Effectiveness of Physiotherapy and GaAlAs Laser

in the Management of Temporomandibular Joint Disorders

Tatjana Dostalova , M.D., Ph.D., DrSci, M.B.A.,
1
Petra Hlinakova M.D.,
1
Magdalena Kasparova, M.D.,
1
Adam Rehacek, D.M.D.,
1
Lenka Vavrickova, M.D.,
2
and Leos Navra til, M.D., Ph.D. DrSc
3
Abstract
Objective: Low-level laser therapy (LLLT) is a treatment method commonly used in physiotherapy for mus-
culoskeletal 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 ve treatment sessions
(energy density of 15.4J/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. Signicant 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 signicantly atter 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 42mm. Conclusions: The laser therapy was effective in the improvement of the range of temporo-
mandibular disorders (TMD) and promoted a signicant reduction of pain symptoms.
Introduction
T
emporomandibular disorders (TMD) occur as a re-
sult of problems with the jaw, temporomandibular
joint (TMJ), and surrounding facial muscles that control
chewing and moving the jaw.
1
The TMJ is the hinge joint that
connects the lower jaw(mandible) to the temporal bone of the
skull, which is immediately in front of the ear on each side of
the head. The joints are exible, allowing the jaw to move
smoothly up and down and from side to side. Symptoms of
TMD include headaches, tenderness of the chewing muscles,
and clicking or locking of the joints.
2
More than 40% of the
general population has at least one sign of TMD; however,
only one in four of such people is actually aware of, or reports
any symptoms, with only 1020 % seeking treatment.
3
One of
the most popular areas of TMD research is developing clear
guidelines for diagnosing these disorders. Automatic mea-
surement and classication of TMDs before and during the
treatment can assist in early diagnosis and accurate moni-
toring of treatment, and can enhance the efcacy of the
treatment.
Current methods for TMD detection involve a physical
examination by an expert in the TMJ area.
2
A dentist or
clinician almost always diagnoses a TMD, based solely on
a persons medical history and on a physical examination.
A typical clinical nding of patients with TMD is a lateral
and posterior tenderness of the TMJ on palpation, and pain
in the area of the TMJ during maximum opening and
during lateral excursion. A TMD patient has pain/ dis-
comfort in the jaw, mainly in the region of the TMJ and/or
muscles of mastication, and limitation of mandibular
function.
47
These patients can be managed with nonsurgical thera-
pies, but some end-stage TMJ patients require surgical TMJ
repair or reconstruction. A multifactor etiology for TMD is
proposed. The possible suggested causal factors include
many different structural parameters such as psychological
variables, acute trauma, degenerative articular illness, and
1
Department of Paediatric Stomatology, 2nd Medical Faculty, Charles University, Prague, Czech Republic.
2
Department of Stomatology, Charles University, Hradec Kralove, Czech Republic.
3
Department of Medical Biophysics and Medical Informatics, 3rd Medical Faculty, Charles University, Prague, Czech Republic.
Photomedicine and Laser Surgery
Volume 30, Number 5, 2012
Mary Ann Liebert, Inc.
Pp. 275280
DOI: 10.1089/pho.2011.3171
275
functional mandibular overload variables. The patient can
develop end-stage TMJ as a result of trauma, osteoarthritis,
reactive arthritis, ankylosis, idiopathic condylar resorption,
connective tissue/autoimmune diseases (e.g., rheumatoid
arthritis, psoriatic arthritis, lupus, scleroderma, Sjogrens
syndrome, ankylosing spondylitis) or other TMJ pathologies.
4
Unclear etiology of TMD, the same clinical ndings re-
sulting from various causes and the proven relation between
TMD and psychological factors, are the main reasons why
there is still no consensus in classication of TMD.
1,8
One of
the most commonly used diagnostic schemes intended for
research purposes is the Research Diagnostic Criteria for
TMD (RDC/TMD). It standardizes clinical examination of
patients with TMD, improves reproducibility among clini-
cians, and facilitates comparison of results among research-
ers.
1
TMD is considered to be a subgroup of musculoskeletal
disorders.
810
This may explain reports of successful use of
physical therapy in the treatment of TMD.
Low-level laser therapy (LLLT) is a local application of a
monochromatic, narrow-band, coherent light source. LLLT
is recommended as a treatment option for TMD guidelines
but with limitations, because of heterogeneous laser pa-
rameters and a lack of dosage consensus in the LLLT liter-
ature. The action of LLLT is disputed, but it the analgesic,
anti-inammatory and stimulative effects have been con-
rmed.
