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Dextrose Prolotherapy and
Pain of Chronic TMJ Dysfunction
ROSS A. HAUSER,
M.D.; MARION A. HAUSER, MS RD,; KRISTA A. BLAKEMORE
Contact the authors
of this article
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,9-11 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 Modality
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.
While practitioners of prolotherapy since the time of Dr.
Schultz have commonly used prolotherapy for all sorts of
TMD, even in cases not involving subluxation, no other
studies have been done since that time. This retrospective
observational study was undertaken to evaluate the
effectiveness of Hemwall-Hackett dextrose prolotherapy—not
just for TMJ pain—but also for quality of life measures.
Patients and Methods
Framework and Setting.
In October 1994, the authors started
a Christian charity medical clinic
called Beulah Land Natural Medicine
Clinic in an impoverished area in
southern Illinois. The primary
modality of treatment offered was
Hemwall-Hackett dextrose
Prolotherapy for pain control.
Dextrose was selected as the main
ingredient in the solution because
it is the most common proliferant
used in Prolotherapy, is readily
available, is inexpensive when
compared to other proliferants, and
has a high safety profile. The
clinic met every three months until
it ended in July 2005. All
treatments were given free of
charge.
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FIGURE 1.
Typical injection sites
for Hemwall-Hackett dextrose
Prolotherapy of the TMJ. |
Patient Criteria.
General inclusion criteria included
being at least 18 years old, having
TMD for more than six months, and a
willingness to undergo at least four
Prolotherapy sessions (unless the
pain remitted with fewer sessions).
Interventions. Each
patient received four to six
injections of a 15% dextrose, 0.2%
lidocaine solution with a total of
two to four cc’s of solution used
per temporomandibular joint.
Typically, one cc of solution was
injected into the joint and the
remaining solution was injected onto
the TMJ ligament and capsular
attachments on the zygomatic arch
and mandibular condyle and neck (See
Figures 1 and 2). The patients were
asked to hold their mouths half open
while the injections were given. No
other therapies were used. The
patients were asked to reduce or
stop other pain medications and
therapies they were using as much as
the pain would allow.
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FIGURE 2.
Ligamentous structures
of the TMJ typically treated
with Hemwall-Hackett
dextrose Prolotherapy. |
Data Collection.
Patients who were seen in the clinic
in the years from 2001- 2005 and met
the inclusion criteria were called
by telephone and interviewed by an
independent data collector who had
no prior knowledge of Prolotherapy
and was the sole data collector
gathering the patient information
during the telephone interviews. The
patients were asked a series of
detailed questions about their pain
and previous treatments before
starting Prolotherapy. Their
response to
Prolotherapy treatments
was also documented in detail with
an emphasis on the effect the
treatments had on their need for
subsequent pain treatments, as well
as their quality of life.
Specifically, patients were asked
questions concerning years of pain,
pain intensity, overall disability,
number of physicians seen,
medications taken, stiffness,
crunching sensations in the joint,
quality of life concerns, and
psychological factors. Also noted
was whether the post-treatment
benefits continued substantially
after the sessions concluded.
Statistical Analysis.
For the analysis, the results of the
patient responses were calculated by
another independent data collector
who had no prior knowledge of
Prolotherapy. Pre-prolotherapy
treatment responses were compared
with the patients’ responses to the
same questions after Prolotherapy
treatment.
 Patient
Characteristics. Complete
data was obtained on 14 patients who
met the inclusion criteria. Of the
14 study participants, 63% were
female and 37% were male. The
average age was 50. Patients
reported an average of 5.4 years in
pain. Fifty-one percent had pain
greater than six years. The average
patient saw four medical doctors
before receiving Prolotherapy. Fifty
percent of the patients were told by
their physicians that no other
treatment options existed for their
pain problem and 14% were told that
surgery was their only option.
Thirty-one percent were taking one
pharmaceutical drug, while 39% were
taking two or more drugs for pain
(See Table 1).
Treatment Outcomes
Patients received an average of 4.6
Prolotherapy treatments. The average
time of follow-up from their last
Prolotherapy session was eighteen
months.
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Click on illustration for
larger image
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Pain, Crunching Sensation,
and Stiffness. patients
were asked to rate their pain and
stiffness on a scale of 1 to 10,
with 1 being no pain/stiffness and
10 being severe, crippling
pain/stiffness. The 14 patients had
an average starting pain level of
5.9, crunching sensation in the TMJ
of 5.5, and stiffness of 5.4. Their
average ending pain, crunching, and
stiffness levels were 2.5, 2.7, and
2.4 respectively (See Figure 3).
