Efficacy of Hyaluronic Acid in the Treatment of Internal Derangement – Clinical Study

 

Manay Roshini Srinivas¹, Divya James¹, Prof. Dr. M. R. Muthusekhar²

¹Post Graduate, Department of Oral and Maxillofacial Surgery, Saveetha Dental College

²Head of the Department, Department of Oral and Maxillofacial Surgery, Saveetha Dental College

 

ABSTRACT:

Introduction: Hyaluronic acidis known as Sodium hyaluronate or hyaluronan is an essential component of the synovial fluid. It enables the fluid to act as a lubricant, a shock absorber and a filter controlling the movement of cells and large molecules within the joint.The present study presents a case series on the efficacy of hyaluronic acid injections for the treatment of temporomandibular joint pain by providing patient evaluations. Study Design: Thirty-one temporomandibular joints in 23 patients were evaluated in this study. Six males and 17 females aged 18 to 55 years with chief complaints of limited mouth opening, TMJ pain, and clicking sounds in the TMJ. The TMJ was examined clinically and radiographically. Patients were randomly divided into two groups, were one group received only arthrocentesis and the other group received arthrocentesis plus hyaluronic acid. Both the groups contained patients with disc displacement with reduction with closed lock. Results: Descriptive analysis showed improvements which were maintained over time for all the study parameters. Permutation tests evidenced the significance of changes which occurred in many clinical parameters over three months. Differences with baseline levels remained significant at the end of the follow-up period, particularly for the jaw movements, masticatory efficiency, clicking and pain at mastication parameters. Conclusion: Data from the clinical study support findings from studies on other joints, which prove the efficacy of hyaluronic acid after arthrocentesis to reduce symptoms of osteoarthritis and to maintain improvements over time.

 

 

 

INTRODUCTION:

Patients with temporomandibular disorders (TMD) may present with a cluster of joint and muscle disorders characterized primarily by pain, clicking sound, and irregular or deviating jaw function.[1]

 

Several biochemical investigations of the TMJ synovial fluid have suggested a significant relationship between TMJ disorders and synovitis, [2-4] Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects joints and frequently the temporomandibular joint (TMJ)

 

 

The synovial tissue is extensively infiltrated by activatedT cells, macrophages and plasma cells, which in addition to synovial fibroblasts and synoviocytes are activated to express a large number of cytokines. [5]. Many procedures have been developed to try to alleviate the pain and function complaints of patients suffering from TMJ dysfunctions. The common methods are pharmacologic therapy, occlusal splints, Arthoscopic surgery, Arthrocentesis and Surgery.

 

Arthrocentesis by definition refers to the lavage of the joint space to release adhesions or anchored disc phenomenon and improve joint mobility. [6] Intra- articular corticosteroid injection alone or after arthrocentesis provides long- term palliative effects of subjective symptoms and clinical signs of TMJ pain. [7] Recently, hyaluronic acid has been proposed as an alternative therapeutic agent. It is a polysaccharide of the glycosaminoglycans family, found in many extracellular tissues, including synovial fluid and cartilage. [8]  Hyaluronic acid is produced by the chondrocytes and synoviocytes of the joints. In patients with osteoarthritis, it becomes depolymerized, resulting in decreased molecular weight and viscoelasticity, which increases the susceptibility of cartilage to injury. Exogenous hyaluronic acid can stimulate the synthesis of endogenous hyaluronic acid from the synoviocytes of osteoarthritic joints reducing the joint friction coefficient and decreasing the risks of damages. This highly viscous, high molecular substance plays an important role in joint lubrication and protection of the cartilage. [9] Its anti- inflammatory property has proved to reduce inflammation.[10]

 

This study was undertaken to evaluate the efficacy of arthrocentesis with or without hyaluronic acid injection in a group of patients suffering from TMJ internal derangement.

 

STUDY DESIGN:

Aim and Objective:

To evaluate the efficacy of hyaluronic acid in arthrocentesis into the upper joint space in the treatment of temporomandibular joint (TMJ) internal derangements. The parameters analysed between the two groups were:

1    TMJ pain

2    Mouth Opening

3    Lateral Movements

4    Clicking sounds

 

Patients and Methods:

31 temporomandibular joints in 23 patients were evaluated. 6 males and 17 females, aged 18 to 55 years.

