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

Synthesis of temporomandibular disorders management intervention outcomes for development of core outcome sets: A systematic review

INTRODUCTION

The selection of appropriate outcomes in clinical trials and systematic reviews is a crucial factor in determining the results that are useful, reliable, and relevant for both patients and healthcare professionals. Clinicians and researchers have been encouraged to develop and apply core outcome sets (COS) to minimise the discrepancy between studies.

AIM

This systematic review is the first phase of the COS development project for clinical trials in temporomandibular disorders (COS-TMD). It aims to identify and synthesise the outcomes used in the randomised controlled trials (RCT) that evaluated the effectiveness of interventions used in TMD management.

MATERIALS AND METHODS

An electronic search was performed in several databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library and EMBASE. The eligibility criteria comprised RCT that applied any intervention to treat temporomandibular joint disorders or masticatory muscle disorders. The identified outcomes were categorised according to domains of the Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT).

RESULTS

The electronic search resulted in 1606 studies. After removing duplicates and applying the eligibility criteria, 106 RCT were included. A total of 43 studies evaluated masticatory muscle disorders, 27 evaluated temporomandibular joint disorders, and 36 analysed mixed TMD.

CONCLUSIONS

The evaluation showed significant variability in the types of outcomes and their measurement instruments. In addition, some domains such as physical and emotional functioning, participant ratings of global improvement and adverse events have been neglected when determining the effectiveness of treatments for TMD.

Intraarticular injections of hyaluronic acid in arthrocentesis and arthroscopy as a treatment of temporomandibular joint disorders: A systematic review

OBJECTIVE

To evaluate the benefits of hyaluronic acid intraarticular injection (HA IAI), in conjunction with minimally invasive surgery (arthrocentesis or arthroscopy), as a therapeutic option for temporomandibular joint disorders.

METHODS

An electronic search in PubMed, Cochrane Library, and Scopus databases was conducted in order to answer the following PICOS question: "In clinical trials with patients treated with arthroscopy or arthrocentesis, did the subsequent use of HA IAI provide a better control of postoperative pain and temporomandibular joint function compared to those patients who did not receive it?"

RESULTS

Following PRISMA criteria, six randomized controlled clinical trials were selected. HA IAI showed significant differences in terms of pain reduction in three of them and improvement of mandibular function in two, compared to the control group.

CONCLUSION

Based on scientific evidence, the level of recommendation found regarding this type of intervention is type B (recommendation based on inconsistent or limited-quality patient-oriented evidence).

Association between axial spondyloarthritis and temporomandibular disorders: A systematic review

This study aimed to assess the frequency of temporomandibular disorders (TMDs) in patients with axial spondyloarthritis (axSpA) compared with the healthy individuals. We systematically searched PubMed, Embase, Scopus, Web of Science, CINAHL, and Google Scholar databases from their inception until 2022, without language restriction. A standardized dataset was used to extract data from the observational studies. Patients were required to have axial spondyloarthritis and clinical and/or radiographic evidence of temporomandibular joint dysfunction. Meta-analysis was performed with a random effects model. A systematic review was registered under number CRD42020206283. We identified seven relevant studies, which provided data for 745 patients and 216 temporomandibular disorders events. The combined odds ratio (OR) showed that the risk of temporomandibular disorders in individuals with axial spondyloarthritis was higher than the control group (pooled OR = 5.26, 95% CI 2.50-11, 06; p < 0.02; I2  = 58%). Also, these individuals do not appear to refer possible temporomandibular joint symptoms to the rheumatologist or dentist. The results of this systematic review and meta-analysis suggest that patients with axial spondyloarthritis have an increased frequency of temporomandibular disorders. TMDs seem to be secondary to postural alterations rather than direct involvement of the temporomandibular joints (TMJs).

Umbilical Cord Stem Cell Lysate: A New Biologic Injectate for the Putative Treatment of Acute Temporomandibular Joint Inflammation

Objective

To compare in vivo, the acute anti-inflammatory effects of a lysate derived from human umbilical perivascular mesenchymal cells with the cells themselves in both an established hind-paw model of carrageenan-induced inflammation and also in the inflamed temporomandibular joint.

