A randomized controlled clinical trial of concentrated growth factor combined with sodium hyaluronate in the treatment of temporomandibular joint osteoarthritis

OBJECTIVE

To investigate the effect of concentrated growth factor (CGF) combined with sodium hyaluronate (SH) on temporomandibular joint osteoarthritis (TMJOA).

METHODS

Sixty patients with TMJOA who were diagnosed by cone-beam computed tomography (CBCT) between March 2020 and March 2023 at the Stomatological Hospital of Xi'an Jiaotong University were randomly divided into a control group (n = 30) and an experimental group (n = 30). The patients in the experimental group were treated with CGF + SH, and those in the control group were treated with SH only. The visual analogue scale (VAS) score indicating pain in the temporomandibular joint (TMJ) area; the Helkimo Clinical Dysfunction Index (Di); and changes in condylar CBCT at the first visit and 2 weeks, 3 months and 6 months after treatment were recorded. The CBCT data of the patients in the experimental and control groups were collected, and the three-dimensional CBCT image sequences were imported into Mimics Medical 19.0 software in DICOM format for condylar reconstruction.

RESULTS

The VAS scores at 2 weeks, 3 months and 6 months after treatment were significantly lower in the experimental group than in the control group (P < 0.05), and the pain in the experimental group was significantly relieved. The Di was significantly lower in the experimental group than in the control group (P < 0.05), and the clinical function of the TMJ improved. After treatment, the CBCT score was significantly lower in the experimental group than in the control group (P < 0.05), and the condylar bone cortex was obviously repaired. Observation of the condylar bone cortex by three-dimensional reconstruction showed the same results as those obtained by CBCT.

CONCLUSION

CGF combined with SH is effective in the treatment of TMJOA and can improve muscle pain, TMJ pain, Impaired TMJ function, Impaired range of movement, Pain on movement of the mandible and promote bone repair.

THE REGISTRATION NUMBER (TRN)

ChiCTR2400082712.

THE DATE OF REGISTRATION

April 5, 2024.

Effect of botulinum toxin type A on muscular temporomandibular disorder: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin type A (BTX-A) is increasingly used to manage painful temporomandibular disorders (TMD). However, the effect of BTX-A on muscular TMD remains unclear.

OBJECTIVE

To assess the efficacy, safety and optimal dose of BTX-A for treating TMD.

METHODS

We conducted systematic literature searches in MEDLINE, Embase, Web of Science, ClinicalTrials.gov and Cochrane Library until March 2023. We extracted data from randomized controlled trials (RCTs) that evaluated the efficacy and safety of BTX-A in treating muscular TMD. We performed a meta-analysis using a random-effects model.

RESULTS

Fifteen RCTs involving 504 participants met the inclusion criteria. BTX-A was significantly more effective than placebo in reducing pain intensity, as measured on a 0-10 scale, at 1 month (MD [95% CI] = -1.92 [-2.87, -0.98], p < .0001) and 6 months (MD [95% CI] -2.08, [-3.19 to -0.98]; p = .0002). A higher dosage of BTX-A (60-100 U bilaterally) was associated with a greater reduction in pain at 6 months (MD [95% CI] = -2.98 [-3.52, -2.44]; p < .001). BTX-A also resulted in decreased masseter muscle intensity (μV) (MD [95% CI] = -44.43 [-71.33, -17.53]; p = .001) at 1 month and occlusal force (kg) at 3 months (MD [95% CI] = -30.29 [-48.22 to -12.37]; p = .0009). There was no significant difference in adverse events between BTX-A and placebo.

CONCLUSIONS

BTX-A is a safe and effective treatment for reducing pain and improving temporomandibular muscle and joint function in muscular TMD patients. A bilateral dose of 60-100 U might be an optimal choice for treating muscular TMD pain.

The effectiveness of botulinum toxin for temporomandibular disorders: A systematic review and meta-analysis

OBJECTIVE

The current body of research on utilizing botulinum toxin (BTX) to manage temporomandibular disorders (TMDs) has not yet yielded definitive conclusions. The primary objective of this study was to determine the effectiveness of BTX in pain reduction for TMDs compared to placebo and other treatments. The secondary outcomes evaluated were adverse events, maximum mouth opening, bruxism events, and maximum occlusal force.

MATERIALS AND METHODS

A literature search was performed on PubMed, Dimension Publication, Scopus, and Google Scholar. The RoB 2 tool was used for quality assessment. The mean differences in pain scores were estimated to measure the effect of BTX on pain reduction. For adverse events, the risk ratio for the incidence of side effects was calculated.

RESULTS

Two hundred and sixty non-duplicate articles were identified; however, only 14 RCTS were included in this review. The total study population included 395 patients. The overall risk of bias showed a low to moderate quality of evidence. Results from 6 studies were reported only narratively; four studies were used for meta-analysis on pain reduction, and five were used for meta-analysis on adverse events. The control used in the meta-analysis was placebo injections. Results of the meta-analysis for pain reduction were statistically insignificant for the BTX group with mean differences at MD = -1.71 (95% CI, -2.87 to -0.5) at one month, -1.53 (95% CI, -2.80 to -0.27) at three months, and -1.33 (95% CI, -2.74 to 0.77) at six months. This showed that BTX treatment was not significantly better than placebo for a reduction in pain scores at 1, 3, and 6 months. Regarding safety, the placebo group showed a relative risk of 1.34 (95%CI, 0.48-6.78) and 1.17 (95%CI, 0.54-3.88) at 1 and 3 months respectively. However, the risks were not statistically significant. There was also no difference in the effectiveness of BTX compared to placebo and other treatments for maximum mouth opening, bruxism events, and maximum occlusal force.

CONCLUSION

BTX was not associated with better outcomes in terms of pain reduction, adverse events, maximum mouth opening, bruxism events, and maximum occlusal force. More high-quality RCTs are needed to better understand this topic.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prediction of duloxetine efficacy in addition to self-management in painful temporomandibular disorders: A randomised, placebo-controlled clinical trial

BACKGROUND

Conditioned pain modulation (CPM) is a potential predictor of treatment response that has not been studied in temporomandibular disorders (TMD).

OBJECTIVES

We conducted a randomised, double-blind, placebo-controlled trial (RCT) of duloxetine in addition to self-management (SM) strategies to investigate its efficacy to reduce pain intensity in painful TMD patients. Moreover, we investigated whether baseline CPM would predict the duloxetine efficacy to reduce TMD pain intensity.

METHODS

Eighty participants were randomised to duloxetine 60 mg or placebo for 12 weeks. The primary outcomes were the change in the pain intensity from baseline to week-12 and CPM-sequential paradigm at baseline. Safety, physical and emotional functioning outcomes were also evaluated.

RESULTS

Of 80 participants randomised, 78 were included in intention-to-treat analysis. Pain intensity decreased for SM-duloxetine and SM-placebo but did not differ between groups (p = .82). A more efficient CPM was associated with a greater pain intensity reduction regardless of the treatment group (p = .035). Physical and emotional functioning did not differ between groups, but adverse events (p = .014), sleep impairment (p = .003) and catastrophizing symptoms (p = .001) were more prevalent in SM-duloxetine group.

CONCLUSION

This study failed to provide evidence of a beneficial effect of adding duloxetine to SM strategies for treatment of painful TMD. Nonetheless, this RCT has shown the feasibility of applying pain modulation assessment to predict short-term treatment response in painful TMD patients, which confirms previous finds that CPM evaluation may serve a step forward in individualising pain treatment.

