Over the years we have received our fair share of emails from patients seeking treatment for their TMJ. In many of these emails, the sender will describe to us osteoarthritis of the jaw that came as a result of a traumatic injury such as a jaw dislocation during a hockey game or a dislocation or a fractured jaw from an accident. Some will write that their TMJ problems developed when they had some wisdom teeth removed. Others will suggest that TMJ came upon them slowly as a degenerative joint disease. This article will focus on the later, the connection of degenerative TMJ and degenerative cervical disc disease.
When TMJ has its root in cervical spine disorders
TMJ can develop from a combination of slow moving inter-related factors, sometimes starting with poor head posture that contributes to the stretching and weakening of the cervical spine ligaments and lateral TMJ ligaments. As a result of these degenerative changes, the lower jaw slips forward and creates a worsening of the patient’s problems. Like the people I described above, who had an acute event that began their TMJ problems, people who develop TMJ over time can also experience loud popping or the clicking of bones rubbing together in the loosened joint, accompanied by pain and stiffness as the muscles tighten, trying to compensate for the instigating laxity.
Many people with TMJ have a neck problem.
There is a lot of research connecting TMJ to neck pain and cervical spine instability. This research agrees with what we have seen in our clinical practice. Many people with TMJ have a neck problem.
In January 2020,(1) researchers in Switzerland announced that they were embarking on a study to assess the evidence of association of cervical spine signs and symptoms with temporomandibular disorders. They noted “the association of cervical spine impairments (in relation to neck posture, cervical spine mobility, muscle tenderness, muscle activity and neck disability) with temporomandibular disorders has been widely discussed in the literature. Clarification of this relationship is important for health professionals to better assess and treat temporomandibular disorders.”
In our more than 25 years experience in helping patients with TMJ, we have seen many patients that needed a better assessment of their TMJ pain.
When TMJ makes neck pain worse, when neck pain makes TMJ worse
We see a lot of patients where traditional TMJ treatments such as night appliances, bite guards, pain medications, et al, did not provide relief. The question is why? Sometimes, after an examination of the patient’s head, jaw and neck, we find that many of these patients have a cause and effect relationship where their neck pain and neck instability is causing and affecting a worsening of their TMJ problems. Their neck is hurting their jaw.
In these patients we find that pain can be traced to soft tissue damage and weakness in the back of the skull, the cervical vertebrae facet joints, the cervical neck ligaments, and the cervical neck muscles. The idea of cervical neck problems causing TMJ problems are not a new idea. In a study published in the journal Clinical Oral Investigations (2) researchers found that 31 consecutive patients with symptoms of TMJ indicated stability problems at the C0-C3 vertebral levels and tender points in the muscles of the cervical spine.
In 2003 study found that instability in the cervical spine impacted TMJ problems.(3) The researchers of this study found that in many TMJ patients the right and left masticatory muscles were so badly imbalanced that they were causing the cervical spine to become displaced and distorted the patient’s posture.
In 2016, researchers added (4) to this line of study by studying whether neck strengthen exercises would relive jaw pain in patients with temporomandibular
Why are the cervical neck muscles not more full explored when treating patients with TMJ?
When doctors make TMJ worse
Over the years we have seen many patients with a history of many years of treatment. In some of these cases the patient may not have received the best treatments for what was truly causing their challenges. This would include surgery that may have been ill advised.
A 2021 paper in the Journal of oral rehabilitation (7) makes this point more forcibly:
“Regarding iatrogenesis (caused by medical care), 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 (an expectation that the medical treatment you are being recommended to won’t work), and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs.”
Conventional and non-conventional treatments for TMJ: A comparison of Platelet Rich Plasma injections and other treatments.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the jaw and neck are to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in injury and degenerative disease healing.
In the first study, doctors at Al-Azhar University, Faculty of Dental Medicine, Cairo in Egypt studied 50 patients with TMJ-osteoarthritis, they found that PRP performed better than hyaluronic acid during long-term follow-up in terms of pain reduction and increased interincisal distance (the ability to open their mouth).(8)
This was a influential study in that it is cited by newer research. Here are some of those studies:
Comparing PRP injections and hydrocortisone with local anesthetic injections
A 2018 study in the National journal of maxillofacial surgery,(11) researchers compared PRP injections and hydrocortisone with local anesthetic injections in temporomandibular disorders: Here twenty patients with internal derangements of the TMJ were divided in two groups.
