Management of Internal Disc Derangement Using Normal Saline and Sodium Hyaluronate: A Comparative Study.

BACKGROUND: Arthrocentesis of the temporomandibular joint (TMJ) is the unadorned form of surgical therapy which comprises of lavage of inflammatory enzymes and mediators and improve joint mobility and eliminate pain by pressure of the lavage solution in the upper compartment of TMJ.
OBJECTIVES: The current study was conducted to assess and compare the effectiveness of arthrocentesis with normal saline alone and in conjunction with sodium hyaluronate (SH) injection in the treatment of internal derangement of the TMJ.
METHODOLOGY: Sixty patients with internal derangement of the TMJ were randomly divided into two equal groups; Group 1 was performed with normal saline and Group 2 with normal saline followed by 1 ml of SH. The patients were followed up after 1 week to check for any postoperative complications and 1, 2, and 3 months for subsequent sessions and changes in subjective and objective variables.
RESULTS: The increase in mouth opening from preoperative to 3 months' postoperatively was 4.9 mm for Group 1 and 6.43 mm for Group 2. The change in the pain score (visual analogue scale scale) in Group 1 from the preoperative session to 3 months' follow-up was 7.23-4.1 and in Group 2 was 7.36-3.7. The difference in clicking/popping in Group 1 from preoperative session to 3 months' follow-up was 2.43-1 and in Group 2 was 2.4-0.53.
CONCLUSION: Patients refractory to conservative treatment showed promising results with arthrocentesis with SH than arthrocentesis alone in treatment of TMJ internal derangement. Copyright:

INTRODUCTION

Temporomandibular disorders (TMDs) are a category of deteriorating musculoskeletal conditions related to structural and functional deformities associated with temporomandibular joint (TMJ) pain, constrained range of motion, muscle tenderness, and intermittent joint sounds (clicking or popping).[12] Other nonspecific symptoms include headaches, earaches, tinnitus, neck, and shoulder pain.[3] One of the most common types of TMD is internal derangement (pathology or malpositioning of the TMJ disc) as is reported to affect around 80% of patients.[1234]

The etiology of TMD is multifaceted and can risk of mounting TMD, initiating factors are involved in the commencement of the disease and perpetuating factors interfere with curing or augment the progression.[5] Primary factors involved in the development of disease include occlusal abnormalities, bruxism, orthodontic treatment, macro trauma and micro trauma, joint laxity, psychological factors such as stress, mental tension, anxiety, or depression.[56]

Minimally invasive modalities include sodium hyaluronate (SH) and corticosteroid injections, arthrocentesis, and arthroscopy. Invasive modalities include discectomy, disc replacement, restructuring or re-enactment of the articulating surfaces, and implantation of autologous or alloplastic materials.[7]

It is a simple and a widespread modality for the management of internal disorders of the TMJ, indicated primarily in cases of displacement of the articular disc and to treat degenerative inflammatory diseases of the joints.[8910]

A variety of irrigating solutions such as Ringer's lactate, normal saline are better tolerated by the tissues due to its similarity to human serum. Corticosteroids, hyaluronic acid, SH, and platelet-rich plasma has been tried after flushing with saline/ringer's lactate.[11] SH has been reported to more compatible for TMJ along with a strong analgesic and anti-inflammatory action.[1112]

The present study was conducted to evaluate and compare the efficacy of arthrocentesis with normal saline alone and in conjunction with SH injection for the management of TMDs.

METHODOLOGY

The present study was conducted on patients reporting with a complaint of pain, restricted mouth opening, and joint clicking or popping and diagnosed with internal derangement of the TMJ. Sixty subjects above 18 years of age were selected and randomly categorized into two groups: Group 1 comprised of 30 subjects on whom arthrocentesis was performed with normal saline and Group 2 comprised of 30 subjects on whom arthrocentesis was performed with normal saline followed by 1 ml of SH. The subjects having ankylosis, extra capsular pain and dysfunction, rheumatoid arthritis, osteoarthritis, and gout were excluded from the study.