Pharmacological therapy in the management of temporomandibular disorders and orofacial pain: a systematic review and meta-analysis

BACKGROUND

Temporomandibular disorders (TMD) are manifested by soreness in the jaw joint area and jaw muscles, clicks or creaks when opening or closing the mouth. All these symptoms can be disabling and occur during chewing and when the patient yawns or speaks. Several classes of drugs are used to treat symptoms. This review aims to assess which drug suits the different signs.

METHODS

Pubmed, Web of Science and Lilacs were systematically searched until 01/02/2023. Clinical trials were selected that dealt with drugs used in temporomandibular dysfunction RESULTS: Out of 830 papers, eight studies were included. The Meta-Analysis with Continuous Outcomes with Pre-Calculated Effect Sizes resulted in the rejection that there is intergroup variability (p.0.74).

CONCLUSIONS

Treatment of orofacial pain is still a significant challenge for dentistry. We can conclude that there is no drug of first choice in the treatment of temporomandibular pain. However, the clinician must distinguish the type of pain and the aetioloic cause of the pain so that the patient can be treated and managed pharmacologically.

Treatments for painful temporomandibular disc displacement with reduction: a network meta-analysis of randomized clinical trials

There is currently no consensus on the best treatment for painful temporomandibular disc displacement with reduction (DDwR), and no network meta-analysis of randomized clinical trials (RCTs) comparing all types of treatment for this condition has been conducted. The objective of this study was to compare and rank all treatments for DDwR, including conservative treatments, occlusal splints, low-level laser therapy (LLLT), manual therapy, no treatment (control), arthrocentesis (Arthro) alone, Arthro plus intra-articular injection of platelet-rich plasma (Arthro-PRP) or hyaluronic acid (Arthro-HA), and Arthro plus occlusal splint. Predictor variables were pain intensity and maximum mouth opening (MMO). The mean difference with 95% confidence interval was estimated using Stata software. The GRADE system was used to assess the certainty of the evidence. Twenty RCTs reporting 1107 patients were identified in the literature search; 980 of these patients were included in the network meta-analysis. Direct meta-analysis showed that Arthro-PRP significantly reduced pain intensity compared to Arthro alone, while occlusal splint and manual therapy were superior to conservative treatment (all very low quality evidence). Arthro with intra-articular injection of PRP/HA ranked as the most effective treatment in terms of pain reduction, whereas LLLT ranked the best choice for increasing MMO for patients with DDwR. However, it is important to note that the evidence for the superiority of these treatments is generally of very low quality. Therefore, further high-quality research is needed to confirm these findings and provide more reliable recommendations for the treatment of DDwR.

Pharmacological Treatments of Temporomandibular Disorders: A Systematic Review Including a Network Meta-Analysis

OBJECTIVE

Temporomandibular disorders (TMD) comprise a cluster of conditions with a wide range of etiological factors that causes pain and discomfort in the masticatory muscles (TMD-M) and temporomandibular joints (TMD-J). More than 50% of the patients with TMD report regular usage of drugs. However, there is still no consensus, nor is there any evidence-based support for clinicians when choosing between different drugs. Therefore, this systematic review, including a network meta-analysis (NMA), aimed to evaluate the scientific evidence and discuss the pharmacological treatment options available to treat painful TMD.

METHOD

An electronic search was undertaken to identify randomized controlled trials (RCTs) investigating pharmacological treatments for TMD-M and/or TMD-J, published until 6 April 2023. Since only 11 articles could be used for an NMA regarding TMD-M, a narrative synthesis was also performed for all 40 included RCTs. The quality of evidence was rated according to Cochrane's tool for assessing risk of bias, while the certainty of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

When it comes to TMD-M, evidence arises for wet needling therapies with BTX-A, granisetron, and PRP as well as muscle relaxants. For TMD-J, evidence points toward pharmacological treatment approaches including non-steroidal antiinflammatory drugs (NSAIDs) and glucocorticosteriods (for inflammatory conditions) as well as hyaluronic acid and dextrose.

CONCLUSIONS

The evidence clearly indicates that the pharmacological treatment approaches differ between TMD-M and TMD-J. Therefore, it is of great importance to first try to uncover each patient's individual and multifactorial etiology and then employ a multifaceted treatment strategy, including pharmacological treatment approaches.

Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline

CLINICAL QUESTION

What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)?

CURRENT PRACTICE

TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations.

RECOMMENDATIONS

For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and β blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids.

HOW THIS GUIDELINE WAS CREATED

An international guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective.

THE EVIDENCE

Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD.

UNDERSTANDING THE RECOMMENDATION

These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.

Hyaluronic acid injections for pain relief and functional improvement in patients with temporomandibular disorders: An umbrella review of systematic reviews

BACKGROUND

Temporomandibular disorders (TMD) are the main cause of chronic facial pain, and intra-articular (IA) injections of hyaluronic acid (HA) are commonly performed.

OBJECTIVES

This umbrella review of systematic reviews aimed at analysing the effectiveness of HA injections on pain and functional outcomes in patients affected by TMD.

METHODS

PubMed, Cochrane Library and PEDro were systematically searched from inception until 17 January 2023 to identify systematic reviews evaluating the effects on pain and functional outcomes of HA IA injections. PROSPERO registration number: CRD42022382586.

RESULTS

Out of 316 papers suitable for title/abstract screening, 18 articles were included in the umbrella review. Thirteen studies included only randomized controlled clinical trials (RCTs). The included systematic reviews reported no statistically significant differences between HA and corticosteroids, whereas platelet derivates seem to have good results in pain relief. The literature did not show severe adverse events, except for mild pain in the site of injection. Concerning the quality assessment of the 18 systematic reviews, 2 (11.11%) had a high quality, 3 (16.67%) a moderate quality, 7 (38.89%) a low quality and 6 (33.33%) a critically low quality.

CONCLUSIONS

Taken together, findings of this umbrella review showed intriguing effects of IA HA injections in terms of reduction of pain intensity and improvement of functioning in patients affected by TMD. Furthermore, there is no agreement on the effectiveness of a combination of arthrocentesis or arthroscopy with IA HA injections. Although the literature showed these positive results after IA HA injections, the overlapping of primary studies in the systematic reviews included might have affect our results, such as the very low quality of the papers. Thus, further RCTs are needed to confirm the efficacy of IA injections of HA on pain relief in patients with TMD.

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

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

Effect of Botulinum Toxin on Masticatory Muscle Pain in Patients with Temporomandibular Disorders: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

This study aimed to evaluate the efficacy of botulinum toxin type A (BoNT/A) in patients with temporomandibular disorders (TMDs) associated with masticatory muscle pain (MMP) and headaches. This randomized, double-blind, placebo-controlled pilot study is the first clinical trial to evaluate both disorders simultaneously. Twenty-one patients with myogenous TMD were randomly assigned to two groups. The experimental and control groups received injections of either BoNT/A or saline into the sites showing tenderness after palpation of a total of 16 muscle areas, including each masseter, a temporalis, splenius capitis, sternocleidomastoid, and trapezius muscle. During each visit, the clinical effects, based on the intensity of orofacial pain (OVAS), headache (HVAS), number of tender points (TPs), maximum mouth opening (MMO), and headache frequency (HF), were evaluated at four time points, namely, pre-injection and 4, 8, and 12 weeks after the injection, in both groups. Friedman and Mann-Whitney tests were used for the analyses. In the experimental group, the reductions in OVAS, TP, HVAS, and HF showed significant differences over time, excluding MMO, whereas there was no significant difference in any of the variables in the control group. In addition, the decline in TPs was significantly different between the experimental and control groups at all time points, especially after 4 and 12 weeks, compared to that during pre-injection. In conclusion, treatment with BoNT/A was relatively effective for masticatory muscle pain caused by TMDs and headache compared to the saline placebo.

