The evidence and comparisons of TMJ injection treatments
Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
David N. Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, IL
The evidence and comparisons of TMJ injection treatments
We often see patients with varying degrees of, and medical histories of, TMJ syndrome or TMD (Temporomandibular joint dysfunction). They tell us about how their TMJ developed, whether it was from extensive dental work, a traumatic injury suffered in an accident, or other reasons such as a history of teeth grinding that has lead to degenerative joint disease of the jaw. They may also tell us about frequent jaw dislocations and problems with their neck. They also tell us about a lot of treatments that did not work for them. In this article, we will discuss these treatments and the possible solution regenerative medicine injections may offer.
Problems that are far beyond a disc or a TMJ appliance problem
For some of these people, their doctors may have found it inconceivable that they did not respond to the treatments they offered and may recommend a psychiatric examination.
Someone who has been suffering from long-term TMJ problems, at some point, starts to realize that their challenges are challenges far beyond a disc or a TMJ appliance problem. When this person then has a failed TMJ surgery, these challenges they face become that much greater and their jaw problem that started out as an annoyance has turned into years of searching for anything that will help them with the new cascade of symptoms they suffer from beyond opening their mouths without pain.
TMJ surgery and appliances do help people. But these are not the patients we see in our clinics. We see the people TMJ surgery and appliances did not help. These are people, perhaps like yourself, whose TMJ has turned into a problem of headaches, neck pain, difficulty swallowing, and dizziness. For some of these people, their doctors may have found it inconceivable that they did not respond to the treatments they offered and may recommend a psychiatric examination. Generally speaking, if you are searching for a cure for your problem, your problem is not “all in your head.”
- Over the course of this article, we are going to start making connections to a different approach to your treatment.
- Our connection is that perhaps your standard care treatments did not help you because the problems caused by degenerated and damaged TMJ ligaments were not addressed.
- In 27 plus years of experience helping patients with TMJ, we have found undiagnosed, damaged ligaments to cause jaw instability and excessive, unnatural mobility in the jaw joint. This causes grinding, disc displacement, and osteoarthritis.
- Further, as frequently seen, TMJ pain and jaw dislocation is a problem associated with Ehlers-Danlos syndrome which also causes weakened loose cervical neck and jaw ligaments and is seen more commonly in younger patients.
Introduction video: Unresolved chronic TMJ pain may be coming from your neck
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
- By the time we see a patient with TMJ problems, they’ve tried splints, night guards, advanced dental work, pain medication, cortisone shots even and nothing has helped long term.
- We treat TMJ with simple dextrose Prolotherapy injections into the TMJ joint. The treatment which is explained in great detail below strengthens the ligaments of the TMJ and reduces and eliminates the jaw hypermobility that can cause degenerative TMJ disease.
- In other cases, those that are more complex and unresponsive to traditional treatments, we evaluate the neck and shoulder. Even at this later point of their medical care, patients have come in surprised that research and clinical observation have linked cervical spine and neck instability and TMJ. More surprising is that they were unaware of this link.
- Some people with chronic TMJ pain may have an underlying neck issue or in rare cases a shoulder issue that is putting tension on their TMJ. This is why therapies focused on the TMJ itself can be unsuccessful. The problem the patient is suffering from is one that has its origin in the cervical spine and/or shoulder.
At 1:53 of the video, the question is asked: “How do you determine if neck instability is involved in a case of chronic TMJ pain?”
- Based on the patient’s examination and their medical history we may suspect that there could be a cervical spine neck component of their TMJ problem. This is when we may order a DMX or Digital Motion X-Ray evaluation. A DMX will take an “x-ray movie,” of the patient’s neck and jaw in motion.
- At 2:23 of the video, you can see the “x-ray movie,” of a patient going through a range of motions in their neck and jaw. The DMX gives us a motion picture of what happens to your cervical vertebrae when you move your neck. Here we can see if your vertebrae are shifting out of place, moving too far forward or backward, and then also what’s happening to your jaw when you move your jaw, like shifting to one side or the other when you open and close your mouth.
At 2:47 of the video, the question is asked: “How many Prolotherapy treatments are needed to resolve TMJ Pain”
- Generally, if TMJ problems are determined to be one of degenerative TMJ in the joint, TMJ often times resolves in 4 to 6 treatments.
- If TMJ problems are centered in problems of the cervical spine and neck instability. It can take more.
TMJ is a problem. The medical community is responding by pumping out a lot of research. Let’s look at some of these new studies to see what is benefiting patients and what is not.
The steroid injection made the TMJ pain worse
Steroids / Anti-inflammatories – research questions effectiveness and worthiness in helping TMJ patients.
In September 2018, in the Journal of Oral Rehabilitation, (1) researchers from leading medical universities in Sweden looked at steroid injection, specifically Methylprednisolone as a means to help alleviate TMJ patient symptoms.
In this study, the researchers looked at inflammation as a symptom problem in the TMJ. Clearly, they hypothesized, an anti-inflammatory would help with the inflammatory pain the patient was suffering from. What they found was the exact opposite, the steroid injection made the pain worse.
- In this study, 54 patients were randomly assigned to single-dose injection with methylprednisolone (27 patients) or saline (27 patients).
- At 4 week follow up after injection, the researchers found little difference in pain relief in the steroid group and the saline group.
- What they did find was that in addition to the Methylprednisolone providing no additional benefit for reducing pain, the steroid injection caused more harm. “Treatment-related adverse events were doubled in the methylprednisolone group.”
Hyaluronic acid injections and steroid injection
Also in September 2018, in the Hungarian Medical Weekly, (2) researchers at the world-renowned Semmelweis University’s Faculty of Dentistry published their findings comparing hyaluronic acid injections and steroid injection.
- Comparing the two treatments, three hyaluronic acid injections were significantly more effective than cortisone in relieving patients’ symptoms.