1118
Although LLLT is a treatment method com-
monly used in physiotherapy of musculoskeletal disorders,
there are few studies that deal with its utilization in the
treatment of TMD.
The aim of study is monitor the function of TMJ and
surrounding tissues and compare the objective results of the
effect of LLLT.
Materials and Methods
Subjects
The study group consisted of 104 consecutive patients (17
men with average age 18.57 years and 87 women with av-
erage age 27.57 years) with TMJ pain, who were referred
from medical practitioners and dentists to the Department of
Oral and Maxillofacial Surgery at Charles University in the
years 20102011. The clinic is the primary referral center for
TMD at the institution, as both conservative and surgical
treatments are offered. Patients were referred to the center
for treatment with reported pain or malfunction of the tem-
poromandibular region as the primary problem. The patients
including in our study were divided into several groups
according to the type of therapy used:
1. No treatment, 2 patients (2.08 %);
2. Conservative treatment and stabilization splint, 48 pa-
tients (49.92 %);
3. Conservative treatment, stabilization splint and physical
therapy including GaAlAs laser, 27 patients (28.08 %);
4. Conservative treatment, stabilization splint and ar-
throcentesis, 12 patients (12.48 %);
5. Conservative treatment, stabilization splint and wis-
dom teeth extraction, 8 patients (8.32 %); and
6. Surgical therapy; TMJ prosthesis, 7 patients (7.28 %).
The criteria of inclusion/exclusion for different groups
were presence of pain, tenderness over the TMJ, swelling of
the TMJ, and abnormal motion of the TMJ.
Average length of treatment was 11.58 months for men
and 9.45 months for women.
Of the total of 104 TMJ pain patients referred for the rst
assessment, 77 did not meet the inclusion criteria; 27 subjects
were included in this study. All had failed to obtain satis-
factory pain relief after an initial treatment protocol, in-
cluding self-care (soft diet, cold/hot packs) and occlusal
appliance (hard acrylic, full-arch maxillary stabilizationtype
splint). Patients were instructed to adhere to this treatment
protocol for a period of 6 weeks; they were not subjected to
treatment within the last 2 weeks before the trial.
The prospective study was conducted according to
American Dental Association (ADA) recommendations. Pa-
tients were requested to provide informed consent to the
clinical examination and regular follow-ups, including pho-
tographic records by means of the informed consent form in
accordance with the Declaration of Helsinki.
Clinical examination
Treatment was initiated in the incorrect jaw alignment
evaluation. A gradual analysis of TMJ was evaluated by
cephalometric radiography, orthopantomogram, TMJ to-
mogram (Gendex, Oralix 9200, Milan, Italy), and computer
face-bow record (Arcus Digma, KAVO Dental, Biberach,
Germany). Twenty-four different measurements (22 skull
points; computer-assisted analysis) were used as determi-
nates of the skeletal sagittal jaw relationship (Fig. 1). Dol-
phin Imaging 11.0 Cephalometric Tracing Analysis
(CephX Inc. Las Vegas, NV) evaluated the planes: SNA,
sella-nasion point A; SNB, sella-nasion point B; SGo NMe,
sella-gonion nasion-menton; Ar-Go-Me, articulare gonion-
menton; the results were compared with healthy ortho-
dontic patients.
19
Computer face-bow record (Arcus Digma, KAVO Dental,
Biberach, Germany) and functional analysis with Protar ar-
ticulator settings (KAVO Dental, Biberach, Germany) moni-
tored the TMJ movement before and after treatment (Fig. 2).
Interalveolar space between central incisors before and
after therapy was measured.
Subjective observations
Patients evaluated pain on the Visual Analog Scale (VAS);
where 0 indicates no pain and 100 indicates the worst
possible pain. The reported pain by patients on VAS was
determined.
Treatment
Patients were recommended not to open the mouth max-
imally; to avoid biting hard food, and not to chew gum.
Stabilization with hard acrylic splint was made to cover all
the teeth in the upper jaw. The splint surface was smooth to
provide centric relation occlusion, eliminating posterior in-
terferences and anterior guidance on frontal teeth and re-
ducing neuromuscular activity. When the pain was not
reduced the low-level laser was applied.
Statistical analysis
Statistical Student t test (at the signicance level p =0.01)
including standard deviation was implemented to monitor
objective measurements and subjective pain evaluation.
276 DOSTALOVA

ET AL.
