|Year : 2016 | Volume
| Issue : 2 | Page : 102-108
Clinical and biochemical assessment of different injection materials following arthrocentesis for the treatment of internal derangement of the temporomandibular joint: A comparative study
Shereen Wagdy Arafat, Ingy Mohamed Chehata
Department of Oral & Maxillofacial Surgery, October University for Modern Sciences and Arts (MSA), Cairo, Egypt
|Date of Submission||03-Apr-2016|
|Date of Acceptance||03-Jun-2016|
|Date of Web Publication||23-Aug-2016|
Shereen Wagdy Arafat
36B North Caneon Building, Dream Land, 6th October city, Cairo
Source of Support: None, Conflict of Interest: None
The present study was performed to evaluate and compare the effect of ozonized water lavage followed by ozone injection with that of lactated Ringer lavage followed by either corticosteroid or sodium hyaluronate injection.
Materials and methods
A total of 27 patients suffering from internal derangement of the temporomandibular joint and not responding to conservative therapy were randomly classified into three groups. In group A joint lavage was performed using ozonized water followed by injection of ozone. In group B joint lavage was performed using lactated Ringer solution followed by corticosteroid injection. In group C joint lavage was performed using lactated Ringer solution followed by sodium hyaluronate injection. The treatment outcome was evaluated biochemically by measuring the change in tumor necrosis factor-α (TNF-α) level in the synovial fluid preoperatively and 1 week postoperatively. Clinical measurements of maximal mouth opening and lateral and protrusive excursions were taken preoperatively and at 1 week, 1, and 3 months postoperatively. Pain was measured using the Visual Analogue Scale at the study intervals. These data were statistically analyzed.
The three groups showed significant improvement (P ≤ 0.05) in all biochemical and clinical measurements. However, joint lavage using ozonized water followed by ozone injection provided more favorable results compared with treatment with sodium hyaluronate, which in turn was more superior to corticosteroid treatment with respect to maximal mouth opening. All of the study groups showed significant reduction (P ≤ 0.05) in TNF-α level in the synovial fluid. Group A had the highest reduction of TNF-α level with significant difference (P ≤ 0.05) between its results and those of groups B and C, whereas groups B and C showed nonsignificant difference between their results (P ≥ 0.05).
Data from our study suggested more favorable outcomes from ozonized water lavage followed by ozone injection with regard to the clinical and biochemical parameters.
Keywords: arthrocentesis, internal derangement, ozone, ozonized water, tumor necrosis factor-α
|How to cite this article:|
Arafat SW, Chehata IM. Clinical and biochemical assessment of different injection materials following arthrocentesis for the treatment of internal derangement of the temporomandibular joint: A comparative study. Tanta Dent J 2016;13:102-8
|How to cite this URL:|
Arafat SW, Chehata IM. Clinical and biochemical assessment of different injection materials following arthrocentesis for the treatment of internal derangement of the temporomandibular joint: A comparative study. Tanta Dent J [serial online] 2016 [cited 2017 Jun 22];13:102-8. Available from: http://www.tmj.eg.net/text.asp?2016/13/2/102/188909
| Introduction|| |
Temporomandibular disorders represent a wide range of functional changes and pathological conditions affecting the temporomandibular joint (TMJ), masticatory muscles, and other components of the orofacial region. Internal derangement (ID) of the TMJ is defined as a localized mechanical fault that interferes with the smooth action of the joint . Treatment of ID has always presented a therapeutic challenge to the oral and maxillofacial surgeons. Therefore, a wide variety of treatment modalities have been used with varying degrees of success. Painful joints were treated by medication, and manipulation of the mandible with or without splint therapy .
Synovial fluid (SF) of the TMJ has been increasingly analyzed for the presence of various pain and inflammatory mediators that are produced or released in the SF at the site of tissue injury, such as bradykinin, interleukin, and tumor necrosis factor (TNF) ,,. It was found that there is a positive correlation between preoperative pain and TNF-α, whose values suggest a biochemical basis for the origin of pain associated with TMJ. Therefore, it has been suggested that TNF-α could be used as a marker of pain to follow the response to therapy ,,. TNF-α is a cytokine secreted by monocytes and macrophages. It has been shown to be not only an inflammatory mediator but also a modulator of bone resorption by inducing the secretion of collagenases by fibroblasts ,.