Study Design

Human umbilical cord perivascular cells were harvested and cultured in xeno- and serum-free conditions to P3. In addition, P3 cells were used to prepare a proprietary 0.22 micron filtered lysate. First, CD1 immunocompetent mice underwent unilateral hind-paw injections of carrageenan for induction of inflammation, followed immediately by treatment with saline (negative control), 1% cell lysate, or viable cells. The contralateral paw remained un-injected with carrageenan. Paw circumference was measured prior to injections and 48 hr later and myeloperoxidase and TNF-alpha concentrations were measured post-sacrifice in excised tissue. Second, immunocompetent Male Wistar rats underwent unilateral intra-articular temporomandibular (TMJ) injections from the same treatment groups and were sacrificed at 4 and 48 hr post-injection. The contralateral TMJ remained un-injected with carrageenan. Articular tissue and synovial aspirates, from the treated TMJ were obtained for histologic and leukocyte infiltration analyses.

Results

The lysate and cell-treated hind-paw demonstrated reduced tissue edema, and significantly lower concentrations of myeloperoxidase and TNF-alpha at 48 hr compared to untreated controls. Treated TMJs demonstrated lower concentrations of leukocytes in the synovium compared to controls and histologic evidence, in the peri-articular tissue, of reduced inflammation.

Conclusion

In this preliminary study, both the human umbilical perivascular cells and a highly diluted lysate produced therefrom were anti-inflammatory.

Comparison of Four Treatment Protocols with Intra-Articular Medium Molecular Weight Hyaluronic Acid in Induced Temporomandibular Osteoarthritis: An Experimental Study

The aim was to compare the effect between a single intra-articular infiltration (1i) and two infiltrations (2i) of medium molecular weight hyaluronic acid (MMW-HA) of high viscosity (HV) and low viscosity (LV) on the histopathological characteristics of temporomandibular joint (TMJ) osteoarthritis (OA) induced in rabbits. An experimental study was conducted on Oryctolagus cuniculus rabbits, including 42 TMJs, distributed between (1) TMJ-C, control group; (2) TMJ-OA, group with OA; (3) TMJ-OA-wt, group with untreated OA; (4) group treated with HA-HV-1i; (5) group treated with HA-HV-2i; (6) group treated with HA-LV-1i; and (7) group treated with HA-LV-2i. The results were evaluated using the Osteoarthritis Research Society International (OARSI) scale and descriptive histology considering the mandibular condyle (MC), the articular disc (AD), and the mandibular fossa (MF). The Kruskal-Wallis test was used for the statistical analysis, considering p < 0.05 significant. All treated groups significantly decreased the severity of OA compared to the TMJ-OA-wt group. The HA-HV-2i group showed significant differences in the degree of OA from the TMJ-OA group. The degree of OA in the HA-HV-2i group was significantly lower than in the HA-LV-1i, HA-LV-2i, and HA-HV-1i groups. The protocol that showed better results in repairing the joint was HA-HV-2i. There are histological differences depending on the protocol of the preparation used: two infiltrations seem to be better than one, and when applying two doses, high viscosity shows better results.

Comparative effectiveness of hyaluronic acid, platelet-rich plasma, and platelet-rich fibrin in treating temporomandibular disorders: a systematic review and network meta-analysis

OBJECTIVE

This study aims to compare the efficacy of intra-articular injections of hyaluronic acid (HA), platelet-rich plasma (PRP), and platelet-rich fibrin (PRF) for treating temporomandibular disorders (TMDs) and summarize their mechanisms of action.

METHODS

Randomized controlled trials (RCTs) published until November 13, 2021, were identified using electronic and manual searches. Each study was evaluated for the risk of bias using the Cochrane risk of bias tool. The studies found via searches were categorized by follow-up time (1, 3, or 6 months). Evidence quality was graded according to the GRADE system.

RESULTS

Twelve RCTs were included that involved 421 patients with TMD. The network meta-analysis showed that all treatment groups improved compared to the placebo groups in terms of pain and maximal mouth opening (MMO). For pain evaluated via the visual analog scale, PRF exhibited better analgesic effects than PRP or HA after 1 and 3 months. PRP appeared to be more effective than PRF was after 6 months but there were no statistically significant differences between the two. For MMO, the effect of PRP was superior to those of PRF and HA after 1 month. However, after 3 and 6 months, PRF provided more encouraging results in improving MMO.