Over 71% percent said that they had
retained at least 75% of the
improvements and 91% noted that they
retained at least 50% of their
improvements in their pain,
crunching, and stiffness levels
since the last treatment session.
Ninety-three percent of patients
reported that pain relief was at
least 50% while 57% reported greater
than 75% pain relief. Only one
person noted that the long term pain
relief was only somewhat successful
in having only 25-49% of the pain
relieved.
Range of Motion.
Patients were asked to rate their
range of motion on a scale of 1 to
7, with 1 being no motion, 2 through
5 were fractions of normal motion, 6
was normal motion, and 7 was
excessive motion. The average
starting range of motion was 4.3 and
ending range of motion was 5.1.
Before Prolotherapy, 29% had very
limited motion (49% or less of
normal motion). This decreased to
only 7% after treatments were
concluded.
Pain Medication Utilization.
Seventy-one percent discontinued
pain medications altogether after
Prolotherapy. In all, 90% of
patients on medications at the start
of Prolotherapy were able to
decrease them by 75% or more. None
of the patients had to increase pain
medication usage after stopping
Prolotherapy. Fifty-seven percent of
patients needed no additional pain
management care after Prolotherapy.
After Prolotherapy, 93% of patients
were able to decrease additional
pain management care by 50% or more.
FIGURE 3.
Starting and ending pain, crunching,
and stiffness levels before and
after receiving Hemwall-Hackett
dextrose Prolotherapy in 14 patients
with unresolved TMJ pain.
Disability. In
regard to quality of life issues
prior to receiving treatment, 50%
exhibited overall disability of at
least 50% in that they could only do
about half of the jaw motions
without pain. This decreased to 7%
after Prolotherapy. In regard to
overall TMJ disability, only 14%
noted almost no disability (25% or
less) prior to Prolotherapy, but
this increased to 72% after
treatment(See Figure 4).
Depression & Anxiety.
Prior to Prolotherapy, 56% of
patients reported feelings of
depression and 64% reported feelings
of anxiety. After treatments, only
28% reported depressed feelings and
36% reported feelings of anxiety
(See Figures 5 and 6). Patients
reported that on average 86% of the
improvements in depression and
anxiety have at least somewhat
continued. Seventy-eight percent of
these patients reported 75%
continuing improvement at the time
of follow-up.
Sleep. Sixty-four
percent of patients reported their
pain interrupted their sleep prior
to Prolotherapy treatments and 55%
of them subsequently showing
improvements in their sleeping
ability after treatments.
Quality of Life. To
a simple yes or no question, “Has
Prolotherapy changed your life for
the better?” 100% of patients
treated answered “yes.” In
quantifying the response,
• Eighty-six percent felt their life
was at least very much better from
Prolotherapy
• Sixty-nine percent stated that the
results from Prolotherapy have very
much continued to this day (75% or
greater).
• One hundred percent felt that they
still have some benefits (at least
25%) from the Prolotherapy they
received.
Patients who experienced regression
of some of their symptoms were
asked, “Are there reasons beside the
Prolotherapy effect wearing off that
are causing some return of your
pain/disability?” 79% answered
“yes.” The patients noted the
reasons for some of their returning
pain were the following:
• stopped Prolotherapy treatments
too soon, (before pain was
completely gone):37%
• re-injury: 14%
• increased life stressors: 21%
• new area of pain: 7%
Of the patients whose pain recurred
after Prolotherapy was stopped, 58%
were planning on receiving
additional Prolotherapy treatments.
Patient Satisfaction.
Eighty-six percent of patients knew
someone who had benefited from
Prolotherapy. In fact, 44% came to
receive their first Prolotherapy
session at the recommendation of a
friend who had already received
Prolotherapy. Ninety-three percent
of patients treated considered the
Prolotherapy treatment to be very
successful (greater than 50% pain
relief). Fifty-seven percent noted
the Prolotherapy was very successful
(greater than 75% pain relief). None
indicated that the Prolotherapy
treatment made them worse. One
hundred percent had subsequently
recommended Prolotherapy to someone.
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FIGURE 7.
Starting and ending
pain, crunching, and
stiffness levels before and
after eceiving
Hemwall-Hackett dextrose
Prolotherapy in 7 patients
with unresolved TMJ pain who
were told that there were no
other treatment options. |
“No Other Treatment Options”
Subgroup Analysis. Fifty
percent (n=7) of the patients had
been told by their doctors that
there were no other treatment
options for their pain prior to
presenting for Prolotherapy. This
group had average starting pain,
stiffness, and crunching levels of
7.1, 5.9, and 5.7, respectively,
before Prolotherapy. Their ending
levels were 3.1, 3.1 and 3.3 for
pain, stiffness and crunching levels
after treatment (See Figure 7).