Assessing change in functional outcomes and quality of life in myogenic temporomandibular disorders undergoing botulinum toxin injection: A before and after comparison

PURPOSE

This prospective study aimed to evaluate the changes in functional outcomes and quality of life after the injection of botulinum toxin (BTX) into the masticatory muscles for the management of myogenic temporomandibular disorders (TMDs).

MATERIALS AND METHODS

This study was conducted with 45 individuals who presented with clinically myogenic TMDs according to the Diagnostic Criteria for Temporomandibular Disorders. All patients received BTX injections in the temporalis and masseter muscles. The Oral Health Impact Profile-Temporomandibular Dysfunction (OHIP-TMD) questionnaire was used to evaluate the effects of treatment on quality of life. The OHIP-TMD, visual analogue scale (VAS), and maximum mouth opening (MMO) scores before and 3 months after BTX injection were evaluated.

RESULTS

The preoperative and postoperative assessments revealed a statistically significant reduction (p ≤ 0.001) in the average overall OHIP-TMD scores. A significant increase in the MMO scores and a significant decrease in the VAS scores were observed (p < 0.001).

CONCLUSIONS

The injection of BTX into the masticatory muscles is beneficial for improving the clinical and quality of life parameters in the management of myogenic TMD.

Therapeutic effects of kartogenin on temporomandibular joint injury by activating the TGF-β/SMAD pathway in rats

Patients with temporomandibular dysfunction (TMD) usually suffer from pathology or malpositioning of the temporomandibular joint (TMJ) disk, leading to the degenerative lesion of condyles. Kartogenin can promote the repair of damaged cartilage. This study aimed to explore whether intra-articular injection of kartogenin could alleviate the TMJ injury induced by type II collagenase. We measured the head withdrawal threshold and found that kartogenin alleviated the pain around TMD induced by type II collagenase. We observed the morphology of the condylar surface and found that kartogenin protected the integration of the condylar surface. We analyzed the density of the subchondral bone and found that kartogenin minimized the damage of TMJ injury to the subchondral bone. We next explored the histological changes and found that kartogenin increased the thickness of the proliferative layer and more collagen formation in the superficial layer. Then, to further ensure whether kartogenin promotes cell proliferation in the condyle, we performed immunohistochemistry of proliferating cell nuclear antigen (PCNA). The ratio of PCNA-positive cells was significantly increased in the kartogenin group. Next, immunofluorescence of TGF-β1 and SMAD3 was performed to reveal that kartogenin activated the TGF-β/SMAD pathway in the proliferative layer. In conclusion, kartogenin may have a therapeutic effect on TMJ injury by promoting cell proliferation in cartilage and subchondral bone. Kartogenin may be promising as an intra-articular injection agent to treat TMD.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes of IncobotulinumtoxinA Injection on Myalgia and Arthralgia in Patients Undergoing Temporomandibular Joint Arthroscopy: A Randomized Controlled Trial

BACKGROUND

Several studies have considered Botulinum Neurotoxin Type A injections effective in treating temporomandibular joint disorder (TMD) symptoms. A double-blind, randomized, controlled clinical trial investigated the benefit of complementary incobotulinumtoxinA (inco-BoNT/A) injections in the masticatory muscles of patients submitted to bilateral temporomandibular joint (TMJ) arthroscopy.

METHODS

Fifteen patients with TMD and an indication for bilateral TMJ arthroscopy were randomized into inco-BoNT/A (Xeomin, 100 U) or placebo groups (saline solution). Injections were carried out five days before TMJ arthroscopy. The primary outcome variable was a Visual Analogue Scale for TMJ arthralgia, and secondary outcomes were the myalgia degree, maximum mouth opening, and joint clicks. All outcome variables were assessed preoperatively (T0) and postoperatively (T1-week 5; T2-6-month follow-up).

RESULTS

At T1, the outcomes in the inco-BoNT/A group were improved, but not significantly more than in the placebo group. At T2, significant improvements in the TMJ arthralgia and myalgia scores were observed in the inco-BoNT/A group compared to the placebo. A higher number of postoperative reinterventions with further TMJ treatments were observed in the placebo group compared to inco-BoNT/A (63% vs. 14%).

CONCLUSIONS

In patients submitted to TMJ arthroscopy, statistically significant long-term differences were observed between the placebo and inco-BoNT/A groups.

Effect of dextrose prolotherapy on internal derangement of the temporomandibular joint

OBJECTIVE

This study aimed to evaluate the effect of dextrose prolotherapy in treating internal derangement of the temporomandibular joint.

PATIENTS AND METHODS

A total of 20 patients with temporomandibular joint internal derangement were enrolled in the study. The diagnosis of internal derangement was confirmed by magnetic resonance imaging (MRI). The posterior and anterior disc attachment, as well as the most tender part of the masseter muscle, were injected with 12.5% dextrose. Pain, maximum mouth opening, clicking, and deviation were assessed immediately before treatment, as well as at 2-, 4-, and 12- weeks post-treatment.

RESULTS

There was a significant improvement in the four clinical variables at the three-time intervals. Pain at two weeks was reduced by 60% (6 vs. 3.75) and by 200% (6 vs. 1.9) at 4 weeks. The maximum mouth opening was increased by 6.4 mm at 2 weeks and 7.85 mm at 4 weeks. The percentage of patients with clicking decreased from 70%, preoperatively- to 50% at 2 weeks, 15% at 4 weeks, and 5% at 12 weeks. The ratio of patients with deviation was decreased from 80% preoperatively to 35% at 2 weeks, 15% at 4 weeks, and 5% at 12 weeks.

CONCLUSIONS

Prolotherapy is a safe and effective treatment for alleviating the symptoms of internal derangement of the temporomandibular joint.

Establishment of quantitative indicators for an efficient treatment on masticatory muscle pain

BACKGROUND

Although several studies have investigated effective treatments for masticatory muscle pain (MMP), no unified conclusion has been drawn regarding the effectiveness of these treatments.

OBJECTIVES

This study aimed to define quantitative indicators for predicting the outcome of MMP treatment.

MATERIALS AND METHODS

In total, patients aged 20-70 years were recruited and divided into the MMP (n = 24) and control (n = 36) groups, based on the presence of MMP according to the Diagnostic Criteria for Temporomandibular Disorders. At pretreatment, the MMP group was assessed using quantitative indicators such as subjective pain levels, pain duration, graded chronic pain scale (GCPS), and perceived stress scale (PSS). Salivary alpha-amylase (sAA) and interleukin-6 (IL-6) levels were analyzed. The masticatory muscle palpation score and the range of mouth opening were measured. At posttreatment, subjective pain levels, mouth opening, and treatment/medication duration were examined. The PSS and sAA levels were assessed in the control group.

RESULTS

sAA levels in the MMP group were significantly higher than those in the control group (p < .05). The masseter muscle palpation score (MPS) showed a positive correlation with IL-6 levels (ρ = 0.503, p < .05) and a negative correlation with nonsteroidal anti-inflammatory drug (NSAID) treatment period (ρ = -0.462, p < .05). The temporalis muscle palpation score (TPS) was positively correlated with pain duration and GCPS grade (ρ = 0.483, p < .05, and ρ = 0.445, p < .05, respectively).

CONCLUSIONS

Treatment with NSAIDs was effective in the MMP group with high MPS and IL-6 levels, but not in the MMP group with high TPS, pain duration, and GCPS grade.

