FAQs

BACKGROUND AND DIAGNOSIS

WHAT IS TMD

TMD refers to all disorders related to the temporomandibular joint or TMJ.

WHAT IS THE TMJ, AND IS IT UNIQUE

The TMJ or temporomandibular joint is the joint just in front of the ear that acts as a hinge for the jaw bone or mandible.  As the primary joint involved in both eating and speaking it is the most important single joint in the body.  It is unique in beings the only joint in the body to be composed of fibrocartilage instead of hyaline cartilage.  It also has a unique disk that sits within the joint and is mobile.  Because it is such a complicated joint it is subject to complicated abnormalities.

THE ORIGIN OF THE TMD INSTITUTE

Most TMD patients are treated by dentists with mouth guards.  However, many patients do not respond.  To help these patients, and recognizing that TMD is a joint disorder, Dr. Hatz decided to join forces with internationally renowned Orthopaedic Surgeon Chadwick Prodromos MD – to form the ideal combination of expertise to tackle this problem.  They formed the TMD institute (TMDI) to study and utilize cutting edge yet proven treatments which are described below. 

HOW MANY PEOPLE ARE AFFECTED BY TMD

The National Institute of Dental and Craniofacial Research estimates that about ten million Americans suffer from TMD

WHERE DOES THE PAIN COME FROM IN TMD

The TMJ can produce pain from degeneration of the joint or from damage to the unique disk that exists within the joint.

HOW IS TMD DIAGNOSED

It is diagnosed by a combination of the history, physical exam and, in some cases, imaging studies, especially MRI.

WHAT OTHER PROBLEMS ARE ASSOCIATED WITH TMD

Many patients have pain in the jaw muscle or masseter.  This can result in Trismus, or grinding of the teeth.  Others have frontal headache in the temporalis muscle or in the neck muscles.

TREATMENT

HOW HAS TMD USUALLY BEEN TREATED IN THE PAST

Traditional treatment has utilized various mouth guards or other appliances.  These are usually prescribed by your dentist.   We are interested in treating patients for whom this traditional treatment has failed.  Many studies have shown that these treatments may not be beneficial. 

HOW DO YOU TREAT TMD

We utilize platelet rich plasma and stem cell injections as well Low level laser therapy and Oro-Facial Headache Pain, as described below.

WHY DO YOU HAVE BOTH A DENTIST AND AN ORTHOPAEDIC SURGEON EVALUATING PATIENTS

This is a major strength of our program.  While TMD is traditionally a dental problem, the treatment of joint disorders is usually done by Orthopaedic surgeons.  Our program is unique in combining the expertise of these two disciplines. All patients are seen initially for a consultation by Dr. Marilyn Hatz DDS who will design a customized treatment program.    Many patients will also be evaluated by noted Orthopaedic surgeon, Chadwick Prodromos MD: an international leader in platelet rich plasma (PRP) and stem cell treatment.   His Orthopaedic expertise is also of particular value for the associated head and neck pain that often accompanies TMD.


FAQs - PLATELET RICH PLASMA TREATMENT

What is PRP (Platelet Rich Plasma)?

A small amount of a patient’s blood that has been centrifuged and processed to concentrate platelets, growth factors and anti-inflammatory cytokines from platelets

Uses

What are prp injections used for?

They are designed to help heal the TMJ and to reduce painful inflammation naturally

How many centers offer PRP injections for TMJ disorders

We are one of the only centers in the USA and the world offering PRP for TMJ disorders

Results

What are your success rates using PRP?

At least 80% of affected joint obtain substantial relief of symptoms. The success rate is less in joints that have no significant cartilage remaining

How many treatments are needed?

Often only one, sometimes two or three are usually sufficient to produce meaningful long lasting relief

How long does it take for treatment to work?

Relief may occur within a few days; in some it may take 3 – 4 weeks

How Long Does PRP Injection provide relief?

Usually for at least one year, often much longer

Can PRP injection be repeated?

Yes PRP is good for the health of the joint and can be repeated as often as necessary

Is PRP effective even if you are older?

Yes, in our studies age has not been a factor, even in patients in their ninth decade of life

Risks

Are there risks/complications from PRP injection?

No medical treatment is 100% safe, but we have had no adverse events

No complications have been reported in the literature to our knowledge

You cannot have a reaction to your own tissue, and no other drugs are used

There is a theoretical risk of injection after any injection but we have never seen one and none has ever been reported to our knowledge

Can I be treated with PRP if I am on blood thinners or other medicines?

Yes, patients should maintain all prior medications (except NSAIDs) for PRP or stem cell treatment. Coumadin or other blood thinners are not a problem

Mechanism Of Action

How Does PRP work?

Via growth factors that help your tissue heal (eg transforming growth factor beta, platelet derived growth factor)

Also via anti-inflammatory cytokines (eg interleukin 1 receptor anatagonist) that fight inflammation

A substance called Lubricin that is a natural lubricant for joints has also been recently discovered to be in PRP

Technique

Who does the actual injection in your clinic?