The preoperative and the postoperative assessment of the clinical symptoms and signs were done by a single expert. Mouth opening was recorded in terms of millimeters from the incisal edges of the upper central incisors to lower incisors. Pain was assessed using visual analogue scale (VAS) ranging from 0 to 10 where 0 represents no pain and 10 represents maximum pain. The presence of joint sounds was evaluated with the help of intra-auricular approach while opening and closing movements. Informed consent was obtained from all patients and volunteers.

Procedure

The patients were made to sit comfortably on the dental chair in a semi reclined position with the head rotated towards the affected side. A pen was used to draw a straight line on the skin connecting the middle of the tragus to the lateral canthus of the ipsilateral eye. Two points were marked on this line for needle insertion; first point was marked at a distance of 10 mm from the tragus and 2 mm inferior (posterior entrance/corresponding to the posterior end of glenoid fossa), second point was marked 20 mm anterior to tragus and 10 mm (corresponding to the height of articular eminence) [Figure 1]. Auriculotemporal nerve block was given after the marking of lines and points and the areas of joint penetration were infiltrated.

Figure 1

Marking of the cantho-tragal line and points with insertion of needles

After the 2 points had been marked, 18 gauge needles were inserted with their bevels in front of each other to facilitate the free surge of the fluid through the exit needle. A volume of 2 ml of normal saline was infused through the needle at the posterior entrance point to distend the superior joint space, followed by which another 18 gauge needle was inserted into the distended compartment to ascertain a free flow of the solution through the superior joint space. A 20 ml normal saline syringe was attached to one of the needles and the joint was then irrigated with 100 ml of normal saline [Figure 2]. The patient was instructed to move the mandible in excursive and lateral protrusive motion to assist in detachment of adhesions. In the second group, after the completion of joint lavage, the anterior needle was removed followed by which 1 ml of SH was injected through the posterior needle.

Figure 2

Insertion of needled with infusion of solution

All patients were given postoperative instructions and a course of analgesic was prescribed and advised soft diet. The patients were followed up clinically after 1, 2 weeks, 1 month, 2 months, 3 months (1, 2, and 3 months for the arthrocentesis sessions). During every follow-up, the evaluation of clinical signs and symptoms was done in terms of VAS score, mouth opening in millimeters [Figure 3] and presence or absence of clicking/popping sounds [Figure 4]. The readings were recorded in master chart, and the data analysis was carried out.

Figure 3

Measuring mouth opening in milli meters with scale

Figure 4

Checking joint sounds during opening and closing

RESULTS

Our study comprised of 60 patients diagnosed with internal derangement of the TMJ. All the subjects were above 18 years of age and none of them reported with any postoperative complications or worsening of symptoms. However, the difference was insignificant Tables 1 and 2, Graph 1].

Table 1

Arthrocentesis with normal saline

Source of variation	Sum of squares	Df	Mean sum of square	F
Between the samples	408	4−1=3	408/3=136	136/9.17=14.83
Within the samples	1063.98	120−4=116	1063.98/116=9.17

Calculation of ratio of Fraction

Table 2

Arthrocentesis with sodium hyaluronate

Source of variation	Sum of squares	df	Mean sum of square	F
Between the samples	691.8	4−1=3	691.8/3=230.6	230.6/8.86=26.02
Within the samples	1028.193	120−4=116	1028.193/116=8.86

Calculation of ratio of Fraction

The mean of pain score (VAS scale) in Group 1 and Group 2 in preoperative session including 1–2 and 3 months' follow-up was tabulated in Tables 3 and 4, Graph 2.

Table 3

Pain score (visual analog scale) - Group 1

Source of variation	Sum of squares	df	Mean sum of square	F
Between the samples	166.8	4−1=3	166.8/3=55.6	55.6/0.87=63.90
Within the samples	101.985	120−4=116	101.985/116=0.87

Calculation of ratio of Fraction

Table 4

Pain score (visual analog scale) - Group 2

Source of variation	Sum of squares	df	Mean sum of square	F
Between the samples	224.1	4−1=	224.1/3=74.7	74.7/0.70=106.71
Within the samples	116.344	120−4=116	116.344/116=0.70

Calculation of ratio of Fraction

The mean of clicking/popping in Group 1and Group 2 in preoperative session including 1–2 and 3 months' follow-up was noted in Tables 5 and 6, Graph 3.