We have looked at Hyaluronic injections at length. The injections are a lubricating gel designed to help with pain-free movement in the joint. We have examined research on these injections and wrote of our findings. In our article on knee injections, Are Hyaluronic injections low-value health care? -we wrote “It should be noted that we see many patients who have tried hyaluronic acid injections. These injections have worked for these people in the short-term. These patients are now in our office because the short-term has not transpired to the long-term and now a different treatment approach needs to be undertaken.”
Steroids, Hyaluronic acid injections, and Platelet Rich Plasma Therapy
Platelet Rich Plasma Therapy is a treatment that utilizes your blood platelets as a healing injectable. This treatment will be explained later in this article.
A June 2019 study published in The Journal of Craniofacial Surgery (3) from Turkish a team of hospital and university researchers in Turkey evaluated the use of intra-articular corticosteroids, hyaluronic acid, and platelet-rich plasma in patients with temporomandibular joint (TMJ) pain and clinically diagnosed with TMJ-osteoarthritis. They found that intra-articular PRP injections decreased TMJ palpation pain more effectively compared with the hyaluronic acid and corticosteroid groups.
Non-surgical conservative treatment methods for TMJ
A comparison of the outcomes of four minimally invasive treatment methods for anterior disc displacement of the temporomandibular joint. Why didn’t they help some people?
The above heading is taken in part from the title of a paper from University medical researchers in Turkey publishing in the International Journal of Oral and Maxillofacial Surgery.(4)
As the researchers point out, the purpose of this study was to compare the effectiveness of four non-surgical conservative treatment methods for temporomandibular displacement disorders. We are going to examine the phenomena of effusion and swelling in this study and compare it to another new study.
Patients were divided into four groups according to the treatment method:
- splint therapy, (various devices put into the mouth to stabilize the jaw joint).
- arthrocentesis, (aspiration of fluid in the jaw)
- medical therapy, (a medical treatment possibly involving arthroscopic procedures).
- and low-level laser therapy (LLLT). LLLT stimulates the immune responses to heal joints by themselves.
Magnetic resonance imaging (MRI) was performed before treatment and at the 1-month follow-up. Patients were followed up after treatment for 6 months.
- Mouth opening increased and pain scores decreased at 1, 3, and 6 months after treatment in all groups.
- No statistically significant difference in the improvements in clinical symptoms was observed between the groups.
Note: So all these treatments worked well, except in our opinion the very ominous problem of effusion.
Symptom suppression successful, BUT the underlying problem is still there
Back to the research and why we consider this ominous.
A positive correlation was found between pain and TMJ effusion. A significant positive relationship was also found between internal derangement (structural problems) and effusion.
It was determined that the effusion demonstrated on MRI was associated with pain. Although the symptoms improved after treatment, joint effusion did not show any decrease in the 1-month follow-up MRI.
In other words, the underlying problem was still there and the symptom relief could only be temporary
The problem of fluid buildup, a jaw joint trying to stabilize by swelling is a chronic and long-term problem of the degenerative joint disease
In 2017 study, doctors publishing in The Journal of Headache and Pain (5) made these observations:
The aim of their study was to investigate cytokine levels in the masseter muscle (inflammation of the jaw muscle), and the response to tooth-clenching. The response the researchers were looking for was if tooth clenching caused inflammation and accompanying pain, fatigue and psychological distress in patients with temporomandibular disorders (TMD) myalgia (pain).
- What they found was when the patients clenched their teeth, already elevated levels of inflammatory markers increased in the jaw muscle, BUT, there was no correlation between this increased inflammation and the jaw muscle pain and fatigue the patients were experiencing.
What does this mean?
According to the researchers, “This implies that subclinical muscle inflammation may be involved in TMD myalgia pathophysiology (The process of TMD), but that there is no direct cause-relation between inflammation and pain.”
What does this mean?
- For one thing, go to the first study we cited in this article, steroids made the TMJ pain worse.
- Subclinical means something not detected or understood. There is a chronic inflammatory response because something is not healing. In our experience that something is that the entire TMJ is in degenerative disease. This is a problem of whole jaw joint disease and treatments must address the entire jaw joint not a TMJ disc.
TMJ and Joint Hypermobility Syndrome. This could be you all along and undiagnosed.
We are going to make some fascinating connections here to show that TMJ and jaw-related pain are much more than TMJ disc degeneration in many patients.
- In this first study, research shows that it is not only a problem of the TMJ disc but a problem of jaw instability.
Like any joint, excessive movement in the Temporomandibular joint and/or chronic subluxation/dislocations of the Temporomandibular is caused by weakness of the connective tissue that holds the joint in place. In the jaw important connective tissue include the Temporomandibular ligament, and the stylomandibular ligament, and sphenomandibular ligament which provide limitation of mandibular movements.
In a late 2015 publication date, national defense and university medical researchers in Taiwan combined to release their research finding in the journal Clinical Oral Investigations (6) on the TMJ/TMD – Joint Hypermobility Syndrome connection.
What is Joint Hypermobility Syndrome? It is a common musculoskeletal disorder that makes your joints too flexible. For some people, this is very advantageous, especially in gymnastics, dance, and swimming. For others, it leads to chronic dislocations.
The research aimed to investigate the risk factors of temporomandibular disorders, including disc or non-disc-related disorders, and Joint Hypermobility Syndrome retrospectively and to analyze the association between the two conditions.
What is so fascinating about this study in that in patients who had TMJ and were found to have Joint Hypermobility Syndrome, 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. In 9 out of 10 patients with TMJ diagnosed patients with Joint Hypermobility Syndrome – pain does not come from degenerated discs.
- So what does this mean to you? The source of your TMJ pain does not need to involve a displaced disc it can be weakness of the jaw/TMJ ligaments. Any treatment should involve a determination of ligament weakness.
