Temporomandibular disorders (TMJ) are a group of pathological health conditions that affect the muscles involved in food mastication as well as soft tissue components. Collectively, they are regarded as musculoskeletal disorders of the head and neck masticatory assembly.
This condition is very common. Approximately 15% of the global population suffers from osteoarthritis. The prevalence and symptom rate of TMJ OA are similar to generalized OA. There are reported 3 million cases per year in the US alone. Currently, it is estimated that more than 10 million Americans are in active treatment for this disorder.
TMJ disorders commonly occur in the 18-45 age group and are two times more frequent in women than men. 80% of those seeking treatment are women.
The common symptoms are:
- Discomfort in the orofacial region around the TMJ
- Muscle tenderness
- Restricted jaw motion
- Clicking, popping or grating noises when the jaw is opened and closed
- Locking of the jaw
- Pain on chewing
- Muscle spasms or muscle pain in the region
- Ear Pain
Frequently, there are additional neurological symptoms such as,
- Migraines
- Vertigo
- Altered vision
Dental problems such as,
- Malocclusion
- Tooth pain Swelling inside or outside the mouth
The temporomandibular joint is a hinge like assembly with sliding motions. The parts of the bones are covered in cartilage and separated by a disc. The disc absorbs shock and functions to keep the action of this joint smooth.
TMJ is one of the most unique joints in the human body in terms of the composition. The TMJ consists of two joints in one bone. The two joints connect the head and the mandible. In other joints, the joint surface is covered by a layer of hyaline cartilage. However, the TMJ is special in the fact it is composed of fibrocartilage. Fibrocartilage contains both collagen type 1 and 2 compared to hyaline cartilage which contain only type 1. Fibrocartilage can withstand sheer forces better, since it contains tissue components with a high density of fibers which are less likely to break down over time.
Common causes of TMJ dysfunction
- Trauma to the jaw
- Dislocation of the joint
- Arthritis
- Stress
- Grinding of the teeth Improper bite caused by teeth or ill-fitting dentures.
- Connective tissue disorders
- Tooth pain
TMJ OA is a degenerative disease that occurs due to an imbalance in the synthesis and degradation of the condylar matrix. Degenerative changes in the TMJ are mediated by chondrocytes and fibrocartilage cells in the fibrocartilage of the structure. This degradation results in a loss of the extracellular matrix components of the subchondral bone and articular cartilage. The articular surface is covered with fibrocartilage to resist stress, but the underlying subchondral bone is stress sensitive and remodeling occurs there over time. Defects in the cartilage and bone are not easily healed due to the lack of blood supply and reduced metabolic activity. If the cartilage is not treated, it affects the surrounding tissues and leads to OA. Microscopically, the loss of collagen and proteoglycans is observed resulting in the loss of structure and the mechanical properties of the joint.
Diagnosis
- Dental exam
- X-rays usually done in a dental environment such as panoramic views
- MRI is the current state of the art. Gives excellent views of the anatomy of the TMJ
- Arthroscopic exam- where a camera views the interior anatomy
Non-Surgical Treatments
- NSAIDS to relieve pain and reduce inflammation
- Muscle relaxants to relieve tight muscle usually in people who grind their teeth
- Tricyclic antidepressants to relieve pain and stress
- Oral appliances such as mouth guards and splints
- Corrective dental procedures to replace missing teeth or correct ill-fitting dentures
- Physical therapy to strengthen jaw muscles and to stretch jaw muscles
- Diet changes to reduce the amount of chewing and to decrease the size of food inserted at one time into the mouth
Injections
- Steroids with and without lidocaine to reduce pain and inflammation.
- Hyaluronic acid to add cushioning and lubrication to the joint area.
- Botulinum toxin for muscle relaxation
- Platelet Rich Plasma
- Exosomes
Surgical
Arthrocentesis is invasive minimally and consists of needles inserted into the joint space and irrigation and then delivery of anti-inflammatory agents. TMJ arthroscopic surgery where a lighted tube is inserted into the joint and corrective action is then performed depending on the pathology.
Open surgery used to repair or replace the joint when all other therapies fail. Spacers can be placed but these have failed in the past. Newer materials are performing better but as with any surgery, there are risks.
Platelet Rich Plasma is an autologous blood concentrate, rich in cytokines and growth factors that has been proven in hundreds of studies to repair and rejuvenate damaged tissues. PRP exerts its therapeutic effects by attracting, promoting and differentiating cells as well as redesigning tissue. PRP has an inhibitory effect on specific proinflammatory mediators such as prostaglandin. These mediators have a detrimental effect to the stages of healing. Interleukin 1 is produced from activated macrophages and has specific actions on reparative cells that is inhibited by PRP. PRP, in TMJ, has a chondrogenic proliferation which facilitates the repair of the cartilage and overall structure of the joint. PRP also acts on the cannabinoid receptors, CB1 And CB2, which causes the analgesic effects of this therapy.