Comparison of chemical-induced temporomandibular osteoarthritis rat models (monosodium iodoacetate versus collagenase type II) for the study of prolonged drug delivery systems

OBJECTIVE

To compare two agents that can induce a rat model of temporomandibular joint osteoarthritis (TMJOA) by chemical induction: monosodium iodoacetate (MIA) and collagenase type 2 (Col-2). We wished to ascertain the best agent for assessing drug-delivery systems (DDSs).

METHOD

Male Wistar rats underwent intra-articular injection with MIA or Col-2. They were manipulated for 30 days. The head withdrawal threshold (HWT), immunohistological assessment, and positron emission tomography (PET) were used to evaluate the relevance of our models.

RESULTS

For both the MIA and Col-2 groups, pain persisted for 30 days after injection. Change in the HWT showed that Col-2 elicited a strong action initially that decreased progressively. MIA had a constant action upon pain behavior. Histology of TMJ tissue from both groups showed progressive degradation of TMJ components.

CONCLUSIONS

MIA and Col-2 induced orofacial pain by their local chemical action on TMJs. However, based on a prolonged and greater sustained effect on the pain threshold, persistent histological changes, and imaging results, MIA appeared to be more suitable for creation of a rat model of TMJOA for the study of DDSs.

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.

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..

Efficacy of computer-guided versus conventional sodium hyaluronate injection in superior joint space in treatment of temporomandibular joint (TMJ) internal derangement: Comparative randomized controlled trial

OBJECTIVES

evaluate the feasibility and clinical outcomes of computer-guided sodium hyaluronate injection in superior joint space compared to conventional injection for the treatment of TMJ Internal Derangement (TMJ-ID).

PATIENTS AND METHODS

Randomized controlled trial conducted on 40 patients diagnosed with bilateral TMJ-ID divided into two groups. Group A treated with four computer-guided sodium hyaluronate injections in superior TMJ space with one-week intervals. Group B received similar injections but with the conventional method. The intraoperative assessment included total procedural time and patient convenience during the injection. The postoperative evaluation included maximum unassisted mouth opening (MUMO), modified Helkimo's clinical dysfunction index, and pain intensity on a visual analog scale (VAS).

RESULTS

Group A showed better improvement in maximum mouth opening and pain intensity than group B after a week of the second, third and fourth injection. At the six months, group A continued to show better improvement regarding maximum mouth opening, while improvement in pain and TMJ dysfunction was similar in both groups. There were differences between both groups regarding procedural time and patient convenience across the study except the time of the first injection, which was similar in both groups CONCLUSION: Using the virtual planning and injection guide for intra-articular TMJ injection is considered promising to increase the accuracy and efficacy of injectable material securing faster results besides rendering the procedure easily reproducible and simpler to both clinicians and patients. However, the authors could not ensure the long-term superiority of the computer-guided injection technique over the conventional one in light of the results of this study.

The effect of intraarticular botulinum toxin-A injection on symptoms of temporomandibular joint disorder

INTRODUCTION

Application of arthrocentesis in temporomandibular joint disorders preferred and suggested therapeutic treatment option in recent years. This study was designed to investigate and compare the effect of intra-articular injection of botulinum toxin-A (Btx-A) on pain and mouth opening after arthrocentesis in nonreduction disc displacement.

MATERIALS AND METHODS

This restrospective study was conducted on 30 patients with a visual analogue scale is higher than five and limited mouth opening. Patients were divided into 2 groups as conventional arthrocentesis group (group A) and intra-articular Btx-A injection following arthrocentesis group (group B). Maximum mouth openining and temporomandibular joint pain were measured in preoperative (t0) and at postoperative 1^st-week (t1), 1^st-month (t2) and 6^th-month (t3).

RESULTS

When VAS scores of group A and group B were examined, no statistical difference was observed at t0 and t1 time intervals; an increased in mouth opening values and decreased VAS score values were observed in both groups in the 1^st month (t2) and 6^{th (}t3) months, mostly in group A.

CONCLUSION

İntra-articular injection of Btx-A following arthrocentesis can induce mouth opening and reduce the pain and dysfunction in patients with anterior disc displacement.

Circulating Omega-6 and Omega-3 Polyunsaturated Fatty Acids in Painful Temporomandibular Disorder and Low Back Pain

Preclinical studies demonstrate opposing effects of long-chain polyunsaturated fatty acid (PUFA) metabolites on inflammation and nociception. Omega-6 (n-6) PUFAs amplify both processes while omega-3 (n-3) PUFAs inhibit them. This cross-sectional study examined relationships between PUFAs in circulating erythrocytes and 2 chronic idiopathic pain conditions: temporomandibular disorder (TMD) and low back pain in a community-based sample of 503 U.S. adults. Presence or absence of TMD and low back pain, respectively, were determined by clinical examination and by responses to established screening questions. Liquid chromatography-tandem mass spectrometry quantified PUFAs. In multivariable logistic regression models, a higher ratio of n-6/n-3 long-chain PUFAs was associated with greater odds of TMD (odds ratio ((OR) = 1.75, 95% confidence limits (CL): 1.16, 2.64) and low back pain (OR = 1.63, 95% CL: 1.07, 2.49). Higher levels of the pronociceptive n-6 long-chain arachidonic acid (AA) were associated with a greater probability of both pain conditions for women, but not men. Higher levels of the antinociceptive long-chain n-3 PUFAs eicosapentaenoic and docosahexaenoic acids were associated with a lower probability of both pain conditions for men, but not women. As systemic inflammation is not a hallmark of these conditions, PUFAs may influence idiopathic pain through other mechanisms. PERSPECTIVE: This cross-sectional clinical study found that a higher ratio of circulating n-6/n-3 long-chain PUFAs was associated with greater odds of 2 common chronic overlapping pain conditions. This suggests that the pro and antinociceptive properties of n-6 and n-3 PUFAs, respectively, influence pain independently of their well-established inflammatory pathways.

Superficial cervical plexus block on pain control in patients with temporomandibular joint internal derangement with headache: a retrospective cohort study

OBJECTIVES

Temporomandibular disorders (TMDs) are a group of disorders with varied pathophysiology and clinical manifestations. Masticatory and cervical motor systems have a functional relationship. Superficial cervical muscles have greater hyperactivity in myogenous and mixed TMDs than in healthy individuals, demonstrating an abnormal pattern of contraction. This study aimed to demonstrate the effects of superficial cervical plexus block (SCPB) anesthesia during arthrocentesis in patients with temporomandibular joint (TMJ) internal derangement and headache.

METHOD AND MATERIALS

This retrospective cohort study included 2 men and 23 women with cervicogenic headache and TMJ internal derangement treated by arthrocentesis, and 40 TMJs with established cervicogenic headaches. The average follow-up period was 9.36 ± 2.679 months. TMJ and muscle pain during mastication, maximum and non-assisted mouth opening, and lateral excursion were recorded. Pain and dysfunction were determined using the visual analog scale. Patients were monitored before, during, and after arthrocentesis while inducing SCPB anesthesia, and vital findings were recorded. In addition, skin surface temperature was measured.

RESULTS

Patients experienced a significant increase in their clinical values. Changes in non-assisted mouth opening (mean from 29.65 ± 6.31 to 33.3 ± 5.21 mm) (P < .05), assisted mouth opening (mean from 38.98 ± 7.62 to 43.35 ± 6.17 mm), right excursions (mean from 7.28 ± 2.08 to 9.13 ± 1.86 mm), and left excursions (mean from 7.48 ± 1.71 to 8.90 ± 1.82 mm) were statistically significant (P < .05). Patients were relieved after SCPB, resulting in decreased pain and hemodynamic values. Increase in mean temperature after SCPB was statistically significant (P = .002, P < .05).

