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ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 196-200

Arthrocentesis - A minimally invasive treatment of temporomandibular joint dysfunction: Our experience


1 Department of Oral and Maxillofacial Surgery, Meghna Institute of Dental Sciences, Mallaram, Nizamabad, Andhra Pradesh, India
2 Department of Oral Pathology, Azamgarh Dental College, Azamgarh, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Meghna Institute of Dental Sciences, Mallaram, Nizamabad, Andhra Pradesh, India

Date of Web Publication29-Aug-2013

Correspondence Address:
Vallela Sasidhar Reddy
Department of Oral and Maxillofacial Surgery, Meghna Institute of Dental Sciences, Mallaram,Nizamabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.117191

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  Abstract 

Background: Temporomandibular joint dysfunction (TMJD) is a clinically significant condition which can be a source of acute or chronic orofacial pain and dysfunction including limitation of mandibular movement, pain with mandibular function and joint sounds. Arthrocentesis is joint lavage which washes out these inflammatory mediators, thereby, relieving pain.
Aim: The aim of this study is to evaluate the efficacy of arthrocentesis of temporomandibular joint (TMJ) followed by intra-articular injection of piroxicam in patients with TMJD.
Materials and Methods: Forty TMJ's from thirty patients, aged 18-48 years (mean age 27.33 years) with clinical and radiological diagnosis of TMJD, based on clinical diagnostic criteria (CDC/TMD) were included in the study and underwent arthrocentesis followed by injection of piroxicam. Patient evaluation was done preoperatively and post operatively immediately following the procedure and on 7 th day, 2 nd , 3 rd and 4 th week, 2, 3, 4, 5 and 6 months. Pain on mouth opening on a Visual Analogue Scale (VAS) scale (score 0-10), clicking or popping sounds and maximum mouth opening were recorded at each interval. Magnetic resonance imaging (MRI) was performed before treatment and 6 months after treatment in both groups.
Results: Evaluation of assisted and unassisted mouth opening showed increase at all time intervals. There was significant improvement in pain, range of motion, joint effusion and joint sounds.
Conclusion: Arthrocentesis followed by intra-articular injection of piroxicam is a safe, simple, minimally invasive and effective treatment of temporomandibular joint dysfunction.

Keywords: Arthrocentesis, intra-articular injection, piroxicam, temporomandibular joint dysfunction


How to cite this article:
Reddy R, Reddy VS, Reddy S, Reddy S. Arthrocentesis - A minimally invasive treatment of temporomandibular joint dysfunction: Our experience. J NTR Univ Health Sci 2013;2:196-200

How to cite this URL:
Reddy R, Reddy VS, Reddy S, Reddy S. Arthrocentesis - A minimally invasive treatment of temporomandibular joint dysfunction: Our experience. J NTR Univ Health Sci [serial online] 2013 [cited 2019 Jan 21];2:196-200. Available from: http://www.jdrntruhs.org/text.asp?2013/2/3/196/117191


  Introduction Top


Temporomandibular joint (TMJ) is a compound joint, composing of temporal bone and mandible, numerous associated muscles and a specialised fibrous tissue the articular disk. [1] Anatomically TMJ is a diarthrodial synovial joint, with associated muscles and ligaments, dictating and limiting the freedom of discontinuous articulation between two bones. [2] Functionally TMJ is a compound joint composed of four articulating surfaces with articular disk separating the joint into upper and lower compartments. The lower compartment permits hinge or rotatory motion while upper compartment permits sliding or translator movements. Articular disk is a non-vascularised, non-innervated dense fibrous tissue with adequate strength to resist pressure, [3] and adapts to functional demands of articular surfaces due to its flexibility. [4]

Temporomandibular joint dysfunction (TMJD) is a clinically significant condition with 5% of general population affected of which 2% seek treatment. [5] Dysfunction of TMJ and associated masticatory system can be a source of acute or chronic orofacial pain and dysfunction. [6] Three cardinal signs of TMJD may be (a) limitation of mandibular movement