Three of the patients noted less
than 25% normal TMJ motion before
Prolotherapy, but after Prolotherapy
every patient said they had improved
to greater than 25% of normal
motion. Before Prolotherapy all
seven patients were taking at least
one pain medication while, after
treatment, only two were taking
medications. Five of the patients
(71%) had 75% or greater pain
relief, with the other two patients
achieving 50-74% pain relief. Before
Prolotherapy, 100% had depressed
feelings, with three of the seven
(43%) being on medications. All
three on medications were able to
get off medications after
Prolotherapy and four of the seven
(57%) no longer had depressed
feelings (See Figure 8). In this
group of seven patients, six felt
they still had at least 75% of the
benefit they received after the
Prolotherapy treatments stopped.
Principal Findings.
The results of this retrospective,
uncontrolled, observational study,
demonstrated that Prolotherapy helps
decrease pain and improve the
quality of life of patients with
chronic temporomandibular joint
symptoms. Decreases in pain,
stiffness, and crunching levels of
the TMJ were seen, even in patients
who were told by their physicians
that no other treatment options were
available. Fifty-seven percent of
the patients achieved greater than
75% pain relief with Prolotherapy
and 93% of patients stated
Prolotherapy relieved them of at
least 50% of their pain. In regard
to quality of life issues prior to
receiving treatment, 50% had an
overall disability of at least 50%
(jaw motions restricted by about
half). This decreased to 7% after
Prolotherapy. Prolotherapy also
caused clinically relevant
improvements in patients’ TMJ range
of motion, sleep, depressive and
anxious feelings. Ninety percent of
patients on medications at the start
of Prolotherapy were able to
decrease them by 75% or more. One
hundred percent of patients said
that dextrose Prolotherapy changed
their life for the better. Eighteen
months, on average, after their last
Prolotherapy treatment, one hundred
percent of patients said they had
retained the majority of their
benefits from the treatment.
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FIGURE 8.
Starting and ending
depression levels before and
after receiving
Hemwall-Hackett dextrose
Prolotherapy in 7 patients
with unresolved TMJ pain who
were told that there were no
other treatment options. |
Study Strengths and
Weaknesses. Our study does
not compare to clinical trial in
which an intervention is
investigated under controlled
conditions. Instead, its aim was to
document the response of patients
with chronic temporomandibular joint
dysfunction to the Hemwall-Hackett
technique of dextrose Prolotherapy.
Strengths of the study were that
numerous quality of life parameters
affecting TMJ sufferers were
studied. Quality of life issues such
as stiffness, range of motion,
overall disability, sleep, anxiety,
and depression—in addition to pain
level—are important factors
affecting an individual with chronic
TMJ syndrome. Decreases in
medication usage and additional pain
management care were objective
measures that were also documented.
Though the sample in this study was
small (n=14), the quality of the
cases treated is notable. The
average person in this study had
unresolved TMJ pain/dysfunction for
5.4 years and had been seen, on
average, by four medical doctors
prior to receiving Prolotherapy.
Fifty percent of the cases were told
that no other treatment options
existed and 14% were told surgery
was their only option. A follow-up
time of eighteen months, on average,
since their last treatment session
provided a measure of the
long-lasting effect of this
modality.
Because this was a charity medical
clinic with limited resources and
personnel, the only therapy offered
was Prolotherapy treatments given
every three months. In private
practice, the Hemwall-Hackett
technique of dextrose Prolotherapy
is typically given every four to six
weeks. If a client is not improving
or has poor healing ability, the
Prolotherapy solutions may be
changed or strengthened or the
client is advised about additional
measures to improve their overall
health. This can include advice on
diet, supplements, exercise, changes
in medications, additional blood
tests, physiotherapy, and/or other
medical care. Often clients are
weaned immediately off any
anti-inflammatory and narcotic
medications that inhibit the
inflammatory response that is needed
to achieve a healing effect from
Prolotherapy. Since none of these
were done, the results of this study
are expected to represent the least
optimum level of success achievable
with Hemwall-Hackett dextrose
Prolotherapy.