The first report on arthroscopy was published by Ohnishi in 1975 . On the basis of observations made during TMJ arthroscopic lysis and lavage and analysis of the outcomes of such treatments, new insights have been gained in the joint pathology of ID ,. The arthroscopic findings led to the development of TMJ arthrocentesis for obtaining symptomatic relief and restoring the normal range of motion. Arthrocentesis was described by Nitzan et al.  as the simplest form of TMJ surgery with low morbidity and low cost compared with other TMJ surgical procedures . To enhance arthrocentesis outcomes, various drugs are injected at the end of the procedure, such as morphine, local anesthesia, sodium hyaluronate (SH), corticosteroids, and recently ozone.
Glucocorticoids are yet the most effective anti-inflammatory drugs available, promoting symptomatic improvements of a series of clinical manifestations. It was found that corticosteroids have a potent anti-inflammatory effect on synovial tissues and are known to reduce effusion, decrease pain, and bring about an increase in the range of motion . Intra-articular injections of glucocorticosteroids have been used for more than three decades in the treatment of patients with TMJ pain and dysfunction . However, local side effects of intra-articular glucocorticosteroids include destruction of articular cartilage, bone resorption, and infections. But the cause of these reactions has not been fully explained. Thus, an interval of at least 4 weeks between glucocorticosteroid injections and a maximum number of three injections in each joint have been recommended ,.
Hyaluronic acid (HA) is a mucopolysaccharide acid that is present in ground substance of animal tissues. It is the major component of the SF and has an important role in lubrication, nutrition, homeostasis, and load absorption of articular tissues . SH increases the concentration and molecular weight of HA in the SF, restoring tissue lubrication and nutrition as well as minimizing mechanical stress . Moreover, intra-articular SH injection has an analgesic effect as it blocks receptors and endogenous substances that cause pain in synovial tissues. In addition, it promotes the release of adhesion areas between the articular disc and the mandibular fossa, increasing joint mobility and allowing better SF circulation .
In 1840 ozone was first researched and documented by a German chemist Christian Friedrich when he detected an 'odorful gas' on passing electrical discharge through water. He is also considered as the father of ozone therapy . Ozone is a natural, colorless, unstable, and highly reactive gaseous molecule that is chemically composed of oxygen (O2) with an extra molecule added (O3). It is produced when ultraviolet light or an electric spark passes through oxygen. Among oxidant agents, ozone is the third strongest, a fact that explains its high reactivity. The actions of ozone on the human body include analgesic, antimicrobial, immune stimulating, antihypoxic, detoxicating, biosynthetic, and bioenergetic effects .
Ozonated water is used for its antimicrobial effect to irrigate and disinfect cavity preparations, root canals, and periodontal pockets, and during ultrasonic scaling. Moreover, it is used to control various oral infections and pathogens . On the other hand, evidence shows that the respiratory system is sensitive to ozone and the gas should never be inhaled. Known side effects are upper respiratory irritation, rhinitis, cough, headache, nausea, and vomiting. Thus, correctly scavenging the excess ozone gas and preventing it from escaping into the office environment is essential. Furthermore, all materials that come in contact with the gas must be ozone resistant, such as glass, silicon, and Teflon . Intra-articular injection of ozone was reported principally for the knees and shoulder joints as being effective and relevant in cases of acute and chronic painful diseases of the joints . In a study by Daif and Basha  to examine ozone therapy as a new treatment modality for TMJ dysfunction, it was reported that intra-articular ozone injection had 95% improvement in pain on opening and 97% improvement in limited movement.
Therefore, it was the aim of this study to compare intra-articular injection of ozone, corticosteroid, and SH following arthrocentesis of TMJ.
| Patients and Methods|| |
The patients for this study were selected from those attending the outpatient clinic, Oral and Maxillofacial Surgery Department, October University for Modern Science and Arts (MSA). The study was approved by October University for Modern Sciences and Arts Institutional Review Board and Ethics Committee. The inclusion criteria were complaint of TMJ pain and dysfunction and fulfillment of at least two of the following diagnostic criteria for ID of TMJ as suggested by the American Association of Oral and Maxillofacial Surgery (AAOMS) .
- Pain and tenderness in the region of TMJ and muscles of mastication
- Sounds during condylar movement (popping, clicking, crepitus, etc.)
- Limitation of mandibular movement
- Clinical and radiographic evidence of organic changes in the integrity of the joint.
Moreover, MRI was performed preoperatively to assess the presence of anterior disc displacement with reduction. The selected patients were healthy adults who were free from any systemic diseases that might cause or reflect joint pain or interfere with its treatment. All patients were subjected to conservative therapy for 4 weeks.
