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ANESTHESIA/FACIAL PAIN
J Oral Maxillofac Surg69:2962-2970, 2011
The Efficacy of Dextrose Prolotherapy forTemporomandibular Joint Hypermobility:A Preliminary Prospective, Randomized,
Double-Blind, Placebo-ControlledClinical Trial
Hamida Refai, BDS, MSc, PhD,* Obada Altahhan, BDS,† and
Rehab Elsharkawy, BDS, MSc, PhD‡
Purpose: The aim of this study was to assess the efficacy of dextrose prolotherapy for the treatment oftemporomandibular joint (TMJ) hypermobility.
Patients and Methods: A prospective, randomized, double-blind clinical study using a placebo controlwas carried out. Twelve patients with painful subluxation or dislocation of the TMJ were randomlyassigned to 1 of 2 equal-sized groups. Patients in the active group received 4 injections of dextrosesolution (2 mL of 10% dextrose and 1 mL of 2% mepivacaine) for each TMJ, each 6 weeks apart, whereaspatients in the placebo group received injections of placebo solution (2 mL of saline solution and 1 mLof 2% mepivacaine) on the same schedule. A verbal scale expressing TMJ pain on palpation, maximalmouth opening (MMO), clicking sound, and frequency of luxations (number of locking episodes permonth) were assessed at each injection appointment just before the injection procedure and 3 monthsafter the last injection. The collected data were then statistically analyzed.
Results: By the end of the study, each group showed significant improvement in TMJ pain on palpationand number of locking episodes and insignificant improvement in clicking sound. With the exception ofthe MMO, there were no statistically significant differences throughout the study intervals between theactive and placebo groups. The active group showed a significant reduction in MMO at the 12th weekpostoperatively. Differences compared with mean baseline value remained significant at the end of thefollow-up period. On the other hand, the placebo group showed an insignificant difference in MMOthroughout the study periods. For the last 2 intervals, the placebo group showed statistically significantlyhigher mean MMO values than the active group. By the end of the 12th postoperative week, thepercentages of decrease in MMO were significantly greater in the active group.
Conclusion: Prolotherapy with 10% dextrose appears promising for the treatment of symptomatic TMJhypermobility, as evidenced by the therapeutic benefits, simplicity, safety, patients’ acceptance of theinjection technique, and lack of significant side effects. However, continued research into prolotherapy’seffectiveness in patient populations with large sample sizes and long-term follow-up is needed.© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:2962-2970, 20110
d
Received from the Department of Oral and Maxillofacial Surgery,
Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
*Professor.
†Researcher.
‡Lecturer.
Address correspondence and reprint requests to Dr Refai: De-
partment of Oral and Maxillofacial Surgery, Faculty of Oral and
2962
Dental Medicine, Cairo University, Cairo, Egypt; e-mail: prof
© 2011 American Association of Oral and Maxillofacial Surgeons
278-2391/11/6912-0011$36.00/0
oi:10.1016/j.joms.2011.02.128
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REFAI, ALTAHHAN, AND ELSHARKAWY 2963
Hypermobility of the temporomandibular joint (TMJ)joint aroused the interest of oral and maxillofacialsurgeons long ago, and surgical and conservativetreatment continues to play a limited but useful rolein the management of patients with this condition.“Hypermobility” refers to hypertranslation of themandibular condyle anterior and superior to the ar-ticular eminence during mouth opening. Thus thephysiologic maximal translation of the mandibularcondyle is defined as the point where the greatestconvexity of the condyle meets the greatest convexityof the articular eminence.1
TMJ hypermobility could be classified according toits reduction as subluxation or dislocation. TMJ sub-luxation is a condition where the condyle translatesanterior to its normal range and the patient exhibits amomentary inability to close the mouth from a max-imally open position (temporary locking sensation)that either abates spontaneously or can be reducedwith manual self-manipulation.2,3 When it is asymp-tomatic, it should be viewed as a variant of normal.4
TMJ dislocation (luxation) occurs when the condylemoves outside the glenoid fossa, locking anteriorly tothe articular eminence, where it cannot be self-re-duced. This locking action is maintained by spasms ofmasticatory muscles.5 It can occur as acute or recur-ent dislocation.
