Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction
According to the American Dental Association, more than 15% of American adults suffer from chronic facial pain.1 One of the most common causes is Tempomandibular Joint Disease (TMD), a collective term used to describe a group of medical disorders causing temporomandibular joint (TMJ) pain and dysfunction, and is estimated by The National Institute of Dental and Craniofacial Research of the National Institutes of Health to affect 10.8 million people in the United States at any given time.2 It occurs predominantly in women, with the female to male ratio ranging from 2:1 to 6:1, with 90% of those seeking treatment being women in their childbearing years.3,4
The TMJ is often predisposed to similar degenerative changes and pathologies seen in other synovial joints as a consequence of the frequent and repetitive stresses that the TMJ undergoes.5 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.6 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.7
The first-line approach to managing TMD typically includes resting the jaw, relaxing the jaw muscles, and doing jaw exercises as recommended by a physical therapist.8 Recommendations may also include eating a soft diet that minimizes hard repetitive chewing of crunchy or chewy foods, such as bagels and steak. All gum chewing must be stopped, talking minimized, and teeth clenching discouraged. Relaxation exercises that emphasize gentle range of motion of the joint are recommended. Application of warm compresses to the affected area twice daily, for 10 minutes, to decrease pain and increase joint movement are done. If this fails, then typically a short course of an anti-inflammatory medication such as ibuprofen is prescribed and often a dental consultation is given. The dentist then evaluates the patient for malocclusion and bruxism. Many times, a mouth splint used at night can completely resolve or control the problem.
When pain, clicking, and locking symptoms persist, TMD sufferers commonly seek out the advice of a myriad of TMJ dental and surgical specialists. Because the causes of TMD are varied and run the gamut from mechanical issues—such as disc degeneration and dislocation or erosion of the fibrocartilagenous surfaces of the condyle, fossa and articular eminence—to hormonal as well as psychological causes,9,10,11 the treatment approaches for the chronic TMJ case are also quite varied. As surgery is considered a last resort for TMD, it is common for sufferers to seek out alternatives and one of the treatments they may consider is prolotherapy.
This article presents a retrospective analysis of patients who received dextrose prolotherapy to their tempomandibular joints, and was conducted on a patient population from a charity clinic in rural Illinois. Patients were called by an independent data collector and asked numerous questions concerning their response to the dextrose prolotherapy they received. The data was analyzed in all TMJ pain patients, as well as a subset whose medical doctors told them there were no other treatment options for their TMJ dysfunction and pain.
Prolotherapy, as defined by Webster’s Third New International Dictionary, is “the rehabilitation of an incompetent structure, such as a ligament or tendon, by the induced proliferatin of cells.” “Prolo” comes from the world proliferate. Prolotherapy injections proliferate or stimulate the growth of new, normal ligament and tendon tissue.12 In human studies on prolotherapy, biopsies performed after the completion of treatment showed statistically significant increases in collagen fiber and ligament diameter of up to 60%.13
Prolotherapy is based on the concept that the cause of most chronic musculoskeletal pain is ligament and/or tendon weakness (or laxity). Prolotherapy has been shown in one double-blinded animal study over a six-week period to increase ligament mass by 44%, ligament thickness by 27%, and the ligament-bone junction strength by 28%.14 Another animal study confirmed that prolotherapy induced the normal healing reaction that occurs when an injured tissue is healing itself. In this study, the prolotherapy caused the circumference of tendons to increase by approximately 25% after six weeks time.15
Prolotherapists have a long history treating TMD since the time of Louis W. Schultz, MD, DDS in the 1930’s. Dr. Schultz was unique in that he was both a dentist and a medical doctor. He was an Associate Professor in the Department of Surgery at the University of Illinois and Rush College of Medicine. He published several papers on the treatment of subluxation of the temporomandibular joint, including one in 1937 in the Journal of the American Medical Association.16 In this paper he described just how common TMJ syndrome was and that the traditional treatments of rest, appliances in the mouth, physical therapy, and surgery were only partially successful. He described a simple method of shortening and strengthening the TMJ capsule by injection (later termed prolotherapy). He tested various solutions in animals until he found one that caused a strengthening of the ligaments that support the TMJ but caused no injury to other structures.17 In regard to prolotherapy into the TMJ he found that:
- There was no alteration of the normal joint cavity; the proliferation occurred in the ligaments.
- There were no gross changes in the ligaments other than their thickening.
- Lymphocytes infiltrate the area injected within 30 minutes.
- Proliferation of tissue can be seen in four to six days.
He found that a series of three to five injections were required to often permanently stop the clicking, pain, and hypermobility of the TMJ joint. Dr. Schultz noted that over the course of his twenty years of doing prolotherapy for TMD, not only was it effective, but the treatment lacked significant side effects.
Dr. Schultz taught the technique of TMJ prolotherapy to Gustav S. Hemwall, MD. The primary author has worked with Dr. Hemwall and eventually assumed his practice upon his retirement from medicine in 1996. After acquiring Dr. Hemwall’s practice, Dr. Schultz’s son came to the clinic for a prolotherapy evaluation. He commented that in his father’s many years of practice as a dentist, medical doctor, and surgeon, the procedure that gave him the most amount of satisfaction in treating a TMJ case was prolotherapy.