CONCLUSION

This study presents a straightforward novel protocol, clinically efficient for arthrocentesis on pain control in patients with TMJ internal derangement and cervicogenic headache.

Oxygen-Ozone Therapy for Reducing Pro-Inflammatory Cytokines Serum Levels in Musculoskeletal and Temporomandibular Disorders: A Comprehensive Review

To date, the application of oxygen-ozone (O₂O₃) therapy has significantly increased in the common clinical practice in several pathological conditions. However, beyond the favorable clinical effects, the biochemical effects of O₂O₃ are still far from being understood. This comprehensive review aimed at investigating the state of the art about the effects of O₂O₃ therapy on pro-inflammatory cytokines serum levels as a modulator of oxidative stress in patients with musculoskeletal and temporomandibular disorders (TMD). The efficacy of O₂O₃ therapy could be related to the moderate oxidative stress modulation produced by the interaction of ozone with biological components. More in detail, O₂O₃ therapy is widely used as an adjuvant therapeutic option in several pathological conditions characterized by chronic inflammatory processes and immune overactivation. In this context, most musculoskeletal and temporomandibular disorders (TMD) share these two pathophysiological processes. Despite the paucity of in vivo studies, this comprehensive review suggests that O₂O₃ therapy might reduce serum levels of interleukin 6 in patients with TMD, low back pain, knee osteoarthritis and rheumatic diseases with a concrete and measurable interaction with the inflammatory pathway. However, to date, further studies are needed to clarify the effects of this promising therapy on inflammatory mediators and their clinical implications.

Effects of Botulinum Toxin Type A on the Psychosocial Features of Myofascial Pain TMD Subjects: A Randomized Controlled Trial

AIMS

To determine the effects of botulinum toxin type A (BoNT-A) on the psychosocial features of patients with masticatory myofascial pain (MFP).

METHODS

A total of 100 female subjects diagnosed with MFP were randomly assigned into five groups (n = 20 each): oral appliance (OA); saline solution (SS); and three groups with different doses of BoNT-A. Chronic pain-related disability and depressive and somatic symptoms were evaluated with the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II instruments at baseline and after 6 months of treatment. Differences in treatment effects within and between groups were compared using chi-square test, and Characteristic Pain Intensity (CPI) was compared using two-way ANOVA. A 5% probability level was considered significant in all tests.

RESULTS

Most patients presented low pain-related disability (58%), and 6% presented severely limiting, high pain-related disability. Severe depressive and somatic symptoms were found in 61% and 65% of patients, respectively. In the within-group comparison, BoNT-A and OA significantly improved (P < .001) scores of pain-related disability and depressive and somatic symptoms after 6 months. Only the scores for pain-related disability changed significantly over time in the SS group. In the between-group comparison, BoNT-A and OA significantly improved (P < .05) scores of all variables at the final follow-up when compared to the SS group. No significant difference was found between the BoNT-A and OA groups (P > .05) for all assessed variables over time.

CONCLUSION

BoNT-A was at least as effective as OA in improving pain-related disability and depressive and somatic symptoms in patients with masticatory MFP.

[Bioregulation therapy in the treatment of age-related osteoarthropathy of the temporomandibular joint.]

The study consists of clinical and radiological parallels between the severity of functional pathology of the temporomandibular joint, bone density of the joint elements and the effect of bioregulatory therapy on it at different ages. Male patients (35-74 years old) with functional pathology of the temporomandibular joint were under observation. The study showed a significant decrease in bone density and correlation of this index with the severity of the disease course in all patients with temporomandibular joint dysfunction compared with the control group of healthy subjects. After a course of bioregulatory therapy the bone density and functional pathology index of the temporomandibular joint indicate a change from the severe course to a form of moderate severity in the group of elderly patients. The correlation correlation between the severity of the course of functional pathology and the decrease in the density of bone structures of the temporomandibular joint has been revealed, increasing with age. Use of bioregulatory therapy in complex treatment of functional pathology has favorable influence on a course of functional pathology of a temporomandibular joint at elderly patients.

Botulinum Toxin for Treating Temporomandibular Disorders: What is the Evidence?

AIMS

To systematically review the scientific literature for evidence concerning the clinical use of botulinum toxin (BTX) for the management of various temporomandibular disorders (TMDs).

METHODS

A comprehensive literature search was conducted in the Medline, Web of Science, and Cochrane Library databases to find randomized clinical trials (RCT) published between 2000 and the end of April 2021 investigating the use of BTX to treat TMDs. The selected articles were reviewed and tabulated according to the PICO (patients/problem/population, intervention, comparison, outcome) format.

RESULTS

A total of 24 RCTs were selected. Nine articles used BTX injections to treat myofascial pain, 4 to treat temporomandibular joint (TMJ) articular TMDs, 8 for the management of bruxism, and 3 to treat masseter hypertrophy. A total of 411 patients were treated by injection of BTX. Wide variability was found in the methods of injection and in the doses injected. Many trials concluded superiority of BTX injections over placebo for reducing TMD pain levels and improving maximum mouth opening; however, this was not universal.

CONCLUSION

There is good scientific evidence to support the use of BTX injections for treatment of masseter hypertrophy and equivocal evidence for myogenous TMDs, but very little for TMJ articular disorders. Studies with improved methodologic design are needed to gain better insight into the utility and effectiveness of BTX injections for treating both myogenous and TMJ articular TMDs and to establish suitable protocols for treating different TMDs.

Pharmacologic Treatment for Temporomandibular and Temporomandibular Joint Disorders

Temporomandibular joint disorder is defined by pain and/or loss of function of the temporomandibular joint and its associated muscles and structures. Treatments include noninvasive pharmacologic therapies, minimally invasive muscular and articular injections, and surgery. Conservative therapies include nonsteroidal anti-inflammatory drugs, muscle relaxants, benzodiazepines, antidepressants, and anticonvulsants. Minimally invasive injections include botulinum toxin, corticosteroids, platelet-rich plasma, hyaluronic acid, and prolotherapy with hypertonic glucose. With many pharmacologic treatment options and modalities available to the oral and maxillofacial surgeon, mild to moderate temporomandibular joint disorder can be managed safely and effectively to improve symptoms of pain and function of the temporomandibular joint.

Effects of Botulinum Toxin Type A on Pain among Trigeminal Neuralgia, Myofascial Temporomandibular Disorders, and Oromandibular Dystonia

The differences in analgesic effects of botulinum toxin type A were compared in 28 patients with trigeminal neuralgia, 53 patients with myofascial temporomandibular disorders, and 89 patients with the jaw closing oromandibular dystonia. The patients were treated by injection of botulinum toxin type A into the masseter, temporalis, medial pterygoid, and other muscles based on the symptoms of each patient. The pain severity was evaluated using the visual analog scale, pain frequency, and pain scale of the oromandibular dystonia rating scale. Botulinum toxin injection was performed 1068 times in all patients without significant adverse effects. The visual analog, pain frequency, and pain scales at baseline were reduced (p < 0.001) after two, four, eight, and 12 weeks after the first botulinum toxin therapy and at the endpoint. The effects differed significantly (p < 0.001) among the groups (repeated-measures analysis of variance). The mean improvement (0%, no effect; 100%, complete recovery) at the endpoint was 86.8% for trigeminal neuralgia, 80.8% for myofascial pain, and 75.4% for oromandibular dystonia. Injection of the botulinum toxin can be a highly effective and safe method to treat trigeminal neuralgia, myofascial pain, and oromandibular dystonia.

