Use of sodium hyaluronate in treating temporomandibular joint disorders: a randomized, double-blind, placebo-controlled clinical trial

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.

A Rare Complication of Temporomandibular Joint Viscosupplementation Associated With the Intra-Articular Agent: A Case Report

Viscosupplementation, which has been referred to as intra-articular injections of hyaluronic acid, is preferable in the treatment of patients with degenerative disease of the temporomandibular joint who have not responded to conservative therapy. The complications of intra-articular injections are reported as pain, swelling, heat, rash, itching, bruising, or redness. This article describes a patient who underwent arthrocentesis followed by viscosupplementation and subsequently experienced pain and malocclusion related to the applied agent.

Use of Sodium Hyaluronate and Triamcinolone Acetonide Following Arthrocentesis in Treatment of Internal Derangement of Temporomandibular Joint: A Prospective Randomized Comparative Study

Background

Internal derangement (ID) of temporomandibular joint (TMJ) is a common temporomandibular disorder (TMD) which causes hypomobility of the joint. Minimally invasive treatment modality like arthrocentesis is used as first-line of management having low morbidity and high efficacy. This prospective randomized comparative study was carried to compare the efficacy of intra-articular injection with sodium hyaluronate (SH) and triamcinolone acetonide (TA) after arthrocentesis in ID of TMJ.

Materials and Methods

A total 40 patients diagnosed with ID (stage 1-4) were included in the study and randomly divided in two groups. Twenty patients (group A) received intra-articular injection of SH while 20 patients (group B) received intra-articular injection of TA, after arthrocentesis. The clinical parameters of pain (VAS), Maximum mouth opening (MMO) (mm) and clicking sound (present/absent) were evaluated pre-operatively and at seventh day, 1 month and 3 months post-operatively.

Results

There was statistically significant improvement in pain scores in both the groups at all time intervals with SH being superior (p value 0.0086). All the patients showed improved mouth opening at all time intervals, TA being superior but statistically insignificant (p value 0.59). There was reduction in the clicking sound in both the groups which was statistically insignificant at all time intervals.

Conclusions

Arthrocentesis followed by intra-articular injection with SH is superior to TA in terms of pain reduction, while TA showed superiority in terms of improved mouth opening.

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.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of Platelet-Rich Plasma Versus Hyaluronic Acid Following Arthrocentesis for Temporomandibular Joint Disc Disorders: A Randomized Controlled Trial

Purpose

Injection of intra-articular medicaments is an accepted therapy for temporomandibular joint disorders (TMDs). This study compares the efficacy of arthrocentesis followed by platelet-rich plasma (PRP) as compared to hyaluronic acid (HA) injections for TMDs unresponsive to conservative therapy. PRP injection following arthrocentesis was hypothesized to be better compared to arthrocentesis alone or when combined with HA injection.

Methods

Forty-seven patients with TMDs enrolled in an RCT were randomly assigned to three groups: Group A-PRP, Group B-HA or Group C-control group of arthrocentesis alone. Pre-operative evaluation and post-operative changes at 1-, 3-, 6-month intervals were assessed for improvement in pain, maximum mouth opening, joint sounds and excursive movements. Statistical significance was set at P value < 0.05.

Results

Post-operative joint sounds were present in three out of 16 patients in Group A; six out of 15 patients in Group B and eight out of 16 patients in Group C at 6-month follow-up. For the remaining outcome variables, no statistical difference between groups was observed.

Conclusion

Both medicaments produced significant clinical improvements when compared to the control group. When comparing PRP against HA, none showed superiority over the other.Clinical trial registration number: CTRI/2019/01/017076.

Comparison between two viscosupplementation protocols for temporomandibular joint osteoarthritis

OBJECTIVE

This clinical trial aimed to compare the efficacy of two protocols using high molecular weight hyaluronic acid (HA) intra-articular injection in patients with temporomandibular joint (TMJ) osteoarthritis and evaluate involvement of subchondral bone changes and psychosocial factors as predictors of HA treatment.

METHODS

Twenty-one individuals were divided into two groups: (A) received three intra-articular HA injections, and (B) received one injection. Outcomes observed were pain intensity, functional limitation, maximum voluntary mouth opening, maximum assisted mouth opening, and treatment tolerability. Follow-ups were performed weekly for 21 days, and two months after the treatment started.

