The evidence and comparisons of TMJ injection treatments and conservative care treatments

Ross A. Hauser, MD. Danielle R. Steilen-Matias, MMS, PA-C.

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 led 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.

Because the cure for TMD has been so elusive, perhaps no other disorder involves so many allied health care professionals including pain clinicians, dentists, physical therapists, psychologists, mental health professionals, speech-language pathologists, physiatrists, radiologists, internists, family physicians, endodontists, orofacial surgeons, otolaryngologists, neurologists, and craniofacial specialists.

In this article, we will discuss these treatments and the possible solutions regenerative medicine injections may offer.

Discussion points of this article

It is the recommendation of The National Institute of Dental and Craniofacial Research, a branch of the US government’s National Institutes of Health, that less treatment is best in treating TMJ disorders. They recommend that patients avoid treatments that cause permanent changes in the bite or jaw. Such treatments include crown and bridge work to balance the bite, orthodontics to change the bite, grinding down teeth to bring the bite into balance (occlusal adjustment), and repositioning splints, which permanently change the bite. They also state that finding the right care can be difficult, and they recommend looking for a healthcare provider who understands musculoskeletal disorders (affecting muscle, bone, and joints) and is trained in treating pain conditions. Pain clinics in hospitals and universities are often a good source of advice.

We often find that we are in agreement with the first part of this recommendation, the latter part we find ourselves frequently in disagreement with it. TMJ has always been and will continue to be like other chronic painful disorders: a joint instability issue. Until this is addressed, treatment regimes will continue to be pain management and not pain cure.

TMJ instability

Part 1: Treating TMJ, success and failures: When doctors made the TMJ worse

Researchers at the University of Illinois at Chicago College of Dentistry and the Department of Biomedical Technologies, School of Dentistry, University of Siena, Italy wrote in a 2021 paper in the Journal of Oral Rehabilitation (1) that some of the problems TMJ sufferers have were caused by their doctors. This is noted in the paper’s opening sentence: “Based on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been (now been understood). . . Regarding iatrogenesis (complication caused by medical treatment), sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect (the patient does not think the treatment will work), and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification (worsening pain) of TMDs.”

Again, while getting a cortisone shot, taking an NSAID (nonsteroidal anti-inflammatory medication), or using an occlusal splint or other appliance might seem harmless, it truly isn’t because the underlying etiological diagnosis goes missing: TMJ instability. When the standard treatments such as those just mentioned don’t work, some doctors may be quick to recommend an innovative surgical option, because of all the internal derangement or other osteoarthritis seen on MRI.

The mutilation of jaws that I have seen by surgery is unconscionable. I have seen people who have had their condyles taken off and when they chew, the rest of their jaw just flaps in the wind. Surgical and medical treatments from the past have included meniscectomies, retracting the condyle with a steel headband or even wiring the jaws shut for months, psychotherapy, multidisciplinary teams, complete resection of the articular meniscus, amputation of the condylar heads leaving the discs intact, reconstructive surgeries to “recapture the articular disc,” disc replacements using plastic implants, and the list goes on and on.

malocclusion TMJ

Unfortunately, people with TMD end up with these surgeries and other invasive procedures because the imaging studies on their jaws show something “terrible.” Such diagnostic tests include radiographs of the TMJ with and without appliances, various x-ray views including panoramic, transcranial, and oblique views, laminographic studies, CT MRI of the TMJ, dynamic arthrography, mandibular kinesiography, EMG of mastication muscles, and thermography. This does not even include all the diagnostic criteria a dentist uses to show how “off” one’s bite is. There is a strong correlation between abnormal joints and a history of orthodontics. It is now recommended by many in the dental profession to eliminate the patient’s TMJ pain and dysfunction before initiating any type of orthodontic mechanics. It should be noted that throughout my career and even right now, there are still dentists and others who believe malocclusion is the cause of TMD. While I acknowledge it can be involved, it is rarely—and I mean rarely—the cause. It is actually the other way around! Instability in the TMJ causes malocclusion.

