Efficacy of Prolotherapy for Temporomandibular Joint Dysfunction: An Interventional Clinical Study

Introduction

The temporomandibular joint (TMJ) disorders must be distinguished from the many conditions that mimic them. Patients are asked to describe the pain and designate painful areas. Typically, these areas include muscles of mastication (temporalis, masseter, and medial pterygoids), and cervical and occipital muscles are palpated for general tenderness and trigger points. When patients open their mouths, the mandible typically deviates toward the painful side. Palpation and auscultation of the joint during opening and closing may reveal tenderness and catching and intracapsular sounds such as clicking/popping or crepitus. Condylar motion can best be palpated by bilaterally placing the middle fingers on the preauricular areas (lateral poles of the condyle) and exerting gentle medial pressure, or by placing the 5th fingers into the external ear canals and exerting very gentle forward pressure as patients move their jaw. Some conditions that mimic temporomandibular disorders are sinusitis, giant cell arteritis, post-therapeutic neuralgia, otitis media, fibromyalgia, Eagle syndrome, and fractures of the zygomatic arch. Regenerative injection therapy (RIT) [1,2] is a percutaneous treatment for pain and healing in orthopedic injuries that is non-invasive compared with the historical orthopedic invasive techniques. Depending on the diagnosis and goal of the treatment, the injected substance includes several possible restoring and regenerative compounds. Perineural injection therapy and prolotherapy mostly involve subcutaneous to deep intra-lesional injection using longer needles and cellular therapy of administering cellular products to an area of pathologic injury. Proliferative injection therapy, therefore, can be described as the process whereby an incompetent structure that includes ligaments, tendons, or other structures is rehabilitated by promoting the proliferation of new cells. “Prolo” originated from proliferate and prolotherapy injections cause the proliferation of cells or stimulate the formation of healthy, original ligament and tendon tissue [1].

Prolotherapy is carried out based on assessment of areas of weakness through administering naturally occurring therapeutic solutions that trigger the body’s healing process through the generation of enhanced inflammation that is propelled by a flood of stem cells that are useful in the repair of tissues [2]. In 2000, Reeves and Hassanein [3] broadened the scope of prolotherapy to include any treatment that involved the use of growth factors or growth factor inducers to promote growth of normal cells or tissues. This promotion is brought about by a low-grade inflammation at the injection site which in turn causes collagen synthesis and even strengthening of the cartilage by fibroblasts. Inflammatory prolotherapy has been used for many years, while non-inflammatory prolotherapy seems to be growing at an extremely rapid rate [2]. Regarding strict classification, there are 2 standard directions of prolotherapy, namely the Hackett method, developed as a continuation of G. Hackett’s work, and the West Coast methodology [1]. The Hackett method employs dextrose as the proliferant since it causes the least amount of cellular disruption and no nerve damage [1,2]. It is a slow technique in its operation but very simple to explain and has equal variation in its solution application. Temporomandibular disorder refers to a set of clinical problems that entail muscles of mastication, the temporomandibular joints, and surrounding tissues [3]. These disorders involve painful, localized sensations in the TMJ and/or the muscles that control the jaw, restricted or deviated movement in the mandible, and sounds from the TMJ during jaw movements and functions [3]. Even though most cases give rise to temporomandibular disorders (TMDs), their specific etiology is not entirely understood, and as such, an idiopathic yet specific hypothesis may be tendered: that occlusal disharmony is hypothetically related to TMD [3,4]. Progressive developments in imaging techniques in the late 1960’s unveiled several intracapsular causes for TMDs [5,6]. Nevertheless, a universally applicable, standardized diagnostic tool, classification, and treatment approach for TMD is still lacking. Thus, managing this disorder remains complex. Over the years, strategies for the management of tendinopathy have shifted and among these options, prolotherapy has proved viable. Some simple tests include examination of the muscles of mastication, probing for tenderness with light pressure over the TMJs while the patient opens and closes his or her mouth, and checking for noise or irregular movements in both TMJs and testing the patient’s TMJs by placing a finger in the outer area of the ears and opening and closing the patient’s mouth [7]. The recording of the maximum interincisal opening normally falls in the range of 37–52 mm, which can be estimated as ‘3 finger breadths.’ The normal jaw movements should be smooth, straight, and without pain, and the width of the gap should be recorded. While examining for joint sounds, it is best not to use a stethoscope because it does not usually record noticeable TMJ sounds. If palpation does not give data, sometimes audible clicks or crepitation are present, and then a careful look on obstetric or vascular doppler can be useful [2–7]. The contraindicator for prolotherapy includes allergy to the solution used as the proliferent, an acute infection, using anticoagulant drugs, presence of malignant disease, local abscess, proven hemorrhagic diathesis, certain types of septic arthritis, and parafunctional habits [5]. Possible adverse reactions associated with prolotherapy are post-prolotherapy reactions that may arise from improper injection methods rather than the proliferant solution itself. Nonetheless, as with any medication that is to be administered to a patient through an injection, the patient has to be checked for allergy to the injected substance. There are some possible adverse effects which are associated with TMJ prolotherapy. Some of the possible adverse effects are given below: Pain during the procedure, temporary loss of sensation from the procedure, which may stretch up to the eye and cause ptosis. Extravasation which may lead to external bleeding and at the time of the procedure, there may be skin bruising seen over the face. There could be a dizzy feeling during the procedure, maybe because of anxiety, which could result in syncope [8–13]. Specifically, the objective of this 6-month, retrospective, and observational study was to explore the outcomes of Hemwall-Hackett dextrose prolotherapy and the measurement of TMJ pain, which is related to quality-of-life.