Table 5

Clicking/popping-Group 1

Source of variation	Sum of squares	df	Mean sum of square	F
Between the samples	561.9	4−1=3	561.9/3=187.3	187/0.55=340
Within the samples	64.25	120−4=116	64.25/116=0.55

Calculation of ratio of Fraction

Table 6

Clicking/popping-Group 2

Source of variation	Sum of squares	df	Mean sum of square	F
Between the samples	61.32	4−1=3	20.44/3=136	20.44/0.24=85.16
Within the samples	28.22	120−4=116	0.24/116=9.17

Calculation of ratio of Fraction

DISCUSSION

TMDs associated with pain, joint sounds like clicking and/or popping, constraint in joint movements[10] are routinely treated with conservative modalities to begin with, which may include diet modification, occlusal splint therapy, physiotherapy, transcutaneous electrical nerve stimulation, and stress reduction techniques followed by invasive surgical methods such as arthroscopy, disc repositioning, discectomy, eminectomy, and disc perforation repair.[11]

The present study comprised of 60 patients diagnosed with internal derangement of the TMJ. The subjects were randomly divided into two groups; Group 1 comprised of 30 subjects on whom arthrocentesis was performed with normal saline and Group 2 comprised of 30 subjects on whom arthrocentesis was performed with normal saline followed by 1 ml of SH. The patients were followed up after 1 week to check for any post-operative complications and 1, 2, and 3 months for subsequent sessions and changes in subjective and objective variables.

The increase in mouth opening from preoperative to 3 months' postoperatively was 4.9 mm for Group 1 and 6.43 mm for Group 2, these results were statistically significant. These findings were in concordance with the study conducted by Tozoglu S et al. who reported reduced mouth opening, TMJ pain, and jaw deviation with SH was superior to arthrocentesis alone.[12]

The change in the pain score (VAS scale) in Group 1 from the preoperative session to 3 months of follow-up was 7.23–4.1. The change in the VAS scale in Group 2 from the preoperative session to 3 months' follow-up was 7.36–3.7. The findings were in concordance with the study conducted by Vasconcelos et al. concluded that arthrocentesis was shown to be effective in reducing pain and increasing jaw motion in his series of cases.[13]

The difference in clicking/popping in Group 1 from preoperative session to 3 months of follow-up was 2.43–1. The difference in clicking/popping in Group 2 from preoperative session to 3 months' follow-up was 2.4–0.53. These findings were in concordance with the findings of Vasconcelos BC et al. who found similar results in both betamethasone and SH.[14]

None of the patients in our study reported with any postoperative complications. A study was conducted by Yavuz et al. to evaluate the intraoperative and postoperative complications of arthrocentesis included temporary swelling, hemorrhage, facial paralysis, lingual anesthesia, inferior nerve anesthesia, tachycardia, syncope, dizziness, severe pain, and limitation of mouth opening, Possible temporary complications include facial palsy, lingual anesthesia, trismus, temporary swelling in peri-particular region, hemorrhage, impaired hearing, dizziness, and syncope.[14]

In our study, there was a significant reduction in symptoms in both the groups, but the SH was superior to arthrocentesis alone. The improvement in objective and subjective symptoms after the therapy can be attributed to the fact that the flow of liquid under hydraulic pressure in joint causes flush of catabolites, distension of joint with breakage of adhesions, and mobilization of disc.

CONCLUSION

Patient's refractory to conservative treatment showed promising results with arthrocentesis with SH than arthrocentesis alone in treatment of TMJ internal derangement. It has been reported to increase mouth opening, reduce pain, increase jaw motion, and improve function. We need more sample size and increased follow-up period to assess the results in a more stratified manner. Further research is needed to better determine the efficacy of these agents in the treatment of internal derangement.

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

Nil.

Conflicts of interest

There are no conflicts of interest.