Yet, 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 clinic. 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.”

Understanding the TMJ temporomandibular joint itself. What are we seeing in this image?

TMD is often described as an internal derangement (joint misalignment), which is a problem with the articular disc in an abnormal position, leading to mechanical interference and restriction of mandibular activity. Internal derangement typically causes continuous pain that will be exacerbated by jaw movement. Clicking and locking will result in restricted mandibular opening or deviation of mandibular movements during opening and closing. While there are nomenclature systems that divide TMD into classification systems including disc derangements, hypermobility disorders (subluxations), and hypomobility conditions (adhesions and ankyloses), some doctors believe ultimately what initially causes all of these conditions is joint instability of the TMJ.

In this simplified view of the TMJ, we can get an understanding of the mechanisms behind TMJ disc displacement. When this person would close their mouth, they would get the characteristic clicking sound and accompanying “pop” or feeling of displacement. See that the disc in this image has ligaments behind it. The ligaments are there to provide structural stability between the jaw bone at the skull. The ligaments are holding the jaw to the skull. In front of the disc towards the face are the powerful jaw muscles. Attaching these power muscles to the jaw are the muscle tendons. Notice how the muscle turns white as they approach the bone. The tendons are the muscles attached to the bones and they are white in color. They hold the muscles to the jaw. If the ligaments or tendons are weak, damaged, stretched out, or lax, the jaw is floating, and the disc can be displaced.

In this simplified view of the TMJ, we can get an understanding of the mechanisms behind TMJ disc displacement. When this person would close their mouth, they would get the characteristic clicking sound and accompanying "pop" or feeling of displacement. See that the disc in this image has ligaments behind it. The ligaments are there to provide the structural stability between the jaw bone at the skull. The ligaments are holding the jaw to the skull. In front of the disc towards the face are the powerful jaw muscles. Attaching these power muscles to the jaw are the muscle tendons. Notice how the muscle turns white as they approach the bone. The tendons are the muscles attachments to the bones and they are white in color. They hold the muscles to the jaw. If the ligaments or tendons are weak, damaged, stretched out, or lax, the jaw is floating, the disc can be displaced.

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 syndrome occurs when the joints, 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).

Bruxism

There has been a great deal of emphasis on occlusal devices in the treatment of TMJ because of the tremendous forces that occur with bruxism. Bruxism is defined as the clenching or grinding of the teeth during nonfunctional movements of the mandible. When it occurs during sleep, it is termed nocturnal bruxism. Most individuals engage in nocturnal bruxism activity at some point in their lives. The etiology of nocturnal bruxism by most traditionally-minded practitioners is that it is a sleep disorder related to the patient’s waking emotional state that is centrally mediated and precipitated by emotional stress. It occurs in greater frequency during periods of emotional or physical stress, as well as the anticipation of stress.

Many people we have evaluated for bruxism have clicking and grinding in their TMJ.  While bruxism can cause TMJ, TMJ instability can cause bruxism. Most bruxism completely stops once the TMJ instability is resolved. It is imperative that it stops because nocturnal bruxism can generate incredible forces resulting in significant loads to the TMJ complex.

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 a 2017 study, doctors publishing in The Journal of Headache and Pain (2) made these observations on 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) and myalgia (pain).

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?

Bruxism and chronic inflammation

Let’s return to our discussion of bruxism. Doctors are realizing that there is a connection between inflammation and bruxism. It is just hard to prove. In July 2023, doctors at Wroclaw Medical University in Poland, writing in the journal Brain Sciences (3) evaluated the relationship between inflammatory status and sleep bruxism. The researchers examined data from five studies and could only suggest that sleep bruxism could be associated with inflammation but there are no papers conclusively showing that the inflammatory status in bruxers is comparable to non-bruxers. What does this mean? There is a connection between inflammation and bruxism. It is just hard to prove.

