Conservative approaches, such as soft diets, anti-inflammatory drugs and photobiomodulation therapy (PBMT) or low-level laser therapy (LLLT), have been used to manage TMD. Lasers have proven to be successful in clinical settings and treatments of soft tissues, musculoskeletal pain, bone regeneration, dentinal hypersensitivity, and provide reduction in symptoms and improved function. The mechanism of action in PBMT is via absorption of light, with deeply penetrating wavelengths ranging from 630 nm to 1300 nm, to stimulate tissues with direct irradiation to achieve analgesic and anti-inflammatory effects. The output energy in PBMT does not affect skin temperature and is classified as a soft laser, which increases lymphatic flow, reduces edema and prostaglandin E2 (PGE2) and cyclooxygenase (COX) levels. A systematic review for pain management reported placebo vs LLLT for practical and clinically relevant parameters using 700nm to 1200nm.

1. MANAGEMENT OF TMD SYMPTOMS WITH
PHOTOBIOMODULATION THERAPY
Ammaar H. Abidi; Alan O. Blanton, Christopher J. Walinski, The New York State Dental Journal ● NOVEMBER
2020
NISHU PRIYA
2nd year PGT

2. INTRODUCTION
 Temporomandibular disorder reflect a subgroup of orofacial
disorders that results in pain of the temporomandibular joint,
masticatory muscles and surrounding tissues.
The etiology ofTMD is multifactorial
and has been linked to emotional
stress, psychological factors,
traumatic injury, proinflammatory
immune responses, neoplastic
growth, occlusal interferences, loss
or malpositioning of the teeth,
dysfunction of masticatory muscles
and adjacent structures, etc
• Conservative approaches, such as soft diets, anti-inflammatory drugs
and photobiomodulation therapy (PBMT) or low-level laser therapy
(LLLT), have been used to manageTMD.
•Lasers have proven to be successful in clinical settings and treatments of
soft tissues, musculoskeletal pain, bone regeneration, dentinal
hypersensitivity, and provide reduction in symptoms and improved
function.

3.  LLLT utilizes electromagnetic radiation at a particular wavelength and contributes to management of
pain, impaired wound healing, and inflammations. Also, LLLT is usually used clinically for the treatment
of TMJ pain.

5.  The mechanism of action in PBMT is via absorption of light, with deeply penetrating wavelengths
ranging from 630 nm to 1300 nm, to stimulate tissues with direct irradiation to achieve analgesic and
anti-inflammatory effects.
 The output energy in PBMT does not affect skin temperature and is classified as a soft laser, which
increases lymphatic flow, reduces edema and prostaglandin E2 (PGE2) and cyclooxygenase (COX)
levels.
 A systematic review for pain management reported placebo vs LLLT for practical and clinically
relevant parameters using 700nm to 1200nm.

6. CASE REPORT
 A 25-year-old patient presented with a chief complaint of migraines, nocturnal bruxism, frequent cheek
biting, teeth clenching, bilateral jaw pain when chewing, jaw popping and clicking, neck pain and
shoulder stiffness.
 Her medical history included a hernia repair and tonsillectomy. Her family history included cancer,
diabetes, high blood pressure and snoring (mother).
jaw pain
headaches
neck pain

7. The pain was continuous but dull and most
acute in the region of her TMJ, temporalis,
temporal tendon, masseter and shoulders
bilaterally.
Her jaw pain had increased after
admittance to graduate school and was
exacerbated by chewing, stress,
exercise, clenching, mouth opening and
holding her mouth open for a short time.