RESULTS

No statistically significant intergroup differences were observed in any of the evaluated outcomes. However, Group A showed significant improvement in all outcomes, whereas Group B showed significant improvement only in pain intensity and functional limitation.

CONCLUSION

This study demonstrated the effectiveness of both protocols in terms of pain intensity and functional limitation caused by osteoarthritis.

Clinical Evaluation of Intra-Articular Injection of Chondroitin Sulfate and Sodium Hyaluronate in the Management of Degenerative Osteoarthritis of Temporomandibular Joint

AIM: This study aims to evaluate the effectiveness of intra-articular injection of chondroitin sulfate and sodium hyaluronate in cases of temporomandibular joint (TMJ) degenerative osteoarthritis. MATERIAL AND METHODS: Thirty patients ASA I of both sexes, who were selected from outpatient clinic of Oral Surgery Department, Faculty of Dentistry – Suez Canal University, complaining of painful TMJ, presence of unilateral or bilateral TMJ pain, impairment of jaw movements, and joint sounds. Clinical examination was performed to all patients and pre-operative measurements of visual analog scale (VAS) for morning pain, pain with movement and spontaneous pain, maximum mouth opening, and presence or absence of clicking. Patients were randomly divided into two groups; (a) Study group consisted of 15 patients, they had intra-articular injection of chondroitin sulfate and sodium hyaluronate once weekly for 3 weeks and (b) control group consisted of 15 patients, they had intra-articular injection of sodium hyaluronate once weekly for 3 weeks. Post-operative measurements of VAS for previous pain types, maximum mouth opening, and clicking were obtained at 1 month, 3 months, and 6 months post-injection. RESULTS: There was a statistically significant reduction of all types of pain in the study group compared to the control group at all time intervals (p ≤ 0.05), for maximum mouth opening, there was a significant improvement in mouth opening in the study group for all time intervals (p ≤ 0.05), but for the clicking, there was not statistically significant difference between the study and control groups after 1 month, 3 months, and 6 months. The difference between groups was barely statistically significant (p = 0.05). CONCLUSION: Intra-articular injection of a combination of chondroitin sulfate and sodium hyaluronate is an effective tool in reducing pain, clicking, limited mouth opening, and other symptoms associated with degenerative TMJ diseases.

Effects of low and high molecular weight hyaluronic acid on the osteoarthritic temporomandibular joint in rabbit

OBJECTIVE

To compare the effect between intra-articular infiltration of low molecular weight (LMW-HA) and high molecular weight hyaluronic acid (HMW-HA) on the histopathological characteristics of the cartilage and disc of the temporomandibular joint (TMJ) osteoarthritis (OA) induced in rabbits.

MATERIAL AND METHODS

An experimental study was conducted on 38 rabbit TMJs. The effect of different hyaluronic acids was compared at 30 and 135 days. Histopathological analysis was performed. Cartilage damage was assessed with the OARSI scale.

RESULTS

The severity of the induced OA according to OARSI was 3.4 degrees in the mandibular condyle (MC) and 3.2 in the mandibular fossa (MF); the articular disc (AD) presented disorganization of the collagen fibers, with randomly arranged hypertrophic chondrocytes. At 30 days, untreated TMJs worsened. TMJ treated with LMW-HA reduced its severity to 1.5 degrees in MC and 1.6 in MF, the AD presented histological aspects within normal limits. TMJ treated with HMW-HA presented 2.4 degrees in MC and 2.2 in MF, the AD maintained characteristics similar to the group with OA. At 135 days, all groups worsened.

CONCLUSION

Exogenous HA is effective in the management of TMJ-OA induced in rabbits, showing cartilage and articular disc repair at 30 days. The LMW-HA group had better effects on joint tissue than HMW-HA 30 days after treatment. However, at 135 days, both groups presented regression of joint tissue repair.

CLINICAL RELEVANCE

HA is effective in the anti-arthritic treatment of TMJ-OA induced in rabbits; LMW-HA shows better results in cartilage and articular disc repair than HMW-HA.