Part 2: Non-surgical conservative treatment methods for TMJ

Non-surgical conservative treatment methods for TMJ

The problem with any of these approaches is that they do not repair the weakened TMJ ligament and, thus, do not alleviate the chronic pain that people with this condition experience. 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 benefits, 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. Why didn’t they help some people? Was it Inflammation?

The above heading is taken in part from the title of a paper from University medical researchers in Turkey published 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. Patients were divided into four groups according to the treatment method:

Magnetic resonance imaging (MRI) was performed before treatment and at the 1-month follow-up. Patients were followed up after treatment for 6 months.

Note: All these treatments worked well, except in our opinion the very ominous problem of effusion.

Symptom suppression is 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 evidence and comparisons of TMJ injection treatments

A February 2022 review in the journal Oral and Maxillofacial Surgery Clinics of North America (5) offers us this summary of the myriads of treatments available to TMJ patients.

“Treatments include noninvasive pharmacologic therapies, minimally invasive muscular and articular injections, and surgery. Conservative therapies include nonsteroidal anti-inflammatory drugs, muscle relaxants, benzodiazepines, antidepressants, and anticonvulsants.

Minimally invasive injections include botulinum toxin, corticosteroids, platelet-rich plasma, hyaluronic acid, and Prolotherapy with hypertonic glucose. With many pharmacologic treatment options and modalities available to the oral and maxillofacial surgeon, mild to moderate temporomandibular joint disorder can be managed safely and effectively to improve symptoms of pain and function of the temporomandibular joint.”

“Nonsteroidal anti-inflammatory drugs (with proton pump inhibitors) and muscle relaxants are first-line therapies shown to improve symptoms of temporomandibular joint disorder. Oral benzodiazepines, tricyclic antidepressants, and anticonvulsants are alternative therapies that may be considered in resistant or refractory temporomandibular joint disorder, in consultation with the patient’s physician. Botox injections have been shown to be a safe and effective treatment for myofascial temporomandibular joint disorder as intramuscular injections. Intra-articular injections have shown marked improvement in symptoms. Evidence suggests they share similar effectiveness. Prolotherapy with hypertonic glucose is effective for treating hypermobility and subluxation of the temporomandibular joint.”

An April 2023 paper (6) from the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, at Mansoura University compared the outcomes in patients of different intra-articular injections using a mixture of hyaluronic acid (HA) and platelet-rich plasma (PRP) versus hyaluronic acid and corticosteroid in the management of TMJ internal derangement with reduction (dislocation.) The research was published in the Journal of maxillofacial and oral surgery.

In this study: Sixty patients were randomly divided into two equal groups.

Pain intensity according to the visual analogue scale (0 no pain to 10 unbearable pain), maximum inter-incisal opening (MIO – Mouth opening ability), lateral movement, and joint sound were measured pre-operatively and at 1 week, 1 month, and 6 months post-operatively.

Mouth opening ability and lateral movements were improved in both groups, with a reduction in the number of patients suffering from clicking sounds during the follow-up periods with both groups showing significant results.

Hyaluronic acid injections and steroid injection

In September 2018, in the Hungarian Medical Weekly, (7) researchers at the world-renowned Semmelweis University’s Faculty of Dentistry published their findings comparing hyaluronic acid injections and steroid injections.

They found:

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.”

Beyond our opinion, there is good debate in the medical community There is a debate in the medical community over the effectiveness of hyaluronic acid injections for pain relief and functional improvement in patients with temporomandibular disorders. This is discussed in an August 2023 paper (8) published in the International Journal of Molecular Sciences. Here doctors in Romania conducted an umbrella review of previously published papers. In their examination of the data they suggest: “no statistically significant differences between hyaluronic acid injections and corticosteroids, whereas platelet (PRP) derivates seem to have good results in pain relief. . . Furthermore, there is no agreement on the effectiveness of a combination of arthrocentesis or arthroscopy with hyaluronic acid injections.” The researchers warned that “Although the literature showed these positive results after hyaluronic acid injections, the overlapping of primary studies in the systematic reviews included might have affected our results, such as the very low quality of the papers.” In other words, the positive effects of hyaluronic acid injections were not definitively shown.

