Targeted Injection Therapies for Temporomandibular Joint Disorders: A Comparative Review of Hyaluronic Acid and Botox Techniques

Temporomandibular joint disorders (TMDs) are widely researched diseases in medical literature. They are associated with many symptoms, such as pain, limited mouth opening and joint sounds, resulting in decreased quality of life for the patient. Both the hyaluronic acid (HA) injection and the plateletrich plasma (PRP) injection have a remarkable efficacy in the treatment of TMDs. This study aimed to evaluate the participation of HA with PRP in the treatment of TMDs. The sample consisted of 24 patients with unilateral or bilateral TMDs. They were divided into 2 groups: HA+PRP was used in the test group (12 patients); and HA alone was used in the reference group (12 patients). The injection protocol for both groups was 4 times at 2-week intervals. Pain at mastication, masticatory efficiency, joint sounds, maximum mouth opening (MMO), and functional limitation in the mandibular movement were evaluated at 2 weeks, 1 month, 3 months, and 6 months after the last injection. The outcome variables were the visual analog scale (VAS) evaluations. The Likert-type scale was used to evaluate the functional limitation in the mandibular movement. The mean age was 30.58 years in the reference group, and 23.92 years in the test group. There was alleviation of symptoms in both groups through the follow-up periods. There were significant differences between the groups regarding pain at mastication, masticatory efficiency, MMO, and functional limitation at the end of the follow-up period (p < 0.05). The study results suggest that the HA and PRP injection provides greater improvement in patients with TMDs as compared to the HA injection alone; this may be due to taking advantage of the properties of both HA and PRP.

BackgroundThis study aimed to evaluate the clinical efficacy of platelet-rich plasma (PRP) injection compared with hyaluronic acid (HA) injection for patients undergoing knee osteoarthritis.MethodsWe systematically searched electronic databases including PubMed, Embase, Web of Science, and the Cochrane Library on January 23, 2020 to identify relevant studies issued in English languages. The outcomes evaluating the efficacy of knee osteoarthritis (KOA) treatment were Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (WOMAC pain, function, stiffness, and total scores) at 1, 3, 6, and 12 months; International Knee Documentation Committee (IKDC) scores, Lequesne Index score, Visual Analog Scale (VAS) scores, EQ-VAS scores, and KOOS scores. The pooled data were analyzed by Stata 12.0.ResultsA total of 20 RCTs were enrolled in the present meta-analysis. The pooled results demonstrated that platelet-rich plasma (PRP) injection reduced pain more effectively than hyaluronic acid (HA) injection at 6-month and 12-month follow-up evaluated by WOMAC pain scores and VAS scores. EQ-VAS in the patients treated with PRP injection was lower than that in patients with HA injection at 12 months. Moreover, the patients with PRP injection had a better function recovery than those with HA injection at 1-month, 3-month, 6-month, and 12-month follow-up, as evaluated by WOMAC function scores. WOMAC total scores showed significant difference at 6-month and 12-month follow-up. The IKDC scores indicated PRP injection was significantly more effective than HA injection at 3 months and 6 months. However, the Lequesne Index scores, KOOS scores, and adverse events did not show any significant difference between groups.ConclusionIntra-articular PRP injection appeared to be more efficacious than HA injection for the treatment of KOA in terms of short-term functional recovery. Moreover, PRP injection was superior to HA injection in terms of long-term pain relief and function improvement. In addition, PRP injection did not increase the risk of adverse events compared to HA injection.

Although arthrocentesis is an accepted safe treatment modality for the management of temporomandibular disorders (TMD) in symptomatic patients, the benefit of hyaluronic acid (HA) injections remains uncertain. The aim of this study was to evaluate whether intra-articular HA injections adjunctive to arthrocentesis can be more effective than other medications for the improvement of TMD associated symptoms. Additionally, the impact of HA injections on quality of life of TMD patients was assessed with SF-36® questionnaire in a cohort of patients. An electronic search of Medline, Scopus and Cochrane databases was performed up to March 2020. The following search terms were used: "arthrocentesis", "hyaluronic acid", "intra-articular injections", "visco-supplementation", "temporomandibular disorders". Prospective and retrospective studies that reported the application of HA injections compared to other intra-articular drugs for the treatment of temporomandibular disorders were included. Systematic or narrative reviews and pre-clinical studies were excluded. Additionally, a retrospective clinical study was performed for evaluation of changes in quality of life before and after arthrocentesis with HA injections. In the systematic review, the initial search yielded 1327 articles. After screening of the titles, abstracts, and full texts, 29 studies were selected (26 randomized studies, 2 controlled clinical trials, 1 retrospective report). In the clinical study, 12 patients were included. Intra-articular injections of HA and other medications together with arthrocentesis seemed to be beneficial for improvement of functional symptoms of TMD and pain. The case series also supported the efficacy of HA injections showing an improvement of quality of life of these patients. However, from literature review, it was impossible to identify an optimum drug or a protocol for predictably improving the pain and/or functional symptoms of temporomandibular problems, due to different etiologies, diversity of treatment modalities and conflicting results. In conclusion, there is no consensus in the literature that HA injections shows better results in comparison with other treatment modalities. According to the results of the present clinical study, HA injections with/without arthrocentesis seems to be beneficial in terms of clinical symptoms and quality of life of the TMD patients.

Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears.

BACKGROUND: Adhesive capsulitis of the shoulder causes inflammation and adhesions in the shoulder joint capsule, leading to pain and limited range of motion (ROM). Intraarticular corticosteroid (CS) and hyaluronic acid (HA) injections are common therapeutic options for adhesive capsulitis, but their comparative effectiveness remains unclear. OBJECTIVES: To provide a robust comparison of the outcomes of HA and CS, we conducted a meta-analysis of relevant previous studies that examined the therapeutic effects of intraarticular HA and CS injections in patients with adhesive capsulitis. STUDY DESIGN: Systematic review and meta-analysis. METHODS: This meta-analysis of randomized controlled trials compared the effectiveness of intraarticular HA and CS injections. Of the 10,205 articles, 7 met our predetermined criteria and were included in the analysis. RESULTS: Patients who received CS injections demonstrated superior pain reduction and functional improvement at 2-4 weeks after injection to those who received HA injections. Nevertheless, comparable outcomes were observed between the 2 groups at 6 and 12 weeks. The active or passive range of motion of the shoulder joint was not significantly different between patients who received HA injections and those who received CS injections. LIMITATIONS: The meta-analysis included only a small number of studies, and the number of HA injections examined in those studies varied from one to 3 at a time, whereas an CS injection was performed only once in most of the included studies. CONCLUSIONS: The administration of intraarticular HA injection emerges as a commendable therapeutic option for patients with adhesive capsulitis, particularly for those requiring repetitive injections or at risk of developing side effects from injections of CS. Although intraarticular CS injections offer accelerated short-term (2-4 weeks) pain relief and functional improvement, comparable effects were observed within 6 and 12 weeks after intraarticular HA and CS injections. KEY WORDS: Adhesive capsulitis, shoulder, corticosteroid, hyaluronic acid, pain, function, injection, meta-analysis

Effects of supplementing extracorporeal shockwave therapy to hyaluronic acid injection among patients with rotator cuff lesions without complete tear: a prospective double-blinded randomized study.

To determine whether hyaluronic acid (HA) injection into rheumatoid arthritis ankles and feet can achieve improvement in foot function and reduce synovial hyper-vascularization. Forty-four patients with RA having unilateral or bilateral painful ankle and foot involvement (N = 75) were studied. All the patients were randomized to receive HA (N = 40) or lidocaine (LI) (N = 35) injection at 2-week intervals; Clinical assessments were performed using a visual analog scale (VAS) and foot function index (FFItotal) including subscales of pain (FFIpain) before injection at baseline, 4 weeks (first evaluation) and 12 weeks (secondary evaluation). Imaging evaluation based on color Doppler ultrasound (CDUS) and synovitis scores was performed simultaneously. HA injection improved the VAS score (p = .009), FFIpain (p = .041), and FFItotal (p = .032) considerably more than LI injections did at the first evaluation. The CDUS values at first evaluation (p = .005) and secondary evaluation (p < .001) decreased significantly compared with the base line values. HA injections reduced the CDUS values of more than half of the joints (54%, p = .042) while the control group exhibited no change (20%, p = .56). However, HA injection did not reduce the CDUS values more than LI injection did. Regarding the evaluation of synovial hypertrophy, no significant difference was observed between or within the groups in the synovitis scores. HA injection improved short-term foot function and pain reduction. HA injection may have a modest effect in reducing synovial hyper-vascularization. Further large-scale study is warranted to confirm this result.

Background Rotator cuff syndrome, including tendinopathy and partial-thickness tears, is a common cause of shoulder pain. While conservative management remains the first-line treatment, subacromial hyaluronic acid (HA) injections have been proposed as an alternative for patients with persistent symptoms. Methods This retrospective case series evaluated the clinical outcomes of subacromial HA injections in adults diagnosed with rotator cuff syndrome, presenting with tendinopathy or partial-thickness tears on MRI. Patients received two HA injections, two weeks apart. The primary outcome was the improvement in the American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included the Single Assessment Numeric Evaluation (SANE) score and pain reduction using the visual analog scale (VAS). Assessments were conducted at baseline and at one, three, six, and 12 months post-injection. Results A total of 41 patients (68 shoulders) were included, with a mean age of 50.1 ± 14.5 years; 53.6% were female. The ASES score improved from 45.5 ± 17.2 at baseline to 63.4 ± 25.1 at 12 months (p < 0.001). The SANE score increased from 61% ± 17 to 76% ± 19 (p = 0.013), while VAS decreased from 6.3 ± 1.9 to 4.3 ± 3.0 (p < 0.001). There was no difference in the ASES, SANE, and VAS scores between the tendinopathy and partial tear groups at any moment. Conclusion Subacromial HA injections resulted in clinically and statistically significant improvement in ASES, SANE, and VAS scores at 12 months. The treatment provided consistent symptom relief and functional improvement over time, with no reports of complications.