CONCLUSION

PRP and PRF exhibited similar short-term efficacy in treating TMD, while PRF was more advantageous in terms of long-term efficacy. Therefore, PRF was recommended for treating TMD.

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.

Does the Use of Injectable Platelet-Rich Fibrin After Arthrocentesis for Disc Displacement Without Reduction Improve Clinical Outcomes?

PURPOSE

Many studies have reported the role of arthrocentesis to alleviate symptoms of patients with disc displacement without reduction (DDWoR). Nevertheless, the benefit of injectable platelet-rich fibrin (i-PRF) remains unclear. The aim of this study was to answer the following question: among patients with DDWoR, do those treated with intra-articular injection of i-PRF after arthrocentesis, when compared to those treated with arthrocentesis only, have better clinical outcomes in terms of pain reduction and improvement of jaw movement?

MATERIALS AND METHODS

This single-blind randomized, controlled study included patients with diagnosed DDWoR, in the Department of Oral and Maxillofacial Surgery at the School of Dentistry, Ege University, who had localized joint pain and limited range of motion. Patients were treated either with arthrocentesis (AC group) or arthrocentesis in combination with intra-articular i-PRF injection (AC + i-PRF group). The predictor variable was treatment (ie, arthrocentesis with or without i-PRF). The primary outcome variable was pain (visual analog scale). The secondary outcome variables were maximum mouth opening, lateral and protrusive movements. Outcome variables were recorded at pretreatment and at the postoperative 1st, 2nd, 3rd, 6th, and 12th months. Statistical analysis was performed using the Brunner-Langer model, with a significance level P < .05.

RESULTS

This study comprised 76 patients (34 females/4 males, mean age 47.2 ± 9.1 for the AC + i-PRF group; 35 females/3 males, mean age 46.8 ± 10.2 for the AC group). The treatment success rate was 73.7% for the AC group and 100% for the AC + i-PRF group (P = .012). Pain levels in the AC + i-PRF group were found to decrease more than the AC group over 12 months postoperatively (palpation: -6.9 ± 1.2 vs -5.3 ± 1.3; chewing: -6.9 ± 1.5 vs -5.1 ± 1.7; jaw movements: -6.9 ± 1.1 vs -5.1 ± 1.4). This difference was statistically significant (P < .001). The degree of jaw movement in the AC + i-PRF group was found to increase more than the AC group over 12 months postoperatively (maximum mouth opening: 8.0 ± 2.1 vs 4.9 ± 2.0; contralateral: 1.8 ± 0.8 vs 0.2 ± 1.0; ipsilateral: 2.9 ± 1.3 vs 0.8 ± 1.5; protrusive: 2.6 ± 1.1 vs 0.8 ± 1.3). This difference was statistically significant (P < .001).

CONCLUSION

Intra-articular injection of i-PRF after arthrocentesis produced greater improvements in pain reduction and jaw movement when compared to arthrocentesis only. These results indicate that i-PRF used in combination with arthrocentesis is an effective adjunctive treatment.

Synergistic effect of platelet rich plasma with hyaluronic acid injection following arthrocentesis to reduce pain and improve function in TMJ osteoarthritis

Increasing evidence supports the use of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) for the treatment of knee osteoarthritis, which effectively promotes cartilage repair. This study aimed to determine whether injection of PRP+HA following arthrocentesis reduces pain and improves maximum incisal opening. This was a single-blind, prospective, randomized control study. The patients were selected based on the Hegab classification: Group I: patients treated with arthrocentesis followed by a single PRP injection; Group II (Control): patients treated with arthrocentesis followed by a single HA injection; and Group III: patients treated with arthrocentesis followed by a single PRP+HA combination injection. The primary predictor variable was the medication used for injection. The primary outcome variables were the maximum voluntary mouth opening and pain index scores. The secondary outcome variable was joint sounds. All outcome variables were assessed and compared among the three groups at baseline and at 1-, 3-, 6-, and 12-month intervals. Other variables, including patients' age and sex, were evaluated in relation to the patient outcomes. Injecting PRP+HA showed statistically significant improvement in the primary and secondary treatment outcomes over PRP or HA injection throughout the study period (P<0.005). Injection of PRP+HA following arthrocentesis had significant long-term clinical efficacy regarding pain relief that considered the main concern of both the patient and clinician.

