TMJ Problems – When First-Line Therapies Don’t Work

What to do when a nightguard, medications, and a soft diet do not ease your patient’s pain.?

As most practitioners have come to realize, TMJ problems are common. It has been reported that the overall prevalence of TMJ is approximately 31% for adults and the elderly and 11% for children and adolescents.

Some of the most recognizable symptoms include pain, limited jaw motion, TMJ clicking/locking, and a sense that the way the teeth come together has changed.?These problems can have a muscle origin; others relate to compromise of the intracapsular structures of the TMJ or a combination of the two. Inflammation typically drives pain, and this may be present in the joint and associated ligaments and/or the jaw muscles and their tendon connections. Commonly experienced muscle?soreness and fatigue can also give rise to daily symptoms of discomfort or acute pain.

Certainly, clenching during the day and nighttime grinding or clenching have been identified as risk factors that drive muscle and/or joint symptoms. At times, there may be a history of trauma and/or past medical or dental procedures that may have inadvertently?sprained a jaw ligament or strained jaw muscles or tendons.?At other times, systemic diseases or disorders may predispose to inflammation and pain in connective tissue or instability, leading to joint?hyper-mobility and mechanical compromises.

Regardless of the reason, after a diagnosis is made, there are several common strategies used to reduce pain, improve jaw motion limitations and stabilize joint mechanics. These treatments?include the use of anti-inflammatory medications or muscle relaxants, adherence to a protective diet, modification or elimination of jaw overuse behaviors and or fatiguing head postures during the day, jaw and neck exercises, and, of course, a nightguard to address grinding and clenching of the teeth during sleep. These are the basic staples of care. At times, physical therapy is recommended, particularly if the neck is thought to be contributing to the jaw problems.

When these treatments do not work, and pain along with motion deficits and joint instability remain, the need to refine a working diagnosis and add more interventional treatment becomes necessary. Many of these treatments require?injection?therapies designed to assist healing in muscles,?tendons, ligaments, or the TMJ itself. They include muscle injections, tendon and ligament injections, and joint injections.

1. A. Muscle Injections?

• Trigger Point/Dry Needling: Often called trigger point injections or dry needling, these muscle injections are designed to reduce spasms, soreness, guarding, hyperexcitability, and referred pain. Whether or not?these trigger points, or what I call myoneural?points, truly exist as a physical entity has been debated for years. However, recent ultrasound studies seem to have confirmed their existence.
• The mechanical prodding of the trigger/myoneural point is truly what creates the benefit. It is the needle itself and not a specific ingredient that allows this treatment to be effective. Local anesthetics such as lidocaine are often deposited in the muscles during the needling process and are thought to help break the cycle of pain.
• Muscle injections may be required several times in order to return an active trigger/myoneural point capable of pain production and referred symptoms to its latent non-symptom-producing form.
• After muscle injections are delivered, active stretching is required with the assistance of a vapocoolant spray. Between injection visits,?daily stretching exercises and/or formal physical therapy?is necessary to help restore muscle length and health.
• BOTOX?: The most common muscle locations where BOTOX? is used in an Orofacial Pain practice are the masseters, temporalis, trapezius, frontalis, and occipitalis. I’ve written extensively about BOTOX? therapy – here are some of the most important considerations:
• BOTOX? not only diminishes the initiation and strength of muscle contraction but also reduces the release of pain-promoting neurotransmitters. These two features commonly lead to a reduction of muscle pain as the biochemical environment of the muscle has a chance to normalize.
• Controlling new injury after the BOTOX? is injected remains critical.
• After BOTOX? injections, jaw muscle contraction due to awake or sleep bruxism still occurs, but at a lower level with less likely tissue injury.
• If the nerve endings in muscles have already been irritated prior to BOTOX? being injected, the injections may only reduce pain over the short term and will need to be repeated. If multiple injection sessions are required, caution must be exercised to avoid muscle atrophy and narrowing of facial profiles.
• BOTOX? should be considered a management strategy to be used in conjunction with other traditional forms of care.