A variety of therapeutic approaches designed toimit the forward excursion of the condylar head haveeen applied, such as intracapsular injection of scle-osing solutions,6 lateral pterygoid myotomy,7 and
scarification of the temporalis tendon.8 Creating amechanical obstacle in the condylar path has alsobeen achieved by positioning the disc anterior to thecondyle, by down-fracturing of the zygomatic archand fixation medial to the eminence, or by the inser-tion of implants into the eminence3,9-11 and bonerafting augmentation12 or application of a well-de-igned alloplastic impediment with Vitallium mesh oritanium plates.9 Removal of the mechanical obstacles
in the condylar path occurs, thereby permitting freemovement of the condyle; 1 such procedure is emi-nectomy, which has been used with satisfactory re-sults and efficacy.3,13
Prolotherapy is also known as “regenerative injec-tion therapy” and “growth factor stimulation injectiontherapy.” It has traditionally been thought of as amethod of strengthening lax ligaments by injectingvarious types of sclerosing or proliferant solutions.Various agents have been used with prolotherapyincluding psyllium seed oil,14 dextrose,15,16 and com-binations of dextrose, glycerin, and phenol.17 Pro-lotherapy (growth factor or growth factor stimulationinjection) raises growth factor levels or increasesgrowth factor effectiveness to promote tissue repair
or growth. Prolotherapy may use inflammatory ornoninflammatory mechanisms.18 The most commonolutions used for prolotherapy create a brief inflam-atory response. Temporary cellular stress causes a
elease of cytokines and increased growth factor ac-ivity with migration of macrophages and then multi-lication of repair cells specific to the tissue. Unlikeepair after an injury, disruption of the architecture ofhe tissue does not occur from injury, and new cellsnd matrix can be deposited in an organized fashion,ith maturation of new tissue for 6 to 8 weeks.19
Despite the fact that prolotherapy as a treatmentfor TMJ hypermobility was first reported by Schultz14
in 1937, the published studies on the efficacy of TMJprolotherapy lack comparison to placebo.14,16 Thus aignificant portion of the response to drugs (oftenuoted as 40%) can be attributed to placebo.20 There-ore it was the purpose of this work to assess thefficacy of dextrose prolotherapy for treatment ofMJ hypermobility based on a prospective, random-
zed, double-blind, placebo-controlled study.
Patients and Methods
STUDY DESIGN
The study was approved by the Research EthicsCommittee at the Faculty of Oral and Dental Medi-cine, Cairo University, Cairo, Egypt. The study wasperformed in a randomized, double-blind, placebo-controlled manner. Twelve patients with bilateralTMJ symptomatic hypermobility were included in thisstudy. They were interviewed and clinically examinedat the outpatient clinic of the Oral and MaxillofacialSurgery Department, Faculty of Oral and Dental Med-icine, Cairo University. Their ages ranged from 19 to38 years, with a mean of 26.4 years. There were 2men and 10 women. Table 1 shows the demographicdata of the selected patients.
The criteria for inclusion in this study were thepresence of a diagnosis of painful subluxation or dis-location of the TMJ in the absence of medical condi-tions that may significantly interfere with healing andwillingness to follow instructions. The diagnosis ofTMJ hypermobility was based on the patient’s historyand the clinical recognition of an excessive abnormalexcursion of the condyle that slides over the articulareminence, catches briefly anterior to the eminence,and then returns to the fossa by self-reduction ormedical assistance. The radiographic observation ofanterior positioning of the mandibular condyle to thearticular eminence on wide opening confirmed theclinical diagnosis (Fig 1).
The study program was explained to the patients,who gave informed consent to undergo treatment.After agreeing to be enrolled in this study, each pa-
tient was randomly assigned to 1 of 2 equal-sized
J Hyper
2964 DEXTROSE PROLOTHERAPY FOR TMJ HYPERMOBILITY
groups. Patients in the active group received 4 injec-tions of dextrose solution (2 mL of 10% dextrose and1 mL of 2% mepivacaine), each 6 weeks apart,whereas patients in the placebo group received injec-tions of placebo solution (2 mL of saline solution and1 mL of 2% mepivacaine) on the same schedule.
We used 3-mL injection syringes with 30-gauge nee-dles. The dextrose solution (2 mL of 10% dextrose and1 mL of 2% mepivacaine) and the placebo solution (2mL of saline solution and 1 mL of 2% mepivacaine)were prepared by the same colleague so that the loadedsyringes resembled each other in size and color. Localanesthetic was included in the injected solution for
Table 1. DEMOGRAPHIC DATA OF SELECTED PATIENTS
Group Patient No. Age (yr) Gender
Active 1 24 F Clicking on righleft side
2 24 F Locking on yaw3 21 F Clicking and loc4 23 F Pain and clickin5 19 F Facial pain6 27 F Pain and clickin
Placebo 1 28 M Pain2 27 F Locking on open3 38 F Locking on open4 21 F Clicking during5 34 F TMJ pain6 31 M Pain on left side
Refai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TM
FIGURE 1. Right and left TMJ tomograms in closed and open poswide opening.