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.

Treatment of Mandibular Hypomobility by Injections into the Temporomandibular Joints: A Systematic Review of the Substances Used

INTRODUCTION

Hyaluronic acid, steroids and blood products are popularly injected into the temporomandibular joint (TMJs) to relieve pain and increase the extent of mandibular abduction. The purpose of this review is to identify other injectable substances and to evaluate them in the above-mentioned domains.

MATERIAL AND METHODS

The review included articles describing clinical trials of patients treated with intra-articular injections with or without arthrocentesis.

RESULTS

The following emerging substances were initially evaluated to be effective in treating TMJ pain and increasing the amplitude of mandibular abduction: analgesics, dextrose with lidocaine, adipose tissue, nucleated bone marrow cells and ozone gas.

DISCUSSION

Better effects of intra-articular administration are achieved by preceding the injection with arthrocentesis.

CONCLUSIONS

The most promising substances appear to be bone marrow and adipose tissue.

Arthrocentesis versus nonsurgical methods in the management of temporomandibular joint closed lock and pain: a double-blind randomized controlled trial

OBJECTIVE

The present double-blind randomized clinical trial aimed to compare the efficacy of conservative treatment and articular lavage, either alone or combined, to reduce joint pain and improve mandibular opening.

STUDY DESIGN

The sample consisted of patients presenting with limited mouth opening and joint pain. The diagnosis was made according to the diagnostic criteria for temporomandibular disorders guideline and confirmed by magnetic resonance imaging. Sixty patients were selected and randomly allocated to 4 groups of 15 patients each with different treatments: group A (conservative), group B (conservative + medication), group C (arthrocentesis), and group D (arthrocentesis + medication). The groups were compared in terms of maximal interincisal opening and pain.

RESULTS

The average age of the patients was 34.17 ± 13.1 years, 88.1% were women, 72.9% had internal derangement, 54% had joint sounds, and 55.9% presented with locking. Clinical improvement was noted in all parameters compared with baseline in all groups (P < .005), but no significant differences were observed when the groups were compared (P > .05).

CONCLUSIONS

Both arthrocentesis and conservative modalities were efficient treatments to reduce joint pain and increase mandibular opening.

Mechanisms of Action and Efficacy of Hyaluronic Acid, Corticosteroids and Platelet-Rich Plasma in the Treatment of Temporomandibular Joint Osteoarthritis-A Systematic Review

Temporomandibular joint osteoarthritis (TMJ OA) is a low-inflammatory disorder with multifactorial etiology. The aim of this review was to present the current state of knowledge regarding the mechanisms of action and the efficacy of hyaluronic acid (HA), corticosteroids (CS) and platelet-rich plasma (PRP) in the treatment of TMJ OA.: The PubMed database was analyzed with the keywords: "(temporomandibular joint) AND ((osteoarthritis) OR (dysfunction) OR (disorders) OR (pain)) AND ((treatment) OR (arthrocentesis) OR (arthroscopy) OR (injection)) AND ((hyaluronic acid) OR (corticosteroid) OR (platelet rich plasma))". After screening of 363 results, 16 studies were included in this review. Arthrocentesis alone effectively reduces pain and improves jaw function in patients diagnosed with TMJ OA. Additional injections of HA, either low-molecular-weight (LMW) HA or high-molecular-weight (HMW) HA, or CS at the end of the arthrocentesis do not improve the final clinical outcomes. CS present several negative effects on the articular cartilage. Results related to additional PRP injections are not consistent and are rather questionable. Further studies should be multicenter, based on a larger group of patients and should answer the question of whether other methods of TMJ OA treatment are more beneficial for the patients than simple arthrocentesis.