Laser system treatment
LLLT was performed in ve treatment sessions by semi-
conductive GaAlAs laser (BTL Beauty-line Technology Laser,
Brno, Czech Republic) with an output operating power of
280 mW, emitting radiation wavelength of 830 mm. The laser
supplied a spot of *0.2 cm.
2
Patients were treated with an energy density of 15, 4 J/cm
2
in ve sessions (ve weekly treatments)
15
(Table 1). The laser
probe with collimation tip was placed over the spots that
were tender to palpation on the masticatory muscles, which
were detected during the clinical examination in front of the
tragus, when the mouth was open, through the meatus
acusticus externus, when the mouth was open, and 2 cm in
FIG. 2. Computer face-bow record and
functional analysis with Protar articulator
settings monitor the TMJ movement before
and after treatment.
FIG. 1. Dolphin imaging 11.0 cephalometric tracing analysis.
GaAlAs LASER IN THE MANAGEMENT OF TMJ DISORDERS 277
front of tragus, under the zygomatic arch, when the mouth
was closed. The total treatment dose was 46.2 J/cm
2
; total
energy was 9.24 J.
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. Signicant differences were seen in
the posterior face height and anterior face height. Relation-
ships SNA, SNB, and SGo:Nme were signicantly lower and
the Ar-GoMe area was signicantly higher (Table 2) when
the values were compared with the healthy patients.
Also, the results comparing healthy and impaired TMJ
sagittal condyle paths showed that patients with TMJ pain
during function had atter nonanatomical movement during
function. Those differences between left and right TMJ were
also signicant (Table 3).
The running evaluation of the treatment results showed
that decrease in pain occurred in the majority of TMD
patients between the second and fourth therapeutic sessions.
The unpleasant feeling was reduced on the pain VAS after
therapy from 27.5 (variability 9.89) to 4.16 (variability
5.84) (Fig. 3).
The pain had reduced the ability to open the mouth. After
application of laser, the ability to open the mouth increased
from 34 (variability 4.32) to 42 mm (variability 3.77)
(23.53 %) (Fig. 4).
Paired Student t test at the signicance level p= 0.01 ob-
jectively veried interalveolar space increase and conrmed
VAS pain decrease.
Discussion and Conclusions
The initial treatment of TMD frequently focuses on the
use of placebo control methods.
15
LLLT was applied in our
study as a noninvasive auxiliary therapy for pain decrease
in patients with TMD. It has been employed as element that
has biomodulatory, anti-inammatory and analgesic effects
on physiological, cellular, and systemic responses. LLLT
has been considered effective in reducing pain and mus-
cular tension, thus improving the quality of patients lives.
20
Dose and beam parameters are critical for successful laser,
LED, and other light therapy treatment.
21
In our study, it
was conrmed that patients not only had anatomical
changes in the TMJ but also had reduced anterior and
posterior face height. Deformities were the cause the TMJ
pain, and analgesic effects helped to reduce the chronic
pain.
Evaluations analyzing the painful symptoms at the
right and the left sides in the treated group show that there
was a signicant difference between the healthy and im-
paired TMJ. LLLT was effective in reducing the painful
symptoms following optimal mouth opening. LLLT in-
creased pain tolerance because of changes in cellular
membrane potency, vasodilatation, reduction of edema,
Table 1. Laser Experimental Arrangement
Laser medium GaAlAs laser diode
Wavelength 830 nm
Output power - maximum 400 mW
Output power - operating 280 mW
Probe aperture 0.2 cm
2
Energy density 15.4 J/cm
2
Time 11 sec
Frequency Continuous
Kind of application Contact
Number of treatment sessions 5
Number of treated points 3
Total treatment dose 46.2 J/cm
2
Total energy 9.24 J
Table 2. Cephalometric Analysis
Analysis
20
SNA SNB Sgo:Nme Ar-Go-Me
Bjork 82.0
SD:3.5
80.9
SD:3.4
120.8
SD:6.7
Roth-Jarabak 82.0 80.9 65.0
SD:4.0
120.8
SD:6.7
Jarabak 82.0 80.9 65.0 120.8
SD:6.7
McLaughlin 82.0 80.0
SD:3.0
Czech standard
population
80.82
SD: 4.20
78.66
SD: 3.94
70.83
SD:5.49
Czech TMJ
diseases
80.08
a
SD: 3.16
76.56
a
SD: 3.88
64.84
a
SD:5.65
125.32
a
SD: 7.07
SNA, sella-nasion Point A; SNB, sella-nasion Point B; SGo:Nme,
sella-gonion nasion-menton; Ar-GoMe, articulare gonion-menton.
a
Signicant value; SD. standard deviation.