Refai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TMJ Hyper
postinjection comfort. The solutions were identical incolor. Only that colleague had access to the treatmentcodes, and we were not aware of the randomizationcodes until the study was completed.
PROLOTHERAPY TECHNIQUE
The skin surface of the preauricular area was disin-fected with Betadine surgical scrub solution (PurdueProducts, Stamford, CT). The anatomic landmarkswere located by asking the patient to open widely toallow drawing of the articular fossa and then to closelightly on the posterior teeth to draw the condyle
ef Complaint Reduction of Open Lock
on opening and severe pain on Self-reduction
Assisted reductionn opening Self-reductionawing Self-reduction
Self-reductiong eating Self-reduction
Self-reductionSelf-reductionSelf-reductionAssisted reductionAssisted reductionSelf-reduction
mobility. J Oral Maxillofac Surg 2011.
owing hypertranslation of condylar head anterior to eminence on
Chi
t side
ingking og on y
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inging
eating
ition sh
mobility. J Oral Maxillofac Surg 2011.
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REFAI, ALTAHHAN, AND ELSHARKAWY 2965
within the glenoid fossa. Typically, each joint had 3injection sites:
● In the superior capsular attachment on the lateralmargin of the glenoid fossa, 0.8 mL of the solu-tion was slowly injected (Fig 2).
● In the inferior capsular attachment on the con-dylar neck, 0.8 mL of the coded solution wasinjected (Fig 3). The needle was then directedsuperficial to the TMJ capsule, and 0.4 mL of thesolution was deposited.
FIGURE 2. Injection at superior capsular attachment.
efai, Altahhan, and Elsharkawy. Dextrose Prolotherapy forMJ Hypermobility. J Oral Maxillofac Surg 2011.
FIGURE 3. Injection at inferior capsular attachment.
Refai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for
TMJ Hypermobility. J Oral Maxillofac Surg 2011.● The superior joint space was approached withthe needle directed superiorly and anteriorly to-ward the apex of the fossa, where contact wasmade with the periosteum. A spacer measuringabout 1 cm was placed between the anteriorteeth to allow access to the superior joint space,as well as to stabilize and fix the condylar posi-tion on the operated side during injection. Often,slight momentary resistance was felt as the nee-dle penetrated into the joint capsule. One milli-liter of the coded solution was slowly injectedinto the superior joint space (Fig 4).
Postoperatively, the patients were asked to reducer stop other pain medications and therapies that theyere using as much as the pain would allow. Theyere also instructed to ingest only a soft diet for 2eeks to decrease the effort of the TMJ.TMJ pain as expressed by a verbal scale noting no,ild, moderate, or severe pain on palpation; maximalouth opening (MMO) as measured by the distance
n centimeters between the incisal edges of the uppernd lower incisors; clicking sound; and frequency ofuxations (number of locking episodes per month)
ere assessed by the same blinded operator at eachnjection appointment just before the injection pro-edure and 3 months after the last injection.
STATISTICAL ANALYSIS
Quantitative data are presented as means and stand-ard deviations. The Student t test was used to comparemean mouth opening values between the 2 groups. Thepaired t test was used to study the changes with time
FIGURE 4. Injection into superior joint space.
efai, Altahhan, and Elsharkawy. Dextrose Prolotherapy forMJ Hypermobility. J Oral Maxillofac Surg 2011.
within each group. The Mann-Whitney U test was used
o
csp
R J Hyper
R
2966 DEXTROSE PROLOTHERAPY FOR TMJ HYPERMOBILITY
for comparison between numbers of locking episodes inthe 2 groups. It was also used to compare between thepercentage changes in mean mouth opening and num-bers of locking episodes. The percentage changes inthese parameters were calculated as follows: (Postoper-ative parameter – Preoperative parameter � 100)/Pre-perative parameter.The Wilcoxon signed rank test was used to study the
hanges with time in mean numbers of locking epi-odes. Qualitative data are presented as frequencies andercentages. The �2 test was used for comparisons be-
tween the 2 groups. The significance level was set at P� .05. Statistical analysis was performed with SPSS soft-ware for Windows, version 16.0 (SPSS, Chicago, IL).