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

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

Otolaryngeal and Oropharyngeal Conditions: Temporomandibular Disorders

Temporomandibular disorders (TMDs) is a collective term for a group of heterogeneous musculoskeletal and neuromuscular conditions involving the temporomandibular joint (TMJ) complex, masticatory muscles, and surrounding osseous structures. TMDs affect 5% to 12% of the US population, with a peak incidence at ages 45 to 65 years. Common clinical manifestations include facial pain, ear pain, headache, TMJ discomfort, and adventitious sounds. The etiologies of TMDs are multifactorial and include behavioral, social, emotional, and occlusive factors. Common causes of TMDs are myofascial pain and dysfunction, articular disk displacement, and degenerative joint conditions. In most cases, the diagnosis can be made based on the history and physical examination. In the absence of trauma, imaging typically is reserved for patients with chronic TMDs. Initial management includes education, self-management, behavioral therapy, and physical therapy. Occlusal devices are recommended for management of sleep bruxism or diurnal clenching. Adjunctive pharmacotherapies include nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antidepressants, and anticonvulsants. (This is an off-label use of some NSAIDs and an off-label use of benzodiazepines, antidepressants, and anticonvulsants.) Intra-articular injections have been used alone or with arthrocentesis. Patients who do not benefit from these therapies should be referred to an oral and maxillofacial surgeon.

Efficacy and safety of intraarticular corticosteroid injections in adolescents with juvenile idiopathic arthritis in the temporomandibular joint: a Norwegian 2-year prospective multicenter pilot study

BACKGROUND

Intraarticular corticosteroids (IACs) have been used to treat temporomandibular joint (TMJ) arthritis. However, prospective clinical studies with magnetic resonance imaging (MRI) scoring are lacking. The aim of this study was to examine efficacy and safety of a single IAC in the TMJ in adolescents with juvenile idiopathic arthritis (JIA) in a clinical setting.

METHODS

In this Norwegian prospective multicenter pilot study 15 patients with JIA (mostly persistent oligoarthritis or RF negative polyarthritis categories) and a clinically and MRI-verified diagnosis of TMJ arthritis were treated with IACs and followed for 2 years. Demographics, systemic medication, general disease activity and outcome measures were recorded including a pain-index score and maximal incisal opening (MIO). Inflammation and bone damage scores were assessed, using two recently published MRI scoring systems with masked radiological evaluation.

RESULTS

Among the 15 patients, 13 received a single IAC (5 bilateral), and 2 repeated IACs once unilaterally. Thus, the total number of IACs was 22. Median age was 15 years and the majority had an age not thought of as critical regarding mandibular growth retardation due to steroid injection. During the 2-year observation period systemic medication with disease modifying antirheumatic drugs (DMARDs) including biologics was initiated or adjusted in 10/15 (67%) patients. At the 2-months study visit after injection we observed a minimal improvement in MIO from median 44 (1st, 3rd quartiles; 36, 48) mm to 45 (43, 47) mm, p = 0.045 and decreased MRI mean additive inflammatory score from 4.4 ± 1.8 standard deviations (SD) to 3.4 ± 2.0, p = 0.040. From baseline to the 2-months follow-up pain improved in 6/11 patients but pain scores were not significantly improved. MRI-assessed damage increased in two patients with repeated IACs, and decreased in 3 patients but most of the patients were stable over the 2-year follow-up. Intra-rater repeatability of the MRI scoring system domains varied from poor to excellent.

CONCLUSIONS

In this pilot study of predominately single IACs to the TMJ in combination with systemic treatment we observed improvement in MRI-assessed inflammation, mostly stable condylar bone conditions and minimal clinical improvement in adolescents with JIA and TMJ arthritis. No severe side effects were seen.

Therapeutic Effect of Sodium Hyaluronate and Corticosteroid Injections on Pain and Temporomandibular Joint Dysfunction: A Quasi-experimental Study

AIM

The aim was to evaluate and compare the therapeutic effect of sodium hyaluronate (SH) and corticosteroids (CS) on pain and temporomandibular dysfunction (TMD).

MATERIALS AND METHODS

Thirty patients with TMD [characterized by painful symptoms, affectations, and limitations of the mandibular movement and noises or clicks in the temporomandibular joint (TMJ)] were selected and divided into two equal groups nonrandomized. The clinical questionnaire was applied to each patient before performing the clinical procedures and included a visual analog scale with progressive values from 0 to 10 for the measurement of pain and clinical examination: maximum oral aperture (MOA), mandibular laterotrusive movement (MLM), and maximum protrusion (MP), before and after infiltration intra-articular with SH and CS up to 2 months.

RESULTS

Both groups described benefits from treatment at the 1st and 2nd weeks, and at 1 and 2 months of follow-up, presenting a reduction in TMJ pain, and improvement in mandibular mobility with an increase of the MOA, lateralities, and protrusion. No statistically significant difference was found among these variables between the two drugs. However, SH showed a greater therapeutic effect in relation to a reduction in joint noises compared to CS.

CONCLUSION

Intra-articular infiltration with SH and CS in TMD is effective for the relief of TMJ pain and also reduces joint noises and improves mandibular mobility. Both drugs can be used with similar optimal results in the treatment of TMD.

CLINICAL SIGNIFICANCE

This research allows to know what is the therapeutic impact of injectable CS on the TMJ.

Intra-articular corticosteroids for treatment of temporomandibular joint internal disorders: protocol for systematic review and network meta-analysis

INTRODUCTION

Internal temporomandibular joint (TMJ) disorders are present in approximately 80% of patients with symptomatic temporomandibular disorders. Among the minimally invasive therapies, we find the intra-articular infiltration of substances, such as corticosteroids, hyaluronic acid or platelet-rich plasma accompanied or not by an arthrocentesis. There are several studies on minimally invasive therapy for internal TMJ disorders; however, none compares the effectiveness of the different intra-articular corticosteroids to each other.The purpose of this study is to evaluate the effectiveness of the different intra-articular corticosteroids for the treatment of internal disorders of the TMJ and compare them to each other or to other minimally invasive therapies.

METHODS AND ANALYSIS

A systematic search will be carried out up to December 2019 in the electronic databases: Medline, Cochrane Library, EMBASE, SCOPUS and LILACS.Randomised clinical trials evaluating patients with internal disorders of the TMJ, with intra-articular corticosteroid therapy and comparing these to each other and/or to other minimally invasive therapy will be included. The main outcomes will be pain and range of motion measured through validated scales.Two review authors will independently screen search results, extract data from included studies and assess the risk of bias in those studies using the Revised Cochrane Risk of Bias Tool (RoB 2.0). In the case of any discrepancy and failure to reach consensus, this will be resolved by a third reviewer.A network meta-analysis will be conducted based on direct comparisons to generate indirect comparisons of the different treatments. Data will be combined in a meta-analysis using a random effects model.The principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system will be used to assess the overall quality of the body of evidence associated with the main results.

ETHICS AND DISSEMINATION

This protocol will not require ethical approval. The results of this review will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

CRD42019129014.

Arthrocentesis versus glucocorticosteroid injection for internal derangement of temporomandibular joint

BACKGROUND

It is necessary to clarify that temporomandibular joint disorders (TMDs) are one of the most misdiagnosed and mistreated maladies in the medical practice. It is an umbrella term, embracing conditions which involve the temporomandibular joint (TMJ) and related muscles. One of these common irritating disorders is the internal derangement which is used specifically to describe the displacement of the TMJ disc. The treatment can vary according to the severity and chronicity into non-invasive, minimally invasive, and invasive procedures. However, permanent recovery is rarely obtained.

AIM OF THE STUDY

This study was established to compare the effectiveness of two minimally invasive procedures: arthrocentesis and glucocorticosteroid (GCS) local single joint injection in the management of internal derangement of the TMJ.

