Effect of arthrocentesis and sodium hyaluronate injection on nitrite, nitrate, and thiobarbituric acid-reactive substance levels in the synovial fluid

Lavage Volume of Arthrocentesis in the Management of Temporomandibular Disorders: A Systematic Review and Meta-Analysis

The aim of this study was to investigate the most effective lavage volume of arthrocentesis in the management of temporomandibular disorders. A comprehensive electronic search, based on the PRISMA guidelines, was performed, which included a computer search with specific keywords, a reference list search and a manual search. The inclusion criteria were the following: a randomized controlled trial, at least 20 subjects who underwent arthrocentesis, mention of the irrigation materials used for the arthrocentesis, mention of the irrigation volumes used for the arthrocentesis, MMO and pain measured as VAS or NRS, were reported as outcome figures, mention of a specific diagnosis or signs and symptoms, and inclusion of the data on the MMO or VAS/NRS at 6-month follow-up. Sixteen publications were enrolled in the meta-analysis, comparing arthrocentesis with a lavage volume <150 mL and arthrocentesis with a lavage volume ≥150 mL, in the efficacy of the improvement in the mouth opening and pain reduction. The results revealed the group with a lavage volume <150 mL had a greater improvement in the mouth opening and pain reduction. However, results are to be interpreted with caution, due to the paucity of the randomized controlled literature and other confounding factors. Further high-quality studies are required to provide a better conclusion to the treatment outcomes of the different lavage volumes.

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.

Intra-articular treatment with hyaluronic acid associated with gold nanoparticles in a mechanical osteoarthritis model in Wistar rats

This study aimed to evaluate the effects of intra-articular treatment with hyaluronic acid (HA) associated with GNPs in a mechanical model of osteoarthritis induced by median meniscectomy (MM). Fifty Wistar rats (2 months weighing between 250 and 300 g) were used, divided into five groups of 10 animals each: Sham, osteoarthritis (OA), OA + HA, OA + gold nanoparticles (GNPs), and OA + HA + GNPs. Intra-articular treatment was started 30 days after the model was induced, with a frequency of 2 weeks for 60 days. Fifteen days after the last application, the animals were euthanized with the removal of the joint tissue for biochemical and histological analysis. The model used was able to mimic osteoarthritis, characterized by the presence of high levels of proinflammatory cytokines, oxidative stress, and degeneration of joint surfaces (Grade III, according to SCORE OARSI). The isolated use of HA or GNPs provided beneficial results to the joint; however, only the group subjected to the association between HA and GNPs showed the attenuation of oxidative stress and reduced proinflammatory markers, with a simultaneous increase in levels of anti-inflammatory cytokines and growth factors. Upon histological analysis, only the OA + HA + GNPs group achieved the restoration of the thickness of the joint cartilage with reduced damage and return to the intact joint surface. The results found demonstrated that the association of GNPs with HA was able to reverse the deleterious effects caused by the model by inhibiting the progressive degeneration of joint surfaces, representing a promising treatment for osteoarthritis.

Effects of arthrocentesis and low-level laser therapy on patients with osteoarthritis of the temporomandibular joint

This retrospective study examined whether arthrocentesis combined with 10 sessions of low-level laser therapy (LLLT) improved the clinical outcomes of patients with temporomandibular joint osteoarthritis (TMJ-OA) compared with arthrocentesis alone. Data from two groups of patients (total: n=36) with unilateral TMJ-OA were evaluated. The groups were established according to their treatment regimens: Group 1 (arthrocentesis alone; n=19) and Group 2 (arthrocentesis plus LLLT; n=17). All patients had been diagnosed in accordance with the Research Diagnostic Criteria for Temporomandibular Joint Disorders (RDC/TMD) (Axis I Group IIIb) protocol. They all underwent the same arthrocentesis protocol, but those in Group 2 also received 10 sessions of LLLT immediately afterwards. The outcome variables were the visual analogue scale scores (VAS 1, VAS 2) for various treatment outcomes and millimetric measurements of mandibular movements over both the short and long term. Intra-group comparisons showed significant short and long-term improvements for both groups, but outcomes were better over the long term than the short term in both. In addition, greater improvements in muscle palpation scores and mandibular movements were achieved in Group 2 than in Group 1. In conclusion, although both techniques improved joint pain and function, a combination with LLLT seemed to have an additional benefit for myofascial components.

