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Effect of intra-articular morphine sulfate following arthrocentesis of the temporomandibular joint: a prospective comparative study.



The objective was to evaluate the effect of intra- articular morphine sulfate injection following arthrocentesis on patients with TMJD.

Thirty patients with refractory TMJD underwent arthrocentesis for the TMJ and were divided into two groups. First group was given morphine sulphate intra-articularly post arthrocentesis but to the other group no intra-articular medication was given. Patients were evaluated for pain joint sounds and mouth opening pre and postoperatively.

There was a significant improvement regarding pain scores mouth opening and joint sounds in both groups. The first group showed more improvement immediately post operatively.

Arthrocentesis of the TMJ is a simple procedure for refractory TMJD cases with significant im- provement in symptoms. Morphine sulphate as an intra-articular injection following arthrocentesis further improves the immediate post operative symptoms.

Key Words: Temporomandibular joint Arthrocentesis Morphine.


The temporomandubular joint (TMJ) is a compound diarthrodial synovial joint with two compartments and four articulating surfaces.1 Temporomandibular joint dysfunction (TMJD) is a significant condition that affects 5% of population. The cardinal signs are pain clicking and limitation of mouth opening. Various non- surgical and surgical treatment modalities have been described.23

Arthrocentesis is a simple minimally invasive and safe technique for treatment of TMJD by flushing out the TMJ through placing small needles into the upper

compartment using local anesthesia and sedation. Ringer's lactate or physiologic saline are the most commonly used solutions for lavage. The effectiveness of this method can be explained by the joint space expansion achieved with the introduction of fluid and by the washing out of inflammatory mediators and cataboltes.45

Many researchers have reported the analgesic effect of opiods for the peripheral receptors however few studies have reported the intra- articular analgesic effects.67 Morphine sulfate as an intra- articular injec- tion was used in many joints of human body including TMJ and knee joints with an evidence of sustained

analgesic effect without causing histological changes

in any of the joint space tissues.6-8

The aim of this study was to evaluate the effect of intra- articular morphine sulfate injection following arthrocentesis on patients with TMJD in comparison with arthrocentesis with no other intra- articular in- jections.


in the department of oral and maxillofacial surgery at King Hussain Medical Center between 2011 and 2013 thirty patients (19 female 11 male) with refractory TMJD underwent arthrocentesis. TMJD was diagnosed using the clinical and radiographical criteria. All pa- tients had undergone prior medical and conservative treatments including nSAiDS muscle relaxants bite plates and physiotherapy with no clinical improvement.

The preoperative evaluation for the involved pa- tients included pain upon mouth opening which was recorded according to the pain visual analogue scale (VAS) score 0-10; presence of joint clicking sounds and maximum mouth opening measured by the maximum inter- incisal distance (MiiD).

Arthrocentesis procedures were performed by the same surgeon with the aid of local anesthesia and iV sedation. nitzan et al's9 surgical technique was applied in which the first needle was inserted 10mm from the tragus on the cantho-tragus line and 0.5mm below this line. The second needle was inserted 20mm from the tragus and 1mm below it. 19G needles were placed on each point and the joint irrigated with 250cc of normal saline under continuous pressure.

Patients were divided into two groups; in the first one 10mg morphine sulfate was injected intra- articu- larly immediately at the end of arthrocentesis procedure while in the second group no injections were given. All patients were re-evaluated immediately postoperatively and on the 2nd day 2nd week 3rd and 6th month in terms of pain clicking and limitation of mouth opening.


Thirty patients were involved in this study with a mean age of 21 years. There was a significant decrease in VAS scores at all postoperative intervals (pless than 0.01) with more improvement presented in the first group for the immediate postoperative VAS scores. However two patients from the second group reported no pain improvement (Table 1).

Evaluation of mouth opening revealed increased MiiD at all postoperative intervals (pless than 0.01). There was a significant difference between the two groups immediately postoperatively with more improvement in the first group. However this difference became insignificant at the following postoperative intervals (Table 2).

Joint sounds improved in 8 patients however 22 patients reported no or minimal improvement. There was no significant difference between the two groups regarding joint sounds.