8. ASSESSMENT
 The initial assessment of the patient for this study was conducted in the Dental Sleep Medicine and
Orofacial Pain Clinic and, along with the previous case report information, revealed the following vital
data:
Neck circumference —12.0 inches
Blood pressure—115/63
Pulse—68
100% SpO2
5 feet, 3 inches and 121 lbs.
Mild tenderness was elicited
• sternocleidomastoid on the
right
• trapezius neck area on the right
• deep masseter on the right
• temporal tendon on the left
• anterior temporalis on the left
• lateral TMJ capsule bilaterally
• posterior joint space bilaterally.
On palpation
Moderate tenderness was elicited
• superficial masseter bilaterally
• trapezius shoulder area
bilaterally
• greater occipital bilaterally.
• anterior temporalis on the right
• temporal tendon on the right
• middle temporalis on the right

9.  The patient said she could hear clicking on the left side when she opened her jaw, but there was no
palpable clicking or popping in either joint on opening or closing.
 The clinical examination revealed the TM joints were within normal limits.
Mandibular range of motion measurements
revealed
- maximum inter-incisal opening of 48 mm
- maximum protrusive of 10 mm
- left lateral excursion of 6 mm
- right lateral excursion of 7 mm
- normal mandibular midline
- normal maxillary midline
- overbite of -1 mm and overjet of 1 mm.
•Jaw measurements have been noted in professional literature as a 42 mm to 52 mm average
opening, and average lateral measurements of 9 mm to 11 mm.

10. The clinical impression was myalgia bilaterally, cervicalgia
bilaterally, headache bilaterally and synovitis and
tenosynovitis (unspecified) bilaterally.
• The patient complained of excessive daytime sleepiness and frequently yawned during the
evaluation exam. There may have been an undiagnosed sleep-related breathing disorder or,
possibly, some other underlying sleep disorder, such as insomnia or narcolepsy.

11. TREATMENT PLAN
 The treatment plan consisted of referral for evaluation by a sleep physician for
possible sleep study to determine if there was an underlying sleep-related breathing
disorder or other sleep disorder present causing the daytime sleepiness, restless
sleep and unrefreshing sleep the patient reported.
 The patient was recommended for PBMT to relieve some of her residual chronic
pain.

12. PBMT
 The patient regimen for the PBMT was planned for five
consecutive days, with one of two laser devices being used on
each side of the jaw. PBMT was performed on both sides of the
jaw, including masticatory muscles and areas affected
(temporalis, masseter, sternocleidomastoid and shoulders).
 On the first day of treatment, the patient’s initial survey for
pain and headaches was reported to be at 5.5 on both sides on
a pain scale of 1 to 10.
 The left side of the jaw was to be treated with theThor laser
while the right side of the jaw would be treated with the
OraLase

13.  The patient’s temporalis, masseter, sternocleidomastoid and shoulders were treated once each
day, and the survey was completed for each treatment regimen.
 The patient reported decreased pain and headaches on the second day; improvement was seen
following subsequent appointments in a cumulative effect.
 Thor laser was applied with a significant reduction in pain and headaches—down to 2 on a 1 to
10 pain scale at the end of the five-day treatment regimen.
 The OraLase was applied on the right side, which exhibited reduction down to 3 on a 1 to 10
pain scale on the fourth day; however, the pain returned on the fifth day to between 3 and 4 on a
1 to 10 pain scale.
The patient reported that from the third day onward, she felt less tension in her jaw. Furthermore,
her symptoms had decreased significantly enough for her to state that further treatments would
benefit her. The constant tension in her jaw that was present regardless of her stress was alleviated
by the PBMT regimen. One of the most obvious improvements was that her jaw was not clicking
when she yawned or stretched her jaw.

14.  The patient was followed up weekly for a month after treatment.
 However, three weeks after her treatment, she noticed the clicking of the jaw and continuous tension
in the jaw had returned.
 In the one-month follow-up, the patient’s experience was charted; she wanted to continue laser
therapy for maintenance every month if possible. She described it to be beneficial, as she had
increased maximal jaw opening, reduced clicking and less tension. She also reported that PBMT was
very comfortable for her, as the appointments were short and did not require jaw manipulation.
Follow up

15. DISCUSSION
 The use of PBMT for TMD is a good alternative for reducing TMJ and myofascial pain
because of its ability to reduce inflammation, while exhibiting regenerative and analgesic
effects.
 Several studies have differed on frequency and number of applications for PBMT. The PBMT
applications were performed once each day for five consecutive days. Publications include
several suggested regimens: a total of eight sessions with application two times/week or a
total of six sessions with application of two times/week.

16. INITIAL TREATMENT FOR PATIENTS WITH TEMPOROMANDIBULAR
DISORDERS:
PAIN RELIEF AND MUSCLE TONE RELIEF BY
PHOTOBIOMODULATION THERAPY
USING CARBON DIOXIDE LASER
Hiroshi Fukuoka & Nobuko Fukuoka & Yuki Daigo & Erina Daigo & Toshiro Kibe & Masatsugu Ishikawa; Laser Dent Sci (2020) 4:203–
209

18. ASSESSMENT OFTMD
 Through clinical interviewing, the pain site was noted.
 A tenderness test was performed on the masticatory muscles and temporomandibular joint.
 The pressing time was 2 s for the purpose of detecting tenderness only and 5 s for detecting the presence or
absence of related pain.
 Using this method, the trigger point was identified.

19.  When crepitus was sensed on palpation, complementary imaging tests such as X-ray
imaging were performed as necessary.Through X-ray examination, patients with other
possible diseases such as hyperplasia of the mandibular coronoid process and Jacob
disease were excluded.
 Maximum mouth opening capacity differs depending on the age and gender of each
individual.Therefore, established a 40-mm threshold, below which we diagnosed “limited
opening”.

20. THERAPY SESSIONS
 Treatment included Amfenac sodium as pharmacotherapy (50 mg per day, 3 times a day after meals) for 1–
2 weeks to treat acute symptoms.
 All patients took the drug for at least 1 week, and if the acute symptoms were severe, the drug was
continued for an additional week.
 After the acute symptoms had eased in response to pharmacotherapy, trigger points were identified again
in each patient, and PBMT and mouth opening training were initiated.
 The patients were given instructions for self-care at home, including application of a hot compress to the
area of muscle tenderness, information pertaining to tooth-contacting habit, and the mandibular resting
position to prevent clenching.

21.  One cycle of PBMT and mouth opening training was conducted per week, and the observation period
was set at approximately 6 weeks, from the start of treatment to the completion of 4 treatment
cycles to determine the effects of the treatment.
 Pain and maximum mouth opening capacity were measured before treatment and after the
completion of 4 cycles of PBMT and mouth opening training.

22. LASER IRRADIATION
A Takara Belmont CO2 laser (wavelength; 10.6 μm, Bel Laser, Takara Belmont, CO. Ltd., Osaka, Japan) was used
during all laser procedures.
The laser irradiance conditions were
output 1.5W, on time 0.01 s, off time
0.05 s, and repeat pulse.
The distance between the
laser source and the skin
was approximately 10 cm.
The laser hand piece was moved in
an elliptical pattern, and irradiation
time was 3 minutes.

23. MOUTH OPENINGTRAINING
 After PBMT, muscle massage and stretching
therapy were implemented as mouth opening
training.
 Mouth opening training involved extraoral
massaging of the areas of muscle contracture
in the masseter, temporal, digastric, and
sternocleidomastoid muscles that were the
trigger points in each patient, as well as
stretching therapy to improve the flexibility of
the temporomandibular joint.

24.  In stretching therapy, when the left temporomandibular joint was the affected side, the therapist’s left
index finger was placed on the left mandibular molar area, the right index finger was placed on top of
the tip of the left finger, and the right thumb was placed on the left maxillary premolar area. Force
was then applied straight down along the masseter muscle.
 These finger positions were reversed (inverted left to right) if the right temporomandibular joint was
affected.
 These stretch therapies were performed with the patients in a relaxed position.