Arthrocentesis and Sodium Hyaluronate Infiltration in Temporomandibular Disorders Treatment. Clinical and MRI Evaluation

Arthrocentesis in temporomandibular joint disorders can be associated with the intra-articular infiltration of various drugs with the objective of increase treatment efficacy. The aim of this study was to evaluate the clinical indexes variation in patients affected by temporomandibular joint disorders treated with arthrocentesis and sodium hyaluronate (SH) injections. A total of 28 patients suffering from temporomandibular joint disorders underwent one cycle of five arthrocentesis and infiltrations of sodium hyaluronate. Spontaneous mouth opening improved from 36.3 ± 7.5 mm to 45.1 ± 1.9 mm at six months follow-up. A significant reduction in the pain at rest and during mastication mean values emerged at follow-up (p < 0.0001). The mean masticatory efficiency, evaluated through a visual analogic scale, showed improvement at the follow-up period, highlighted by the increase of mean value from a baseline of 3.1 ± 1.2 to a mean value of 8.5 ± 1.2 (p < 0.0001). The mean severity of the joint damage at baseline time was 2.4 ± 0.9 and decreased to 0.4 ± 0.3 at the end of the follow-up period. The decrease in values is confirmed by statistical test (p < 0.05). Our data show how arthrocentesis integrated with sodium hyaluronate infiltrations performed under local anesthesia is a valid method of treating temporomandibular joint disorders.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mandibular lateral deviation induces alteration in vascular endothelial growth factor expression and oxidative stress/nitric oxide generation in rat condyle, synovial membrane and masseter muscle

OBJECTIVE

We aimed to investigate alteration in cellular signaling mediated by vascular endothelial growth factor (VEGF) and parameters of oxidative stress/nitric oxide generation, superoxide dismutase (SOD) and neuronal nitric oxide synthase (nNOS), underlying altered functional mechanical loading of TMJ (temporomandibular joint) during lateral mandibular deviation.

DESIGN

Thirty-eight 5-week-old male Wistar rats were divided into experimental group, which received acrylic resin appliance that shifted mandible to the left during closure, and control group. Computed tomography and histomorphometry were used for condyle analyses, while samples of condyle, synovial membrane and m. masseter were analyzed with enzyme-linked immunosorbent assay and spectrophotometry to determine VEGF and nNOS protein concentrations, and SOD activity.

RESULTS

Experimental group of rats developed smaller and asymmetrical mandibles. Less of new bone and cartilage formation and larger bone marrow cavities area were found in the experimental group. Higher VEGF expression in condyle and m. masseter as well as higher nNOS expression in m. masseter and synovial membrane were found in the experimental compared to the control group. Alteration of SOD activity was found in m. masseter and synovial membrane in the experimental group.

CONCLUSIONS

Lateral mandibular deviation induces mandibular and condylar morphological changes as well as significant cellular signaling alterations in condyle, synovial membrane and masticatory muscle. Cellular VEGF protein overexpression and oxidative stress/nitric oxide disbalance could be the mechanisms underlying unbalanced functional TMJ loading due to mandibular deviation.

Temporomandibular Disorders Clinical and Anatomical Outcomes After Fat-Derived Stem Cells Injection

Temporomandibular disorders (TMD) are common disorders that usually involve temporomandibular joint (TMJ), masticatory muscles, and other relevant structures. The symptoms may vary limiting the patients' quality of life. Many treatment options were proposed during the last years with the aim to treat the pathology. In this article, we analyze the effect of the injection of the fat-derived stem cell in the joint as a new treatment option.

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

BACKGROUND

Internal derangements are the commonest disorders of temporomandibular joint (TMJ). Different treatment modalities have been proposed to treat this disorder. Arthrocentesis and intra-articular injection are gaining popularity in the treatment of internal derangement of TMJ.

PURPOSE

The aim of this study was to compare between the effect of arthrocentesis and intra-articular injection using a mixture of hyaluronic acid and corticosteroid in the management of TMJ internal derangement.

MATERIALS AND METHODS

Sixteen patients with TMJ internal derangement were selected and divided into 2 equal groups. In group I, arthrocentesis was performed with Ringer solution. In group II, intra-articular injection was performed with a mixture of 0.5ml hyaluronic acid and 0.5ml corticosteroid. Assessment of pain, maximum mouth opening, lateral movement and clicking was done before the treatment, one week, one month and three months after the treatment. All parameters were subjected to statistical analysis.

RESULTS

All studied parameters showed improvements. There was no statistically significant difference between the two groups regarding intensity of pain, maximum mouth opening, lateral movement and joint sound.

CONCLUSIONS

TMJ arthrocentesis and intra-articular injection of a mixture of hyaluronic acid and corticosteroid have been found to be effective for treatment of TMJ internal derangement with reduction. Nevertheless, the simplicity of intra articular injection makes it the treatment of choice.

Effect of occlusal splint on interleukin 6, malondialdehyde and 8-hydroxydeoxyguanosine levels in the synovial fluid of patients with temporomandibular disorders

The actual role of splint therapy in preventing excessive loading of the temporomandibular joint (TMJ) is still debated. Lower intra-articular pressure levels have been measured in patients wearing occlusal splints, which may also reduce oxidative stress in the articular spaces. The aim of this study was to determine whether splint therapy reduces oxidative stress and inflammation in TMJ internal derangement patients by measuring interleukin 6 (IL-6), malondialdehyde (MDA), and 8-hydroxydeoxyguanosine (8-OHdG) levels in the synovial fluid (SF). Twenty-four patients with a temporomandibular disorder (TMD) were included in the study. TMJ SF samples were obtained prior to arthrocentesis. Twelve patients used a 2-mm hard acrylic, maxillary stabilization-type splint for 3 months after arthrocentesis. Twelve patients had no treatment after the SF aspiration. Second SF samples were obtained from all patients at 3 months post arthrocentesis. IL-6, MDA, and 8-OHdG levels in the samples were evaluated. All patients showed a significant symptomatic improvement after treatment (P < 0.005). No statistical correlation was found between the two groups concerning pre-treatment and 3-month SF levels of MDA, 8-OHdG, and IL-6. Although splint therapy was found to be successful in eliminating clinical symptoms of TMD, the results showed no beneficial effect on inflammation and oxidative stress markers in the synovial fluid.

