Temporomandibular Joint Syndrome – TMJ | Temporomandibular Joint Disorder – TMD
In this article Ross Hauser, MD discusses Temporomandibular Joint (TMJ) Syndrome/ TMD (Temporomandibular Joint Disorder) treatments including Prolotherapy and Stem Cell Therapy.
Before continuing on with this article, do you have a question about Temporomandibular Joint Syndrome or need help? Get help and Information from the Caring Medical staff.
This article was updated on October 25, 2017 to reflect newly published medical studies on Prolotherapy and TMJ.
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.”1
So back then we were able to show at least 50% reduction in pain in more then 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.
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.
Anxiety and depression, we found, were important parts of the TMJ treatment plan because of joint hypermobility syndrome
We are going to make some fascinating connections here to show that TMJ and jaw related pain are much more than disc degeneration in many patients.
- First step: The connection between TMJ/TMD disorders and Joint Hypermobility syndrome and the absence of degenerative disc disorder in the jaw.
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 on the TMJ/TMD – Joint Hypermobility syndrome connection.
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.
- One of their findings said this: 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. In 9 out of 10 patients with TMD diagnosed patients with Joint Hypermobility Syndrome – pain does not come from degenerated discs.2
- 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).3
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) 4
- 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.5
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 successful outcome.
The temporomandibular joint
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 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 which 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.6
- 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 seek and receive treatment for their pain with botulinum toxin and that these treatments creates risk of reduced bone mineral density, or osteopenia (bone loss) 15
- 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.
A standard practice is the use 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.
A comparison of the outcomes of four minimally invasive treatment methods for anterior disc displacement of the temporomandibular joint
As the researchers point out, the purpose of this study was to compare the effectiveness of four non-surgical conservative treatment methods for temporomandibular 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.7
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 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.7
In other words, the underlying problem was still there.
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.”8
What does this mean?
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 state, it is dying. This is a problem of whole jaw joint disease and treatments must address the entire jaw joint.
Prolotherapy and Stem Cell Therapy 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.
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.9
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.10
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.
- Chinese 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.12
In supportive research doctors at the University of Karadeniz Technical University 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. 13
- 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.14
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.16
In research published here at Caring Medical, 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.1
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.
Do you have a question about Temporomandibular Joint Syndrome or need help? Get help and Information from our Caring Medical staff
1. Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Practical Pain Management. 2007; November/December:49-55.
2. 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.
3. List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia. 2017 Jun;37(7):692-704.
4. 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.
5. 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.
6. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):109-24.
7. 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.
8. 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.
9. 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.
10. Zhang S, Yap AU, Toh WS. Stem Cells for Temporomandibular Joint Repair and Regeneration. Stem Cell Rev. 2015 Jun 28.
11. 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.
12. 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.
13. 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.
14. 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.
15. 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.
16. 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.