Many people contact my office asking about 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 part of the skull that holds the brain). 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.
One characteristic of TMJ is the loud popping or clicking of bones rubbing together in the loosened joint, accompanied by pain and stiffness as the muscles tighten, compensating for the ligament laxity. 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.”
“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.”
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 (x) 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.”
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 June 2020 paper (2) 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 (3) 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.
Platelet Rich Plasma for TMJ and TMJD
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). (4)
Doctors in Turkey concluded that patients suffering from TMJ disc dislocation benefited more from PRP injections than from surgery to manipulate the jaw back into place. Clearly, PRP stabilized the joint and reduced chronic instability.(5)
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.(6)
A 2022 paper published on line in December 2021 writes: (7)
“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.
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.(9)
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 (8) 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.
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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 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.
3 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.
4 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.
5 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. Journal of Cranio-Maxillofacial Surgery. 2015 Jan 1;43(1):162-6.
6 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.
7 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.
8 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.
9 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.