Efficacy of arthrocentesis and lavage for treatment of post-traumatic arthritis in temporomandibular joints

Objectives

Joint injuries frequently lead to progressive joint degeneration that causes articular disc derangement, joint inflammation, and osteoarthritis. Such arthropathies that arise after trauma are defined as post-traumatic arthritis (PTA). Although PTA is well recognized in knee and elbow joints, PTA in the temporomandibular joint (TMJ) has not been clearly defined. Interestingly, patients experiencing head and neck trauma without direct jaw fracture have displayed TMJ disease symptoms; however, definitive diagnosis and treatment options are not available. This study will analyze clinical aspects of PTA in TMJ and their treatment outcomes after joint arthrocentesis and lavage.

Materials and Methods

Twenty patients with history of trauma to the head and neck especially without jaw fracture were retrospectively studied. Those patients developed TMJ disease symptoms and were diagnosed by computed tomography or magnetic resonance imaging. To decrease TMJ discomfort, arthrocentesis and lavage with or without conservative therapy were applied, and efficacy was evaluated by amount of mouth opening and pain scale. Statistical differences between pre- and post-treatment values were evaluated by Wilcoxon signed-rank test.

Results

Patient age varied widely between 20 and 80 years, and causes of trauma were diverse. Duration of disease onset was measured as 508 posttrauma days, and 85% of the patients sought clinic visit within 2 years after trauma. In addition, 85% of the patients showed TMJ disc derangement without reduction, and osteoarthritis was accompanied at the traumatized side or at both sides in 40% of the patients. After arthrocentesis or lavage, maximal mouth opening was significantly increased (28-44 mm on average, P<0.001) and pain scale was dramatically decreased (7.8-3.5 of 10, P<0.001); however, concomitant conservative therapy showed no difference in treatment outcome.

Conclusion

The results of this study clarify the disease identity of PTA in TMJ and suggest early diagnosis and treatment options to manage PTA in TMJ.

Is Single-Puncture TMJ Arthrocentesis Superior to the Double-Puncture Technique for the Improvement of Outcomes in Patients With TMDs?

PURPOSE

Arthrocentesis is a common treatment for temporomandibular joint disorders. Although modifications of the standard double-puncture technique have been described, no consensus has been reached regarding which is the best. The aim of the present study was to compare the outcomes of the single- and double-puncture arthrocentesis techniques (SPT and DPT, respectively).

MATERIALS AND METHODS

A systematic review following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. Two independent reviewers conducted electronic searches in the MEDLINE/PubMed, Cochrane Library, and Scopus databases for relevant studies reported up to January 2019. Studies comparing type I SPT (only 1 cannula) or type II SPT (2 soldered cannulas) to conventional DPT were considered. Data regarding the maximal mouth opening (MMO), joint pain, and operative time were extracted for the meta-analysis. In the case of statistically significant heterogeneity (P < .10), a random effects model was used to assess the significance of the treatment effects. Otherwise, a fixed effects model was used. The included randomized controlled trials (RCTs) were assessed for methodologic quality using the Cochrane Collaboration tool.

RESULTS

Nine studies were included for qualitative synthesis. Two were suitable for quantitative synthesis per outcome. The meta-analysis did not find any differences between SPT and DPT in relation to the MMO. However, in relation to joint pain, the results slightly favored the use of DPT. No differences in operative time were found between type I SPT and DPT (P = .49).

CONCLUSIONS

The present study found no differences between the SPT and DPT in relation to the MMO, and no difference was found in operative time between the DPT and type I SPT. Because of the heterogeneity between studies, it might be interesting to conduct more homogeneous RCTs to elucidate which technique results in better clinical outcomes.

What is the Evidence of Hyaluronic Acid and Polyacrylamide Hydrogel in Intra-articular Therapy in Equines? Systematic Literature Review

A systematic review was conducted to investigate evidence to support or refute the use of hyaluronic acid and polyacrylamide hydrogel as intra-articular therapy in equines, which are frequent treatment options in the routine of veterinarians of equines in cases of osteoarthritis. In total, 19 studies were included, among clinical and in vitro studies, as well as a retrospective series of cases. The outcomes of the included studies provided fragile evidence supporting the recommendation for intra-articular use of hyaluronic acid. No study was included showing any clinical outcome in diseased synovial tissues of the polyacrylamide hydrogel. There is no concrete evidence of benefits, treatment protocols, and mechanisms of action of hyaluronic acid in the joint therapy in equines.