0
20
40
60
80
100
No
pain
Mild
Mod
erat
e
Sev
ere
No
pain
Mild
1st visit 6th we
Per
cent
age
(%)
Active gro
FIGURE 5. Percentage changes in pain intensity
efai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TM
0
1
2
3
4
5
6
1st visit 6th week
Mea
n fre
quen
cy o
f lux
atio
ns
Active
FIGURE 6. Changes with time in mea
efai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TMJ Hyper
Results
All patients tolerated the TMJ injection well with-out serious complications. Discomfort after injec-tion did not appear to vary between groups. Threepatients in each group had mild pain after injection.After the first injection, 4 patients in the activegroup and 2 in the placebo group complained of anitching sensation at the site of injection. This sen-sation disappeared spontaneously after a few dayswithout any treatment. Some patients had transientfacial palsy due to the anesthetic inclusion in theinjected solution. The anesthetic effect diminishedwithin 60 to 90 minutes postoperatively.
Sev
ere
No
pain
Mild
Mod
erat
e
No
pain
Mild
No
pain
Mild
12th week 18th week 3 months
Placebo group
t side in the 2 groups through all study intervals.
mobility. J Oral Maxillofac Surg 2011.
week 18th week 3 months after last injection
Placebo group
uency of luxations within each group.
Mod
erat
e
ek
up
on lef
12th
group
n freq
mobility. J Oral Maxillofac Surg 2011.
pcrbts
J Hyper
R
REFAI, ALTAHHAN, AND ELSHARKAWY 2967
TMJ PAIN ON PALPATION
Preoperatively, TMJ pain on palpation was anobvious sign in all patients, but it was the chiefcomplaint in 4 patients in the active group and 3 inthe placebo group. Figure 5 shows percentage im-
rovements in pain. Both groups showed a statisti-ally significant decrease in pain intensity on theight and left sides through all periods. Comparisonetween the 2 groups showed an insignificant sta-istical difference in pain intensity throughout thetudy intervals.
FREQUENCY OF LUXATIONS
Common to all the patients was a history of openlock. The mean frequency of luxations significantlydecreased in the active group at the sixth postopera-tive week and in the placebo group at the 12th post-operative week. By the end of the study, none of thepatients in the active group had locking. Comparisonbetween the 2 groups with respect to both means andchange percentages in the frequency of luxations
Table 2. MEANS, STANDARD DEVIATIONS, AND RESULCHANGES WITH TIME IN FREQUENCY OF LUXATIONS W
Period
Active
Mean Difference
First visit to sixth week �2Sixth week to 12th week �0.212th week to 18th week 0.218th week to 3 mo after injection �0.2First visit to 12th week �2.2First visit to 18th week �2First visit to 3 mo after injection �2.2
*Significant at P � .05.
Refai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TM
0
1
2
3
4
5
6
1st visit 6th week
Mea
n M
MO
(cm
)
FIGURE 7. Changes with tim
efai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TMJ Hyper
showed insignificant differences throughout thestudy intervals (Fig 6, Table 2).
MAXIMAL MOUTH OPENING
Figure 7 and Table 3 show assessments of MMOfor the study intervals. The active group showed asignificant reduction in MMO at the 12th postoper-ative week. Differences compared with mean base-line values remained significant at the end of thefollow-up period. On the other hand, the placebogroup showed an insignificant difference in MMOthroughout the study periods. Comparison be-tween the 2 groups with respect to both means andchange percentages in MMO at the 18th postoper-ative week and 3 months after the last injectionshowed that the placebo group had a statisticallysignificantly higher mean MMO than the activegroup. By the end of the 12th postoperative week,the mean differences compared with baselineshowed that the percentages of decrease in MMO
WILCOXON SIGNED RANK TEST FOR ANALYSIS OFBOTH GROUPS
Placebo Group
P Value Mean Difference SD P Value
.042* �2.3 2.7 .102
.317 �0.7 0.8 .102
.317 �0.7 1.6 .317
.317 0.3 0.8 .317
.026* �3 3.1 .048*
.042* �3.7 2.4 .027*
.026* �3.3 2.7 .027*
mobility. J Oral Maxillofac Surg 2011.
eek 18th week 3 months after last injection
e groupebo group
an MMO within each group.
TS OFITHIN
Group
SD
1.80.40.40.41.61.81.6
12th w
ActivPlac
e in me
mobility. J Oral Maxillofac Surg 2011.
idwm
tiatpaditf1s
wptlctmt
S113
*
J Hyper
2968 DEXTROSE PROLOTHERAPY FOR TMJ HYPERMOBILITY
were significantly greater in the active group thanin the placebo group (Fig 8).