 

TMJ was examined clinically and radiologically with a detailed history including chief complaints, initial symptoms and duration of symptoms, history of noise or limited mouth opening and previous treatments.

 

Inclusion parameters in the study:

Limited mouth opening, TMJ pain, impeded lateral movements towards the unaffected side and clicking sounds. Patients were randomly divided into 2 groups, with only arthrocentesis performed in group 1 and arthrocentesis plus intra articular injection with hyaluronic acid in the other. Both the groups contained patients with disc displacement with reduction and closed lock.

 

Technique:

A line connecting the tragus of the ear to the outer canthus of the eye was drawn on the patients skin in relation to the affected joint (fig.1). The skin was penetrated with a 20- gauge needle at a point 10 mm infront of the tragus and 2 mm below the canthal- tragus line (point A) For the auriculotemporal nerve block, 0.3 to 0.5 ml of an anaesthetic solution was injected and the needle was introduced into the upper joint compartment and approximately 1.5 to 1.7 ml of anesthethic solution was injected. After which 2ml syringe alone is removed leaving behind the needle in the upper joint compartment. A 20 ml syringe filled with ringer lactate solution connected to the first needle and joint distended with 2-3 ml of RL. Second needle was introduced 2mm anterior to the former one (point B).The upper joint compartment was irrigated with 200 to 300 ml of RL solution, allowing a free flow through both the needles. (fig 2) On termination of the procedure, 1 ml of commercially available hyaluronic acid [Halonox injection- Cadila (IRM pharma) was injected into the upper joint space in 16 joints in 12 patients. After completion of the procedure the needles were removed and a gauze dressing was placed. Post- operative medications included Mysospaz TID for 3 days.

 

 

Fig 1: Canthus –tragus line (red line), point A (black) 10 mm from the tragus and 2 mm below CT line, Point B (black): 2 mm Anterior to point A

 

Evaluation of the patients was done before the procedure, on post operative week 1, then at 1, 2, and 3 months after the procedure. This evaluation was randomized and non- blinded.

 

The parameters were each measured pre operatively, post operative week 1, then at 1,2 and 3 months after the procedure.

 

RESULTS:

Mean and standard deviation were estimated in each group using Mann-whitney U- test.

Proportions were compared between two groups by using either Pearson’s chi-square test with/ without Yate’s continuity correction or Fishers’sExact test (2-tailed) appropriately. There is a significant difference in mean pain score, mouth opening, lateral jaw movement, between Group A and Group B when progression from treatment to 1^st week, 1^st month, 2^nd month and 3^rd month ( P= 0.04,< 0.0001, <0.0001, < 0.0001).

 

 

DISCUSSION:

Hyaluronic acid,also known as “hyaluronan” [21] one of the main components of synovial fluid, has been reported to have anti- inflammatory actions such as scavenging of free radicals, reduction in vascular permeability, inhibition of migration polymorph nuclear leucocytes and macrophages, and phagocytosis, as well as analgesic properties [11-13]. Intra- articular injection of sodium hyaluronate has been reported as an effective for rheumatoid arthritis, osteoarthritis, and also disorders of temporomandibular joint [14-16].

 

Recent observations indicate that an increase in joint friction co- efficient is a main-risk for degenerative joint pathologies [17,18] and that hyaluronic acid, being an essential component for joint lubrication, may help in reducing joint friction [19,20]. In the present study, maximum mouth opening and lateral jaw movements increased, jaw function improved, while pain and joint noises disappeared or lessened statistically more significant in patients treated with arthrocentesis followed by hyaluronic acid than in patients treated with arthrocentesis alone.

 

CONCLUSION:

The study confirms a reasonable success rate of using Sodium Hyaluronate along with arthrocentesis, but it requires a long term follow- up ad more number of patients to establish that arthrocentesis with hyaluronic acid as the treatment of choice for internal derangement TMJ especially closed lock.

 

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Accepted on 19.02.2018        © RJPT All right reserved

Research J. Pharm. and Tech 2018; 11(8):3483-3485.