Abstract
This study examined the clinical and radiological effects of intra-articular tenoxicam injection following arthrocentesis and compared them with arthrocentesis alone in patients with disc displacement without reduction (DDwoR). 24 temporomandibular joints (TMJs) in 21 patients with DDwoR were studied. Patients were divided randomly into Group A in which only arthrocentesis was performed (14 TMJs in 14 patients) and Group AT which received arthrocentesis plus intra-articular injection of tenoxicam (10 TMJs in 7 patients). Patients were evaluated before the procedure, on postoperative day 7, then 2, 3, 4 weeks, and 2, 3, 4, 5, 6 months postoperatively. Intensity of joint pain was assessed using a visual analog scale. Maximum mouth opening was recorded at each follow-up. TMJ sounds and palpation scores were noted as positive or negative. Magnetic resonance imaging (MRI) was performed before and 6 months after treatment in both groups. Disc form, disc location during neutral position, reduction with movement, joint effusion, structures of the articular surfaces, and bone marrow anomalies were evaluated all in MRIs. Both treatments succesfully increased maximum mouth opening and reduced TMJ pain; there were no complications. Difference between the groups was not statistically significant and a larger controlled study is necessary to clarify this use of tenoxicam.
Arthrocentesis is a simple and minimally invasive technique that is quite effective in the treatment of internal derangements of the temporomandibular joint (TMJ). Significant improvements in TMJ pain and width of mouth opening have been reported with proven long-term results following arthrocentesis . The increase in mouth opening might result from the elimination of the vacuum effect within the joint compartment , but less is known about the mechanism of reduction of joint pain .
Recent studies have identified a significant level of pain-related chemical mediators in the synovial fluid of painful TMJs . Symptomatic temporomandibular disorders (TMDs) are accompanied by accumulation of these mediators in synovial fluid. Once such mediators have accumulated in the intra-articular space, they remain for some time because of the relatively avascular anatomy of the space . Arthrocentesis washes out these inflammatory mediators to relieve pain . The direct action of instilled medication on intracapsular receptors also has an effect in pain reduction .
Review articles on arthrocentesis report that the most common intra-articular injections following arthrocentesis are steroids, with sodium hyaluronate in second place.
Non-steroidal anti-inflammatory drugs (NSAIDs) have been used to treat acute and chronic inflammatory articular disorders, such as rheumatoid arthritis and osteoarthritis . Their mechanism is thought to be the reduction of biosynthesis of prostaglandins by direct inhibition of cyclo-oxygenase (COX) . Prostaglandins also have a role in maintaining normal gastrointestinal, platelet, and renal function . NSAIDs may therefore reduce inflammation in the target tissue, but may increase the risk of complications, such as gastric ulcer, hemorrhagic diathesis and nephrotoxicity when used systemically .
Combined treatment with arthrocentesis and NSAIDs is logical for an inflamed synovial joint as it removes the inflammatory and associated mediators from the synovial space, alters the intra-articular pressure and thus reduces synovial inflammation .
In this study, the authors used a long-lasting non-steroidal analgesic drug, tenoxicam, following arthrocentesis in patients with disc displacement without reduction (DDwoR). The use of intra-articular tenoxicam injection has been described for its long-lasting non-steroidal analgesic effect after arthroscopic knee surgery , and because of its long half-life (60–80 h) local infiltration of the drug concentrates the pain-control effects in the local area . Local infiltration of the drug also eliminates the systemic complications. The purpose of this pilot study is to examine the clinical and radiological effects of intra-articular tenoxicam injection following arthrocentesis and to compare the effects of it with arthrocentesis alone in patients with DDwoR.
Materials and Methods
This study was carried out with the approval of the Istanbul University Ethics Committee of School of Medicine (2006/1204) and informed consent was obtained from all patients.
Patients included in this study had TMJ pain and limited mouth opening between August 2006 and December 2007. 24 TMJs from 21 patients (4 males, 17 females) aged 15–52 years (mean 26.43 years) with clinical and radiological diagnosis of TMJ DDwoR were included in this study ( Table 1 ). A clinical diagnosis of TMD was made according to the clinical diagnostic criteria (CDC/TMD) . The TMJ ID-III (DDwoR) subgroup was characterized by: a history of sudden reduction in mandibular opening; unassisted mandibular opening <35 mm; and mandibular opening with assistance increased by 3 mm or less. In patients with a history of click, the disappearance of the click and sudden decreased opening had to coincide. Patients were excluded from the study if they had previous TMJ surgery, systemic inflammatory joint disease, direct trauma to or fractures of facial bones, condylar hypoplasias/hyperplasias/tumours and contraindications for arthrocentesis and magnetic resonance imaging (MRI).