Evaluation of serum prolidase activity and oxidative stress in patients with temporomandibular joint internal derangement

Objective: To investigate serum prolidase activity and oxidative stress in patients with temporomandibular joint internal derangement (TMJ-ID).Methods: Seventy patients with Wilkes stage III, IV, and V joints and 70 healthy controls were included. Serum prolidase activity and oxidative stress parameters, including total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), advanced oxidation protein products (AOPP), glutathione (GSH), ferric reducing antioxidant power (FRAP), and lipid hydroperoxide (LOOH) were measured.Results: The levels of prolidase, TOS, OSI, AOPP, and LOOH were significantly higher in the TMJ-ID group than in the control (p = .0001). TAS and FRAP level was significantly lower in the TMJ-ID group than in the control (p = .0001). There was no significant difference in GSH between groups.Conclusion: Significantly increased prolidase activity and oxidative stress in patients with TMJ-ID may be related to long-term collagen tissue damage, and inflammation and can be effective in the etiology of TMJ-ID.

Clinical factors affecting the outcome of arthocentesis

Objectives

This study aimed to evaluate the effect of clinical factors on the outcome of arthrocentesis in the treatment of temporomandibular joint (TMJ) internal derangement.

Materials and Methods

Fifty patients with TMJ internal derangement underwent arthrocentesis using ringer's lactate. The present study evaluated the contribution of the clinical variables of age, time since onset, visual analogue scale (VAS) pain level, and range of motion (ROM) on the outcomes of TMJ arthrocentesis: age (≤25 years, >25 and ≤40 years, >40 and ≤60 years), VAS pain level (≤5, >5 and ≤7, >7 and ≤10), and ROM (<25 and ≥25 mm). Odds ratios (ORs) were used to describe the proportional benefit of each variable the on successful outcome of arthrocentesis. For the OR to be clinically relevant or even clinically noticeable, we assumed that the OR would need to be larger than 2.

Results

Mean preoperative pain score was 6.49±1.560 and at 6 months postoperative was 0.46±1.147 with an average decrease of pain score 6 (P<0.001). The mean preoperactive maximum mouth opening was 26.14±4.969 mm and mean maximum mouth opening at 6-month inerval was 38.92±3.392 mm. The mean increase in the mouth opening was a mean difference of 12.78 mm (P<0.001). Logistic regression showed that the maximum benefit occurred in patients aged <25 years (OR, 12.01; P=0.012), a VAS pain level of >7 (OR, 11.25; P=0.039), and a maximum vertical opening of <25 mm (OR, 7.70; P=0.038).

Conclusion

Lavage of the superior joint space with ringer's lactate resulted in significant reduction in pain and improvement in mouth opening. Patients with a greater inflammatory component and younger patients benefitted more from arthrocentesis. Evaluation of these clinical variables helped in predictive modelling, which may provide clinicians with the opportunity to identify "at-benefit" patients early and initiate specific treatment.

Arthrocentesis of Temporomandibular Joint- Bridging the Gap Between Non-Surgical and Surgical Treatment

The temporomandibular joint forms one of the most fascinating and complex synovial joints in the body. Movements of the temporomandibular joint are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently. Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components. The management of refractory pain and dysfunctions in the temporomandibular joint poses challenge both to the oral physician and maxillofacial surgeon. Arthrocentesis is a simple, minimally invasive technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. This review provides a full comprehensive overview of the literature about the various technical and prognostic aspects in relation to arthrocentesis of the temporomandibular joint, and every clinician must take into account this consideration when performing this procedure in treating patients with temporomandibular disorders.

Effectiveness of Sequential Viscosupplementation in Temporomandibular Joint Internal Derangements and Symptomatology: A Case Series

Viscosupplementation is a minimally invasive technique that replaces synovial fluid by intra-articular injection of hyaluronic acid (HA). Although effective in some joints, there is not conclusive evidence regarding temporomandibular disorders. This case series described the efficacy of a viscosupplementation protocol in intra-articular temporomandibular disorders. Ten patients with a diagnosis of disc displacement and/or osteoarthritis by Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were submitted to four monthly injections of low or medium molecular weight HA. Pain, mandibular function, image analysis by tomography and magnetic resonance, and quality of life were assessed at baseline and follow-ups (1 and 6 months). Pain, jaw range-of-motion, mandibular function, and quality of life improved at follow-up evaluations. Osteoarthritis changes decreased, and 20% of patients improved mandibular head excursion after treatment. Resolution of effusion and improvement in disc morphology were observed for most patients. This viscosupplementation protocol reduced pain and symptoms associated with internal derangement of temporomandibular joint, improved quality of life, and showed benefits from both low and medium molecular weight HA in alternate cycles.