Hyaluronic injections vs. glucosamine and oral NSAID

An  October 2021 study in the Journal of Clinical Oral Investigations (9) compared the effects of 4 biweekly hyaluronan (Hyaluronic injections) injections with glucosamine and diclofenac oral administration on TMJ osteoarthritis patients. These are the paper’s learning points:

Results:

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 (10) from 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.

More recently in November 2022 in the medical journal Life (11), researchers compared the long-term effect on pain of intra-articular TMJ injections of betamethasone (corticosteroid), sodium hyaluronate, and platelet-rich plasma. The study group was made up of 114 patients, who were randomly distributed into three groups at least three years prior to completion of the study and who achieved a total remission of pain after treatment.

Can steroid injections make TMJ pain worse?

Any medical treatment can make a condition worse. Many people have very successful outcomes with steroids. Much of the research demonstrated in this article shows short-term relief in many cases. However, the adverse effects of corticosteroids are well-known and cause concern among patients and the medical community.

Steroids / Anti-inflammatories – research questions effectiveness and worthiness in helping TMJ patients.

In a January 2019 paper in the Journal of Oral Rehabilitation,(12) 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.

BOTOX® – Botulinum toxin injections for TMJ

Most people recognize the more familiar BOTOX® brand name for Botulinum toxin injection. Most are also familiar that these injections give a more youthful facial appearance by relaxing muscles and thereby reducing wrinkles. This concept of relaxing muscles is the basis behind botulinum toxin injection as an alternative treatment for TMJ and related jaw pain. The treatment is injected into the muscles of the face and jaw where spasm causes pain and discomfort.

Myofascial pain syndrome is a common painful muscle disorder caused by taut bands or trigger points in the muscles including the muscles of the TMJ. Myofascial trigger points are tender areas in muscles causing local and referred muscle pain. Trigger points may cause tight muscles and tight muscles may cause trigger points. That is not a play on words, that is actually what can happen, you have spasms because of instability in the jaw. Those continuous spasms can cause points of pain sensitivity within the muscle from “over-spasming.”

A November 2021 paper in The Journal of Craniofacial Surgery (13)  analyzed the clinical outcome of botulinum toxin type A intramuscular injections into the head and neck, particularly the masticatory muscles of patients with temporomandibular disorder (TMD).

A December 2020 paper in the Journal of Oral Science (14) listed improvements however as temporary. In this paper, twenty-two patients who received a diagnosis of chronic masseter and temporalis myofascial pain were evaluated by using a visual analog pain scale (no pain is a zero score – unbearable pain is a score of 10), among other disability and pain scoring surveys. The outcome was that while at two months after botulinum toxin treatment the patients showed significant improvement in quality of life, those improvements did not hold at seven months. However, the conclusion of the researchers was that botulinum toxin type A injections resulted in safe, effective short-term pain relief for patients with chronic facial pain affecting the masseter and temporalis muscles.

A June 2020 paper published in The British Journal of Oral & Maxillofacial Surgery (15) also found good but short-term benefits. The researchers wrote: “Despite showing benefits, consensus on the therapeutic benefit of botulinum toxin in the management of myofascial temporomandibular joint disorders is lacking. Further randomized controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed.”

In September 2023 researchers writing in the Journal of Stomatology, Oral and Maxillofacial Surgery (16) provided an updated assessment of the effectiveness of myogenic (muscle-related)  botulinum toxin injection and provided a before and after comparison. In this paper of 45 patients who received botulinum toxin injections in the temporalis and masseter muscles, the researchers found significant improvement in pain, function, and quality of life.

Botulinum toxin and jaw bone degeneration?

