Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
The evidence for TMJ Prolotherapy injection treatments
We often see patients with varying degrees of and medical histories of TMJ syndrome or TMD.
They tell us about how their TMJ developed, whether it was from extensive dental work, a traumatic injury suffered in an accident, or other reasons such as a history of teeth grinding that has lead to a degenerative joint disease of the jaw.
They also tell us about a lot of treatments that did not work for them. In this article we will discuss these treatments an the possible solution regenerative medicine injections may offer.
TMJ is a problem. The medical community is responding by pumping out a lot of research. Let’s look at some of these new studies to see what is benefiting patients and what is not.
The steroid injection made the pain worse
Steroids / Anti-inflammatories – research questions effectiveness and worthiness in helping TMJ patients.
In September 2018, in the Journal of oral rehabilitation, (1) researchers from leading medical universities in Sweden looked at steroid injection, specifically Methylprednisolone as a means to help alleviate TMJ patient symptoms.
In this study, the researchers looked at inflammation as a symptom problem in the TMJ. Clearly, they hypothesized, an anti-inflammatory would help with the inflammatory pain the patient was suffering from. What they found was the exact opposite, the steroid injection made the pain worse.
- In this study 54 patients were randomly assigned to single-dose injection with methylprednisolone (27 patients) or saline (27 patients).
- At 4 week follow up after injection, the researchers found little difference in pain relief in the steroid group and the saline group.
- What they did find was that in addition to the Methylprednisolone providing no additional benefit for reducing pain, the steroid injection caused more harm. “Treatment-related adverse events were doubled in the methylprednisolone group.”
Hyaluronic acid injections and steroid injection
Also in September 2018, in the Hungarian Medical Weekly, (2) researchers published their findings comparing hyaluronic acid injections and steroid injection.
- Comparing the two treatments, three hyaluronic acid injections were significantly more effective than cortisone in relieving patients symptoms.
We have looked at Hyaluronic injections at length. The injections are a lubricating gel designed to help with pain free movement in the joint. We have examined research on these injections and wrote of our findings. In our article on knee injections, Are Hyaluronic injections low-value health care? -we wrote “It should be noted that we see many patients who have tried hyaluronic acid injections. These injections have worked for these people in the short-term. These patients are now in our office because the short-term has not transpired to the long-term and now a different treatment approach needs to be undertaken.”
Non-surgical conservative treatment methods for TMJ
A comparison of the outcomes of four minimally invasive treatment methods for anterior disc displacement of the temporomandibular joint
The above heading is taken from the title of a paper from University medical researchers in Turkey publishing in the International journal of oral and maxillofacial surgery.(3)
As the researchers point out, the purpose of this study was to compare the effectiveness of four non-surgical conservative treatment methods for temporomandibular displacement disorders. We are going to examine the phenomena of effusion and swelling in this study and compare it to another new study.
Patients were divided into four groups according to the treatment method:
- splint therapy, (various devices put into the mouth to stabilize the jaw joint).
- arthrocentesis, (aspiration of fluid in the jaw)
- medical therapy, (a medical treatment possibly involving arthroscopic procedures).
- and low-level laser therapy (LLLT). LLLT stimulates the immune responses to heal joints by themselves.
Magnetic resonance imaging (MRI) was performed before treatment and at the 1-month follow-up. Patients were followed up after treatment for 6 months.
- Mouth opening increased and pain scores decreased at 1, 3, and 6 months after treatment in all groups.
- No statistically significant difference in the improvements in clinical symptoms was observed between the groups.
Note: So all these treatments worked well, except in our opinion the very ominous problem of effusion.
Symptom suppression successful, BUT the underlying problem is still there
Back to the research and why we consider this ominous.
A positive correlation was found between pain and TMJ effusion. A significant positive relationship was also found between internal derangement (structural problems) and effusion.
It was determined that the effusion demonstrated on MRI was associated with pain. Although the symptoms improved after treatment, joint effusion did not show any decrease in the 1-month follow-up MRI.
