domain (p = 0.378). The oQoL after the intervention worsened in female patients (p = 0.039) and with a higher level of pain at baseline (p = 0.002). Self-perceived QoL improvement should be considered stable long term after temporomandibular joint arthrocentesis plus HA, regardless of concurrence with DJD or ID subtype. QoL should be used as clinical assessment measure of ID patients, with special attention to those with higher levels of pain.

Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of dietary supplements in addition to physiotherapeutic treatment on pain and functional outcomes. PubMed, The Cochrane Library, Web of Science, and Embase were searched from inception to November 2021 (Prospero registration: CRD42021291951). Studies were eligible if the interventions consisted of physiotherapeutic approaches that were combined with dietary supplementation and if they reported measures of pain and/or function. Six studies were included in the meta-analysis. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated and analysed using a Review Manager software. Subgroup analysis was performed to explore possible associations between the study characteristics and the effectiveness of the intervention. Additional dietary supplementation during physiotherapeutic treatment significantly improved the reduction in pain score (SMD = −0.74, 95% CI, −1.37 to −0.10; p < 0.05), while it had no effect on functional outcomes (SMD = 0.29, 95% CI, 0.00 to 0.58; p > 0.05). This systematic review and meta-analysis suggests that additional nutritional interventions may improve physiotherapeutic treatment outcomes in the management of tendinopathies.

Evaluation of aggrecan and adipokine levels in temporomandibular joint synovial fluid

The aim of this study was to investigate the effect various mediators in synovial fluid (SF) on the pathogenesis of temporomandibular disorders (TMD) and to evaluate the relationship between clinical and radiological features of temporomandibular joint (TMJ) diseases. Patients who had received SF sample during arthrocentesis because of TMD were included in this study. Clinical and radiological records were evaluated retrospectively. Enzyme-Linked ImmunoSorbent Assay (ELISA) method was used for analysis of aggrecan, adiponectin, resistin, apelin, Vascular Endothelial Growth Factor (VEGF) and Prostaglandin E2 (PGE2) in SFs. 59 joints of 41 patients were included in the study. Anterior disc displacement with reduction (ADDwR) was detected in 22 joints, anterior disc displacement without reduction (ADDwoR) was detected in 29 joints and osteoarthritis (OA) in 8. In OA group, PGE2 level was significantly higher than the other groups (p = 0.029). Aggrecan and PGE2 levels were statistically higher in joints with localized pain (p = 0.030, p = 0.029). The aggrecan level was statistically significant higher in patients who had degenerative changes in radiological examinations (p = 0.044). Resistin was correlated with PGE2 and aggrecan (p = 0.011), and apelin showed positive correlation with VEGF (p˂0.001). The detection of aggrecan and adipokines in SF may be a precursor of degenerative joint disease and it should be taken into account that the presence of localized pain in the joint area may be an early sign of degenerative changes.

Evaluation of the effectiveness of different puncture points for second cannula in double puncture arthrocentesis of temporomandibular joint

The study at checking if treatment outcomes in double puncture temporomandibular joint (TMJ) arthrocentesis (DPTMJA) changed when the puncture points of the second cannula punctate were changed. Using a retrospective cohort study design, the investigators enrolled a sample of temporomandibular joint disorder (TMD, internal derangement) patients receiving DPTMJA. The decision of whether to perform a modified or traditional arthrocentesis was made by the patients: Patients who accepted the close cannula relationship were evaluated as group 1 (modification group), and those who did not agree as group 2 (traditional group). The predictor variable was puncture points of the second cannula (close to vs. far from the first cannula; group 1 and 2, respectively). The main outcome variables included maximum mouth opening (MMO), and pain assessed using a Likert-type (0-10) visual analogue scale (VAS) before treatment and at 1st day and 3rd months intervals. Appropriate statistics were computed using P < .05 was considered significant. The study sample comprised 32 patients (93.8% females; 50% in each study arm) with an average age of 36.9 ± 15.3 years (range, 18-78). Although, patient age and gender, and baseline VAS in both groups were not significant different (P > .05), the baseline MMO in group 2 was significant higher than that in group 1 (P = .03). The within-group analyses demonstrated the significant improvement of both MMO and VAS at postoperative month 3 (P < .05). However, the between-group analyses rejected the significant differences between the 2 groups at day 1 and month 3 (P > .05). Within the limitations of the study the choice of one or the other technique should be left to the discretion of the surgeon.