A February 2020 (17) study in the journal Scientific Reports addressed the controversy surrounding masticatory muscle atrophy induced by botulinum toxin injection. The controversy exists because it cannot be shown (definitely) if botulinum toxin injection causes enough muscle atrophy to create more instability in the jaw and an eventual bone-on-bone grinding of the jaw bone and the mandible. In this study, a group of 39 women (average age about 27) and 38 post-menopausal women (average age about 55) had an application of a stabilization splint, and/or two times of botulinum toxin injection in the bilateral temporalis and masseter muscles within a six-month treatment period.  It was observed in the patients a decreased masticatory muscle thickness (atrophy of the muscle), especially in post-menopausal females. The botulinum toxin injection may induce muscle atrophy that damages the jaw bone by way of joint instability.

Prolotherapy Injections versus the TMJ splint

Prolotherapy is the injection of simple sugar, dextrose. The idea is that 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, pull things back into place, and reduce degenerative disc and destructive joint forces in the jaw. In this next section, we will discuss the research and clinical outcomes of this injection treatment and compare these treatments to other injections.

A July 2021 paper in the journal Scientific Reports (18) tackled the problem of assessing consistent effective outcomes in patient treatment results utilizing Prolotherapy. The study authors write:

“Hypertonic dextrose prolotherapy (a higher concentration of dextrose is being injected) has been reported to be effective for temporomandibular disorders (TMDs) in clinical trials but its overall efficacy is uncertain.”

To assess this problem the researchers then conducted a systematic review (they looked at previously published studies) and analyzed those randomized controlled trials that met their criteria to synthesize evidence on the effectiveness of Prolotherapy for temporomandibular disorders. What they were looking for as good outcomes were levels of pain intensity. The secondary outcome they were looking for was mouth-opening ability.

Here are their results:

In a meta-analysis of 5 randomized controlled trials, dextrose prolotherapy was significantly superior to placebo injections in reducing TMJ pain at 12 weeks. In this systematic review and meta-analysis, evidence from low to moderate-quality studies shows that dextrose prolotherapy conferred a large positive effect that met the criteria for clinical relevance in the treatment of TMJ pain, compared with placebo injections.

In November  2020: Published in the Journal of Cranio-Maxillo-Facial Surgery (19) compared the effectiveness of  Dextrose Prolotherapy and occlusal (mouth) splints in treating internal derangement of the temporomandibular joint.

Results: Nine patients in the (Prolotherapy) study group had a complete absence of pain, compared with only one (splint group) patient in the control group. The results showed that patients who received Prolotherapy demonstrated improvement in pain, mouth opening, and clicking, but no significant difference in deviation was observed between the groups after 1 year.

Conclusion: Prolotherapy was found to be superior in providing long-term clinical relief, with a reduction in pain and clicking along with improved mouth opening.

The research on Prolotherapy for Temporomandibular Joint Pain and Dysfunction

Treating the whole joint. Comprehensive Prolotherapy for TMJ. 

“Dextrose Prolotherapy is one of the most promising approaches in the management of TMD”

A March 2021 study in the Journal of Maxillofacial and Oral Surgery (20) writes:

“Temporomandibular joint (TMJ) disorders can be treated by both conservative and surgical approaches. Conservative interventions with predictable benefits can be considered as first-line treatments for such disorders. Dextrose Prolotherapy is one of the most promising approaches in the management of TMDs, especially in refractory (difficult) cases where other conservative management has failed.

(The researchers) conducted a study on 25 patients suffering from various TMJ disorders who were treated with Prolotherapy. . . The standard program is to repeat the injections three times, at 2-week intervals, which totals four injection appointments over 6 weeks with a 3-month follow-up.

Results: There was an appreciable reduction in tenderness in TMJ and masticatory muscles with significant improvement in mouth opening. The effect of the treatment in improving clicking and deviation of TMJ was found to be statistically significant. There were no permanent complications.

Conclusion: (This) study concluded that Prolotherapy is an effective therapeutic modality that reduces TMJ pain, and improves joint stability and range of motion in a majority of patients. It can be a first-line treatment option as it is safe, economical, and an easy procedure associated with minimal morbidity.”