(b) pain with mandibular function (c) joint sounds. Successful treatment depends on accurate assessment, comprehensive evaluation and diagnosis. [6] Various non-surgical and surgical treatment modalities of TMJD have been contemporarily described. Arthrocentesis is a simple, safe and minimally invasive technique for the treatment of TMJD. Significant improvements have been reported in terms of reduction in TMJ pain, mouth opening and clicking or popping sounds in the TMJ following arthrocentesis. [7],[8],[9] Significant levels of pain-related chemical mediators have been identified in the synovial fluid of painful TMJs, accumulation of which results in symptomatic temporomandibular disorders (TMDs) and temporomandibular joint dysfunction (TMJD). Arthrocentesis is joint lavage which washes out these inflammatory mediators, thereby, relieving pain. [10],[11] Most common intra-articular injections following arthrocentesis are steroids and sodium hyaluronate. [12],[13] Non-steroidal anti-inflammatory drugs (NSAIDs) have been used to treat acute and chronic inflammatory articular disorders, such as rheumatoid arthritis and osteoarthritis. Combined treatment with arthrocentesis and NSAIDs for inflamed synovial joint removes the inflammatory mediators, alters the intra-articular pressure and reduces synovial inflammation. [14] In this study, we used a long lasting non-steroidal analgesic drug, piroxicam following arthrocentesis in patients with temporomandibular dysfunction. The purpose of this study was to evaluate the efficacy of a minimally invasive technique of arthrocentesis followed by intra-articular injection of piroxicam for the treatment of TMJD.


  Materials and Methods Top


This study was conducted at department of oral and maxillofacial surgery at our centre between July 2010 and December 2011. Forty TMJ's from 30 patients (19 female and 11 male) aged 18-48 years (mean age 27.33 years) with clinical and radiological diagnosis of TMJD, based on clinical diagnostic criteria (CDC/TMD) were included in the study [Table 1] and underwent arthrocentesis followed by injection of piroxicam. All the patients were given stabilisation splints to be worn at night for 6 months and advised to take soft diet. Post operative physiotherapy was started on the 7 th post operative day. Patient evaluation was done preoperatively and post operatively immediately following the procedure and on 7 th day, 2 nd , 3 rd and 4 th week, 2, 3, 4, 5 and 6 months in terms of pain, mouth opening and clicking. Pain on mouth opening on Visual Analogue Scale (VAS) scale (score 0-10), clicking or popping sounds and maximum mouth opening were recorded at each interval. MRI was performed before treatment and 6 months after treatment in both groups. Disc form, disc location during the neutral position, reduction with movement, range of motion (ROM), joint effusion, structure of the articular surfaces, and bone marrow anomalies were evaluated on preoperative and postoperative MRIs from all patients. Arthrocentesis to lavage and lyse the joint space may remove inflammatory mediators accumulated within the synovial fluid, as well as alter the intra-articular pressure releasing adhesions. As the number of patients in this study was low, non-parametric Wilcoxon signed test and McNemar's tests were used for statistical analysis and significance was set at P < 0.05.
Table 1: Inclusion and Exclusion Crtteria

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Technique

Arthrocentesis can be comfortably performed under local anaesthesia, but intravenous (IV) conscious sedation or general anaesthesia can also be used depending on surgeon and patient comfort and preference. We have performed the procedure in all the patients included in our study under a local anaesthetic block of auriculotemporal nerve and infiltration into the areas of joint penetration. Surgical field is draped and painted with povidone iodine following the measurement of preoperative mouth opening [Figure 1]. External auditory canal is protected from accumulation of blood and fluid using a cotton pledget. A cantho-tragal line is drawn from outer canthus of ipsilateral eye to midpoint of tragus. A point approximating the posterior extent of the articular fossa is marked 10 mm anterior to the midtragal point and 2 mm inferior to canthotragal plane. A second point is marked at 20 mm anterior to tragus and 10 mm inferior to canthotragal line, which corresponds to height of articular eminence [Figure 2]. Auriculotemporal nerve block with 2% lignocaine and 1:80,000 adrenaline is administered and superior joint space is entered at 10-2 point with an 18-gauge needle at anterio-medio-lateral direction reaching posterior aspect of articular eminence. Several millilitres of normal saline is injected passively into the joint until there is rebound of syringe with mandibular movement. A second needle is inserted slightly anterior to first needle at 20-10 point for outflow of irrigant from joint space. After lavage is performed using approximately 500 ml of normal saline, joint is manipulated through opening, closing, protrusive and excursive movements of the mandible and post operative mouth opening is measured [Figure 3]. 2 ml (40 mg) of piroxicam was injected into the upper joint compartment following arthrocentesis.
Figure 1: Measurement of preoperative mouth opening