Short-Term Effect of Ultrasound-Guided Low-Molecular-Weight Hyaluronic Acid Injection on Clinical Outcomes and Imaging Changes in Patients with Rheumatoid Arthritis of the Ankle and Foot Joints. A Randomized Controlled Pilot Trial

Background: Tendinopathies are manifested by pain, swelling, and limited mobility functions.Corticosteroid injections have been a mainstay in the treatment of tendinopathy, and are widely used despite the controversy regarding their usefulness and safety.The peri-tendinous administration of hyaluronic acid (HA) has shown promising results in the management of tendinopathy. Objectives: The aim of the current study was to evaluate the efficacy of peri-tendinous injections of hyaluronic acid versus steroid injections on pain reduction in patients with painful tendinopathies. Patients and methods: A prospective study, including a total of 90 patients with tendinopathy who were recruited from the Rheumatology and Rehabilitation Outpatient Clinic at Sohag University Hospital. Demographic data including age, disease duration, and tendon affected were evaluated. Patients were divided into three groups, each group contained 30 patients. First group received peritendinous steroid injection, second group received peritendinous hyaluronic acid injection, and the third group received both peritendinous hyaluronic acid and steroid injections. Groups were compared using in visual analogue scale, tenderness and range of motion after one week, one month and after 3 months from injection. Results: Best improvement was seen in the group of combined hyaluronic acid and steroid; followed by the group of steroid injection alone, which showed early response better than hyaluronic acid alone. Conclusion: Local injection for tendinopathies by combined hyaluronic acid and steroid gives significantly better and more long standing effect compared to either hyaluronic acid or steroid alone. On the other hand, monotherapy showed non-significant difference between steroid and hyaluronic acid.

Arthrocentesis plus intra-articular hyaluronic acid (HA) injection for temporomandibular joint (TMJ) disorders is known to be a safe and minimally invasive surgical procedure. Arthrocentesis plus HA injection has a pain-reducing effect on TMJ disorders. It is also a palliative treatment that yields positive results in terms of clinical findings such as clicking and mouth opening. Even though some complications have been reported after the performance of this highly successful procedure, the development of bilateral TMJ dislocation after arthrocentesis plus intra-articular HA injection has not been reported to date. This case report presents bilateral TMJ dislocation following arthrocentesis plus intra-articular HA injection that developed within a few hours and resisted manual Hippocrates manoeuvre in a 21-year male. Herein, his treatment with systemic corticosteroid therapy, myorelaxant and anti-inflammatory drugs is also presented. Key Words: Arthrocentesis, Hyaluronic acid, Joint dislocation, Temporomandibular joint, Steroids.

We aimed to assess the relationship between myeloperoxidase (MPO) and internal derangement (ID) of temporomandibular joint (TMJ) and effects of arthrocentesis procedure, either alone or in combination with hyaluronic acid (HA) injection on the prognosis of ID of TMJ. A prospective randomised controlled trial has been conducted through patients, who underwent arthrocentesis for the treatment of ID of TMJ, were randomly divided into two groups. Group SS (n=10) and Group HA (n=14) patients were assigned 0·9% NaCl solution and sodium hyaluronate intra-articularly, respectively. Synovial fluid samples were assayed for MPO at the time of arthrocentesis and pain visual analogue scale (VAS) and maximum mouth opening (MMO) scores were recorded at pre- and post-operative periods as well as first-week, first-month and third-month intervals. There was a statistically significant decrease in MPO levels between the first to second arthrocenteses only in Group 2 (P=0·001). Both VAS scores and MMO measurements decreased in the course of time following arthrocentesis and donot differ between the patients administered HA or SS. Similarly MPO levels do not change significantly between the two groups at either first or second arthrocenteses. In HA group, MPO levels significantly decreased from first to second sessions. In HA group, MPO levels decreased significantly only in patients with clinical success. Arthrocentesis procedure improves both pain VAS and MMO scores in the course of time, but these parameters do not differ between patients receiving either HA or SS. HA significantly reduces levels of MPO in synovial fluid, but SS does not. HA appears to alleviate inflammation inside the TMJ in patients with TMJ-ID.