In other words, the underlying problem was still there and the symptom relief could only be temporary
The problem of fluid buildup, a jaw joint trying to stabilize by swelling is a chronic and long-term problem of the degenerative joint disease
In 2017 study, doctors publishing in The journal of headache and pain made these observations:
The aim of their study was to investigate cytokine levels in the masseter muscle (inflammation of the jaw muscle), and the response to tooth-clenching. The response the researchers were looking for was if tooth clenching caused inflammation and accompanying pain, fatigue and psychological distress in patients with temporomandibular disorders (TMD) myalgia (pain).
- What they found was when the patients clenched their teeth, already elevated levels of inflammatory markers increased in the jaw muscle, BUT, there was no correlation between this increased inflammation and the jaw muscle pain and fatigue the patients were experiencing.
What does this mean?
According to the researchers, “This implies that subclinical muscle inflammation may be involved in TMD myalgia pathophysiology (The process of TMD), but that there is no direct cause-relation between inflammation and pain.” (4)
What does this mean?
- For one thing, go to the first study we cited in this article, steroids made the TMJ pain worse.
- Subclinical means something not detected or understood. There is a chronic inflammatory response because something is not healing. In our experience that something is that the entire TMJ is in degenerative disease. This is a problem of whole jaw joint disease and treatments must address the entire jaw joint not a TMJ disc.
TMJ and Joint Hypermobility Syndrome. This could be you all along and undiagnosed.
We are going to make some fascinating connections here to show that TMJ and jaw related pain are much more than TMJ disc degeneration in many patients.
- In this first study, research shows that it is not only a problem of the TMJ disc but a problem of jaw instability.
Like any joint, excessive movement in the Temporomandibular joint and/or chronic subluxation/dislocations of the Temporomandibular is caused by weakness of the connective tissue that hold the joint in place. In the jaw important connective tissue include the Temporomandibular ligament, and the stylomandibular ligament, and sphenomandibular ligament which provide limitation of mandibular movements.
In a late 2015 publication date, national defense and university medical researchers in Taiwan combined to release their research finding in the journal Clinical oral investigations (5) on the TMJ/TMD – Joint Hypermobility Syndrome connection.
What is Joint Hypermobility Syndrome? It is a common musculokeletal disorder that makes your joints too flexible. For some people this is very advantageous, especially in gymnastics, dance, and swimming. For others, it leads to chronic dislocations.
The research aimed to investigate the risk factors of temporomandibular disorders, including disc or non-disc-related disorders, and Joint Hypermobility Syndrome retrospectively and to analyze the association between the two conditions.
What is so fascinating about this study in that in patients who had TMJ and were found to have Joint Hypermobility Syndrome, 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. In 9 out of 10 patients with TMJ diagnosed patients with Joint Hypermobility Syndrome – pain does not come from degenerated discs.
- So what does this mean to you? The source of your TMJ pain does not need to involve a displaced disc it can be weakness of the jaw/TMJ ligaments. Any treatment should involve a determination of ligament weakness.
TMJ is more than a physical problem related to the jaw
- What does this mean? As pointed out by Spanish researchers in the medical journal European psychiatry : the journal of the Association of European Psychiatrists,that problems of jaw pain (TMJ) may be an indication of a body wide problem with loose joints and further, joint hypermobility syndrome and TMJ may manifest themselves as a potential link to the neural bases of anxiety and related somatic symptoms (pain that causes major emotional distress) (6)
- What does this mean? As doctors writing in the Journal of oral and facial pain and headache point out TMJ is more than a physical problem related to the jaw.(7)
- As we will see below, degenerative or displaced disc is one part of a diseased joint environment. All the parts must be treated to give the patient the best chance of successful outcome.
In 2007, researchers here at Caring Medical published our findings in the medical journal Practical Pain Management that “Many of the subjective symptoms of pain, stiffness, and crunching sensation in patients with TMJ dysfunction were reduced greater than 50% in 92% of the prolotherapy patients.”(8) We will examine this research below in greater detail.
So back then we were able to show at least 50% reduction in pain in more then 9 out of 10 patients with simple dextrose Prolotherapy. What has happened in the ten years since we first published this study? More good results and a better understanding within the medical community of the complexity of TMJ/TMD.
TMJ is a cause of cervical neck instability and poor posture
In our article on Cervicogenic dysphagia, swallowing difficulties as being caused by problems in the neck and brain, we explored research that noted that TMJ patients and cervical neck instability patients have difficulties in swallowing.