TMJ is more than a physical problem related to the jaw
- What does this mean? As pointed out by Spanish researchers in the medical journal European Psychiatry: the journal of the Association of European Psychiatrists, that problems of jaw pain (TMJ) may be an indication of a body-wide problem with loose joints and further, joint hypermobility syndrome and TMJ may manifest themselves as a potential link to the neural bases of anxiety and related somatic symptoms (pain that causes major emotional distress) (7)
- What does this mean? As doctors writing in the Journal of Oral and Facial Pain and Headache point out TMJ is more than a physical problem related to the jaw.(8)
- As we will see below, degenerative or displaced disc is one part of a diseased joint environment. All the parts must be treated to give the patient the best chance of a successful outcome.
In 2007, researchers here at Caring Medical published our findings in the medical journal Practical Pain Management that “Many of the subjective symptoms of pain, stiffness, and crunching sensation in patients with TMJ dysfunction were reduced greater than 50% in 92% of the prolotherapy patients.”(9) We will examine this research below in greater detail.
So back then we were able to show at least a 50% reduction in pain in more than 9 out of 10 patients with simple dextrose Prolotherapy. What has happened in the ten years since we first published this study? More good results and a better understanding within the medical community of the complexity of TMJ/TMD.
TMJ is a cause of cervical neck instability and poor posture
In our article on Cervicogenic dysphagia, swallowing difficulties as being caused by problems in the neck and brain, we explored research that noted that TMJ patients and cervical neck instability patients have difficulties in swallowing.
TMJ and neck problems have long been linked together, however, it is not often that a patient will report to us that their previous health care providers made this link and offered treatments addressing both concerns. In the following research the links and the treatments for both TMJ and cervical neck instability point to a problem in the neck.
In many patients, we see with primary problems related to neck pain and cervical instability we see problems of TMJ. In many patients that we see with problems of TMJ, we see cervical neck pain. Surprisingly, despite the research suggesting the connection, many patients were not made aware that their jaw pain could be a problem originating in the neck.
In the medical journal Clinical Oral Investigations, (10) oral surgeons in Belgium made a connection between TMJ and cervical instability.
They conducted a study looking for possible correlations between clinical signs of temporomandibular disorders (TMD) and cervical spine disorders.
- Thirty-one consecutive patients with symptoms of TMD and 30 controls underwent a standardized clinical examination of the masticatory system, evaluating the range of motion of the mandible, temporomandibular joint (TMJ) function, and pain of the TMJ and masticatory muscles.
- Afterward, subjects were referred for clinical examination of the cervical spine, evaluating segmental limitations, tender points upon palpation of the muscles, hyperalgesia, and hypermobility.
- The results indicated that segmental limitations (especially at the C0-C3 levels) and tender points (especially in the sternocleidomastoideus and trapezius muscles) are significantly more present in patients with TMJ than the control subjects
In the European Journal of Orthodontics, (11) doctors in Japan made a connection:
- In this study, the doctors compared the mandibular stress distribution and displacement of the cervical spine. In simple terms, how TMJ instability and hypermobility of the jaw negatively effected the cervical spine.
- What did they find? “(an) imbalance between the right and left masticatory muscles antagonistically act on displacement of the cervical spine, i.e. the morphological and functional characteristics in patients with mandibular lateral displacement may play a compensatory role in posture control.”
What? The TMJ altered your posture by stressing your cervical spine? Isn’t posture a problem of swallowing difficulties? Isn’t posture a problem of everything?
Craniocervical physical therapy in patients with myofascial temporomandibular pain disorders. Focus on muscle spasms
In a 2017 study (12) from researchers at the University of Comenius’ Faculty of Medicine in Slovakia, doctors suggested that physical therapy could improve craniocervical dysfunction and myofascial pain symptoms in the head and neck. Here are the highlights of this study:
- The group of patients diagnosed with myofascial dysfunctional pain syndrome contained 98 patients out of which 79 patients (81 %) were females and 19 patients (19 %) were males.
- The majority of the patients were aged between 26 and 35 years; the total age range was 14-77 years with an average of 38 years.
- Observed patients were subdivided into three groups.
- Standard therapeutic methods aimed at the temporomandibular joint were provided to the patients of the first group.
- The second group of the patients received therapy aimed at cervical muscles only.
- Complex rehabilitation was applied in the third group of patients.
According to the study’s results, all three groups of patients saw an improvement in pain perception, but the overall subjective remission of painful sensations in the third group took place in as many as 88 % of patients. In this group, there was a significant decrease in the tenderness of trigger points in the trapezius and sternocleidomastoid muscles. This was achieved by a combination of simple relaxing and stretching exercises of cervical muscles with a standard method used in the therapy of masticatory muscles is significantly more efficient.
In this study, the focus was on muscle spasms and the pain they cause. If you can relax the muscles of the TMJ and cervical neck region, you would have less pain. For some people, this will be very effective. For others, it will not. Typically, the people who will not find success will be people who have ligaments damage or weakness and tendon attachment weakness or damage. For muscle techniques to work, there needs to be a resistance that allows the muscles to strengthen. If ligaments and tendons are damaged, there is lesser resistance and the treatment will not succeed as wished. We address this problem below.
Craniocervical muscle problems in older patients with myofascial temporomandibular pain disorders
A 2019 study from Orthopedic and Oral and Maxillofacial Surgeons in South Korea published in the journal Archives of Gerontology and Geriatrics (13) demonstrated the associations among degenerative changes in the cervical spine, head and neck postures, and myofascial pain in the craniocervical musculature in elderly with myofascial temporomandibular disorders (TMDs).
In this research:
- A total of 120 participants (overage age about 68) were included:
- 45 participants had no signs of orofacial or cervical pain,
- 26 participants had myofascial TMD only and
- 49 participants had both myofascial TMD and cervical pain.
- Myofascial trigger points were evaluated in the temporalis, masseter, trapezius, sternocleidomastoid, sub-occipitalis, and splenius capitis muscles. Relationships among the number of trigger points, head postures, and cervical degeneration were investigated using repeated-measure analysis.
