Intra-articular injection of a mixture of hyaluronic acid and corticosteroid versus arthrocentesis in TMJ internal derangement

Corticosteroids for the Treatment of Internal Temporomandibular Joint Disorders: A Systematic Review and Network Meta-Analysis

Background: We evaluated the comparative effectiveness of all intra-articular injection corticosteroids for treating internal temporomandibular joint (TMJ) disorders. Methods: We searched MEDLINE, CENTRAL, EMBASE, SCOPUS, and LILACS through December 2023. We included randomized clinical trials (RCTs) enrolling patients with symptomatic internal disorders of the TMJ comparing any type of intra-articular corticosteroid therapy against another or to another minimally invasive therapy. The outcomes of interest were pain, range of mandibular motion (RoM), quality of life (QoL) and adverse effects at 1, 3, 6, and 12 months. We assessed the risk of bias using the Cochrane Collaboration's tool. We conducted a frequentist network meta-analysis and assessed the certainty of the evidence (CoE) using GRADE. Results: We included 20 RCTs enrolling 810 participants, which assessed five corticosteroids alone or combined with arthrocentesis or hyaluronic acid. Based on moderate CoE, betamethasone is among the most effective corticosteroids for reducing pain at one (mean difference compared to arthrocentesis [MD], -3.80; 95% confidence interval [CI], -4.55 to -3.05) and three months (MD, -2.74; 95%CI, -3.42 to -2.06), and arthrocentesis plus dexamethasone at six months (MD, -0.80; 95%CI, -1.57 to -0.03). There was no convincing evidence that any intervention was better than arthrocentesis for improving the RoM and QoL at any follow-up time. Methylprednisolone may be more harmful than arthrocentesis for adverse effects. Discussion: Betamethasone and arthrocentesis plus dexamethasone are the most effective in managing pain in the short and medium term compared to arthrocentesis (moderate CoE). Decisions about their use should consider other factors, such as costs, feasibility, and acceptability. Future research should consider QoL as an outcome and assess participants at longer follow-up periods.

Ultrasound-Guided Vs Non-Guided Prolotherapy for Internal Derangement of Temporomandibular Joint. A Randomized Clinical Trial

OBJECTIVES

This randomized clinical trial study aims to compare ultrasound-guided versus non-guided Dextrose 10% injections in patients suffering from internal derangement in the temporomandibular joint (TMJ).

MATERIAL AND METHODS

The study population included 22 patients and 43 TMJs suffering from unilateral or bilateral TMJ painful clicking, magnetic resonance imaging (MRI) proved disc displacement with reduction (DDWR), refractory to or failed conservative treatment. The patients were divided randomly into two groups (non-guided and ultrasound (US)-guided groups). The procedure involved injection of 2 mL solution of a mixture of 0.75 mL 0.9% normal saline solution, 0.3 mL 2% lidocaine and 0.75 mL dextrose 10% using a 25G needle in the joint and 1 mL intramuscular injection to the masseter muscle at the most tender point. The Visual Analogue Score (VAS) was used to compare joint pain intensity over four different periods, beginning with pre-injection, 1-, 2-, and 6-months postinjection.

RESULTS

Twenty-two patients 5 males (n = 5/22, 22.7%) and 17 females (n = 17/22, 77.2%) were included in this study. The mean age was 27.3 ± 7.4 years (30.2 ± 7.0) for the non-guided group and 24.3 ± 6.9 for the US-guided group. The dextrose injection reduced intensity over time in both groups with statistically significant improvement (P value <.05) at 2 and 6 months in both groups. There was no statistically significant difference in VAS assessment between both groups.

CONCLUSION

Intra-articular injection of dextrose 10% for patients with painful clicking and DDWR resulted in reduced pain intensity in both US-guided and non-guided groups with significant symptomatic improvement over time in both groups. US guidance allowed accurate anatomical localization and safe procedure with a single joint puncture.