- One group received PRP injection and the other received hydrocortisone with local anaesthetic.
- 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.
Doctors from Jagiellonian University, Medical College in Poland (12) found that platelet-rich plasma injections into the temporomandibular joints has a positive impact on the reduction of the intensity of pain experienced by patients treated for temporomandibular joint dysfunction.
A June 2019 (13) study out of Turkey compared corticosteroids, hyaluronic acid, and platelet-rich plasma (PRP) for treating TMJ osteoarthritis related pain. Presence of crepitation, loss of function, and loss of strength were assessed before treatment and every month for 3 months. Significant changes were observed in the PRP and hyaluronic acid groups when the patients were evaluated according to the visual analog scale (pain assessment) scores evaluated at different follow-up times for TMJ pain on lateral palpation. However, the findings of this study have shown that intra-articular PRP injections decreased TMJ palpation pain more effectively compared with the hyaluronic acid and corticosteroids groups.
A 2020 study (14) published in the Journal of oral & facial pain and headache concluded: “Based on current evidence, PRP injections may reduce pain more effectively than placebo injections in TMJ osteoarthritis at 6 months (level of evidence: moderate) and 12 months (level of evidence: moderate) post-injection. This significant difference in pain reduction could also be seen when PRP was compared to hyaluronic acid at 12 months post-injection (level of evidence: low). It can be cautiously interpreted that PRP has a beneficial effect on the relief of TMJ osteoarthritis pain.”
Arthrocentesis (fluid aspiration)
Aspiration or arthrocentesis of the jaw joint and platelet-rich plasma injections
A 2019 study in the International journal of molecular sciences,(9) found that aspiration or arthrocentesis of the jaw joint and platelet-rich plasma injections in temporomandibular disorders’ management were found to be effective in reducing pain and joint sound as well as in improving mandibular motion in a maximum follow-up of 24 months. A 2015 study in the Journal of cranio-maxillofacial surgery concluded that patients suffering from TMJ disc dislocation benefited more from PRP injections than from arthrocentesis to manipulate the jaw back in place. Clearly PRP stabilized the joint and reduced chronic instability.(10)
A study published in September 2019 in the publication Dental and medical problems (15) suggested that treating patients with TMJ displacement who did not have reduction (limited mouth opening) with PRP and arthrocentesis (fluid aspiration) appeared to be a superior treatment to arthrocentesis plus Hyaluronic acid injections or arthrocentesis alone.
Most recently in this line of research is a July 2021 study (16) which also examined the efficacy of hyaluronic acid, corticosteroids and platelet-rich plasma (PRP) in the treatment of TMJ osteoarthritis: In an analysis of 16 published studies, this paper found arthrocentesis alone effectively reduced pain and improved jaw function in patients diagnosed with MJ osteoarthritis. Additional injections of hyaluronic acid, either low-molecular-weight high-molecular-weight hyaluronic acid, or corticosteroids at the end of the arthrocentesis do not improve the final clinical outcomes. In fact corticosteroids presented several negative effects on the articular cartilage. Results related to additional PRP injections are not consistent and are rather questionable.
So what we have are inconstant findings. Empirically we have observed benefits of PRP when given in a consistent manner and beyond one injection/one treatment methods.
Mesenchymal stem cells derived from the bone marrow
In the journal Stem Cells International, October 2017, (17) research suggests that Mesenchymal stem cells, derived from the bone marrow play a role as seed cells for the cartilage regeneration of TMJ osteoarthritis. In addition to addressing abnormal remodeling of the subchondral bone (the jaw bone under the TMJ cartilage). The study notes research that has revealed the interaction between chondrocyte (cartilage makers) and adjacent osteoclast or osteoblast (bone makers) to regulate the bone-remodeling process during stem cell repair.
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.
More recently, an April 2021 study in the journal Stem cells international (18) described the possibilities surrounding the use of Mesenchymal stem cells in TMJ cases: “Temporomandibular joint osteoarthritis is a degenerative disease characterized by cartilage degeneration, disrupted subchondral bone remodeling, and synovitis, seriously affecting the quality of life of patients with chronic pain and functional disabilities. Current treatments for Temporomandibular joint osteoarthritis are mainly symptomatic therapies without reliable long-term efficacy, due to the limited self-renewal capability of the condyle and the poorly (understood) pathogenesis of Temporomandibular joint osteoarthritis. 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.”
