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.

Efficacy of Duloxetine With Arthrocentesis in the Management of TMJ Internal Derangement.

Temporomandibular joint (TMJ) arthrocentesis is one of the most commonly used non-invasive surgical interventions in the treatment of refractory pain and dysfunction associated with internal derangement. Several adjunctive therapies have been used in combination with arthrocentesis in an attempt to increase its efficacy and long-term maintenance. Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor which is used in different chronic pain conditions. This study aimed to assess the efficacy of duloxetine in combination with arthrocentesis compared with arthrocentesis alone. Twenty-eight patients with chronic TMJ pain were included and randomly allocated into 2 groups (control and study groups). The control group included patients who underwent TMJ arthrocentesis only, and the study group included patients who underwent arthrocentesis followed by giving duloxetine (30 mg) orally twice daily for 3 months. Pain, maximum mouth opening, and level of anxiety and depression were assessed preoperatively and followed at regular intervals of 1 week, 1 month, 3 months, and 6 months postoperatively. Pain was significantly reduced in both groups at all postoperative intervals and was significantly lower in the study group than the control group at 6 months. Maximum mouth opening increased significantly in both groups, but the difference between them was not significant. Level of anxiety and depression was significantly decreased in both groups, with no statistically significant difference between them. The results of this study indicate that duloxetine in combination with arthrocentesis may provide effective and long-term pain control; however, its use is associated with a higher risk of adverse events.

INTRA-ARTICULAR PHARMACOLOGICAL INJECTIONS FOR TEMPOROMANDIBULAR JOINT OSTEOARTHRITIS ARE COMPARABLE TO PLACEBO.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Effectiveness of intra-articular injections of sodium hyaluronate, corticosteroids, platelet-rich plasma on temporomandibular joint osteoarthritis: a systematic review and network meta-analysis of randomized controlled trials. Xie Y, Zhao K, Ye G, Yao X, Yu M, Ouyang H. J Evid Based Dent Pract. 2022 Sep;22(3):101720. doi:10.1016/j.jebdp.2022.101720. SOURCE OF FUNDING: National Natural Science Foundation of China (nos. T2121004, 81630065). TYPE OF STUDY/DESIGN: Systematic review with network meta-analysis of data.

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.

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.

Effects of Glucosamine in the Temporomandibular Joint Osteoarthritis: A Review.

Osteoarthritis in the temporomandibular joint (TMJ) is a chronic disease characterized by irreversible damage to articular surfaces, including inflammation, loss of articular cartilage, and subchondral bone alterations, which would be radiographically evident only in later stages. Symptomatic slow-acting so-called nutraceutical drugs have been proposed as a treatment for osteoarthritis in comparison to non-steroidal anti-inflammatory drugs (NSAID) because of their appreciable safety profile even in long-term intake. Glucosamine, being one among them, proved highly efficient in knee osteoarthritis. However, its application in TMJ osteoarthritis dates back only to 2001 and is still inconclusive in its efficiency even with systematic reviews, in restoring the structural and functional aspects of damaged TMJ. Glucosamine, being a natural compound and also a contributor to building the matrix of articular cartilage, can be utilized effectively for TMJ osteoarthritis as an adjunct along with other conventional treatment modalities available till now, which also have moderate prognosis in most of the clinical scenarios. This review summarizes data relating to the mechanism of osteoarthritis and its management using glucosamine formulations. The beneficial effects of glucosamine on the pathophysiology of TMJ osteoarthritis are possibly due to its contribution to hyaluronic acid regulation and in establishing a proper balance between anabolism/catabolism in the articular tissues.

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.

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 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.

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.

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 ß 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.

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.

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.

Consecuencias de la artritis reumatoide en la articulación temporomandibular y su manejo odontológico / Consequences of rheumatoid arthritis in the temporomandibular joint and its dental management