In March 2019, doctors tested this idea. Publishing in the journal Mayo Clinic Proceedings (21)  these doctors from the University of British Columbia, the University of Missouri-Kansas City, the 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:

RESULTS:

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 (22) whose authors included noted Prolotherapy researchers, friends, and colleagues Kenneth Dean Reeves, MD and David Rabago, MD noted:

Patient profile:

Patient treatments:

Outcomes:

Comparison between Prolotherapy vs. lidocaine

Prolotherapy has a promising role in the improvement of oral health-related quality of life of patients with TMD, and its beneficial effects persist at least two years after treatment.

An August 2020 study in The British Journal of Oral & Maxillofacial Surgery (23) wrote: “In the present study we have assessed the influence of Prolotherapy in patients with TMD by the subjective measurement of Quality of Life using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 – 70) years) were included. They had all undergone dextrose Prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks).”

“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 (24) 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.

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.

In a December 2018 study in the Journal of Oral Rehabilitation, (25)  military Oral and Maxillofacial Surgeons in India proposed that dextrose Prolotherapy may cause a 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.

In supportive research doctors at the University of Karadeniz Technical University (27) say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.

Dr. Refai of Cairo University reported in the British Journal of Oral and Maxillofacial Surgery:

A February 2022 study (28) evaluated the effects of prolotherapy on condyles (wear and tear on the bone) in temporomandibular joint hypermobility. In this study, the researchers acknowledged that prolotherapy has gained popularity in recent years and has been reported to have positive short-term and long-term. Their study aimed to evaluate the changes in the trabecular (bone) structure of mandibular condyles in patients who underwent prolotherapy due to TMJ hypermobility.

Result:

A March 2022 study published in the Journal of Cranio-Maxillo-Facial Surgery (29) comes to us from the Faculty of Dentistry, Mansoura University, Egypt. In this research, doctors assessed the effectiveness of dextrose prolotherapy on the clinical signs and symptoms of patients having TMJ disc displacement with reduction.

March 2021 paper in the journal Head and Face Medicine (30) examined and treated forty adolescents and young adults, aged 16 to 30 years old, with a distinct combination of symptoms of TMJ “closed lock”. Patients received anesthetic blockages of the auriculotemporal nerve, then performed mandibular condylar movement exercise for 10 min, and subsequently received hypertonic dextrose prolotherapy in the retro-discal area of TMJ. Clinical assessments at baseline and at follow-up (2 weeks, 2 months, 6 months, and 5 years) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing.

Results: Cone beam CT images of the TMJs revealed joint space changes in all patients and degenerative bone changes in 20% (8/40) of the patients. The patients were diagnosed as having disc displacement without reduction with limited opening. Successful reduction of the displaced disc had been achieved in the treatment. Pain at rest and pain on mastication had substantially decreased in all patients and mandibular function and mouth opening had significantly improved since 2 weeks’ follow-up. The overall success rate was kept at a high level of 97.5% (39/40) at 6 months and 5 years’ follow-up.

Conclusions: The technique combining mandibular condylar movement exercise with auriculotemporal nerve block and dextrose prolotherapy is straightforward to perform, inexpensive, and satisfactory to young patients with TMJ closed lock.

More research published in The British Journal of Oral & Maxillofacial Surgery. (31) Dextrose prolotherapy provided a 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. 

In the July 2018 edition of the Journal of Oral Rehabilitation, Military doctors in India compared Prolotherapy to Placebo injections. They found: “Within the limitations of the study, dextrose Prolotherapy may cause significant reduction in mouth opening and pain associated with TMJ hypermobility. Conclusions with regard to the reduction of episodes of subluxation/dislocation cannot be drawn. ” In their study, they could not give good evidence that TMJ subluxations or dislocations were reduced. (32)

Hypermobility, disc displacement, effusion or swelling, and instability of the TMJ.

TMJ, Joint Hypermobility Syndrome and Ehlers-Danlos syndrome.