The main aim of this study was to find a better, easy, and effective solution for the long-term suffering of patients with TMDs, and to seek out other alternative treatments like prolotherapy for patients suffering from TMD.

Prolotherapy has been proven to be effective in patients with TMD symptoms such as pain, stiffness, and hypermobility. When brought into the clinic and given this treatment, several patients can get relief from long-term suffering and save their money for symptomatic relief devices and surgeries. The present research was intended to determine whether a single injection of dextrose solution combined with lidocaine and sterile water into the area surrounding the TMJ effectively alleviates the pain, rigidity, noises, and restricted mobility in patients who do not respond to other non-surgical approaches to TMDs.

Material and Methods

STUDY DESIGN:

This study aimed to conduct a prospective randomized clinical trial treating patients experiencing TMJ pain and limited mouth opening at King Khalid University College of Dentistry in Abha, Saudi Arabia. The local ethics committee has approved this study, and all participants have signed an informed consent.

INCLUSION AND EXCLUSION CRITERIA:

The study population comprised all patients presenting for evaluation and management of TMJ pain and restricted joint mobility. To be included and excluded in the study sample, patients had to meet the following criteria:

Inclusion criteria: 1) Restricted mouth opening (diagnosed with clinical evaluations). 2) Complaints of clicking, popping, and pre-auricular pain. 3) Age >20 years. 4) Existing clinical and radiographic data at baseline. 5) Patients with known temporomandibular dysfunction for whom physical medicine modalities and home care have proven ineffective or minimally effective. 6) Patients who expressed a desire for treatment and who could accept the pain and inconvenience of injection-based therapies. 7) Patients who can complete the injection protocol as necessary and adhere to a home treatment regimen. 8) Patients with partial or no benefit from oral devices or who are unwilling or unable to wear them.

Exclusion criteria: 1) Patients with bleeding proclivity or receiving any form of anticoagulant therapy. 2) Patients with inflammatory or connective tissue disease. 3) Patients who have any head or neck malignancy. 4) Patients with degenerative joint disease. 5) Patients with previous TMJ treatment or craniofacial surgery. 6) Patients who have existing parafunctional habits, those who have long-time edentulousness. 7) Patients who have a history of trauma, ankylosis, and dislocation. 8) Patients who are unwilling to obey post-treatment instructions.