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Figure 2: Points of insertion of needles

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Figure 3: Post operative mouth opening

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  Results Top


No complaints or complications were seen following the arthrocentesis or injection of piroxicam. Evaluation of assisted and unassisted mouth opening showed increase at all time intervals [Table 2] but was significant on immediate post operative evaluation (P < 0.05). There was significant decrease in VAS pain scores [Table 3] and [Table 4] at all post operative evaluations (P < 0.01). There was decrease in clicking joint sounds but was not statistically significant (P > 0.05). Joint effusion decreased from 90% preoperative levels to 21% in post operative MRI's but was not statistically significant (P = 0.51). Range of motion (ROM) increased significantly from preoperative levels (P = 0.41).
Table 2: Demographic Data


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Table 3: Mouth Opening


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Table 4: Pain Measured on 10-Point Vas Scale


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  Discussion Top


Three mechanisms of injury have been suggested for degenerative process of TMJ: (a) Direct mechanical injury, (b) Hypoxia-perfusion injury and (c) Neurogenic inflammation. The use of orthotic splint appliances, combined with physical therapy and non-steroidal anti-inflammatory drugs (NSAIDS), will allow the surgeon to assess whether intracapsular pathology will respond to a non surgical therapy. Normal function of TMJ is characterised by absence of pain or joint sounds with smooth and coordinated mandibular movements. TMJD, therefore, constitutes limited jaw movement, discomfort sometimes associated with popping or clicking sounds. Aetiology of TMJD can be extracapsular or intracpasular. A thorough joint assessment is necessary to differentiate between the two as both have distinct managements. Myofascial pain, myalgia can refer as TMJ pain, osseous anomalies like calcification of styloid process, coronoid hypertrophy may also impede the normal mandibular function and may mimic intracpasular disorders. Internal disc derangements with or without reduction constitute intracpasular disorders. Arthrocentesis is a safe, rapid and minimally invasive procedure to treat a multitude of disorders affecting the TMJ. TMJD has a multifactorial aetiology possibly including impingement, compression and inflammatory changes in the retrodiskal tissues, synovial membrane and TMJ capsule. Pathophysiology of TMJD could be described by several theories: (i) Changes in the shape and position of the articular disk, (ii) biomechanical and biochemical changes in TMJ, (iii) joint overloading may cause hypoxia and on termination of overloading reoxygenation occurs. The hypoxia-reperfusion cycle can lead to the release and production of reactive oxygen species leading to degradation of hyaluronic acid and reduced viscosity of synovial fluid, [15] resulting in more friction and adhesion of articular surfaces. Arthrocentesis is usually indicated following failure of other non-surgical and pharmacologic methods. Major indications for arthrocentesis include: (a) Acute and chronic limitation of opening because of anteriorly displaced disk without reduction, (b) chronic pain with good range of motion and anterior disk displacement with reduction, (c) degenerative osteoarthritis, [6] (d) TMJ open lock condition where condyle is entrapped anterior to a lagging disk. [15] Piroxicam is a NSAID of the oxicam class. It is a potent analgesic and anti-inflammatory agent and has an established efficacy in postoperative pain relief. In view of its long half-life (˷50 h), once daily administration is sufficient. Piroxicam is effective as an anti-inflammatory agent; it is absorbed completely after oral administration with peak concentrations in plasma occurring within 2-4 hours. After absorption, piroxicam is extensively (99%) bound to plasma proteins with similar concentrations in plasma and synovial fluid at steady state (7-12 days). Piroxicam has been used for the treatment of rheumatoid arthritis and osteoarthritis. The parenteral formulation of piroxicam has an aqueous base, without an organic stabiliser and since the solvent for injection is distilled water, this formulation offers the potential for intra-articular administration. Piroxicam has also been shown to concentrate in the synovium rather than in the cartilage. [16] In the present study, patients were treated with arthrocentesis and piroxicam injection following arthrocentesis to benefit from its anti-inflammatory characteristics. The success rate was falling in the 70-91% success range of previous studies. [7],[17] There was statistically significant difference between the preoperative and post operative measurements of mouth opening, pain and range of motion. Statistically significant difference was not seen in pre and post operative joint effusion and joint sounds. It has been strongly emphasised in the literature that the intra articular administration of NSAIDs has not been studied adequately.