TMJ and neck problems have long been linked together, however, it is not often that a patient will report to us that their previous health care providers made this link and offered treatments addressing both concerns. In the following research the links and the treatments for both TMJ and cervical neck instability point to a problem in the neck.
In many patients we see with primary problems related to neck pain and cervical instability we see problems of TMJ. In many patients that we see with problems of TMJ, we see cervical neck pain. Surprising despite the research suggesting the connection, many patients were not made aware that their jaw pain could be a problem originating in the neck.
In the medical journal Clinical Oral Investigations, (9) oral surgeons in Belgium made a connection between TMJ and cervical instability.
They conducted a study looking for possible correlations between clinical signs of temporomandibular disorders (TMD) and cervical spine disorders.
- Thirty-one consecutive patients with symptoms of TMD and 30 controls underwent a standardized clinical examination of the masticatory system, evaluating range of motion of the mandible, temporomandibular joint (TMJ) function and pain of the TMJ and masticatory muscles.
- Afterwards subjects were referred for clinical examination of the cervical spine, evaluating segmental limitations, tender points upon palpation of the muscles, hyperalgesia and hypermobility.
- The results indicated that segmental limitations (especially at the C0-C3 levels) and tender points (especially in the sternocleidomastoideus and trapezius muscles) are significantly more present in patients with TMJ than the control subjects
In the European journal of orthodontics, (10) doctors in Japan made a connection:
- In this study, the doctors compared the mandibular stress distribution and displacement of the cervical spine. In simple terms, how TMJ instability and hypermobility of the jaw negatively effected the cervical spine.
- What did they find? ” (an) imbalance between the right and left masticatory muscles antagonistically act on displacement of the cervical spine, i.e. the morphological and functional characteristics in patients with mandibular lateral displacement may play a compensatory role in posture control.”
What? The TMJ altered your posture by stressing your cervical spine? Isn’t posture a problem of swallowing difficulties? Isn’t posture a problem of everything?
Understanding the TMJ temporomandibular joint
The temporomandibular joint connects the mandible (lower jaw) to the part of the skull known as the temporal bone. The joint allows the lower jaw to move in all directions so that the teeth can bite off and chew food efficiently.
Temporomandibular joint ( TMJ ) syndrome occurs when the joint, muscles and ligaments involved do not work together properly, resulting in pain.
Temporomandibular joint syndrome and TMD or TemporoMandibular Disorders have been demonstrated to be caused by ligament weakness in many patients, often as a result of clenching the jaw or grinding the teeth, sleeping position or a forward positioned mandible (lower jaw).
Malocclusion, or a poor bite, places stress on the muscles and may also lead to temporomandibular joint syndrome, as may an injury to the head, jaw or neck that causes displacement of the joint. If left untreated, jaw osteoarthritis can result.
As we wrote back in 2007:
- “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.”
- “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.”
The head and neck pain associated with temporomandibular joint syndrome (TMJ) has received a myriad of traditional treatments, many of which involve surgery. They include:
- Temporomandibular joint (TMJ) surgery which can be divided into 3 types of surgery: Arthroscopy, arthroplasty, and total joint replacement. The complications associated with these procedures increase with complexity. They all include injury to adjacent structures, infections, and bleeding problems, as documented in research in the journal Oral and maxillofacial surgery clinics of North America.(11)
- TMJ implants,
- cervical spine surgery,
- botulinum toxin injections into muscles. In recent research doctors from New York University College of Dentistry noted that patients with temporomandibular muscle and joint disorder are increasingly seek and receive treatment for their pain with botulinum toxin and that these treatments creates risk of reduced bone mineral density, or osteopenia (bone loss). (12)
- surgical cauterization, which treats the bones with a radio frequency wave destroying the treated area. Although the pain is temporarily eliminated, however vital structures are also destroyed in the process.
The problem with any of these approaches is that they do not repair the weakened TMJ ligament and, thus, does not alleviate the chronic pain that people with this condition experience. And thus, most dentists and oral surgeons believe that TMJ cannot be cured and the best hope is for temporary symptom relief.