Another shortcoming of this study
was the subjective nature of some of
the evaluated parameters, including
pain, anxiety, depression, and
disability levels since the results
relied on answers to questions by
the patients. Further, any
additional pain management care that
the patients may have been receiving
was not controlled. Lack of x-ray
and MRI correlation for diagnosis
and response to treatment, as well
as a lack of physical examination
documentation in the patients’
charts made categorization of the
patients into various diagnostic
parameters impossible.
Discussion. While
the exact cause of chronic
temporomandibular dysfunction is
still debated, this study did
demonstrate that the Hemwall-Hackett
technique of dextrose Prolotherapy
improves not only the pain level for
those having chronic TMD, but also a
host of other quality of life
measures. The Hemwall-Hackett
technique of dextrose Prolotherapy
to the temporomandibular joint
involves injections into the joint,
as well as the fibro-osseous
junction of the ligament and
capsular attachments on the
zygomatic arch, as well as the
mandibular neck and condyle. Clearly
the structural goal of Hemwall-
Hackett dextrose Prolotherapy is to
improve the stability of the TMJ by
enhancing capsular and ligament
strength. Congenital disorders that
are characterized by overstretched
ligaments, such as
Ehlers-Danlos Syndrome (EDS), are typically predisposed
to TMJ problems.18
Weakening of the TMJ capsule and
ligament would explain a lot of the
varied pathology involving TMD
including joint subluxations, disc
displacements, as well as muscle
spasms and myofascial pain patterns.
The most common cause of TMJ pain is
myofascial pain dysfunction syndrome
and primarily involves the muscles
of mastication.19 While
massage, physiotherapy, pain
medications, splints, surgeries, and
other treatment modalities offer
temporary help, they rarely cure the
condition. 20-22 A known
cause of persistent muscle spasms
and myofascial pain dysfunction is
underlying
Ligament laxity.23
By stimulating ligament and
capsular repair for such cases,
Prolotherapy would represent a more
permanent solution.
The most common presentation of the
TMJ is disc displacement.24
In essence, this is when the
articular disc, attached anteriorly
to the superior head of the lateral
pterygoid muscle and posteriorly to
the retrodiscal tissue, moves out
from between the condyle and the
fossa, so that the mandible and
temporal bone contact something
other than the articular disc. In
most instances of the disorder, the
disc is displaced anteriorly upon
translation. On opening, a “pop” or
“click” can sometimes be heard—and
usually felt—indicating the condyle
is moving back onto the disc.25
The TMJ is divided into an upper and
lower joint cavity by a
fibrocartilaginous articulating
disc.26 It is thicker
posteriorly, thus making posterior
dislocations more unlikely.
Anteriorly, the disc is fused with
the thin, loose, and fibrous joint
capsule. The ligaments which
contribute to the formation of the
fibrous joint capsule and unite the
articular bones are the
temporomandibular (a.k.a. lateral),
sphenomandibular, and
stylomandibular. The
temporomandibular ligament restrains
the movement of the mandible and
prevents compression of tissues
behind the condyle.27
Some authors note that this
collateral ligament is simply a
thickening of the joint capsule.28
The joint capsule itself attaches to
the articular eminence, the
articular disc, and the neck of the
mandibular condyle. Basically, the
articular disc is a fibrous
extension of the capsule between the
two bones of the joint.29
The sphenomandibular and
stylomandibular ligaments keep the
condyle, disc, and temporal bone
firmly opposed and the multiple
ligamentous attachments provide disc
stability. Laterally, the disc is
continuous with ligament tissue
attaching it to the neck of the
condyle.30 While the
cause of disc displacement is still
under debate, an argument could be
made that for many, it is injury to
the joint capsule and TMJ ligament
complex that is the issue.
Anteriorly, the TMJ disc depends on
the support of the joint capsule and
TMJ ligament complex. If, for some
reason, these became weakened,
stretched, or torn, anterior disc
dislocation would result. Only
treatments designed to specifically
strengthen and repair the injured
joint capsule and ligament
structures—such as
Prolotherapy—would have a lasting
effect.
Conclusions
In this observational study, the
Hemwall- Hackett technique of
dextrose Prolotherapy used on
patients who presented with over
five years of unresolved TMJ pain
and dysfunction were shown to
improve their quality of life even
eighteen months subsequent to their
last Prolotherapy session. All
patients reported significantly
reduced levels of pain, stiffness,
crunching sensation, disability,
depression, anxiety, medication, and
other pain therapy. They also
reported improved range of motion
and sleep. The results confirm that
Prolotherapy is a treatment that
should be highly considered for
people suffering with unresolved
temporomandibular joint pain and
dysfunction.
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