Temporomandibular Joint Disorder (TMJ)

Photomed Laser Surg. 2016 Nov 29. [Epub ahead of print]

Comparative Study of the Physiotherapeutic and Drug Protocol and Low-Level Laser Irradiation in the Treatment of Pain Associated With Temporomandibular Dysfunction.

Cavalcanti MF1, Silva UH2, Leal-Junior EC3, Lopes-Martins RA4, Marcos RL5, Pallotta RC5, Diomede F6, Trubiani O6, De Isla N7, Frigo L8.

Author information

  • 11 UMR 7365 CNRS-Université de Lorraine, Faculté de Médicine, Vandoeuvre-Les-Noucy-France and Postgraduation Department-Cruzeiro do Sul University, São Paulo, SP, Brasil .
  • 22 Departamento de Odontologia-DOD, Rio Grande do Norte Federal University , Natal, Brazil .
  • 33 Center for Research and Innovation in Laser, Nove de Julho University , São Paulo, SP, Brasil .
  • 44 Biomedicine Engineering, Mogi das Cruzes University , Mogi das Cruzes, São Paulo, Brasil .
  • 55 Nove de Julho University , São Paulo, SP, Brasil .
  • 66 Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University , Chieti, Italy .
  • 77 UMR 7365 CNRS-Université de Lorraine , Faculté de Médecine, Vandoeuvre-lés-Nancy, France .
  • 88 Cruzeiro do Sul University , São Paulo, SP, Brasil.

Abstract

BACKGROUND:

The temporomandibular joint (TMJ) is a structure of the craniofacial complex affected by neurological diseases. Orthopedic and musculoskeletal changes can also cause temporomandibular disorders (TMD) and pain. Low-level laser (LLL) therapy has been studied in the treatment of temporomandibular jaw (TMJ) dysfunction, and controversial results were obtained.

OBJECTIVE:

The objective of this work was comparing the physiotherapeutic and drug protocol (PDP) to LLL therapy in the treatment of pain associated with TMD.

METHODS:

A sample of 60 female patients, 20-50 years of age, TMD triggering agents (stress, parafunctional habits) controlled, was randomly divided into three groups, group 1 (G1)-LLL (780?nm laser, dose of 35.0?J/cm2, for 20?sec, thrice a week, for 4 weeks); group 2 (G2)-PDP (hot packs thrice a day, morning, afternoon, and evening, for 15?min, exercise of opening and closing the mouth, twice a day, myorelaxing and anti-inflammatory drug administration); and group 3 (G3)-Placebo (450?nm halogen lamp, Max LD Gnatus, light curing unit).

RESULTS:

Patients were evaluated every return appointment for the presence (P) or absence (A) of pain for 4 weeks and results were statistically analyzed. First week: 60% of G1, 100% G2, and 70% of G3-related pain. Second week: 55% of G1, 15% of G2, and 100% of G3-related pain. Third week: 10% of G1, 15% of G2, and 85% of G3-related pain. Last week: 0% of G1, 0% of G2, and 100% of G3-related pain.

CONCLUSIONS:

Based on obtained data, we concluded that, compared to PDP, LLL treatment is effective to control pain associated with TMD.

Lasers Med Sci. 2016 Aug;31(6):1051-9. doi: 10.1007/s10103-016-1946-3. Epub 2016 May 4.

Low-level laser therapy stimulates tissue repair and reduces the extracellular matrix degradation in rats with induced arthritis in the temporomandibular joint.

Lemos GA1, Rissi R2, de Souza Pires IL2, de Oliveira LP2, de Aro AA2, Pimentel ER2, Palomari ET2.

Author information

  • 1Department of Structural and Functional Biology, Institute of Biology, University of Campinas – UNICAMP, Charles Darwin, s/n, CP 6109, 13083-970, Campinas, SP, Brazil. lemos.george@yahoo.com.br.
  • 2Department of Structural and Functional Biology, Institute of Biology, University of Campinas – UNICAMP, Charles Darwin, s/n, CP 6109, 13083-970, Campinas, SP, Brazil.

Abstract

The objective of this study was to characterize morphological and biochemistry action of low-level laser therapy (LLLT) on induced arthritis in the temporomandibular joint (TMJ) of rats. Twenty-four male Wistar rats were randomly divided into groups with 12 animals each: (AG) group with arthritis induced in the left TMJ and (LG) group with arthritis induced in the left TMJ and treated with LLLT (830 nm, 30 mW, 3 J/cm(2)). Right TMJs in the AG group were used as noninjected control group (CG). Arthritis was induced by intra-articular injection of 50 ?l Complete Freund’s Adjuvant (CFA) and LLLT began 1 week after arthritis induction. Histopathological analysis was performed using sections stained with hematoxylin-eosin, Toluidine Blue, and picrosirius. Biochemical analysis was determined by the total concentration of sulfated glycosaminoglycans (GAGs) and evaluation of matrix metalloproteinases (MMP-2 and MMP-9). Statistical analysis was performed using paired and unpaired t tests, with p?<?0.05. Compared to AG, LG had minor histopathological changes in the TMJ, smaller thickness of the articular disc in the anterior (p?<?0.0001), middle (p?<?0.0001) and posterior regions (p?<?0.0001), high birefringence of collagen fibers in the anterior (p?<?0.0001), middle (p?<?0.0001) and posterior regions (p?<?0.0001) on the articular disc, and statistically lower activity of MMP-2 latent (p?<?0.0001), MMP-2 active (P?=?0.02), MMP-9 latent (p?<?0.0001), and MMP-9 active (p?<?0.0001). These results suggest that LLLT can increase the remodeling and enhancing tissue repair in TMJ with induced arthritis.

Lasers Med Sci. 2016 Apr 16. [Epub ahead of print]

Effects of oral motor exercises and laser therapy on chronic temporomandibular disorders: a randomized study with follow-up.

Machado BC1,2, Mazzetto MO3, Da Silva MA2,3, de Felício CM4,5.

Author information

  • 1Department of Ophtalmology, Otorhinolaryngology, and Head and Neck Surgery, School of Medicine, University of São Paulo, Av. dos Bandeirantes 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil.
  • 2Craniofacial Research Support Centre, University of São Paulo, São Paulo, Brazil.
  • 3Department of Restorative Dentistry, School of Dentistry, University of São Paulo, São Paulo, Brazil.
  • 4Department of Ophtalmology, Otorhinolaryngology, and Head and Neck Surgery, School of Medicine, University of São Paulo, Av. dos Bandeirantes 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil. cfelicio@fmrp.usp.br.
  • 5Craniofacial Research Support Centre, University of São Paulo, São Paulo, Brazil. cfelicio@fmrp.usp.br.

Abstract

This study investigated the efficacy of combining low-level laser therapy (LLLT) with oral motor exercises (OM-exercises) for rehabilitation of patients with chronic temporomandibular disorders (TMDs). Eighty-two patients with chronic TMD and 20 healthy subjects (control group) participated in the study. Patients were randomly assigned to treatment groups: GI (LLLT?+?OM exercises), GII (orofacial myofunctional therapy-OMT-which contains pain relief strategies and OM-exercises), and GIII (LLLT placebo?+?OM-exercises) and GIV (LLLT). LLLT (AsGaAl; 780-nm wavelength; average power of 60 mW, 40 s, and 60?±?1.0 J/cm²) was used to promote analgesia, while OM-exercises were used to reestablish the orofacial functions. Evaluations at baseline (T1), after treatment immediate (T2), and at follow-up (T3) were muscle and joint tenderness to palpation, TMD severity, and orofacial myofunctional status. There was a significant improvement in outcome measures in all treated groups with stability at follow-up (Friedman test, P?<?0.05), but GIV did not show difference in orofacial functions after LLLT (P?>?0.05). Intergroup comparisons showed that all treated groups had no difference in tenderness to palpation of temporal muscle compared to GC at follow-up (Kruskal-Wallis test, P?<?0.01). Moreover, GI, GII, and GIII showed no difference from GC in orofacial functional condition (T2 and T3) while they differed significantly from GIV (P?<?0.01). In conclusion, LLLT combined with OM-exercises was more effective in promoting TMD rehabilitation than LLLT alone was. Similar treatment results were verified with the OMT protocol.

Case Rep Dent. 2015;2015:424213. Epub 2015 Oct 26.

Evaluation of Low-Level Laser Therapy in TMD Patients.

Ayyildiz S1, Emir F1, Sahin C2.
Author information
1Department of Prosthodontics, Center of Dental Sciences, Gulhane Military Medical Academy, Etlik, 06018 Ankara, Turkey.
2School of Dental Technology, Hacettepe University, 06100 Ankara, Turkey.
Abstract
Light amplification by stimulated emission of radiation (laser) is one of the most recent treatment modalities in dentistry. Low-level laser therapy (LLLT) is suggested to have biostimulating and analgesic effects through direct irradiation without causing thermal response. There are few studies that have investigated the efficacy of laser therapy in temporomandibular disorders (TMD), especially in reduced mouth opening. The case report here evaluates performance of LLLT with a diode laser for temporomandibular clicking and postoperative findings were evaluated in two cases of TMD patients. First patient had a history of limited mouth opening and pain in temporomandibular joint (TMJ) region since nine months. Second patient’s main complaint was his restricted mouth opening, which was progressed in one year. LLLT was performed with a 685?nm red probed diode laser that has an energy density of 6.2?J/cm2, three times a week for one month, and application time was 30 seconds (685?nm, 25?mW, 30?s, 0.02?Hz, and 6.2?J/cm2) (BTL-2000, Portative Laser Therapy Device). The treatment protocol was decided according to the literature. One year later patients were evaluated and there were no changes. This application suggested that LLLT is an appropriate treatment for TMD related pain and limited mouth opening and should be considered as an alternative to other methods.
J Maxillofac Oral Surg. 2014 Dec;13(4):444-50. doi: 10.1007/s12663-013-0544-1. Epub 2013 Jun 9.

Management of Temporomandibular Disorders with Low Level Laser Therapy.

Sayed N1, Murugavel C2, Gnanam A2.

Author information

  • 1Department of Oral and Maxillofacial Surgery, SRM Dental College, Chennai, India ; Department of Oral and Maxillofacial Surgery, Srinivas Institute of Dental Sciences, Srinivasnagar, Mukka, Mangalore, 575021 Karnataka India.
  • 2Department of Oral and Maxillofacial Surgery, SRM Dental College, Chennai, India.

Abstract

PURPOSE:

To evaluate the efficacy of low level laser therapy (LLLT) in the treatment of temporomandibular disorders (TMD) in relation to pain intensity, tender points, joint sounds and jaw movements.

MATERIALS AND METHODS:

Twenty patients received 6 sessions of LLLT (3 times a week for 2 weeks) with semiconductive diode laser (gallium arsenide; 904 nm, 0.6 W, 60 s, 4 J/cm(2)). Pain intensity, number of tender points, joint sounds and active range of motion were assessed before and immediately after each session and after 1, 2 weeks, 1, 3 and 6 months.

RESULTS:

Statistically significant results were achieved in all study parameters.

CONCLUSION:

LLLT promoted satisfactory results in reducing the pain intensity, number of tender points, joint sounds and improvement in the range of jaw motion. Hence it is an effective and efficient treatment method for TMDs.

Lasers Med Sci. 2015 Apr 9. [Epub ahead of print]

Assessment of different energy delivery settings in laser and LED phototherapies in the inflammatory process of rat’s TMJ induced by carrageenan.

de Castro IC1, Rosa CB, Carvalho CM, Aragão JS, Cangussu MC, Dos Santos JN, Pinheiro AL.

Author information

  • 1Center of Biophotonics, School of Dentistry, Federal University of Bahia, Av. Araújo Pinho, 62, Canela, Salvador, BA, CEP 40110-150, Brazil, isabeledecastro@gmail.com.

Abstract

Temporomandibular disorders (TMDs) are mostly inflammatory conditions widespread in the population. Previous studies have shown positive effects of either laser or light-emitting diode (LED) phototherapies on treating TMDs, but their action and mechanism in the inflammatory infiltrate of the temporomandibular joint are still poorly understood. The aim of this study was to assess, through histological analysis, the effectiveness of using laser light (? 780 nm, 70 mW, continous wave (CW), 10 J) and LED (? 850?±?10 nm, 100 mW, CW, 10 J) on the inflammation of the temporomandibular joint of rats induced by carrageenan. Forty-five animals were divided into three groups with five animals each according to the experimental times of 2, 3, and 7 days: inflammation, inflammation+laser phototherapy, and inflammation+LED phototherapy. The first irradiation was performed 24 h after induction with an interval of 48 h between sessions. After animal death, specimens were processed and stained with hematoxylin-eosin (HE) and picrosirius. Then, the samples were examined histologically. Data were statistically analyzed. The inflammation group showed mild to moderate chronic inflammatory infiltrate between bone trabecules of the condyle. Over the time course of the study in the laser group, the region of the condyle presented mild chronic inflammation and intense vascularization. In the LED group, the condyle showed aspects of normality and absence of inflammation in some specimens. In all the time points, the laser-irradiated groups showed greater amount of collagen deposition in the condyle (p?=?0.04) and in the disc (p?=?0.03) when compared to the inflammation and LED groups, respectively. Laser- and LED-treated groups demonstrate a smaller number of layers of the synovial membrane when compared to the non-irradiated groups. It was concluded that, in general, laser and LED phototherapies resulted in a reduction of inflammatory infiltrate in the temporomandibular joint of rat.

J Phys Ther Sci. 2015 Jan;27(1):295-301. doi: 10.1589/jpts.27.295. Epub 2015 Jan 9.

Analysis of laser therapy and assessment methods in the rehabilitation of temporomandibular disorder: a systematic review of the literature.