The efficacy of intra-articular injectable platelet-rich fibrin application in the management of Wilkes stage III temporomandibular joint internal derangement

The aim of this retrospective study was to compare the effectiveness of hyaluronic acid (HA) and injectable platelet-rich fibrin (i-PRF) in the management of Wilkes stage III internal derangement, and to evaluate the biosupplementation capacity of i-PRF. The records of all 54 relevant patients with Wilkes stage III internal derangement confirmed by magnetic resonance imaging and treated with arthrocentesis alone or in combination with HA or i-PRF were selected. The outcome variables were pain intensity at rest (VASr) and in function (VASf), evaluated with a visual analogue scale, and maximum mouth opening (MMO), evaluated in millimetres; assessments were made preoperatively, immediately after the procedure, and at 1 week, 1 month, and 3 months postoperatively. When compared to the HA and arthrocentesis groups, the i-PRF group showed significantly better improvements in MMO at 1 and 3 months (P=0.024 and P=0.006, respectively), VASr at 1 and 3 months (both P<0.001), and VASf at 1 week (P=0.019) and 1 and 3 months (both P<0.001) postoperatively. In all groups, better MMO, VASr, and VASf values were observed compared to the preoperative status. The application of i-PRF after arthrocentesis is more effective than arthrocentesis alone or with HA in the short term. HA was found not to provide significant additional benefits over arthrocentesis alone.

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

The purpose of this study was to compare clinical outcomes obtained with the use of glucosamine, chondroitin sulfate, and methylsulfonylmethane (GCM) supplementation after arthrocentesis plus intraarticular hyaluronic acid (HA) injection. A randomized clinical trial was implemented with adult participants with TMJ-OA who were referred to the author's clinic between February 2014 and May 2015. The sample was entirely composed of patients with TMJ-OA who were treated randomly with a one-session arthrocentesis plus intraarticular HA injection only (control group), or an initial one-session arthrocentesis plus intraarticular HA injection followed by 3 months of GCM supplementation (study group). The predictor variable was management (treatment) technique. The outcome variables were visual analog scale evaluations (masticatory efficiency, pain complaint, joint sound) and mandibular mobility (maximal interincisal opening [MIO], and lateral and protrusive motions of the mandible). The outcome variables were recorded preoperatively and 12 months postoperatively. Thirty-one participants were enrolled in the study. Five were lost during follow-up. The final study sample consisted of 26 participants (age 28.35 ± 10.85 y): 14 in the control group (age 28.71 ± 10.94 y); and 12 in the study group (age 27.92 ± 11.20 y). Pain complaints (p < 0.001) and joint sounds (p = 0.030 for the control group; p = 0.023 for the study group) showed statistically significant decreases. Masticatory efficiency (p < 0.001 for the control group; p = 0.040 for the study group) and lateral mandibular motion (p = 0.040 for the control group; p = 0.004 for study group) showed statistically significant increases in both groups, whereas MIO and protrusive mandibular motion showed no significant changes in either group (p > 0.05). After estimating the differences between the follow-up and baseline outcomes, the mean changes in the primary outcome variables (VAS scores, MIO, and mandibular motion) showed no statistically significant differences between the two groups (p > 0.05). Progressions (reparative remodeling) of hard-tissue TMJ structures were observed on CBCT scans of some participants in both groups. These findings suggested that the use of GCM supplementation after arthrocentesis plus intraarticular HA injection produced no additional clinical benefits or improvements for patients with TMJ-OA compared with arthrocentesis plus intraarticular HA injection alone.

Temporomandibular Joint Arthrocentesis and Microfragmented Adipose Tissue Injection for the Treatment of Internal Derangement and Osteoarthritis: A Randomized Clinical Trial

PURPOSE

Internal derangement and osteoarthritis are the most common degenerative temporomandibular joint diseases and initial treatment for such conditions relies on arthrocentesis. Microfragmentation of adipose tissue has been proven in orthopedic literature to represent a more effective method to preserve stem cells, but no application has ever been reported in the temporomandibular joint. The purpose of this randomized clinical trial is to compare standard treatment conducted by injecting hyaluronic acid after the procedure to the new treatment relying upon microfragmented adipose tissue injection using the Lipogems technology.

MATERIALS AND METHODS

A randomized clinical trial was designed enrolling 20 patients in the control group receiving the standard treatment and 20 patients in the experimental group receiving microfragmented adipose tissue obtained through the Lipogems technology after arthrocentesis. Two main outcomes were defined, pain (visual analogic scale) and function (maximum interincisal opening). Both were measured in the immediate preoperative time, and 10 days, 1 month, and 6 months after the procedure.

