|Year : 2013 | Volume
| Issue : 2 | Page : 49-52
Prolotherapy: A new hope for temporomandibular joint pain
A Vijay Kumar1, HP Jaishankar2, AP Kavitha2, Purnachandra Rao Naik1
1 Department of Oral Medicine and Radiology, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India
|Date of Web Publication||4-Oct-2013|
A Vijay Kumar
Department of Oral Medicine and Radiology, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
The most common cause of orofacial pain is the Temporomandibular Joint Disorder (TMD), a collective term used to describe a group of medical disorders causing temporomandibular joint (TMJ) pain and dysfunction. As the causes of TMD are varied and run the gamut from mechanical issues, such as disc degeneration and dislocation or erosion of the fibrocartilaginous surfaces of the condyle, fossa, and articular eminence, 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 alternative treatments is 'Prolotherapy,' which is also known as Regenerative Injection Therapy. This article provides an overview of this new alternative therapy.
Keywords: Prolotherapy, proliferants, TMD, TMJ pain
|How to cite this article:|
Kumar A V, Jaishankar H P, Kavitha A P, Naik PR. Prolotherapy: A new hope for temporomandibular joint pain. Indian J Pain 2013;27:49-52
| Introduction|| |
One of the most common causes of orofacial pain is the Temporomandibular Joint Disorder (TMD), a collective term used to describe a group of medical disorders causing temporomandibular joint (TMJ) pain and dysfunction.
The TMJ is often predisposed to degenerative changes and pathologies as seen in other synovial joints, as a consequence of the frequent and repetitive stresses that the TMJ undergoes. 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, limited movement or locking of the jaw, painful clicking or popping sounds with opening or closing of the mouth, and difficulty in chewing or speaking. Even as pain is the most common symptom, some people report no pain, but still have problems using their jaws. Additional symptoms may include ringing in the ears, ear pain, decreased hearing, dizziness and vision problems. 
The first-line approach to manage TMJ pain typically includes resting the jaw, relaxing the jaw muscles, and doing jaw exercises as recommended by a physical therapist. Recommendations may also include eating a soft diet that minimizes hard repetitive chewing of crunchy or chewy foods. Relaxation exercises that emphasize gentle range of motion of the joint are recommended. If these methods fail, then typically a short course of an anti-inflammatory (NSAIDs) medication is prescribed. However, studies have shown that the use of NSAIDs may interfere with healing and is questionable in the treatment of musculoskeletal injuries. 
As the causes of TMD are varied and run the gamut from mechanical issues, such as disc degeneration and dislocation or erosion of the fibrocartilaginous surfaces of the condyle, fossa, and articular eminence, 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 alternative treatments is 'Prolotherapy'.
| What is Prolotherapy?|| |
Prolotherapy is a method of injection treatment designed to stimulate 'healing'. George S. Hackett coined the term 'Prolotherapy' in the 1950s from the Latin 'proli-' meaning 'offspring', and from which we get the word 'proliferate', that is, 'to grow'. ,
Proliferative injection therapy (Prolotherapy) is also known as Regenerative Injection Therapy (RIT), Reconstructive Therapy, Non-surgical Tendon Ligament and Joint Reconstruction, Growth Factor Stimulation Injection, and Sclerotherapy. , According to some authors the term 'sclerotherapy' is a misnomer because biopsy studies have not demonstrated scar formation with prolotherapy, with the agents and concentrations currently in use. Rather, studies have shown a proliferation of new, normal, thicker, and stronger connective tissue after prolotherapy injections. ,
| Definition|| |
The basic practice of prolotherapy involves injections in the tendon and ligament insertions with a medicament that stimulates proliferation of fibrous tissue, to repair and stabilize the fibro-osseous junction. Of late, in 2007, Reeves defined prolotherapy as, an injection of growth factors or growth factor production stimulants to grow normal cells or tissue. 