- The degenerative changes recorded in each level of the cervical spine had complex interactions with head postures. Cervical degeneration, particularly at the level of second to the third vertebra appeared to be linked to the development of active trigger points in the masticatory and cervical muscles. The results of this study demonstrated that degenerative changes in the cervical spine were related to altered head postures and the development of active trigger points in the craniocervical musculature in the elderly with myofascial TMD.
Cervical Muscle Tenderness in Temporomandibular Disorders
A 2020 study appearing in the Journal of Oral & Facial Pain and Headache (14) examined 192 patients with TMD and cervical muscle tenderness. What they found was cervical muscle tenderness was notable only in those with a myogenous (muscle problems) TMD diagnosis, but not in arthrogenous (degenerative TMJ disc disease). (Our note: the problems was not in the TMJ joint but likely a problem of cervical spine instability). This is something the researchers concluded as well:
“cervical muscle tenderness differentiated between TMD patients and controls and between TMD diagnoses. Specific patient and pain characteristics associated with poor outcome in terms of cervical muscle tenderness included effects of interactions between myogenous TMD, female sex, whiplash history, comorbid body pain and headaches, and pain on opening. It can, therefore, be concluded that routine clinical examination of TMD patients should include assessment of the cervical region.”
Understanding the TMJ temporomandibular joint itself
At this point in our article we will return to the examination of the TMJ itself.
The temporomandibular joint connects the mandible (lower jaw) to the part of the skull known as the temporal bone. The joint allows the lower jaw to move in all directions so that the teeth can bite off and chew food efficiently.
Temporomandibular joint ( TMJ ) syndrome occurs when the joint, muscles and ligaments involved do not work together properly, resulting in pain.
Temporomandibular joint syndrome and TMD or TemporoMandibular Disorders have been demonstrated to be caused by ligament weakness in many patients, often as a result of clenching the jaw or grinding the teeth, sleeping position or a forward-positioned mandible (lower jaw).
Malocclusion, or a poor bite, places stress on the muscles and may also lead to temporomandibular joint syndrome, as may an injury to the head, jaw, or neck that causes displacement of the joint. If left untreated, jaw osteoarthritis can result.
As we wrote back in 2007:
- “Symptoms commonly associated with TMD include pain at the TMJ, generalized orofacial pain, chronic headaches and ear aches, jaw dysfunction including hyper- and hypo-mobility and limited movement or locking of the jaw, painful clicking or popping sounds with opening or closing of the mouth, and difficulty chewing or speaking.”
- “While pain is the most common symptom, some people report no pain, but still have problems using their jaws. Sometimes the bite just feels “off.” Additional symptoms may include ringing in the ears, ear pain, decreased hearing, dizziness, and vision problems.”
The head and neck pain associated with temporomandibular joint syndrome (TMJ) has received a myriad of traditional treatments, many of which involve surgery. They include:
- Temporomandibular joint (TMJ) surgery can be divided into 3 types of surgery: Arthroscopy, arthroplasty, and total joint replacement. The complications associated with these procedures increase with complexity. They all include injury to adjacent structures, infections, and bleeding problems, as documented in research in the journal Oral and Maxillofacial Surgery Clinics of North America.(15)
- TMJ implants,
- cervical spine surgery,
- botulinum toxin injections into muscles. In recent research doctors from New York University College of Dentistry noted that patients with temporomandibular muscle and joint disorder are increasingly seeking and receiving treatment for their pain with botulinum toxin and that these treatments create risk of reduced bone mineral density, or osteopenia (bone loss). (16)
- surgical cauterization, which treats the bones with a radio frequency wave destroying the treated area. Although the pain is temporarily eliminated, however, vital structures are also destroyed in the process.
The problem with any of these approaches is that they do not repair the weakened TMJ ligament and, thus, does not alleviate the chronic pain that people with this condition experience. And thus, most dentists and oral surgeons believe that TMJ cannot be cured and the best hope is for temporary symptom relief. This takes us back to the research we cited earlier on physical therapy. If you do not look for tendon attachment and ligament damage in the jaw and cervical neck areas, the patient’s TMJ/TMD related pain will be considered difficult to treat and the treatments will move onto symptom suppression, not disorder healing. This will include the standard practice of steroids and anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.
The research on Prolotherapy for Temporomandibular Joint Pain and Dysfunction
Treating the whole joint. Comprehensive Prolotherapy for TMJ.
In this section, we will discuss how to turn a degenerative TMJ environment into a healing environment through the use of Comprehensive Prolotherapy. The basic concepts are discussed in the video above.
Prolotherapy is the injection of a simple sugar, dextrose. The idea is that the dextrose will cause a strengthening and rebuilding of the soft tissue holding the jaw in place. Strengthened soft tissue, i.e, ligaments, will stabilize the jaw joint and pull things back into place and reduce destructive joint forces in the jaw.
In March 2019, doctors tested this idea. Publishing in the journal Mayo Clinic Proceedings (17) these doctors from the University of British Columbia, University of Missouri-Kansas City, School of Medicine, the University of Wisconsin School of Medicine and Public Health, and the Chinese University of Hong Kong announced these findings in their study to assess the LONG-TERM effectiveness of dextrose prolotherapy injections in study participants with temporomandibular dysfunction.
Here is the research review:
- Forty-two participants (12 bilateral) meeting temporomandibular dysfunction criteria were randomized to
- 3 monthly Prolotherapy injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year.
- Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction.
- Randomization produced a control group with:
- more female participants
- longer pain duration
- and less maximal interincisal opening.
- Upon 3-month analysis, dextrose Prolotherapy group participants reported:
- decreased jaw pain
- less jaw dysfunction
- and improved maximal interincisal opening.
- CONCLUSION: “Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high.”
Study – Dextrose injections (Prolotherapy): Clinically important and statistically significant improvement in pain and maximal jaw opening.