All injections are done by Dr. Prodromos or Dr. Hatz. Although they are certainly qualifieid to do so, we do not have nurses or physician’s assistants performing the injections as is the case at many clinics

Do you use sedation or medications?

None are used, none are needed

Is the injection painful?

There is some discomfort but it is minimal and usually far less than patients expect. Many patients are surprised that the injection has been completed so easily.

Can I come by myself and drive home?

Yes

How long do treatments take?

PRP preparation total treatment time is under one hour

Are Dr. Prodromos and Dr Hatz experienced in regenerative medicine?

Yes, Dr. Prodromos is one of the few board certified Orthopaedic Surgeons who is also board certified in Regenerative Medicine. Dr. Hatz is one of the few practicing Dentists who is also board certified in regenerative medicine

How Does PRP Injection Compare to Injection With Cortisone?

Cortisone has been shown to destroy cartilage cells. It has also been shown to sometimes cause infection. Even when it reduces pain the results usually are short lived.. For all of these reasons we never inject cortisone into the TMJ.

Cost

Is PRP Injection Covered by insurance?

PRP treatments are not covered by insurance. However, our charges are quite modest

FDA

Is PRP injection FDA approved?

Yes, and we perform all procedures in strict accordance with FDA guideline


FAQs - STEM CELL TREATMENT

Definitions

What Are Autologous Mesenchymal Stem Cells?

Partially differentiated stem cells from your body that are active in cartilage, tendon, ligament, and bone

They are NOT fetal or embryonic

Results

What are your success rates using stem cells?

In moderate arthrosis over 80% of patients respond well to these treatments. In bone on bone joints response is less

How many treatments are needed?

One successful treatment will usually last years

How long does it take for treatment to work?

Relief may occur in just a few days but, in some cases, can take several months to show benefit

Autologous Versus Allogeneic

What Do Autologous And Allogeneic Mean?

Autologous means the tissue – stem cells in this case -comes from the patient being treated

Allogeneic means the tissue comes from someone else, or is pooled from a number of other people about which generally nothing is known

Do You Use Autologous or Allogeneic Stem Cells?

We use autologous stem cells in all patients (unless they have active cancer) due to greater efficacy, safety, and lower cost

Are Autologous Mesenchymal Stem Cells More Effective Than Allogeneic?

Yes, your own tissue is always more effective in you than someone else’s

Beware of advertised stem cell treatments, such as amniotic fluid, that are not from you, and do not have real living stem cells in them. In fact, if they did have living cells they would be classified as a “351” tissue which the FDA prohibits

Are There Greater Risks From Allogeneic Tissue?

Yes, there are always greater risks from tissue from others. Improper processing can result in a higher risk of infection and even death

Are Allogeneic Treatments More Expensive Than Autologous?

Yes, allogeneic treatments usually come from pharmaceutical or other companies who will always impose additional costs from preparation and from taking their profit as middlemen. Autologous tissue is prepared directly by us from you with no intermediary to drive up costs.

Are Your Own Autologous Stem Cells Effective Even If You Are Older?

Yes, in our studies age has not been a factor, even in patients in their ninth decade of life

If Autologous Is More Effective, Safer And Less Expensive, Why Are Allogeneic Used By Some?

There are huge potential profits to companies that can produce an “off the shelf” allogeneic product. Therefore companies that distribute them market them heavily to doctors

It is much easier for any doctor to use allogeneic tissue; whereas using your own autologous tissue takes significant technical expertise and an investment of time by the doctor to become experienced in these techniques.

Risks

Are There Any Risks Or Complications From Autologous Mesenchymal Stem Cell Injection?

We have had no complications or adverse events from mesenchymal stem cell injection

Can I be treated with Stem Cell if I am on blood thinners or other medicines?

Yes, patients should maintain all prior medications (except NSAIDs) for stem cell treatment. Coumadin or other blood thinners are not a problem

Mechanism Of Action

How Do Autologous Mesenchymal Stem Cells Work?

Via Growth Factors That Help Your Tissue Heal (E.G. Transforming Growth Factor Beta, Platelet Derived Growth Factor)

Also Via Anti-Inflammatory Cytokines (Eg Interleukin 1 Receptor Antagonist) That Fight Inflammation

A Substance Called Lubricin That Is A Natural Lubricant For Joints Has Also Been Recently Discovered To Be In Stem Cells

There Is New Evidence That Mesenchymal Stem Cells Take Root and Live After They Are Injected, and Keep Working Long After the Injection

Stem Cells Do NOT Impair Healing as Cortisone and NSAIDs Do. Rather They Stimulate Healing Directly and By Inducing Your Own Stem Cells to Work

Note That While Stem Cells Do Help the Joint to Heal No Stem Cell Treatment Has Been Shown To Generate New Tissue, Despite Some Misleading Claims to the contrary.

Technique

Who Does the Actual Injection In Your Clinic?

All injections are done by Dr. Prodromos or by Dr. Hatz. Although they are certainly qualified to do so, we do not have nurses or physician’s assistants performing the injections as the case at many clinics

Do You Use Sedation Or Medications?