Twenty-seven patients out of 35 (77%) (10 men and 17 women) had anterior disc displacement with reduction and did not respond to the conservative therapy; their ages ranged from 23 to 56 years. Full oral and written information about the treatment and the purpose of the study was provided to all participants, all of whom signed an informed consent form.
Preparation of ozonized water
The preparation of ozonized water was carried out by using a glass cylinder about three-fourth filled with bidistilled water through which the gas mixture bubbled continuously for at least 5 min to achieve saturation of 20 µg/ml. The ozonized water was maintained in a glass bottle tightly closed with a silicone or Teflon cap and kept at 5°C ([Figure 1]).
Under aseptic conditions, auriculotemporal nerve block anesthesia was induced using one carpule of mepivacaine (mepivacaine HCl 2% with levonordefrin 1: 20 000) with subcutaneous injection of a few drops of local anesthetic at the site of the inlet and outlet needles . The surgical technique of Nitzan et al.  was applied. The first needle (inlet), corresponding to the glenoid fossa, was marked 10 mm from the mid-tragus and 2 mm below the canthotragal line. A second needle (outlet), corresponding to the articular eminence, was marked 10 mm from the first point and 10 mm below the line. Patients were randomly divided into three equal groups.
In this group arthrocentesis was performed using 100 ml ozonized water with a concentration of 20 µg/ml for lavage. After completion of the lavage, the outlet cannula was withdrawn and 20 µg/2 ml ozone gas was injected into superior joint space ([Figure 2]).
In this group arthrocentesis was performed using 100 ml of lactated Ringer solution followed by injection of 1 ml of depomedrole 40 mg (methylprednisolone acetate) into the superior joint space at the end of the lavage ([Figure 3]).
In this group arthrocentesis was performed using 100 ml of lactated Ringer solution followed by injection of SH (Suplasyn; Bioniche Pharma Group Ltd, County Galway, Republic of Ireland) into the superior joint space at the end of the lavage ([Figure 4]).
Throughout the entire lavage, intermittent blockage of the outflow cannula was performed to help lysis of the adhesions with pressure technique. Moreover, the mandible was manipulated in all directions. Finally, the inlet cannula was withdrawn, and the preauricular area was covered with a sterile pressure dressing for the next 24 h. The use of NSAIDs and muscle relaxants for 1 week was advised.
Patients were evaluated for pain upon mouth opening, which was recorded according to the pain Visual Analog Scale (VAS) on a range of 0–10 with the extremes being 'no pain' and 'pain as bad as the patient ever experienced'. Moreover, jaw range of motion function in millimeters was assessed in terms of maximum mouth opening (MMO) measured by the maximum interincisal distance, lateral excursion bilaterally, and protrusive movement. The patients were assessed for all the parameters preoperatively, and on day 1, 1 week, and 3 months postoperatively by the same operator.
This included detection and quantitation of TNF-α factor in SF and was carried out immediately preoperatively and one week postoperatively for all patients ([Figure 5]).
Human TNF-α was a competitive enzyme immunoassay that measures the natural and recombinant forms of the cytokine TNF-α. Goat antibodies were used to capture specific TNF-α complex in each sample. The assay was visualized using streptavidin alkaline phosphatase conjugate and an ensuing chromogenic substrate reaction.
Data were presented as mean and SD. Analysis of variance and Duncan's tests were used for comparison between groups. The significance level was set at P value less than or equal to 0.05. Statistical analysis was performed with IBM SPSS Statistics, version 20 (SPSS, Inc., an IBM Company, IBM Corporation, NY, USA.), for Windows.
| Results|| |
Twenty-seven patients (17 women and 10 men; age 23–56 years) with TMJ disc displacement with reduction for which conservative management had failed were selected for this study. They were randomly divided into three equal groups: group A for ozonized water lavage and ozone injection, group B for corticosteroid injection, and group C for SH injection following lactated Ringer lavage.
The three groups showed statistically significant improvement (P ≤ 0.05) in all biochemical and clinical measurements. However, joint lavage using ozonized water followed by ozone injection (group A) provided more favorable results compared with corticosteroid treatment (group B) and SH treatment (group C). SH (group C) was superior to corticosteroid (group B) in terms of MMO.