| History|| |
Historically, the use of prolotherapy dates back to Hippocrates, who treated dislocated shoulders of soldiers on the battlefields with red-hot needle cautery to stabilize the joint. It was during the 1930s that George Hackett, a general surgeon, made the observation - while doing hernia surgery on patients previously treated with a proliferant-type therapy - that 'injections made at the junction of the ligament and bone resulted in profuse proliferation of the new tissue at this union'. Hackett then spent many years developing and refining injection therapy for tendons and ligaments, publishing his research and text in 1956. 
| Prolotherapy Technique|| |
Prolotherapy may involve a single injection or a series of injections, often diluted with a local anesthetic. During an individual prolotherapy session, therapeutic solutions are injected at the sites of painful and tender ligament and tendon insertions and in the adjacent joint spaces.  In most cases two to six treatment sessions are required over two to twelve months to reach the maximum effect. The standard protocol includes restriction from non-steroidal anti-inflammatory drugs one to two days before treatment and 10 to 14 days after treatment. After the injection, the patients are cautioned against taking aspirin or other anti-inflammatory agents to relieve the discomfort. After the injection, patients should be encouraged to be active and move the injured area. The movement will actually enhance the healing of the ligament injury. ,
| Temporomandibular Joint Prolotherapy|| |
The Hemwall-Hackett technique of dextrose prolotherapy to the temporomandibular joint involves injections into the joint and 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 the capsular and ligament strength [Table 1]. 
|Table 1: Review of few studies that have shown significant effects of prolotherapy for TMJ pain|
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The most common cause of TMJ pain is the myofascial pain dysfunction syndrome (MPDS) which primarily involves the muscles of mastication. Even as physiotherapy, analgesics, splints, surgeries, and other treatment modalities offer temporary help, they rarely cure the condition. A known cause of persistent muscle spasms and myofascial pain dysfunction is the underlying ligament laxity. By stimulating the ligament and capsular repair for such cases prolotherapy would represent a more permanent solution. ,
| Mechanism of Action|| |
A brief knowledge of the wound healing process is essential to understand the mechanism behind prolotherapy. The process of wound healing occurs in three stages, that is, the Inflammatory, Proliferative, and Remodeling stages. Inflammation initiates the biological process of wound healing. Following injury, the granulocytes migrate into the injured tissue. Monocytes and macrophages follow the granulocytes to the wound site. The growth factor is released and activates the fibroblasts, which produce the matrix and new collagen fibrils. ,
Inflammation is a necessary component of soft tissue healing and the ability of NSAIDs to inhibit the healing response has been well-documented in experimental situations and has been observed clinically.  However, prolotherapy re-initiates the inflammatory process and stimulates the healing process. Histological studies have demonstrated fibroblast proliferation originating in the periosteum following injection of the prolotherapy solution. ,
| Proliferants|| |
The various injection solutions used in prolotherapy are called proliferant solutions. A wide range of proliferants are used in the procedure which have different mechanisms of action [Table 2]. However, the ultimate goal of injection therapy is to initiate inflammation and wound healing, and thus, stimulate the formation of a new ligament or tendon. These proliferants are 'inflammatory agents,' which, by initiating the first step in the wound healing cascade, lead to fibroplasia. The various proliferants are grouped as follows:
|Table 2: Classification of proliferant solutions and mechanism of action|
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Irritants or haptens form the first class of a proliferant solution. They are exemplified by phenol, haptens, and tannic acid. These compounds have phenolic hydroxyl groups that are readily oxidized to produce reactive quinone-like compounds, which are known to directly alkylate the proteins on the surfaces of cells. By attaching themselves or their quinonoid oxidation products to the surfaces of cells at the injection site they either damage the cells directly or render them antigenic. In either case, granulocytes and macrophages are attracted to the injection site and early inflammation occurs; in other words, the wound healing cascade is initiated. ,
Particulates such as pumice flour are irritants of a different type. They are small particles, in the order of one micron (about the same size as bacteria), which attract the macrophages. The macrophages phagocytize small particles in the same manner in which they ingest bacteria and cellular debris. Once the macrophages arrive at the injection site and ingest the pumice granules, they likely secrete polypeptide growth factors that result in fibroplasia and new collagen deposition. Granulocytes also may be attracted to the cellular trauma caused by the injection of particulates. ,
These proliferants are characterized by osmotic shock. These agents act by dehydrating cells at the injection site. In osmosis, concentrated solutions cause a net flow of solvent across a semi-permeable membrane from solutions that are less concentrated.