25. ASSESSMENTOF PAIN PERCEPTION
 A numeric rating scale (NRS) was used
to assess pain before and after
treatment. Patients used the scale to
rate pain on a scale of 0–10, with 0
being no pain and 10 being the worst
pain imaginable.
Maximum mouth opening capacity was measured
in millimeters.
Briefly, the patients opened their mouth as wide
as possible, and the distance between the mesial
corner of the maxillary right central incisor and
that of the mandibular right central incisor was
measured with calipers.
MOUTH OPENING

26. RESULTS
 The symptoms ofTMD had disappeared in 28 of the 36 patients (78%) after the 4 cycles of physical therapy.
 Symptoms resolved in all of the remaining 8 patients after an additional 2–5 cycles of PBMT and mouth
opening training, and 4 of these remaining 8 patients required splinting treatment to address tooth-
contacting habit.
ASSESSMENTOF PAIN PERCEPTION
The mean (SD) pain levels, as determined via NRS,
were 4.9 (3.6) and 2.7 (3.0) before and after four
treatment cycles with physical therapy using
PBMT and mouth opening training, respectively.
The mean (SD) of MMO was 39.6 mm
(5.9) and 44.6 mm (4.8) before and
after 4 cycles of treatment with
physical therapy using PBMT and
mouth opening training, respectively.
MOUTH OPENING

27. DISCUSSION
 InTMD, wrong timing when introducing physiotherapy muscle massage therapy or muscle-stretching
therapy may worsen symptoms.
 Furthermore, using a semiconductor laser for irradiation in patients may yield different results in patients
depending on whether they are in the acute or chronic phase, and differences also exist on the maximum
mouth opening capacity increase that could be achieved when comparing acute and chronic patients.
 Therefore, pharmacotherapy was started first with Amfenac sodium to avoid starting treatment in the
acute phase.

28.  Splinting treatment has been reported to be effective in preventing clenching and protecting teeth and
temporomandibular joints; however, the effects are not constant according to the literature, and changes in
occlusion such as open bite are feared.Therefore, splinting treatment was not administered as part of the
initial treatment.
 In this study, only 4 patients whose symptoms did not improve with laser treatment and mouth opening
training received splinting treatment, and the symptoms improved after the sprint was attached.
 Considering these cases, factors such as clenching and tooth contacting habit (TCH) are significant, and
splint therapy may be effective if clenching orTCH does not improve even after patient education.

29.  For muscle massage therapy and muscle-stretching therapy, there is a method involving extraoral and
intraoral application.
 However, in this study, as it is difficult for patients to maintain mouths opened, a method involving extraoral
application was used.
 Considering that the CO2 laser was of the tissue surface absorption type, irradiation was hindered in cases
where hair was present, for example, when there was a trigger point in the temporal muscle.Therefore, laser
irradiation was not performed on the temporal muscle, and only muscle massage therapy was performed.

30. EVALUATION OF LOW-LEVEL LASER THERAPY IN TMD PATIENTS
Simel Ayyildiz, Faruk Emir, Cem Sahin; Hindawi Publishing Corporation Case Reports in Dentistry Volume 2015, Article ID 424213,
6 pages

31. CASE REPORT
 25-year-old female patient had come with the complaints of
limited mouth opening and pain inTMJ region continuing for nine
months.
 The medical history of the patient revealed no systemic disease. In
questioning there was no history of trauma but she was a student
and was preparing for an important exam, so she had nocturnal
and diurnal tooth grinding.
 In dental examination there was no teeth loss but limited mouth
opening was determined.
 According to the report of MRI there was anterior disc dislocation
without reduction in both sides.
Patient 1

32.  The clinical examination revealed bilateral
TMJ pain during opening and lateral
movements.
 The muscle examination revealed no pain
or tenderness.
 The patient was instructed about the LLLT
and a free informed consent form was
obtained from her.
• The maximum mouth opening
(MMO) was 34 mm
• left excursions (LE) and right
excursions (RE) were 5mm
separately,
• the patient was feeling pain at these
limits.

33.  In every session, the patient marked theVAS scale (0–10cm) before
and after the treatment. Also in every session, maximum mouth
opening, left and right lateral excursion of the patient, was
recorded.
 At the end of the treatment an occlusal splint was fabricated as a
night guard and the patient was informed about the use of this
splint.
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, 25mW, 30 s, 0.02Hz, and 6.2
J/cm2).