RESULTS

In both groups, pain reduction and mouth opening significantly improved compared with the preoperative situation (P = .001). At 6-month follow-up, there was an almost statistically significant reduction of pain compared with preoperative visual analogic scale (P = .0546) and a statistically significant improvement of mouth opening (P = .0327). Overall, statistical analyses showed that the experimental group had a statistically significant superiority in the success rate of the procedure compared with the control group (P = .018).

CONCLUSIONS

Preliminary results of this clinical trial show that the injection of microfragmented adipose tissue can significantly improve outcomes of pain and function compared with the standard treatment and encourage to pursue research on this topic. Further studies with a longer follow-up time are needed to evaluate the clinical stability of the achieved improvement in pain and function.

Interdisciplinary Approach to the Temporomandibular Joint Osteoarthritis-Review of the Literature

Background and objectives: There are an increasing number of patients applying for dental treatment who suffer from temporomandibular joint osteoarthritis (TMJOA). Osteoarthritis may be the cause of the pain in the area of temporomandibular joints, but its course may also be absolutely asymptomatic. The aim of this study was to present an interdisciplinary approach to TMJOA, including current diagnostics and treatment modalities on the basis of the available literature. Materials and Methods: PubMed and Scopus databases were analyzed using the keywords: ((temporomandibular joint AND osteoarthritis) AND imaging) and ((temporomandibular joint AND osteoarthritis) AND treatment). The bibliography was supplemented with books related to the temporomandibular joint. After screening 2450 results, the work was based in total on 98 publications. Results and Conclusions: Osteoarthritis is an inflammatory, age-related, chronic and progressive degenerative joint disease. Magnetic resonance imaging (MRI) and cone-beam computed tomography (CBCT), together with clinical symptoms, play significant roles in TMJOA diagnosis. Current MRI techniques seem to be clinically useful for assessment of bony changes in temporomandibular joint (TMJ) disorders. Treatment of TMJOA requires a complex, interdisciplinary approach. TMJOA treatment includes the cooperation of physiotherapists, rheumatologists, gnathologists, orthodontists and quite often also maxillofacial surgeons and prosthodontists. Sometimes additional pharmacotherapy is indicated. Thorough examination of TMJ function and morphology is necessary at the beginning of any orthodontic or dental treatment. Undiagnosed TMJ dysfunction may cause further problems with the entire masticatory system, including joints, muscles and teeth.

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.

The hierarchy of different treatments for arthrogenous temporomandibular disorders: A network meta-analysis of randomized clinical trials

PURPOSE

Different treatment options for patients with arthrogenous Temporomandibular Disorders (TMDs) have been reported. However, evidence regarding the most effective intervention using network meta-analysis (NMA) has not been performed. Thus, we conducted a NMA of randomized clinical trials (RCTs) to identify the most effective treatment of arthrogenous TMDs with respect to pain reduction and improved mouth opening, and to generate a ranking according to their effectiveness.

MATERIAL AND METHODS

An electronic search on three major databases was undertaken to identify RCTs published before August 2019, comparing up to fourteen different treatments against control/placebo patients for arthrogenous TMDs with respect to pain reduction and improved mouth opening. The treatment variables were controls/placebo, conservative treatment (muscle exercises and occlusal splint therapy), occlusal splint therapy alone, intraarticular injection (IAI) of hyaluronic acid (HA) or corticosteroid (CS), arthrocentesis with or without HA, CS and platelet-rich plasma (PRP), arthroscopy with or without HA and PRP, open joint surgery, and physiotherapy. Frequentist NMA was performed using STATA software. Studies meeting the inclusion criteria were divided according to the length of follow-up (short-term (≤5 months) and intermediate-term (≥6 months to 4 years) and type of TMJ arthrogenous disorders; internal derangement (ID) and TMJ osteoarthritis (OA). The standardized mean differences (SMD) in post-treatment pain reduction and maximum mouth opening (MMO) were analysed.

