|Year : 2015 | Volume
| Issue : 4 | Page : 553-558
Evaluation of laser therapy and routine treatment modalities in the management of myofascial pain dysfunction syndrome
Smriti B Jagdhari, Vinod Madanlal Patni, Mukta Motwani, Pawan Motghare, Shweta Gangotri
Department of Oral Medicine and Radiology, VSPMS' Dental College and Research Center, Nagpur, Maharashtra, India
|Date of Submission||17-Aug-2015|
|Date of Acceptance||25-May-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Smriti B Jagdhari
Department of Oral Medicine and Radiology, VSPM'S Dental College and Research Center, C/o Dr. Anil Golhar, 256 Ramdaspeth, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To evaluate the efficacy of laser as a monotherapy and in combination with exercise therapy in comparison to only exercise in the treatment of Myofascial Pain Dysfunction Syndrome (MPDS) or Temporomandibular Myofascial Pain. Materials and Methods: A total of 60 patients with MPDS were included in the study and were randomly divided into three groups: exercise, laser, and the combination of both (exercise and laser). Results: Significant reduction in pain at rest and pain on movement was observed with all three types of treatment modalities. Pain reduction was more in those patients who received combination of exercise and laser therapy. Similarly, decrease in the muscle tenderness was more when combination of exercise and laser therapy was used. Conclusion: The ideal therapy should be fast, cheap, and have a long-term effect. Laser (Helium Neon) as monotherapy or in combination with exercise had shown promising results and can be used as an effective treatment modality for the treatment of MPDS.
Keywords: Drug therapy, exercise, laser, myofascial pain dysfunction syndrome
|How to cite this article:|
Jagdhari SB, Patni VM, Motwani M, Motghare P, Gangotri S. Evaluation of laser therapy and routine treatment modalities in the management of myofascial pain dysfunction syndrome. J Indian Acad Oral Med Radiol 2015;27:553-8
|How to cite this URL:|
Jagdhari SB, Patni VM, Motwani M, Motghare P, Gangotri S. Evaluation of laser therapy and routine treatment modalities in the management of myofascial pain dysfunction syndrome. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2021 Jul 26];27:553-8. Available from: https://www.jiaomr.in/text.asp?2015/27/4/553/188760
| Introduction|| |
Myofascial pain dysfunction syndrome (MPDS) is one of the most common cause of chronic pains in the orofacial region. , It is the most common form of temporomandibular disorders (TMDs) that primarily involves the muscles of mastication. MPDS is currently thought to be multifactorial and includes the presence of parafunctional habits, stress, depression, and occlusal factors. There are other systemic factors such as nutritional inadequacies, poor physical conditioning, and fatigue. The exact psychophysiological mechanism underlying the production of pain in MPDS is unknown. The tenderness, pain, and discomfort experienced in this condition have often been attributed to muscle hyperactivity. ,,,,
Management of MPDS is based on certain principles that include the recognition of symptoms leading to an accurate diagnosis followed by appropriate treatment. Based on the multifactorial etiology of such problems, the treatment usually involves more than one modality in order to obtain complementary effects and that includes counseling, drug therapy, and physical therapy. For long-term effect, treatments such as exercise therapy, anti-inflammatory drugs and local anesthetics injections, stretching therapy, occlusal splint, psychotherapy, ultrasound, biofeedback, and Transcutaneous Electrical Nerve Stimulation (TENS) are used, but every treatment modality has its own pros and cons.
Laser is one of the most recent treatment modalities in the field of physiotherapy. On the basis of energy level, it is divided as soft tissue (wavelength of 500-900 nm) and hard tissue (wavelength of 1000-2800 nm) laser. Hard tissue laser is used in gingivoplasty, gingivectomy, frenectomy, coagulation of graft donor site, periodontal pocket, caries removal and tooth preparation, tooth whitening, curing of composite, dentinal hypersensitivity, root canal debridement, placement of implant, dental laser welding for fabricating the metal frameworks of prostheses. Modern dentistry utilizes low-level Lasers (soft laser) in tissue healing, pain alleviation, reducing inflammation in the orofacial region. Low-level laser therapy (LLLT) is non-invasive modality and has been safely used in the treatment of myofascial pain due to its analgesic, myorelaxant, tissue healing, and biostimulation effects through direct irradiation without causing thermal response. ,,, This study was therefore designed to investigate and evaluate laser therapy along with exercises and drugs in the management of MPDS.
Aims and objectives
The aim of the study was to evaluate the efficacy of oral physical exercises, laser, and its combination as a treatment modality for MPDS and to compare the three treatment modalities.
| Materials and Methods|| |
This study was carried out in the Department of Oral Medicine and Radiology, VSPM'S Dental College and Research Center, Nagpur, in collaboration with VSPM'S College of Physiotherapy after obtaining permission from the Institutional Ethics Committee of NKP Salve Institute of Medical Sciences and Research Centre (NKPSIMS). In this study, patients were divided into three different groups. In each groups, twenty patients were included with minimum follow-up of 2 months. The study included 34 females and 26 males in the age range of 15-60 years.
Only those patients who fulfilled at least 3 out of 5 of the following criteria were included in the present study, unilateral or bilateral pain in preauricular region, tenderness of one or more muscles of mastication on palpation, limitation or deviation of mandible on opening, bruxism, clicking or popping noises in the temporomandibular joint (TMJ). Patients with congenital anomalies of TMJ, history of trauma, and any other diseases causing TMJ pain were excluded from the study. After obtaining informed consent, patient's clinical examination was carried out. Patients with acute pain were prescribed drug containing chlorzoxazone (500 mg), diclofenac sodium (50 mg), and paracetamol (500 mg) for initial 5 days. Patients were randomly divided into three groups of 20 patients each.
Group I: Patients were advised to do TMJ exercises for 30 days. The TMJ exercises included opening, protrusion, and lateral excursion movement against resistance. Patients were advised to perform each type of exercise 10 times and twice a day. All the patients were guided and taught exercises.
Group II: In this group, patients were treated with laser therapy, which was given in 10 sessions for 30 days, 3 sessions per week (alternate day), and each session lasted 9 min. A laser device with a wavelength of 632.8 nm used at output of 4 j/cm 2 was used.
Group III: In these patients, combination of both exercise and laser therapy as mentioned for Group I and II patients was given.
All the patients were evaluated for the following parameters before, during, and after treatment - Intensity of pain, palpation of muscles, maximum mouth opening (MMO). Measurement of MMO was done on the 1 st , 15 th , 30 th , and 60 th day using digital vernier caliper. Observation of pain at rest, on movement of jaw and the grade of tenderness in various muscles were noted on the 1 st , 15 th , 30 th , and 60 th day. Intensity of pain was evaluated on the visual analog scale (VAS) on the 1 st , 15 th , 30 th , and 60 th day. Laser (Biotech company, India) of 632 nm and 1.5 j/cm 2 intensity was used in the present therapy.
Laser therapy technique
Before starting the treatment, patient was explained about the nature of treatment and duration of treatment. Subjects were made to lie down in lateral position. Laser probe was applied over TMJ region or on the trigger point (TrP). A pulsed mode of 30-40 Hz was used. Patient was asked to close his/her eyes during the procedure and the operator was wearing goggles. No complications occurred in any of the patients after therapy. Statistical analysis was carried out by using Wilcoxon Sign Rank test, paired t-test, Kruskal-Wallis test, Chi-square test, and Z-test.
| Results|| |
- Comparison of pain [Table 1], [Table 2], [Table 3] and Graphs 1-4, the scores on VAS scale (mean and median value) on 15 th , 30 th , 60 th day as compared to that of 1 st day for pain at rest and on movement showed significant pain reduction in all the three groups (P < 0.01). It was observed that pain reduction was more in those patients who received laser therapy as compared to those who received only exercise therapy. Moreover, combination of exercise and laser therapy (88%) was found to be better than exercise (69%) and laser therapy (81%) when used independently (the difference was statistically significant)
- Comparison of range of motion (mouth opening) before and after therapy [Table 1] and [Table 2] showed significant increase in mouth opening (mean and median value) at three different intervals with reference to 1 st day in all the three treatment groups (P < 0.01), but the difference was not statistically significant
- Comparison of the tenderness of muscles before and after therapy [Table 1] and [Table 2] indicates that all treatment modalities were effective in reducing tenderness (mean and median value). The decrease in muscle tenderness was slightly more when combination of exercise and laser therapy (100%) was used compared to the use of laser (93%) and exercise (62.5%) alone, but the difference was statistically not significant.
|Table 1: Mean and standard deviation values of four parameters in three study groups |
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|Table 2: Statistical significance of difference in the median score of each parameter at 15th, 30th, and 60th day as compared to 1st day for each treatment modality |
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|Table 3: Statistical significance of difference in median values of modified visual analog scale scores for various treatment comparisons at 60th day |
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| Discussion|| |
MPDS causes mandibular dysfunction that generally leads to limitation in jaw opening along with deviation, presence of TrPs, and clicking or popping noises in the joints.  Management based on the clinician's understanding that MPDS is a psychophysiologic disease and the results of treatment must be considered in the light of placebo effects  and the contribution of a good doctor-patient relationship.  Varieties of therapeutic modalities offered to individuals with thermal-mechanical detection TMDs include mechanical, like orthopedic stabilization and intraoral appliances; physiological, like behavioral therapy; psychological, like counseling; and pharmacological such as analgesics, muscle relaxants, and antidepressants drugs.
An alternative mode of management could be the use of low-level lasers (soft laser) therapy. It provides an analgesic and anti-inflammatory effect by increasing pain threshold in sensory nerve endings, by stimulating the electrolyte exchange in the cell protoplasm and thus increasing the metabolism without causing thermal damage. In addition to this, laser irradiation stimulates collagen production, alters DNA synthesis, and improves the function of damaged neurologic tissues. ,, Numerous clinical studies indicate that inflammation in superficial muscles, tendons, and ligaments can be alleviated by irradiation of affected areas by laser. 