Non-invasive different modalities of treatment for temporomandibular disorders: review of literature

Temporomandibular disorders (TMDs) are diseases that affect the temporomandibular joint and supporting structures. The goal of treatment for TMDs is elimination or reduction of pain and return to normal temporomandibular joint function. Initial treatment for TMDs is non-invasive and conservative, not surgical. Oral and maxillofacial surgeons should fully understand and actively care about non-invasive treatments for TMDs. The purpose of this study is to review the validity and outcomes of non-invasive and surgical treatment modalities for TMDs.

Analysis of synovial fluid visfatin level in temporomandibular joint disorders

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

Expression of chemerin in the synovial fluid of patients with temporomandibular joint disorders

The synovial membrane and fluid are significantly involved in the pathogenesis of temporomandibular joint (TMJ) disorders. This study aimed to investigate the relation between levels of chemerin in the synovial fluid (SF) of patients with TMJ disorder and their relationship. Sixty samples of SF were obtained from patients with an internal derangement (ID) or osteoarthritis (OA). Chemerin in the SF was examined by enzyme-linked immunosorbent assay (ELISA). The results showed greater levels of chemerin in the SF of patients with OA than ID. While chemerin levels were positively correlated with pain scores, they were inversely correlated with MMO. Chemerin levels increased progressively as the disorder stage became more severe. The findings of this study suggest that chemerin in SF may play role as a predisposing factor and may represent a novel potential prognostic biochemical marker in the pathogenesis of TMJ disorders.

Effect of hyaluronic acid on the regulation of inflammatory mediators in osteoarthritis of the temporomandibular joint: a systematic review

Osteoarthritis is one of the most frequent pathologies affecting the temporomandibular joint (TMJ). There is evidence that the use of intra-articular hyaluronic acid (HA) for the treatment of this disorder achieves positive effects through a reduction in inflammatory mediators. A systematic review of the available evidence regarding the regulation of inflammatory mediators when applying HA in osteoarthritis of the TMJ in humans was performed. The Web of Science, Embase, ScienceDirect, MEDLINE, Scopus, EBSCOhost, and LILACS databases, SciELO library, and search engine Trip Database were searched systematically. Two thousand eight hundred and sixty-three related articles were found, of which only two met the selection criteria (both were clinical trials and evidence level 2b for treatment studies). These two articles represented a population of 87 patients. Both articles reported that the application of HA had a positive effect on the regulation of inflammatory mediators; the mediators studied were those of the plasminogen activator system and levels of nitric oxide. The limited evidence available suggests that the application of HA regulates various inflammatory mediators in osteoarthritic processes in the TMJ. Nevertheless, further evidence in this regard is required, through the study of specific pathologies of the TMJ, complementing the assessment of clinical parameters with molecular studies, and generating good quality clinical studies with larger sample sizes.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Is arthrocentesis plus platelet-rich plasma superior to arthrocentesis plus hyaluronic acid for the treatment of temporomandibular joint osteoarthritis: a randomized clinical trial

A randomized clinical trial was implemented in adult patients with temporomandibular joint osteoarthritis (TMJ OA). The sample comprised 49 osteoarthritic joints in 31 consecutive patients. Patients were divided randomly into two groups according to the treatment technique applied: the platelet-rich plasma (PRP) group patients underwent initial arthrocentesis plus PRP injection and then four consecutive PRP injections; the hyaluronic acid (HA) group patients underwent one session of arthrocentesis plus HA injection. The predictor variable was the treatment technique. The outcome variables included visual analogue scale (VAS) evaluations and maximum inter-incisal opening (MIO) measurements. Outcome variables were recorded preoperatively and at 12 months postoperative. Descriptive and bivariate statistics were computed and significance was set at P<0.05. The PRP group included 32 joints in 18 subjects, and the HA group included 17 joints in 13 subjects. No statistically significant difference was observed between the groups for any of the changes in VAS parameters or MIO measurements. Both treatment techniques resulted in significant clinical improvements in all VAS parameters and painless MIO. These findings suggest that arthrocentesis plus PRP injections is not superior to arthrocentesis plus a single HA injection; thus PRP injection should not be considered as the first line treatment. Arthrocentesis plus HA injection would appear to be more acceptable for patients.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences Regarding Branded HA in Italy, Part 2: Data from Clinical Studies on Knee, Hip, Shoulder, Ankle, Temporomandibular Joint, Vertebral Facets, and Carpometacarpal Joint

OBJECTIVES

The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet.

METHODS

An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on HAs that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA.

RESULTS

Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication.

CONCLUSIONS

There are only a few products with some evidences, while the majority of products remain without proof. Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.

