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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 432-436

Comparative study of mouth exercise program and with combination of ultrasound therapy in temporomandibular disorder

Department of Oral Medicine and Radiology, Government Dental College and Hospital, Hyderabad, Telangana, India

Date of Submission25-Jun-2021
Date of Decision12-May-2022
Date of Acceptance23-Nov-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Sambhana Sailaja
Associate Professor, Department of Oral Medicine and Radiology, Government Dental College and Hospital, Afzalgunj, Hyderabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_176_21

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Introduction: Temporomandibular disorders (TMDs) are multifactorial, with several clinical presentations. The treatment is extensive and diverse, involving several therapies. Objectives: To evaluate and compare the combination of ultrasound therapy and mouth exercise with a mouth exercise program alone on pain and pain-free maximum mouth opening (inter-incisal distance) in TMD patients. Materials and Methods: A total of 30 patients who were clinically diagnosed with TMDs were equally divided into two groups. VAS score and pain-free mouth opening were recorded before and during the treatment for four weeks in all the patients. Results: Statistical analysis revealed a mean difference of 0.33 ± 0.09, 0.47 ± 0.01 in the VAS score in ultrasound with physiotherapy and physiotherapy alone. The pre- and post-treatment change in mean mouth opening (MMO) was 2.60 ± 0.21, 0.30 ± 0.87 in ultrasound with physiotherapy group and 0.27 ± 0.23, 0.20 ± 0.03 in the physiotherapy group alone, respectively. These differences in VAS score and mouth opening were statistically significant (P < 0.05). Conclusion: Both treatment modalities were effective in giving symptomatic relief, but ultrasound therapy with mouth exercises outstands showed better results in reducing pain and improving joint function.

Keywords: Mouth-opening exercise and ultrasound therapy, pain, temporomandibular disorders

How to cite this article:
Daruri S, Sailaja S, Lavanya R, Ravali C T, Dhanabalan S, Bojanapu S, Komanduri S. Comparative study of mouth exercise program and with combination of ultrasound therapy in temporomandibular disorder. J Indian Acad Oral Med Radiol 2022;34:432-6

How to cite this URL:
Daruri S, Sailaja S, Lavanya R, Ravali C T, Dhanabalan S, Bojanapu S, Komanduri S. Comparative study of mouth exercise program and with combination of ultrasound therapy in temporomandibular disorder. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 3];34:432-6. Available from: http://www.jiaomr.in/text.asp?2022/34/4/432/363019

   Introduction Top

TMD is a complex disease with multifactorial etiology, so we have to recognize the contributing factors and identify the predisposing factors, initiate factors, and perpetuating which interfere with TMJ.[1],[2],[3] TMD presents with varied clinical presentation.[4],[5]

The physician's goal is mainly to relieve the patients from painful episodes associated with TMDs and encourage comfortable jaw movements by using comparative analysis to evaluate the effectiveness of these two therapies.

   Materials and Methods Top

The prospective study was designed for two years in the Department of OMR at GDC & Hospital, Hyderabad, among 30 participants after taking permission from the Institutional ethical board committee dated 20/2/2018(GDCHIEC/PG/1708).

Selection of sample

Thirty patients (sample size calculation using 95% CF with an α value of 0.05 with an expected power value of 80%) include both males and females of age group 18–60 yrs. Patients were clinically diagnosed with TMD. Subjects with a history of trauma to TMJ or upper back, inflammatory disorders, or other rheumatic, neurological, and psychiatric disorders are observed. History of medication for TMD and past treatment for TMD within the past three months were excluded. The selection of the sample is outlined in [Flowchart 1].

Materials used

For clinical examination: Sterile gloves, mouth masks, kidney trays, mouth mirrors, straight probes, tweezers, stethoscope, Vernier calipers. Therapeutic ultrasound machine with an output of 1.0 W/cm2 for five minutes using a pulsed mode with a frequency of 1 MHz for four sessions in four weeks (1 session/week).

   Methodology Top

A total of 30 patients with the symptoms were selected and randomly divided into two groups. Group A was treated with mouth exercise therapy in combination with ultrasound therapy; group B was treated with mouth exercise (physiotherapy) therapy alone. All the participants' informed consent was taken.

