Rajiv Gandhi University of Health Sciences s56

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE AND DR. BIMLESHWAR KUMAR ADDRESS POST GRADUATE STUDENT, DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, FORT BANGALORE-560002.

2. NAME OF THE INSTITUTE GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.

3. COURSE OF STUDY AND MASTER OF DENTAL SURGERY IN SUBJECT ORAL AND MAXILLOFACIAL SURGERY. 4. DATE OF ADMISSION TO COURSE 31.05.2008

5. TITLE OF THE TOPIC:

“COMPARISION OF CORTICOSTEROID AND SODIUM HYALURONATE AFTER ARTHROCENTESIS IN THE TREATMENT OF INTERNAL DERANGEMENT OF TEMPOROMANDIBULAR JOINT”.

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY: -

Several treatment modalities have been proposed to treat internal derangements of temporomandibular joint (TMJ), these include conservative methods such as diet modification, occlusal splint therapy, physiotherapy, pharmacotherapy, transcutaneous electrical nerve stimulation(TENS) and stress reduction techniques and surgical methods such as arthroscopy, reconstruction arthroplasty(disk reposioning), meniscectomy(diskectomy), eminectomy, and repair of perforation of disk . Although essential to treat internal derangement of TMJ, conservative approaches had minimal effect on alleviating symptoms, While surgical approaches had complications such as adhesions, excessive bone resorption of condyle or glenoid fossa and failure to reduce pain level in TMJ1, 2.

1 Recently arthrocentesis is gaining popularity in the treatment of internal derangement of TMJ. Being minimally invasive it doesn’t have the demerits of surgical approaches and at the same time is producing better results than conservative approaches3.

. Further corticosteroid injection into the joint at the termination of arthrocentesis has once again improved the outcome of long term palliative effect, subjective symptoms and clinical signs of TMJ pain. Recently Sodium hyaluronate has been proposed instead of corticosteroid, at the end of arthrocentesis on the joint with a similar effect, as corticosteroid injection is known to have unpredictable results and cause local side effects.4

However no studies have been conducted comparing the corticosteroid and sodium hyaluronate after arthrocentesis in the treatment of internal derangement of TMJ. This study has been taken up to enlighten further and fill this void.

6.2 REVIEW OF LITERATURE:

1. W.L.MCcarty has stated that if mandibular opening is less than 27 mm, lateral excursion is less than one forth of normal mouth opening and joint noises occur. Then after a through evaluation treatment of internal derangement should be begin with non surgical treatment such as medication, physical therapy and occlusal modification. If patients are unresponsive to non surgical therapy, surgical treatment such as reconstruction arthroplasty, menisectomy should be done.

2. V.Karis and R.Glickman in the study state that treatment of any TMJ disorder should be started with non surgical methods such as diet, pharmacotherapy, physical therapy, stress reduction techniques occlusial and occlusal appliance therapy. L. B. Heffez state that open surgical therapy of TMJ internal derangement is now tertiary line of cares following non surgical therapy and arthrocentesis/arthroscopy.He also state that arthrocentesis with and without steroid injection has become main stay of treatment.

3. In the study of 17 patients complaining of suddenly occurring severe and persistent limited mouth opening were treated by irrigation of the TMJ joint with ringer’s lactate solution. Thus simple treatment was found to be highly effective in re-establishing normal opening and relieving pain for a follow-up period of 4 to 14 months.

4. In the study of 41 TMJ patients complained that limited mouth opening TMJ pain and tenderness and joint noises during function in which one group received arthrocentesis and other group had taken arthrocentesis with Sodium hyaluronate. Although and concluded that patient benefited from both techniques, arthrocentesis with injection of Sodium hyaluronate seemed to be superior to arthrocentesis alone.

2 6.3 AIM AND OBJECTIVES OF THE STUDY: - The aim of the study is to compare the effectiveness of Corticosteroid (Betamethasone) and Sodium hyaluronate after Arthrocentesis in the treatment of internal derangement.

OBJECTIVES:-

1. Evaluate the incidence of complication and local side effects after treatment.

MATERIALS AND METHODS : -

7.1 SOURCES OF THE DATA.

Patients visiting the Department of Oral and Maxillofacial Surgery, Government Dental college and Research Institute , Bangalore.

7.2 METHODS OF COLLECTION OF DATA.

Patients are selected randomly who have internal derangement of TMJ, sample size 20 (10 in each group).

INCLUSION CRITERIA: -

1. Patient complaining of sudden, severe TMJ pain with limited mouth opening.

2. Patient diagnosed clinically and radiographically of internal derangement.

EXCLUSION CRITERIA: -

1. Patient with previous TMJ surgery.

2. Medically compromised patient

3 PROCEDURE:

Patient who have TMJ problem with internal derangement are selected randomly and divided into two groups, one group receiving corticosteroid(Betamethasone) and other group receiving sodium hyaluronate after arthrocentesis.

Two points are marked over the skin surface of the affected joint followed by injection of local anesthetic to block the auriculotemporal nerve. A 19 gauge needle is then inserted into the superior compartment at the articular fossa, followed by injection of 2 to 3 mL of ringer’s solution to distend the joint space. Another 19 gauge needle is then inserted into the distended compartment to enable free flow of the solution through superior compartment. The Ringer’s lactate is connected to one of the needles and sufficient pressure is given to allow free flow of 200 ml during 15 to 20 minute. On termination of the procedure, 1 ml (6 mg) Betamethasone or 1 ml sodium hyaluronate is injected into the joint space followed by removal of the needle.

Both groups are followed for a period of 6 months and evaluated for pain, maximal mouth opening(MMO) and clicking before the procedure, then at 2 days , 1 and 2 weeks and 1, 2, and 6 months after the procedure. Intensity of pain is determined by the self-assessment using visual analog scale (VAS), ranging from 0-10.The clinical examination of MMO is measured by the distance between the incisal edge of the upper and lower central incisor. Presence of clicking is determined clinically as non, early, or late click and crepitus

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

NOT REQUIRED

4 8. LIST OF REFERENCES:

1. David. A. Keith: Surgery of the temporomandibular joint. Boston, Blackwell Scientific Pub. 2nd edition; 1992; 180-224.

2. M. Milaro, G. E. Ghali, P. E. Larsen, P. D. Waite: Peterson`s Principles of oral and maxillofacial surgery. Hamilton, London, BC Decker Inc, 2nd edition 2004, 931-1048.

3. D.W. Nitzan, M.F. Dolwik: Temporomandibular joint arthrocentesis: A simplified treatment for severe, limited mouth opening. J Oral Maxillofac surg 1991: vol 49, 1163-1167.

4. Gokhan H Alpaslan, Cansu Alpaslan : Eficacy of Temporomandibulr Joint arthrocentesis with and without injection of sodium hyaluronate in the treatment of internal derangements. J Oral Maxillofac Surg 2001:59; 613- 618.

5 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11 NAME AND DESIGNATION OF

11.1 GUIDE DR. A. SIDDARAJU, ASSOCIATE PROFESSOR, DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE.

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

6 11.5 HEAD OF THE DEPARTMENT DR. GIRISH GIRADDI, PROFESSOR AND HEAD, DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE. 11.6 SIGNATURE

12. 12.1 REMARK OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE