Photomedicine and Laser Surgery

Volume 25, Number 4, 2007

© Mary Ann Liebert, Inc.
Pp. 297–303
DOI: 10.1089/pho.2007.2053

Effectiveness of Low-Level Laser Therapy

in Temporomandibular Joint Disorders:
A Placebo-Controlled Study

H. FIKÁČKOVÁ, M.D.,1,2 T. DOSTÁLOVÁ, M.D., Prof., Dr.Sci., M.B.A.,3

L. NAVRÁTIL, M.D., Ph.D.,1,4 and J. KLASCHKA, R.N.Dr., Ph.D.1,5

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 du-
ration of disorders. Background Data: Although LLLT is a physical therapy used in the treatment of muscu-
loskeletal 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/cm2 or 15 J/cm2, and the control group of 19 patients was treated
with 0.1 J/cm2. 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 cm2 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/cm2 or 15 J/cm2 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/cm2 and 15 J/cm2) can be considered as a useful method for the treatment of TMD-re-
lated pain, especially long lasting pain.

INTRODUCTION research purposes is the Research Diagnostic Criteria for TMD

(RDC/TMD).1 This standardizes the clinical examination of pa-
Temporomandibular joint disorders (TMD) and their most tients with TMD, improves reproducibility among clinicians,
common signs and symptoms such as pain, limited mouth open- and facilitates comparison of results among researchers.1
ing, and joint sounds, could be caused by muscle disorders, in- TMD is considered to be a subgroup of musculoskeletal dis-
tracapsular derangement of the components of the temporo- orders.1,2 This may explain reports of the successful use of phys-
mandibular joint (TMJ), and degenerative changes to the bony ical therapy in the treatment of TMD. Low-level laser therapy
components of the joint itself.1,2 (LLLT) is one modality of physical therapy, used for its anal-
There is still a lack of consensus on the classification of gesic, anti-inflammatory, and stimulative effects.1–19 Although
TMD, largely because there is unclear etiology and clinical find- LLLT is a treatment method commonly used in physiotherapy
ings can result from different causes, including psychological of musculoskeletal disorders, there are few studies that deal
causes.1–3 One commonly used diagnostic scheme intended for with its utilization in the treatment of TMD.

1Institute of Biophysics and Informatics, 1st Medical Faculty.

2Department of Anatomy and Biomechanics, Faculties of Physical Education and Sports
3Department of Paediatric Stomatology, 2nd Medical Faculty, Charles University, Prague, Czech Republic.
4Department of Radiology and Toxicology, Faculty of Health and Social Sciences, South Bohemia University, Ceske Budejovice, Czech

Republic.
5Institute of Computer Science, Academy of Sciences of the Czech Republic, Prague, Czech Republic.

297
298 Fikáčková et al.

TABLE 1. THE CRITERIA FOR MYOFASCIAL PAIN AND ARTHRALGIA ACCORDING TO RDC/TMD

Diagnosis

Clinical examination Myofascial pain Arthralgia TMJ

Tenderness to palpation Three or more of the following muscle Pain in one or both lateral
sites: m. temporalis (posterior, middle, poles and/or posterior
anterior); m. masseter (origin, body, attachment during palpation
insertion); m. digastricus (venter anterior,
posterior); submandibular region, lateral
pterygoid area, tendon of the temporalis
Characteristics of the pain Report of pain or aching in the jaw, Pain in the region of the joint
temples, face, preauricular area, or inside at rest or during maximum
the ear at rest or during use opening or lateral excursion

RDC/TMD, Research Diagnostic Criteria for Temporomandibular Joint Disorders.

