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TMJ Arthralgia: Methylprednisolone Injection May Be No Better than Saline for Relief

Researchers set out to determine the effectiveness of a single-dose IA injection of the corticosteroid for the relief of temporomandibular joint pain.

Reviewed by Leonard Goldstein, DDS, PhD

 

The temporomandibular joint (TMJ) connects the mandible to the temporal bone on the side of the skull. This joint is one of the most complex joints in the body because it has to allow for movement in several directions: up and down, side to side, and to some degree forward and backward. Talking, chewing, swallowing, and even yawning require fluid movement of the TMJ. Unfortunately, disorders of this joint are distressingly common. Misalignment or other disorders of the tendons, ligaments, and bones of the TMJ can create chronic, often intense pain. Headaches, earaches, limited motion of the joint, popping or even locking of the jaw are some of the common results of temporomandibular disorders.1 When arthralgia of the TMJ is not associated with general inflammatory disease, such as rheumatoid arthritis, local inflammation is usually thought to be involved.2

Treatments for TMJ pain typically include conventional analgesics and NSAIDs. When these are not effective, intra-articular (IA) injections of corticosteroids are often used to suppress localized inflammation. However, evidence as to the effectiveness of IA injections has been less than robust, particularly in patients without inflammatory disease.

The Swedish Agency for Health Technology Assessment and Assessment of Social Services determined that more evidence was needed to evaluate the efficacy of such treatments. In response, a team of Swedish researchers conducted a multicenter RCT to determine the effectiveness of a single-dose IA injection of the corticosteroid methylprednisolone for relief of TMJ pain. Results were published in the Journal of Oral Rehabilitation.2

Researchers concluded that methylprednisolone does not offer any advantage over saline over the course of 4 weeks and in fact may worsen TMJ pain. (Image: iStock)

Protocol

Study participants included patients from eight dental clinics in Sweden. Subjects were at least 18 years old with diagnosed unilateral TMJ arthralgia. Patients were excluded if they had:

  • existing connective tissue disease (including rheumatoid arthritis, Sjögren syndrome, and psoriatic arthritis – diseases which have been shown to respond well to a single IA dose of methylprednisolone)
  • TMJ sounds in the affected joint
  • an ongoing bacterial or viral infection
  • fibromyalgia or other generalized pain
  • ongoing dental surgery
  • received an IA corticosteroid injection within the past 6 months
  • were breastfeeding
  • were taking certain drugs
  • were allergic to local anesthetics.

Subjects were screened and diagnosed, after which 54 patients were randomly assigned to receive either a single-dose IA injection of methylprednisolone or a single IA dose of saline. 

Before the methylprednisolone injection was given, the auriculotemporal nerve was blocked using prilocaine-felypressin. After treatment, patients were allowed to use rescue analgesics if necessary. If pain relievers were used, patients recorded the dose and type of drugs used.

At the first visit, before receiving treatment, participants were given a diary to record their pain and use of analgesics during the 3 days before the treatment. One week later, they returned the diaries to the researchers for evaluation. After treatment, patients made diary entries for another 5 days. (In some of the study centers, the diary was not used.) Immediately prior to treatment, the Visual Analogue Scale (VAS) was used to rate pain on a scale from “no pain” to “worst pain imaginable.”

The patients were seen again – for the third and final visit of the study – 4 weeks after the treatment. At this visit, patients completed another pain questionnaire and were examined by a second dentist. This clinician was blind to the therapy group. In addition to administering the pain questionnaire, this second dentist evaluated patients for maximum mouth opening with and without pain, as well as for operator-assisted opening. In addition, the distance between the lower and upper jaw incisal teeth edges was measured and the presence of crepitation was recorded.2

Results

According to the VAS scale, there was an absolute pain reduction of about 42% in both treatment groups. This led the researchers to conclude that methylprednisolone does not offer any advantage over saline over the course of 4 weeks. They also found that IA methylprednisolone actually worsened pain on the days following the injection. In addition, adverse events were twice as high in the methylprednisolone group as in the placebo group. These effects primarily included increased pain, although some patients experienced transient paresthesia of the eyelid, transient numbness, a rash or local allergic reaction, and/or headache. TMJ sounds and difficulty opening the jaw were noted by a small number of the methylprednisolone subjects; misalignment of teeth was noted by a small number in both groups.2

 

In addition to its relatively small size, one limitation of the study was that neither CT nor MR imaging was used by the diagnosing clinicians to ensure that none of the patients had osteoarthritis of the TMJ, nor was disc displacement without reduction, a differential diagnosis to arthralgia, ruled out.2

Nonetheless, the results were relatively straightforward, leading to further questions about the mechanism behind the improvement. “The question becomes whether TMJ arthralgia is caused by an inflammation triggered by IA agents, which is diluted at the IA intervention, or whether the nerve block anaesthetic stops a windup phenomenon,” the authors wrote, and continued, “although injected extra‐articularly, the agent may have had an impact on the study results.” Further research will be needed to sort out the reason for the demonstrated pain reduction.

Last updated on: April 9, 2020
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