34. Laser beam was applied at three points in eachTMJ:
(a) the posterior aspect of the joint in maximum opening to treat the posterior
articular branches of the auriculotemporal nerve and posterior discal
attachment region by applying the beam from the anterior of the external
auditory channel and
(b) same region in maximum opening from inside the external auditory channel
(c) to the inferior branches of the medial pterygoidmuscle with the fine fiber
optic probe of the device from inside the mouth through the posterior of the
tubermaxilla.

35.  The patient was evaluated immediately after the application and at the follow-up appointments after 15
days, 1, 3, and 6 months of the end of the treatment, to investigate effectiveness and cumulative effects.
The mouth opening of the patient was increased gradually during the sessions.At the
end of the treatment MMO was 45mm, RE and LE were 8 and 6mm, respectively and
she was painless during these limits of movement.
Six months later there was a little relapse at clinical evaluation; MMO was 42mmand RE
and LE were 6 mm, but no pain was recorded during evaluation or function.

36.  The second case was 18-year-old male patient, who was a student in Military School and also he was a
regular kick boxer.
 The main complaint was his restricted mouth opening that progressed in one year due to the impact
taken to the mandible in an exercise.
 In the extraoral inspection of theTMJ, the masseter and temporal muscle region were palpated normally;
there was no hypertonicity or hypersensitivity. But the posterior region of the condyle that was palpated
from the meatus acusticus externus was hypersensitive during opening.
 The ligament of the anterior temporal muscle that was passing through the ramus was also sensitive
during intraoral examination.
Patient 2

37.  The patient was instructed about the LLLT and a free informed consent form was
obtained from him. The same curing method of the first patient was applied to the
patient with the same protocol.
The interincisal midline was coincided with the facial midline, the MMO was 9 mm, and both LE and RE were 1
mm.

38. • At the end of the treatment an occlusal splint was fabricated as a night guard and the
patient was informed about the use of this splint.
• The patient was evaluated immediately after the application and at the follow-up
appointments after 15 days, 1, 3, 6, and 12 months of the end of the treatment, to
investigate effectiveness and cumulative effects.
Follow up

39. • The MMO of the patient was increased
gradually during the sessions. After the last
application of the treatment MMO was
increased to 45mm, RE and LE were also
increased to 8mm, and he was painless
during these limits of movement.
• There were no changes in the MMO in 1-
year follow-up.

40. The MMO of the patient was increased gradually during the sessions. After the last application of the
treatment MMO was increased to 45mm, RE and LE were also increased to 8mm(Figure 5), and he
was painless during these limits of movement. There were no changes in the MMO in 1-year follow-
up.

41. DISCUSSION
 In the study red probe diode laser (685 nm, 25mW, 30 s, 0.02Hz, and 6.2 J/cm2) was used inTMJ region
at three points, including one point for intraoral and two different points for extraoral regions.These
applications were made in three times a week for one month for each patient.
 In some studies the efficiency of 632nm wavelength for laser treatments was found better than short
wavelength lasers and the former penetrates musculoskeletal tissues better.
 Additionally some authors reported that 632 nm lasers were more effective in pain reduction than 820
nm.
 Therefore the wavelength of 685 nm, which was used in this study, can be regarded as effective.

42.  In the literature there is still no consensus on frequency of low-level lasers and number of sessions of laser
applications.
 On frequency and number of application sessions, some authors discussed eight sessions with application
twice per week.
 On the other hand some authors found that six sessions with application of twice per week would be proper.
And also some authors agreed in the number of ten sessions but in terms of frequency each one used
different values.
 The treatment protocol for two patients in this study was three times a week for one month.The aim of this
protocol was to protect the obtained mouth opening of the patient after each session.Thus, the effectiveness
of treatment and patient motivation were enhanced.

43. CONCLUSION
 PBMT is a simple, safe, non-invasive, time saving, on pharmaceutical, well tolerated
procedure, it has few or no side effects, it contributes to increased patient comfort.
 Photobiomodulation is a newly emerging field in dentistry that combines light energy
along with laser for therapeutic benefits. Its wide application in the field of medicine and
dentistry, photobiomodulation is well establishing its efficacy in the upcoming days and
future.