A standard practice is the use of steroids and anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.
The research on Prolotherapy for Temporomandibular Joint Pain and Dysfunction
Treating the whole joint. Comprehensive Prolotherapy for TMJ.
In this section we will discuss how to turn a degenerative TMJ environment into a healing environment through the use of Comprehensive Prolotherapy. The basic concepts are discussed in the video above.
Indian doctors writing in the Journal of maxillofacial and oral surgery found positive results utilizing Prolotherapy injections for TMJ in new research (June 2017). Here is what they said:
Hypermobility disorders of the Temporomandibular joint (TMJ) can be treated by both conservative and surgical approaches. Conservative approaches should be considered as first line treatment for such disorders.
- Prolotherapy with 25 % dextrose being injected into the posterior pericapsular tissues is one such treatment modality with favorable outcomes.
In their study, the researchers examined 23 patients suffering from either chronic recurrent dislocation or subluxation of the TMJ who were treated with the single injection technique prolotherapy with 25 % dextrose into the pericapsular tissues along with auriculotemporal nerve block.
- Overall success rate in the study was 91.3 % (21/23) with a minimum follow up period of 13.9 months.
- Number of successfully treated patients requiring one injection was 7 (30.4 %), two injections was 8 (34.7 %) and requiring three injections was 6 (26.1 %). There were no permanent complications.(13)
Prolotherapy reports on TMJ disc dislocation
In Prolotherapy research, doctors say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.
- Chinese doctors writing in the British journal of oral and maxillofacial surgery found that Prolotherapy injections was curative in preventing recurrent TMJ dislocations. In fact nearly 2 of 3 of these patients achieved this result with a single treatment.(14)
In supportive research doctors at the University of Karadeniz Technical University say that they see appreciable improvements in the number of episodes of dislocation and clicking after Prolotherapy treatment.
- The overall success rate, defined as the absence of any further dislocation or subluxation for more than 6 months, was 91%.
- Of the 41 rehabilitated patients,
- 26 (63%) required a single injection,
- 11 (27%) had 2 treatments,
- and 4 (10%) needed a third injection.
- All patients tolerated the injections well. The modified dextrose prolotherapy is simple, safe, and cost-effective for the treatment of recurrent dislocation of the TMJ. (15)
Dr. Refai of Cairo University reported in the British journal of oral and maxillofacial surgery:
- Sixty-one patients with symptomatic hypermobility of the TMJ were each given four sessions of intra-articular and pericapsular Prolotherapy injections six weeks apart.
- Each injection comprised 10% dextrose/mepivacaine solution 3ml.
- Clinical outcomes including:
- severity of pain on movement according to the numerical rating scale (NRS),
- maximal interincisal opening,
- and frequency of locking were measured before treatment (T1), during treatment (T2) (just before the third session of injections), at the short-term follow-up (T3) (three months after treatment), and at the long-term follow-up (T4) (1-4 years after treatment).
- Condylar translation (movement of the TMJ joint) and osseous (bony) changes of each joint were evaluated at T1 and T4 using tomography.
- There was significant reduction in all variables by T2
- The pain scores and clicking had decreased significantly by T3.
- Linear tomograms of each joint at T1 and T4 showed no alteration in the morphology of the bony components of the joint, and at T4, tomographic open views of all joints showed condylar hypertranslation.
- Dextrose prolotherapy provided significant and sustained reduction of pain and recovery of constitutional symptoms associated with symptomatic hypermobility of the TMJ without changing either the position of the condyle or the morphology of the bony components of the joint.(16)
Doctors at Ordu University in Turkey published in The Journal of alternative and complementary medicine suggesting that Prolotherapy and aspiration (Arthrocentesis) provided significant relief for TMJ patients.
In this October 2017 study, 10 adults with disc displacement and painful, hypermobile TMJ were selected.
- Arthrocentesis and Prolotherapy were consecutively performed using a 30% dextrose solution that was simultaneously injected into five areas: posterior disc attachment, superior joint space, superior and inferior capsular attachments, and stylomandibular ligament.
Scoring tests were used to assess the maximum mouth opening, clicking sounds, pain, and subluxation of the TMJ. Patients with rheumatoid arthritis and parafunctional habits such as teeth clenching and grinding and biting of the cheeks or any other objects and those who had undergone surgery were excluded from this study.