CLICKING SOUND
There were insignificant changes in prevalence ofclicking within each group and between the groupsthroughout the study intervals (Fig 9).
Discussion
It was the purpose of this work to assess the effi-cacy of dextrose prolotherapy for the treatment ofTMJ hypermobility based on a prospective, random-ized, double-blind, placebo-controlled study. Dex-trose was selected as the main ingredient in the activesolution because it is the most common proliferantused in prolotherapy, is readily available, is inexpen-sive when compared with other proliferants, and hasa high safety profile.16 Dextrose prolotherapy may usenflammatory or noninflammatory mechanisms. Aextrose concentration greater than 10% partiallyorks by inflammation, as do phenol and sodiumorrhuate.15
It is not fully understood how elevation of glucoselevels raises growth factor levels. A wide variety of
Table 3. MEANS, STANDARD DEVIATIONS, AND RESULIN 2 GROUPS
Period
Active Group
Mean (cm)
First visit 5.03ixth week 4.722th week 4.538th week 4.35mo after last injection 4.33
Significant at P � .05.
Refai, Altahhan, and Elsharkawy. Dextrose Prolotherapy for TM
-15
-10
-5
0
5
1st visit – 6th 6th week – 12th 12th week – 18th week – 3 1st
Mea
n %
cha
nge
Active group Placeb
week week 18th week m after injection week
dextrose concentrations have been used with varyingdegrees of success. Hakala and Ledermann21 believedhat the precise concentration of dextrose is not crit-cal so long as it is strongly hypertonic and causesdequate cell wall lysis to attract fibroblasts and beginhe regenerative process. Clinical improvement ofatients with TMJ pain and dysfunction was achievedfter TMJ prolotherapy with 12.5%, 15%, and 25%extrose injections.15,16,21 The results of our study
ndicate that tightening of loose ligaments by injec-ion of a subinflammatory level of dextrose (10%) iseasible. This complements studies on the effects of0% dextrose on large and small joints that showed atatistically significant benefit as well.18,22,23 In our
study a series of 4 injections, each 6 weeks apart, wasperformed. This series of injections was based on thefinding of Schultz14 that a series of 3 to 5 injections
as required to often permanently stop the clicking,ain, and hypermobility of the TMJ joint. The injec-ion was performed every 6 weeks because mostigaments heal over a 6-week period.19 In contrast, ahart review of patients with TMJ pain and dysfunc-ion treated with a series of 4 prolotherapy appoint-ents over a period of 12 weeks showed significant
herapeutic benefit.21
STUDENT t TEST FOR COMPARISON BETWEEN MMO
Placebo Group
P ValueMean (cm) SD
4.97 0.49 .8084.93 0.54 .5034.88 0.52 .2624.93 0.51 .043*4.97 0.48 .039*
mobility. J Oral Maxillofac Surg 2011.
2th 1st visit – 18th 1st visit – 3 m
p
FIGURE 8. Percentage changesin MMO in the 2 groupsthroughout study periods.
Refai, Altahhan, and Elsharkawy.Dextrose Prolotherapy for TMJ Hy-permobility. J Oral Maxillofac Surg2011.
TS OF
SD
0.430.540.500.350.45
visit – 1
o grou
week after injection
iososasoacd
fotlpcaititm
ttlsl
pi
2p
6th w
REFAI, ALTAHHAN, AND ELSHARKAWY 2969
In our study all the evaluated parameters were notsignificantly different between groups preoperatively,which is important as part of the statistical protocol.In addition, the establishment of specific inclusioncriteria is important when judging results. With theexception of MMO, there were no statistically signif-icant differences throughout the study intervals be-tween the active and placebo groups. Both groupsmproved significantly in terms of pain and numberf locking episodes. However, the placebo grouphowed an insignificant difference in MMO through-ut the study periods. The mechanism of convertingymptomatic hypermobility in the placebo group intolmost asymptomatic hypermobility is not fully under-tood. However, it could be explained based on onef the proposed components of prolotherapy’s mech-nisms of action, that the mechanical transection ofells and matrix induced by the needle causes cellularamage, stimulating an inflammatory cascade.24
The active group in this study showed a statisticallysignificant decrease in pain intensity through all thestudy periods, although the results obtained were notsignificantly superior to those recorded in the placebogroup. Somewhat different findings were reported byReeves and Hassanein.18,22 On evaluation of the ef-ects of dextrose prolotherapy on knee and fingersteoarthritis, they found that pain improvement inhe dextrose-treated joints (10% dextrose and 0.075%idocaine in bacteriostatic water) was statistically su-erior to that in placebo-treated joints (0.075% lido-aine in bacteriostatic water). They attributed thepparent benefit of dextrose injection over placebonjection to the beneficial effect of hypertonicity ofhe dextrose solution. In our study the great painmprovement in the placebo group could not be at-ributed to placebo analgesia. The injection technique
0
20
40
60
80
100
Clic
king N
o1st visit
Per
cent
age
(%)
FIGURE 9. Prevalence of click-ing within each group.