Nanotherapy in Joints: Increasing Endogenous Hyaluronan Production by Delivering Hyaluronan Synthase 2

Osteoarthritis (OA) is a common joint degenerative disease that causes pain, joint damage, and dysfunction. External hyaluronic acid (HA) supplement is a common method for the management of osteoarthritis which requires multi-injections. It is demonstrated that biodegradable mesoporous silica nanoparticles successfully deliver an enzyme, hyaluronan synthase type 2 (HAS2), into synoviocytes from the temporomandibular joint (TMJ) and generate endogenous HA with high molecular weights. In a rat TMJ osteoarthritis inflammation model, this strategy promotes endogenous HA production and inhibits the synovial inflammation of OA for more than 3 weeks with one-shot administration. Such nanotherapy also helps repairing the bone defects in a rat OA bone defect model.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Efficacy of Temporomandibular Joint Arthrocentesis with Sodium Hyaluronate in the Management of Temporomandibular Joint Disorders: A Prospective Randomized Control Trial

PURPOSE

This study was designed to investigate the efficacy of the temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate (SH) in the treatment of temporomandibular joint disorders.

PATIENTS AND METHODS

A total of sixty two TMJs in 34 males and 28 females aged 20-65 years comprised the study material. The patients' complaints were limited mouth opening, TMJ pain, and joint noises during function. Patients were randomly divided into 2 groups in which arthrocentesis plus intra-articular injection of sodium hyaluronate was performed in 1 group and only arthrocentesis was performed in the other group. Both groups contained patients with disc displacement with reduction and without reduction. Clinical evaluation of the patients was done before the procedure, immediately after the procedure, at 1 week and 1, 3 and 6 months postoperatively. Intensity of TMJ pain was assessed using visual analog scales. Maximal mouth opening and lateral jaw movements also were recorded at each follow-up visit.

RESULTS

Both techniques increased maximal mouth opening, lateral movements, and function, while reducing TMJ pain and noise.

CONCLUSIONS

Although patients benefitted from both techniques, arthrocentesis with injection of SH seemed to be superior to arthrocentesis alone.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of hyaluronic acid injections in patients with osteoarthritis of the temporomandibular joint. A comparative study

The aim of the present study was to report the 1-year therapeutic outcome of intra-articular injections of high-molecular-weight hyaluronic acid (HA) without arthrocentesis in a group of 25 patients with osteoarthritis (OA) of the temporomandibular joint (TMJ). The results were compared with those of a group of 10 patients with OA of the TMJ, treated with nonsteroidal anti-inflammatory drugs.Twenty-five patients (group A) underwent a cycle of 5 injections of HA into the TMJ. Ten patients (group B) underwent a therapy with nonsteroidal anti-inflammatory drugs for 1 month. The follow-up assessments after the end of treatment were at 1, 3, 6, and 12 months.Regarding the first follow-up (1 month), statistical analysis for all clinical parameters showed no significant differences (ie, beneficial effect for 2 groups) between groups A and B (P > 0.001). Significant statistical differences (ie, encouraging effect for group A) for all clinical parameters were recorded 1 year after the end of treatment between groups A and B (P < 0.001).A cycle of 5 intra-articular injections of HA without arthrocentesis for patients with OA of the TMJ is considered successful at 1-year follow-up period.

Intra-articular injections with corticosteroids and sodium hyaluronate for treating temporomandibular joint disorders: a systematic review

INTRODUCTION

In some cases, conservative treatment of internal derangements of the Temporomandibular Joint (TMJ) is considered little responsive. Thus, it is necessary to accomplish treatments that aim at reducing pain and improve function in patients who present arthrogenic temporomandibular disorders.

OBJECTIVE

This study, by means of a systematic review of the literature, aimed to analyze the effectiveness of intra-articular injections with corticosteroids and sodium hyaluronate for treating internal derangements of the TMJ.

METHODS

Carry out a research in the following databases: MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs, and BBO, considering publications issued between 1966 and October 2010, focusing on randomized or quasi-randomized controlled clinical trials, single or double-blind.