WITHDRAWN: Arthrocentesis and lavage for treating temporomandibular joint disorders

The Cochrane Oral Health Group withdrew this review as of Issue 12, 2015. The review is out of date and does not meet current Cochrane methodological standards. It will be superseded by a new Cochrane review on Surgical interventions for managing temporomandibular disorders.

The editorial group responsible for this previously published document have withdrawn it from publication.

Assessment of functional improvement with temporalis myofascial flap after condylectomy in elderly patients with anterior disc displacement without reduction and an erosive condylar surface

Background

The purpose of this study was to investigate the functional effects of temporalis myofascial flap after condylectomy, with or without disc removal, in elderly patients with anterior disc displacement (ADD) without reduction and an erosive condylar surface of the temporomandibular joint (TMJ).

Methods

A total of 15 joints from 11 elderly patients (71–78 years old) were included. The patients had pain, mandibular dysfunction symptoms, and unilateral or bilateral ADD as well as an erosive condylar surface of the TMJ. All patients underwent temporalis myofascial flap reconstruction after condylectomy, with or without disc removal. If the maximal mouth opening (MMO) remained <35 mm after condylectomy, coronoidotomy was also performed. Self-assessed pain and mandibular function, including MMO and protrusive and lateral movements, were evaluated.

Results

No patient experienced serious complications. Most measurements improved significantly after surgery compared to preoperatively. Most patients achieved nearly-normal mouth opening at 4 weeks after surgery. Although most patients felt discomfort during active postoperative physiotherapy, no patient reported serious pain during the follow-up period.

Conclusion

Although nonsurgical therapy is often the first treatment choice for ADD without reduction of the TMJ, surgical intervention involving condylectomy and temporalis myofascial flap reconstruction may be a reasonable first option for elderly patients with an erosive condylar surface of the TMJ.

Single puncture arthrocentesis of temporomandibular joint; introducing a novel device: A pilot study

INTRODUCTION

Arthrocentesis is a method of irrigating the temporomandibular joint (TMJ) with a therapeutic substance. It is usually performed by dual puncture with two needles to the joint space. Several studies have shown that arthrocentesis of the upper compartment of the TMJ may be a highly effective method to restore normal maximal mouth opening and functioning. Nonetheless, the classical two needle technique has some limitations, such as the low tolerability and difficulty in performing it in the presence of intra-articular adherences. The adoption of a single puncture technique for both fluid injection and aspiration might have some advantages with respect to the traditional two needle approach in terms of time of execution, tolerability, and retention of medication.

MATERIALS AND METHODS

A single puncture technique with a self fabricated device is used to assess the efficacy of this device. This study involved 20 patients of age ranging between 20- 64 years diagnosed with TMD. Patients follow up done at 3(rd), 14(th), 45(th) and 90(th) day and assessment of pain, mouth opening, clicking and deviation done with comparison of pre and post-operative data.

RESULTS

The procedure was successful in all the patients. Most of the patients reported reduction in pain more than half of the previous value and two patients reported only moderate reduction. There was a clinically significant improvement in mouth opening, clicking and deviation.

CONCLUSION

Arthrocentesis is effective in treating TMJ internal derangement and restoring its function. Single puncture arthrocentesis, is a minimally invasive, simple, inexpensive & highly efficient procedure that can be performed under local anaesthesia.

A comparative study on the impact of intra-articular injections of hyaluronic acid, tenoxicam and betametazon on the relief of temporomandibular joint disorder complaints

OBJECTIVE

The aim of this study was to compare the efficacy of intra-articular injections of three different agents with well known anti-inflammatory properties.

MATERIALS AND METHOD

Between April 2010 and January 2013 a total of 100 patients who were diagnosed as temporomandibular joint disorder in the Department of Otolaryngology at Bozok University School of Medicine were prospectively studied. Patients with symptoms of jaw pain, limited or painful jaw movement, clicking or grating within the joint, were evaluated with temporomandibular CT to investigate the presence of cartilage or capsule degeneration. In the study group there were 55 female and 45 male patients who were non-responders to conventional anti-inflammatory treatment for TMJ complaints. The patients were randomly divided into four groups consisting of a control group and three different groups who underwent intra-articular injection of one given anti-inflammatory agent for each group. We injected saline solution to intra-articular space in the control group. Of three anti-inflammatory agents including hyaluronic acid (HA, Hyalgan intra-articular injection, Sodium hyaluronate 10 mg/ml, 2 ml injection syringe, Bilim Pharmaceutical Company, Istanbul, Turkey); betamethasone (CS, Diprospan flacon, 7.0 mg betamethasone/1 ml, Schering-Plough Pharmaceutical Company, Istanbul, Turkey) and; tenoxicam (TX, Tilcotil flacon, 20 mg tenoxicam/ml, Roche Pharmaceutical Company, Istanbul, Turkey) were administered intra-articularly under, ultrasonographic guidance. Following the completion of injections the, changes in subjective symptoms were compared with visual analogue scales, (VAS) scores at 1st and 6th weeks' follow-up visits between four groups.

