The Administration of Hyaluronic Acid into the Temporomandibular Joints' Cavities Increases the Mandible's Mobility: A Systematic Review and Meta-Analysis

Effects of Hyaluronic Acid (HA) and Platelet-Rich Plasma (PRP) on Mandibular Mobility in Temporomandibular Joint Disorders: A Controlled Clinical Trial

Hyaluronic acid (HA) is a glycosaminoglycan composed of D-glucuronic acid and N-acetylglucosamine with an up-to-several-million-Daltons chain-length responsible for the lubricating properties of the temporomandibular joint (TMJ) synovial fluid. Arthritis results in the predominance of HA degradation over synthesis leading to temporomandibular disorders (TMDs). TMD injection treatments are divided into HA supplementation and platelet-rich plasma (PRP) inflammation suppression. We questioned whether either approach lubricated the TMJ better and answered it in a two-arm equal-allocation trial with a non-concurrent active treatment control (two groups of 39 patients each). HA statistically significantly improved (p < 0.01) and PRP did not statistically significantly change (0.06 ≤ p ≤ 0.53) articular mobility compared to baselines in 128 TMJs. Statistically significant inter-group discrepancies were observed for abduction (MD = -4.05 mm; SE = 1.08; p = 0.00; d = -0.85) and protrusion (MD = -0.97 mm; SE = 0.43; p = 0.03; d = -0.51) but not for rightward (MD = -0.21; SE = 0.43; p = 0.63; d = -0.11) and leftward (MD = -0.30; SE = 0.42; p = 0.47; d = -0.16) movements. HA supplementation proved superior to PRP autografting in ad hoc TMJ lubrication and hence is more appropriate in hypomobile TMD cases of symptomatic treatment.

Assessing the Efficacy of Arthrocentesis in Managing Temporomandibular Joint Disorders and Internal Derangements: A Case Series

Internal joint derangements (IJD) of the temporomandibular joint (TMJ) encompass a multifaceted array of conditions that have the potential to induce a gradual decline in joint health, ultimately resulting in persistent pain and disruptions in daily living. The management of these conditions poses significant hurdles to achieving effective pain management and restoration of normal TMJ functionality, presenting ongoing challenges in the medical field. At present, the approach of utilizing arthrocentesis in conjunction with intra-articular injections containing corticosteroids (CSs) and hyaluronic acid (HA) is a commonly employed method aimed at addressing chronic pain, surpassing the outcomes of more conservative treatment modalities. Nevertheless, further advancements in treatment strategies are warranted to enhance outcomes and provide holistic relief for individuals with TMJ-related concerns. The effectiveness of arthrocentesis in combination with intra-articular injections of HA and CSs has been demonstrated with the help of five case reports of elderly patients with IJD. All were chronic patients who were unresponsive to conservative management and presented with chronic pain and reduced mouth opening. Open- and closed-mouth magnetic resonance imaging (MRI) provided the diagnosis of IJD, and the patients were treated with arthrocentesis using a two-needle approach that involved flushing the joint space with Ringer's lactate solution followed by intra-articular injections of 0.5 ml HA and 0.5 ml prednisolone at a concentration of 40 mg/ml into the joint space. All patients showed a significant reduction in pain and improvement in mouth opening at the follow-up visits.

Therapeutic challenges in temporomandibular disorders

Background and aims

This study aimed at evaluating the etiology and treatment challenges of temporomandibular disorders (TMDs).

Methods

160 subjects with TMDs, 38 males (23.8%) and 122 females (76.3%) were studied. A personalized coefficient was designated, which included the resolution of the main symptom, correction of secondary symptoms, patient collaboration (emotional parameter), treatment duration, and cost.

Results

The most frequent cause for consultation was muscle impairment (42.5%), or limitation of mouth opening, followed by joint impairment (23.1%). Muscle pain was noticed, particularly in the masseter (57.5%) and lateral pterygoid muscles (51.9%). Tooth pain or gingival retraction was frequently associated with tooth wear (48.1%) and dental abfraction (31.3%). Remote symptomatology was dominated by otologic symptomatology. Iatrogenic etiology was highest (69.4%), followed by untreated missing teeth (66.9%). Treatment options included muscle relaxation, occlusal balancing (equilibration), kinesitherapy, medication, and swallowing re-education. Most patients benefited from four to seven different types of therapy, which resulted in a higher cost and a longer and more uncomfortable treatment. The primary symptom was relieved in 82.3% of cases, with recurrence occurring in 15.7%.