The sample size was meticulously calculated for a significance level of P=0.05 and a robust power of 80%, ensuring the ability to detect a clinically meaningful difference in inter-incisal opening before and after treatment, specifically within the range of 20 to 35 mm. This careful consideration underscores the reliability and validity of our findings. To strengthen the study’s statistical power and effectively manage potential dropouts during the planned study period, we assigned 25 patients with TMD through a random selection process. A self-completed, structured questionnaire form to cover symptom intensity and the presence or absence of TMJ clicking and restricted joint mobility was used. The maximum incisor height for mouth opening was measured in millimeters, the pain degree was obtained from the VAS score, and the data obtained were evaluated using Microsoft Excel, 2010 and subjected to the following statistical tests: One-way analysis of variance (ANOVA) and the Kruskal-Wallis test were used to compare the mean values of the numerical variables for pain and mobility. The results were compared using the Chi-square test, and a P-value of less than 0.05 unequivocally indicates statistical significance, compellingly demonstrating strong evidence against the null hypothesis. Both univariate and multivariate regression models were estimated to assess the unadjusted and adjusted associations between the mouth opening and pre-auricular pain data in the subjects and the behaviors that were found to be significantly associated with TMDs. The adjusted crude odds ratios (COR) and 95% confidence intervals (CI) were reported for the multivariate analysis.

ETHICAL CONSIDERATIONS:

The patients were asked for consent for the study based on information explaining the objective of the research, its significance, and the 6-month duration of the study. They were informed that the required data would be gathered through a questionnaire form, and they were advised to meet every 2 months to repeat the procedure. This process is crucial for the success of the study. To ensure the confidentiality of the study, it was explained to the patient, in detail, that the information we collect from this research project will be kept confidential and that only the researchers can see it. Any information about the patient will have a number on it instead of their name; only the researchers will know what the number is and will lock that information up with a lock and key; it will not be shared with or given to anyone except the research committee who will have access to the information, such as research sponsors, the board, and clinicians. The consent was documented, and authorization for the study was granted for diagnostic procedures, therapy, and access to patients’ documents by the local ethical committee of the College of Dentistry King Khalid University (SRC/REG/2017-2018/18).

PROCEDURES AND PROTOCOL:

The participants were instructed to complete a self-administered symptom severity and functional status questionnaire for TMJ using the appropriate symbols for preauricular pain, stiffness, clicking, restricted mouth opening, and hypermobility. The Visual Analog Scale (VAS) was adopted to denote the pain severity and the degree of suffering, ranging from 0 to 10 (0 indicating that the patient does not feel any pain or suffering and 10 indicating that the patient feels severe and excruciating pain). A 0 rating was indicative of the subject having no symptoms of TMJ. At the beginning of the study, the mouth opening in millimeters was measured using a divider. Regarding the scale of maximum inter-incisal distance, an average distance between 30 and 70 mm was considered normal, and anything below this was considered a restriction. The principal investigator and co-investigator evaluated all subjects independently to blind the surgeon. The procedure of prolotherapy and the adverse effects, even if temporary, were all discussed with the patients. Thereafter, only 7 patients out of the 25 who were initially enrolled agreed to the procedure and volunteered to be treated at the clinic. The patients who did not participate probably declined participation due to improper motivation or fear regarding the injection technique. The patients who agreed to have the prolotherapy sessions were referred to an oral surgeon who administered the treatment. The assessment process was done after the procedure and then after 1, 3, and 6 months following the procedure. The solution was prepared for prolotherapy injection by drawing 0.75 ml of 12% dextrose, 0.75 ml of sterile water, and 1.5 ml of 2% lidocaine using a 3 ml syringe for every injection site [1]. The solution was prepared as explained earlier, stirred properly for uniformity, and then a 30-gauge needle was used for injection. The patient was ideally positioned supine or reclined to prepare for the procedure, with the head gently turned to the side opposite the injection site. Given the heightened sensitivity of the facial area and the TMJ, ensuring that the injections administered in this region are as atraumatic as possible is crucial. The prevalence of anterior disc displacement in TMJ highlights the importance of prioritizing repairing any extended or torn posterior disc attachments.