  Conclusion Top


The procedure is safe, simple, minimally invasive and effective for the treatment of temporomandibular joint dysfunction. There are successful examples of intra-articular NSAID injection following arthroscopic knee surgery and this study evaluating the efficacy of arthrocentesis and intraarticular piroxicam injection for temporomandibular joint dysfunction can be used as a pilot study for future long-term studies in this field.

 
  References Top

1.Miloro M, Ghali GE, Peter EL, Peter DW. Peterson's Principles of Oral and Maxillofacial Surgery. 2 nd ed. London: BC Decker Inc Hamilton; 2004. p. 963-89.  Back to cited text no. 1
    
2.DuBrul EL. Sicher's oral anatomy. 7 th ed. St. Louis (MO): C. V. Mosby; 1980. p. 146-61, 174-209.  Back to cited text no. 2
    
3.Bell WE. Temporomandibular disorders: Classification diagnosis and management. 2 nd ed. Chicago: Yearbook Medical Publishers; 1986. p. 16-62.  Back to cited text no. 3
    
4.Okeson JP. Management of temporomandibular disorders and occlusions. 2 nd ed. St Louis (MO): C. V. Mosby; 1989. p. 3-26.   Back to cited text no. 4
    
5.Rayne J. Functional anatomy of the temporomandibular joint. Br J Oral Maxillofac Surg 1987;25:92-9.  Back to cited text no. 5
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6.Fonseca R, Marciani R, Turvey T. Oral and maxillofacial surgery. 2 nd ed. St. Louis (MO): Saunders, Elsevier; 2009. p. 833, 815.  Back to cited text no. 6
    
7.Hosaka H, Murakami K, Goto K, Iizuka T. Outcome of arthrocentesis for temporomandibular joint with closed lock at 3 years follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:501-4.  Back to cited text no. 7
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8.Nishimura M, Segami N, Kaneyama K, Suzuki T. Prognostic factors in arthrocentesis of the temporomandibular joint: Evaluation of 100 patients with internal derangement. J Oral Maxillofac Surg 2001;59:874-7.  Back to cited text no. 8
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9.Nitzan DW, Samson B, Better H. Long-term outcome of arthrocentesis for sudden-onset, persistent, severe closed lock of the temporomandibular joint. J Oral Maxillofac Surg 1997;55:151-7.  Back to cited text no. 9
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10.Frost DE, Kendell BD. Part 2: The use of arthrocentesis for treatment of temporomandibular joint disorders. J Oral Maxillofac Surg 1999;57:583-7.  Back to cited text no. 10
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11.Kaneyama K, Segami N, Nishimura M, Sato J, Fujimura K, Yoshimura H. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the temporomandibular joint by arthrocentesis. J Oral Maxillofac Surg 2004;62:657-61.  Back to cited text no. 11
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12.Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: A review article. Int J Oral Maxillofac Surg 2007;36:773-82.  Back to cited text no. 12
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13.Ethunandan M, Wilson AW. Temporomandibular joint arthrocentesis-more questions than answers? J Oral Maxillofac Surg 2006;64:952-5.  Back to cited text no. 13
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14.Ishimaru JI, Ogi N, Mizui T, Miyamoto K, Shibata T, Kurita K. Effects of a single arthrocentesis and a COX-2 inhibitor on disorders of temporomandibular joints. A preliminary clinical study. Br J Oral Maxillofac Surg 2003;41:323-8.  Back to cited text no. 14
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15.Truelove EL, Sommers EE, LeResche L, Dworkin SF, Von Korff M. Clinical diagnostic criteria for TMD. New classification permits multiple diagnosis. J Am Dent Assoc 1992;123:47-54.  Back to cited text no. 15
    
16.Nitzan DW. Temporomandibular joint "open lock" versus dislocation: Signs and symptoms; imaging; treatment and pathogenesis. J Oral Maxillofac Surg 2002;60:506-11.  Back to cited text no. 16
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17.Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: A simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49:1163-7.  Back to cited text no. 17
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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