Conclusion

The treatment of temporomandibular joint dysfunction is time-consuming, demanding, and intricate. Most patients required four to seven different types of therapy, which increased the expense, treatment duration, and suffering.

Temporomandibular Joint Injections and Lavage: An Overview of Reviews

Objectives: This overview was conducted following the Preferred Reporting Items for Overviews of Reviews guidelines and aimed to collect and compare the results of systematic reviews on temporomandibular joint injection treatment. Methods: Systematic reviews of randomized clinical trials on temporomandibular disorders treated with lavage or intra-articular administrations were qualified for syntheses. The final searches were conducted on 27 February 2024, without time frame restrictions. Results: Of the 232 identified records, 42 systematic reviews were selected. The most evidence-based conclusions call into question the clinical differences between many therapeutic approaches, including the following: (1) injectable selection for the treatment of pain and hypomobility; (2) the method of performing arthrocentesis; (3) the use of imaging when rinsing the TMJ cavity; (4) the supplementation of the extracapsular administration of unprocessed blood with intracapsular deposition in the treatment of TMJ hypermobility. Conclusions: Systematic reviews based solely on randomized clinical trials proved the following differences: (1) in painful temporomandibular hypomobility, a better therapeutic effect is observed with arthrocentesis followed by I-PRF administration compared to lavage alone; (2) in painful temporomandibular hypomobility, inferior- or double-compartment injection leads to better results than superior-compartment injection; (3) in temporomandibular joint recurrent dislocation, hypertonic dextrose administration is superior to placebo, although (4) unprocessed blood has a better effect than hypertonic dextrose. PROSPERO registration number: CRD42024496142.

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.

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.

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

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

Injectable Platelet-Rich Fibrin (I-PRF) Administered to Temporomandibular Joint Cavities: A Scoping Review

The aim of this review was to systematically map the research on the intra-articular administration of injectable platelet-rich fibrin (I-PRF) to the temporomandibular joints (TMJs). Medical databases covered by the ACM, BASE, Google, NLM, and ResearchGate were searched on 23 February 2023. The assessment of the level of evidence was based on the Oxford Center for Evidence-Based Medicine 2011 scale. The risk of bias was assessed for randomized controlled trials with the RoB2 tool. Extracted data were tabulated, and the changes in effect values were calculated. A total of eight studies qualified, of which five trials on 213 patients were randomized and controlled (RCTs). In each of the RTC study groups, arthrocentesis was performed, and 1-2 mL per joint of I-PRF (700 rpm/3 min/60 g centrifugation) was administered. Articular pain in three months decreased to 0-25% of the initial pre-interventional values in the study and 38-50% in the control groups. Mandible mobility increased to 121-153% and 115-120% in the I-PRF groups and controls, respectively. The main limitations of the evidence were the small number of RCTs and the lack of any RCT study groups receiving I-PRF without prior arthrocentesis. In conclusion, supplementing the temporomandibular joint rinsing with I-PRF administration further relieves pain and improves mandible mobility. The lack of RCTs on the intra-articular administration of I-PRF as a stand-alone procedure encourages further research. This research received no external funding. The review protocol has not been previously published.

Intra-Articular Injections into the Inferior versus Superior Compartment of the Temporomandibular Joint: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to validate the hypothesis that intra-articular injections into the inferior temporomandibular joint compartment are more efficient than analogous superior compartment interventions. Publications reporting differences between the above-mentioned techniques in the domains of revealing articular pain, decreasing the Helkimo index, and abolishing mandibular mobility limitation were included. Medical databases covered by the Bielefeld Academic Search Engine, Google Scholar, PubMed, ResearchGate, and Scopus engines were searched. The risk of bias was assessed using dedicated Cochrane tools (RoB2, ROBINS-I). The results were visualized with tables, charts, and a funnel plot. Six reports describing five studies with a total of 342 patients were identified. Of these, four trials on a total of 337 patients were qualified for quantitative synthesis. Each eligible report was at moderate risk of bias. From 19% to 51% improvement in articular pain, 12-20% lower Helkimo index, and 5-17% higher maximum mouth opening were observed. The evidence was limited by the small number of eligible studies, discrepancies regarding the substances used, possible biases, and the differences in observation times and scheduled follow-up visits. Despite the above, the advantage of inferior over superior compartment temporomandibular joint intra-articular injections is unequivocal and encourages further research in this direction.