Herpich CM1, Amaral AP1, Leal-Junior EC2, Tosato Jde P3, Gomes CA4, Arruda ÉE1, Glória IP1, Garcia MB1, Barbosa BR1, Rodrigues MS4, Silva KL4, El Hage Y5, Politti F5, Gonzalez Tde O6, Bussadori SK1, Biasotto-Gonzalez DA1.

Author information

  • 1Postgraduate Program in Rehabilitation Sciences, Movement Analysis Research Support Center, University Nove de Julho (UNINOVE): Rua Profa Maria Jose Barone Fernandes, 300, Sao Paulo, SP, 02117-020, Brazil.
  • 2Postgraduate Program in Rehabilitation Sciences, Laboratory of Phototherapy in Sports and Exercise, University Nove de Julho (UNINOVE), Brazil.
  • 3Postgraduate Program in Biophotonics Applied to Health Sciences, University Nove de Julho (UNINOVE), Brazil.
  • 4Graduation Phisical Therapy, Universidade Nove de Julho (UNINOVE), Brazil.
  • 5Program in Rehabilitation Sciences, Movement Analysis Research Support Center, University Nove de Julho (UNINOVE), Brazil.
  • 6Department of Physical Therapy Universidade Nove de Julho (UNINOVE), Brazil.

Abstract

The aim of the present study was to perform a systematic review of the literature on the effects of low-level laser therapy in the treatment of TMD, and to analyze the use of different assessment tools. [Subjects and Methods] Searches were carried out of the BIREME, MEDLINE, PubMed and SciELO electronic databases by two independent researchers for papers published in English and Portuguese using the terms: “temporomandibular joint laser therapy” and “TMJ laser treatment”. [Results] Following the application of the eligibility criteria, 11 papers were selected for in-depth analysis. The papers analyzed exhibited considerable methodological differences, especially with regard to the number of sessions, anatomic site and duration of low-level laser therapy irradiation, as well as irradiation parameters, diagnostic criteria and assessment tools. [Conclusion] Further studies are needed, especially randomized clinical trials, to establish the exact dose and ideal parameters for low-level laser therapy and define the best assessment tools in this promising field of research that may benefit individuals with signs and symptoms of TMD.

J Phys Ther Sci. 2014 Aug; 26(8): 1297–1300.
Published online 2014 Aug 30. doi:  10.1589/jpts.26.1297

A Meta-analysis of Clinical Effects of Low-level Laser Therapy on Temporomandibular Joint Pain

Wen-Dien Chang, PhD,1 Chia-Lun Lee, PhD,2 Hung-Yu Lin, PhD,3 Yung-Chun Hsu, MS,4 Chung-Jieh Wang, PhD,5 andPing-Tung Lai, BS6,*

1) Department of Sports Medicine, China Medical University, Taiwan

2) Physical Education Section of General Education, National Sun Yat-sen University, Taiwan

3) Department of Occupational Therapy, I-Shou University, Taiwan
4) Rehabilitation Therapy Center, Tungs’ Taichung MetroHarbor Hospital, Taiwan
5) Department of Rehabilitation Science, Jen-Teh Junior College of Medicine, Nursing and Management, Taiwan
6) Department of Physical Therapy and Rehabilitation, Da-Chien General Hospital, Taiwan
* Correspondence author. Ping-Tung Lai, Department of Physical Therapy and Rehabilitation, Da-Chien General Hospital: No. 6, Shin Guang Street, Miaoli, Taiwan. (E-mail: wt.moc.oohay@ydnam-nevets)

Author information ? Article notes ? Copyright and License information ?

Received 2014 Jan 15; Accepted 2014 Feb 16.

Copyright 2014©by the Society of Physical Therapy Science

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) Licens

INTRODUCTION

Temporomandibular disorder is a common disease of the facial joint. The ordinary symptoms include pain in the temporomandibular joint (TMJ), disability of mouth opening, and sounds of the joint. The pain occurs in palpation or during mastication. These discomforts affect the daily lives of patients1). The necessity of surgery can be reduced by some of the effective conservative treatments, such as diet changes, medications, and physical therapies2). Modality therapies, including electrotherapy, low-level laser therapy (LLLT), and laser acupuncture, are also adopted at the beginning of treatment of temporomandibular disorder3, 4).

LLLT is often used to clinically treat TMJ pain; the output power of LLLT is less than 500?mW, and the therapeutic doses are less than 35?J/cm2, 5). The intensity of the laser does not harm the tissue, but can cause biochemical effects on cells, so the laser is also known as the cold laser or soft laser6). Previous literature indicates that LLLT can affect the synthesis of prostaglandin, causing arachidonic acid to enter endothelial tissues and smooth muscles and allowing them to generate vasodilatation and anti-inflammation7, 8). Therefore, LLLT is a popular treatment for musculoskeletal diseases9). Furthermore, laser irradiation could lead to a change in biochemical reactions in cells and tissues6). This is called laser photobiomodulation of which is produced using different laser dosages and wavelengths10, 11). A pervious study found that the applicable laser dosage would follow the Arndt-Schultz rule, which means that photobiomodulation only occurs when the dosage reaches the threshold level11). Such an effect would be suppressed if the dosage exceeds the threshold. With different media and wavelengths, the laser would also have different penetration depths. Appropriate parameters that influence the therapeutic effects for TMJ pain remain controversial at present12). Various clinical doses, methods, and modes of LLLT could also result in different treatment effects. Therefore, the aim of this systematic review study was to investigate the analgesic effect of applying LLLT for TMJ pain. The research results may serve as references for clinical physicians when treating patients with TMJ pain.

SUBJECTS AND METHODS

This study searched and reviewed research articles available in the electronic databases of Medline, PubMed, and CINAHL that had been published between 2005 and January 2010 with the key words “low-level laser”, “low-level laser therapy”, “temporomandibular joint disease” and “temporomandibular joint pain”. In addition, further investigation was performed by examining some review articles that met the requirements. The literature review and meta-analysis in this study was performed to investigate the analgesic effect of LLLT that was used to treat TMJ pain, and articles describing randomized controlled trials (RCTs) were selected. The articles had to meet the following criteria: the patients had to have been diagnosed with TMJ pain or pain on masticatory muscles by the physical examination; LLLT was used as the treatment to TMJ pain, and the exposure site including the inflammatory TMJ or point of muscle tenderness; the experimental design had to have been randomized, single-blind, or double-blind tests; and the control group had to have been treated without laser therapy or with a placebo as a control. According to these inclusion criteria, all articles are assessed using the Physiotherapy Evidence Database (PEDro) scale13).

The data from the selected articles were coded and collected. The analysis included two parts. In the first part of the analysis, article-related information, such as authors, year of publication, and subject number, and treatment-related information, such as the treatment site and wavelength, output power, therapeutic doses, and course of laser treatment used in the experiments, were summarized. The results after using LLLT and the quality of the reviewed articles were also summarized. In the second part of the analysis, the effect size (ES) of pain relief was calculated to evaluate the effect of the treatments. The visual analogue scale (VAS) is often used to estimate the degree of analgesia. The VAS is graded before and after treatment, when observing the actions of the TMJ and the pain conditions under normal conditions and palpation.

Statistical analysis was performed using the MedCalc software (MedCalc, Mariakerke, Belgium). The meta-analysis was performed with the means and standard deviations of the VAS scores to estimate the ES of each variable and the aggregated ES14). The pooled ES of every variable is the sum of all the individual ES weighted by the total number of subjects. A negative ES for pain relief suggests a decrease in the pain threshold and analgesia. On the other hand, a positive ES implies an increase in the pain threshold and no analgesic effect. The analgesic ES is given with a 95% confidence interval (CI). Inclusion of 0inside the 95% CI was considered to indicate acceptance of the null hypotheses. The absolute value of ES was determined by the Cohen’s d method; 0.2 indicates an inferior ES, 0.5 suggests a moderate ES, and 0.8 means a superior ES14).

RESULTS

As a result of our search for research articles, 7 articles discussing clinical findings with a PEDro score of between 9 and 11 were selected to examine the pain relief effect of LLLT when treating TMJ pain15,16,17,18,19,20,21). All of the treatment parameters and PEDro scores are shown in Table 1. In these studies, the patients in the experimental groups generally felt less pain in the TMJ after being treated with LLLT.

Table 1.

 

 

The parameters of LLLT and the PEDro scores in each article

A meta-analysis analysis on the VAS scores was conducted. A lower VAS scores indicates a better treatment effect, so a negative ES is considered the analgesic effect. Table 2 show the ES of pain relief after subjects were treated with LLLT. The results of Fikácková et al. showed the category variable of successful and unsuccessful rate after LLLT18). Their data could not be subjected to meta-analysis. Therefore, the results are based on the treatment outcomes of 223 subjects in six articles15,16,17, 19,20,21). Four of the articles showed a positive effect on pain relief after LLLT was employed15, 17, 19, 20). But no statistically significant differences (p > 0.05) existed in the results of the studies of Emshoff et al.16) and Venancio et al.21). The pooled ES was –0.6, with a 95% confidence interval (95% CI: –0.73 to –0.47, p < 0.05) that did not contain 0. This ES suggests a moderate effect (0.8 >|pooled ES|> 0.5), and that LLLT results in statistically significant analgesia (p < 0.05).

 

Table 2.

 

Effect sizes of LLLT on analgesia in each article

DISCUSSION

 At present, the mechanism of LLLT in pain relief is still unclear. In a previous cell study in vitro, the researchers found that a low-level laser could inhibit the synthesis of cyclooxygenase (COX–2), thus hindering the transformation of arachidonic acid to prostaglandins (PGE2, PGF2?) and thromboxane. They inferred that the analgesia was caused by the decrease in synthesis of those precursors15). They also indicated that a low-level laser could penetrate tendons or the joint capsule to decrease the prostaglandin (PGE2) level in vivo and inflammation15). In some clinical studies, researchers believed that the analgesic mechanism of LLLT was an increase in the beta-endorphin content in the central nervous system, thus increasing raise the pain threshold15, 19, 21). Venancio et al., for example, considered that LLLT could increase the discharge of urine glucocorticoid, a synthetic inhibitor of endorphin, to generate an analgesic effect21). Da Cunha et al., on the other hand, thought that the local irradiation of LLLT could stimulate the microcirculation of peripheral nerve tissues and block the pain sensation to achieve the analgesic effect15). Moreover, some studies found that LLLT could increase the generation of adenosine triphosphate in the mitochondrion. This reaction provides the energy for local metabolism and inhibits the release of endogenous pain-producing substances, such as histamine acetylcholine and bradykinin, to decrease the synthesis of pain factors16, 21). Therefore, the analgesic mechanism of LLLT is still unconfirmed. Our review study found that LLLT has a pain relief effect in treatment of TMJ pain, regardless of whether it is the TMJ or tender point of the masticatory muscle that is irradiated.

Table 3 demonstrates the parameters of LLLT and the analgesic ES in a meta-analysis. In fact, the analgesic ES in the laser groups with wavelengths of 830?nm and 780?nm from the reviewed articles was moderate or superior. For example, de Cunha et al. indicated that a laser with a wavelength of 830?nm could penetrate the soft tissue to a depth of 1 to 5?cm, so it was suitable for treatment of TMJ pain15). Cetiner et al. performed a study after this and utilized the same laser wavelength and dosage (830?nm, 7?J/cm2). Their results also showed that a laser with a wavelength of 830?nm was able to treat TMJ pain20). In addition, Mazzetto et al. suggested that a laser with a wavelength of 780?nm is also appropriate for treatment of TMJ pain, since such a laser was not easily absorbed by tissues, provided better penetration, and caused no thermal effect or metabolic response in tissues19). However, Emshoff et al. argued that a laser with a shorter wavelength can provide better penetration but that laser treatment a wavelength of 632.8?nm did not generate the desired analgesic effects16). They believed the outcome was caused by 20 treatment sessions being insufficient to have the desired effects16). Furthermore, most of the scholars considered the analgesia of LLLT to depend on the laser wavelength and the radiation dosage when using LLLT to treat TMJ pain16, 18,19,20,21). Radiation dosage was determined by the irradiation time and treatment course. The key to an effective treatment is the adequacy of the dosage delivered to the tissue. In addition, although the pain in the TMJ is relieved after treatment with LLLT, Venancio et al. found that the activity of the TMJ increased significantly (p < 0.05) and that the pain was obviously relieved at a two-month follow-up21). The alleviation of pain in the TMJ may be caused by reformation of the occlusal function, and this is similar to the segmental result in other studies18, 19). Da Cunha and Venancio explained that irradiation with a low-level laser could excessively stimulate the proprioception receptors in joint capsules, changing the secondary afferent signals, which can relax masticatory muscles, so the damage to the TMJ was reduced15, 21).

Table 3.

 

 

Analysis of laser wavelength and treatment parameters and effect sizes of analgesia

Application of LLLT to the masticatory muscle or joint capsule of the TMJ had a moderate analgesic effect. The evidence from the articles suggested that the analgesia mechanism was possibly photobiomodulation that decreased the inflammatory factors. It also suggested that nerve stimulation via LLLT occurs that changes the activity of the masticatory muscle. However, the optimal parameters for LLLT to treat TMJ pain have not been confirmed. More clinical studies of RCTs are required to find more answers.

Acknowledgments

The authors are grateful for financial support from China Medical University under the contract Nos. CMU102-SR-27 and DMR-103-138.