Comparative evaluation of cognitive behavioural therapy versus standard treatment in temporomandibular disorders: A systematic review

BACKGROUND

Temporomandibular disorders (TMDs) are musculoskeletal and neuromuscular conditions affecting the temporomandibular joint and associated structures. Cognitive-behavioural therapy (CBT) has emerged as a potential intervention for TMDs, but its comparative effectiveness against standard treatments remains unclear. This systematic review aimed to evaluate and compare the efficacy of CBT versus standard treatment interventions in managing TMDs.

METHODS

A comprehensive search was conducted across multiple databases using MeSH keywords and Boolean operators. Inclusion criteria encompassed clinical trials comparing CBT/CBT in combination with standard treatment interventions or a control group in individuals with TMDs. The primary outcome measured was pain. Secondary outcomes such as disability, depression and jaw function were also looked into. Two reviewers independently assessed for the eligibility of the articles and conducted data extraction. Quality assessments were performed using RoB 2.0 for randomised clinical trials.

RESULTS

The initial search identified 623 articles, of which a total of eight clinical studies met the inclusion criteria and were included in the systematic review. Seven out of eight studies demonstrated improvements in outcomes related to TMD. Pain was significantly decreased in studies that showed a positive outcome. Jaw function, quality of life and psychological well-being were superior among individuals receiving CBT alone or in combination with conventional modalities, as well as hypnotic therapy coupled with CBT-based interventions. The quality of studies assessed showed all articles to be of good quality as per RoB-2 evaluation.

CONCLUSION

This systematic review highlights the potential benefits of CBT in managing TMDs, suggesting its effectiveness in improving pain outcomes and enhancing overall well-being. The findings indicate that CBT may be a valuable adjunct or alternative to standard treatment interventions for individuals with TMDs. However, further research with larger sample sizes and standardised outcome measures is warranted to establish definitive conclusions regarding the comparative efficacy of CBT versus standard treatments in TMD management.

Arthroscopy versus arthrocentesis and versus conservative treatments for temporomandibular joint disorders: a systematic review with meta-analysis and trial sequential analysis

The aim of this systematic review was to assess the efficacy of arthroscopy compared to arthrocentesis and to conservative treatments for temporomandibular joint disorders. Thirteen controlled studies on various patient outcomes were included after a systematic search in seven electronic databases. Meta-analyses were conducted separately for arthroscopic surgery (AS) and arthroscopic lysis and lavage (ALL), and short-term (<6 months), intermediate-term (6 months to 5 years), and long-term (≥5 years) follow-up periods were considered. No significant differences in pain reduction and complication rates were found between AS or ALL and arthrocentesis. Regarding improvement in maximum mouth opening (MMO), both AS at intermediate-term and ALL at short-term follow-up were equally efficient when compared to arthrocentesis. However, at intermediate-term follow-up, ALL was superior to arthrocentesis for MMO improvement (mean difference 4.9 mm, 95% confidence interval 2.7-7.1 mm). Trial sequential analysis supported the conclusion of the meta-analysis for MMO improvement for ALL versus arthrocentesis studies at intermediate-term follow-up, but not for the other meta-analyses. Insufficient evidence exists to draw conclusions regarding other patient outcomes or about comparisons between arthroscopy and conservative treatments. Due to the low quality of the primary studies, further research is warranted before final conclusions can be drawn regarding the management of temporomandibular joint disorders.

Efficacy of the transcutaneous electrostimulation in treatment dysfunctions of the TMJ associated with occlusion distortions

BACKGROUND

The study evaluation of the effectiveness the method of electrostimulation in treatment TMJ associated with occlusion disorders with the use of a patches by the company "Aganyan''.

METHODS

The study included 54 patients with temporomandibular dysfunction syndrome who had previously undergone endodontic dental treatment. In patients temporomandibular disorders (TMD) determined on the basis of Diagnostic criteria for temporomandibular disorders(DC/TMD).All patients had occlusion disorders due to errors after dental filling restoration. To diagnose the TMJ, a CT scan was used. The complex therapy also included therapy and with the use of a patches by the company "Aganyan''. The wearable patch includes a flexible substrate, a binder an adhesive layer, with an electrode foil attached to it. Patients applied one patch behind each TMJ. The patches were applied for eight hours every third day for three months. All the patients were given full-fledged endodontic treatment and restoration of the crown part, taking into account anatomical features.