Temporomandibular Joint Osteoarthritis: Pathogenic Mechanisms Involving the Cartilage and Subchondral Bone, and Potential Therapeutic Strategies for Joint Regeneration

The temporomandibular joint (TMJ) is a specialized synovial joint that is crucial for the movement and function of the jaw. TMJ osteoarthritis (TMJ OA) is the result of disc dislocation, trauma, functional overburden, and developmental anomalies. TMJ OA affects all joint structures, including the articular cartilage, synovium, subchondral bone, capsule, ligaments, periarticular muscles, and sensory nerves that innervate the tissues. The present review aimed to illustrate the main pathomechanisms involving cartilage and bone changes in TMJ OA and some therapeutic options that have shown potential restorative properties regarding these joint structures in vivo. Chondrocyte loss, extracellular matrix (ECM) degradation, and subchondral bone remodeling are important factors in TMJ OA. The subchondral bone actively participates in TMJ OA through an abnormal bone remodeling initially characterized by a loss of bone mass, followed by reparative mechanisms that lead to stiffness and thickening of the condylar osteochondral interface. In recent years, such therapies as intraarticular platelet-rich plasma (PRP), hyaluronic acid (HA), and mesenchymal stem cell-based treatment (MSCs) have shown promising results with respect to the regeneration of joint structures or the protection against further damage in TMJ OA. Nevertheless, PRP and MSCs are more frequently associated with cartilage and/or bone repair than HA. According to recent findings, the latter could enhance the restorative potential of other therapies (PRP, MSCs) when used in combination, rather than repair TMJ structures by itself. TMJ OA is a complex disease in which degenerative changes in the cartilage and bone develop through intricate mechanisms. The regenerative potential of such therapies as PRP, MSCs, and HA regarding the cartilage and subchondral bone (alone or in various combinations) in TMJ OA remains a matter of further research, with studies sometimes obtaining discrepant results.

A Scoping Review of the Use of Pioglitazone in the Treatment of Temporo-Mandibular Joint Arthritis

Thiazolidinediones (TZDs) are a group of diabetes medications currently being investigated for anti-arthritis effectiveness, one of which is pioglitazone. The purpose of this scoping review is to evaluate the potential use of pioglitazone in the treatment of temporomandibular joint (TMJ) arthritis. The criteria of eligibility were studies with the diagnosis of arthritis and pioglitazone treatment with a change in any inflammation index as an outcome. Of the 1169 records initially identified following the selection process, two animal studies and four clinical studies were included in the review. Improvements from the baseline were observed in each treatment group for each inflammation indicator. The results of the animal studies on the temporomandibular joints and on patients with rheumatoid and psoriatic arthritis indicate that the drug in question may have potential to treat arthritis, including within the temporomandibular joint.

Prospective bacterial and fungal sources of hyaluronic acid: A review

The unique biological and rheological properties make hyaluronic acid a sought-after material for medicine and cosmetology. Due to very high purity requirements for hyaluronic acid in medical applications, the profitability of streptococcal fermentation is reduced. Production of hyaluronic acid by recombinant systems is considered a promising alternative. Variations in combinations of expressed genes and fermentation conditions alter the yield and molecular weight of produced hyaluronic acid. This review is devoted to the current state of hyaluronic acid production by recombinant bacterial and fungal organisms.