METHODS

Thirty patients aged from 18 to 42 years were included in this study with internal derangement which was confirmed clinically and with a cone beam CT scan. The patients were divided into two groups of 15 patients. Arthrocentesis was performed to one group (group A) by using Shepard's cannula and lactated Ringer's solution. Glucocorticosteroid injection was done to the other group (group B) using a 1 ml/40 mg methylprednisolone acetate vial. The study was performed in the Department of Oral and Maxillofacial Surgery, Ghazi Alhareery Hospital-Medical City, from October 2017 to September 2018.

RESULTS AND CONCLUSION

After 4 months of clinical follow-up, the results revealed that the GCS injection has minimal outcomes in the treatment of TMJ internal derangement compared to arthrocentesis. On the other hand, arthrocentesis and lavage had dedicated promising outcomes.

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.

Evaluating the effectiveness of nonsteroidal anti-inflammatory drug(s) for relief of pain associated with temporomandibular joint disorders: A systematic review

AIM

The aim of this systematic review was to compile the latest evidence to assess the effectiveness of nonsteroidal anti-inflammatory drug(s) (NSAID) in patients with temporomandibular joint disorders (TMDs) in relieving pain. TMDs are a group of musculoskeletal disorders that affect the temporomandibular joint and/or masticatory muscles.

METHODS

After a literature review, a comprehensive search was conducted via Pubmed, Scopus, Google Scholar, and Cochrane databases with a systematic search strategy. The inclusion criteria were randomised controlled trials in humans, published in the last 50 years evaluating the effect of NSAIDs on TMDs. Although this duration chosen would potentially identify studies that have utilised outdated treatments, research methodology, and TMDs diagnostic criteria, and this has been considered before making clinical recommendation, it was used to advise future methodological changes necessary. The included studies were subjected to full-text review.

RESULTS

Out of 646 studies initially identified through searches, 12 were selected for full-text review of which 11 were included in the data synthesis. All 11 studies were randomised controlled trials. In total, 424 patients were included in this review. The earliest study included was 1996. Diagnostic criteria varied among all studies, and some did not specify enough signs and symptoms to construct a diagnosis. Intervention varied among all studies, as did the control. Nonspecific diagnosis, variable control groups, and heterogenous intervention protocols affected the outcome of this review. Despite the reduction of pain in the joint and/or masticatory muscles as well as improved range of motion, conclusive clinical recommendation could not be made.

CONCLUSION

Heterogeneity did not allow for definitive conclusion; however, there was some evidence to support the use of NSAIDs in patients with TMDs for relief of pain. Further studies with strict, consistent diagnostic criteria and treatment are required.

Evaluation of Effect of Glucosamine-Chondroitin Sulfate, Tramadol, and Sodium Hyaluronic Acid on Expression of Cytokine Levels in Internal Derangement of Temporomandibular Joint

AIM

Evaluation of the effect of glucosamine-chondroitin combination, tramadol, and sodium hyaluronic acid in temporomandibular joint (TMJ) disorders and its impact on the expression of various cytokines such as IL-6, IL-1β, TNF-α, and PGE2.

MATERIALS AND METHODS

The present study was conducted on 60 patients (males-30, females-30) suffering from internal derangement such as disc displacement with reduction of TMJ. The patients were divided into three groups of 20 each. Group I received a combination of 1.5g of glucosamine and 1.2 g of chondroitin sulfate per day and group II received 50 mg tramadol HCL peroral. Group III received sodium hyaluronate 10 mg/mL, 2 mL injection syringe on each joint. Pain (VAS) scale and maximum mouth opening (MMO) was measured. The level of IL-6, IL-1β, TNF-α, and PGE2 levels were measured using Enzyme-linked immuno sorbent assay (ELISA).

RESULTS

There was an improvement in maximum mouth opening in all three groups (p < 0.05). There was a reduction in pain in all groups. IL- 1β, TNF-α, and PGE2 leve ls showed reduction while IL-6 showed an increase in value in group II and III.

CONCLUSION

The efficacy of glucosamine chondroitin sulfate , tramadol and hyaluronic acid in TMJ disorders has been found to be effective.

CLINICAL SIGNIFICANCE

IL-6, IL-1β, TNF-α, and PGE2 levels indicate the risk of TMJ disorders. Thus earlier assessment of their levels helps in diagnosis, and better management may be done.

Septic arthritis of the temporomandibular joint after acute otitis media in a child

Septic arthritis of the temporomandibular joint as a complication of acute otitis media is rare in the Western world. This report describes the case of a 7-year-old boy who had pain in his right ear and limited mouth opening, following the onset of acute otitis media. A contrast-enhanced computed tomography scan revealed right-sided mastoiditis and hydrops of the right temporomandibular joint, suggesting septic arthritis. Real-time PCR and microbiologic analysis identified Streptococcus pyogenes and Staphylococcus epidermidis in the joint aspirate. Treatment with arthrocentesis and antibiotics led to full recovery of temporomandibular joint function.

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.

Botulinum Neurotoxin Injection for the Treatment of Recurrent Temporomandibular Joint Dislocation with and without Neurogenic Muscular Hyperactivity

The aim of this study was to compare treatment outcomes following intramuscular injection of botulinum neurotoxin (BoNT) in patients with recurrent temporomandibular joint dislocation, with and without muscle hyperactivity due to neurological diseases. Thirty-two patients (19 women and 13 men, mean age: 62.3 years) with recurrent temporomandibular joint dislocation were divided into two groups: neurogenic (8 women and 12 men) and habitual (11 women and 1 man). The neurogenic group included patients having neurological disorders, such as Parkinson’s disease or oromandibular dystonia, that are accompanied by muscle hyperactivity. BoNT was administered via intraoral injection to the inferior head of the lateral pterygoid muscle. In total, BoNT injection was administered 102 times (mean 3.2 times/patient). The mean follow-up duration was 29.5 months. The neurogenic group was significantly (p < 0.001) younger (47.3 years) than the habitual group (84.8 years) and required significantly (p < 0.01) more injections (4.1 versus 1.7 times) to achieve a positive outcome. No significant immediate or delayed complications occurred. Thus, intramuscular injection of BoNT into the lateral pterygoid muscle is an effective and safe treatment for habitual temporomandibular joint dislocation. More injections are required in cases of neurogenic temporomandibular joint dislocation than in those of habitual dislocation without muscle hyperactivity.

Imaging findings of Copa syndrome in a 12-year-old boy

Copa syndrome is a newly described autosomal dominant autoinflammatory disease that presents as pulmonary hemosiderosis and polyarticular arthritis. Twenty-one cases from five families have been reported to date. We present chest computed tomography (CT) and temporomandibular joint magnetic resonance (MR) findings of a 12-year-old boy presenting with dyspnea on exertion, fatigue and clubbing. Additional findings included a restrictive pattern of pulmonary involvement and positive inflammatory markers and autoantibodies. Genetic testing revealed a p.W240R variant of the COPA gene confirming the diagnosis of Copa syndrome. CT of the chest showed a nonspecific interstitial pneumonia pattern distributed mainly in the lower lobes. MR of the temporomandibular joints and follow-up CT three years later are also described.

Evaluation of articular disc loading in the temporomandibular joints after prosthetic and pharmacological treatment in model studies

BACKGROUND

Temporomandibular joint dysfunction is often related to excessive load in the stomatognathic system.

OBJECTIVES

The objective of the model tests, using numeric calculations, was to assess the articular disc loads in the temporomandibular joints after prosthetic and pharmacological treatment of functional disorders of the masticatory organ.