An August 2020 study in the Journal of alternative and complementary medicine (18) whose authors included noted Prolotherapy researchers, friends, and colleagues Kenneth Dean Reeves, MD and David Rabago, MD noted:
- Several intraarticular injections, including dextrose and lidocaine, are reported to reduce pain and dysfunction in temporomandibular dysfunction and increase maximal jaw opening; (the study’s) goal was to determine whether dextrose/lidocaine outperforms sterile water/lidocaine for temporomandibular dysfunction (TMD).
- Patients with chronic (more than three months) of moderate-to-severe (more than 6 on a scale of 10) jaw or facial pain meeting research-specific TMD criteria.
- Randomization of 29 participants (25 female, average age 47, youngest about 39, oldest about 56). Of the 29 patients, 14 had both sides of their jaw treated.
- Blinded intraarticular dextrose prolotherapy (20% dextrose/0.2% lidocaine) versus intraarticular lidocaine (0.2% lidocaine in sterile water) at 0, 1, and 2 months.
- Participants were then unblinded and offered Prolotherapy by request for 9 additional months.
- The patients were then asked to grade their pain and dysfunction on a Numerical Rating Scale (0-10 points) score. The outcome “successful” treatment was measured by patients achieving more than 50% improvement in pain and dysfunction (0, 3, and 12 months).
- Secondary: Maximal interincisal opening (mouth opening).
Comparison between Prolotherapy vs. lidocaine
- Three-month pain and dysfunction improvements were similar between Prolotherapy and lidocaine, but more Prolotherapy-treated joints improved by more than 50% in pain.
- Mouth opening improved in both groups.
- Twelve-month analysis revealed that joints in the original dextrose Prolotherapy injection group improved more in jaw pain and jaw dysfunction.
- There were no adverse events; satisfaction was high.
- Conclusions: Intraarticular DPT resulted in clinically important and statistically significant improvement in pain and dysfunction at 12 months compared to lidocaine injection.
“I would consider referring a patient with chronic temporomandibular pain for dextrose injection, if a clinician with experience in this procedure were available.”
In May 2019 editor Allan S. Brett, MD reviewed this study for his colleagues, here is what he wrote in the New England Journal of Medicine:
Injection of hypertonic dextrose was quite effective in a randomized trial.
“In this double-blind randomized trial from British Columbia, researchers identified 42 patients with chronic temporomandibular joint pain and dysfunction. Patients received either 20% dextrose plus lidocaine (Prolotherapy) or lidocaine alone, injected into the temporomandibular joint three times at monthly intervals. At baseline, the mean pain score was 8, and the mean jaw dysfunction score was 7 (on 0–10-point scales). At 3 months, a decrease in mean pain score was significantly greater in the dextrose group (Prolotherapy) than in the control group (−4.3 vs. −1.8 points). A decrease in jaw dysfunction also was significantly greater in the dextrose group (−3.5 vs. −1.0 points).
“These results are quite impressive; the study methods are described in great detail, which increases my confidence in the findings. Although the results should be corroborated in another randomized trial, I would consider referring a patient with chronic temporomandibular pain for dextrose injection, if a clinician with experience in this procedure were available.”
Indian doctors writing in the Journal of maxillofacial and oral surgery (19) found positive results utilizing Prolotherapy injections for TMJ in recent research (June 2017). Here is what they said:
Hypermobility disorders of the Temporomandibular joint (TMJ) can be treated by both conservative and surgical approaches. Conservative approaches should be considered as first-line treatment for such disorders.
- Prolotherapy with 25 % dextrose being injected into the posterior pericapsular tissues is one such treatment modality with favorable outcomes.
In their study, the researchers examined 23 patients suffering from either chronic recurrent dislocation or subluxation of the TMJ who were treated with the single-injection technique prolotherapy with 25 % dextrose into the pericapsular tissues along with auriculotemporal nerve block.
- Overall success rate in the study was 91.3 % (21/23) with a minimum follow up period of 13.9 months.
- Number of successfully treated patients requiring one injection was 7 (30.4 %), two injections was 8 (34.7 %) and requiring three injections was 6 (26.1 %). There were no permanent complications.
In a December 2018 study in the Journal of oral rehabilitation, (20) military Oral and Maxillofacial Surgeons in India proposed that dextrose prolotherapy may cause significant reduction in mouth opening and pain associated with TMJ hypermobility.
Prolotherapy reports on TMJ disc dislocation
In Prolotherapy research, doctors say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.
- Doctors writing in the British Journal of Oral and Maxillofacial Surgery found that Prolotherapy injections was curative in preventing recurrent TMJ dislocations. In fact, nearly 2 of 3 of these patients achieved this result with a single treatment.(21)
In supportive research doctors at the University of Karadeniz Technical University (22) say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.
- The overall success rate, defined as the absence of any further dislocation or subluxation for more than 6 months, was 91%.
- Of the 41 rehabilitated patients,
- 26 (63%) required a single injection,
- 11 (27%) had 2 treatments,
- and 4 (10%) needed a third injection.
- All patients tolerated the injections well. The modified dextrose prolotherapy is simple, safe, and cost-effective for the treatment of recurrent dislocation of the TMJ.
Dr. Refai of Cairo University reported in the British Journal of Oral and Maxillofacial Surgery:
- Sixty-one patients with symptomatic hypermobility of the TMJ were each given four sessions of intra-articular and pericapsular Prolotherapy injections six weeks apart.
- Each injection comprised 10% dextrose/mepivacaine solution 3ml.
- Clinical outcomes including:
- severity of pain on movement according to the numerical rating scale (NRS),
- maximal interincisal opening,
- and frequency of locking were measured before treatment (T1), during treatment (T2) (just before the third session of injections), at the short-term follow-up (T3) (three months after treatment), and at the long-term follow-up (T4) (1-4 years after treatment).
- Condylar translation (movement of the TMJ joint) and osseous (bony) changes of each joint were evaluated at T1 and T4 using tomography.
- There was significant reduction in all variables by T2
- The pain scores and clicking had decreased significantly by T3.
- Linear tomograms of each joint at T1 and T4 showed no alteration in the morphology of the bony components of the joint, and at T4, tomographic open views of all joints showed condylar hypertranslation.