When PRP is applied, growth factors and bioactive proteins are released from the alpha granules on the platelet. This elevated amount of growth factors mimics the early phase of the inflammatory process, which is defined by neutrophil cells, monocyte cells and macrophage migration to the damaged area. The mediators then begin the regeneration process of vascular repair, fibroblast proliferation and inflammatory cell mobilization. Then PRP exerts an inhibitory influence on particular pro-inflammatory mediators that would be harmful to the overall healing process. One such pro-inflammatory mediator is Interleukin 1. This allows repair of the chondral surface to occur. In temporomandibular joint dysfunction, the repair of the cartilage and articular tissues results in a reduction of pain and a decrease in the grinding sounds when the jaw is open and closed.
Studies
Bioinformation 2022 Oct 31;18(10): 991-997 PMID 37693922
Purpose: Comparison was made between Platelet Rich Plasma and Hydrocortisone in the treatment of Temporomandibular disorders. Patients were evaluated for tenderness, maximum incisal opening and clicking sounds post treatment.
Conclusion: There was statistically no difference between the two groups, however the overall results were more successful in the PRP group.
Author note: side effects of cortisone re: elevation of blood sugar and degradation of cartilage and tissue was noted as a detrimental reason to avoid steroid use.
Hyaluronic acid has long been known to be an integral substance in all joints of the body. It provides cushioning and lubrication to the joint and aids in the degradation caused by repeated stress and friction. Conditions such as osteoarthritis and collagen disease have a decreased amount of hyaluronic acid in the capsule of the joint and are therefore prone to cartilage degeneration. Supplementation has been used for many years to rectify the loss of HA in these diseases.
J Biomed Sci 2023 Sep 11;30(1). Doi 10.1186/s12929-23-00962-y PMID 37691117
Purpose: Bioactive materials have now raised considerable attention for the treatment of osteoarthritis, such as knee OA, rheumatoid OA, and temporomandibular joint OA. TMJ-OA is a common disease associated with an imbalance of cartilage regeneration, tissue inflammation and disability in mouth movement. In this study, we used the combination of human platelet rich plasma with hyaluronic acid for a TMJ-OA therapy to perform a clinical trial in dish to humans.
Conclusion: This study highlighted the therapeutic potential of the HA-PRP combination for TMJ-OA therapy with detailed evidence from bench to bedside.
Exosomes are nanosized vesicles of endocytic origin that play important roles in regenerative medicine. They are derived from cell membranes during endocytic internalization and stabilize in biological fluids. Their efficacy is increasingly well documented in regenerative therapies. Exosomes play a critical role in the regulation of the inflammatory response, nociceptive behavior, bone healing and cartilage repair.
Biomaterials 2019 Apr; 20:35-47. Doi: 10.1016/j.biomateriqls.2019.02.006 PMID 30771585
Purpose: We investigated the role of MSC exosomes in an immunocompetent rat model of temporomandibular osteoarthritis.
Conclusion: Our observations suggest the MSC Exosomes promote TMJ repair and regeneration in OA through a well orchestrated mechanism of action that involved multiple cellular processes to restore the matrix and overall joint homeostasis. This study demonstrates the translational potential of a cell free ready to use exosome based therapeutic for treating TMJ pain and degeneration.
Int J Mol Sci 2020 Feb 24;21(4):1541 PMID 32102392
Purpose: Exosomes have been studied as an alternative approach to tissue repair and regeneration. We will look at the use of exosomes in the treatment of TMJ.
Conclusion: Exosomes are capable of regenerating cartilage and osseous compartments and restore injured tissues and can treat dysfunction and pain caused by TMJ
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA cleared and designed for safety, sterility and effectiveness. Our kits are scientifically manufactured to provide a platelet concentrate, devoid of red blood cells with a minimum number of leukocytes, critical to the regenerative cascade.
Juventix Regenerative Medical offers a patent pending LED Activator to activate the platelets and begin the regenerative process. The activation is a critical step in the release of cytokines, growth factors and bioactive proteins and is accomplished with LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin or Collagen. This activation by LED light also provides sustained growth factor release versus older methods of activation while adhering to the minimal manipulation guidelines of the FDA.
Juventix Regenerative Medical supplies a Bio-incubator that transforms the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The Platelet Rich Fibrin, commonly called “the second generation of platelet products” has different cytokines and growth factors than the original PRP. These different cytokines provide an anti-inflammatory environment and can be used confidently in inflammatory conditions.
Juventix Regenerative Medical has a Platelet Rich Plasma Kit that contains non-cross-linked Hyaluronic Acid. This could be used in confidence in cases such as temporomandibular joint dysfunction. In aesthetic practices, the PRP-HA can be transformed into a natural filler without the long-term side effects currently seen in this market.
Juventix Regenerative Medical is collaborating with Evolutionary Biologics to offer regenerative products and other tissue-based therapies such as exosomes. These products complement PRP and offer the regenerative medical practitioner a complete line of treatment options which can be used solely or in conjunction with other therapeutic modalities.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