RESULTS

Thirty-six RCTs were identified that performed comparative outcome assessments for pain and 33 RCTs for MMO. At the short term (≤5 months), IAI-HA (SMD = -2.8, CI: -3.7 to -1.8) and IAI-CS (SMD = -2.11, CI: -2.9 to -1.2) (all very low quality evidence) achieved a substantially greater pain reduction than control/placebo. At intermediate term (≥6 months), a statistically significant decrease in posttreatment pain intensity was observed following Arthroscopy-PRP (SMD = -3.5, CI: -6.2 to -0.82), Arthrocentesis-PRP (SMD = -3.08, CI: -5.44 to -0.71), Arthroscopy-HA (SMD = -3.01, CI: -5.8 to -0.12), TMJ surgery (SMD = -3, CI: -5.7 to -0.28), IAI-HA (SMD = -2.9, CI: -4.9 to -1.09) (all very low quality evidence), Arthroscopy-alone (SMD = -2.6, CI: -5.1 to -0.07, low quality evidence) and Arthrocentesis-HA (SMD = -2.3, CI: -4.5 to -018, moderate-quality evidence) when compared to the control/placebo groups. Relative to MMO, the most effective treatments for short- and intermediate-term improvement were the arthroscopy procedures (PRP > HA > alone, all very low-quality evidence) followed by Arthrocentesis-PRP (very low-quality evidence) and Arthrocentesis-HA (moderate-quality evidence). The non-invasive procedures of occlusal splint therapy, physical therapy, conservative therapy, placebo/control provided significantly lower quality outcomes relative to pain and MMO.

CONCLUSION

The results of the present meta-analysis support a paradigm shift in arthrogenous TMJ disorder treatment. There is a new evidence (though on a very low to moderate quality level) that minimally invasive procedures, particularly in combination with IAI of adjuvant pharmacological agents (PRP, HA or CS), are significantly more effective than conservative treatments for both pain reduction and improvement of MMO in both short (≤5 months) and intermediate term (6 months-4 years) periods. In contrast to traditional concepts mandating exhaustion of conservative treatment options, minimally invasive procedures, therefore, deserve to be implemented as efficient first-line treatments (e.g. IAIs and/or arthrocentesis) or should be considered rather early, i.e. as soon as patients do not show a clear benefit from an initial conservative treatment.

Experimental Methods to Inform Diagnostic Approaches for Painful TMJ Osteoarthritis

Temporomandibular joint (TMJ) osteoarthritis (OA) is a degenerative disease of the joint that can produce persistent orofacial pain as well as functional and structural changes to its bone, cartilage, and ligaments. Despite advances in the clinical utility and reliability of the Diagnostic Criteria for Temporomandibular Disorders, clinical tools inadequately predict which patients will develop chronic TMJ pain and degeneration, limiting clinical management. The challenges of managing and treating TMJ OA are due, in part, to a limited understanding of the mechanisms contributing to the development and maintenance of TMJ pain. OA is initiated by multiple factors, including injury, aging, abnormal joint mechanics, and atypical joint shape, which can produce microtrauma, remodeling of joint tissues, and synovial inflammation. TMJ microtrauma and remodeling can increase expression of cytokines, chemokines, and catabolic factors that damage synovial tissues and can activate free nerve endings in the joint. Although studies have separately investigated inflammation-driven orofacial pain, acute activity of the trigeminal nerve, or TMJ tissue degeneration and/or damage, the temporal mechanistic factors leading to chronic TMJ pain are undefined. Limited understanding of the interaction between degeneration, intra-articular chemical factors, and pain has further restricted the development of targeted, disease-modifying drugs to help patients avoid long-term pain and invasive procedures, like TMJ replacement. A range of animal models captures features of intra-articular inflammation, joint overloading, and tissue damage. Although those models traditionally measure peripheral sensitivity as a surrogate for pain, recent studies recognize the brain's role in integrating, modulating, and interpreting nociceptive inputs in the TMJ, particularly in light of psychosocial influences on TMJ pain. The articular and neural contributors to TMJ pain, imaging modalities with clinical potential to identify TMJ OA early, and future directions for clinical management of TMJ OA are reviewed in the context of evidence in the field.

The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: a review

PURPOSE

The aim of this review was to assess the efficacy of intra-articular analgesics in improving outcomes after temporomandibular joint (TMJ) arthrocentesis.

MATERIAL AND METHODS

An electronic search of PubMed, Scopus, and Google scholar databases was performed for papers in English published up to December 2017 reporting the use of intra-articular analgesics after TMJ arthrocentesis. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), comparative studies, retrospective studies, and case series were included while case reports, technical reports, animal studies, cadaveric studies, and review papers were excluded.