RESULTS

After applying the inclusion criteria we collected 9 articles, 7 of which were randomized controlled double-blind clinical trials and 2 randomized controlled single-blind clinical trials.

CONCLUSION

After analyzing the literature, it was found that intra-articular injection with corticosteroids and sodium hyaluronate seems to be an effective method for treating internal derangements of the TMJ. However, further randomized controlled clinical trials, with representative samples and longer follow-up time must be carried out in order to assess the real effectiveness of this technique.

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

OBJECTIVE

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

MATERIALS AND METHOD

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

RESULTS

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

CONCLUSION

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

Epidemiology, diagnosis, and treatment of temporomandibular disorders

Temporomandibular disorder (TMD) is a multifactorial disease process caused by muscle hyperfunction or parafunction, traumatic injuries, hormonal influences, and articular changes. Symptoms of TMD include decreased mandibular range of motion, muscle and joint pain, joint crepitus, and functional limitation or deviation of jaw opening. Only after failure of noninvasive options should more invasive and nonreversible treatments be initiated. Treatment can be divided into noninvasive, minimally invasive, and invasive options. Temporomandibular joint replacement is reserved for severely damaged joints with end-stage disease that has failed all other more conservative treatment modalities.

Evaluation of efficacy of arthrocentesis (with normal saline) with or without sodium hyaluronate in treatment of internal derangement of TMJ - A prospective randomized study in 20 patients

PURPOSE

To compare the outcome of arthrocentesis alone and arthrocentesis with sodium hyaluronate in internal derangement of TMJ.

MATERIALS AND METHODS

20 patients of disc displacement with reduction of TMJ were randomized into 2 experimental groups. Control group of patients received arthrocentesis alone and study group of patients received arthrocentesis with sodium hyaluronate. Patients TMJ status and clinical symptoms were evaluated for 6 months follow up. The clinical parameter recorded were maximal mouth opening (MMO), lateral excursions (right and left side), protrusive movement, joint noises, and pain (at rest, at function).

RESULTS

When 2 groups are compared there was no statistically significant difference in terms of inter-incisal opening, lateral excursion, protrusive movement, joint noises and pain however the group with sodium hyaluronidase has shown better results than the control group.

CONCLUSION

Both study and control group found to be statistically insignificant but patient who were in the group of arthrocentesis with admission of sodium hyaluronidase had better results.

WITHDRAWN: Hyaluronate for temporomandibular joint disorders

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

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

Temporomandibular joint arthrocentesis. Review of the literature

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

Interventions for the management of temporomandibular joint osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis of the temporomandibular joint (TMJ), and can often lead to severe pain in the orofacial region. Management options for TMJ OA include reassurance, occlusal appliances, physical therapy, medication in addition to several surgical modalities.

OBJECTIVES

To investigate the effects of different surgical and non-surgical therapeutic options for the management of TMJ OA in adult patients.

SEARCH METHODS

We searched the following databases: the Cochrane Oral Health Group Trials Register (to 26 September 2011); CENTRAL (The Cochrane Library 2011, Issue 3); MEDLINE via OVID (1950 to 26 September 2011); EMBASE via OVID (1980 to 26 September 2011); and PEDro (1929 to 26 September 2011). There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any form of non-surgical or surgical therapy for TMJ OA in adults over the age of 18 with clinical and/or radiological diagnosis of TMJ OA according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guideline or compatible criteria.Primary outcomes considered were pain/tenderness/discomfort in the TMJs or jaw muscles, self assessed range of mandibular movement and TMJ sounds. Secondary outcomes included the measurement of quality of life or patient satisfaction evaluated with a validated questionnaire, morphological changes of the TMJs assessed by imaging, TMJ sounds assessed by auscultation and any adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors screened and extracted information and data from, and independently assessed the risk of bias in the included trials.

MAIN RESULTS

Although three RCTs were included in this review, pooling of data in a meta-analysis was not possible due to wide clinical diversity between the studies. The reports indicate a not dissimilar degree of effectiveness with intra-articular injections consisting of either sodium hyaluronate or corticosteroid preparations, and an equivalent pain reduction with diclofenac sodium as compared with occlusal splints. Glucosamine appeared to be just as effective as ibuprofen for the management of TMJ OA.

