Research on different TMJ injections

Marc Darrow, MD, JD.

Many people contact our office asking about temporomandibular joint (TMJ) treatments. For the most part they are contacting us to learn about the possibilities of how regenerative medicine injection treatments may help them. Among these injections are bone marrow aspirate concentrate (a procedure that uses cells from your own bone marrow to initiate healing) and Platelet Rich Plasma injections. We use these treatments in orthopedic conditions such as osteoarthritis, joint degenerative disease, neck and back pain), and for the purpose of this article problems of TMJ and TMJD (Temporomandibular joint dysfunction).

The temporomandibular joint (TMJ) is located where the jawbone meets the cranium. The condition known as temporomandibular joint syndrome develops from a combination of interrelated factors, usually starting with poor head posture, that contribute to the stretching and weakening of the cervical ligaments and lateral TMJ ligaments. As a result, the lower jaw can slip forward, aggravating the situation further by putting additional stress on the ligaments and the joints. Conventional treatments include TMJ arthroscopy and various types of surgery, TMJ implants, injections of botulinum toxins, and cauterization. All of these treatments are invasive and somewhat risky, and their use as the chosen treatment for TMJ may ignore or even cause negative consequences.

When doctors make TMJ worse – “misdiagnosis and undertreatment.”


The problem of negative consequences is discussed in a 2021 paper in the Journal of oral rehabilitation (1) where worsening conditions “caused by medical care” becomes a significant problem for some TMJ sufferers.

“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.”

The same researchers wrote in 2023 (2) about how “some management practices in the field of orofacial musculoskeletal disorders (also described as temporomandibular disorders [TMDs]) are based on (surgical) concepts about occlusal relationships, condyle positions, or functional guidance; for some patients, these procedures may be producing successful outcomes in terms of symptom reduction, but in many cases, they can be examples of unnecessary overtreatment.” The suggestion is the patient may have been getting more surgery than was necessary or getting surgery when conservative care would have worked just as well. The idea is that overtreatment may have been unnecessary or overcomplicated surgery.


Cortisone and TMJ


When most people get a “TMJ Injection” it is a cortisone injection. Cortisone is an anti-inflammatory and the hope is that the TMJ problem is one of inflammation and the steroid can help. The problem of inflammation can be one of rheumatoid arthritis. In rheumatoid arthritis patients suffering with TMJ problems, cortisone is seen as an effective short-term solution. This is demonstrated by a December 2021 study (3) stating: “Methylprednisolone injections in the TMJ alleviate pain and improve mouth opening capacity for approximately three weeks, allowing patients to perform jaw exercises during this timeframe of temporary relief. It thus seems useful for the short-term management of TMJ involvement in rheumatoid arthritis.”

The outcomes of 40 patients treated with local anesthesia combined with hydrocortisone OR intra-articular injection of PRP for TMJ related problems was published in an October 2022 paper (4). The paper found both treatments were effective but “intra-articular injection of PRP was more successful in treating patients in this trial than local anesthetic combined with hydrocortisone.” “Patients were evaluated for tenderness, maximum inter incisal opening (MIO) and clicking sound at TMJ prior to and following treatment at intervals of one week, one month and 6 months of the first week and third month.”


TMJ and botulinum toxins


Botulinum toxin injection, more commonly known as BOTOX® has been used as an alternative treatment for TMJ and related jaw pain. The treatment is injected into the muscles of the face and jaw where spasm and discomfort occurs. The injections relax the muscles and there by reduce the painful spasms.

A July 2024 study (22)  evaluated the effects of low doses of botulinum toxin type A to control pain in patients with sleep bruxism, awake bruxism, and temporomandibular disorder (TMD) during a 180 day treatment period.

  • thirty-five patients with chronic pain related to TMD, sleep bruxism, and awake bruxism received a single dose of 20 U of botulinum toxin type A in masseter and temporalis muscles. The pain was assessed with a visual analog scale (VAS recording pain scores from 0 – 10) before and after 15, 30, 60, 90, and 180 days of the application.

The three clinical conditions sleep bruxism, awake bruxism, and temporomandibular disorder (TMD) experienced decrease in pain after 15 days of treatment, the maximum pain relief persisted for up to 90 days after botulinum toxin type A application in patients with sleep bruxism and awake bruxism and 15 days for patients with TMD. Conclusion: A low dose of BoNT-A may be effective for controlling chronic pain related to sleep bruxism and awake bruxism, but TMD pain reduction was short-lived.

A June 2020 paper (5) critically investigated and assess the evidence relating to the use and efficacy of botulinum toxin in the management of temporomandibular joint disorders and masticatory myofascial pain. The researchers could not come up with a solid recommendation for botulinum toxin, writing: “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.”


Is there a bone problem associated with botulinum toxin


A February 2020 (6) study aimed to clarify how masticatory muscle atrophy induced by botulinum toxin injection affects cortical bone quality of the mandible. A total of 39 young (average age about 27) and 38 post-menopausal (average age about 55) females were included. Computed tomography (CT) images were obtained before and after 12 months of treatment.

