Quantitative histological changes of repeated antigen-induced arthritis in the temporomandibular joints of rabbits treated with intra-articular corticosteroid

Background:  To compare the inflammatory changes of antigen-induced temporomandibular joint (TMJ) arthritis in rabbits by different histological methods and to evaluate the immunomodulatory effect of intra-articular corticosteroid injections histologically.
Methods:  35 rabbits (10 weeks old) pre-sensibilized with ovalbumin were divided into three groups: a placebo group of five (saline), an arthritis group of 15 (ovalbumin) and a steroid-treated group of 15 (ovalbumin + corticosteroid). Additionally, a group of seven rabbits receiving no sensibilization with ovalbumin and no intra-articular injections served as controls. Histomorphometry of the inflammatory changes in the subsynovial connective tissue (SSCT) of the TMJ included: (i) semi-quantitative (S-Q) scoring of inflammation and synovial proliferation, (ii) thickness measurements and fractional surface and (iii) stereological quantitative assessment of volume and plasma cells in thick sections of the SSCT by an optical fractionator.
Results:  The histomorphometry showed synovial proliferation in both the arthritis and the steroid groups. The plasma cell count obtained by the optical fractionator was significantly reduced when treating the TMJ with corticosteroids. However, the thickness of the synovial lining and volume of the SSCT as well as S-Q scoring of inflammation showed no difference between the arthritis and the steroid-treated groups. The optical fractionator proved a superior tool compared to S-Q assessments.
Conclusion:  Counting of plasma cells in the SSCT showed that corticosteroids reduced the inflammation, but did not eliminate it. Semiquantitative scoring of synovial proliferation and inflammation demonstrated low sensitivity regarding changes in immunomodulation in antigen-induced arthritis compared to stereological quantitative estimations using an optical fractionator.     

Long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint arthritis

The long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid (betamethasone) was compared in a sample of 24 patients who had pain and tenderness to palpation in the temporomandibular joint (TMJ arthritis) of at least six months duration, and who had not responded to conservative treatment. The two drugs were randomly allocated to the patients. The drugs, 0.5 ml, were injected twice into the superior joint compartment of the TMJ with a two-week interval between injections. The effect on subjective symptoms, clinical signs, and bite force was assessed. At the one and two-year follow-ups both the hyaluronate-and the corticosteroid-group had significantly reduced subjective symptoms as well as clinical signs, and the maximum voluntary bite force was significantly increased. The differences in effect between treatments were not statistically significant. It was concluded that both drugs have a significant long-term effect on chronic arthritis of the TMJ and that either of the drugs can be helpful; however, sodium hyaluronate might be the best alternative due to the least risk for side effects.     

化脓性颞下颌关节炎的内镜诊断和治疗

目的：探讨化脓性颞下颌关节炎内镜诊断和治疗的临床应用价值。方法：收集我院因化脓性颞下颌关节炎而行关节镜治疗的7例患者,对其临床表现、影像学特点、内镜下表现和治疗方法进行总结分析。结果：化脓性颞下颌关节炎的主要临床症状为关节区疼痛和开口困难;5例患者行磁共振成像,4例显示关节腔积液;2例患者行CT扫描,均显示关节周围间隙蜂窝织炎;7例患者均行内镜检查,2例急性期患者表现为滑膜肿胀和充血,5例慢性期患者主要表现为广泛黏连、软骨破坏和骨质缺损,3例患者关节盘穿孔,2例被诊断为纤维性强直。化脓性颞下颌关节炎内镜治疗方法主要为灌洗、黏连松解和关节面清理术。平均随访期57.4个月,术后无复发。结论：内镜被证实是诊治化脓性颞下颌关节炎的一种有效方法,尤其适用于慢性期患者。     

Long-term follow-up of intra-articular injections into the temporomandibular joint in patients with rheumatoid arthritis

