Prolotherapy with 12.5% dextrose to treat temporomandibular joint dysfunction (TMD)

Introduction: Temporomandibular joint dysfunction (TMD) is a collective term used to describe a complex and multifactorial disorders of the orofacial region. Symptoms commonly associated with TMD include TMJ pain, limited mandibular movement or locking and painful clicking or popping sounds. Most of patients diagnosed with TMD are initially treated conservatively. Failure of such conservatism poses a great challenge for the treating physician. Prolotherapy has been used successfully in many joints in the body by orthopedics and spinal surgeons. Injection prolotherapy has also been used in management of weakening tendons or ligaments in head and neck. Aim of the study: To evaluate the effi cacy of dextrose prolotherapy with 12.5% concentration in the treatment of intractable temporomandibular joint dysfunction. Material & Methods: A prospective clinical study with 33 patients with the diagnosis of TMD were included in this study during the period from Jan. 2012 to Jan.2015. Inclusion criteria were; adult patients above 18 years old, with TMD symptoms for more than 6 months, had failed conservative treatment and have no pathological fi ndings on dynamic magnetic resonance imaging. Prolotherapy was achieved by six sessions of 12.5% dextrose (3ml) injection per joint with one month interval. A Semi-structured questionnaire developed by the author was utilized to gather all demographic data. All variables were collected, tabulated and analyzed. Follow up appointments were booked after the last session, every 3 months for up to 24 month. Results: I used maximum mouth opening, clicking and visual analogue pain score to judge the effi cacy of my protocol. There was statistical signifi cant improvement of all previous variables outcomes. Conclusion: Dextrose prolotherapy can be used in patients diagnosed with TMD whom had failure of conservative treatment to control their symptoms. More than four prolotherapy sessions is not recommended as per results of this study. It is safe and effi cient technique. Research Article Prolotherapy with 12.5% dextrose to treat temporomandibular joint dysfunction (TMD) Ehab Shehata* Associate Professor in Maxillofacial and Plastic Surgery Department. Faculty of dentistry, University of Alexandria. Egypt Received: 02 April, 2019 Accepted: 16 April, 2019 Published: 17 April, 2019 *Corresponding author: Ehab Shehata, Associate Professor in Maxillofacial and Plastic Surgery Department. Faculty of dentistry, University of Alexandria, Egypt, E-mail:


Introduction
Temporomandibular joint disorder, commonly known as TMJD or TMD, was defi ned by the American Dental Association (ADA) as "A group of orofacial disorders characterized by pain in preauricular region, TMJ or muscles of mastication, limitation or deviation of mandibular range of motion, TMJ sounds during mandibular function" [1].

National institute of Dental and Craniofacial research has
reported an incidence of 10.8 million people in USA at any given time [2]. TMJD 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 child-bearing years [3,4].
Symptoms commonly associated with TMD include pain localized to the joint, generalized oro-facial pain, chronic headache and jaw dysfunction which includes hyper and hypomobility, limited movement or locking of the jaw, painful clicking and or popping sounds. (5) Additional symptoms may include otalgia, decreased hearing, dizziness and visual problems [6].
Causes of TMD are often unclear and are usually considered to be multifactorial. TMJ capsular damage or infl ammation and muscle pain / spasm can be caused by malocclusion, para-functional habits, stress, anxiety or abnormalities of the intra-articular disc (meniscus) [7]. It can be due to hormonal or psychological problems [8,9]. The common way to manage patients experiencing TMD but without pathological fi ndings is Prolotherapy means rehabilitation of an incompetent structure such as a ligament or tendon by induction of cellular proliferation. Prolo comes from the word proliferate.
Prolotherapy injections stimulate growth of new, normal ligament and tendon tissues by stimulation of low grade infl ammation [10]. Monocytes, granulocytes, macrophages migrate to injured tissue by prolotherapy with activation of fi broblasts to produce matrix and new collagen fi brils. The temporary cellular stress causes release of cytokines and increased growth factors activity. Unlike repair after injury, disruption of the architecture of the tissue does not occur from injury and new cells and matrix are deposited in an organized fashion, with maturation of new tissue for 6-8 weeks [11].
Different concentration of dextrose solution have been used as a therapeutic injecting material. Prolotherapy has been used successfully to treat many painful joints in the body [12].
The aim of this study was to evaluate the effi cacy of injecting dextrose solution (12.5%), a prolotherapy technique, in the treatment of resistant tempro-mandibular joint dysfunction.

Material & Methods
In the period from January 2012 to January 2015, 33 consecutive patients diagnosed with TMD were treated by prolotherapy. Inclusion criteria were adult patients above 18 years old, with TMD symptoms for more than 6 months, After completion of the procedure patients were instructed to eat soft diet, prescribed analgesics as required but prohibited  Success was defi ned as absence or reduction of pain (at least 75% on visual analogue score) or absence of the need to take analgesics, improvement of maximum incisal distances and the absence or reduction of clicking. The data were analyzed to assess the effi cacy of the prolotherapy technique.
Quantitative data are presented as mean (SD). Wilcoxon signed rank test was used to identify signifi cant changes in outcomes.
Qualitative data are presented as numbers (%). Probabilities

Discussion
The exact cause of chronic TMJ dysfunction is obscure.
The mechanism of dextrose prolotherapy is to improve the stability of TMJ by enhancing capsular and ligament strength [14]. Weakening of the TMJ capsule and ligaments would explain joint subluxation, disc displacement as well as muscle spasms and myofacial pain patterns. The most common cause of TMJ pain is myofacial pain dysfunction syndrome and primarily involves the muscles of mastication [15]. In general, prolotherapy agents are four general types: osmotic agents, infl ammatory mimetics, chemical and physical irritants. In this study, osmotic agent was used. 12.5% dextrose produces a hypertonic extracellular environment causing lysis of the adjacent cell walls. Release of cellular proteins, infl ammatory breakdown products and debris cause localized infl ammation and fi brous healing.
It was the aim of this study to assess the effi ciency of dextrose prolotherapy for treatment of TMD. Dextrose 12.5% was used as the active gradient in the solution as it is the most common proliferant agent in prolotherapy management. It is readily available, inexpensive and has satisfactory safety profi le [16,17]. Dextrose concentration more than 10% partially works by stimulation of infl ammatory reaction as do phenol and sodium morrhuate [18]. Hakala et al advocate for the use of dextrose in a concentration greater than 10%, which is enough to initiate adequate cell wall lysis to attract fi broblasts and begin the required proliferation/regeneration process [12]. The exact concentration of dextrose proliferant agent may not be critical as long as it is above 10%. Different concentration have been published in recent articles suggesting 12.5%, 15%, 25% of dextrose solution for prolotherapy management of TMD [13,[16][17][18]. Refai, et. al., reported usage of 10% dextrose as subinfl ammatory concentration in tightening loose ligaments for treatment of TMJ hypermobility [16]. The effects of 10% dextrose concentration also showed statistically signifi cant benefi t upon injecting the prolotherapy agents in small joints [19][20][21]. In the