The patients 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 interval.  In patients a decreased masticatory muscle thickness was noted that may lead to alterations of the mandibular cortical structures, especially in post-menopausal females. The botulinum toxin injection may induce muscle atrophy that damages the jaw bone.


A comparison of Platelet Rich Plasma injections and other treatments.


Platelet Rich Plasma Therapy is an injection technique that can accelerate the body’s own inflammatory response to repair cartilage and ligament damage at the TMJ. 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 injured area to stimulate healing and regeneration. The platelets are rich in several growth factors  which play key roles in tissue repair mechanisms. PRP can enhance bone and soft-tissue healing.

Research into PRP for TMJ disorders has been going on for many years.

In a 2015 study on PRP and TMJ, doctors in Egypt studied 50 patients with TMJ-osteoarthritis. They found that PRP performed better than hyaluronic acid injections during long-term follow-up in terms of pain reduction and increased interincisal distance (i.e., the ability to open the mouth widely). (7)

Doctors in Poland found that platelet-rich plasma injections into the temporomandibular joints have a positive impact on the reduction of the intensity of pain experienced by patients being treated for temporomandibular joint dysfunction.(8)

A June 2019 (9) 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 (10) 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.”

The level of the available scientific evidence on PRP for TMD in the current literature.

A 2022 paper published on line in December 2021 writes: (11)

“Intra-articular platelet rich plasma injections [PRP] or platelet rich growth factors [another name for PRP] injections have been used as therapeutic treatment options for patients with temporomandibular joint disorder [TMD] in recent years. The purpose of this paper is to evaluate the level of the available scientific evidence in the current literature on the benefits of applying PRP or PRGF injections to patients with TMD simultaneously or after arthrocentesis (TMJ  fluid aspiration) or arthroscopy to reduce post-operative pain and improve temporomandibular joint function.”

In conducting this research, the study authors reviewed the current published research for patients in the study groups who were injected with intra-articular PRP or PRGF simultaneously or after arthrocentesis or arthroscopy while comparing them to the patients in the control group had arthrocentesis or arthroscopy without an intra-articular injection or received an injection of hyaluronic acid or Ringer’s lactate solution.

In examining eight randomized controlled clinical trials, some sturdies showed PRP and PRGF intra-articular injections demonstrated significant differences in terms of pain reduction and improved mandibular function. The treatment with PRP or PRGF intra-articular injections demonstrated slightly better clinical results but of little significance in comparison with the control group.


A mixture of hyaluronic acid (HA) and platelet-rich plasma (PRP)


An April 2023 paper 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.(12)

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

  • Group I was injected with hyaluronic acid and PRP
  • Group II was injected with hyaluronic acid and corticosteroid.

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 along the follow-up periods with both groups showing significant results.

  • Regarding pain, the group injected with hyaluronic acid (HA) and platelet-rich plasma (PRP) achieved the best results after six months, while patients treated with hyaluronic acid and corticosteroids obtained the best results at the end of the 1st week.

Arthrocentesis (fluid aspiration), cortisone, hyaluronic acid injections and PRP


There are numerous studies that compare the various treatments offered for TMJ. A study published in September 2019 (13) 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.

A 2019 study in the International journal of molecular sciences,(14) 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.

More recently in this line of research is a July 2021 study (15) 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.

A September 2023 study (16) assessed the effectiveness of bone marrow aspirate concentrate (BMAC) as a treatment for TMJ osteoarthritis and compared its effectiveness to that of  hyaluronic acid. Two groups of 12 patients first had joint arthrocentesis performed followed by intra-articular BMAC injection in Group I or in Group II received hyaluronic acid injection.

RESULTS: “A trend towards long term joint repair at 12 and 18 months follow up period was observed in the bone marrow aspirate concentrate (BMAC) group as a therapeutic modality for TMJ osteoarthritis by providing necessary growth factors and anti-inflammatories that impedes the progression of the osteoarthritic degeneration.” The researchers also observed  hyaluronic acid injections were not as successful and the hyaluronic acid treated group “showed relapse of patients conditions.”

The data from seven research studies were examined and published in a November 2023 paper (17) looking to assess the effectiveness of intra-articular injections of platelet-rich plasma (PRP) after arthrocentesis. The patient outcomes with PRP were then compared to other treatments, such hyaluronic acid or saline injections after arthrocentesis. Five of the studies found that PRP injections led to significant improvements in mandibular range of motion and pain intensity up to 12 months after treatment as compared to hyaluronic acid or saline after arthrocentesis, while the remaining two studies found similar results for the different treatments.

An August 2023 systematic review (18) of patient cases found no statistically significant differences between injections of hyaluronic acid and corticosteroids, but platelet derivates (PRP) seem to have good results in pain relief. . . Furthermore, there is no agreement on the effectiveness of a combination of arthrocentesis or arthroscopy with intra-articular hyaluronic acid injections.