AUTHORS' CONCLUSIONS

In view of the paucity of high level evidence for the effectiveness of interventions for the management of TMJ OA, small parallel group RCTs which include participants with a clear diagnosis of TMJ OA should be encouraged and especially studies evaluating some of the possible surgical interventions.

Lubricin in human temporomandibular joint disc: an immunohistochemical study

AIMS

To evaluate, immunohistochemically, the presence and distribution of lubricin in human temporomandibular joint (TMJ) discs without any degenerative changes, obtained from autopsies, in order to elucidate the TMJ lubrication system and disc tribology.

METHODS

Immunohistochemistry for lubricin detection was carried out on 34 TMJ discs. Any disc had signs of degenerative or inflammatory joint disease nor disc were displaced. Sections were incubated with diluted rabbit polyclonal anti-lubricin antibody and scored according to the percentage of lubricin immunopositive cells. Three different TMJ disc tissue compartments taken from the intermediate zone were analysed, namely: the central region as well as the temporal (superior) and condylar (inferior) disc surfaces. The Friedman test, was used to compare lubricin at a protein level expression, amongst the regions of disc specimens.

RESULTS

Staining was noted within the TMJ disc cell populations in every disc tissue sample, however, the number of disc cells immunolabelled varied according to disc tissue regions. The percentage of immunostained cells, was statistically significant lower in the central region than in each disc surface (p<0.0001), whilst any statistically significant difference was found when comparing the two surfaces one another.

CONCLUSIONS

Lubricin is present in several location of TMJ disc being significantly more expressed at disc surfaces than in the central part.

Preliminary evaluation of histological changes found in a mechanical arthropatic temporomandibular joint (TMJ) exposed to an intra-articular Hyaluronic acid (HA) injection, in a rat model

OBJECTIVE

This study investigates the histological effects of Hyaluronic acid injections in the treatment of induced temporomandibular joint (TMJ) osteoarthritis in rats.

STUDY DESIGN

Twenty-four male Wister rats were subjected to induced mechanical osteoarthritis by manual hypermobility for 10 successive days. Animals were then divided into two groups; group I (control) and group II (experimental). Ten days after the induction of hypermobility, the right TMJ of the experimental animals was injected with a dose of 0.12 mg HA intra-articularly and 0.12 mg saline was injected into the left joint; while animals in the control group were left without any treatment. Two rats from group I were killed at one, two and six weeks; while 6 animals from group II were killed at one, two and four weeks post injection.

RESULTS

The disk of the right joints in the experimental animals was of normal thickness and there was an increase in the thickness of the fibrocartilagenous layer. In the left joint; ulcerative changes in the disk were evident where the fibres were not well oriented and scalloped areas in the temporal bone area were present denoting osteoclastic activity.

CONCLUSIONS

Repeated intra-articular TMJ injection of Hyaluronic acid appears to be a safe and effective way of inhibiting the progression of osteoarthritic changes in the joint through development of articular cartilage and reducing fibrous tissue proliferation.

Effects of intra-articular administration of sodium hyaluronate on plasminogen activator system in temporomandibular joints with osteoarthritis

OBJECTIVE

The aim of this study was to investigate the effect of intra-articular sodium hyaluronate (SH) injections on the main components of plasminogen activator (PA) system in the synovial fluid of temporomandibular joint (TMJ) osteoarthritis (OA).

STUDY DESIGN

Forty patients diagnosed with TMJ OA and 20 healthy control subjects were included in this study. Synovial fluid was collected in the OA group and the healthy group at baseline. The OA patients were randomly divided into 2 groups (20 patients for each group): One group received 5 injections of SH, and the other received 5 injections of physiologic saline solution in the upper joint space at weekly intervals. Synovial fluid was collected before and after treatment. Urokinase-type PA (uPA), soluble uPA receptor (suPAR) and PA inhibitor 1 (PAI-1) levels in synovial fluid were quantified by enzyme-linked immunosorbent assay.