Patient-Reported Quality of Life versus Physical Examination in Treating Temporomandibular Disorders with Intra-Articular Platelet-Rich Plasma Injections: An Open-Label Clinical Trial

Temporomandibular disorders, often manifested by articular pain, limitation of the mouth opening range, and unpleasant acoustic symptoms originating from inside the joint, have been associated with reduced quality of life. These symptoms, among others, can be treated with intra-articular injections of various substances, including repeated platelet-rich plasma (PRP) administration. The reported study was designed as an uncontrolled open-label clinical trial of consecutive cases. The participants completed a Fonseca questionnaire and evaluated acoustic symptoms, and spontaneous and provoked pain on VAS, and were subjected to a physical examination before, during, and after PRP therapy. The total Fonseca questionnaire results were statistically significantly (p < 0.05) correlated with 340 out of 348 (98%) other variables. The fully subjective assessment of the presence and intensity of acoustic symptoms coming from the temporomandibular joints was correlated with the physical examination results (0.45-0.63) and the maximum mouth opening with the maximum pain-free mouth opening (0.73-0.87). There were no correlations observed between the patient's and the physician's assessment of mandibular mobility. The Fonseca questionnaire seems to cover the entire spectrum of temporomandibular disorders, making it a balanced tool for assessing the quality of life in TMDs. However, it is worth considering extending the standard 3-point response scale to an 11-point one. The patient is somewhat able to perform a self-diagnosis with regard to the acoustic symptoms, but it is not possible for them to determine without measurement whether the range of mandibular mobility is appropriate..

Autologous Stem Cells Transplants in the Treatment of Temporomandibular Joints Disorders: A Systematic Review and Meta-Analysis of Clinical Trials

This systematic review aims to analyze the outcomes of the treatment of temporomandibular joint (TMJ) articular pain (AP) and restricted maximum mouth opening (MMO) with intra-articular administration of mesenchymal stem cells (MSCs). The inclusion criteria allowed primary studies involving AP and/or MMO pre-treatment and post-intervention values. Medical databases that were covered by ACM Digital, BASE, EBSCOhost, Google Scholar, PubMed, Scopus, and Web of Science engines were searched. The risk of bias was assessed with RoB 2 and ROBINS-I tools. The results were tabulated, plotted, and analyzed for regression. A total of 5 studies involving 51 patients/69 TMJs were identified, and 4 studies on 50 patients/67 TMJs were synthesized. Interventions were each time effective in decreasing AP and increasing MMO in a 6-month follow-up period by an average of about 85% and over 40%, respectively. Regression analysis showed a good fit of the logarithmic model for AP relief (5.8 − 0.8 ln x; R² = 0.90) and MMO increase (33.5 + 2.4 ln x; R² = 0.89). The results for AP and MMO were based on 3 studies in 39 patients and 4 studies in 50 patients, respectively, all at high risk of bias. The intra-articular administration of MSCs to TMJs, based on weak evidence, may be highly effective in reducing AP and improving MMO. This study received no funding.

Repeated Intra-Articular Administration of Platelet-Rich Plasma (PRP) in Temporomandibular Disorders: A Clinical Case Series

Background: Temporomandibular joint disorders (TMDs) are manifested, inter alia, by pain and limited scope of the mandibular abduction. Among the treatment strategies for these ailments, intra-articular injections of autologous blood preparations, including platelet-rich plasma (PRP), are administered. This prospective case series was aimed at assessing the effectiveness of repeated platelet-rich plasma (PRP) administration to the TMJ cavities in terms of reducing articular pain and increasing the mobility of the mandible. Material and methods: 40 consecutive patients diagnosed with TMJ pain qualified for the case series. The entire treatment program consisted of five PRP administrations and a summary appointment. Regression was analyzed for (1) intensity of spontaneous pain; (2) effectiveness of spontaneous pain relief; (3) mastication efficiency values; (4) painless mandibular abduction; (5) maximum mouth opening. The correlations between the abovementioned variable series were analyzed. Results: The mean spontaneous pain decreased consistently with successive PRP administrations in line with the regression model: −0.4x + 4.2 (R2 = 0.98). Articular pain improvement was reported in 71% of joints treated. Improvement in chewing quality at the end of the entire injection cycle was found in 63% of patients. The equations for the linear regression models for painless mandibular abduction (five applications of PRP) and maximum mouth opening (the first four applications of PRP) were x + 34 (R2 = 0.89) and 0.6x + 43.6 (R2 = 0.96), respectively. Improvement in these domains was found in 78% and 53% of patients, respectively. The strongest correlations were found between pain and chewing efficiency (−0.95), pain and painless mandible abduction (−0.96), and painless mandibular abduction and mastication efficiency (0.94). Conclusion: PRP injections into TMJ cavities should be considered as a low invasive, highly accessible form of treatment for various TMDs causing pain and mandible movement limitation.

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.