MATERIAL AND METHODS

The study involved 10 patients, aged 21-48 years, of both sexes, randomly selected from a group of 120 patients treated with relaxation occlusal splints (60 patients, group I) and intramuscular injection of botulinum toxin type A (60 patients, group II), suffering from temporomandibular joint dysfunction with the dominant muscle component. In all subjects, a specialized functional examination was carried out. Treatment groups: occlusal splint therapy (group I) and intramuscular injection of botulinum toxin type A (group II). An assessment of the loads of 4 disc zones of the temporomandibular joints was carried out based on the results of clinical studies (phase I of the study), and numeric model tests (phase II). In the representatives of the study groups (5 patients in each group), measurements of occlusal forces and an evaluation of tension of the masseter and temporalis muscle were performed.

RESULTS

The results of the average load values for all evaluated zones of the right and left articular disc differ in a statistically significant way in favor of group II, with the exception of the external mid part of the discs. In the case of the anterior of the right disc, the load was lower in patients belonging to group I than in those obtained in group II.

CONCLUSIONS

Botulinum toxin type A significantly reduces the loads within the temporomandibular joints, generated by masseter muscle hypertonia.

Comparison of intra-articular injection of plasma rich in growth factors versus hyaluronic acid following arthroscopy in the treatment of temporomandibular dysfunction: A randomised prospective study

PURPOSE

The main objective of our study was to evaluate the effectiveness of the injection of plasma rich in platelet-derived growth factors (PRGF) versus hyaluronic acid (HA) following arthroscopic surgery in patients diagnosed with internal derangement of the temporomandibular joint (TMJ) with osteoarthritis (OA).

MATERIALS AND METHODS

A total of 100 patients were randomised into two study groups. Group A (n = 50) received an injection of PRGF, and Group B (n = 50) received an injection of HA. The mean age was 35.5 years (range 18-77 years), and 88% of the patients were women. The pain intensity (visual analogue scale) and the extent of maximum mouth opening before and after the procedure were statistically analysed.

RESULTS

Better results were observed in the group treated with PRGF, with a significant reduction in pain at 18 months, compared with HA treatment. Regarding mouth opening, an increase was observed in both groups, with no significant difference.

CONCLUSIONS

The injection of PRGF following arthroscopy is more effective than the injection of HA with respect to pain in patients with advanced internal derangement of the TMJ.

Evaluation of remission of temporomandibular joints pain as a result of treatment of dysfunction using intraarticular injection

The temporomandibular joint pain, which occurs in the course of temporomandibular joint dysfunction, is one of the main clinical problems in the treatment of joint disc displacement. The aim of the study was to evaluate changes in temporomandibular joints pain in treatment supporting disc displacement without reduction using intra-articular injection of hyaluronic acid and platelet-rich plasma.

MATERIAL AND METHODS

The study consisted of a group of 60 patients, aged 35-49, who reported for treatment, because of pain in the preauricural area. The functional examination stated disk dicplacement without reduction, along with the accompanying pain of temporomandibular joints. Patients were treated between January 2015 and February 2017. They were divided into two groups of 30 persons. The intraarticular injection of hyaluronic acid was administered in the I-test group, and the injection of platelet-rich plasma in the control group. This treatment was carried out parallel to the use of repositioning splits.

THE RESULTS

Analysis of regression of symptoms other than intensity of pain during the treatment, evaluated in this study shows a decrease of individual symptoms, but the results of the regression of pain between two groups did not differ statistically significantly, because "p" is bigger than 0.05.

CONCLUSION

The results of the research show the clinical benefits of application of hyaluronic acid and plate rich plasma in the treatment of temporomandibular joint dysfunction.

[Efficacy of semiconductor laser therapy combined with botulinum toxin A type injection in treatment of temporomandibular disorders]

PURPOSE

To observe the efficacy of semiconductor laser therapy in combination with botulinum toxin A type injection in treating temporomandibular disorders and the influence on serum levels of interleukin(IL)-1 and tumor necrosis factor(TNF)-α.

METHODS

Ninety patients with temporomandibular disorders were selected and randomly divided into control group and treatment group with 45 cases in each group. Patients in the control group received semiconductor laser therapy,once per day and 1 course for 1 week. Patients in the treatment group was given semiconductor laser therapy in combination with botulinum toxin A type. 50 U botulinum toxin A type were injected into the masseteric and temporal muscles with 5 injections at different sites in each side. The treatment course of patients was 2 weeks. Fricton scale indexes, pain index, and efficacy were compared between the two groups. Serum levels of IL-1 and TNF-α were detected in both groups. SPSS19.0 software package was used for data analysis.

RESULTS

After treatment, PI, DI and CMI in the treatment group were significantly lower than the control group (P<0.01). After 1 and 2 weeks of treatment, VAS score of the treatment group was significantly lower than the control group (P<0.01). The total efficacy rate of the treatment group was 93.33%,which was significantly higher than control group (66.67%, P<0.05). Serum levels of IL-1 and TNF-α of the treatment group were significantly lower than the control group (P<0.01).

CONCLUSIONS

The efficacy of semiconductor laser therapy in combination with botulinum toxin A type injection in treating temporomandibular disorders is significant,and may be related to decreased serum levels of IL-1 and TNF-α.

Clinical effects of an avocado-soybean unsaponifiable extract on arthralgia and osteoarthritis of the temporomandibular joint: preliminary study

The aim of the present preliminary study was to investigate the effectiveness of an avocado-soybean unsaponifiable extract (ASU) in patients with arthralgia and osteoarthritis of the temporomandibular joint (TMJ). A randomized, double-blind, placebo-controlled trial was carried out. Fourteen women diagnosed with arthralgia and osteoarthritis of the TMJ using the Research Diagnostic Criteria for Temporomandibular Disorders were included in the statistical analysis. The women were allocated randomly to two groups: ASU group and placebo group. Pain was measured using a visual analogue scale and pressure algometer. Mandibular function was evaluated through measurement of mandibular movements. Quality of life was measured using the Oral Health Impact Profile (OHIP-14). The medication (ASU capsules or placebo capsules) was used for 4 months and the total follow-up was 6 months. Those taking the ASU extract had a decrease in pain symptoms and an improvement in quality of life. Moreover, a significant reduction in the use of rescue medication was found in the ASU group compared to the placebo group. This preliminary study provides strong evidence of the effectiveness of an avocado-soybean unsaponifiable extract in patients with degenerative joint diseases and arthralgia in the TMJ. Further studies with larger samples should be performed.

Mitomycin C Effect on Fibrous Adhesions of Rabbit Temporomandibular Joint

OBJECTIVE: To evaluate influence of mitomycin C on fibrosis in temporomandibular joints of rabbits with mandibular traction.

STUDY DESIGN: Twenty rabbits (8 control, 12 mitomycin C group) were included. Titanium screws were placed in the anterior edge of the right masseter tuberosity and the posterior part of the right zygoma. Elastic bands were placed between 2 screws to initiate posterio-superior displacement of the mandible to the right. Animals in the control group (CG) received intraarticular NaCl (0.9%) on the nondrawing (left) side, and animals in the study group (SG) received mitomycin C weekly (0.4 mg/mL) for 6 weeks. Rabbits were decapitated, temporomandibular joints were removed, and histopathological investigation was performed.

RESULTS: Microscopically, 4 of 6 rabbits in the CG had fibrosis in the temporomandibular joint, whereas only 1 of 11 rabbits in the SG had fibrosis ( P < 0.05).

CONCLUSION: Application of mitomycin C to the temporomandibular joint of rabbits significantly reduces formation of intraarticular fibrous adhesions.

SIGNIFICANCE: This is the first study in the literature investigating the use of mitomycin C in the joints.