The osmotic proliferants causes a net flow of water into the injection site by removing water from living cells. Upsetting the delicate balance within these living cells causes severe, but localized, tissue trauma and the cells at the injection site are killed. These morbid or dead cells release cellular fragments (proteins, membrane fragments) that are attracted to granulocytes and macrophages. Thus, local tissue damage causes an influx of inflammatory cells and initiates the wound healing cascade. These are basically concentrated solutions of simple water-soluble compounds that include concentrated glucose, glycerin, and zinc sulfate. ,
This class of proliferants has only one member currently; sodium morrhuate, which contains the biosynthetic precursor to certain chemotactic agents that attract inflammatory cells. Sodium morrhuate is the sodium salt of the fatty acid component derived from cod liver oil.
The documented powerful proliferant action of sodium morrhuate may be due to its arachidonic acid component being directly converted into prostaglandins and related mediators of inflammation. ,
| Indications of Prolotherapy|| |
- Prolotherapy has been used to successfully treat a large variety of musculoskeletal syndromes, including cervical, thoracic, and lumbar pain syndromes. Also, mechanical low back pain, plantar fasciitits, foot or ankle pain, chronic rotator cuff or bicipital tendinitis, and lateral and medial epicondylitis.
- TMJ pain and musculoskeletal pain related to osteoarthritis. ,,
| Contraindications of Prolotherapy|| |
- Immunocompromised patients, smokers, poor nutritional status.
- Needle phobia.
- Allergy to a proliferant solution.
- Acute infections such as cellulitis, local abscess or septic arthritis are an absolute contraindication for prolotherapy.
- Relative contraindications include current and long-term use of high doses of systemic corticosteroids or NSAIDS, as these are counterproductive to the inflammatory process. ,
| Future Prospective|| |
At some point in the future, chemotactic factors and polypeptide growth factors produced by genetic engineering technology, will become available to the clinician. When this occurs, clinicians may be able to recruit fibroblasts directly to an injured ligament and perhaps avoid the discomfort of an inflammatory response. ,
| Conclusion|| |
Prolotherapy is a treatment modality that provides a long-term solution rather than just palliation. It should be considered in appropriate patients prior to resorting to long-term narcotic therapy or surgical intervention. Although very less data is available on TMJ Prolotherapy and many studies are in the seminal stage, prolotherapy may yet become a safe and effective treatment for TMJ pain in future.
| References|| |
|1.||Hauser RA, Hauser MA, Blakemore KA. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Pract Pain Manage 2007;1:49-55. |
|2.||Alderman D. Prolotherapy for musculoskeletal pain. Pract Pain Manage 2007;1:10-5. |
|3.||Hauser RA. The Regeneration of articular cartilage with Prolotherapy. J Prolother 2009;1:39-44. |
|4.||Fullerton BD. high-resolution ultrasound and magnetic resonance imaging to document tissue repair after prolotherapy: A report of 3 cases. Arch Phys Med Rehabil 2008;89:377-85. |
|5.||Hakala RV. Prolotherapy (Proliferation Therapy) in the Treatment of TMD. Cranio 2005;23:1-6. |
|6.||Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Prim Care 2010;37:65-80. |
|7.||Banks AR. A rationale for Prolotherapy. J Orthop Med 1991;13:1-12. |
|8.||Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med 2005;15:376-86. |
|9.||Paoloni JA, Orchard JW. The use of therapeutic medications for soft-tissue injuries in sports medicine. Med J Aust 2005;183:384-8. |
[Table 1], [Table 2]