Hyaluronic Acid and TMJ
Hyaluronic acid (HA) composed of repeating units of 12500 monosaccharides is a mucopolysaccharide acid present in ground substance animal tissues. HA plays an important role in the lubrication, nutrition, hemostasis and pressure buffering functions of temporomandibular joint (TMJ). Since 1987, clinical use of HA in medicine has become widely available. HA promotes wound healing and moderates inflammation and cellular immune response and therefore provides analgesic, anti-inflammatory and cartilage protection functions (Balazs EA, 1993. Lehninger A,2002. Nitzan DW,2002)。
The HA application on treating joint disorders began in the late 1960s for treating traumatic arthritis in racing horses (Rydel NW, 1970). The HA application on human body began in 1970s for treating osteoarthritis in large joints (e.g. femoral, knee, shoulder joints) (Peyron JG, 1974). Case reports of HA application for treating internal derangement of TMJ were published after 1979 (Kopp S,1981)。
In inflamed or degenerative joints, the content and molecular weight of HA decrease(Listrat V,1997.Radin EL,1971). When the undertaken forces go beyond the capacity of the joint, tissue hypoxia occurs and free radicals are generated to break down HA, leading to decreasing viscosity of synovial fluid, loss of lubricating function, increasing intra-articular friction and damage of articular structure.
Intra-articular injection of HA can increase the concentration of high molecular weight HA in the joint, and therefore restore its lubrication, nutrition and joint protection functions to reduce the harm from physical pressure, improve range of joint motion and circulation of synovial fluid (Quinn JN,1990. Nitzan DW,2002).
In addition intra-articular injection of HA reduces the concentration of intra-articular pain associated intrinsic factor and blocks the receptor to reach the goal of joint pain relief
Shots of corticosteroids (also referred to as glucocorticoids or steroids) were widely used to treat all kinds of arthritis in the early times. While corticosteroids can be highly effective in anti-inflammation, it was discovered that significant side effects (e.g. articular infection, damage of cartilage or ligament) developed with long-term use or overdoses, due to their strong and negative effects on metabolism. General recommendation of applying shots of corticosteroids is not exceed two times with 6 months, which therefore is not applicable to treatment of long-term or chronic TMJ arthritis (Wannmacher L,1998)。
Clinical references showed that compared to intra-articular steroid injection, intra-articular HA injection had similar or even better analgesic effect in short-(Shi ZD,2002. Kopp S,1991), medium- (Bertolami CN,1993. Hepguler S,2002), or long-term (Bjørnland T,2007. Kopp S,1991 ) treatment while avoiding the side effects of long-term or massive dose of intra-articular steroid injection. Moreover, arthroscopy or arthrocentesis combined with intra-articular HA injection greatly reduce the pain with longer duration (Miguel-Angel MM,2010)。
For patients exhibiting poor response to conservative treatments of TMJ internal derangement combined with osteoarthritis and joint pain, intra-articular HA injection is a good therapeutic option. Better clinical outcomes can be achieved if further combined with TMJ arthroscopy.
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