The initial target for the injection was the supra-articular joint space (Figure 1), also known as the posterior joint space, which can be identified by feeling the depth of the depression that forms just anterior to the tragus of the ear. This anatomical landmark becomes evident as the condyle shifts forward and downward during mouth opening. A disposable bite block was carefully placed between the patient’s anterior teeth to maintain an open mouth throughout the procedure.

Once the preparatory steps were complete, the injection needle was precisely positioned at the marked entry point, and angled medially and slightly anteriorly. The needle was then advanced, often reaching its full 1-inch length or nearly so, until it touched the medial wall of the fossa. Following a careful aspiration to confirm the correct placement, 1 ml of the prolotherapy solution was gently deposited into this targeted site, facilitating the necessary therapeutic effects.

The second target for injection was identified as a location at the anterior disc attachment, (Figure 2) where the disc connects to the superior portion of the lateral pterygoid muscle. It is important to note that spasm of this muscle frequently occurs in chronic disc displacement cases. By injecting a prolotherapy solution into this area, we can effectively strengthen the tendinous attachment of this muscle to the disc. To locate this target area, we began by palpating the slight depression that could be felt anterior to the condyle when the mouth is closed. Marking this point is essential before injecting into the posterior aspect of the joint, as it can become challenging to palpate the depression after the posterior joint recess has been treated. For the injection procedure, we removed the bite block and gently asked the patient to close his or her mouth. This served to bring the condyle back into the fossa, making the injection easier. We inserted the needle at the marked point, directing the tip medially and slightly anteriorly, using the entire 1-inch length of the needle. After aspirating, we proceeded to inject an additional 1 ml of prolotherapy solution into this area. This approach targets the problem effectively and empowers the patient on his or her journey toward recovery.

INJECTION PROTOCOL:

The recommended protocol involves administering injections on 3 occasions: during the first, third, and sixth months. This structured approach allows for 3 injection appointments over 12 weeks. During each appointment, healthcare providers assessed the joints for any signs of pain or noise, and evaluated the affected muscles for discomfort. Additionally, measurements of jaw motion were taken, and inter-incisal distance was recorded to monitor progress effectively.

POST-INJECTION ADVICE:

Patients were advised to ingest a semisolid diet for at least 3 days, until the posterior occlusion was re-established; rubbing or scratching the anaesthetized zone was to be avoided, eye drops could be used if the patient complained of ptosis until the eyes become normalized. Patients were also advised not to use any anti-inflammatory agents unless there was pain in the joint region.

PATIENT DISCHARGE PROTOCOL:

The pulse was recorded as an indication of the patient’s readiness for discharge, and any adverse reactions were noted. Later on, the injection sites were rubbed with alcohol, to erase the washable ink with which the patients were temporarily tattooed, and each patient was discharged with detailed recommendations for the care of the joint at home until the subsequent follow-up visits (first, third, and sixth months). Post-injection complications following prolotherapy were explained to the patient, and it was explained that such complications would likely result from faulty injection technique rather than from the proliferant solutions. For each follow-up visit, any presence of pain and noises experienced during joint manipulation, and even slight relaxation of the mouth opening was noticed and recorded properly. An additional questionnaire based on the symptoms of the TMD was included in the VAS scale so as to assess the efficiency of the prolotherapy treatment method. If no positive effect was gained for the patient or if their condition worsened, the patient was considered for palliative treatment with analgesics. The possibility of subsequent alternate procedures, such as physiotherapy and prostheses, was explained.