| Group A | Group AT | |
|---|---|---|
| Patients ( n ) | 14 | 7 |
| TMJs ( n ) | 14 | 10 |
| Age (years) | Mean, 25.28; range, 17–52 | Mean, 28.71; range, 15–52 |
| Female/male ( n ) | 12/2 | 5/2 |
| Period of locking | Mean, 5; range, 0.1–24 | Mean, 5.58; range, 0.1–24 |
| Depression scores | Mean, 0.71; range, 0.19–2.94 | Mean, 0.66; range, 0.16–2.81 |
| Follow-up period | 6 months | 6 months |
The patients’ depression scores were calculated according to the Research Diagnostic Criteria described by D workin & L e resche at the start of treatment. Patients were divided randomly into two groups: Group A was treated with arthrocentesis only (14 TMJs in 14 patients); Group AT was treated with intra-articular tenoxicam injection following arthrocentesis (10 TMJs in 7 patients). In both groups, stabilization splints were used as described by O keson for all patients. Arthrocentesis was performed under local anaesthesia according to the technique described by N itzan et al. . In Group AT, 2 ml of tenoxicam was injected into the upper joint compartment following arthrocentesis.
Stabilization splints were used only during the night for 6 months, and occlusal adjustments were made at each appointment. Patients were asked to eat a soft diet following arthrocentesis and given active and passive mouth-opening exercises starting on postoperative day 7.
The patients were evaluated before the procedure and on postoperative day 7, then 2, 3, 4 weeks, and 2, 3, 4, 5, 6 months after the procedure. Maximum mouth opening (mm), TMJ sounds (positive or negative), visual analog scale (VAS) pain scores (0–10), TMJ and masticatory muscle palpation results (positive or negative) were recorded at each appointment.
To evaluate clinical success, the criteria proposed by the American Association of Oral and Maxillofacial Surgeons in 1995 were used . The criteria are: a level of pain that is of little or no concern to the patient; a maximal mouth opening of 35 mm or more; improvement in the ability to masticate a normal or nearly normal diet; a functional and stable occlusion; limited period of disability; and acceptable clinical appearance.
MRI results were obtained with a 1.0 T MR scanner (Siemens Magnetom Impact, Erlangen, Germany) with the mouth closed and at the maximal opening position on coronal T1-weighted (480/15 ms) and sagittal T1 and T2-weighted (3000/90 ms) pulse sequences.
A non-ferromagnetic intermaxillary device was used to obtain the various mouth-opening positions. Sequential bilateral images were made with the mouth closed and in the various mouth-opening positions until maximum mouth opening was achieved. These images, which depicted the disc, condyle, articular eminence and glenoid fossa, were selected for analysis of the disc–condyle relationship.
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. All the preoperative and postoperative MRI results were evaluated by a neuroradiologist (S.S.) who was unaware of the patients’ clinical information before and after treatment.
Normal disc position was defined by location of the posterior band of the disc at the superior or 12 o’clock position relative to the condyle. Diagnosis of the type of internal derangement was categorized as displaced without reduction, and defined according to the finding of a closed mouth-related diagnosis of the presence of disc displacement with no open mouth-related interposition of the disc between the condyle and the articular eminence .
The form of the disc was recorded as normal or having signs of deformation. On the T2-weighted images, joint effusion was identified as an area of high signal intensity in the region of the joint space. When more than a line of high signal was evident in at least two consecutive sections, it was considered positive for TMJ effusion and it was recorded as none (0), moderate (1) and high (2).
MRI diagnosis of degenerative bony changes was defined by the presence of flattening, subchondral sclerosis, surface irregularities, osteophytes or erosion . It was recorded as negative (0) or positive (1).
Bone marrow edema was defined by the presence of a hypointense signal on T1-weighted and a hyperintense signal on T2-weighted images and recorded as negative (0) or positive (1).
As the number of patients in this pilot study was low, non-parametric tests were used for statistical analysis. Between group analysis was carried out using the Kruskal–Wallis test and the χ 2 test; within group analysis was carried out using the Wilcoxon signed test and McNemar’s test.
Significance was set at p < 0.05. For all statistical analysis, the SPSS x package (15.0 Version; SPSS Inc, Chicago, IL, USA) was used.
Results
No complications or complaints were noted during or after arthrocentesis or intra-articular tenoxicam injections. 12 cases (86%) were judged successful in Group A and 8 (80%) in Group AT ( Table 2 ). There was no statistically significant difference between the two groups according to their treatment success.
| Group A | Group AT | p | |
|---|---|---|---|
| n (%) | n (%) | ||
| Treatment success | |||
| Successful | 12 (85.7%) | 8 (80.0%) | 1.000 |
| Unsuccessful | 2 (14.3%) | 2 (20.0%) | |
Within group analysis showed an increase in assisted and unassisted maximum mouth opening in both groups following arthrocentesis at all time intervals, but the increase was significant only in Group A ( p < 0.05). Between group analysis did not show any significant difference in assisted and unassisted maximum mouth opening ( Figs 1 and 2 ).
Within group analysis showed a significant decrease in VAS pain scores in both groups at all time intervals. The decrease in Group A was statistically more significant ( p < 0.01) than the decrease in Group AT ( p < 0.05). Between group analysis did not show any differences ( Fig. 3 ).