RESULTS

The HA group did significantly better pain relief scores compared to the, other groups at 1st and 6th weeks (p < 0.05). TX and CS groups' pain scores were better than control group values (p < 0.05, for both agents). The pain relief effect of TX was noted to decrease significantly between the 1st and 6th week (p < 0.05) (Fig. 1). We did not observe the same pattern in HA, CS and control (saline) groups between 1st and 6th week (p > 0.05).

CONCLUSION

We found that HA produced better pain relief scores when compared to the other anti-inflammatory agents studied. The main disadvantage of HA is its relatively higher cost. Additionally it does not have a reimbursement status by state or private health insurance systems in Turkey. Despite the lower VAS scores, intra-articular TX and CS may be assessed as more economic alternatives to intra-articular HA injections.

Arthrocentesis and temporomandibular joint disorders: clinical and radiological results of a prospective study

Purpose. We evaluated the efficacy of arthrocentesis in the treatment of temporomandibular joint (TMJ) disorders. Material and Methods. In this prospective clinical case series, 30 consecutive patients with TMJ disorders underwent arthrocentesis using saline and sodium hyaluronate injections. Outcome measures were TMJ pain, maximum mouth opening (MMO), joint noises, and anatomical changes in the TMJ architecture. Patients were evaluated using cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) at the beginning of treatment and 60 days after the last arthrocentesis. Pretreatment and posttreatment clinical parameters were compared using paired and unpaired t-tests, and McNemar's test was used to evaluate CBCT and MRI changes (P < 0.05). Results. At 1-year follow-up examinations, visual analogue scale scores indicated that pain was reduced significantly and mean postoperative MMO was increased significantly. CBCT findings showed no significant change, and MRI showed only slight reductions in inflammatory signs. Conclusions. Within the limitations of this study, we can conclude that arthrocentesis is a simple, minimally invasive procedure with a relatively low risk of complications and significant clinical benefits in patients with TMJ disorders. This trial is registered with NCT01903512.

WITHDRAWN: Hyaluronate for temporomandibular joint disorders

This review has been withdrawn from publication because it is out of date and does not meet the current methodological standards of The Cochrane Collaboration.

The editorial group responsible for this previously published document have withdrawn it from publication.

Temporomandibular joint arthrocentesis. Review of the literature

The treatment of the temporomandibular joint (TMJ) is still controversial. TMJ arthrocentesis represents a form of minimally invasive surgical treatment in patients suffering from internal derangement of the TMJ, especially closed lock. It consists of washing the joint with the possibility of depositing a drug or other therapeutic substance. Resolution of symptoms is due to the removal of chemical inflammatory mediators and changes in intra-articular pressure. Numerous clinical studies regarding this technique have been published. The goal of this paper is to review all clinical articles that have been published with regard to the critique of this technique. 19 articles with different designs fulfilling selection guidelines were chosen. A series of clinical and procedure variables were analyzed. Although the mean of improvement was higher that 80%, further research is needed to determine more homogeneous indications for TMJ athrocentesis.

Total antioxidant capacity and total oxidant status of synovial fluids in patients with temporomandibular joint pain and dysfunction

OBJECTIVES

The objective of this study was to investigate whether a relationship exists between total antioxidant capacity (TAC) and total oxidant status (TOS) of synovial fluids (SFs) of temporomandibular joint (TMJ) pain patients with pain and dysfunction.

MATERIALS AND METHODS

Forty-two patients with TMJ pain were included in this study. TAC and TOS values of SFs were measured with a novel colorimetric method. Independent t test and correlations were used to analyze the data.

RESULTS

TAC of SFs in patients with TMJ pain and limited mouth opening (LMO; n = 21) were significantly lower (P = 0.03) than patients without LMO (n = 21). TOS of SF was negatively correlated with duration of the disease. There was no correlation between TAC, TOS, and VAS scores of the patients as well as age and maximum mouth opening values.

CONCLUSIONS

Antioxidant response to oxidative changes (TAC and TOS) in SF decreased as the stage of dysfunction increased.

CLINICAL RELEVANCE

Local administration of antioxidant agents might be considered in management of TMJ pain and dysfunction to prevent possible increased oxidative stress.

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

AIMS AND OBJECTIVES

Internal derangements are the commonest disorders of temporomandibular joint (TMJ). Different treatment modalities including conservative and surgical methods have been proposed to treat the same. Arthrocentesis is gaining popularity in the treatment of internal derangement of TMJ. Being minimally invasive it does not have the demerits of surgical approaches and at the same time is producing better results than conservative approaches. This study evaluates and compares corticosteroid and sodium hyaluronate after arthrocentesis in the treatment of internal derangement of TMJ.

MATERIALS AND METHODS

Sixteen patients with internal derangement were randomly selected and divided into 2 groups (8 in each group). Arthrocentesis of the upper joint space was then performed using Ringer lactate under local anaesthesia followed by injection of either betamethasone or sodium hyaluronate into the joint. Clinical data was collected in the form of pain (visual analog scale), maximum mouth opening, joint sound and deviation before and after treatment up to 6 months.