STATISTICAL ANALYSIS:

All statistical analyses were meticulously conducted using SPSS for Windows version 10, a robust software renowned for its analytical capabilities. A P value of less than 0.05 was firmly established as the threshold for statistical significance, providing a reliable standard for interpreting results. The findings were expressed as the mean accompanied by the standard deviation, showing the data’s central tendency and variability. To compare symptom variables between different groups, we adeptly utilized the Chi-square test alongside individual t-tests, ensuring a comprehensive approach to data comparison. Changes in parameters were calculated relative to the baseline data, allowing us to capture the effect of interventions over time. Through rigorous statistical methods, we assessed critical variables, including levels of pain, occurrences of clicking, and the range of mouth opening, thereby enriching our understanding of the studied conditions.

Results

The study confidently included 25 subjects at baseline, comprising 12 women (48%) and 13 men (52%). The participants had a mean age range from 30 to 32 years, with a well-defined age span of 25 to 56 years. This thoughtfully selected cohort provided a solid foundation for a thorough investigation of the variables under examination. Eighteen subjects, including male and female subjects (72%) opted out of the study due to apprehension and anxiety stemming from concerns about the prolotherapy procedure. Three of the male subjects and 5 of the female subjects (32%) had been suffering from symptoms of TMD for more than 2 years and were taking a multiple drug regimen to control symptoms, and were released with surgery as their only option as treatment modality. Ten male subjects and 7 female subjects (68%) had been suffering from TMD symptoms for less than 1 year and were using only 1 analgesic for pain reduction. The final study sample consisted of 7 patients; 5 men and 2 women (28%) (Table 1).

The most observed signs were preauricular pain and restricted mouth opening in 16 patients (64%), tenderness of the muscles of mastication in 11 patients (36%), crepitus over the joint surface in 8 patients (32%), and intra-auricular pain complaints in 10 patients (40%) (Figure 3). Significant differences were observed between symptom variables in patients who opted for the prolotherapy procedure vs those who did not (Table 2). Among the total of 25 patients initially considered, of which 7 become study subjects, symptom variables like restricted mouth opening and pre-auricular tenderness were observed in 16 subjects (64%) and the COR was 0.3, which is acceptable. Pain in the muscles of mastication and intra-auricular tenderness were observed in 21 (11 and 10) subjects and COR was between 1.31 and 1.71, which is an acceptable range. Clicking and popping were observed in 13 subjects (52%) with COR at 1.16, which is acceptable. Symptom variables like deviation-jerks and crepitus were in an unacceptable range (1.48–1.16). The P-value of 4.76 and COR range from 0.49 to 1.4 indicate an observable though not significant difference denoting disparity between symptom variables for subjects who opted in to the procedure and symptom variables for those who opted out from the study (which was probably due to fear, anxiety, and apprehension among them towards the procedure) (Table 2). A decrease in the individual pain score in this study showed a significant decline from the third month to the end of the sixth month. No change in score in the first month was observed (Figure 4). Refai et al [14] reported significant improvements in maximum mouth opening after 4 sessions at 6-week intervals in the 10% dextrose prolotherapy group, while the placebo group showed no change. Our study showed no significant difference in mouth opening at baseline, remaining stable at 27.68 cm by the end of the first month of treatment. The maximum mouth opening measured by the end of the third month was 29.71 mm, and by the end of the sixth month, it was 34.98 mm, with an average mean of 30.01 mm and a confidence interval ranging from 27.6–32.4 mm by the end of the sixth month of therapy, with a statistically non-significant (but almost significant) P-value of 0.058 (Table 3, Figure 5). Crepitus and pre-auricular pain scores showed significant differences by the end of the sixth month of therapy; the average VAS score at the start of therapy was 7 and by the end of the sixth month it was 1.85, with a confidence interval ranging between 1.38–3.55 and a P-value of 0.04 which at P<0.05 was statistically significant (Table 4, Figure 4). Tenderness in the muscles of mastication showed a significant difference pre- vs post-prolotherapy, with average scores ranging from 7.9 at the start of therapy to 1.9 by the end of the sixth month of treatment, with a range of 1.3–2.5 at 95% CI and a P-value 0.04, which is statistically significant (Table 5, Figure 5). In our study, the only notable adverse effects were mild paresthesia at the zygomatic arch and pre-auricular regions in 3 patients, resolving within a month with vitamin B complex. One patient had a transient eyelid spasm, which recovered after a few weeks. No other complications were observed during treatment and follow-up. Crepitus and mouth opening improved, and the COR between pain score and mouth opening before the start of therapy and at the end of the sixth month ranged from 0.11 to 5.2 with a mean score of 2.18 and confidence interval ranging between 1.26 to 5.6, with a P-value of 0.05, which is bordering on significant (Table 6, Figure 5).