Table 3. Arcus Digma Analysis
TMD
Average
value SD
Sig.
(two-tailed)
Right joint HCN/HCI l. sin. 32.60 7.70 * 0.013
l. dx. 11.56 17.56
Bennett angle l. sin. 8.17 4.90 0.96
l. dx. 7.99 8.91
ISS l. sin. 0.06 0.15 0.34
l. dx. 0.00
Shift angle l. sin. -4.84 15.20 0.64
l. dx. -0.49 18.16
Left joint HCN/HCI l. sin. 31.47 13.65 * 0.11
l. dx. 10.74 24.52
Bennett l. sin. 10.67 7.67 0.74
l. dx. 9.04 8.10
ISS l. sin. 0.12 0.12 0.21
l. dx. 0.04 0.05
Shift angle l. sin. 3.80 15.97 0.97
l. dx. 3.44 20.04
Anterior
guidance
Right l. sin. 22.08 16.55 0.21
l. dx. 38.88 24.52
Middle l. sin. 31.13 25.32 0.67
l. dx. 37.48 21.31
Left l. sin. 34.68 13.01 0.19
l. dx. 21.66 17.15
HCN, joint path angle; HCI, horizontal condylar inclination; ISS,
immediate side shift; l. sin., lateris sinistri (laterotrusion left); l. dx.,
lateris dextri (laterotrusion right).
278 DOSTALOVA

ET AL.
increase in intracellular metabolism, and acceleration of
wound healing.
20,22
The laser therapy was efcient in promoting an increase of
mandibular movements in the patients who received the
active laser dose.
23
We also conrmed the fact that the an-
algesic effect of low-intensity lasers had a direct effect on
mouth opening and decrease in the VAS scores. Those results
showed signicant differences among the healthy and im-
paired TMJ.
It is known that LLLT was applied on the selected points
considering the presence of nociceptors in the periarticular
tissues (discal ligaments, capsular ligaments, and retrodiscal
tissues), because these structures are involved in TMJ
pain.
15,23,24
Our study veried that pain in TMJ is directly
connected with discrepancies in TMJ paths and in the
physiology and anatomy of the dental skull. The actual an-
algesic efcacy of LLLT stems from the fact that TMD
symptoms have been treated by a wide array of methods
separately, such as interocclusal splint, medication, physical
therapy, and surgical procedures, and lasers can be of great
value because of the increase of beta endorphin level, in-
crease of pain discharge threshold, decrease of bradykinin
and histamine release, increase of lymphatic ow, decrease
of edema and algesic substances, increase of blood supply,
time reduction of inammation, and promotion of muscle
relaxation.
25
The results of the study conrmed that the laser therapy
was effective in the improvement of the range of TMD, and
promoted a signicant reduction of pain symptoms.
Acknowledgment
This research has been supported by a Grant of the Czech
Ministry of Education by IGA MZCR 9902-4, 9991-4 Grant,
and GAUK No.: 89008.
Author Disclosure Statement
No conicting nancial interests exist.
References
1. McNeill, C. (1993). Temporomandibular disorders: guide-
lines for classication, assessment and management. Chica-
go: Quintessence Publishing Co., Inc.
2. Dworkin, S.F., and LeResche, L. (1992). Research diagnostic
criteria for temporomandibular disorders: Review, criteria,
examinations and specications, criteria. J. Craniomandib.
Disord. 6, 301355.
3. Okeson, J.P. (1996). Orofacial pain. Guidelines for assess-
ment, diagnosis, and management, Chicago: Quintessence
Publishing Co., Inc.
4. Wilding, R.J. and Shaikh, M. (1997) Muscle activity and jaw
movements as predictors of chewing performance. J. Orofac.
Pain 11, 2436.
5. Christensen, L.V., and Rassouli, M.N. (1995) Experimental
occlusal interferences. Part V. Mandibular rotations versus
hemimandibular translations. J. Oral Rehabil. 22, 865876.
6. Took, C.C., Sanei, S., Chambers, J., and Dunne, S. (2006).
Underdetermined blind source separation of temporoman-
dibular joint sounds. IEEE Trans. Biomed. Eng. 53, 21232126.
7. Kuwahara, T., Bessette, R.W., and Maruyama T. (1995).
Chewing pattern analysis in TMD patients with unilateral
internal and bilateral derangement. Cranio. 13, 167172.
8. McNeill, C. (1997). History and evolution of TMD concepts.
Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 83,
5160.