B. Tendon & Ligament Injections?

There are times when inflammation may be persistent in a tendon or a ligament and may prevent first-line therapies from working. In these cases, certain injection techniques have been found to be very helpful.

• Prolotherapy: Prolotherapy involves injecting a combination of local anesthetic and dextrose, which acts as an irritant and prompts an immune response and new inflammation. The activation of the immune system is thought to be responsible for a proliferative response leading to tissue healing.
• These injections, which are directly administered to a?tendon or ligament?need to be repeated several times over the course of a few months in order for results to be achieved.
• This modality of care has been around for over 50 years and has gained popularity among physical medicine doctors based on current research. In my office, prolo-injections are commonly used to assist tissue healing in the tendons associated with the masseter, temporalis, occipital and sternomastoid muscles. They are also used to address capsular sprains of the TM Joints. In between injections, home care strategies and/or physical therapy is?required to allow adequate healing to occur.
• Steroid Injections Into Tendon & Ligaments: In addition to prolotherapy injections, steroids are often injected to address persistent inflammation in tendons and ligaments. These injections may also have to be repeated and require a cautionary approach if?early results are insufficient.

C. Joint Injections?

It is not uncommon for the TM joints to be compromised by inflammation and/or?structural problems. As a result, pain can be severe and debilitating. At other times, along with pain, there may be mechanical symptoms of clicking and popping and/or gravelly sounds in a joint. When first-line therapies fall short to manage these symptoms, joint injection therapies may be very helpful.

• TMJ Steroid Injections: The use of steroids injected into joints throughout the body is common and used every day to reduce or eliminate inflammation in?knees, hips, and other joint regions. Therefore, it is not surprising that steroid injections are also used in the TM joints.
• With regard to the TM joints, steroid injections have been proven to be very helpful in reducing pain and associated symptoms of limited jaw motion and occlusal?changes. Based on a?specific history, symptoms, clinical examination, and imaging,?a diagnosis of an inflammatory problem in a TM joint can prompt the consideration of using a steroid injection.
• The use of steroids is always a double-edged sword. Inflamed tissue responds well, but healthy tissue can react poorly,?potentially?prompting further joint breakdown. Therefore, in small joints, in particular, steroid injections should only be repeated a few times (unfortunately, the literature has?not defined specific limitations) and should be done under the guidance of an experienced clinician. The results, however, can be profound and capable of altering the trajectory of stubborn joint pain.
• TMJ Prolo-Injections: In addition to using steroids in the TM joints, prolo-injections directly into the joint are often considered. The combination of local anesthetic and dextrose to induce tissue proliferation and healing is an alternative strategy for young patients and patients who are reluctant to have a steroid injected. Like steroids, prolo-injections may need to be repeated.
• TMJ Lubricating Substances/Hyaluronic Acid Injections: The injection of lubricating substances, such as hyaluronic acid, has been ongoing for years in large joints throughout the body. At the outset, these lubricant gels were designed to fill collapsed spaces in arthritic joints to provide a shock-absorbing capacity. Short-term comfort would often be reported in patients receiving the injections in their knees. Recent studies suggest, however,?that when performed in the TM joints, inflammatory markers decrease, leading to diminished pain

What The Future Holds?

On the horizon are injection techniques designed to regenerate tissue in injured or compromised joints, ligament, and tendon structures. Blood components such as PRP, along with stem cells, are the most familiar of these regenerative injections.

At this time, the use of regenerative substances has only recently been investigated in the TM joints. I suspect that in the very near future, these types of injections will become commonplace and will likely prompt healing that has not been achievable in the past with non-surgical techniques.

Conclusion

In summary, there are many options to treat stubborn TMJ/temporomandibular pain and related symptoms. Therefore, when first-line therapies fail, injection techniques may very well help patients who are suffering from persistent problems.