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References:
1 Balthazard P, Hasler V, Goldman D, Grondin F. Association of cervical spine signs and symptoms with temporomandibular disorders in adults: a systematic review protocol [published online ahead of print, 2020 Jan 8]. JBI Database System Rev Implement Rep. 2020;10.11124/JBISRIR-D-19-00107. doi:10.11124/JBISRIR-D-19-00107
2 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.
3. 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
4 Calixtre LB, Grüninger BL, Haik MN, Alburquerque-Sendín F, Oliveira AB. Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. J Appl Oral Sci. 2016;24(3):188-97.
5 Fougeront N, Fleiter B. Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity changes. Canadian journal of physiology and pharmacology. 2018 Aug 1;96(11):1051-9.
6 Lee IS, Kim SY. Effectiveness of manual therapy and cervical spine stretching exercises on pain and disability in myofascial temporomandibular disorders accompanied by headaches: a single-center cohort study. BMC Sports Science, Medicine and Rehabilitation. 2023 Dec;15(1):1-1.
7 Greene CS, Manfredini D. Transitioning to Chronic TMD Pain: A Combination of Patient Vulnerabilities and Iatrogenesis. J Oral Rehabil. 2021 May 9. doi: 10.1111/joor.13180. Epub ahead of print. PMID: 33966303.
8 Hegab AF et al. Platelet-Rich Plasma Injection as an Effective Treatment for Temporomandibular Joint Osteoarthritis. J Oral Maxillofac Surg. 2015 Sep;73(9):1706-13. doi: 10.1016/j.joms.2015.03.045. Epub 2015 Mar 24.
9 Zotti, F., Albanese, M., Rodella, L. F., & Nocini, P. F. (2019). Platelet-Rich Plasma in Treatment of Temporomandibular Joint Dysfunctions: Narrative Review. International journal of molecular sciences, 20(2), 277. doi:10.3390/ijms20020277
10 Hancı M, Karamese M, Tosun Z, Aktan TM, Duman S, Savaci N. Intra-articular platelet-rich plasma injection for the treatment of temporomandibular disorders and a comparison with arthrocentesis. J Craniomaxillofac Surg. 2015 Jan;43(1):162-6. doi: 10.1016/j.jcms.2014.11.002. Epub 2014 Nov 15.
11 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. Natl J Maxillofac Surg. 2018;9(2):205-208.
12 Pihut M, Szuta M, Ferendiuk E, Zeńczak-Więckiewicz D. Evaluation of pain regression in patients with temporomandibular dysfunction treated by intra-articular platelet-rich plasma injections: a preliminary report. Biomed Res Int. 2014;2014:132369. doi: 10.1155/2014/132369. Epub 2014 Aug 3.
13 Gokçe Kutuk S, Gökçe G, Arslan M, Özkan Y, Kütük M, Kursat Arikan O. Clinical and Radiological Comparison of Effects of Platelet-Rich Plasma, Hyaluronic Acid, and Corticosteroid Injections on Temporomandibular Joint Osteoarthritis. J Craniofac Surg. 2019;30(4):1144–1148. doi:10.1097/SCS.0000000000005211
14 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
15 Toameh MH, Alkhouri I, Karman MA. Management of patients with disk displacement without reduction of the temporomandibular joint by arthrocentesis alone, plus hyaluronic acid or plus platelet-rich plasma. Dent Med Probl. 2019;56(3):265-272. doi:10.17219/dmp/109329
16 Derwich M, Mitus-Kenig M, Pawlowska E. Mechanisms of Action and Efficacy of Hyaluronic Acid, Corticosteroids and Platelet-Rich Plasma in the Treatment of Temporomandibular Joint Osteoarthritis—A Systematic Review. International Journal of Molecular Sciences. 2021 Jan;22(14):7405.
17 Cui D, Li H, Xu X, Ye L, Zhou X, Zheng L, Zhou Y. Mesenchymal Stem Cells for Cartilage Regeneration of TMJ Osteoarthritis. Stem Cells International. 2017;2017.
18 Zhao Y, Xie L. An Update on Mesenchymal Stem Cell-Centered Therapies in Temporomandibular Joint Osteoarthritis. Stem Cells Int. 2021 Apr 1;2021:6619527. doi: 10.1155/2021/6619527. PMID: 33868408; PMCID: PMC8035039. 2719
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