The ten patients, 7 women and 3 men average age 36 received a single treatment session of combined arthrocentesis and prolotherapy at the same office visit. Subluxation frequency and pain significantly decreased after the first week of treatment. Subluxation also decreased at the 3-month follow-up.
Clicking sound values did not significantly change at any of the follow-up time points. Maximum mouth opening values improved at all follow-up time points compared to baseline.(17)
In the July 2018 edition of Journal of oral rehabilitation, Military doctors in India compared Prolotherapy to Placebo injections. They found:
- Dextrose Prolotherapy resulted in significant reduction in mouth opening and pain associated with TMJ hypermobility. (18)
Eleven years after our own research on TMJ patients
In the research mentioned above from our Caring Medical research team and published in 2007 our doctors reported on successful dextrose Prolotherapy for patients with chronic neck pain. In this study, fourteen patients who suffered from TMJ pain for an average of 5.4 years and had seen, on average, four medical doctors—including half who were told that no other treatment options were available.
Overall, substantial improvements were reported in:
- range of motion,
- pain medicine utilization,
- quality of life,
- and patient satisfaction.
These improvements persisted through follow up at eighteen months after the conclusion of prolotherapy treatments.
Prolotherapy is a safe and effective natural medicine treatment for repairing tendon, ligament and cartilage damage. In simple terms, Prolotherapy stimulates the body to repair painful areas. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Since the body heals by inflammation, Prolotherapy stimulates healing.
The Physical and emotional aspects of TMJ
In our 2007 study we noted:
- 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.
- 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.
Let’s move to a 2017 study from a team of Swedish and Danish researchers writing in the medical journal Cephalalgia : an international journal of headache. Here is a review of that study:
- Chronic pain is the overwhelming reason that patients with TMD seek treatment.
- TMD can associate with impaired general health, depression, and other psychological disabilities, and may affect the quality of life of the patient.
- The most common types of TMD,
- include pain-related disorders (e.g., myalgia, headache attributable to TMD, and jaw joint pain) as well as disorders associated with the TMJ (primarily disc displacements and degenerative disease).
- As peripheral mechanisms (nerve and pain signals) most likely play a role in the onset of TMD, a detailed muscle examination is recommended.
Conclusion: The persistence of pain involves more central factors, such as sensitization of the supraspinal neurons and second-order neurons at the level of the spinal dorsal horn/trigeminal nucleus (central neural pathways relevant to TMJ/TMD pain), imbalanced antinociceptive activity (the ability to block pain), and strong genetic predisposition (family history).(19)
Stem Cell Therapy for TMJ
While we do offer stem cell therapy for our patients, this is not a treatment we often utilize as a first line treatment. The documented results of the success of simple dextrose Prolotherapy has shown us this treatment is effective.
Many people ask us about stem cell therapy. After an examination and a consultation we discuss the treatment options we can offer. If stem cell treatment is warranted then we would discuss our program with the patient.
Stem cell therapy has become a very popular treatment option.Research is coming in.
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.
In the past decade, progress made in the development of stem cell-based therapies and tissue engineering have provided alternative methods to attenuate the disease symptoms and even replace the diseased tissue in the treatment of TMJ disorders. This represents innovative approaches of cell-based therapeutics, tissue engineering and drug discovery in treatment.(20)
This supports earlier research from the same researchers which stated: Stem Cells could regenerate bone and soft tissue.(21)
Do you have a question about Temporomandibular Joint Syndrome or need help?