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J Dent (Tehran). 2014 May; 11(3): 319–327.
Published online 2014 May 31.
PMCID: PMC4290760

Effect of Low-Level Laser on Healing of Temporomandibular Joint Osteoarthritis in Rats

Ali Peimani1 and Farimah Sardary2
1Assistant Professor, Department of Oral Surgery, Dental School of Rafsanjan University, Rafsanjan, Iran
2Assistant Professor, Department of Oral Medicine, Dental School of Rafsanjan University, Rafsanjan, Iran
Corresponding author: F. Sardary, Department of Oral Medicine, Dental School of Rafsanjan University, Rafsanjan, Iran, moc.oohay@hamiraf_iradrasrd
Author information ? Article notes ? Copyright and License information ?
Received 2013 Dec 28; Accepted 2014 Mar 23.

Abstract

Objective:

Temporomandibular disorders (TMD) are clinical conditions characterized by pain and sounds of the temporomandibular joint (TMJ). This study was designed to assess the effect of low-level laser therapy (LLLT) on healing of osteoarthritis in rats with TMD.

Materials and Methods:

Thirty-two male Wistar rats (250–200 g) were housed in standard plastic cages. After injection of Complete Freund’s adjuvant into the TMJ, rats were randomly divided into two groups of 16 (case and control) and anesthetized; then osteoarthritis was induced via intraarticular injection of 50 µl of Complete Freund’s adjuvant; into the bilateral TMJs. In the case group, LLLT was done transcutaneously for 10 minutes daily, starting the day after the confirmation of osteoarthritis. Exposure was performed for 10 minutes at the right side of the TMJ with 880 nm low-level laser with 100 mW power and a probe diameter of 0.8 mm. Control rats were not treated with laser.

Results:

After three days of treatment the grade of cartilage defects, number of inflammatory cells, angiogenesis, number of cell layers and arthritis in rats in the case group were not significantly different compared with controls (P>0.05). After seven days, the grade of cartilage defects, number of inflammatory cells, number of cell layers, and arthritis in the case group improved compared to controls (P<0.05); angiogenesis in both groups was similar.

Conclusion:

Treatment of TMD with LLLT after 7 days of irradiation with a wavelength of 880 nm was associated with a greater improvement compared to the control group.

Keywords: TMJ disorders, laser therapy, osteoarthritis

INTRODUCTION

Temporomandibular disorders are a varied set of clinical conditions characterized by pain in the temporomandibular joint (TMJ) and/or the masticatory muscles. In the body, the TMJ is a synovial, bilateral joint with unique morphology and function, and a stress-sensitive cartilage that is subject to extensive tissue remodeling [13]. Associations between developments of osteoarthritis-like, degenerative changes of articular cartilage and common dysfunction of TMJ have been reported previously. Commonly, progressive and more degenerative processes, with unknown cause in most cases, occur after osteoarthritic changes in the TMJ during life [48].

Pain relief and functional recovery can be achieved by inhibiting the factors causing cartilage deformity as much as possible, since they result in cartilage loss and articular deformity. Use of non-steroidal anti-inflammatory drugs (NSAIDs), synovectomy, steroids and immunosuppressants as treatment methods for artificially induced osteoarthritis have been studied [913]. Development of drugs or treatment methods that are not harmful seems necessary because of the complications and side effects of most of the existing methods [14]. Low-level laser therapy (LLLT) is a treatment approach with a wide range of applications and with biomodulative and analgesic purposes. In several studies, LLLT was used for the treatment of soft tissue injuries, rheumatoid arthritis, musculoskeletal pain and dental problems. Though controversy was observed in its efficacy, positive clinical results have been reported [1417]. Some studies evaluated the use of LLLT for treatment of atherosclerosis, non-healing ulcers, and various degenerative conditions [1820]. Also, augmentation of heat shock proteins and pathophysiological improvement of arthritic cartilage resulted in an osteoarthritis model for treatment with LLL [21]. Dental and periodontal treatment applications of LLLT have been the subject of many in vivo and in vitro studies; and due to its ability to expedite the healing process, it has been used after gingivoplasty and gingivectomy [2223]. LLLT for temporomandibular disorders, in spite of the common treatment modes available, has proven capable of relieving pain in minutes after administration, bringing about a significant improvement for the patient [24]. Analgesic effects reported by most authors in the literature were the main reason for the use of LLLT for TMD [2527].

Nonetheless, it has been shown that often laser therapy can be used in lieu of anti-inflammatory medication; thus, preventing side effects [26]. However, LLLT is not the definitive treatment for temporomandibular disorders, regardless of all benefits of laser treatment.

Because of ethical reasons much of the research cannot be done on humans and studies in animal models are used for this purpose. Rats may be used as convenient animals for experimental studies for treatment of TMD, due to the similarity of the TMJ of rats and humans. Therefore, our study was designed to assess the effect of LLLT on healing of osteoarthritis in rats with TMD.

MATERIALS AND METHODS

Thirty-two male Wistar rats (200–250 g) were housed in standard plastic cages with food and water available ad libitum. Ethical review of the animal procedures was obtained from the Institutional Animal Care and Use Committee of Rafsanjan University of Medicine, and all experiments were designed to minimize animal suffering and to use the minimum number of animals required to achieve a valid statistical evaluation. The rats were anesthetized intraperitoneally with a ketamine and xylazine mixture (Figure 1-a). Osteoarthritis was induced with an intraarticular injection of 50 µl of Complete Freund’s adjuvant (CFA), (oil/saline at a ratio of 1:1) into the bilateral TMJs using a 30-gauge needle and 1-mL syringe (Figure 1-b). After injection of CFA into the TMJ, using random-maker software “Random Allocation”, the rats were randomly divided into two groups of 16 (case and control). In the case group, LLLT was done transcutaneously for 10 minutes every day, using a LLL AZOR-2k (Azor Medical Equipment, Moscow, Russia), starting the day after the confirmation of osteoarthritis.

Fig 1.

Osteoarthritis induced by an intraarticular injection of 50 µl of complete Freund’s adjuvant, into the bilateral TMJs in rats

Exposure was performed for 10 minutes at the right side of TMJ with 880 nm low-level laser with 100 mW power and a probe diameter of 0.8 mm (Figure 1-c). In the control group, rats were not treated with laser, and the same procedure was performed, but the probe was turned off. Each rat was kept in one cage and was able to rotate 360 degrees to obtain food and water freely.

The heads of the rats were dissected from euthanized rats on day three (8 rats in the case and 8 rats in the control groups), and on day seven (8 rats in the case and 8 rats in the control groups). The separated heads were fixed in 10% formalin and were then carefully oriented in the paraffin blocks (Figure 1-d). The TMJ was removed and fixed in 4% paraformaldehyde and demineralized in 15% EDTA.

The specimens were dehydrated in graded concentrations of alcohol and xylene, embedded in paraffin, and cut serially into 4 µm sagittal sections.

Next, they were stained with hematoxylineosin. An observer, blinded to the experimental design, in consultation with two pathologists, evaluated histopathological alterations of the joints after standardization of the measurements.

The presence of angiogenesis, grade of cartilage defects, the number of cell layers, the number of inflammatory cells, and arthritis were assessed (Figure 3). Arthritis in rats was confirmed using clinical signs and based on swelling and redness.

Fig 3.

Photomicrographs of the histopathological analysis of TMJ. A: control group, B: case group (H&E staining 100×)

All statistical analyses were performed using SPSS software (version 20; SPSS Inc., Chicago, IL).

The data were presented and statistically significant differences among the groups were compared using the Mann-Whitney U test. P-values less than 0.05 were considered to indicate statistical significance.

RESULTS

Figure 2 shows the algorithm of the study, number of rats, treatment, follow-up and analyses.

Fig 2.

Flowchart of the study

Results of the comparison of the frequencies, grade of cartilage defects, number of inflammatory cells, number of cell layers, arthritis and angiogenesis between the case and the control groups after three days of treatment are shown in Table 1.

Table 1.

Comparison of the frequencies of studied variables between the case and control groups three days after the intervention

As shown, the grade of cartilage defect in all rats in the case group was irregular and superficial erosion, and deep defects in the cartilage were more than in the control group, but differences were not statistically significant (P>0.05).

Inflammatory cells and angiogenesis between the groups were similar (P>0.05).

Half the rats in the control group showed one cell layer; while most rats in the case group showed more than one cell layer; also, arthritis in most rats in the case group was average but in the control group was severe. Differences in the number of cell layers and arthritis between the case and control groups were not statistically significant (P>0.05).

Table 2 shows the the results seven days after the intervention assessing the grade of cartilage defect, number of inflammatory cells, number of cell layers, arthritis and angiogenesis between the case and the control groups. The grade of cartilage, number of inflammatory cells, number of cell layers, and arthritis in the case group improved compared to the controls (P<0.05); but angiogenesis was similar between the case and the control groups after seven days (P=0.05).

Table 2.

Comparison of the frequencies of studied variables between the case and control groups seven days after the intervention

Arthritis in all rats in the case group on day 3 was severe or average but on day seven, arthritis in half of these rats improved while in the control group slight arthritis progressed to severe arthritis. These changes between groups were statistically significant (P=0.005). Also, the grade of cartilage defect, number of inflammatory cells and number of cell layers in the case group improved after increasing the time of treatment but in controls exhibited no change after increasing the treatment time.

DISCUSSION

The data of histological analysis in this study suggest that no improvement was observed in the case group after 3 days of irradiation around the TMJ compared to the controls with regard to the grade of cartilage defect, number of inflammatory cells, number of cell layers, arthritis and angiogenesis. With an increase in the laser irradiation days from 3 days to 7 days, statistically significant improvements in the grade of cartilage defect, number of inflammatory cells and number of cell layers were seen.

Based on our findings, increase in the laser irradiation sessions can be useful for treatment of osteoarthritis in rats with TMD.

The stimulatory effects of 630 nm low level laser irradiation on bone formation in the condylar region during mandibular advancement in rabbits were assessed by Abtahi et al, [28]. They showed that after 3 weeks of irradiation around TMJ, a significant increase in newly formed bone was observed.

Other studies reported an over-arching clinical rationale for use of LLL in conditions such as arthritis. Shen and colleagues assessed the efficacy and safety of 650 nm laser irradiation in 40 patients with knee osteoarthritis which were randomly allocated to an active laser group or to a placebo laser group (20 per group). They showed the advantages of laser treatment in these patients [29]. Also, Ekim et al. [30] evaluated the efficacy of LLLT in patients with rheumatoid arthritis with carpal tunnel syndrome and showed that laser therapy seemed to be effective for pain and hand function and suggested that LLLT may be used as a good alternative for treatment of patients with rheumatoid arthritis and carpal tunnel syndrome [33].

These studies concluded that this treatment is associated with anti-inflammatory effects. In agreement with previous in vitro and in vivo studies, our findings showed that laser irradiation can be useful for treatment of TMD.

Cho et al. [35] reported the induction of osteoarthropathy into both knees of 25 normal rabbits and demonstrated that edema and heat sensation significantly decreased and no inflammatory cells were observed histologically in the groups treated with LLLT, as compared to the control groups. They reported that after 2 weeks, no significant treatment effect was seen, but significant improvement was observed after 4 weeks of treatment. They believed that LLLT should be continued for at least 3 weeks in these patients. Brosseau et al. [36] reported that LLLT is effective for rheumatoid arthritis. Amano et al. [37] reported that LLLT is effective for rheumatoid arthritis due to a direct photochemical effect. Our study differed from the studies mentioned above, as we induced non-inflammatory osteoarthritis. However, unlike our study Brosseau et al. [36] reported that LLLT is not effective in osteoarthritis.

The wavelength and the type of irradiation as well as the time of exposure are key factors for the efficacy of laser therapy, and we think that time of exposure, use of just one wavelength and a narrow spectrum of therapeutic doses should be noted as limitations of this study. Therefore, we suggested further studies in order to examine the efficacy of LLL irradiation in various conditions and time periods.

CONCLUSION

Treatment of TMD with LLLT after 7 days of irradiation with a wavelength of 880 nm was associated with a greater improvement compared to the control group.

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Lasers Med Sci.  2014 Feb 7. [Epub ahead of print]

Effectiveness of occlusal splints and lowlevel lasertherapy on myofascial pain.

Demirkol N1, Sari F, Bulbul M, Demirkol M, Simsek I, Usumez A.
  • 1Department of Prosthodontics, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey, dt_nerminhamdemirci@hotmail.com

Abstract

The present study was designed to evaluate the effects of lowlevel laser (Nd:YAG) therapy and occlusal splints in patients with signs and symptoms of temporomandibular disorders (TMD) characterized with myofascial pain (MP). A total of 30 patients were selected after being diagnosed with MP according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TDM). The patients were divided into three groups. The first group was occlusal splint (OS) group A (n=10), the second was lowlevel laser therapy (LLLT) group B (n=10), and the last group C was placebo (n=10). LLLT (1,064 nm, 8 j/cm2, 250 mW, Fotona) was applied to the patients in the study group once a day for 10 days, for a total of ten sessions. The same parameters and application times were used for placebo group, but the patients were not irradiated. The application was on the trigger points. The patients in the OS group were instructed to wear occlusal splints 12 h/day for 3 weeks. Functional examination was based on RDC/TDM, and pressure pain values were obtained with the Visual Analog Scale. Comparisons were made between the groups before and after the treatment according to Wilcoxon, Mann-Whitney U, and Kruskal-Wallis tests. The pain score values decreased significantly after both LLLT (p<0.05) and occlusal splint therapy (p<0.05) compared to placebo group (p<0.05). There was no significant difference between LLLT and OS groups after treatment (p>0.05). OS and LLLT are effective for decreasing MP. In addition, this particular type of LLLT is as effective as occlusal splint for pain relief.

Cranio.  2014 Jan;32(1):51-6.

Efficacy of red and infrared lasers in treatment of temporomandibular disorders–a double-blind, randomized, parallel clinical trial.