Discussion

The authors would like to suggest that prolotherapy will facilitate reduction of pre-auricular pain. One of the treatment modalities for temporo-mandibular joint disorders includes prolotherapy in and around joint tissues and in muscles of mastication [6–8]. In the present study, emphasis was given to the prolotherapy approach employed for the reduction of symptoms. Prolotherapy has been described as a method to manage painful and unstable TMJ injuries due to its effectiveness in the mandibular area, as early as 1937 [9]. Prolotherapy agents are injected into a ligament to induce inflammation in the area of the ligament and this stimulates synthesis of new collagen. After inflammation starts, granulocytes and macrophages are pulled towards the site of the injection and are joined by fibroblasts, which lay new collagen. The new collagen fabric that is formed in the injected region contracts and increases the tensile strength of the ligament, thereby minimizing the looseness [10–12]. A variety of proliferant irritants have been proposed for prolotherapy treatment of hyper-mobile joints [15]. In our study, we specifically selected dextrose as the proliferant due to its prominence in clinical practice, being the most widely utilized agent for this purpose. Dextrose stands out for its accessibility and cost-effectiveness, making it a preferred choice when compared with other proliferants. Moreover, it boasts an excellent safety profile, which further supports its use in therapeutic applications. Research has shown that different concentrations of dextrose, ranging from 10% to 50%, are effective as prolotherapy agents for managing TMJ hypermobility [14–18]. We opted for a 12.5% dextrose solution because of its potent inflammatory capacity, which is critical for stimulating the healing process. To enhance patient comfort during the dextrose injections, we incorporated local anesthetics, namely lignocaine hydrochloride and bupivacaine. These agents effectively mitigate the discomfort associated with the injections without obstructing the inflammatory effects necessary for therapeutic outcomes. Additionally, acetaminophen was prescribed to manage postoperative pain, ensuring comprehensive relief for the patients. Typically, prolotherapy injections are administered in 3 to 5 sessions to maximize therapeutic benefits [19,20]. In our study, we meticulously scheduled dextrose injections across 3 sessions, each spaced 1 month apart over 6 months. Variations in injection sites, the number of sessions, dextrose concentrations, follow-up duration, and the characteristics of the study subjects might account for the differing outcomes observed when comparing our findings to those of previous studies that also employed dextrose prolotherapy for TMJ hypermobility [14,19,20]. In various studies, injection sites have included key anatomical structures such as the superior and inferior joint capsule attachments, the masseter muscle, the anterior and posterior disc attachments, the lateral pterygoid muscle attachment, and the superior joint space [2,14,20]. In contrast, our study specifically focused on administering injections at the posterior disc attachment and the superior joint space for all participants, targeting these critical locations for optimal therapeutic impact.