Arthrocentesis was first described by nitzan et al (1991) as the simplest form of TMJ surgery with low morbidity and low cost compared to other TMJ surgical procedures. it is usually indicated following failure of other non surgical and pharmacological methods of treatment of TMJD. Most common intra- articular in- jections following arthrocentesis are steroids nSAiDS and sodium hyaluronate.1

in the present study morphine sulfate was used as a post arthrocentesis intra-articular injection. This M-agonist opiods have support for use in moderate to sever pain when administered intra-articularly with minimal side effects but whether the resultant anal- gesia is due to local or systemic effect is debatable.1011

Zunga et al9 studied the analgesic efficacy and safe- ty of intra- articular morphine following arthroplasty and concluded that intra- articular TMJ injection with morphine provide short acting analgesia. A prospective double blind placebo controlled clinical trial was per- formed in 2010 by Ziegler et al6 evaluating the analgesic effects of morphine in patients with TMJD concluded that 10mg morphine sulfate intra-articular injection give the best and long lasting analgesic effect.

in the current study there was a significant difference in both groups between the preoperative and postoperative VAS scores as well as the measurement of mouth opening with improvement of joint sounds. in the first group patients reported more improvement in regard of pain and mouth opening immediately post

Table 1: VAS scores for patients in both groups

###Group###Preop.###Immediate###48 hrs post-###2 weeks###3 months post-###6 months postop.

###VAS###postop. VAS###op. VAS###postop. VAS###op. VAS###VAS




Group###Preop MIID###Postop MIID



arthrocentesis procedure which support the analge- sic effect of morphine sulphate as an intra-articular medication. The more improvement regarding mouth opening may be related also to the analgesic properties of morphine which encourage the patients to open more.


Arthrocentesis of the TMJ is a simple minimally invasive procedure for refractory TMJD cases with sig- nificant improvement in symptoms. Morphine sulphate as an intra-articular injection following arthrocentesis further improves the immediate post operative symp- toms.


1 Ramesh Reddy Vallela Sasidhar Reddy Sunitha Red- dy Shailender Reddy. Arthrocentesis - A minimally invasive treatment of temporomandibular joint dysfunction: Our expe- rience. J nTR univ. Health Sci 2013; 2: 196-200.

2 Fonseca R Marciani R Turvey T. Oral and maxillofacial surgery

2nd ed. St. louis (MO): Saunders Elsevier; 2009. P. 815-833.

3 Hosaka H Murakami K Goto K iizuka T. Outcome of ar- throcentesis for temporomandibular joint with closed lock at 3

years follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol

Endod. 1996 nov; 82(5): 501-04.

4 Guarda-nardini l Manfredini D Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique.Oral Surg Oral Med Oral Pathol Oral Radiol En- dod. 2008 Oct; 106(4): 483-86.

5 Murakami K Hosaka H Moriya y Segami n iizuka T. Short- term treatment outcome study for the management of temporo- mandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Sep; 80(3):


6 Ziegler CM Wiechnik J MA1/4hling J. Analgesic effects of in- tra-articular morphine in patients with temporomandibular joint disorders: a prospective double-blind placebo-controlled clinical trial.J Oral Maxillofac Surg. 2010 Mar; 68(3): 622-27.

7 Jaureguito JW Wilcox JF Cohn SJ Thisted RA Reider b. A comparison of intraarticular morphine and bupiva- caine for pain control after outpatient knee arthroscopy. A prospective randomized double-blinded study. Am J Sports Med. 1995 May-Jun; 23(3): 350-53.

8 Joshi GP McCarroll SM O'brien TM lenane P. intraarticu- lar analgesia following knee arthroscopy. Anesth Analg. 1993

Feb; 76(2): 333-36.

9 Zuniga JR ibanez C Kozacko M. The analgesic efficacy and safety of intra-articular morphine and mepivicaine following temporomandibular joint arthroplasty. J Oral Maxillofac Surg.

2007 Aug; 65(8): 1477-85.

10 Gupta A bodin l HolmstrAlm b berggren l. A systematic re- view of the peripheral analgesic effects of intraarticular mor- phine. Anesth Analg. 2001 Sep; 93(3): 761-70.

11 Kalso E TramAr MR Carroll D McQuay HJ Moore RA. Pain relief from intra-articular morphine after knee surgery: a qual- itative systematic review. Pain. 1997 Jun; 71(2): 127-34.
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Article Details
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Author:Al-Rabadi, Hytham Farah; Muhaidat, Hazar; Hijazeen, Hazar M.; El-Naji, Waddah S.; Al-Ghanam, Manal A
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2014
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