RESULTS

Of the six studies included in the review, three were RCTs, two were randomized comparative studies, and one was a retrospective study. Both opioids and non-steroidal anti-inflammatory drugs have been used after TMJ arthrocentesis. Morphine, tramadol, fentanyl, buprenorphine, tenoxicam, and COX-2 inhibitors are the drugs used till date. Placebo-controlled studies reported improved outcomes after TMJ arthrocentesis with morphine and fentanyl but no such results with buprenorphine and tenoxicam. Tramadol was found to be better than COX-2 inhibitor. The quality of literature was not high.

CONCLUSIONS

There is inconclusive evidence in literature on the benefits of using intra-articular analgesics after TMJ arthrocentesis. Well-designed high-quality RCTs with standard protocol studying the effects of intra-articular opioids and NSAIDS after TMJ arthrocentesis would provide stronger evidence on its use.

Pain relief following a single-dose intra-articular injection of methylprednisolone in the temporomandibular joint arthralgia-A multicentre randomised controlled trial

Background

Temporomandibular joint (TMJ) arthralgia is a painful condition assumed to be associated with local inflammation.

Objective

The objective of the present study was to determine the efficacy for reducing pain of a single‐dose intra‐articular (IA) injection of methylprednisolone to the TMJ. The hypothesis was that methylprednisolone would effectively reduce TMJ pain.

Methods

This randomised, double‐blind, parallel‐group, multicentre, controlled study included visits for enrolment, treatment and 4‐week follow‐up. The study included patients 18 years and older who had been diagnosed with unilateral TMJ arthralgia. All participants were randomly assigned to receive 1 mL IA injections of methylprednisolone or saline. The primary outcome was change in recorded pain intensity on a visual analogue scale (VAS) at maximum jaw opening, analysed in the per protocol population.

Results

In total, 54 patients were randomly assigned to single‐dose IA injections with methylprednisolone (n = 27) or saline (n = 27). Between baseline and the 4‐week follow‐up, VAS‐rated pain intensity at maximum jaw opening decreased from a mean of 61.0 (95% confidence interval [CI]: 50.1; 70.7) to 33.9 (95% CI: 21.6; 46.2) in the methylprednisolone group and from 59.6 (95% CI: 50.7; 65.9) to 33.9 (95% CI: 23.8; 43.9) in the saline group. The between‐group difference was not significant (P = 0.812). Treatment‐related adverse events were doubled in the methylprednisolone group.

Conclusion

Methylprednisolone provided no additional benefit for reducing pain, but caused more harm compared with saline following a single‐dose IA injection in patients with TMJ arthralgia.

Efficacy of viscosupplementation with hyaluronic acid in temporomandibular disorders: A systematic review

OBJECTIVE

To perform a systematic review of the viscosupplementation effectiveness with hyaluronic acid (HA) in the articular Temporomandibular Dysfunctions (TMDs) clinical management.

METHOD

Electronic searches were performed in the following databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library, EMBASE, LILACS, BBO, SIGLE (System for Information on Grey Literature in Europe), ClinicalTrials.gov, and the Brazilian Clinical Trials Registry (ReBec). Only randomized clinical trials that evaluated the intra-articular administration of HA or its derivatives in osteoarthritis and/or anterior displacement of the temporomandibular joint (TMJ) disc were included. The primary outcomes evaluated were patients' self-report of pain and/or discomfort in the TMJ. Each study was assessed for the risk of bias, using the Cochrane collaboration's risk of bias tool.

RESULTS

A total of 640 studies were obtained in the electronic search. After the application of the eligibility criteria, manual search, and duplicate removal, 21 articles were included. Five articles classified their volunteers with internal derangements of the TMJ, in 4 articles the treatment was directed to participants with disc displacement with reduction and the other articles evaluated HA therapy in osteoarthritis. The protocols presented heterogeneity, varying in the form of application, associated or not with arthrocentesis, number of applications, molecular weight, dose and concentration. Nine studies presented high risk of bias.

CONCLUSION

Due to the heterogeneity and methodological inconsistencies of the studies evaluated, it was not possible to establish the efficacy of HA in articular TMDs.

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.