RESULTS

The OA patients had significantly higher uPA activity and levels of uPA (median 80.01 ng/L), suPAR (median 7.54 ng/L), and PAI-1 (median 54.9 ng/mL) than the healthy control subjects (median 20.47 ng/L uPA, 2.34 ng/L suPAR, and 19.9 ng/mL PAI-1; (P < .05). The uPA activity and levels of uPA, suPAR, and PAI-1 were significantly decreased after SH injections in TMJs of OA patients (P < .05), and there was no difference after saline injection. Visual analog pain score reduction correlated with changes in uPA and uPAR levels as well as uPA activity.

CONCLUSION

The effects of SH on PA system provide new insight into a possible underlying mechanism by which SH alleviates pain of patients with TMJ OA.

Sodium hyaluronate improves outcomes after arthroscopic lysis and lavage in patients with Wilkes stage III and IV disease

PURPOSE

Among patients with Wilkes stage III and IV disease undergoing arthroscopic lysis and lavage, does the use of an intra-articular injection of sodium hyaluronate (SH), when compared with Ringer lavage, result in better postoperative pain control and temporomandibular joint (TMJ) function?

PATIENTS AND METHODS

We designed and implemented a randomized, double-blind, pilot controlled clinical trial. The study sample was composed of patients with middle Wilkes stage (late stage III and early stage IV) disease. Subjects were randomized to 1 of 2 treatment limbs. The treatment group received Ringer lactate plus an injection of 1 mL of SH after arthroscopy, whereas the control group was given Ringer lactate during arthroscopy. The primary outcome variables were pain and TMJ function measured by use of visual analog scales. Appropriate descriptive and bivariate statistics were computed. A P value less than .05 was considered statistically significant.

RESULTS

The study sample was composed of 40 patients with 20 subjects enrolled in both treatment groups. There were no statistically significant differences between the 2 groups in terms of demographics and preoperative variables. Postoperative analgesia was statistically significant in the treatment group with respect to the control group on the visits on days 14 and 84. No statistically significant differences were observed between the 2 groups in the maximum interincisal opening and tolerance.

CONCLUSIONS

An intra-articular injection of SH after arthroscopic lysis and lavage is effective in reducing pain in patients with TMJ dysfunction, enhancing postsurgical recovery. The analgesic effect of treatment with SH is maintained in the long term.

Pilot investigation of hyaluronate injections for first metacarpal-carpal (MC-C) osteoarthritis

Hyaluronate intraarticular injections are widely used for treatment of pain associated with osteoarthritis of the knee, but there is no published literature on its use in osteoarthritis of the hand. We describe an open-label, baseline-controlled pilot study in which 5 weekly injections of 10 mg sodium hyaluronate (molecular weight 500-730 kDa) in 1 mL was used to treat 16 patients with osteoarthritic first metacarpal-carpal (MC-C) joints. The injections were performed easily and were well tolerated. Mean pain score at 5 months after the last injection, on a 10-point visual analog scale, decreased from 4.74 to 2.56 at rest. Pain on use decreased from 5.91 to 4.33. Pinch strength and a short questionnaire on hand function did not significantly change. The results of this small pilot study suggest that intraarticular injections into the first MC-C joint are easily administered, well tolerated, and could be an effective treatment option for patients with osteoarthritis of this joint. Further investigation using larger, blind controlled clinical studies are warranted.

Emerging intra-articular drug delivery systems for the temporomandibular joint

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

The methodological quality of systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment

BACKGROUND

Temporomandibular joint disorders (TMJD) are multifactor, complex clinical problems affecting approximately 60-70% of the general population, with considerable controversy about the most effective treatment. For example, reports claim success rates of 70% and 83% for non-surgical and surgical treatment, whereas other reports claim success rates of 40% to 70% for self-improvement without treatment. Therefore, the purpose of this study was to (1) identify systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment, (2) evaluate their methodological quality, and (3) evaluate the evidence grade within the systematic reviews.

METHODS

A search strategy was developed and implemented for MEDLINE, Cochrane Library, LILACS, and Brazilian Dentistry Bibliography databases. Inclusion criteria were: systematic reviews (+/- meta-analysis) comparing surgical and non-surgical TMJD treatment, published in English, Spanish, Portuguese, Italian, or German between the years 1966 and 2007(up to July). Exclusion criteria were: in vitro or animal studies; narrative reviews or editorials or editorial letters; and articles published in other languages. Two investigators independently selected and evaluated systematic reviews. Three different instruments (AMSTAR, OQAQ and CASP) were used to evaluate methodological quality, and the results averaged. The GRADE instrument was used to evaluate the evidence grade within the reviews.