Prolotherapy for TMJ

Prolotherapy is the natural stimulation of the body to produce collagen and cartilage in injured or overused areas in order to reduce or eliminate pain. The treatment stimulates the immune system to bring fibroblasts and chondroblasts to areas of pain and grow more soft tissue to rejuvenate the area.

An April 2024 comparison study (21) of ultrasound and non-ultrasound Prolotherapy injections found both injection types improved TMJ symptoms significantly. US guidance allowed accurate anatomical localization and safe procedure with a single joint puncture.


Bone marrow aspirate concentrate stem cell therapy TMJ injection research


In the journal Stem Cells International, October 2017, (19) 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 (20) 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.”

Can any of these treatments help with your TMJ pain?

Call for a free phone consultation with our staff 800-300-9300

Marc Darrow MD JD

1 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.
2 Greene CS, Manfredini D. Overtreatment” Successes”–What Are the Negative Consequences for Patients, Dentists, and the Profession?. Journal of Oral & Facial Pain & Headache. 2023 Apr 1;37(2).
3 Kroese JM, Kopp S, Lobbezoo F, Alstergren P. Corticosteroid injections in the temporomandibular joint temporarily alleviate pain and improve function in rheumatoid arthritis. Clinical rheumatology. 2021 Dec;40:4853-60.
4 Prakash J, Talukder D, Desai K, Singh TK, Bagde R, Randhawa GS, Jha S, Paiwal K. Intra-articular platelet-rich plasma injection versus hydrocortisone with local anesthetic injections for temporo mandibular disorders. Bioinformation. 2022;18(10):920-4.
5 Thambar S, Kulkarni S, Armstrong S, Nikolarakos D. Botulinum toxin in the management of temporomandibular disorders: a systematic review. British Journal of Oral and Maxillofacial Surgery. 2020 Jun 1;58(5):508-19.
6 Hong SW, Kang JH. Decreased mandibular cortical bone quality after botulinum toxin injections in masticatory muscles in female adults. Scientific reports. 2020 Feb 27;10(1):1-2.
7 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.
8 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 research international. 2014 Oct;2014.
9  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
10 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
11 Gutiérrez IQ, Sábado-Bundó H, Gay-Escoda C. Intraarticular injections of platelet rich plasma and plasma rich in growth factors with arthrocenthesis or arthroscopy in the treatment of temporomandibular joint disorders: A systematic review. Journal of Stomatology, Oral and Maxillofacial Surgery. 2021 Dec 11.
12 Attia AA, Awad SS. Hyaluronic Acid and Platelet-Rich Plasma Mixture Versus Hyaluronic Acid and Corticosteroid in the Treatment of Temporomandibular Joint Internal Derangement: A Comparative Randomized Study. Journal of Maxillofacial and Oral Surgery. 2023 Apr 5:1-7.
13 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. Dental and medical problems. 2019;56(3):265-72.
14 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
15 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 Jul 9;22(14):7405.
16 Fayed HM, Khairy MA, Eldahshan D, Sabry D, Ahmed WA. Bone Marrow Aspirate Concentrate–A Novel approach to Alter the Course of Temporomandibular Joint Osteoarthritis (A Clinical Study). Journal of Stomatology, Oral and Maxillofacial Surgery. 2023 Sep 23:101644.
17 Haddad C, Zoghbi A, El Skaff E, Touma J. Platelet‐rich plasma injections for the treatment of temporomandibular joint disorders: a systematic review. Journal of Oral Rehabilitation. 2023 Jun 21.
18 Agostini F, Ferrillo M, Bernetti A, Finamore N, Mangone M, Giudice A, Paoloni M, de Sire A. Hyaluronic acid injections for pain relief and functional improvement in patients with temporomandibular disorders: An umbrella review of systematic reviews. Journal of Oral Rehabilitation. 2023 Aug 22
19 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.
20 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
21 Alhaj Kheder MB, Kandil NM, El‐Ghareeb T, Abdel Aziz OM, Zeitoun R. Ultrasound Guided Vs Non‐Guided Prolotherapy for Internal Derangement of Temporomandibular Joint. A Randomized Clinical Trial. Journal of Ultrasound in Medicine. 2024 Apr 6.
22 de Lima MC, Rizzatti Barbosa CM, Duarte Gaviao MB, Ferreira Caria PH. Is low dose of botulinum toxin effective in controlling chronic pain in sleep bruxism, awake bruxism, and temporomandibular disorder?. CRANIO®. 2021 Sep 16:1-8.


PLEASE HAVE JOINT REHAB DOCTORS OR STAFF CONTACT ME BY EMAIL, PHONE, OR TEXT

 

Do You Have Questions? Ask Dr. Darrow

PLEASE HAVE JOINT REHAB DOCTORS OR STAFF CONTACT ME BY EMAIL, PHONE, OR TEXT.

Most Popular