RESULTS

Both groups of patients were benefited from the treatment at the 6 month follow up and there was slightly less intensity of pain in sodium hyaluronate group compared with corticosteroid group. Maximum mouth opening was also increased in both groups. A decrease in clicking and deviation were seen in both groups. There was no statistically significant difference between betamethasone and sodium hyaluronate.

CONCLUSION

Intra articular injection of corticosteroid or sodium hyaluronate after arthrocentesis had considerable effect on the TMJ. Both betamethasone and sodium hyaluronate can be used after arthrocentesis with similar results.

Arthrocentesis for the treatment of internal derangement of the temporomandibular joint

OBJECTIVE

The study aims to evaluate the efficacy of arthrocentesis in the treatment of internal derangement of the temporomandibular joint (TMJ).

STUDY DESIGN

Thirty patients with TMJ internal derangement underwent arthrocentesis using saline. Pain using visual analog scale, maximum mouth opening, joint noises and mandible deviation were documented pre-operatively and post-operatively. Patients were followed for 1 year. Statistical analysis of pain was done by Wilcoxon signed Rank's test and dysfunction by students paired t test.

RESULTS

The mean pre-operative pain was 4.8 ± 2.65 and post-operatively at 1 year was 0.27 ± 0.45 with an average decrease of 4.72 (P = 0.000). The mean maximal mouth opening pre-operatively was 29.8 ± 2.35 mm and post-operatively 41.9 ± 2.48 mm at 1 year. The mean increase in the mouth opening was 12.1 ± 3.0 mm (P = 0.000).

CONCLUSION

Arthrocentesis is simple, minimally invasive procedure with less risk of complications and significant benefits in patients with TMJ internal derangement.

Chondrogenic effect of the perichondrium graft on the internal derangement and osteoarthritis of the temporomandibular joint of the rabbit

Internal derangement of the temporomandibular joint is usually defined as the disruption of the condyle and disc relationship. In addition to this description the other elements of the joint including the cartilage surface, synovial fluid, the ligaments and the bony surface itself demonstrate varying degrees of pathology in concordance with the stage of the internal derangement, as well. This study is designed to create an osteoarthritic model in the rabbit temporomandibular joint. A 2×2mm defect was performed on the cartilage surface of the both condyles of each animal (n=30). The osteoarthritic changes were demonstrated by computerised tomography sections. The right joints of the animals constituted the control group and the left, the study group. At the time of the defect generation, a perichondrium graft from the animal's ear was implanted onto the defect in the study group. The control group was left to heal secondarily. The joints of three randomized groups of 10 animals for each were inspected at the 4th, 6th, and 8th weeks. Cartilage regeneration and regression of the osteoarthritic changes were demonstrated in the study group both in the 6th and 8th week groups. However, the control group showed less cartilage regeneration and progression of the osteoarthritic changes in all weeks, with progression with time. The perichondrium graft has demonstrated chondrogenic effect on the condyle and this in turn changed the progression to internal derangement.

Temporomandibular joint pain and synovial fluid analysis: a review of the literature

The pathophysiology of temporomandibular joint pain is not well understood. A significant amount of research has been conducted to evaluate synovial fluid in these patients and in healthy controls. Qualitative and quantitative analyses of the synovial fluid have shown a significant difference between these groups. A multitude of inflammatory mediators and degradation products have been identified. The concentration of these products has been shown to correlate with several clinical parameters including pain, chronicity, severity of degenerative change, and response to treatment. A common inflammatory pathway would appear to be involved in most patients. At the present time, synovial fluid analysis does not have the sensitivity or specificity to allow specific diagnoses and targeted treatment. Continued research with the specific aim of establishing more appropriate therapeutic modalities based on the biochemical pathways is warranted.

Arthrocentesis and lavage for treating temporomandibular joint disorders

BACKGROUND

Temporomandibular joint disorders are important oral health problems, reducing the quality of life of sufferers. It has been estimated that approximately 20% to 30% of the adult population will experience temporomandibular joint dysfunction. Arthrocentesis and lavage has been used to treat temporomandibular joint disorders for about 10 years, but the clinical effectiveness of the therapy has not been summarized in the form of a systematic review.

OBJECTIVES

To assess the effectiveness and complications of arthrocentesis and lavage for the treatment of temporomandibular joint disorders compared with controlled interventions.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register (to August 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to August 2009), EMBASE (1980 to August 2009), OpenSIGLE (to August 2009), CBMdisc (1981 to 2007 (in Chinese)) and Chinese Medical Library were searched. All the Chinese professional journals in the oral health field were handsearched and conference proceedings consulted. There was no language restriction.

SELECTION CRITERIA

All randomised controlled trials (RCTs) (including quasi-randomised clinical trials) aiming to test the therapeutic effects of arthrocentesis and lavage for treating temporomandibular joint disorders.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, and three review authors independently assessed the risk of bias of included trials. The first authors of the selected articles were contacted for additional information.