Hypermobility of the TMJ means that the joint is loose and that the jaw is floating abnormally within the head causing grinding and degeneration at the joint. The TMJ discs and meniscus can be displaced causing the onset of osteoarthritis and the development of pain and bone spurs. Omnipresent in this situation is the problem of effusion or swelling adding pressure to the joint. The swelling and inflammation are there to try to stabilize the joint and the fluid is trying to provide a cushion from the degenerative process.

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 (33) 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.

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, 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.

A September 2023 study in the medical journal Cranio, Journal of Craniomandibular Practice (34) also compared the effectiveness of dextrose Prolotherapy in conjunction with arthrocentesis (fluid draining of the TMJ) and dextrose Prolotherapy alone in the management of symptomatic TMJ hypermobility.

Prolotherapy, PRP, and MSCs

In December 2022, researchers writing in the International Journal of Molecular Sciences (35) summarized the problems of degenerative TMJ and possible solutions:

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 have 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.

Mesenchymal stem cell-based treatments (MSCs) have become a very popular treatment option. Research is coming in. Stem cell therapy can involve the use of bone marrow aspiration (or also concentrated) to get the stem cells to the site of the injury.

National University of Singapore doctors (36) 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.

We would like to point out again, that you cannot grow something out of nothing in the current mode of stem cell therapy. If the TMJ meniscus is removed, stem cells cannot regrow a new one.

In the past decade, progress made in the development of stem cell-based therapies, and tissue engineering has provided alternative methods to attenuate the disease symptoms and even replace the diseased tissue in the treatment of TMJ disorders.  This represents innovative approaches to cell-based therapeutics, tissue engineering, and drug discovery in treatment.  This supports earlier research from the same researchers who stated: Stem cells could help regenerate bone and soft tissue. (37)

An April 2021 study in the journal Stem Cells International (38) described the possible use of stem cells in TMJ cases: “Current treatments for Temporomandibular joint osteoarthritis are mainly symptomatic therapies without reliable long-term efficacy. . . Recently, there has been increased interest in cellular therapies for osteoarthritis and TMJ regeneration. Mesenchymal stem cells (MSCs), self-renewing, and multipotent progenitor cells play a promising role in Temporomandibular joint osteoarthritis. Derived from a variety of tissues, MSCs exert therapeutic effects through diverse mechanisms, including chondrogenic differentiation; fibrocartilage regeneration; and trophic, immunomodulatory, and anti-inflammatory effects.”

This was followed by similar research published in 2017 (39) which suggested: “Given the limited self-healing potentials of avascular cartilage, little effective therapy is available for the repair of normal TMJ tissues in osteoarthritis disease. Although conventional nonsurgical or surgical treatments can relieve joint pain to some extent, they cannot completely restore the TMJ function and reverse disease progression. MSCs, which have the multilineage differentiation potentials, may provide an alternative treatment for the cartilage degradation in TMJ osteoarthritis.”

Conversely, an August 2022 paper in the journal Cells (40) examining the outcomes of the treatment of temporomandibular joint (TMJ) articular pain and restricted maximum mouth opening with intra-articular administration of mesenchymal stem cells (MSCs), suggested that while the treatment may be helpful, studies talking of the treatments benefits are based on weak evidence.

In April 2021 researchers wrote in the journal Stem Cells International (41) of the need for continued research in stem cells. “Due to the complicated pathogenesis of TMJ osteoarthritis and poor self-healing capability of a condylar structure, current management for this degenerative disease, both conservative and surgical, are mainly symptomatic therapies. Unmet clinical needs for effective, long-term, disease-modifying strategies to regenerate the osteoarthritic TMJ structure still exist, and therefore lead to the increasing interest in cellular-based therapies, namely mesenchymal stem cells (MSCs) and their related derivatives, such as exosomes and minimally manipulated MSCs.”

Stem cell therapy remains controversial. For most, in our opinion, stem cell therapy is not some type of miracle, single-shot cure. Thinking it is, indeed, is an over-expectation of what the treatment can do.