The aims of this study were (1) to compare the reduction in • Group B: 28 patients treated with 15 J/cm2 (May, June, and
pain in patients with TMD treated with LLLT (10 J/cm2 or 15 September)
J/cm2) or sham laser (0.1 J/cm2), and (2) to evaluate the ther- • Group C: 19 patients treated with 0.1 J/cm2 (October and No-
apeutic effect of LLLT in relation to subgroups of TMD and vember)
duration of TMD-related pain.
Table 2 shows the distribution of patients according to clin-
ical diagnosis and applied energy density.
MATERIALS AND METHODS The standardized examination procedure included a ques-
tionnaire designed according to RDC/TMD criteria to record
Subjects
each patient’s history, previous appointments with physicians
Eighty patients (9 male and 71 female) who participated in and dentists, and intensity and duration of the pain.1 Patients
this study were selected from patients with TMD from the Pros- completed this standardized questionnaire by themselves.
thetic Department of Charles University, 1st Medical Faculty LLLT was the first method of TMD treatment in 32 patients,
in Prague, and referred for LLLT to the Institute of Biophysics and in 48 patients it was recommended after previously unsuc-
and Informatics, 1st Medical Faculty. The average age of pa- cessful treatment using other conservative methods (Table 3).
tients was 41 years (range 16–70 years). Duration of TMD-related pain was recorded by patients in
The entire treatment regimen was accomplished in agree- a self-administered questionnaire before the application of
ment with the Helsinki Declaration. Ethical approval for the LLLT. Twenty patients had TMD-related pain for less than
study was obtained from the University Ethics Committee of 6 months (acute pain) and 50 patients for more than 6 months
the Faculty Hospital of the 1st Medical Faculty of Charles Uni- (chronic pain).20 Ten patients did not answer this question
versity in Prague. (Table 4).
The criteria for patients included in the study were myofas-
cial pain and arthralgia of the TMJ. The exclusion criteria were Equipment
painless joint sounds, disc displacements with limited opening,
Low-level laser therapy was performed in 10 treatment ses-
and degenerative joint diseases related to systemic causes. Clas-
sions by a semi-conductive GaAlAs laser (BTL Beautyline
sification of TMD subgroups was made according to the Re-
Technology Laser, Brnor, Czech Republic) with an output of
search Diagnostic Criteria for temporomandibular joint disor-
400 mW, emitting radiation wavelength of 830 mm. The laser
ders (RDC/TMD) (Table 1).
delivers a spot of approximately diameter 0.2 cm2.
The patients were divided into three groups according to the
month in 2005 when they were referred for treatment:
Treatment protocol
• Group A: 33 patients treated with 10 J/cm2 (from February Patients received LLLT in 10 sessions within 1 month.
to April) Groups A and B were treated by energy density of 10 J/cm2

TABLE 2. DISTRIBUTION OF PATIENTS ACCORDING TO CLINICAL DIAGNOSIS AND THE APPLIED ENERGY DENSITY
Group A Group B Group C
Diagnosis 10 J/cm2 15 J/cm2 (0.1 J/cm2) No. of patients
Myofascial pain 14 8 10 32
TMJ arthralgia 7 10 4 21
Both myofascial pain and 12 10 5 27
TMJ arthralgia
LLLT in Temporomandibular Joint Disorders 299

TABLE 3. LLLT AS A METHOD OF FIRST OR SECOND CHOICE IN THE TREATMENT OF TMD

Group A Group B Group C No. of

10 J/cm2 15 J/cm2 (0.1 J/cm2) patients
LLLT without previous conservative 11 13 8 32
treatment
LLLT after unsuccessful conservative 22 15 11 48
treatment

LLLT, low-level laser therapy; TMD, temporomandibular joint disorder.

and 15 J/cm2, respectively. The control group C received en- reported “reduced” pain were classified as “successful treat-
ergy density of 0.1 J/cm2. ment.”
In patients with myofascial pain, the laser probe was placed In the statistical analysis evaluating the treatment results in
over the spots of tenderness to palpation of masticatory mus- relation to the duration of TMD-related pain, patients who had
cles, that were detected during the clinical examination ac- not answered the question “For how long have you been in
cording to RDC/TMD. pain?” were excluded (n  10).
In patients with arthralgia of the TMJ, the probe was placed Fisher’s exact test was used for contingency 2  2 tables and
on the sites as described by Bradley et al.4: the chi-square test for larger contingency tables. When a sig-
nificant difference was found between the three groups, analo-
• In front of the tragus, when the mouth was open gous post-hoc analyses of subtables for pairs of groups was fol-
• Through the meatus acusticus externus, when the mouth was lowed. Test results with p  0.05 were considered statistically
open significant.
• 2 cm in front of the tragus, under the zygomatic arch, when
the mouth was closed
RESULTS
Patients with both myofascial pain and arthralgia of the TMJ
were treated by both described procedures. Comparison of the effectiveness of LLLT and sham
laser in reduction of TMD-related pain
Evaluation of results
Forty-seven of 61 patients treated with LLLT (group A 10
On the second day after the last (10th) LLLT session, the J/cm2 or group B 15 J/cm2) reported reduction in TMD-related
patients completed the control self-administered questionnaire, pain, two patients reported increased pain, and in 12 patients
where they expressed whether their TMD-related pain was re- pain remained the same after completion of treatment.
duced, increased, or remained the same after LLLT. Seven of 19 patients in the control group C (0.1 J/cm2) re-
Subjective evaluation of changes in intensity of pain after ported reduction in pain, and in 12 patients pain did not change
the application of LLLT was reported by patients in percent- (Fig. 1).
ages from 0%, indicating no change in pain, to 100%, indicat- Statistical analysis showed a significant difference (p 
ing complete relief of pain, in 10% increments. 0.002) in treatment efficacy between groups A and B compared
to sham laser.
Statistical analysis
Evaluation of LLLT in relation to applied
Due to the small number of patients who reported deteri-
energy density
oration in TMD-related pain, the result of therapy was treated
as a variable with two possible categories (successful and un- Although there were more patients with TMD who reported
successful) for use in statistical analysis. The categories “pain reduction in pain in group A (10 J/cm2) than in the group B (15
remained the same” and “increased” were for statistical pur- J/cm2), the between-group difference in the treatment results
poses grouped as “unsuccessful treatment.” The patients who was not significant (Fig. 2).

TABLE 4. DISTRIBUTION OF PATIENTS ACCORDING TO THE DURATION

OF THEIR PAIN AND THE APPLIED ENERGY DENSITY

Group A Group B Group C

Duration of TMD 10 J/cm2 15 J/cm2 (0.1 J/cm2) No. of patients
Acute TMD 9 10 11 20
Chronic TMD 24 18 8 50

TMD, temporomandibular joint disorder.

FIG. 1. The effect the LLLT and the sham laser on reduction in pain in patients with TMD (percentage analysis).

FIG. 2. The evaluation of LLLT in relation to the applied energy density (percentage analysis).

FIG. 3. The results of treatment in relation to the diagnosis (percentage analysis).

LLLT in Temporomandibular Joint Disorders 301

TABLE 5. EFFICACY OF LLLT IN RELATION TO THE DURATION OF DISORDERS AND THE APPLIED ENERGY DENSITY

Group A (10 J/cm2) Group B (15 J/cm2) Placebo (0.1 J/cm2)

Duration of Without Without Without

TMD Worse change Better Worse change Better Worse change Better
Acute pain 0 (0%) 1 (11%) 8 (89%) 0 (0%) 3 (30%) 7 (70%) 0 (0%) 4 (34%)0 7 (66%)
Chronic pain 1 (4%) 3 (12%) 20 (84%) 1 (6%) 5 (28%) 12 (67%) 0 (0%) 8 (100%) 0 (0%)0
p value 0.8150 0.7493 0.0045

Evaluation of the therapeutic effect of LLLT in was no difference between application of 10 J/cm2 or 15 J/cm2
patients who did not respond to previous conservative in patients with chronic pain.
treatment of TMD-related pain
Assessment of progress of therapy of TMD-related
Twenty-nine of 37 patients whose TMD-related pain did not
pain by LLLT
diminish after previous conservative treatment reported reduc-
tion in pain after LLLT (10 J/cm2 or 15 J/cm2); in two patients Ongoing evaluation of the results showed that a decrease in
the pain increased, and in six patients the pain did not change. pain occurred in the majority of TMD patients between the sec-
There was no statistically significant difference in the treatment ond and fourth treatment sessions (Fig. 4).
effects between application of 10 J/cm2 and 15 J/cm2. More than half (25 of 47) of patients who reported reduc-
tion in TMD-related pain reported 70% or more improvement
Evaluation of LLLT in diagnostic subtypes of TMD of TMD after completing LLLT (Fig. 5).
In the combined groups A and B, no significant difference
was found in the therapeutic effects of LLLT comparing the pa-
tients with myofascial pain and TMJ arthralgia (Fig. 3). Simi- DISCUSSION
larly, analysis within groups A and B revealed no significant
differences between patients with myofascial pain and/or TMJ When evaluating a successful treatment of TMD, it is not
arthralgia. easy to determine whether a decrease in pain is a real result of
the treatment or a cyclic spontaneous remission of symptoms
or a placebo effect.3,21 In order to clarify this, the treatment re-
Evaluation of LLLT in relation to duration of TMD sults of the patients treated with LLLT and sham laser were
Although there was no significant difference between the ef- compared and evaluated according to the duration of TMD.
fects of applied energy density of 0.1 J/cm2, 10 J/cm2, and 15 For the control group, we used an energy density of 0.1
J/cm2 in patients with acute pain, different results were obtained J/cm2, the lowest setting on the energy device. The application
in patients with chronic pain, whose treatment results depended of 0.0 J/cm2 was not possible because of an automatic control
on the applied energy density (Table 5). Patients treated with that is a fixed part of the laser. Although even very small
LLLT (group A or B) reported significantly better results than amounts of laser energy may result in cellular responses, we
patients treated with sham laser (group C; p  0.0003). There considered this group as a placebo, because for an analgesic ef-

FIG. 4. The efficacy of the LLLT and the sham laser on reduction in pain in patients with chronic TMD (percentage analysis).
302 Fikáčková et al.