The present study successfully established a first-needle success rate of 91.3% with a solution of 0.75 ml of 12% dextrose, 0.75 ml of sterile water, and 1.5 ml of 2% lidocaine, a solution that has been described in several studies in the literature [4,8]. A single intra-articular injection technique was administered on pericapsular tissue, and mild pain during injection was effectively managed with the 2% lidocaine that was added to the dextrose. In our study, no patient complained of post-injection pain at the 6-week follow-up, but a few of them complained of mild post-injection pain during the second scheduled injection appointment after the first month. No patient suffered any form of permanent damage to his or her facial nerve in our study. Even though there was no significant increase in mouth opening after 1 month of therapy, this did not restrict functional activities such as mastication and speech; there was an average increase within a significant range after 4 weeks post-therapy. In the current research, all 7 subjects who underwent prolotherapy showed results that indicated substantial therapeutic effectiveness of prolotherapy. This success rate may be due to a smaller number of subjects involved in our study with less severe symptoms when compared with other studies in the literature. Ineffectiveness of therapy for controlling pain was demonstrated by firmly palpating the preauricular areas. Ineffectiveness was also indicated by signs and symptoms that failed to resolve even after 5 months of intraoral orthosis, home exercises, and a restricted diet. Similar results were evident in several studies mentioned in the literature [2–9]. Non-surgical care should be viewed as a kind of basic or initial treatment, which proved to be virtually comparable to the baseline. Schultz reported that the palpation pain in 39 joints (71%) was at a rate of 1 or less on a 5-point scale, and 23 joints (42%) remained painless [4,10]. In the current study, the tenderness score was heightened at baseline, but demonstrated an escalating improvement throughout the study. Patients expressed slight discomfort after the first administration of injections, albeit pain relief was noted, before the second administration. The subsequent appointments were more successful. They comprised patients with less joint noise and a decrease in their symptoms, which did not become worse after treatment. This suggests that some aspects of the healing process may take place over the course of at least 12 weeks. There was no report of bruising among the patients tested in our study and only 1 patient experienced paresis of the lower eyelid, which only lasted about 90 minutes. In the current study, the pain due to TMJ was significantly reduced by the end of the first month. At the 12-week follow-up visit in a study by Schultz, the percentage of patients treated who experienced a change in clicking and pain score was 78%, with no change in 22%. In our study, a noticeable change was observed in pain, crepitus, and restricted mouth opening by the end of the 4th week, in contrast to other studies, which observed noticeable changes after only 6 weeks of treatment. Thus, based on the evidence evaluated, we infer that prolotherapy would be more effective as a treatment for TMD in less severe cases. Further studies exploring this modality in different patient groups are needed, as are their symptoms and their overall severity of TMD [11]. The contraindications for prolotherapy include the following: an allergy causing reaction to the components of the prolotherapy solution; an active infection such as a local abscess, septic arthritis, or cellulitis in the area that is about to be injected; a healing disorder; states of abnormal coagulation and bleeding such as hemophilia; presence of malignant tissues in the area that is targeted for the therapy; and existence of parafunctional orofacial activities [12,13]. Our study did not demonstrate any of these reactions. Research in the future may help in synthesizing other chemotactic and polypeptide growth factors by using techniques in genetic engineering. After that, clinicians can guide the fibroblasts right to a damaged ligament and also spare the individual discomforts that arise from inflammation.

Conclusions

The use of regenerative injection therapies is expected to grow significantly as research advances and the demand for prolotherapy, platelet-rich plasma, and stem cell therapies increases. These therapies are increasingly recognized for their potential to effectively address various types of pain. Prolotherapy with 12% dextrose, administered as a single injection or in multiple doses, should be considered as an adjunct treatment for chronic recurrent dislocations and subluxations of the mandible. While surgical intervention may be necessary in specific cases, our study only followed patients for an average of 6 months; longer follow-up is needed to validate this treatment fully. The absence of imaging results before and after injection also represents a significant limitation. Though prolotherapy may not offer permanent results, it provides a more sustainable healing method compared with palliation. It may not be suitable for patients on long-term narcotic treatment or those requiring surgery. In summary, administering the prolotherapy procedure was effective in reducing TMD complaints like pain, crepitus, and restricted mouth opening. Therefore, it could be viewed in the future as a safe and effective option for TMJ pain management.