A long-term (12 years) follow-up of treatment with intra-articular injections into the temporomandibular joint (TMJ) of steroid or non-steroid agents was performed in 21 patients with rheumatoid arthritis (RA) and symptomatic TMJs. The aim of the study was to compare symptoms, signs and radiological appearance of the TMJ initially and at the follow-up in this group of patients. Eleven patients were assigned to a steroid group and 10 patients to a non-steroid group. Initial and follow-up clinical and radiological examination procedures were the same. The radiological evaluation was based on a grading system using standard reference films. At follow-up, 14 patients reported no pain from the TMJ and positive changes in most clinical variables were found in both groups. Radiographic follow-up examination was performed on 12 patients. Initially, all but 4 of the 24 joints had structural bone changes. At follow-up, 2 joints had lower, 11 joints had unchanged and 11 joints had higher radiological grades. Two out of 5 and 3 out of 10 joints in the steroid and non-steroid group, respectively, showed progression of structural bone changes. Among 9 untreated joints, 6 had higher radiological grades and 3 were unchanged. In the 11 TMJs with higher radiological grades at follow-up, there was in most cases moderate progression of erosive changes. The results suggest that the long-term development of symptoms and signs from the TMJ in patients previously treated was good and the long-term progression of joint destruction was low for both steroid and non-steroid agents in this patient group with RA.     

Fibrous adhesions in the joint compartment of the temporomandibular joint associated with experimental opposite drawing mandibular ramus in rabbit

The purpose of this study was to develop a rabbit model of fibrous adhesions in the joint compartment of the temporomandibular joint (TMJ) without surgical invasion into the joint compartment. A unilaterally elastic force of about 120 grams was applied from the anterior edge of masseteric tuberosity to the posterior part of the zygomatic arch between the masseteric fascia layer and the subcutaneous layer in 14 rabbits. The blocks of nondrawing side TMJ were removed after four weeks. Fibrous adhesions were observed in 13 rabbits except for one rabbit that lost over 30% of its body weight. In eight of the rabbits, the adhesions were detected in both joint compartments. This animal model for fibrous adhesion of the TMJ will be useful in understanding the pathogenesis of adhesion in human TMJs.     

Cytokines in temporomandibular joint arthritis

As the article in the current issue by Shinoda and colleagues shows, during the last two decades, there has been a dramatic increase in the understanding of basic biology behind chronic temporomandibular joint (TMJ) pain, inflammation and destruction. The involvement and contribution of cytokines to TMJ pain and inflammation must now be considered as established, evident and fundamental. Based on the present knowledge, it is now possible to design and investigate novel therapeutic strategies. These new and very encouraging approaches include manipulation of cytokine function, immune reactivity and the behaviour of inflammatory cells while maintaining the integrity of the affected tissue.     

The role of trauma on temporomandibular joint ankylosis and mandibular growth retardation: an experimental study

The purpose of this pilot study was to analyze the role of different types of trauma in the formation of temporomandibular joint ankylosis. The specific aim was to explore the physical and histological effects of trauma on temporomandibular joint and mandibular growth. Fifty-five growing white male guinea pigs were used for the study. Initially, cadaveric studies were performed (n = 1) to assess the topographic anatomy of the temporomandibular joint region. Animals were then assigned to pilot (n = 4), experimental (n = 40), and control (n = 10) groups. The pilot group was used to assess the technical feasibility of creating various trauma types and endurance of the animals to the surgery. Four types of trauma were carried out in the experimental group: A) intra-articular hematoma (n = 10), B) mechanical damage to the articular surface (n = 10), C) fracture of the condyle neck (n = 10), and D) excision of the condyle head (n = 10). Each trauma group was further divided into two subgroups. Procedures were performed unilaterally or bilaterally in the subgroups. In the control group, no procedure was performed. Subjects were examined after a 2-month follow-up period. The development and anatomical structure of the mandible were evaluated, and histopathological assessment of the temporomandibular joint was carried out in each group. The results revealed that hyaline cartilage of the condylar head had an important role in the development of the mandible and traumas targeting this site may cause ankylosis, growth retardation, and resultant facial malformations. Hence, mechanical damage to the articular surface (B1, B2) and resection of the condylar head (D1, D2) almost always resulted in ankylosis. Intra-articular hematoma alone (A1, A2) was established not be a causative factor for ankylosis formation, however.     