Pereira TS, Flecha OD, Guimarães RC, de Oliveira D, Botelho AM, Ramos Glória JC, Aguiar Tavano KT.

Abstract

AIM:

Low-level laser therapy has still not been well established, and it is important to define a standardized protocol for the treatment of temporomandibular disorders (TMDs) using low level laser. There is no consensus on controlled clinical trials concerning the best option for laser therapy with regard to wavelength. The aim of this study was to evaluate the efficacy of red and infrared laser therapy in patients with TMD, using a randomized parallel-group double-blind trial.

METHODOLOGY:

Each hemiface of 19 subjects was randomized to receive intervention, in a total of 116 sensitive points. Pain was measured at baseline and time intervals of 24 hours, 30 days, 90 days, and 180 days after treatment. Irradiation of 4 J/cm2 in the temporomandibular joints and 8 J/cm(2) in the muscles was used in three sessions.

RESULTS:

Both treatments had statistically significant results (P<0.001); there was statistical difference between them at 180 days in favor of the infrared laser (P=0.039). There was improvement in 24 hours, which extended up to 180 days in both groups.

Lasers Med Sci. 2013 Nov;28(6):1549-58. doi: 10.1007/s10103-013-1273-x. Epub 2013 Feb 5.

Laser acupuncture in patients with temporomandibular dysfunction: a randomized controlled trial.

Ferreira LA1, de Oliveira RG, Guimarães JP, Carvalho AC, De Paula MV.

 1Diagnostic and Guidance Center for Patients with Temporomandibular Disorders, Federal University of Juiz de Fora, Rua José Lourenço Kelmer, S/N, Campus Universitário, São Pedro, Juiz de Fora, Minas Gerais, 36036-900, Brazil, l3a6f9@yahoo.com.br.

 Abstract

A prospective, double-blind, randomized, and placebo-controlled trial was conducted in patients with chronic temporomandibular disorder (TMD) to check the analgesic efficacy of infrared low-power GaAlAs diode laser applied to acupuncture points. Forty female subjects, ranging in age from 20 to 40 years, with diagnoses of chronic myofascial pain and arthralgia were randomly allocated to two groups: an experimental group (EG) who received the laser acupuncture as adjunct to reversible occlusal splint therapy and a control group (CG) who received a placebo laser associated with occlusal splint therapy. Both approaches were applied once a week for 3 months. Laser acupuncture was defined by the following parameters: 50-mW continuous radiation for 90 s to acupoints ST6, SI19, GB20, GB43, LI4, LR3, NT3, and EX-HN3; defining 4.5-J energy; 1250-W/cm(2) density point; and 112.5-J/cm(2) total density. The outcome measurements included a symptom evolution assessment carried out by checking spontaneous and palpation pain intensity, which was indicated on a visual analog scale (VAS). All evaluations were made by an assessor who was blind to the treatment. The symptom reduction was significant in both groups (EG: VAS?=?0, n?=?20; CG: VAS between 2 and 4, n?=?18). The measurements showed significantly faster and lower pain intensity values in the EG (p???0.002), where there was a higher proportion of patients with remission of symptoms related to the action of laser acupuncture. For patients in whom conservative treatment was adopted, the laser acupuncture is a secure, noninvasive, and effective treatment modality because it improves the chronic pain associated with TMD and has no side effects.

 

Acta Odontol Scand.  2012 Dec 4. [Epub ahead of print]

Evaluation of orofacial function in temporomandibular disorder patients after low-level laser therapy.

Gökçen-Röhlig B, Kipirdi S, Baca E, Keskin H, Sato S.

Source

Department of Prosthodontics, Faculty of Dentistry, Istanbul University , Istanbul , Turkey.

Abstract

Abstract Objective. To evaluate the effect of low-level laser therapy on occlusal contact area, occlusal pressure and bite force in temporomandibular disorder patients.

Patients and method. Twenty patients (14 women, six men, mean age 33.1 ± 3.8 years) diagnosed with myofascial pain according to the Research Diagnostic Criteria for Temporomandibular Disorder (RDC/TMD) participated in the study. Twenty healthy individuals, matched in age and gender, served as a control group. Low-level laser was applied to the mastication muscles three times per week, for a total of 10 sessions. The mandibular mobility range was evaluated. The maximum bite force, occlusal contact area and occlusal pressure were measured bilaterally with a dental pre-scale before and after treatment. All variables were analyzed descriptively. Changes in the masticatory muscle tenderness, mandibular movements, maximum bite force, occlusal contact area and occlusal pressure were compared by paired-sample Student’s t-tests.

Results. There was a significant increase in the pressure pain threshold of the examined muscles. Mandibular movements were significantly improved in all patients. There was also a significant decrease in pain by palpation after laser exposure. However, no significant change was found in the maximum bite force, occlusal contact area or occlusal pressure after the treatment and also the values after the treatment were still significantly lower than those of the healthy individuals.

Conclusion. This particular type of LLLT is effective at relieving pain but does not provide physical improvement.

J Appl Oral Sci. 2012 Nov-Dec; 20(6): 594–602.
doi:  10.1590/S1678-77572012000600002

Effect of low-level laser therapy on pain levels in patients with temporomandibular disorders: a systematic review

Mila Leite de Moraes MAIA,1 Leonardo Rigoldi BONJARDIM,2 Jullyana de Souza Siqueira QUINTANS,3 Maria Amália Gonzaga RIBEIRO,4 Luiz Guilherme Martins MAIA,5 and Paulo César Rodrigues CONTI6

1Specialist in Orthodontics. Master’s student in Health Sciences, Federal University of Sergipe, Aracaju, SE, Brazil.

2PhD, Professor, Department of Physiology, Federal University of Sergipe, Aracaju, SE, Brazil.
3Doctorate student in Health Sciences, Federal University of Sergipe, Aracaju, SE, Brazil.
4PhD, Professor, Department of Dentistry, Federal University of Sergipe, Aracaju, SE, Brazil.
5Doctorate student, Araraquara School of Dentistry, UNESP – Univ Estadual Paulista, Araraquara, SP, Brazil.
6PhD, Professor, Department of Prosthodontics. Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
Corresponding address: Mila Leite de Moraes Maia – Rua Terêncio Sampaio, 309 – Bairro Grageru – 49025-700 – Aracaju – Sergipe – Brazil – Phone: +55 79 9959-2567 – e-mail: moc.liamtoh@searomedalim

Author information ? Article notes ? Copyright and License information ?

Received 2011 Sep 6; Revised 2011 Oct 8; Accepted 2011 Nov 6.

Copyright notice

INTRODUCTION

Temporomandibular disorders (TMD) is considered the most common cause of pain of non-dental origin25 in the orofacial region and encompasses a heterogeneous group of disorders with common features of psychophysiological orofacial pain, masticatory dysfunction, or both30.

Signs and symptoms of this dysfunction are present in 86% of the population, most frequently in women in the 30 year-old age group5. The prevalence of TMD (or symptoms suggestive of TMD) varies from 21.5% to 51.8%4,12,17,34.

Among the several reported signs and symptoms of TMD, pain has, with no doubt, most debilitating and unbearable effect on the patient’s life. It has been found that masticatory muscle pain is the chief complaint of patients with TMD, usually associated with tension and fatigue, ranging from mild sensitivity to extreme discomfort, and frequently worsened by function of the muscles involved12,17.

Contemporary orofacial pain concepts aim to prevent, cure, or alleviate signs and symptoms of pain morbidity, as well as to reduce their impact on the patient´s quality of life. Because of TMD’s multifactorial etiology and variety of clinical presentations, the treatment of this disorder is extensive and diverse, involving professionals from different areas and includes several therapies: low level laser therapy8,19,27, acupuncture22, transcutaneous electrical nerve stimulation (TeNS)32, ultrasound15, massage2, pharmacotherapy24, use of occlusal splints28, and psychological treatment, among others.

The use of laser photobiomodulation to reduce TMD pain and promote anti-inflammatory effects has been of great interest in the recent literature. Currently, its classification is based on the interaction of laser with the target tissue in question. The term LLLT is used when working in compliance with the threshold of cell survival3. Karu18 (2001) stated that this is a non-thermal therapy that can promote cell and tissue alterations caused by different types of metabolic activation, such as: increased activity in the mitochondria and Na(+)/K(+) pump, increased vascularization and the formation of fibroblasts, resulting in an increase in the recovery process and/ or tissue healing with non-invasive characteristics.

The use of laser has grown in all areas of dentistry especially for conditions such as TMD that involves obtaining analgesia and reducing inflammation. In general, patients are receptive to LLLT which also has a positive psychological effect especially in chronic patients31. The therapeutic properties of lasers, such as tissue repair, mediation of inflammatory processes, and analgesia in acute and chronic pain as well as improvement of local microcirculation have been proven by several authors31.

Based on that, the aim of this study is to perform a systematic review of the effect of LLLT in the control of pain in patients with TMD.

Search strategy and inclusion criteria

A literature search was performed to identify interventional studies involving the application of LLLT in patients with painful symptoms caused by TMD. The databases Scopus, embase, ebsco, and PubMed were revised from January 2003 to October 2010. Results of previous studies on the same subject were already summarized and reported in a previous publication3.

The keywords laser therapy, low level laser therapy, temporomandibular joint disorders, temporomandibular joint dysfunction syndrome, temporomandibular joint, temporomandibular, facial pain, and arthralgia, were used either as MeSH (Medical Subject Headings is the NLM controlled vocabulary thesaurus used for indexing papers for PubMed) terms or as free-text in different combinations. We resorted to the logical operator “AND” to combine descriptors and terms used to trace publications. In the present study were only considered papers that used theses descriptors.

Two authors independently screened titles and abstracts for potential eligibility and the full texts for the final eligibility. The data were extracted using a standardized data collection form to record study design and methodological features, patient characteristics, interventions, outcomes, and missing outcome data. We chose not to include theses, monographs, and abstracts presented in events because the conducting of such a systematic search of the same is logistically unfeasible. Studies that focused on intervention in animals and those that were not written in english, Portuguese or Spanish were excluded.

The papers that met the inclusion criteria were carefully examined for the extraction of data, such as: study setting, including site and sample, age range, methods of diagnosis of TMD and pain assessment, sites of laser application, laser type, manufacturer, dose, application time, frequency or number of sessions per week, and pain outcomes.

RESULTS

 

The results are described in the following sequence (Figure 1):

Figure 1

 

 

Figure 1

Flowchart of the selection phases of the study

A progressive selection of the studies and the number of items in each stage,

 

 

– characteristics of the sample from each study,

– parameters used for the LLLT in each study.

At the end of paper selection process, only 14 met the specific inclusion criteria, being seven from Brazil (studies 2, 6, 7, 8, 12, 13, 14), one from Peru (study 1), one from Turkey (study 3), one from the Czech Republic (study 4), one from Cuba (study 5), two from Iran (studies 9, 11), and one from Austria (study 10) (Figure 2). The number of patients involved in the intervention process ranged from fourteen [8] to eighty [4]per group (Figure 2). In all the studies in this systematic review, there was a higher prevalence of women compared to men.

Figure 2

 

 

Profile of each study according to journal, research location, age, gender, groups, temporomandibular disorder (TMD) diagnosis

The results showed that, from the 14 selected studies, 12 (1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 14) included a placebo control group, while one (5) compared the intervention with laser to that with pharmacology and did not include a placebo group, and one study (12) evaluated only the experimental group (Figure 2).

 

 

Regarding the methods used for the diagnosis of TMD, 4 studies (3, 4, 10, 14) used the diagnostic criteria for TMD proposed by the “Research Diagnostic Criteria” (RDC/TMD). Most studies (1, 2, 7, 9, 10, 11, 12, 13, 14) only evaluated the signs and symptoms of TMD, quantifying pain by the Visual Analogue Scale (VAS) (Figure 2).

Some studies, in addition to performing the TMD diagnosis and assessment of pain intensity, made use of additional tests of the masticatory function, such as electromyographic evaluation (14), pressure pain threshold determination (2), and chewing efficiency (8) (Figure 2).

In terms of sites of laser application, seven studies (1, 3, 4, 7, 9, 12, 13) beamed the laser into the joint and/or the affected muscles. Three others (6, 8, 10) applied the laser only at the TMJ. Laser irradiation only in the affected muscles was performed in two studies (11,14), while one study performed applications at acupuncture points as well as the TMJ (5) (Figure 3). Moreover, it is noteworthy that seven studies (1, 3, 7, 11, 12, 13, 14) made application of laser light at the points of greatest pain of the patient, and the rest of the works irradiated pre-established points, whether or not they were points of greatest pain.

Figure 3

 

 

Figure 3

Profile of each study, as well as data referring to laser application

In relation to the wavelengths used in the studies, it was found that six (1, 3, 4, 7, 9, 13) conducted applications in the infrared range, 5 (2, 6, 8, 10, 14) used the red wavelength, 2 studies (11, 12) did a combination of red and infrared, and one study (5) did not specify the wavelength used (Figure 3).

 

 

The energy and power density settings, time of laser application, frequency and number of sessions, and periods of re-evaluation/follow-up are shown in Figure 3. A great variability in the parameters utilized can be seen. The energy density used in the studies ranged from 0.9 J/cm2 to 105 J/cm2, and the power density ranged from 9.8 mW to 500 mW. In relation to application time, some studies suggest the amount of total elapsed time applied to all points in a session, while others seem to inform the time applied to each point; however, this information was not clear in the papers. It is noteworthy that there was insufficient information for the items covered in this paragraph in some studies, as seen in Figure 3.