Introducción: la artritis reumatoide es parte del grupo de las enfermedades autoinmunes con incidencia considerable sobre la población. Se caracteriza por la afección de las articulaciones del cuerpo que la padece; en mayor frecuencia se encuentra afectada la articulación temporomandibular por el complejo articular que ésta presenta; entre los signos y síntomas que comúnmente podemos encontrar en pacientes con este tipo de enfermedad son los chasquidos o ruidos articulares, dolor orofacial, pérdida o imposibilidad del movimiento de la mandíbula y cambios anatómicos localizados en el área de la articulación temporomandibular. Objetivo: describir las consecuencias que desencadena la artritis reumatoide sobre la articulación temporomandibular y cómo es para el odontólogo el manejo de estos pacientes en consulta, evaluar los tratamientos para cada caso sobre un correcto diagnóstico. Material y métodos: se realizó una revisión bibliográfica de artículos recientes sobre el tema, utilizando buscadores como SciELO, Elsevier y PubMed, siendo 30 las fuentes seleccionadas con idiomas en inglés y español. Resultados: esta enfermedad autoinmune se caracteriza por afectar múltiples articulaciones del cuerpo humano simétrica y bilateralmente incluyendo la articulación temporomandibular (ATM), lo cual conlleva al riesgo de desarrollar trastornos temporomandibulares (TTM). Es importante conocer los métodos para realizar un correcto diagnóstico oportuno de la ATM del paciente con artritis reumatoide (AR) con la finalidad de ofrecer un tratamiento conservador. Conclusión: los trastornos temporomandibulares desencadenantes de la artritis reumatoide son afecciones que se deben considerar para el buen manejo del paciente con este padecimiento, comprender y respaldar un diagnóstico clínico es de vital importancia para dar al paciente un tratamiento adecuado dependiendo el grado de complejidad en la que cada individuo se encuentra; conocer el manejo adecuado y encaminar al paciente a una mejor calidad de vida es clave en la consulta odontológica del día a día (AU)

Introduction: rheumatoid arthritis is part of the group of autoimmune diseases with considerable incidence in the population. It is characterized by the affection of the joints of the body that suffers from it; most frequently the temporomandibular joint is affected due to the articular complex that it presents; among the signs and symptoms that we can commonly find in patients with this type of disease are joint clicks or noises, orofacial pain, loss or impossibility of jaw movement and anatomical changes located in the temporomandibular joint area. Objective: to describe the consequences that rheumatoid arthritis triggers on the temporomandibular joint and how it is for the dentist to manage these patients in consultation, to evaluate the treatments for each case on a correct diagnosis. Material and methods: a bibliographic review of recent articles on the subject was carried out, using search engines such as SciELO, Elsevier and PubMed, with 30 sources selected in English and Spanish. Results: this autoimmune disease is characterized by affecting multiple joints of the human body symmetrical and bilaterally including the TMJ which leads to the risk of developing TMD. It is important to know the methods to make a correct diagnosis of the TMJ of the patient with RA in order to offer a conservative treatment. Conclusions: the temporomandibular disorders that trigger rheumatoid arthritis are conditions that should be considered for the proper management of the patient with this condition, understanding and supporting a clinical diagnosis is of vital importance to give the patient an adequate treatment depending on the degree of complexity in which each individual is; knowing the proper management and directing the patient to a better quality of life is key in the day-to-day dental practice (AU)

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.

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.

The significance of masticatory muscle's relaxation in the treatment of the temporomandibular disorders - Review article.

Temporomandibular disorder (TMD) is a disease of multifactorial etiology and a complex of symptoms, related to disorders of the masticatory muscles, temporomandibular joints and the surrounding orofacial structures. One of the main problems in the course of TMD disorders is the systematic increase in the tension of the masticatory muscles (masseter muscles, temporalis and medial and lateral pterygoid muscles), what is the cause of many damages and the development of pathological conditions in the stomatognathic system. The article discusses the differences in the structure of the masticatory and skeletal muscles, as well as the different nature and isoforms of myosin, which determines the much faster generation of contraction in the masticatory muscles and consequently easier generation of excessive, harmful tensions in the masticatory muscles. The article describes the causes of increased tension in the masticatory muscles and methods of their relaxation used in the basic and supportive treatment of temporomandibular disorders. The use of occlusal splints, physiotherapeutic procedures and TMD treatment with botulinum toxin type A were characterized. A role of psychological support and the methods used for patients with TMD were emphasized.

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.

Carboxytherapy for the elimination of pain symptoms (or arthralgia) among the elderly persons with the pathology of the temporomandibular joint.

Temporomandibular arthralgia is difficult to treat, painful and often relapses. 48 patients (19 men and 29 women) aged 61-72 years, suffering from the syndrome of pain dysfunction of the temporomandibular joint, were under observation. In 1st (control) group of patients (18 people), NSAIDs indomethacin in tablet form of 25 mg 3 times a day were used for 9 days. In patients of the 2nd (main) group (30 people), the method of invasive carboxytherapy was used, consisting in subcutaneous injection of carbon dioxide with a volume of 3 ml of 5 procedures every other day. On the 3rd, 9th and 15th days of follow-up, invasive carboxytherapy was more effective than the use of a nonsteroidal anti-inflammatory agent by 8.9; 36,5 and 37%, respectively. The high efficiency of the method of invasive carboxytherapy for the elimination of pain symptoms in pain dysfunction was shown, which was 22,86% on day 3; 64,29% on day 9 and 68,16% on day 15 of observation. The method of invasive carboxytherapy can be used in the complex treatment of patients with pain dysfunction of the temporomandibular joint.

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.