糖皮质激素对关节腔灌洗治疗关节盘不可复性前移位疗效的影响

目的探讨关节腔灌洗后加糖皮质激素注射对治疗关节盘不可复性前移位的短期、长期疗效以及髁突骨质影像改变的影响。方法按照随机原则将90例颞下颌关节盘不可复性前移位患者分为对照组（44例）和试验组（46例）,对照组在关节腔灌洗后只注入生理盐水,试验组在关节腔灌洗后注入生理盐水与醋酸曲安奈德的混合液。治疗后3~4周（短期）和6个月（长期）复查,采用疼痛自评视觉模拟尺和Fricton颞下颌关节指数评价临床疗效,影像学评价髁突骨质的改变。对有疼痛主诉的患者同时记录治疗后1周每天睡前疼痛分值。结果1）治疗后1周,试验组疼痛减轻更显著（P<0.05）。2）2组患者治疗前后的临床体征和疼痛均有统计学差异（P<0.001）,2种治疗方法均能有效改善症状和体征,但2组之间各项指标的比较均无统计学差异。3）治疗后大多数患者的髁突骨质没有明显的变化。结论除炎症疼痛明显者外,关节腔灌洗治疗关节盘不可复性前移位不必再加激素注射。     

颞下颌关节腔注射治疗的研究进展

颞下颌关节腔注射治疗已经有20多年的历史,是治疗颞下颌关节紊乱病的重要方法,但仍存在药物作用时间短,需要重复注射等问题。近年来,学者从不同角度进行了研究,力图提高颞下颌关节腔注射的治疗效果。本文就该方面的研究进展作一综述。     

The short-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint pain and dysfunction

The short-term effect of intra-articular injections of sodium hyaluronate and a corticosteroid (betamethasone) was compared in a sample of 33 patients who had pain and tenderness to palpation in the temporomandibular joint of at least six months duration that had not responded to previous conservative treatment. The two drugs were randomly allocated to the patients. A volume of 0.5 ml of the drug was injected twice into the superior joint compartment of the TMJ with a two-week interval between injections. The effect on subjective symptoms, clinical signs, and bite force was assessed. Both drugs reduced the symptoms and signs significantly, and no statistically significant difference in effect could be found between drugs in this regard. The results indicate that the difference between the drugs in terms of short-term therapeutic effects is small, and that sodium hyaluronate could be used as an alternative to corticosteroid for patients who have signs of TMJ inflammation, especially for those who have symptomatic osteoarthrosis.     

颞下颌关节上腔囊内黏连的内镜手术方法及疗效

目的：介绍颞下颌关节（TMJ）镜下治疗囊内黏连（IA）的术式,评价关节镜手术治疗TMJ上腔IA的疗效。方法：对142例（159侧）关节镜下证实有黏连的关节行黏连松解术、囊内清扫修整术或射频消融术,其中110例（123侧）伴随关节盘移位者,行关节盘复位固定术。术后随访检查包括患者的颌骨运动度、VAS疼痛测量值及自我评价。疗效分为优、良、差3级,将优、良定为手术有效;采用SPSS11.0软件包对手术前、后颌骨运动度和VAS疼痛测量值分别进行配对t检验。结果：平均随访期10.3个月（1～27个月）。疗效评价优33.80%（48/142）,良56.34%（80/142）,差9.86%（14/142）;总有效率90.14%（128/142）。93.66%（133/142）的患者自主症状较术前明显改善。术前平均开口度（23.14±5.93）mm（10～40mm）,术后平均开口度（37.48±3.51）mm（30～40mm）,较术前显著改善,经统计学处理有显著性差异（P〈0.01）。疼痛的VAS测量值术前平均28.94±23.54（0～80）,术后平均4.44±10.10（0～50）,手术前、后VAS测量值有显著差异（P〈0.05）。结论：关节镜手术治疗TMJIA疗效肯定,能增大患者的开口度,改善功能,减轻颌骨运动时的疼痛。     