The number of sessions of laser applications varied from one session (13) to twenty (10), as well as the frequency of applications ranging from daily for 10 consecutive days (5) to 1 time per week for 4 consecutive weeks (7). The re-evaluation periods ranged from 1 week (11, 13) to 12 months after the last application (9) (Figure 3).

The effectiveness of laser photobiomodulation is shown in Figure 3. It can be noted that only one study (10) observed that, at the end, both placebo and treatment groups that received laser intervention had shown pain in the TMJ during mandibular function. The other studies showed a reduction of pain after the end of the laser photobiomodulation sessions, of which in 9 (3, 4, 5, 6, 8, 9, 12, 13, 14) pain was significantly reduced only in the group receiving laser intervention, and in 4 (1, 2, 7, 11) relief of painful symptoms occurred in both the laser and placebo groups.

DISCUSSION

 

Musculoskeletal condition, like TMD are the major cause of non-dental pain in the orofacial region24. epidemiological studies estimate that 40% to 75% of the population, have at least one sign of TMD, while 33% have at least one symptom such as facial or TMJ pain13. Currently, it is disturbing to see the number of patients with TMD treated with non-evidence-based therapies6, often without competent professional assistance37. As an alternative therapy, LLLT with its analgesic, anti-inflammatory, anti-edematous, and biostimulatory effects has proven to be effective in reducing pain and muscle tension in patients with TMD7,9,16,21,23,26,35,38.

LLLT is considered a safe therapeutic procedure, with well-established indications and contraindications well established through positive clinical trials, scientific investigations of the tissue changes that it promotes, and above all a better understanding of its mechanism of action29.

In 2004, the World Association of Laser Therapy approved an agreement on the format of clinical studies with LLLT for muscle and joint pain. This document established the mandatory presence of a placebo group as part of the study design. Corroborating these guidelines, this review found that the majority of studies used a placebo group, except for the work done by Carvalho, et al.8 (2010), who only used the experimental group that received the LLLT, and León, Almagro and García23 (2007), who compared the group that received laser intervention with another that received pharmacological treatment.

There still no consensus on the way TMD diagnosis and measurement of the presence and severity of pain is used by researchers and clinicians. For diagnosis of individual cases, a detailed history is still the most important procedure in formulating the initial diagnostic impression. Physical examination, consisting of muscle and TMD palpation, measurement of mandibular active range of motion, and joint noise analysis, when performed by trained professionals, are important steps in the diagnosis and formulation of management strategies, as well as in monitoring the effectiveness of proposed treatments13. Accordingly, in this review it was found that only four studies9,14,16,38 diagnosed TMD according to the criteria proposed by the Research Diagnostic Criteria for Temporomandibular Disorders, with are widely used for diagnosis of TMD. However, none of these identified the severity of TMD in their patients which is of paramount importance since TMD may also be present in a sub-clinical form. As can be observed in the papers included in the present review, there are no standardization of the diagnostic criteria, which is a limitation of most of systematic reviews involving musculoskeletal conditions as TMD.

Studies using auxiliary methods of diagnosis, as Shirani, et al.36 (2009), who made use of computerized tomography and magnetic resonance imaging of the TMJ, and Venancio, Camparis and Lizarelli37 (2005); Mazzetto, et al.26 (2007); and Carrasco, et al.7 (2008), who used panoramic radiography, should be analyzed with caution because there is not always a direct association between the findings of such examinations and the presence of signs and symptoms of TMD1,33.

The use of LLLT for musculoskeletal disorders is based on the irradiation of some specific and interrelated areas: the painful area, trigger-points and the area of referred pain as well as in acupuncture points. With this in mind, the studies of Kulekcioglu, et al.20 (2003); Çetiner, Kahraman and Yüceta?9 (2006); Fikácková, et al.16 (2007); Cunha, et al.11 (2008); Santos, et al.35 (2010); and Carvalho, et al.8 (2010) did irradiation on the affected area and on areas of referred pain, according to patient symptoms. In contrast, Mazzetto, et al.26(2007), Carrasco, et al.7 (2008), and emshoff, et al.14 (2008) only performed the application at the TMJ. Shirani, et al.39 (2009) and Venezian,et al.38 (2010) made the application only in the muscle region; and León, Almagro and García23 (2007) made the application on acupuncture points: gallbladder, stomach, and TMJ. Furthermore, it is useful to remind that the antiinflammatory and analgesic effects of laser light occur only in the affected tissue, which explains the importance of muscle and joint palpation for the identification of points causing the patient’s pain. Based on this context, only seven studies9,11,13,19,24,38,42 established laser application at the point of greatest pain, while the rest made the application on pre-established points.

Lasers with an infrared wavelength are the most suitable due to their greater penetration. The most commonly used are located in the electromagnetic spectrum from 780 to 904 nm37. The findings of Kulekcioglu, et al.20(2003); Venancio, Camparis and Lizarelli37 (2005); Çetiner, Kahraman and Yüceta?9 (2006); Fikácková, et al.16 (2007); Mazzetto, et al.26 (2007); Carrasco, et al.7 (2008); Cunha, et al.11 (2008); Lassemi, et al.21(2008); Santos, et al.35 (2010); and Venezian, et al.38 (2010) corroborate the above data using wavelengths in the infrared range, whose electromagnetic spectra varied from 780 nm to 980 nm. In contrast, emshoff, et al.14 (2008) did not corroborate with the above authors and used a wavelength in the red range. However, Carvalho, et al.8 (2010) performed a combination of the two wavelengths, red and infrared.

The efficacy of adjuvant therapy has been proven by several studies as cited above. However, the interaction of laser light with tissue can lead to different results. These results depend on several factors such as the wavelength, energy density, and power density, as well as the optical properties of tissue39. Therefore, many studies have been conducted in order to reach a consensus on the intensity, exposure time, and site of laser application10.

In terms of frequency and number of laser sessions applied, Mazzetto, et al.26 (2007), Carrasco, et al.7(2008), and Venezian, et al.38 (2010) argued for eight sessions with applications twice per week. Venancio, Camparis and Lizarelli37 (2005) and Shirani, et al.36 (2009) established the use of six sessions with a frequency of twice per week. Çetiner, Kahraman and Yüceta?9 (2006); Fikácková, et al.16 (2007); and León, Almagro and García23 (2007) argued for 10 sessions; however, each one established different application frequencies.

Studies that have shown the greatest laser photobiomodulation effectiveness appear to be linked to higher irradiation protocols (energy density and/or power density) as well as to a greater number of sessions and frequency of application. It was also noted that, of the eight studies that showed the best results, four applied laser to the points of greatest pain, whether joint or muscle, while the other four applied laser to pre-established points.

The studies of Çetiner, Kahraman and Yüceta?9 (2006); Mazzetto, et al.26 (2007); and Venezian, et al.38(2010) did a follow-up of patients 30 days after the last irradiation. Çetiner, Kahraman and Yüceta?9 (2006) and Venezian, et al.38 (2010) found that pain reduction remained statistically significant during this period, while Mazzetto, et al.26 (2007) found that the least tenderness to palpation was seen at the last session of laser application. Lassemi, et al.21 (2008) followed patients for 2 years and observed significant results for both pain reduction and for clicking. Although most studies of this review did not make use of a patient follow-up period, it may be suggested that for those who carried out the follow-up, the laser applications promoted a relief of painful symptomatology for at least 30 days after the last irradiation.

As can be seen here, there is still no consensus on the best parameters and standards of laser photobiomodulation and, therefore, the definition of the best treatment protocol and clinical recommendation to be used in cases of TMD pain is not possible at the present time.

However, it seems clear that the use of laser brings benefits when properly applied and administered, although the exact mechanism of action is still to be defined. In some studies, it was noted that the results of LLLT were minimum possibly due to the absence of a specific protocol. This difficulty in the establishment of specific irradiation parameters for a particular area is also observed in other fields such as physical therapy and medicine, for example. Recently, for the area of physical therapy, specific guidelines have been published and studies are being performed to test the efficacy of LLLT. Therefore, it is imperative to also draw up specific guidelines for dentistry, as its applicability in this area is extensive, widespread, and extremely important for the control of pain and/or inflammation of the masticatory muscles and temporomandibular joint.

In short, the results allow us to suggest that the effectiveness of LLLT is more accentuated when using the laser in wavelengths in the infrared region of light spectrum, as well as with higher irradiation protocols (energy density and/or power density) and a larger number of sessions and frequency of application.

CONCLUSION

 

Most papers, including those using a doubleblind and placebo-controlled trial, showed that LLLT seemed to be effective in reducing pain from TMD. However, the heterogeneity of the standardization regarding the parameters of laser calls for caution in interpretation of these results. A potential explanation for the LLLT positive results in reducing pain levels could be a dose-specific antiinflammatory, healing and analgesic effect in TMJ as well as in the masticatory muscle painful area. However, more studies are needed to precisely determine optimal treatment procedures and parameters for LLLT in TMD.

ACKNOWLEDGEMENTS

 

M.L.M.M is recipient of CAPES scholarship grant.

REFERENCES

 

 

 

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Cranio.  2012 Oct;30(4):264-71.

 

 

Low level laser therapy as an adjunctive technique in the management of temporomandibular disorders.

da Silva MA, Botelho AL, Turim CV, da Silva AM.

Source

Department of Restorative Dentistry, Dental School of Ribeirão Preto, University of São Paulo, Brazil. marco@forp.usp.br

Abstract

 

The purpose of this study was to assess the effect of low level laser therapy on subjects with intra-articular temporomandibular disorders (IA-TMD), and to quantify and compare severity of signs and symptoms before, during, and after the laser applications. The sample consisted of 45 subjects randomly divided into three groups (G) of 15 subjects each: G-I: 15 individuals with IA-TMD submitted to an energy dose of 52.5 J/cm2; G-II: dose of 105.0 J/cm2; and G-III: placebo group (0 J/cm2). In all groups, the applications were performed on condylar points on the masseter and anterior temporalis muscles. Two weekly sessions were held for five weeks, totaling 10 applications. The assessed variables were: mandibular movements and painful symptoms evoked by muscle palpation. These variables were measured before starting the study, then immediately after the first, fifth, and tenth laser application, and finally, 32 days after completing the applications. The results showed that there were statistically significant differences for G-I and G-II at the level of 1% between the doses, as well as between assessments. Therefore, it was concluded that the use of low level laser increased the mean mandibular range of motion and reduced painful symptoms in the groups that received effective treatment, which did not occur in the placebo group.

 

 

Photomed Laser Surg.  2012 May;30(5):275-80.

Effectiveness of physiotherapy and GaAlAs laser in the management of temporomandibular joint disorders.

 

Dostalová T, Hlinakova P, Kasparova M, Rehacek A, Vavrickova L, Navrátil L.

Source

Department of Paediatric Stomatology, 2nd Medical Faculty, Charles University, Prague, Czech Republic. tatjana.dostalova@fnmotol.cz

 

Abstract

OBJECTIVE:

Low-level laser therapy (LLLT) is a treatment method commonly used in physiotherapy for musculoskeletal disorders. The aim of this study was to monitor the function of temporomandibular joint (TMJ) and surrounding tissues and compare the objective measurements of the effect of LLLT.

BACKGROUND DATA:

LLLT has been considered effective in reducing pain and muscular tension; thus improving the quality of patients’ lives.

MATERIALS AND METHODS:

TMJ function was evaluated by cephalometric tracing analysis, orthopantomogram, TMJ tomogram, and computer face-bow record. Interalveolar space between central incisors before and after therapy was measured. Patients evaluated pain on the Visual Analog Scale. LLLT was performed in five treatment sessions (energy density of 15.4 J/cm(2)) by semiconductive GaAlAs laser with an output of 280 mW, emitting radiation wavelength of 830 mm. The laser supplied a spot of ~0.2 cm(2).

RESULTS:

Baseline comparisons between the healthy patients and patients with low-level laser application show that TMJ pain during function is based on anatomical and function changes in TMJ areas. Significant differences were seen in the posterior and anterior face height. The results comparing healthy and impaired TMJ sagittal condyle paths showed that patients with TMJ pain during function had significantly flatter nonanatomical movement during function. After therapy, the unpleasant feeling was reduced from 27.5 to 4.16 on the pain Visual Analog Scale. The pain had reduced the ability to open the mouth from 34 to 42 mm.

CONCLUSIONS:

The laser therapy was effective in the improvement of the range of temporomandibular disorders (TMD) and promoted a significant reduction of pain symptoms.

Photomed Laser Surg.  2012 May;30(5):275-80.

 

Effectiveness of Physiotherapy and GaAlAs Laser in the Management of Temporomandibular Joint Disorders.

 

Dostalová T, Hlinakova P, Kasparova M, Rehacek A, Vavrickova L, Navrátil L.

Source

1 Department of Paediatric Stomatology, 2nd Medical Faculty, Charles University , Prague, Czech Republic .

Abstract

 

Abstract Objective: Low-level laser therapy (LLLT) is a treatment method commonly used in physiotherapy for musculoskeletal disorders. The aim of this study was to monitor the function of temporomandibular joint (TMJ) and surrounding tissues and compare the objective measurements of the effect of LLLT.

Background data: LLLT has been considered effective in reducing pain and muscular tension; thus improving the quality of patients’ lives.

Materials and Methods: TMJ function was evaluated by cephalometric tracing analysis, orthopantomogram, TMJ tomogram, and computer face-bow record. Interalveolar space between central incisors before and after therapy was measured. Patients evaluated pain on the Visual Analog Scale. LLLT was performed in five treatment sessions (energy density of 15.4?J/cm(2)) by semiconductive GaAlAs laser with an output of 280?mW, emitting radiation wavelength of 830?mm. The laser supplied a spot of?0.2?cm(2).

Results: Baseline comparisons between the healthy patients and patients with low-level laser application show that TMJ pain during function is based on anatomical and function changes in TMJ areas. Significant differences were seen in the posterior and anterior face height. The results comparing healthy and impaired TMJ sagittal condyle paths showed that patients with TMJ pain during function had significantly flatter nonanatomical movement during function. After therapy, the unpleasant feeling was reduced from 27.5 to 4.16 on the pain Visual Analog Scale. The pain had reduced the ability to open the mouth from 34 to 42?mm.

Conclusions: The laser therapy was effective in the improvement of the range of temporomandibular disorders (TMD) and promoted a significant reduction of pain symptoms.

Hua Xi Kou Qiang Yi Xue Za Zhi.  2011 Aug;29(4):393-5, 399.

 

Efficacy evaluation of low-level laser therapy on temporomandibular disorder.

 

[Article in Chinese]

Wang X, Yang Z, Zhang W, Yi X, Liang C, Li X.

Source

State Key Laboratory of Oral Diseases, Sichuan University, Chengdu 610041, China.

Abstract

 

OBJECTIVE:

To evaluate effectiveness of low-level laser therapy (LLLT) on temporomandibular joint (TMJ) pain.

METHODS:

The patients with TMJ pain were randomly assigned laser group (n=21) or control group(n=21), once a day for 6 consecutive days of treatment. TMJ pain and function were measured at baseline, just after treatment course, 1 month and 2 months after the treatment.

RESULTS:

The changes of visual analogue scale (VAS) were appearing over time in both groups but presented statistically significant differences between groups (P<0.001). VAS of laser group decreased faster than that of control group. The same tendency occurred for painless maximum vertical opening (MVO), left lateral excursion (LLE) and right lateral excursion (RLE), which increased faster in laser group. There were no statistically significant differences between groups and evaluation times for protrusion excursion (PE), but an interaction between group and evaluation times existed and should be explored further.

CONCLUSION:

LLLT is an appropriate treatment for TMJ pain.

Photomed Laser Surg.  2011 Apr;29(4):245-54.

 

Evaluation of laser phototherapy in the inflammatory process of the rat’s TMJ induced by carrageenan.

Carvalho CM, Lacerda JA, dos Santos Neto FP, de Castro IC, Ramos TA, de Lima FO, de Cerqueira Luz JG, Ramalho MJ, dos Santos JN, Pinheiro AL.

Source

Center of Biophotonics, School of Dentistry, Federal University of Bahia, Salvador, BA, Brazil.

Abstract

AIM:

The aim of this study was to evaluate, by light microscopy, the effects of laser phototherapy (LPT) at 780?nm or a combination of 660 and 790?nm, on the inflammatory process of the rat temporomandibular joint (TMJ) induced by carrageen.

BACKGROUND:

Temporomandibular disorders (TMDs) are frequent in the population and generally present an inflammatory component. Previous studies have evidenced positive effects of laser phototherapy on TMDs. However, its mechanism of action on the inflammation of the TMJ is not known yet.

MATERIALS AND METHODS:

Eighty-five Wistar rats were divided into 9 groups: G1, Saline; G2, Saline?+?LPT IR; G3, Saline?+?LPT IR?+?R; G4, Carrageenan; G5, Carrageenan?+?LPT IR; G6, Carrageenan?+?LPT IR?+?R; G7, previous LPT?+?Carrageenan; G8, previous LPT?+?carrageenan?+?LPT IR; and G9, previous LPT?+?carrageenan?+?LPT IR?+?R, and then subdivided in subgroups of 3 and 7 days. After animal death, specimens were taken, routinely cut and stained with HE, Sirius Red, and Toluidine Blue. Descriptive analysis of components of the TMJ was done. The synovial cell layers were counted.

RESULTS:

Injection of saline did not produced inflammatory reaction and the irradiated groups did not present differences compared to nonirradiated ones. After carrageenan injection, intense inflammatory infiltration and synovial cell layers proliferation were observed. The infrared irradiated group presented less inflammation and less synovial cell layers number compared to other groups. Previous laser irradiation did not improve the results.

CONCLUSION:

It was concluded that the LPT presented positive effects on inflammatory infiltration reduction and accelerated the inflammation process, mainly with IR laser irradiation. The number of synovial cell layers was reduced on irradiated group.

Complement Ther Clin Pract. 2010 Aug;16(3):158-60. Epub 2010 Jan 27.

Emg analysis after laser acupuncture in patients with temporomandibular dysfunction (TMD). Implications for practice.

Hotta PT, Hotta TH, Bataglion C, Bataglion SA, de Souza Coronatto EA, Siéssere S, Regalo SC.

Ribeirão Preto Dental School/ São Paulo University, Ribeirão Preto, SP, Brazil.

Abstract

The aim of this study was to analyze the effect of low level laser applied to acupuncture points of patients diagnosed with temporomandibular dysfunction (TMD). Ten patients aged between 20 and 50 years were clinically examined with regard to pain and dysfunction of the masticatory system. They received laser applications (GaAlAs diode laser, 780 nm wavelength; 70 mW power output, 35 j/cm(2)) in acupuncture specific points (Ig4, C3, E6, E7) once a week, for ten sessions. The range of jaw movement was registered after each session and visual analogue scale (VAS) was applied. Results were analyzed (SPSS-15.0-Chicago) during the comparison, before and after treatment. Statistical tests showed significant improvements (p < 0.01) in painful symptoms and electromyographic activities of masseter muscles in maximal habitual occlusion after laser applications but no significant improvements (p = 0.05) in measurements of mandibular movements. The laser therapy in specific acupuncture points promoted improvement of symptoms and it may be used as complementary therapy for TMD.

J Orofac Pain. 2010 Summer;24(3):293-7.

The Anti-inflammatory Effect of Low-Level Laser Therapy on Experimentally Induced Inflammation of Rabbit Temporomandibular Joint Retrodiscal Tissues.

Kucuk BB, Oral K, Selcuk NA, Toklu T, Civi OG.

Abstract

Aims: To investigate the effect of low-level laser therapy (LLLT) on experimentally induced inflammation in retrodiscal tissues of the rabbit temporo?mandibular joint (TMJ) using scintigraphic imaging. Methods: Eleven male New Zealand rabbits were included in this study. Six randomly selected rabbits were imaged to provide normal joint images (normal group) before the initiation of the experiment. A 5% formalin solution was locally injected into both right and left TMJs of all rabbits. Subsequently, Ga-Al-As laser (wavelength: 815 nm; energy density: 12 J/cm2; output power: 250 mW) was applied for 48 seconds. The treatment was performed six times for 2 weeks to the left TMJ of all rabbits. The right TMJs of the rabbits were used as the control (nontreated) TMJ group, while left TMJs were used as the treated TMJ group. Static images of TMJ were taken at 24 hours, 7 days, and 14 days after the beginning of the treatment. The images of all TMJs were taken in the posteroanterior direction with the rabbit under sedation and its mouth open. The Mann-Whitney U test was used to compare group differences, and intragroup differences were determined by the Friedman test and Wilcoxon sign test. Results: Significant differences were found between normal and both the control and treated TMJ groups. A reduction of inflammation in both treated and control TMJ groups was obtained, but there was no statistically significant difference between the groups. Conclusion: Under the conditions used in this study, quantitative scintigraphic measurements of TMJ inflammation of the treated TMJ group decreased but did not differ significantly from those of the control TMJ group. J Orofac Pain 2010;24:293-297.

Clin J Pain. 2010 Jul 20. [Epub ahead of print]

Effects of Superpulsed Low-level Laser Therapy on Temporomandibular Joint Pain.

Marini I, Gatto MR, Bonetti GA.

*Department of Orthodontics and Gnathology daggerSchool of Dentistry, Alma Mater Studiorum University of Bologna, Bologna, Italy.

Abstract

OBJECTIVES: A randomized double-blind study was conducted to compare the efficacy of superpulsed low-level laser therapy (SLLLT) with nonsteroidal anti-inflammatory drugs in the treatment of pain caused by temporomandibular joint disorders. METHODS: A total of 99 patients with temporomandibular joint disorders, secondary to disc displacement without reduction or osteoarthritis were randomly divided into 3 groups. Thirty-nine patients received SLLLT in 10 sessions over 2 weeks, 30 patients received ibuprofen 800 mg twice a day for 10 days, and 30 patients received sham laser as placebo in 10 sessions over 2 weeks. Pain intensity was measured by visual analog scale at baseline, 2, 5, 10, and 15 days of treatment. Mandibular function was evaluated by monitoring active and passive mouth openings and right and left lateral motions at baseline, 15 days, and 1 month of treatment. Magnetic resonance imaging was performed at baseline and the end of therapy. RESULTS: Mean visual analog scale pain scores in SLLLT group was significantly lower than in nonsteroidal anti-inflammatory drug group and control group (P=0.0001) from fifth day up to the end of the observation period. As for active and passive mouth openings and right and left lateral motions, superiority of SLLLT was evident 1 month after treatment (interaction time treatment, P=0.0001). DISCUSSION: Mandibular function improved in all SLLLT patients proving the effectiveness in the treatment of pain, as demonstrated by a significant improvement in clinical signs and symptoms of temporomandibular joint disc displacement without reduction and osteoarthritis at the end of treatment and stability over a period of 1 month.

Cranio. 2010 Apr;28(2):84-91.

Low level laser effects on pain to palpation and electromyographic activity in TMD patients: a double-blind, randomized, placebo-controlled study.

Venezian GC, da Silva MA, Mazzetto RG, Mazzetto MO.

Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Brazil.

Abstract

The purpose of this study was to evaluate the effect of diode laser (GaAIAs – 780 nm) on pain to palpation and electromyographic (EMG) activity of the masseter and anterior temporalis muscles. The laser was applied on the temporalis and masseter muscles twice a week (four weeks). Forty-eight (48) patients with myofascial pain were randomly assigned between actual and placebo treatments and between the energetic doses of 25 J/cm2 and 60 J/cm2, and were evaluated using VAS before, immediately after the final application, and 30 days after the laser treatment. Surface electromyography was performed with maximum dental clenching before and after laser therapy. The results show there were no significant statistical differences in the EMG activity between the groups before and after laser treatment. With regard to the pain at palpation, although both groups presented a significant difference in the symptoms before and after the treatment, only the active doses showed statistically significant reductions in pain level in all the regions of the palpated muscles. However, there was no significant statistical difference between groups (experimental and placebo). In conclusion, low level laser did not promote any changes in EMG activity. The treatment did, however, lessen the pain symptoms in the experimental groups.

Schweiz Monatsschr Zahnmed. 2010;120(3):213-25.

Laser acupuncture for myofascial pain of the masticatory muscles.  A controlled pilot study.

[Article in English, German]

Katsoulis J, Ausfeld-Hafter B, Windecker-Gétaz I, Katsoulis K, Blagojevic N, Mericske-Stern R.

Department of Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland. joannis.katsoulis@zmk.unibe.ch

Abstract

PURPOSE: The purpose of this investigation was to evaluate the effectiveness of laser acupuncture within the scope of a pilot study. METHODS: 108 adult patients were examined and of those eleven patients were included in the prospective pilot study. These patients took part voluntarily and were diagnosed with tendomyopathy of the masticatory musculature with maximum face and jaw pain on a visual analogous scale VAS > or = 30 in the last 14 days. Four patients wanted to be sure not to be assigned to the placebo group and were treated with the laser (group1, verum open, N = 4). The remaining seven were split by means of block randomisation into groups 2 (verum blind, N = 3) and 3 (placebo blind, N = 4). Two local points (ST 6, SI 18) and two distant points (SI 3, LI 4) on both sides of the body were stimulated (groups 1 and 2) or placebo-stimulated (group 3) with the LASERneedle machine for 15 minutes twice a week for three weeks (6 sessions). After three months a clinical follow-up was carried out, which included a standardised questionnaire as to the maximum pain intensity (VAS and verbal scale) and on the need for further treatment. A pain reduction (VAS) of about 50% was evaluated as a success. RESULTS: Pain decreased on average 40 VAS points for ten of eleven patients. The pain reduction on the VAS in group 1 (verum open) was more than 50% for all four patients, in group 3 (placebo blind) for three of four patients, and in group 2 (verum blind) all remained under 50%. The evaluation on the verbal scale showed a pain reduction from moderate to very strong pains initially, to moderate, light and no pain after three months for all three groups. DISCUSSION: The range of application of the laser was limited by the narrow inclusion criteria of the pilot study. The laser acupuncture (open and blinded) did not show a negative effect in any group. The pain reduction was strongest with the blinded patients of the placebo group. The worst performance was in the blinded group with laser acupuncture. CONCLUSION: Due to the low number of participants, no clear conclusion can be drawn. Laser needle acupuncture may be a treatment option for patients with an interest in a noninvasive, complementary therapy. But clarification and treatment planning on an individual basis must take place first.

Lasers Med Sci. 2010 Mar;25(2):229-32. Epub 2009 Jun 30.

Wavelength effect in temporomandibular joint pain: a clinical experience.

Carvalho CM, de Lacerda JA, dos Santos Neto FP, Cangussu MC, Marques AM, Pinheiro AL.

Laser Center, School of Dentistry, Federal University of Bahia (UFBA), Av. Araújo Pinho, 62, Canela, 40140-110 Salvador, BA, Brazil.