Get help and Information from our Caring Medical staff
1 Isacsson G, Schumann M, Nohlert E, Mejersjö C, Tegelberg Å. Pain relief following a single‐dose intra‐articular injection of methylprednisolone in the temporomandibular joint arthralgia–a multi‐centre randomised controlled trial. Journal of oral rehabilitation. 2018 Sep 21. [Google Scholar]
2 Vingender S, Restár L, Csomó KB, Schmidt P, Hermann P, Vaszilkó M. Intra-articular steroid and hyaluronic acid treatment of internal derangement of the temporomandibular joint. Orvosi hetilap. 2018 Sep;159(36):1475-82. [Google Scholar]
3 Hosgor H, Bas B, Celenk C. A comparison of the outcomes of four minimally invasive treatment methods for anterior disc displacement of the temporomandibular joint. International Journal of Oral and Maxillofacial Surgery. 2017 Jun 9. [Google Scholar]
4 Jounger SL, Christidis N, Svensson P, List T, Ernberg M. Increased levels of intramuscular cytokines in patients with jaw muscle pain. The journal of headache and pain. 2017 Dec 1;18(1):30. [Google Scholar]
5 Chang TH, Yuh DY, Wu YT, Cheng WC, Lin FG, Shieh YS, Fu E, Huang RY. The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study. Clin Oral Investig. 2015 Feb 17. [Google Scholar]
6 Mallorquí-Bagué N, Bulbena A, Roé-Vellvé N, Hoekzema E, Carmona S, Barba-Müller E, Fauquet J, Pailhez G, Vilarroya O. Emotion processing in joint hypermobility: A potential link to the neural bases of anxiety and related somatic symptoms in collagen anomalies. European Psychiatry. 2015 Jun 30;30(4):454-8. [Google Scholar]
7 Reissmann DR, John MT, Seedorf H, Doering S, Schierz O. Temporomandibular disorder pain is related to the general disposition to be anxious. J Oral Facial Pain Headache. 2014 Fall;28(4):322-30. doi: 10.11607/ofph.1277. [Google Scholar]
8. Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Practical Pain Management. 2007; November/December:49-55. [Google Scholar]
9 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. [Google Scholar]
10 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. [Google Scholar]
11. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):109-24. [Google Scholar]
12. Raphael KG, Tadinada A, Bradshaw JM, Janal MN, Sirois DA, Chan KC, Lurie AG. Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study. J Oral Rehabil. 2014 Aug;41(8):555-63. [Google Scholar]
13. Majumdar SK, Krishna S, Chatterjee A, Chakraborty R, Ansari N. Single Injection Technique Prolotherapy for Hypermobility Disorders of TMJ Using 25 % Dextrose: A Clinical Study. J Maxillofac Oral Surg. 2017 Jun;16(2):226-230. [Google Scholar]
14. Zhou H, Hu K, Ding Y. Modified dextrose prolotherapy for recurrent temporomandibular joint dislocation. Br J Oral Maxillofac Surg. 2014 Jan;52(1):63-6. doi: 10.1016/j.bjoms.2013.08.018. [Google Scholar]
15. Ungor C, Atasoy KT, Taskesen F, Cezairli B, Dayisoylu EH, Tosun E, Senel FC. Short-term Results of Prolotherapy in the Management of Temporomandibular Joint Dislocation. J Craniofac Surg. 2013 Mar;24(2):411-5. [Google Scholar]
16. Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: a single-arm study with 1-4 years’ follow up. Br J Oral Maxillofac Surg. 2017 Apr 28. [Google Scholar]
17. Cezairli B, Sivrikaya EC, Omezli MM, Ayranci F, Cezairli NS. Results of Combined, Single-Session Arthrocentesis and Dextrose Prolotherapy for Symptomatic Temporomandibular Joint Syndrome: A Case Series. The Journal of Alternative and Complementary Medicine. 2017 Oct 10. [Google Scholar]
18 Nagori SA, Jose A, Gopalakrishnan V, Roy ID, Chattopadhyay PK, Roychoudhury A. The efficacy of dextrose prolotherapy over placebo for temporomandibular joint hypermobility: A systematic review and meta‐analysis. Journal of oral rehabilitation. 2018 Jul 19. [Google Scholar]
19 List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia. 2017 Jun;37(7):692-704. [Google Scholar]
20 Zhang S, Yap AU, Toh WS. Stem Cells for Temporomandibular Joint Repair and Regeneration. Stem Cell Rev. 2015 Jun 28. [Google Scholar]
21 Zhang J, Guo F, Mi J, Zhang Z. Periodontal ligament mesenchymal stromal cells increase proliferation and glycosaminoglycans formation of temporomandibular joint derived fibrochondrocytes. Biomed Res Int. 2014;2014:410167. [Google Scholar]