颞下颌关节内压的研究进展

颞下颌关节是口腔颌面部仅有的活动关节,颞下颌关节紊乱病是颌面部最常见的疾病之一。关节内压随着关节内结构的变化和功能运动而改变,关节内压的改变是引起颞下颌关节紊乱的重要因素。对关节内压的研究和测量对疾病的发展及治疗具有一定的指导意义。该文对近年来颞下颌关节内压的研究进行了总结,重点在于关节内压产生的机制、影响因素、关节内压的测定及其对于临床治疗的意义。     

Ultrastructure of the human intra-articular disc of the temporomandibular joint

The ultrastructural appearance of the human intra-articular disc (IAD) was investigated in three discs that had been surgically removed due to disease from three female patients aged 47, 50, and 54 years of age. Regions of the IAD were selected from central areas that appeared to be least affected by disease. Sections were fixed in 2.5 per cent glutaraldehyde in 0.1 M phosphate buffer, pH 7.3 immediately after surgery. The regions examined showed no obvious signs of inflammation. The cells showed moderate amounts of the intracellular organelles associated with protein synthesis and secretion, and possessed considerable amounts of microfilamentous material, thus resembling those described in other mammals. Despite the large number of cells examined, only one cell showed evidence of a chondrocyte-like morphology in that it possessed an incomplete pericellular zone of microfilamentous material separating the cell membrane from the adjacent collagen bundles of the extracellular matrix (ECM). Thus, on morphological grounds, fibrocartilage was virtually non-existent in the specimens examined. The mean collagen fibril diameter was 43.9 nm and the fibril diameter distribution was not unimodal. Although the majority of fibrils had a relatively small diameter, two of the three specimens possessed many fibrils with diameters of over 100 nm, this being consistent with tissue subjected to tension. The mean area of a fibre bundle occupied by collagen (as opposed to the ground substance) was approximately 56 per cent.     

Evaluation of respiratory status and mandibular movement after total temporomandibular joint replacement in patients with rheumatoid arthritis

We performed total TMJ replacement to improve respiratory status and correct occlusion in six patients with destruction of the temporomandibular joint (TMJ) caused by rheumatoid arthritis. Morphological changes were evaluated on lateral cephalograms before and after surgery. Respiratory function and mandibular movement were assessed with the use of an apnea-monitor and an LED mandibular tracking device, respectively. After surgery, symptoms such as snoring and daytime sleepiness improved, and solid food could be masticated. Postoperative cephalograms showed that both the posterior airway space and ramal height were significantly improved by surgery. Postoperative records of mandibular movement indicated stability of the occlusion and improvement of mandibular movement, as compared with the preoperative records. Mean oxygen saturation significantly improved 1 month after surgery, whereas apnea and apnea-hypopnea indices did not change significantly.     

An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphine infusion

The management of refractory pain in the temporomandibular joint (TMJ) is both challenging and controversial. Arthrocentesis is a simple technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. We undertook an audit of 405 arthrocenteses in 298 patients over a 10-year period who had refractory pain in the TMJ. The pain was assessed subjectively by a visual analogue scale, both before arthrocentesis and at 1 and 6 months, and 1 year afterwards. A significant reduction in pain score was found after arthrocentesis (P < 0.001) and 269 patients (90%) found the procedure beneficial. We recommend arthrocentesis as an effective, minimally invasive technique in patients with continuing pain in the TMJ that is unresponsive to conservative management.