Temporomandibular disorders (TMDs) are common painful multifactorial conditions affecting the temporomandibular joint (TMJ) and whose treatment depends on the type and symptoms. Initially, it requires pain control, and, for this, drugs, biting plates, occlusal adjustment, physiotherapy or their association are used. Lately, laser phototherapy (LPT) has been used in the treatment of pain of several origins, including TMDs. This study reports the treatment of a selected group of 74 patients treated at the Laser Center of the Federal University of Bahia between 2003 and 2008. Following standard anamneses, clinical and imaging examination and with the diagnosis of any type of TMD, the patients were prepared for LPT. No other intervention was carried out during the treatment. Treatment consisted of three sessions a week for 6 weeks. Prior to irradiation, the patients were asked to score their pain using a visual analog scale (VAS). Lasers of wavelength (lambda)780 nm, lambda790 nm or lambda830 nm and/or lambda660 nm were used at each session (30/40 mW; spot (varphi) approximately 3 mm; mean dose per session 14.2 +/- 6.8 J/cm(2); mean treatment dose of 170 +/- 79.8 J/cm(2)). Of the patients, 80% were female ( approximately 46 years old). At the end of the 12 sessions the patients were again examined, and they scored their pain using the VAS. The results were statistically analyzed and showed that 64% of the patients were asymptomatic or had improved after treatment and that the association of both wavelengths was statistically significant (P = 0.02) in the asymptomatic group. It was concluded that the association of red and infrared (IR) laser light was effective in pain reduction on TMJ disorders of several origins.

Lasers Med Sci. 2009 Sep;24(5):715-20. Epub 2008 Nov 12.

Low-level laser therapy and myofascial pain dysfunction syndrome: a randomized controlled clinical trial.

Shirani AM, Gutknecht N, Taghizadeh M, Mir M.

Department of Oral Medicine, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran. am_shirani@dnt.mui.ac.ir

Abstract

Myofacial pain dysfunction syndrome (MPDS) is the most common reason for pain and limited function of the masticatory system. The effects of low-level lasers (LLLs) for controlling the discomfort of patients are investigated frequently. However, the aim of this study was to evaluate the efficacy of a particular source producing 660 nm and 890 nm wavelengths that was recommended to reduce of the pain in the masticatory muscles. This was a double-blind and placebo-controlled trial. Sixteen MPDS patients were randomly divided into two groups. For the laser group, two diode laser probes (660 nm (nanometers), 6.2 J/cm(2), 6 min, continuous wave, and 890 nm, 1 J/cm(2) (joules per square centimetre), 10 min, 1,500 Hz (Hertz)) were used on the painful muscles. For the control group, the treatment was similar, but the patients were not irradiated. Treatment was given twice a week for 3 weeks. The amount of patient pain was recorded at four time periods (before and immediately after treatment, 1 week after, and on the day of complete pain relief). A visual analog scale (VAS) was selected as the method of pain measurement. Repeated-measures analysis of variance (ANOVA), the t-test and the paired t-test were used to analyze the data. In each group the reduction of pain before and after the treatment was meaningful, but, between the two groups, low-level laser therapy (LLLT) was more effective (P = 0.031) According to this study, this type of LLLT was the effective treatment for pain reduction in MPDS patients.

Cranio. 2007 Jul;25(3):186-92.

Low intensity laser application in temporomandibular disorders: a phase I double-blind study.

Mazzetto MO, Carrasco TG, Bidinelo EF, de Andrade Pizzo RC, Mazzetto RG.

Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo (FORP-USP), Brazil. mazzetto@forp.usp.br

The purpose of this study was to evaluate the effectiveness of low intensity laser therapy (LILT) for the control of pain from temporomandibular disorder (TMD) in a random and double-blind research design. Forty-eight (48) patients presenting temporomandibular joint (TMJ) pain were divided into an experimental group (GI) and a placebo group (GII). The sample was submitted to the treatment with infrared laser (780 nm, 70 mW, 10 s, 89.7 J/cm2) applied in continuous mode on the affected temporomandibular region, at one point: inside the external auditive duct toward the retrodiskal region, twice a week, for four weeks. For the control group, two identical probes (one active and one that does not emit radiation) were used unknown by the clinician and the subjects. A tip planned for laser acupuncture was used and connected to the active point of the probe. The parameter evaluated was the intensity of pain after palpation of the condylar lateral pole, pre-auricular region and external auditive duct, according to the Visual Analogue Scale (VAS). Four evaluations were performed: Ev1 (before laser application), Ev2 (after 4th application), Ev3 (after 8th application) and Ev4 (30 days after the last application). Data were submitted to statistical analysis. The results showed a decrease in the pain level mainly for the active probe. Among the evaluations, the Ev3 exhibited lower sensitivity to palpation. In conclusion, the results show that low intensity laser is an effective therapy for the pain control of subjects with TMD.

Photomed Laser Surg. 2007 Aug;25(4):297-303.

Effectiveness of low-level laser therapy in temporomandibular joint disorders: a placebo-controlled study.

Fikácková H, Dostálová T, Navrátil L, Klaschka J.

Institute of Biophysics and Informatics, 1st Medical Faculty, Charles University, Prague, Czech Republic.

Abstract

OBJECTIVE: Low-level laser therapy (LLLT) treatment for pain caused by temporomandibular joint disorders (TMD) was investigated in a controlled study comparing applied energy density, subgroups of TMD, and duration of disorders. BACKGROUND DATA: Although LLLT is a physical therapy used in the treatment of musculoskeletal disorders, there is little evidence for its effectiveness in the treatment of TMD. METHODS: The study group of 61 patients was treated with 10 J/cm(2) or 15 J/cm(2), and the control group of 19 patients was treated with 0.1 J/cm(2). LLLT was performed by a GaAlAs diode laser with output of 400 mW emitting radiation wavelength of 830 nm in 10 sessions. The probe with aperture 0.2 cm(2) was placed over the painful muscle spots in the patients with myofascial pain. In patients with TMD arthralgia the probe was placed behind, in front of, and above the mandibular condyle, and into the meatus acusticus externus. Changes in pain were evaluated by self-administered questionnaire. RESULTS: Application of 10 J/cm(2) or 15 J/cm(2) was significantly more effective in reducing pain compared to placebo, but there were no significant differences between the energy densities used in the study group and between patients with myofascial pain and temporomandibular joint arthralgia. Results were marked in those with chronic pain. CONCLUSION: The results suggest that LLLT (application of 10 J/cm(2) and 15 J/cm(2)) can be considered as a useful method for the treatment of TMD-related pain, especially long lasting pain.

Cranio. 2007 Jul;25(3):186-92.

Low intensity laser application in temporomandibular disorders: a phase I double-blind study.

Mazzetto MO, Carrasco TG, Bidinelo EF, de Andrade Pizzo RC, Mazzetto RG.

Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo (FORP-USP), Brazil. mazzetto@forp.usp.br

The purpose of this study was to evaluate the effectiveness of low intensity laser therapy (LILT) for the control of pain from temporomandibular disorder (TMD) in a random and double-blind research design. Forty-eight (48) patients presenting temporomandibular joint (TMJ) pain were divided into an experimental group (GI) and a placebo group (GII). The sample was submitted to the treatment with infrared laser (780 nm, 70 mW, 10 s, 89.7 J/cm2) applied in continuous mode on the affected temporomandibular region, at one point: inside the external auditive duct toward the retrodiskal region, twice a week, for four weeks. For the control group, two identical probes (one active and one that does not emit radiation) were used unknown by the clinician and the subjects. A tip planned for laser acupuncture was used and connected to the active point of the probe. The parameter evaluated was the intensity of pain after palpation of the condylar lateral pole, pre-auricular region and external auditive duct, according to the Visual Analogue Scale (VAS). Four evaluations were performed: Ev1 (before laser application), Ev2 (after 4th application), Ev3 (after 8th application) and Ev4 (30 days after the last application). Data were submitted to statistical analysis. The results showed a decrease in the pain level mainly for the active probe. Among the evaluations, the Ev3 exhibited lower sensitivity to palpation. In conclusion, the results show that low intensity laser is an effective therapy for the pain control of subjects with TMD.

Photomed Laser Surg. 2006 Oct;24(5):637-41.

Evaluation of low-level laser therapy in the treatment of temporomandibular disorders.

Cetiner S, Kahraman SA, Yüceta? S.

Department of Oral and Maxillofacial Surgery, School of Dentistry, Gazi University, Ankara, Turkey. scetiner@gazi.edu.tr

Abstract

OBJECTIVE: The purpose of this study was to assess the effectiveness of low-level laser therapy (LLLT) in the treatment of myogenic originated temporomandibular disorders (TMD).

BACKGROUND DATA: Limited studies have demonstrated that LLLT may have a therapeutic effect on the treatment of TMD.

METHODS: Thirty-nine patients with myogenic TMD-associated orofacial pain, limited mandibular movements, chewing difficulties, and tender points were included in this study. Twenty-four of them were treated with LLLT for 10 sessions per day excluding weekends as test group, and 15 patients with the same protocol received placebo laser treatment as a control group. These parameters were assessed just before, just after, and 1 month after the treatment.

RESULTS: Maximal mouth-opening improvement, and reductions in pain and chewing difficulty were statistically significant in the test group when compared with the control group. Statistically significant improvements were also detected between two groups regarding reduction in the number of tender points.

CONCLUSION: Based on the results of this placebo-controlled report, LLLT is an appropriate treatment for TMD and should be considered as an alternative to other methods.

Photomed Laser Surg. 2006 Feb;24(1):45-9.

Management of mouth opening in patients with temporomandibular disorders through low-level laser therapy and transcutaneous electrical neural stimulation.

Núñez SC, Garcez AS, Suzuki SS, Ribeiro MS.

Centro de Lasers e Aplicações, IPEN-CNEN/SP, Av. Lineu Prestes 2242, CEP: 05508-900 São Paulo, SP, Brazil. silnunez@aol.com

OBJECTIVE: The aim of this study was to evaluate the effectiveness of low-level laser therapy (LLLT) and transcutaneous electrical neural stimulation (TENS) on the improvement of mouth opening in patients with temporomandibular disorder (TMD). BACKGROUND DATA: TMDs are conditions that affect the form and/or function of the temporomandibular joint (TMJ), masticatory muscles, and dental apparatus. Often TMD is associated with pain localized in the TMJ and/or in the muscles of the face and neck. METHODS: This clinical trial was performed in 10 patients, 18-56 years old, diagnosed with TMD of multiple causes. All patients received both methods of treatment in two consecutive weeks. LLLT was delivered via a 670-nm diode laser, output power 50 mW, fluence 3 J per site/4 sites (masseter muscle, temporal muscle, mandibular condyle, and intrauricular). TENS therapy was applied with a two-electrode machine at 20 W, maximum frequency of 60 Hz, adjusted by the patient according to their sensitivity. The amplitude of mouth opening was recorded before treatment and immediately after using a millimeter rule; the measurements were performed from the incisal of the upper incisors to the incisal of the lower incisors. A paired t-test was applied to verify the significance of the results. RESULTS: A significant improvement in the range of motion for both therapies was observed immediately after treatment. Comparing the two methods, the values obtained after LLLT were significantly higher than those obtained after TENS (p < 0.01). CONCLUSIONS: Both methods are effective to improve mouth opening. Comparing the two methods, LLLT was more effective than TENS applications.

Photomed Laser Surg. 2006 Aug;24(4):522-7

Arthralgia of the temporomandibular joint and low-level laser therapy.

Fikácková H, Dostálová T, Vosická R, Peterová V, Navrátil L, Lesák J.

Institute of Biophysics and Informatics, 1st Medical Faculty, Charles University, Prague, Czech Republic. hfikackova@hotmail.com

OBJECTIVE: This case report describes the treatment of a patient with arthralgia of the temporomandibular joint (TMJ) caused by disc displacement. BACKGROUND DATA: The goal of the treatment of TMJ arthralgia is to decrease pain by promotion of the musculoskeletal system’s natural healing ability. METHODS: This report describes the complex treatment of TMJ arthralgia. Low-level laser therapy (LLLT) was chosen for its antiinflammatory and analgesic effects. Laser therapy was carried out using the GaAlAs diode laser with an output power of 400 mW, emitting radiation with a wavelength of 830 nm, and having energy density of 15 J/cm2; the laser radiation was applied by contact mode on four targeted spots in 10 sessions. Physiotherapy was recommended to this patient to prevent the injury of intraarticular tissue caused by incorrect movement during opening of the mouth. Splint stabilization and prosthetic treatment were used to reduce overloading of the TMJ, resulting from unstable occlusion and to help repositioning of the dislocated disc. RESULTS: Five applications of LLLT led to decrease of pain in the area of the TMJ on the Visual Analog Scale, from 20 to 5 mm. The anti-inflammatory effect of the laser was confirmed by thermographic examination. Before treatment, the temperature differences between the areas of the normal TMJ and TMJ with arthralgia was higher than 0.5 degrees C. However, at the conclusion of LLLT, temperatures in the areas surrounding the TMJ were equalized. CONCLUSION: This study showed the effectiveness of complex non-invasive treatment in patients with arthralgia of the TMJ. The analgesic and anti-inflammatory effects of LLLT were confirmed by infrared thermography.

Scand J Rheumatol. 2003;32(2):114-8.

Effectiveness of low-level laser therapy in tempormandibular disorder

Kulekcioglu S, Sivrioglu K, Ozcan O, Parlak M.

Department of Physical Medicine and Rehabilitation, Uludag University School of Medicine, Bursa, Turkey.

OBJECTIVE: To investigate the effectiveness of low-level laser therapy in the treatment of temporomandibular disorder and to compare treatment effects in myogenic and arthrogenic cases.

METHODS: Thirty-five patients were evaluated by magnetic resonance imaging and randomly allocated to active treatment (n=20) and placebo treatment (n= 15) groups. In addition to a daily exercise program, all patients were treated with fifteen sessions of low-level laser therapy. Pain, joint motion, number of joint sounds and tender points were assessed.