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 typical “injections,” at each treatment, not a single injection.

A 2020 study published in the Journal of Oral & Facial Pain and Headache (42) 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 (43) shows emerging evidence suggesting 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).

The hyaluronic acid group showed significant improvements at 1 and 3 months. However, 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 (44) 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. The researchers found: “In the group of PRP injection, the pain was markedly reduced than the group of hydrocortisone with a 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 (45) evaluated the effectiveness of arthrocentesis (TMJ aspiration) or injections with platelet-rich plasma in temporomandibular affections and compared them to arthrocentesis alone or with hyaluronic acid or to hyaluronic acid injections.

The researchers found:

PRP combined with physical therapy

A September 2021 study in the Journal of Oral Rehabilitation (46) assessed the effectiveness of platelet-rich plasma injection combined with physical therapy for the treatment of temporomandibular joint osteoarthritis. These are the summary highlights of this paper:

Results:

Conclusions:

“Platelet-rich plasma injection can significantly improve pain, mouth opening, abnormal joint sound, and mandibular function in patients with TMJ-osteoarthritis and has good repair effect on condylar bone defects. PRP injection combined with individualized comprehensive physical therapy can effectively control the medium- and long-term pain of patients.”

More on “blood injections”

Platelet Rich Plasma is a blood injection, the blood is taken from you and spun in a centrifuge to separate out the blood platelets. It is this separated fluid with concentrated platelets that gives Platelet Rich Plasma its name, and the injection of plasma rich in platelets. There are also autologous blood injections where the blood is taken from one part of the body and simply put back into the painful area, in this case, the jaw and TMJ joint.

“Blood injections” can be somewhat painful, as the blood is very thick. This is why Platelet Rich Plasma injections started to gain popularity because they could offer the healing factor benefits of blood in a less thick injectable.

We are going to look at a January 2020 systematic review paper from the Department of Orofacial Pain and Jaw Function, Malmö University in Sweden published in the journal Clinical Oral Investigations (47) here the doctors looked at a comparison of autologous blood injection and a TMJ Prolotherapy treatment program.

To assess these treatments in comparison, the doctors examined previously published research on randomized controlled trials on TMJ luxation treatment.

 

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:

These improvements persisted through follow-up at eighteen months after the conclusion of Prolotherapy treatments.

We found:

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 from inflammation, Prolotherapy stimulates healing.

The Physical and emotional aspects of TMJ

In our 2007 study, we noted:

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:

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). (29)

Because the cure for TMD has been so elusive, perhaps no other disorder involves so many allied healthcare professionals including pain clinicians, dentists, physical therapists, psychologists, mental health professionals, speech-language pathologists, physiatrists, radiologists, internists, family physicians, endodontists, orofacial surgeons, otolaryngologists, neurologists, and craniofacial specialists. Exploring treatment options such as Prolotherapy may offer benefits not offered by these specialties. Prolotherapy can be an effective treatment for chronic neck, head, TMJ, facial, ear, and mouth pain because it strengthens the structures that are causing the pain.

An October 2022 paper in the journal Cureus (42) helps sum this article up this way: “TMJ prolotherapy, like other joint treatments, can be beneficial to individuals who have a temporomandibular disorder (TMD) that is resistive to or has demonstrated only limited improvement with physical medicine, dietary restrictions, and home care. It can also benefit patients who have not improved sufficiently with oral appliances, or who are unable or unable to wear such equipment, and who are unsuitable or unwilling candidates for TMJ surgery.”

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your TMJ issues.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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Further reading

The many symptoms of TMJ beyond the jaw: Neck muscle spasms, myofascial pain, breathing problems, digestive disorders and dizziness

TMJ and Tinnitus: Should we explore the ligament chain from the cervical spine through the neck to the jaw to the ear?

Ernest Syndrome | Is this the answer to unresolved TMJ, facial, ear and throat pain?

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This page was updated September 2, 2023

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