MAIN RESULTS

Two trials, at unclear to high risk of bias, were included in the review. The two trials, including 81 patients with temporomandibular joint disorders, compared arthrocentesis with arthroscopy. No statistically significant difference was found between the interventions in terms of pain. However, a statistically significant difference in favour of arthroscopy was found in maximum incisal opening (MIO) (weighted mean difference of -5.28 (95% confidence interval (CI) -7.10 to -3.46)).Mild and transient adverse reactions such as discomfort or pain at the injection site were reported in both groups. No data about quality of life were reported.

AUTHORS' CONCLUSIONS

There is insufficient, consistent evidence to either support or refute the use of arthrocentesis and lavage for treating patients with temporomandibular joint disorders. Further high quality RCTs of arthrocentesis need to be conducted before firm conclusions with regard to its effectiveness can be drawn.

Emerging intra-articular drug delivery systems for the temporomandibular joint

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

Superoxide Dismutase Activity in Synovial Fluids in Patients With Temporomandibular Joint Internal Derangement

PURPOSE

To measure the activity of superoxide dismutase (SOD) in the synovial fluid of patients with temporomandibular joint internal derangement and to show the relationship between the activity of SOD and the severity of the disease.

MATERIALS AND METHODS

Twenty patients with internal derangement were classified according to Wilkes by clinical radiological examinations. SOD activity was measured by the method based on nitrobluetetrazolium reduction rate.

RESULTS

The activity of SOD seemed to be progressively decreased as the stage of the disease increased.

CONCLUSION

The reduction of SOD activity observed may result from insufficient scavenging capacity of free radicals. Further investigation and longitudinal studies are required to determine the role of antioxidants that scavenge the free radicals in temporomandibular joint disorders.

Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article

Although arthrocentesis is not a panacea, it has been widely used for a variety of temporomandibular joint (TMJ) disorders. Uncritical acceptance of the procedure has been cautioned against, as further analysis and clarification of published studies was required. The aim of this article was to review the efficacy of arthrocentesis in the treatment of patients with TMJ closed lock. The rationale behind this approach was based on the notion that TMJ surgical results should be reported by the specific category of TMJ disorder. After a Medline search of the international literature, 14 articles were found fulfilling the criteria set forth by this article. Another five articles were added after an additional hand search based on the available references of the papers found. The majority of the reviewed publications were prospective case series with flawed methodology and, despite the impression that arthrocentesis may be beneficial for patients with TMJ closed lock, there have been no good prospective randomized clinical trials that confirm the efficacy of this procedure.

Resection of the disc and suspension of the lateral wall with the temporal fascia in advanced internal derangement of the temporomandibular joint

The abnormal relation between the disc, the condyle, and the temporal bone indicates internal derangement of the temporomandibular joint. The primary symptoms and findings are: limited and painful opening of the jaw, preauricular pain, and clicking sounds or crepitus. We operated on 11 patients admitting for advanced temporomandibular dysfunction. The abnormally stretched disc was tightened by resection of a wedge of tissue from the posterior of the disc and suturing of the edges. A pedicled flap of temporal fascia was turned on to the joint and its surroundings to mimic a lateral joint capsule. All patients were satisfied with the results as they had less pain and improved mouth opening. The procedures provided satisfactory symptomatic relief and supportive findings.

Influence of arthroscopically observed fibrous adhesions before and after joint irrigation on clinical outcome in patients with chronic closed lock of the temporomandibular joint

The aim of this study was to investigate the changes in the state of arthroscopically observed fibrous adhesions (FA) after visually guided irrigation (VGIR) and the influence of FA on clinical outcome in patients with chronic closed lock of the temporomandibular joint (TMJ). Forty-eight TMJs of 48 patients with unilateral chronic closed lock were enrolled in this study. All 48 joints underwent VGIR twice. After the first VGIR (immediately before the second VGIR), clinical outcome was assessed as regards maximal interincisal opening (MIO) and self-evaluated TMJ pain (VAS). Thirty patients were symptom-free (good outcome group) and the remaining 18 patients had symptoms (poor outcome group). In each group, the changes of the MIO, VAS and severity of FA (FA score) after the first VGIR were studied. The influence of FA score in the first and second VGIR on clinical outcome was analyzed by logistic regression analysis. There was no joint with disappearance or reduction of FA after the first VGIR. In both groups, MIO and VAS were significantly improved after the first VGIR even though the state of FA became significantly worse. The multivariate logistic regression analysis showed that the risk of poor outcome for FA scores in the first and second VGIR were 0.89-times (95% CI: 0.33-2.40, P=0.82) and 1.76-times (95% CI: 0.54-5.73, P=0.35), respectively. The dose-response relationships between FA scores in the first or second VGIR were not significant. In conclusion, our results indicate that the presence of FA or a postoperative worsening of FA (including postoperative new FA formation) seems not to affect the clinical outcome as regards MIO and VAS in patients with chronic closed lock of the TMJ.