FIG. 5. The level of decreasing TMD caused pain after finishing the LLLT.

fect to occur, it is necessary to achieve sufficient energy den- both densities of LLLT. On the other hand, in the patients with
sity in the irradiated tissue.5 Tunér and Hode5 reported insuffi- chronic pain (more than 6 months), the treatment results were sig-
cient energy density as a cause of failed LLLT. Our hypothe- nificantly different between active and placebo laser treatment.
sis that application of 0.1 J/cm2 has no analgesic effect was Improvement in TMD-related pain was reported by 76% of the
confirmed in another study,6 that compared the treatment effect patients with chronic pain in the group treated with LLLT, and
in patients who were treated with 0.1 J/cm2, 10 J/cm2, and 15 by none of the patients treated with the sham laser. This suggests
J/cm2, with who received basic conservative treatment (advice that LLLT may be effective for TMD, notwithstanding relief of
to avoid activities that cause repeated traumatization of the pain that may occur with spontaneous remission.
TMJ, such as maximal opening of the mouth and chewing gum Even though the efficacy of LLLT has been shown in many
and hard food) for 1 month. That study showed that the treat- clinical studies, there has still not been any definite consensus
ment effect in the placebo group and in patients with conserv- about the appropriate energy density in TMD. Kulekcioglu et al.8
ative treatment were significantly worse than in patients treated and Nunez et al.10 recommend an applied energy density of 3
with 10 J/cm2 or 15 J/cm2. Moreover, there was no significant J/cm2, Gray et al.13 4 J/cm2, Tunér and Hode5 4–10 J/cm2,
difference in treatment results comparing 0.1 J/cm2 and con- Navrátilová and Navrátil14 6–8 J/cm2, Kobayashi and Kubota15
servative therapy.6 20–40 J/cm2, Sanseverino et al.12 45 J/cm2, and Bradley et al.4
In our study we did not evaluate changes in pain after LLLT 100 J/cm2. The present study evaluated the treatment effect of the
with assessment of changes in mobility of the affected joint, as application of 10 J/cm2 and 15 J/cm2. These energy densities were
has been studied by others.7–10 However, the results suggest chosen both to try to achieve sufficient energy density in the TMJ
that the effect of LLLT on the treatment of pain caused by TMD and masticatory muscles to achieve analgesia, and to avoid pro-
might improve mobility of the joint. longed treatment sessions. Although better treatment results were
We found significantly better therapeutic results in patients obtained from patients treated with 10 J/cm2 than those treated
who were treated with LLLT (improvement in 77% of patients) with 15 J/cm2, this difference was not significant.
compared to those treated with sham laser (improvement in 37% The percentage of the patients who reported decreased pain
of patients). in this study is similar to the results reported by Bradley et al.4
However, there is no general consensus in the literature on and Gray et al.,13 who described reduced pain in 77% and 73%
the effectiveness of laser therapy in treating TMD. Hanssen and of patients, respectively. We found that pain was reduced in
Thorøe22 described no difference between active and placebo 82% of patients with myofascial pain, 77% of patients with TMJ
laser therapy. In a meta-analysis Gam et al.23 did not find a bet- arthralgia, and 73% of patients with both myofascial pain and
ter therapeutic effect for active laser therapy than for placebo. TMJ arthralgia. There was no significant difference in patients
Similarly, significant differences between real and placebo laser with myofascial pain, TMJ arthralgia, or both, even though the
treatment were not found in a study by Conti.24 latter received the highest energy density, LLLT being applied
In support of our findings, better therapeutic results of LLLT to both the TMJ and the masticatory muscles. Kulekcioglu et
compared to placebo laser treatment were also described in al.8 also reported the same therapeutic effect for LLLT for these
studies by Bradley et al.,4 Bertolucci and Grey,7 Kulekcioglu diagnostic groups. However, Bezzur et al.16 described greater
et al.,8 Cetiner et al.,9 Beckerman et al.,11 Sanseverino et al.,12 efficacy for TMJ arthralgia than for myofascial pain.
and Gray et al.13 Pain decreased in 23% of the patients after the second ap-
Besides the influence of applied energy density on the effec- plication, and in 28% after the third application of LLLT. Gray
tiveness of LLLT, we also evaluated the influence of the duration et al.13 reported decreased pain after the fourth application.
of TMD on its therapeutic effect. In patients suffering from pain Since 81% of our patients reported reduced pain after the fifth
for less than 6 months, there was no significant difference in the application, this point could be appropriate for preliminary eval-
final evaluation of the treatment results between sham laser and uation of the treatment and energy density chosen.
LLLT in Temporomandibular Joint Disorders 303