- Dextrose prolotherapy provided significant and sustained reduction of pain and recovery of constitutional symptoms associated with symptomatic hypermobility of the TMJ without changing either the position of the condyle or the morphology of the bony components of the joint.(23)
Prolotherapy and aspiration (arthrocentesis) provided significant relief for TMJ patients.
Doctors at Ordu University in Turkey published in The Journal of alternative and complementary medicine suggesting that Prolotherapy and aspiration (Arthrocentesis) provided significant relief for TMJ patients.
In this October 2017 study, 10 adults with disc displacement and painful, hypermobile TMJ were selected.
- Arthrocentesis and Prolotherapy were consecutively performed using a 30% dextrose solution that was simultaneously injected into five areas: posterior disc attachment, superior joint space, superior and inferior capsular attachments, and stylomandibular ligament.
Scoring tests were used to assess the maximum mouth opening, clicking sounds, pain, and subluxation of the TMJ. Patients with rheumatoid arthritis and parafunctional habits such as teeth clenching and grinding and biting of the cheeks or any other objects and those who had undergone surgery were excluded from this study.
The ten patients, 7 women and 3 men (average age 36), received a single treatment session of combined arthrocentesis and prolotherapy at the same office visit. Subluxation frequency and pain significantly decreased after the first week of treatment. Subluxation also decreased at the 3-month follow-up.
Clicking sound values did not significantly change at any of the follow-up time points. Maximum mouth opening values improved at all follow-up time points compared to baseline.(24)
In the July 2018 edition of the Journal of Oral Rehabilitation, Military doctors in India compared Prolotherapy to Placebo injections. They found:
- Dextrose Prolotherapy resulted in significant reduction in mouth opening and pain associated with TMJ hypermobility. (25)
Twelve years after our own research on TMJ patients
In the research mentioned above from our Caring Medical research team and published in 2007 our doctors reported on successful dextrose Prolotherapy for patients with chronic neck pain. In this study, fourteen patients who suffered from TMJ pain for an average of 5.4 years and had seen, on average, four medical doctors—including half who were told that no other treatment options were available.
Overall, substantial improvements were reported in:
- range of motion,
- pain medicine utilization,
- quality of life,
- and patient satisfaction.
These improvements persisted through follow up at eighteen months after the conclusion of prolotherapy treatments.
Prolotherapy is a safe and effective natural medicine treatment for repairing tendon, ligament and cartilage damage. In simple terms, Prolotherapy stimulates the body to repair painful areas. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Since the body heals by inflammation, Prolotherapy stimulates healing.
The Physical and emotional aspects of TMJ
In our 2007 study we noted:
- Prior to prolotherapy, 56% of patients reported feelings of depression and 64% reported feelings of anxiety.
- After treatments, only 28% reported depressed feelings and 36% reported feelings of anxiety.
- Patients reported that on average 86% of the improvements in depression and anxiety have at least somewhat continued.
- Seventy-eight percent of these patients reported 75% continuing improvement at the time of follow-up.
Let’s move to a 2017 study from a team of Swedish and Danish researchers writing in the medical journal Cephalalgia: an international journal of headache. Here is a review of that study:
- Chronic pain is the overwhelming reason that patients with TMD seek treatment.
- TMD can associate with impaired general health, depression, and other psychological disabilities, and may affect the quality of life of the patient.
- The most common types of TMD,
- include pain-related disorders (e.g., myalgia, headache attributable to TMD, and jaw joint pain) as well as disorders associated with the TMJ (primarily disc displacements and degenerative disease).
- As peripheral mechanisms (nerve and pain signals) most likely play a role in the onset of TMD, a detailed muscle examination is recommended.
Conclusion: The persistence of pain involves more central factors, such as sensitization of the supraspinal neurons and second-order neurons at the level of the spinal dorsal horn/trigeminal nucleus (central neural pathways relevant to TMJ/TMD pain), imbalanced antinociceptive activity (the ability to block pain), and strong genetic predisposition (family history).(26)
Platelet Rich Plasma Therapy for TMJ
In patients where TMJ symptoms are more advanced. We may also use Platelet Rich Plasma therapy in addition to the Prolotherapy treatments. Here we extract a patient’s blood and spin out the healing platelets and growth factors and inject that into the jaw/mandible area.
PRP application differs from office to office and in fact from research study to research study. In our office we combine PRP treatments with Prolotherapy treatments to offer the patient a more comprehensive treatment. PRP injections in our office are typically “injections,” at each treatment, not a single injection.
A 2020 study published in the Journal of Oral & Facial Pain and Headache (27) examined the effect of Platelet-Rich Plasma Injections on pain reduction in patients with Temporomandibular Joint Osteoarthritis. In this paper, the research team examined 6 study outcomes and found according to the results of these trials, intra-articular injections of PRP were more effective than placebo for pain reduction (6 months postinjection and 12 months postinjection. Further: “Based on current evidence, PRP injections may reduce pain more effectively than placebo injections in Temporomandibular Joint Osteoarthritis at 6 months (level of evidence: moderate) and 12 months (level of evidence: moderate) postinjection. This significant difference in pain reduction could also be seen when PRP was compared to hyaluronic acid at 12 months postinjection (level of evidence: low). It can be cautiously interpreted that PRP has a beneficial effect on the relief of Temporomandibular Joint Osteoarthritis pain.
A 2015 study in the Journal of Oral and Maxillofacial Surgery (28) shows emerging evidence suggested platelet-rich plasma (PRP) might be of assistance in the treatment of degenerative conditions of the jaw joint.
In this study, PRP and hyaluronic acid treatments in temporomandibular joint (TMJ) osteoarthritis patients were compared over a long-term follow-up.
A total of 50 patients with TMJ-osteoarthritis were enrolled in the study (29 women and 21 men, age range 31 to 49 years, mean age 38.6).
- In group I, 25 patients received 3 injections of 1 mL of PRP.