RESULTS

The search strategy identified 211 reports; of which 2 were systematic reviews meeting inclusion criteria. The first review met 23.5 +/- 6.0% and the second met 77.5 +/- 12.8% of the methodological quality criteria (mean +/- sd). In these systematic reviews between 9 and 15% of the trials were graded as high quality, and 2 and 8% of the total number of patients were involved in these studies.

CONCLUSION

The results indicate that in spite of the widespread impact of TMJD, and the multitude of potential interventions, clinicians have expended sparse attention to systematically implementing clinical trial methodology that would improve validity and reliability of outcome measures. With some 20 years of knowledge of evidence-based healthcare, the meager attention to these issues begins to raise ethical issues about TMJD trial conduct and clinical care.

What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature

INTRODUCTION

Osteoarthritis (OA) is a disease of the synovial joints and is the most common cause of chronic pain in the elderly. One of the treatment modalities for OA of the hip is viscosupplementation (VS). Today there are several different formulations of viscosupplements produced by different manufactures of different molecular weights. The objective of this review is to asses the efficacy of VS treatment of hip OA osteoarthritis in the current literature.

MATERIAL AND METHODS

The following databases were searched: Medline (period 1966 to November 2006), Cochrane Database of Systematic Reviews (1988 to November 2006), Cochrane Clinical Trial Register (1988 to November 2006), Database of Abstracts on Reviews and Effectiveness, Current Controlled Trials, National Research Register and Embase (January 1988 to November 2006). The search terms [osteoarthritis, hip (joint), viscosupplementation, hyaluronic acid, hyaluronan, sodium hyaluronate and trade names] were applied to identify all studies relating to the use of VS therapy for OA of the hip joint.

RESULTS

Sixteen articles concerning the efficacy of a total of 509 patients undergoing VS treatment for hip OA were included. Twelve European studies, three Turkish studies and one American study with Levels of Evidence ranging from I to IV evaluated the following products: Hylan G-F 20, Hyalgan, Ostenil, Durolane, Fermatron and Orthovisc. Heterogeneity of included studies did not allow pooled analysis of data.

DISCUSSION

Despite the relatively low Level of Evidence of the included studies, VS performed under fluoroscopic or ultrasound guidance seems an effective treatment and may be an alternative treatment of hip OA. Intra-articular injection of (derivatives of) HA into the hip joint appears to be safe and well tolerated. However, VS cannot be recommended as standard therapy in hip OA for wider populations, and therefore the indications remain a highly individualised matter.

Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle

BACKGROUND

The potential benefit of hyaluronans in alleviating pain associated with osteoarthritis (OA) in joints other than the knee is of increasing interest. This double-blind, randomized, controlled study examined the safety and efficacy of intraarticular sodium hyaluronate (Hyalgan) in the treatment of pain associated with ankle OA.

MATERIALS AND METHODS

Thirty consecutive patients with ankle OA documented by X-ray were randomized to treatment with five weekly injections of either sodium hyaluronate 2 mL (HYL) or phosphate-buffered saline 2 mL (control) in the tibiotalar joint. The primary endpoint was pain on movement and weightbearing using the Ankle Osteoarthritis Scale (AOS) 3 months after injection (a 100-mm visual analog scale [VAS]). Additional measures included the Western Ontario and McMaster Universities (WOMAC) OA Index and patient global assessment through 6 months; the Short Form-12 (SF-12) Health Survey at 3 months and 6 months; and all reported adverse events (AEs).

RESULTS

The study groups differed only in age, baseline WOMAC pain, and AOS total scores; 80% of the HYL and 73% of the control patients completed the study. At Month 3, the primary endpoint of the study, the HYL group demonstrated a significantly greater improvement from baseline in AOS total score than did the control group (HYL: -17.4 +/- 5.0 mm;

CONTROL

-5.1 +/- 4.0 mm; p = 0.0407). The incidence of AEs was low, with no significant differences between the groups. There were no post-injection flares.

CONCLUSION

Our study suggests that sodium hyaluronate may be a safe and effective option for pain associated with ankle OA, although larger studies are needed.