Although LLLT initially caused an increase in pain in some 8. Kulekcioglu, S., Sivrioglu, K., Ozcan, O., and Parlak, M. (2003).
patients, 59% reported 70% pain reduction after treatment. Effectiveness of low level laser therapy in temporomandibular dis-
Initial pain may not be a deleterious effect, as it appears related orders. Scandinavian J Rheumatol. 32, 114–118.
to individual sensitivity to treatment, leading to reduced pain 9. Cetiner S., Kahraman S.A., and Yücetas S. (2006). Evaluation of
low-level laser therapy in the treatment of temporomandibular dis-
after completion.4,5,14
orders. Photomed. Laser Surg. 24, 637–641.
Our results suggest that LLLT can be recommended for the 10. Nunez, S.C., Garcer, A.S., Suzuki, S.S., and Riberio, M.S. (2006).
treatment of painful conditions related to TMD. Management of mouth opening in patients with temporomandibu-
lar disorders through low-level laser therapy and transcutaneous
electrical neural stimulation. Photomed. Laser Surg. 24, 45–49.
CONCLUSION 11. Beckerman, H., de Bie, R.A., Bouter, L.M., De Cuyper, H.J., and
Oostendrop, R.A.B. (1992). The efficacy of laser for muscu-
The results of this study found significantly better treatment loskeletal and skin disorders: a criteria-based meta-analysis of ran-
results for TMD-related pain in patients treated by LLLT (10 domized clinical trials. Phys. Ther. 72, 13–21.
12. Sanseverino, N.T.M., Sanseverino, C.A.M., and Ribeiro, M.S.
J/cm2 or 15 J/cm2) than in those treated by sham laser (0.1
(2002). Clinical evaluation of low intensity laser antialgic action
J/cm2). of GaAlAS (wavelength  785 nm) in the treatment of temporo-
The application of energy density of 10 J/cm2 or 15 J/cm2 mandibular disorders. Laser Med. Surg. Abstract issue, 18.
resulted in reduced TMD-related pain in 77% of patients, no 13. Gray, R.J.M., Davies, S.J., and Quayle, A.A. (1994). A clinical ap-
change in pain in 20%, and increased pain in 3%. An im- proach to temporomandibular disorders: A clinical approach to
provement after laser therapy was reported by 82% of patients treatment. Br. Dent. J. 6, 101–106.
with myofascial pain, 77% with TMJ arthralgia, and 73% with 14. Navrátilová, B., and Navrátil, L. (2000). Fototerapie a terapeutický
both myofascial pain and TMJ arthralgia. The greater effec- laser ve stomatologick ých indikacích, in: Moderní Fototerapie
tiveness of 10 J/cm2 compared to 15 J/cm2 was not statistically a Laseroterapie. Navrátil, L. (ed). Prague: Manus Praha, pp.
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15. Kobayashi, M., and Kubota, J. (1999). Treatment of TMJ pain with
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diode laser therapy. Laser Therapy. 1, 11–18.
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ACKNOWLEDGEMENT iomandibular disorders, arthrogenous pain. J Prosthet. Dent. 61,
614–617.
This study was done with financial support from the Re- 18. Fikackova, H., Dostálová, T., Vošicka, R., Peterová, V., Navrátil,
search Project of the Ministry of Education, Youth, and Sports L., and Lesák, J. (2006). Arthralgia of the temporomandibular joint:
Low level laser therapy. Photomed. Laser Surg. 24, 522–527.
of the Czech Republic, grants no. FJ MSM 11100005 and IGA
19. Medlicott, M.S., and Harris, S.R. (2006). A systematic review of
MZ CR 8112–3. the effectiveness of exercise, manual therapy, electrotherapy, re-
We would like to thank R.N.Dr. J. Hořejšová of BTL Beauty- laxation training, and biofeedback in the management of temporo-
line Technology Laser for lending us their GaAlAs laser. mandibular disorder. Phys. Ther. 86, 955–973.
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