- In group II, 25 patients received 3 injections of 1 mL of low-molecular-weight hyaluronic acid.
The hyaluronic acid group showed significant improvements at 1 and 3 months. However, at At 6 and 12 months, the PRP group exhibited better performance compared with the hyaluronic acid group in terms of the recurrence of pain and joint sounds.
The PRP group performed better than the hyaluronic acid group in the treatment of TMJ-osteoarthritis during long-term follow-up in terms of pain reduction and increased interincisal distance.
Researchers at the Department of Oral and Maxillofacial Surgery, Jaipur Dental College, in India published their findings in the National Journal of Maxillofacial Surgery (29) of their assessment of the effectiveness of PRP injections compared to hydrocortisone with local anesthetic in the conservative management of anterior disc displacement with reduction. If you have been diagnosed with TMJ you know that this is the displacement of the TMJ disc and the clicking noises that accompany the displacement.
The researchers found: “In the group of PRP injection, pain was markedly reduced than the group of hydrocortisone with local anesthetic; mouth opening was increased similarly in both groups and TMJ sound was experienced lesser in patients who received PRP.”
PRP and hyaluronic acid injections
A 2019 study from the University of Verona in Italy published in the International journal of molecular sciences (30) evaluated the effectiveness of arthrocentesis (TMJ aspiration) or injections with platelet-rich plasma in temporomandibular affections and to compare them to arthrocentesis alone or with hyaluronic acid or to hyaluronic acid injections.
The researchers found:
- TMJ aspiration with platelet-rich plasma and platelet-rich plasma injections in temporomandibular disorders’ management were found to be effective in reducing pain and joint sound (clicking and popping) as well as in improving mandibular motion in a maximum follow-up of 24 months. Comparison to arthrocentesis alone or to hyaluronic acid injections used in arthrocentesis or by injections provided encouraging results in terms of the effectiveness of platelet-rich plasma use.
Stem Cell Therapy for TMJ
While we do offer stem cell therapy for our patients, this is not a treatment we often utilize as a first-line treatment. The documented results of the success of simple dextrose Prolotherapy has shown us that this treatment is effective and can result in significant enough improvement that stem cell therapy will not be offered. However, many people ask us about stem cell therapy.
Stem cell therapy has become a very popular treatment option. Research is coming in.
National University of Singapore doctors found that they could regenerate the cartilage of the TMJ joint with a stem cell therapy solution and have recently released their report on stem cell therapy for TMJ and TMD. Here are summary facts on their paper.
- Temporomandibular Disorders (TMD) represent a group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint (TMJ), masticatory muscles and/or associated structures.
- They are a major cause of non-dental related face and jaw pain.
- The most common type of TMJ disorders involves displacement of the TMJ articular disc that precedes progressive degenerative changes of the joint leading to osteoarthritis.
In the past decade, progress made in the development of stem cell-based therapies and tissue engineering have provided alternative methods to attenuate the disease symptoms and even replace the diseased tissue in the treatment of TMJ disorders. This represents innovative approaches of cell-based therapeutics, tissue engineering and drug discovery in treatment.(31) This supports earlier research from the same researchers which stated: Stem Cells could help regenerate bone and soft tissue.(32)
Do you need help with your Temporomandibular Joint Syndrome treatments?
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1 Isacsson G, Schumann M, Nohlert E, Mejersjö C, Tegelberg Å. Pain relief following a single‐dose intra‐articular injection of methylprednisolone in the temporomandibular joint arthralgia–a multi‐centre randomised controlled trial. Journal of oral rehabilitation. 2018 Sep 21. [Google Scholar]
2 Vingender S, Restár L, Csomó KB, Schmidt P, Hermann P, Vaszilkó M. Intra-articular steroid and hyaluronic acid treatment of internal derangement of the temporomandibular joint. Orvosi hetilap. 2018 Sep;159(36):1475-82. [Google Scholar]
3 Kutuk SG, Gökçe G, Arslan M, Özkan Y, Kütük M, Arikan OK. Clinical and Radiological Comparison of Effects of Platelet-Rich Plasma, Hyaluronic Acid, and Corticosteroid Injections on Temporomandibular Joint Osteoarthritis. Journal of Craniofacial Surgery. 2019 Jun 1;30(4):1144-8. [Google Scholar]
4 Hosgor H, Bas B, Celenk C. A comparison of the outcomes of four minimally invasive treatment methods for anterior disc displacement of the temporomandibular joint. International Journal of Oral and Maxillofacial Surgery. 2017 Jun 9. [Google Scholar]
5 Jounger SL, Christidis N, Svensson P, List T, Ernberg M. Increased levels of intramuscular cytokines in patients with jaw muscle pain. The journal of headache and pain. 2017 Dec 1;18(1):30. [Google Scholar]
6 Chang TH, Yuh DY, Wu YT, Cheng WC, Lin FG, Shieh YS, Fu E, Huang RY. The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study. Clin Oral Investig. 2015 Feb 17. [Google Scholar]
7 Mallorquí-Bagué N, Bulbena A, Roé-Vellvé N, Hoekzema E, Carmona S, Barba-Müller E, Fauquet J, Pailhez G, Vilarroya O. Emotion processing in joint hypermobility: A potential link to the neural bases of anxiety and related somatic symptoms in collagen anomalies. European Psychiatry. 2015 Jun 30;30(4):454-8. [Google Scholar]