None are used, none are needed

Are the injections painful?

The injections have some discomfort but it is usually far less than patients expect.

Can I Come by Myself And Drive Home?

You could, but it is preferable to have someone drive you

How Long Do Treatments Take?

Stem cell treatment takes about 1 hour and 45 minutes

Where Do You Harvest Mesenchymal Stem Cells From?

The back of the iliac bone, (this is not the hip or spine, but rather a non-weight bearing readily accessible pelvic bone at waist level)

A small lipo-aspiration of fat (fat contains stem cells and is used for its cushioning effect) from the love handle area

Very little pain is involved, only a light local anesthetic is used,

Are Dr. Prodromos And Dr. Hatz Knowledgeable and Experienced In Regenerative Medicine?

Yes, Dr. Prodromos is one of the few board certified Orthopaedic Surgeons who is also board certified in Regenerative Medicine. Dr. Hatz is one of the only dentists who is also board certified in regenerative medicine

Cost

Are Stem Cell Injections covered by insurance?

No, However, our charges are lower than most comparable centers for stem cell treatments.

When do you use Stem Cells versus PRP?

Stem cell treatments have lasted far longer in our study, but treatment is more expensive

Are these procedures FDA approved?

Yes, we perform all procedures in strict accordance with FDA guidelines


FAQs - Low Level Laser Therapy (LLLT)

What Is Low Level Laser Therapy?

When laser power is reduced below the level where it produces perceptible heat, lasers can have powerful clinical effects to promote healing and reduce pain without side effects. This Low-Level Laser Therapy (LLLT) is what we use in our clinic.

What Kind of Laser Do You Use?

We use a Weber Laser from Germany. Developed by Dr. Michael Weber, one of the pioneers in this field who trained me in its use in Germany, it is a so-called 3b laser (5-500 milliwatts or mw). Our treatments usually use 100 mw of power. This is far less than class 4 lasers, which, by definition, are powered at more than 500 mw. We avoid class 4 lasers because, unlike the 3b laser we use, they can produce burns and there is no evidence that they are more beneficial. There is also a weaker laser called 3a. This laser is powered at less than 5mw. These are less expensive and in more common use and can have beneficial effects but we believe that the more powerful 3b laser we use at 100mw is the best power range to produce maximum clinical benefit without risk.

How is Low Level Laser Treatment Performed?

Treatment is performed by attaching 4 - 7 small adhesive pads with lasers inserted in them onto the skin. The treatment consists of 20 minutes of continuous light. There are no pain, heat or side effects. During the treatment, patients occasionally describe that they can feel a pleasant sensation as their pain lessens.

How Effective is Low Level Laser For TMJ?

We have found LLLT to be effective in nearly all of our TMJ patients. It probably exerts much of its effect on muscular pain from the masseter and pterygoid muscles and also the ligaments of the TMJ – which are often quite severe. (Botox has been used for this purpose but has been shown to cause jaw osteoporosis, and occasional other side effects and we therefore never use it).

When Are Results of Laser Treatment Felt?

Results are usually seen shortly after the treatment is completed while the patient is still in our office; in some cases not until later that evening.

Can The Laser Be Used with PRP and Stem Cell Treatment?

Yes. In fact, LLLT is an ideal complement to our use of PRP and stem cell treatment for the TMJ. Pain relief is usually additive and greater than for each treatment alone. It is also very effective for the secondary headaches, and sometimes neck pain, from which many TMJ patients suffer.

How Does Low Level Laser Work?

Research from a Harvard study at their Wellman Center for Photo medicine at the Massachusetts General Hospital, and elsewhere, indicates that laser light can stimulate mitochondrial activity which improves cell respiration and cell energy production. The laser light seems to work directly on the cytochrome oxidase molecule to dissociate it from its Nitric Oxide (NO) side chain. This side chain inhibits cell respiration. The effect of dissociating the NO is to increase cellular respiration. This produces more energy, ATP and blood flow to improve healing of damaged tissue.

Laser light can also work like acupuncture without needles to stimulate the acupuncture meridians. There is evidence from Dr. Peter Dorsher at the Mayo Clinic and others to suggest that this stimulates parasympathetic nerves which produce a direct anti-inflammatory effect.

Here* are two excellent paper reviewing how LLLT works. *MOJ Orthop Rheumatol. 2015; 2(5): 00068. The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain. Howard B Cotler, Roberta T Chow, Michael R Hamblin, and James Carroll https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743666/

IEEE J Sel Top Quantum Electron. 2016 ; 22(3): 2561201. Proposed Mechanisms of Photobiomodulation or Low-Level Light Therapy. Lucas Freitas de Freitas and Michael R Hamblin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215870/pdf/nihms797827.pdf

Types Of Laser Light

Typically, Red and Infra-Red wavelengths are used. We are one of the few centers to also have available Blue and Yellow lasers. Emerging research has shown improved efficacy for some wavelengths in specific problems. Intravenous laser treatment also shows promise in decreasing generalized inflammation and we are beginning work in this area.

See patient testimonials here