9. Goldstein, B. (1999). Temporomandibular disorders: A re-
view of current understanding. Oral Surg. Oral Med. Oral
Pathol. Oral Radiol. Endod. 88, 379385.
10. Bradley, P., Groth, E., and Gursoy, B. (2000). The maxillofacial
region: recent research and clinical practice in low intensity
level laser therapy, in: Lasers in Medicine and Dentistry. Z. Si-
munovic (ed.). Vitagrad: DTP Studio, pp. 385400.
11. Beckerman, H., de Bie, R.A., Bouter, L.M., De Cuyper, H.J.,
and Oostendrop, R.A.B. (1992). The efcacy of laser for
musculoskeletal and skin disorders: a criteria based meta-
analysis of randomized clinical trials. Phys. Ther. 72, 1321.
12. Bertolucci, L.E., and Grey, T. (1995). Clinical analysis of mid-
laser versus placebo treatment of arthralgic TMJ degenera-
tive joints. J. Craniomandibular Pract. 13, 2729.
13. Kulekcioglu, S., Sivrioglu, K., Ozcan, O., and Parlak, M.
(2003). Effectiveness of low level laser therapy in temporo-
mandibular disorders. Scand. J. Rheumatol. 32, 114118.
14. Gray, R.J.M., Davies, S.J., and Quayle, A.A. (1994). A clinical
approach to temporomandibular disorders: A clinical ap-
proach to treatment. Br. Dent. J. 6, 101106.
15. Tuner, J., and Hode, L. (2002). Laser therapy. Clinical practice
and scientic background. Tallinn, Estonia: Prima Books.
16. Fikackova, H., Dostalova, T., Navratil, L., and Klaschka,
J. (2007). Effectiveness of lowlevel laser therapy in
FIG. 3. Visual Analog Scale (VAS).
FIG. 4. Interalveolar space between central incisors before
and after therapy.
GaAlAs LASER IN THE MANAGEMENT OF TMJ DISORDERS 279
temporomandibular joint disorders: a placebo-controlled
study. Photomed. Laser Surg. 25, 297303.
17. Kobayashi, M., and Kubota, J. (1999). Treatment of TMJ pain
with diode laser therapy. Laser Ther. 1, 1118.
18. Bezzur, N.J., Habets, L.L.M., and Hansson, T.L. (1988). The
effect of therapeutic laser in patients with craniomandibular
disorders. J. Craniomandib. Disord. 2, 8386.
19. Hansson, T. (1989). Infrared laser in the treatment of cra-
niomandibular disorders, arthrogenous pain. J. Prosthet.
Dent. 61, 614617.
20. Janega, M., Rehacek, A., Hofmanova, P., Dostalova, T.,
Smahel, Z., Veleminska, J., and Fendrychova, J. (2009). Ce-
phalometric analysis of cephalometric radiograms of healthy
patients in prosthodontics and orthodontics. Prakt. Zubn.
Lek. 57, 112116.
21. Jenkins, P. A., Carroll, J. D. (2011). How to report low-level
laser therapy (LLLT) / photomedicine dose and beam pa-
rameters in clinical and laboratory studies. Photomed. Laser
Surg. 29, 7857.
22. Mazzetto, M.O., Carrasco, T.G., Bidinelo, E.F., Pizzo, R.C.A.,
and Mazzetto, R.G. (2007). Low intensity laser application in
temporomandibular disorders: a phase I double-blind study.
J. Craniomandib. Pract. 25, 186192.
23. Kulekcioglu, S, Sivrioglu, K, Ozcan, O, and Parlak, M.
(2003). Effectiveness of low-level laser therapy in temporo-
mandibular disorder. Scand. J. Rheumatol. 32, 114118.
24. Nunez, S.H., Garcez, A.S., Suzuki, S.S., and Ribeiro, M.S.
(2006). Management of mouth opening in patients with
temporomandibular disorders through low-level laser ther-
apy and transcutaneous electrical neural stimulation. Pho-
tomed. Laser Surg. 24, 4549.
25. Pinheiro, A.L.B., Cavalcanti, E.T., Rego, T., Pinheiro, M., and
Manzi, C.T. (1997). Low power laser therapy in the man-
agement of disorders of the maxillofacial region. J Clin Laser
Med Surg. 15, 181183.
Address correspondence to:
Tatjana Dostalova
Charles University in Prague, 2nd Medical Faculty
Department of Paediatric Stomatology
V Uvalu 84
150 06, Prague 5
Czech Republic
E-mail: [email protected]
280 DOSTALOVA

ET AL.