RESULTS

The dynamics of the complex treatment of patients diagnosed with TMJ dysfunction syndrome showed that after treatment, the clinical symptoms gradually decreased and disappeared at the end of treatment. CT scan a year after treatment showed a normal ratio of TMJ elements. Сomplex treatment was effective in 87% of patients, after 3-5 months gradually decreased pain, noise in the joints, restriction of opening and closing of the mouth disappeared. Patients recovered their chewing functions, psycho-emotional state.

CONCLUSION

The results of the studies revealed a positive effects for the complex treatment dysfunctions syndrome TMJ the using the patches by the company "Aganyan" through electrical stimulation with low intensity.

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.

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.

Intra-articular injection of hyaluronic acid versus platelet-rich plasma following single puncture arthrocentesis for the management of internal derangement of TMJ: A double-blinded randomised controlled trial

The present study aimed to compare the efficacies of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) following single needle arthrocentesis in patients with TMJ internal derangement. This double-blinded randomised controlled trial involved the enrolment of patients diagnosed with unilateral TMD, falling into either Wilkes' stages II or III. In Group A, single needle arthrocentesis was performed using Ringer's lactate serving as a control group; in Group B, intra-articular injection of 1 ml hyaluronic acid injection was given following arthrocentesis; and in Group C, autologous intraarticular injections of 1 ml of PRP was given after arthrocentesis, twice in two weeks' interval. The primary outcome variables were maximum mouth opening and pain, while TMJ clicking sounds formed the secondary outcome variable. All the outcome variables were assessed preoperatively (T0) and postoperatively after the second dose of injection at one month (T1), three months (T2), and six months (T3). The alpha level was set to p < 0.05. Ninety patients (N = 90) comprised the final sample size of the study with thirty patients(n = 30) in each treatment group. A statistically significant decrease in the management in mean pain scores was noted between T0 [mean scores were 7.30 ± 1.05 (Group A), 7.63 ± 1.12 (Group B), and 7.56 ± 1.04(Group C)] and T3 [mean scores were 2.66 ± 0.88 (Group A), 2.4 ± 0.72 (Group B), and 1.66 ± 0.66 (Group C)] time intervals between Group A and C(p < 0.001). Significant improvement was noted in preoperative maximum mouth opening (MMO) of Group A, B, and C which was 22.83 ± 3.58, 22.17 ± 4.07, and 21.37 ± 3.69, respectively to 28.90 ± 2.72, 32.17 ± 3.97, and 34.10 ± 3.80 mm, respectively at six months postoperatively (p < 0.001). A significant decrease in joint sounds was evident for all three groups(p = 0.003 for Group A, p < 0.001 for Group B, and p < 0.001 for Group C) across the time intervals. Moreover, Group C showed a significant decrease in the prevalence of joint sound compared to the other two groups at all-time intervals postoperatively when equated to baseline (p = 0.02 at T1, p = 0.009 at T2, and p = 0.002 at T3). Within the limitations of the present study, it can be concluded that intra-articular PRP may be preferable over HA whenever appropriate, following single needle arthrocentesis in the treatment of TMJ internal derangement.