TNF-α level in the SF showed statistically significant reduction (P ≤ 0.05) in the three groups. Group A had the highest reduction of TNF-α with statistically significant difference (P ≤ 0.05) between its results and those of groups B and C, whereas groups B and C showed statistically nonsignificant difference between them (P ≥ 0.05) ([Figure 6]).
|Figure 6: TNF-α mean values of the study groups preoperatively and at 1 week postoperatively. TNF-α, tumor necrosis factor-α.|
Click here to view
Concerning pain measurement, there was statistically significant reduction (P ≤ 0.05) in VAS measurements in the three groups at 1 week, 1, and 3 months postoperatively in comparison with the preoperative measurements ([Figure 7]). Group A showed the highest reduction in VAS scale at all postoperative intervals, with statistically significant difference (P ≤ 0.05) between its results and those of groups B and C at 1 and 3 months postoperatively. Groups B and C had a statistically nonsignificant difference (P ≥ 0.05) between them at 1 and 3 months postoperatively ([Table 1]).
|Figure 7: Mean values of VAS in the three groups at the study intervals. MMO, Maximum mouth opening; VAS, Visual Analog Scale.|
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Concerning the MMO, there was a statistically significant increase in maximal mouth opening (P ≤ 0.05) in the three groups at 1 and 3 months postoperatively in comparison with the preoperative measurement. Groups A and C showed the highest increase in MMO at 1 and 3 months postoperatively, with significant difference (P ≤ 0.05) between their results and that of group B at 1 and 3 months postoperatively ([Table 2]).
Regarding the lateral movement to the right side, there was a statistically significant increase (P ≤ 0.05) in the three groups at 1 week and 1 month compared with preoperative measurements, whereas at 3 months postoperatively there was a statistically nonsignificant difference (P ≥ 0.05) between the three groups.
Concerning lateral movement to the left side and protrusive movement, there was a statistically nonsignificant difference (P ≥ 0.05) in the three groups at the study intervals compared with preoperative measurements. Moreover, there was a statistically nonsignificant difference (P ≥ 0.05) among the three groups at the study intervals.
| Discussion|| |
The present investigation was designed to obtain a deeper understanding of the effectiveness of TMJ arthrocentesis under three different treatment protocols in a comparative clinical and biochemical trial. This study clearly demonstrated that intra-articular injections of ozone after ozonized water lavage and intra-articular injection of either corticosteroids or SH after lactated Ringer lavage reduce pain and inflammation and improve mandibular function in patients with ID of the TMJ.
Regarding the biochemical analysis, the present study found significant levels of TNF-α in the SF of all patients and statistically significant reduction after treatment in the three groups, indicating a role for this cytokine in the pathogenesis of ID of TMJ. This finding agrees with those of Fu et al. , Refai et al. , and Nishimura et al. . The statistically significant improvement in pain and mandibular function in our study in the steroid and SH groups is in agreement with the findings of Machado et al. , who concluded that intra-articular injection with corticosteroids and SH seems to be effective for treating ID of TMJ. Furthermore, this result agrees with those of Hepguler et al. , Wenneberg et al. , and Manferdini et al. . The statistically significant improvement in pain and mandibular function in the ozonized water group in this study agrees with the findings of Daif , who reported that 87% of patients with ID of TMJ who received intra-articular ozone gas injection were either completely recovered or improved. In contrast to this study, Huddleston Slater et al.  reported that administration of dexamethasone following arthrocentesis did not appear to have a significant additional effect on overall pain reduction.
The findings of this study suggested that statistically nonsignificant differences existed between SH and corticosteroid injections regarding pain and inflammation. These results agree with a systematic review showing that HA and glucocorticoids had the same short-term and long-term effects on improvement of symptoms, clinical signs, and the overall condition of TMJ disorders . This result disagrees with that of Gencer et al. , who found that HA produced better pain relief scores when compared with corticosteroid injection for the relief of TMJ disorders.
However, in the present study SH injection showed statistically significantly better outcomes compared with corticosteroid injection with respect to MMO. This finding could be explained through the action of Sodium Hyaluoronate (NAH), which maintains a better lubrication within the joint. Our study revealed that the patients who had received ozonized water lavage and ozone injection had statistically significantly better outcomes than the corticosteroid and SH groups.
| Conclusion|| |
The findings of our study led us to the conclusion that arthrocentesis with ozonized water followed by injection with ozone gas gives the best results for the treatment of anteriorly displaced disc with reduction of the TMJ. This could be due to the advantages of arthrocentesis (using ozonized water) with high pressure and jaw manipulation, which causes breaking of intra-articular adhesions, and also due to the anti-inflammatory and pain relief effect caused by ozone gas. Longer follow-up periods and enlarged sample sizes are needed to confirm the findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]