الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
SUMMARY
Chronic pain associated with temporomandibular disorders (TMD) is one of the most debilitating symptoms that has a negative impact on the patient’s quality of life. The international association for the study of pain (IASP) defines chronic primary pain as pain that persists for more than three months, and associated with significant emotional distress such as depression, anxiety and frustration and/ or functional disability that interferes with daily life activity.123
Treatment of chronic pain of TMJ and associated muscles has always been challenging due the complex pathophysiology of TMD. One of the most currently accepted theories is the biopsychosocial model, which was presented by Dworkin and Le Resche in 1992. This concept integrates physical disorders with psychological and social factors, based on this model Dworkin and Le Resche introduced an integrated assessment and classification system, the Research Diagnostic Criteria for TMD (RDC/ TMD) which is a dual axis system, axis Ⅰ represents the physical disorders and axis Ⅱ represents psychosocial illness impact factors.6 It has been well established that psychological factors are strongly related to TMD, they are not only predisposing factors but also initiating
and perpetuating factors.6,7 This biopsychosocial model structured a multimodal approach in the management of TMD including internal derangement (ID).
Treatment guidelines of ID include starting with non- surgical approach such as stress management, diet modification, occlusal appliances and pharmacological agents, if proven to be unsuccessful, surgical intervention was indicated. Historically surgical management of ID included meniscectomy, disc plication and condylotomy, but these surgeries was highly invasive with high rate of complications. The development of arthroscopy followed by arthrocentesis bridged the gap between the non- surgical and surgical interventions, with high success rate and much lower risk of complications.30
Over the last decades, Arthrocentesis became one of the leading minimally invasive surgical intervention used for management of ID in refractory cases, with high success rate ranging from 80-94%.144 Several adjunctive therapies have been used in combination with arthrocentesis in an attempt to increase its efficacy and long-term maintenance. Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor which is used in different chronic pain conditions such as chronic low back pain, knee osteoarthritis. Recently Jia et al. conducted a study to evaluate the effectiveness of duloxetine in the management of refractory
idiopathic dentoalveolar pain (Atypical odontalgia), and showed that duloxetine significantly reduced the chronic pain. 122
This study aimed to assess the efficacy of duloxetine in combination with arthrocentesis compared with arthrocentesis alone. Twenty-eight patients with chronic TMJ pain were included and randomly allocated into two groups (control and study groups). The control group included patients who underwent TMJ arthrocentesis only, and Study group included patients who underwent arthrocentesis followed by giving Duloxetine (30mg) orally twice daily for 3 months. Pain, maximum pain-free mouth opening, and level of anxiety and depression were assessed pre- operatively and followed at regular intervals of 1 week, 1 month, 3 months, and 6 months postoperatively.
Pain significantly reduced in both groups at all postoperative intervals and was significantly lower in the study group than the control group at 6 months. Maximum mouth opening increased significantly in both groups and the difference between them was not significant. Level of anxiety and depression was significantly decreased in both groups with no statistically significant difference between them.
The results of this study indicate that duloxetine in combination with arthrocentesis may provide effective and long- term pain control, however, its use is associated with a higher risk
of adverse events. Patient preferences, cost considerations, and potential adverse events must be taken into consideration before the prescription of this medication. Further studies with larger sample sizes and longer follow-ups are required, also the safety and the efficacy of long-term use of duloxetine more than three months is needed to be investigated.