Viscosupplementation in the upper and lower compartments of the temporomandibular joint checked by ultrasonography in an ex vivo and in vivo study

Viscosupplementation (VS) of the temporomandibular joint (TMJ) aims to treat temporomandibular dysfunction (TMD) by stimulating synovial cells to improve intracapsular lubrication. The purpose of the present study was to assess a VS protocol planned with the aid of cone-beam computed tomography (CBCT) and checked by ultrasonography (US). The study was carried out in 3 stages. The first was to check the correspondence between the proposed facial reference points and the osseous components of the joint by means of CBCT. In the second stage, the upper and lower compartments of 20 TMJs of fresh frozen cadavers were injected with coloured liquids, and the accuracy of the technique was confirmed by dissecting the anatomical specimens. The third stage consisted of VS in 10 patients (20 TMJs), with real-time verification of the location of the needle tip by means of ultrasonography. CBCT confirmed the correct locations of the marked points used in the proposed VS protocol. The dissections showed that 13 of the 14 injections effectively reached the upper and lower compartments. The location of the needle tip was effectively verified by ultrasonography, confirming the correct access to both compartments. The proposed protocol was effective for accessing the upper and lower compartments of the TMJ. The evaluated protocol proved to be accurate, safe and clinically reproducible means of VS in the upper and lower compartments of the TMJ.

Treatment of temporomandibular joint disc displacement using arthrocentesis combined with injectable platelet rich fibrin versus arthrocentesis alone

Background/purpose

Temporomandibular joint disc displacement is the most frequently reported temporomandibular disorder that may severely impair quality of life and can be challenging to treat. This study aimed to evaluate and compare the efficiency of intra-articular injection of injectable platelet rich fibrin (i-PRF) following arthrocentesis or arthrocentesis alone in treatment of patients with TMJ disc displacement with reduction.

Materials and methods

Forty patients for a total of forty joints with reducible anterior disc displacement, as confirmed by Magnetic Resonance Imaging (MRI) were selected and divided into 2 equal groups. In group I (control group), arthrocentesis alone was performed with Ringer solution. In group II (study group), a combination of arthrocentesis and intra-articular injection with 1.5 ml i-PRF was performed. The outcome variables included pain intensity evaluated with a visual analogue scale, inter-incisal opening, lateral movement evaluated in millimeters, and clicking. Assessments were done pre-operatively, and 1 week, 3 months, and 6 months postoperatively.

Results

There was statistically significant reduction in pain intensity and clicking sound and increase in mouth opening and lateral movement in i-PRF group when compared to arthrocentesis group. In addition, the differences between preoperative and postoperative status in all the measured parameters were statistically significant within the study and the control group throughout the postoperative period.

Conclusion

The combination of i-PRF with arthrocentesis is a safe and effective method in the treatment of TMJ disc displacement with reduction.

Internal derangement of temporomandibular joint: Umbrella perforated screw technique

Introduction:

Umbrella shaped Perforated Screws (UPS) were developed for the use of orthopedic surgery to facilitate anchoring and fixation of the tissue to bone. We here present a retrospective study of Temporomandibular joint Internal derangement (ID) with fixation using this type of screws.

Materials & Methods:

We conducted a retrospective study including patients treated for ID using UPS to reposition the articular disc. The study included patients treated between 1998 and 2005. Patients were selected in concordance with clinical symptoms and signs of severity. All patients had an MRI (open/closed mouth) to confirm the diagnosis. Wilkes classification of temporomandibular disease (TMD) was adopted in the selection criteria.

Results:

Hundred and five patients were included, 92 female and 13 males with average age of 37.56. Dentists or general physicians mainly addressed these patients to our unit. The mean time from symptoms initiating to first consultation was 3.77 years, while the mean timing of surgery after initial consultation was 9.38 months. Patients have presented with various symptoms before the surgery including pain, limitation in eating habits and clicking. 77% of the patients had no or minimal pain post surgery. Hundred and one patients had good eating habits after surgery. Only 34 patients had persistent clicking despite surgery. We had neither infection nor hematoma as complication. Major complication to this technique is frontal paresis (14 patients), which was explained to all patients preoperatively. This paresis recovered in less than 2 months in all patients. We had 89.5% of the patients satisfied with their results.

Conclusion:

UPS are useful in the field of plastic surgery. This novel technique has the advantage of not compromising the vascular supply of the TMJ articular surface. This technique provides a simple, fast and efficient technique for posterior aponeurosis flap fixation. Our overall satisfactory rate was comparable to other studies.

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.

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.