Refai, Altahhan, and Elsharkawy.Dextrose Prolotherapy for TMJ Hy-permobility. J Oral Maxillofac Surg2011.
ay play a role in this context by inducing inflamma- n
ion with the subsequent creation of new collagenhat stabilizes the joint. Thus it was thought thatigamentous laxity contributes to joint instability withubsequent activation of nociceptive fibers withinigaments and tendons.25 It is also possible that therewas some therapeutic effect from inclusion of anes-thetic in the solution as well, and if so, this mayexplain some benefit in both groups.
In this study the effect on MMO was the moststriking difference between the active and placebogroups. The mean MMO values showed a statisticallysignificant decrease in the active group and an insig-nificant difference in the placebo group throughoutthe study periods. Moreover, the active group showeda significant decrease in mean MMO and significantlyhigher percentages of decrease in MMO comparedwith the placebo group. These findings could beexplained based on the histologic findings of Oh etal26 examining dextrose prolotherapy in the rabbitcarpal tunnel, where 1 forepaw was randomly in-jected with 10% dextrose solution and the contralat-eral paw was injected with a similar amount of 0.9%saline solution as a control. These findings showedthat whereas the saline solution side showed minimalchanges at any time period, the dextrose side showedprogressive noninflammatory subsynovial connectivetissue fibrosis, with vascular proliferation and thick-ening of collagen bundles. Similar histologic findingswere also reported by Yoshii et al.27 The observedtherapeutic benefits of prolotherapy in this study sup-port the concept of Hakala and Ledermann21 that this
rocess stabilizes the joint, helps prevent dislocationn a hypermobile joint, and relieves pain.
The sample size and the short-term evaluation arelimitations of our study. However, this study is a
reliminary investigation, and it is better to test a
No
Clic
king N
o
Clic
king N
o
Clic
king N
o
eek 12th week 18th week 3 months
Active group Placebo group
Clic
king
ew research hypothesis in a small number of sub-
2970 DEXTROSE PROLOTHERAPY FOR TMJ HYPERMOBILITY
jects first. An expansion and extension of our studywill be undertaken by following up the patients ofthe present study and treatment of further patientswith dextrose prolotherapy to enlarge the samplesize with follow-up of more than 1 year. Long-termradiographic follow-up data from the current studypatients will be helpful to note the effect on thearticular surfaces of the TMJ. Therefore the patientsare being followed up for long-term radiographicfindings. Further studies using a large number ofpatients and providing more data on other factors,such as the concentration of dextrose and series ofinjections, are necessary before final recommenda-tions can be made.
Prolotherapy with 10% dextrose looks promisingfor the treatment of symptomatic TMJ hypermobility,as evidenced by the therapeutic benefits, simplicity,safety, patients’ acceptance of the injection tech-nique, and lack of significant side effects. However,continued research into prolotherapy’s effectivenessin patient populations with large sample sizes andlong-term follow-up is needed.
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15. Reeves KD: Prolotherapy: Basic science, clinical studies, andtechnique, in Lennard TA (ed): Pain Procedures in ClinicalPractice (ed 2). Philadelphia, PA, Hanley and Belfus, 2000, pp172-190
16. Hauser R, Hauser M, Blakemore K: Dextrose prolotherapy andpain of chronic TMJ dysfunction. Practical Pain Management49, 2007
17. Klein RG, Bjorn CE, DeLong B, et al: A randomized doubleblind trial of dextrose-glycerine-phenol injections for chroniclow back pain. J Spinal Disord 6:23, 1993
18. Reeves KD, Hassanein K: Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy forosteoarthritis thumb and finger (DIP, PIP, and trapeziometacar-pal) joints: Evidence of clinical efficacy. J Altern ComplementMed 6:311, 2000
19. Banks A: A rationale for prolotherapy. J Orthop Med (UK)13:54, 1991
20. Jureidini J: Is there a role for placebo analgesia? N Z Med J116:1179, 2003
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