The prevalence of knee osteoarthritis is increasing in the aging U.S. The efficacy and cost-effectiveness of the use of hyaluronic acid (HA) injections for the treatment of knee osteoarthritis are debated. In this study, we assessed the utilization and costs of HA injections in the 12 months preceding total knee arthroplasty (TKA) and evaluated the usage of HA injections in end-stage knee osteoarthritis management in relation to other treatments. MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases (Truven Health Analytics) were reviewed to identify patients who underwent TKA from 2005 to 2012. The utilization of patient-specific osteoarthritis-related health care (including medications, corticosteroid injections, HA injections, imaging, and office visits) and payment information were analyzed for the 12 months preceding TKA. A total of 244,059 patients met the inclusion criteria. Of those, 35,935 (14.7%) had ≥1 HA injection in the 12 months preceding TKA. HA injections were responsible for 16.4% of all knee osteoarthritis-related payments, trailing only imaging studies (18.2%), and HA injections accounted for 25.2% of treatment-specific payments, a rate that was higher than that of any other treatment. Patients receiving HA injections were significantly more likely to receive additional knee osteoarthritis-related treatments compared with patients who did not receive HA injections. Despite numerous studies questioning the efficacy and cost-effectiveness of HA injections for osteoarthritis of the knee, HA injections are still utilized for a substantial percentage of patients. Given the paucity of data supporting the effectiveness of HA injections and the current cost-conscious health-care climate, decreasing their use among patients with end-stage knee osteoarthritis may represent a substantial cost reduction that likely does not adversely impact the quality of care.

Category: Ankle, Arthroscopy Introduction/Purpose: Non-operative treatment options with symptomatic OLT after failed primary arthroscopic treatment may be treated by various methods such as analgesics, anti-inflammatory drug, steroid injection, Platelet rich plasma (PRP) injection and hyaluronic acid (HA) injection. HA injection could be treated OLT besides osteoarthritis on knee or ankle joint. Effect of HA is viscoelastic and lubricating properties primarily, and other biomechanical effect can be considered. Purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection in the patients with recurrent pain after the arthroscopic microfracture for OLT Methods: This study included 20 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between June 2014 and August 2016. All patients had persistent pain for more than 3 months after the index surgery. The patients were followed for 16.7 months (range: 4.6-30.9). At each visit, the efficacy of HA injection in reducing pain was evaluated by a Visual Analog Scale (VAS). In addition, subjective satisfactions were assessed by the Alexander scale. Results: The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS scores decreased from 6.7 ± 1.1 at a pre-injection to 3.8 ± 2.3 at post-injection six months (p = 0.02). According to the Alexander scale, there were 65.0% (13/20) good, 25.0% (5/20) fair, and 10.0% (2/20) poor results at post-injection six months. There was no severe adverse effect. Conclusion: The HA injection may be a useful treatment option after failed arthroscopic microfracture in OLT. Further studies will be needed to evaluate long-term results.

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Objectives: The present study aims to investigate the effects of high molecular weight hyaluronic acid (HA) injections in treating CTS, as HA is frequently used for various musculoskeletal conditions but has not been studied for this specific application. Methods: A randomized controlled trial was conducted involving 60 patients diagnosed with mild to moderate CTS with a 1:1 allocation ratio. The patients were randomly assigned to two groups: A control group received lidocaine and normal saline injections, while an HA group received lidocaine and 2% HA injections. Splints were provided to both groups. The injections were administered under ultrasound (US) guidance using an in-plane ulnar approach, and outcome assessments were carried out by blinded investigators. The Boston Carpal Tunnel Questionnaire (BCTQ), Visual Analog Scale (VAS), and electrodiagnostic and sonographic measures were evaluated before treatment and at a 10-week follow-up. Results: Forty-eight patients completed the study (25 in the HA group, 23 in the control group). Both groups demonstrated statistically significant improvements over 10 weeks. However, the HA group achieved a notably greater reduction in pain, with VAS scores declining from 6.08 ± 1.68 to 2.44 ± 1.04 (mean difference: 3.64 ± 1.32) compared to a decrease from 6.39 ± 0.99 to 3.96 ± 1.67 (mean difference: 2.44 ± 1.59; P = 0.006). Similarly, improvements in both the symptom severity and functional status components of the BCTQ were significantly superior in the HA group (P = 0.005 and P = 0.004, respectively). Although both groups exhibited significant within-group improvements in electrophysiological parameters (DSL and DML) and reductions in the median nerve (MN) cross-sectional area, no significant between-group differences were observed. Notably, a higher percentage of patients in the HA group attained a normal CTS severity state (32% vs. 8.7%), although this difference was not statistically significant (P = 0.103). Conclusions: The findings suggest that ultrasound-guided HA injection via an in-plane ulnar approach significantly alleviates pain and improves functional status in patients with mild to moderate CTS, whereas electrodiagnostic and sonographic outcomes did not differ significantly between the treatment and control groups.