8 Reissmann DR, John MT, Seedorf H, Doering S, Schierz O. Temporomandibular disorder pain is related to the general disposition to be anxious. J Oral Facial Pain Headache. 2014 Fall;28(4):322-30. doi: 10.11607/ofph.1277. [Google Scholar]
9 Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Practical Pain Management. 2007; November/December:49-55. [Google Scholar]
10 De Laat A, Meuleman H, Stevens A, Verbeke G. Correlation between cervical spine and temporomandibular disorders. Clinical oral investigations. 1998 Aug 1;2(2):54-7. [Google Scholar]
11 Shimazaki T, Motoyoshi M, Hosoi K, Namura S. The effect of occlusal alteration and masticatory imbalance on the cervical spine. The European Journal of Orthodontics. 2003 Oct 1;25(5):457-63. [Google Scholar]
12 Halmova K, Holly D, Stanko P. The influence of cranio-cervical rehabilitation in patients with myofascial temporomandibular pain disorders. CLINICAL STUDY. 2017 Jan 1;710:713. [Google Scholar]
13 Hong SW, Lee JK, Kang JH. Relationship among Cervical Spine Degeneration, Head and Neck postures, and Myofascial Pain in Masticatory and Cervical Muscles in Elderly with Temporomandibular Disorder. Archives of gerontology and geriatrics. 2019 Mar 1;81:119-28. [Google Scholar]
14 Almoznino G, Zini A, Zakuto A, Zlutzky H, Bekker S, Shay B, Haviv Y, Sharav Y, Benoliel R. Cervical Muscle Tenderness in Temporomandibular Disorders and Its Associations with Diagnosis, Disease-Related Outcomes, and Comorbid Pain Conditions. Journal of oral & facial pain and headache. 2019 Aug. [Google Scholar]
15 Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):109-24. [Google Scholar]
16 Raphael KG, Tadinada A, Bradshaw JM, Janal MN, Sirois DA, Chan KC, Lurie AG. Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study. J Oral Rehabil. 2014 Aug;41(8):555-63. [Google Scholar]
17 Louw WF, Reeves KD, Lam SK, Cheng AL, Rabago D. Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover. In Mayo Clinic Proceedings 2019 Mar 14. Elsevier. [Google Scholar]
18 Zarate MA, Frusso RD, Reeves KD, Cheng AL, Rabago D. Dextrose Prolotherapy Versus Lidocaine Injection for Temporomandibular Dysfunction: A Pragmatic Randomized Controlled Trial [published online ahead of print, 2020 Aug 11]. J Altern Complement Med. 2020;10.1089/acm.2020.0207. doi:10.1089/acm.2020.0207
19 Majumdar SK, Krishna S, Chatterjee A, Chakraborty R, Ansari N. Single Injection Technique Prolotherapy for Hypermobility Disorders of TMJ Using 25 % Dextrose: A Clinical Study. J Maxillofac Oral Surg. 2017 Jun;16(2):226-230. [Google Scholar]
20 Nagori SA, Jose A, Gopalakrishnan V, Roy ID, Chattopadhyay PK, Roychoudhury A. The efficacy of dextrose prolotherapy over placebo for temporomandibular joint hypermobility: A systematic review and meta‐analysis. Journal of oral rehabilitation. 2018 Dec;45(12):998-1006. [Google Scholar]
21 Zhou H, Hu K, Ding Y. Modified dextrose prolotherapy for recurrent temporomandibular joint dislocation. Br J Oral Maxillofac Surg. 2014 Jan;52(1):63-6. doi: 10.1016/j.bjoms.2013.08.018. [Google Scholar]
22 Ungor C, Atasoy KT, Taskesen F, Cezairli B, Dayisoylu EH, Tosun E, Senel FC. Short-term Results of Prolotherapy in the Management of Temporomandibular Joint Dislocation. J Craniofac Surg. 2013 Mar;24(2):411-5. [Google Scholar]
23 Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: a single-arm study with 1-4 years’ follow up. Br J Oral Maxillofac Surg. 2017 Apr 28. [Google Scholar]
24 Cezairli B, Sivrikaya EC, Omezli MM, Ayranci F, Cezairli NS. Results of Combined, Single-Session Arthrocentesis and Dextrose Prolotherapy for Symptomatic Temporomandibular Joint Syndrome: A Case Series. The Journal of Alternative and Complementary Medicine. 2017 Oct 10. [Google Scholar]
25 Nagori SA, Jose A, Gopalakrishnan V, Roy ID, Chattopadhyay PK, Roychoudhury A. The efficacy of dextrose prolotherapy over placebo for temporomandibular joint hypermobility: A systematic review and meta‐analysis. Journal of oral rehabilitation. 2018 Jul 19. [Google Scholar]
26 List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia. 2017 Jun;37(7):692-704. [Google Scholar]
27 Li F, Wu C, Sun H, Zhou Q. Effect of Platelet-Rich Plasma Injections on Pain Reduction in Patients with Temporomandibular Joint Osteoarthrosis: A Meta-Analysis of Randomized Controlled Trials. J Oral Facial Pain Headache. 2020;34(2):149–156. doi:10.11607/ofph.2470
28 Hegab AF, Ali HE, Elmasry M, Khallaf MG. Platelet-rich plasma injection as an effective treatment for temporomandibular joint osteoarthritis. Journal of Oral and Maxillofacial Surgery. 2015 Sep 1;73(9):1706-13. [Google Scholar]
29 Gupta S, Sharma AK, Purohit J, Goyal R, Malviya Y, Jain S. Comparison between intra-articular platelet-rich plasma injection versus hydrocortisone with local anesthetic injections in temporomandibular disorders: A double-blind study. National Journal of Maxillofacial Surgery. 2018 Jul;9(2):205. [Google Scholar]
30 Zotti F, Albanese M, Rodella LF, Nocini PF. Platelet-Rich Plasma in Treatment of Temporomandibular Joint Dysfunctions: Narrative Review. International journal of molecular sciences. 2019 Jan;20(2):277. [Google Scholar]
31 Zhang S, Yap AU, Toh WS. Stem Cells for Temporomandibular Joint Repair and Regeneration. Stem Cell Rev. 2015 Jun 28. [Google Scholar]
32 Zhang J, Guo F, Mi J, Zhang Z. Periodontal ligament mesenchymal stromal cells increase proliferation and glycosaminoglycans formation of temporomandibular joint derived fibrochondrocytes. Biomed Res Int. 2014;2014:410167. [Google Scholar]