Pain was the chief complaint of all the patients with MPDS (100%). All sixty patients had preauricular pain, 54 had temporal pain, 45 had cheek, and 23 had neck pain [Table 4], [Table 5], [Table 6]. In the present study, age of occurrence was reported to be the second and third decade of life which is consistent with other studies. ,,, Regarding sex predilection, it is consistent with other studies ,,, which suggest female predilection in case of MPDS.
|Table 4: Number of patients with different region at 1st and 60th day of treatment and significance of difference between the proportions for regional involvement |
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|Table 5: Group wise number of patients with different region involvement at 1st and 60th day of treatment |
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|Table 6: Significance of difference in number of patients getting relief between groups according to regional involvement |
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On clinical examination, it was observed that the masseter muscle is involved in all sixty subjects, followed by temporalis in 54 subjects, medial pterygoid in 45 subjects, lateral pterygoid in 32 subjects, and neck muscles in 16 subjects [Table 7], which correlates with the finding of Butler et al. that masseter is the most frequently involved muscle followed by the temporalis. However, Solberg et al. reported lateral pterygoid as the most commonly affected muscle. The patients were divided in to three groups depending upon the modality of treatment, i.e., exercise or laser or both. However, all the patients were given chlorzoxazone with nonsteroidal anti-inflammatory drug (diclofenac sodium and paracetamol) for the initial 5 days. No side effects were seen in any of the patients, due to the fact that the drugs were given for short duration.
|Table 7: Number of patients with different muscle involvement at 1st and 60th day of treatment and significance of difference between the proportions for each muscle involvement |
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Parafunctional habit is also an important causative factor in MPDS. In the present study, 62% patients with MPDS had some parafunctional habit. It is well reported in the literature that stress is one of the causes for MPDS. History of some sort of stress was present in 82% of our patients, which suggests stress has an important role as an etiological factor in MPDS. Similar to our observation, many authors ,,, have emphasized the strong tendency of stress among the patients with MPDS.
In the present study, 89% patients had class I occlusion, 8% had class II and III occlusion and in 3% patients occlusion could not be ascertained because of missing teeth. According to literature, ,, occlusion, abnormal jaw relationship, more than five missing posteriors, and crossbite may sometimes cause muscular overextension or over contraction. This may lead to muscle fatigue and persistent myospasm. Contrary to this, in the present study, no correlation was found between MPDS and occlusion as most of the patients had normal occlusion.
In Group I patients, where exercise was the basic modality of treatment, 69% decrease in pain at the end of 60 th day was observed, which was statistically significant. The efficacy of exercise therapy in reducing pain in MPDS observed in the present study is similar to the observations made by Nicolakis et al., Exercise therapy was intended to improve coordination of the muscles of mastication, reduce muscle spasm, and correct the jaw closure pattern.
In Group II patients, where laser was the basic modality of treatment, 81% decrease in pain at the end of 60 th day was observed, which was statistically significant. According to Emshoff et al.,  no reduction in pain over TMJ following use of laser of 632 nm wavelength and 1.5 J/cm 2 intensity was seen and, therefore, they suggested that such laser was not useful for joint disorder but may be useful in musculoskeletal pain. Laser of 632 nm wavelengths penetrate more deeply into musculoskeletal tissues, and it results in improvement of musculoskeletal pain. Since, in the present study all the patients had only muscle involvement without any joint disorder, this could be the reason that laser therapy showed improvement. Methodological differences in patient selection, TrPs treated (active or inactive), and the application parameters of LLLT (wavelength, intensity, duration) may affect the final improvement in pain or functional limitation. Application of duration of LLLT is an important parameter determining the success of therapy. The most important parameter is the energy intensity in J/cm 2 adjusted using the other parameters. 
In Group III patients, where exercise and laser were used in combination, 88% decrease in pain at the end of the 60 th day was observed, which was statistically significant. Laser provides analgesia by decreasing the spasm in muscle arterioles which is essential for tissue oxygenation and by increasing adenosine triphosphate formation with a consequent normalization in metabolic rate of the tissues with diminished energy levels. The other mechanism may be related to its effect on endorphin levels, which may reduce pain, and exercise is also known to affect endorphin levels and hence can control pain. By all these mechanisms, the vicious cycle of the TrP can be interrupted. According to Kulekcioglu et al.,  the indirect influence of exercise is through the reduction of muscle spasm and recovery of proper muscular function. Improvement of TMJ functions in patients can be explained by both the analgesic and biostimulating effects of laser therapy.
| Conclusion|| |
The ideal therapy should be fast, cheap, and have a long-term effect. Laser (Helium Neon) as monotherapy or in combination with exercise had shown promising results and can be used as an effective treatment modality for the treatment of MPDS. Results from our study thus justify the use of laser therapy in the management of MPDS. However, further long-term trial with larger sample size and using different type of laser with varying intensity should be done to arrive at a definite conclusion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]