RESULTS: Significant reduction in pain was observed in both active and placebo treatment groups. Active and passive maximum mouth opening, lateral motion, number of tender points were significantly improved only in the active treatment group. Treatment effects in myogenic and arthrogenic cases were similar.

CONCLUSION: Low-level laser therapy can be considered as an alternative physical modality in the management of temporomandibular disorder.

Australian J Physiother. 2003; 49: 107-116.

A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders.

Bjordal J M, Couppè, C, Chow R, Tunér J, Ljunggren A E.

The authors investigated if low level laser therapy of the joint capsule can reduce pain in chronic joint disorders (CJD). A literature search identified 88 randomised-controlled trials, of which 20 trials included patients with CJD. Six trials had to be excluded for not irradiating the joint capsule. Three trials used doses lower than a denominated a priori dose range for reducing inflammation in the joint capsule. These trials found no significant difference between active and placebo treatments. The remaining 11 trials, including 565 patients, were of acceptable methodological quality with an average PEDro score of 6.9 (range 5-9). In these trials, LLLT within the suggested dose-range was administered to the knee, temporomandibular and zygapophyseal joints. The results showed a mean weighted difference in change of pain on VAS by 45.6 % (95 % CI 35.0 to 56.2) in favour of LLLT. Global status was improved for 33.4 % (95% CI 20.9 to 45.9) more patients in the LLLT group. LLLT with the suggested dose range significantly reduces pain in CJD, but the heterogeneity in patient samples, treatment procedures and trial design calls for cautious interpretation of the results.

Laser med Surg Abstract issue, 2002: 18

Clinical evaluation of the low intensity laser antialgic action of GaAlAs (wavelenght=785 nm) in the treatment of the temporomandibular disorders.

Sanseverino N T M, Sanseverino C A M, Ribeiro M S et al.

The improved outcome of laser therapy, if higher doses are given, is documented in the study by Sanseverino 10 patients with pain and limitation of movements of the jaw were treated by 785 nm GaAlAs laser, dose 45 J/cm2. The joint and tender points in the masticatory and otherwise involved muscles was applied three times per week during three weeks. A control group of 10 patients was given sham laser therapy. The evaluation was performed through subjective pain assessment and measurement of the movements of the jaw. There was a significant improvement in the laser group only.

Clinical evaluation of the low intensity laser antialgic action of GaAlAs in the treatment of the temporomandibular disorders. 2001.

SANSEVERINO, N. T. M.

Dissertation (Professional Master’s Degree “Lasers in Dentistry”) – Nuclear and Energy Research Institute / School of Dentistry, University of São Paulo, São Paulo.
Advisor: Eduardo De Bortoli Groth, DDS, PhD, Martha Simões Ribeiro, DDS, PhD

The therapy with laser emitting low intensity has been currently used in the most diverse fields of medicine as therapeutic conduct for pain. lt is a non-invasive, painless, non-thermal and aseptic type therapy, without any collateral effects, having a good cost/benefit relationship. However, for the therapy with low-intensity laser to result in positive effects, a correct diagnosis is fundamental, as well as a protocol of adequate application. In odontology, the majority of patients diagnosed with temporomandibular disorders (TMD), present pain and limitations in the movements of the jaw. In this work, a GaAlAs laser emitting low intensity, was used, ?=785nm, in patients having a dysfunction of the temporomandibular joint with a complaint of pain. Twenty patients were divided into two groups. The group treated received laser treatment in the temporomandibular articulations and in the muscles affected. The dose applied was 45J/cm2, while the ten patients in the control group received 0J/cm2, in a total of nine applications, carried out three times a week, during three weeks. The evaluation of the patients was made through clinical examinations of manual palpation of the masseter, temporal, cervical, posterior neck and sternocleidomastoid muscles, and measurements of opening and laterality of the mouth. The results obtained showed a diminishing of the pain and an increase of the mandibular mobility in the patients treated, when compared to the control group. These results point to this therapy as being an important tool in the treatment of pain in patients with a dysfunction in the TMJ, indicating this therapeutic modality as a co-adjuvant in these treatments.

J Clin Laser Med Surg. 1998 Aug;16(4):223-6.

Low-level laser therapy is an important tool to treat disorders of the maxillofacial region.

Pinheiro AL, Cavalcanti ET, Pinheiro TI, Alves MJ, Miranda ER, De Quevedo AS, Manzi CT, Vieira AL, Rolim AB.

Laser Center, School of Dentistry, Universidade Federal de Pernambuco, Brazil.

Abstract

OBJECTIVES: The authors report on the effects of low-level laser therapy (LLLT) in the treatment of maxillofacial disorders. SUMMARY AND BACKGROUND DATA: Further to our previous studies, this paper reports the results of the use of LLLT on the treatment of several disorders of the oral and maxillofacial region. This paper presents LLLT as an effective method of treating such disorders. METHODS: Two hundred and five female and 36 male patients ages between 7 and 81 years old (average 38.9 years old), suffering from disorders of the maxillofacial region, were treated with 632.8, 670, and 830 nm diode lasers at the Laser Center of the Universidade Federal de Pernambuco, Recife, Brazil (UFPE). The disorders included temporomandibular joint (TMJ) pain, trigeminal neuralgia, muscular pain, aphatae, inflammation, and tooth hypersensitivity postoperatively and in small hemangiomas. Most treatment consisted of a series of 12 applications (twice a week) and in 15 cases a second series was applied. Patients were treated with an average dose of 1.8 J/cm2. RESULTS: One hundred fifty four out of 241 patients were asymptomatic at the end of the treatment, 50 improved considerably, and 37 were symptomatic. CONCLUSIONS: These results confirm that LLLT is an effective tool and is beneficial for the treatment of many disorders of the maxillofacial region.

J Clin Laser Med Surg. 1997;15(4):181-3.

Low-level laser therapy in the management of disorders of the maxillofacial region.

Pinheiro AL, Cavalcanti ET, Pinheiro TI, Alves MJ, Manzi CT.

School of Dentistry, Universidade Federal de Pernambuco, Recife, Brazil.

Abstract

OBJECTIVE: The authors analysed the effects of low-level laser therapy (LLLT) on the treatment of maxillofacial disorders. SUMMARY BACKGROUND DATA: Pioneer work published by Mester et al. opened a new frontier in the clinical treatment of many disorders with the use of LLLT. Although LLLT is not well accepted in many places, its use is growing steadily in others, including Europe and more recently in Brazil. METHODS: One hundred forty-one female and 24 male patients, between 7 and 81 years of age (average = 39.2 years old), suffering from disorders of the maxillofacial region were treated with 632.8-nm, 670-nm, and 830-nm diode lasers at the Laser Center of the Universidade Federal de Pernambuco. The disorders included temperomandibular joint pain, trigeminal neuralgia, muscular pain, aphatae, inflammation, and tooth hypersensitivity both postoperatively and in small hemangiomas. Most treatment consisted of a series of 12 applications (twice a week), and in eight cases a second series was applied. Patients were treated with an average dose of 2.5 J/cm2. RESULTS: One hundred twenty out of 165 patients were asymptomatic at the end of the treatment, 25 improved considerably, and 20 were symptomatic. CONCLUSIONS: These preliminary results indicate that LLLT is an important tool and brings many benefits for the treatment of many disorders of the maxillofacial region.

Ann Ital Chir. 1997 Jul-Aug;68(4):505-9.

The treatment of cranio-facial pain by electroacupuncture and laser irradiation.

Costantini D, Delogu G, Lo Bosco L, Tomasello C, Sarra M.

Istituto di Anestesiologia e Rianimazione Università degli Studi di Roma La Sapienza.

Abstract

Craniofacial neuralgias represent an interesting medical challenge, especially regarding the complex therapeutical aspects. Our study was performed treating more than 700 patients, applying steel inox needles variable in diameters and length for about 20 minutes, with a total application number ranging between 10 and 20. Results have been defined referring to a 4-grades response scale: excellent, good, fairly good and insufficient. It is important to emphasise that the best results have been achieved with patients who chose the acupuncture as the first therapeutic approach, while patients who underwent other previous medical and/or surgical treatment have had a worse response. The authors assert that acupuncture and infrared laser reflex therapy represent a harmless and effective treatment of such a diffuse and invalidating disease.

Cranio. 1997 Apr;15(2):144-9.

 

Low level laser therapy in the treatment of temporomandibular disoders (TMD): a double-blind pilot study.

Conti PC.

Bauru School of Dentistry, University of Sao Paulo, Brazil.

The aim of this paper was to evaluate the efficacy of a Low-Level Laser therapy in patients with Temporomandibular Disorders (TMD) using a double-blind design. A sample of 20 patients with a chief complaint of pain was divided into myogenous and arthrogenous groups. The sample was also divided on the basis of the treatment rendered: real versus placebo treatment. An 830 nm Ga-Al-As Laser device with a energy power of 4 joules was used (OMNILASE, LASERDYNE PTY LTD.) in three treatment sessions. To evaluate the effectiveness of laser treatment, a Visual Analogue Scale (VAS) was used for pain and active range of motion (AROM) was used to measure changes in mandibular function. Using real laser treatment, the author found that there was a reported improvement in pain only for the myogenous pain patients (p < or = 0.02). For the arthrogenous pain patients, real laser treatment resulted in an improvement in Total Vertical Opening (TVO) (p < 0.05), Protrusive excursion (PROT) (p < 0.02) and Left lateral excursion (LATLEF) (p < 0.02). The placebo control group showed improvement in TVO and PROT for those patients having myogenous pain and LATLEF for those patients having arthrogenous pain. A repeated measurement one-way ANOVA demonstrated no significant differences between real and placebo groups. Considering the non-invasive and harmless characteristics of this modality, more research is recommended, using higher power and increased frequency of laser applications.

Tandlægebladet. 1994; 98 (2): 526-529.

GaAlAs laser treatment evaluated for trigeminal neuralgia, paresthesia, atypical facial pain and temporo-mandibular joint pain in a 5 year study. –

In Danish.

Eckerdal A, Lehmann Bastian H.

Can low reactive-level laser therapy be used in the treatment of neurogenic facial pain? A double-blind, placebo controlled investigation of patients with trigeminal neuralgia. Laser Therapy. 1996; 8: 247-252. At the Odense University Hospital, Denmark, Arne Eckerdal has evaluated the effect of 830 nm, 30 mW, laser treatment for a number of indications. Patients suffering from trigeminal neuralgia (n = 36) had a positive result in 81% at the end of treatment, 42% at 1-year control. Patients having received previous alcohol blocks (n = 14) responded less favourably to the treatment. 50% were pain free at the end of the treatment period, 20% at 1 year control. Patients with non-specific facial pain (n = 63) were pain free at the end of treatment, 44% at follow up one year later.  In a group of 22 patients with paresthesias (n = 22), only 5 were successful at end of treatment , 4 were improved and 13 were not improved.  The result at 6 and 12 months were the same.   Patients with temporo-mandibular pain (n = 40) were improved in 73% and at 1 year control still 70% were pain free.

LOW INTENSITY LASER THERAPY (LILT) IN THE MAXILLOFACIAL REGION

Paul Bradley The Royal London School of Medicine and Dentistry, London, England

The region of the face and mouth is well suited to Low Intensity Laser Therapy (LILT) in view of ease of access. It is also an area associated with a variety of painful conditions and intractable ulcers which have proved amenable to LILT in a total of around 500 cases. Our practice is based on several postgraduate research projects:

1. Studies of depth penetration of 820nm. These have been undertaken using a CCD camera to demonstrate penetration depths in non vital tissue specimens augmented by observations in the living subject with isotropic detectors.
2. Investigation of vascular response. A thermographic camera has been used for local heating effects while laser doppler has been employed to measure microcirculatory flux. Ultrasound doppler allowed monitoring of arterial status. A variety of wavelengths and fluxes have been investigated.
3. Double blind clinical trial in temporomandibular joint disorder pain. Methods have included algometry for pressure point thresholds, electromyography for muscular activity and sensor tracking for mandibular movement.
4. Study of effect on osseointegration of implants in jaw and femur.

Research methods have involved mechanical push out testing, radiovisiography, x-ray microtomography and histomorphometry in the rabbit experimental model. On the basis of the data acquired clinical practice has been undertaken particularly in the following conditions:
1. Post Herpetic Neuralgia,
2. Temporomandibular Joint Disorder Pain
3. Trigeminal Neuralgia
4. Atypical Facial Pain,
5. Pain from Acute Maxillofacial Trauma
6. Palliation of Pain from Unresectable Orofacial Cancer,
7. Intractable Oral Ulcerations, 8. Nerve Lesions,
9. Cavernous Haemangiomas Of the Facial Region in Infants

The results of this clinical practice are described and analyzed.

 

 

PhD dissertation on TMD problems

Dr Sajee Sattayut of The Department of Oral & Maxillofacial Surgery, St Bartholomew’s and the Royal London School of Medicine and Dentistry (professor Paul Bradley) has put forward his PhD thesis on the effect of 820 nm low level laser on patients with TMD (temporo-mandibular-joint-disorders). In a double blind study on 30 female TMD patients one group was given placebo laser, one a low dose from a 60 mW laser and the third a high dose from a 300 mW GaAlAs laser. Three treatments were given during one week. The patients in the high energy density group had significantly increases in Pressure Pain Threshould and EMG amplitude, recorded from voluntary clenching. A significantly greater number of patients recovered from myofacial pain and TMJ arthralgia as assessed clinically in the higher energy group. At a period of 2 to 4 weeks review after LLLT, there was an average 52% reduction of pain as assessed by Symptom Severity Index pain questionnaire. In an in vitro study laser was observed to reduce IL-1 stimulated PGE2 production.