In group A, participants were instructed to be seated comfortably in a dental chair position so that the treatment area was accessible. The skin surface to be treated was properly inspected and kept free of oil and dirt. The nature of the treatment was explained to the patient. Ultrasound gel was applied to the skin surface. The transducer head was moved continuously over the surface while even pressure was maintained to remove the irregularities in a sonic field; these participants were asked to do mouth-opening exercises.

In group B, the patient was explained to perform various mouth exercises such as slow active and passive mouth-opening and closing exercises, isometric mouth exercises, mouth stretching exercises, and resistive mouth exercises; each exercise is performed twice daily for six seconds with 10 repetitions for four weeks. Patients were also informed to deal with TMJ pain through lifestyle changes, ergonomic regulation, and coping mechanisms.

A visual analog scale was used to evaluate the pain scores before the treatment, during the treatment, and at the end of the treatment in each group. Pain-free inter-incisal distance (IID) on mouth opening was recorded with Vernier calipers before and during treatment.

Statistical analysis

Data was summarized using SPSS software of 16.0 (Social Science IBM Corporation, Armonk, NY, USA). Friedmann test and Wilcoxon test are used for intra-group VAS score comparison. Mann–Whitney U test is for inter-group VAS score comparison. ANOVA one-way and paired t test for intra-group IID comparisons and independent sample t test for inter-group IID comparisons are observed.

   Results Top

Out of 15 patients in group A, eight were females and seven were males, while in group B, nine were females and six were males, between the mean age of 18–58 years.

In group A, the patient's VAS scoring revealed that there was a decrease in the mean value of 5.67,4.07, 2.53, 2.40, and 2.07 with the standard deviation of 1.54, 1.82, 2.50, 2.03, and 1.94 at the baseline, 1st, 2nd, 3rd, and 4th week, respectively, with statistically significant P < 0.05. The result shows a significant reduction in VAS score in 1st week, 2nd week, 3rd week, and 4th week compared to the baseline score and a nonsignificant reduction between 2nd, 3rd, and 4th weeks [Table 1].
Table 1: Intra-group comparison of VAS scores in combination with ultrasound and mouth exercise program in TMD patients

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In group B participants, there was a statistically significant reduction of VAS scores 6.93, 6.43, 4.47, 3.80, and 3.33 observed at baseline, 1st, 2nd, 3rd, and 4th week with the standard deviations 1.66, 1.94, 2.44, 2.22, and 2.23, respectively. When VAS scores were observed, there was a significant reduction in scores in the 1st, 2nd, 3rd, and 4th weeks compared to baseline and a nonsignificant reduction between the 3rd and 4th weeks.

The IID among group A participants revealed no significant increase in IID between baseline and 1st week, 1st week and 2nd week, and between 3rd and 4th weeks but a significant increase in IID in 2nd, 3rd, and 4th weeks compared to baseline and between 1st and 3rd weeks, 1st and 4th weeks, 2nd and 3rd weeks, 2nd and 4th weeks [Figure 1] and [Figure 2] [Table 2], [Graph 1]. Group B participants showed a significant increase in IID values between the 1st and 4th weeks [Figure 3] and [Figure 4], [Graph 2].
Figure 1: Group A mouth opening at base line

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Figure 2: Group A participant mouth opening after fourth week

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Table 2: Inter-group comparison of IID between in combination of ultrasound and mouth exercise program in TMD patients and treatment with physiotherapy alone patients

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Figure 3: Group B mouth opening at intinal visit

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Figure 4: Group B mouth opening after fourth week

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A comparison of the VAS score in both groups showed a significant reduction in the VAS score in group A in 1st and 2nd weeks and a nonsignificant reduction in 3rd and 4th weeks. [Graph 3] The comparison between the change brought by ultrasound therapy in combination with physiotherapy and physiotherapy alone in the IID scoring among the sample showed a significant increase in pain-free mouth opening in the 3rd and 4th weeks of group A compared to the 1st and 2nd weeks [Figure 1], [Figure 2], [Figure 3], [Figure 4].

   Discussion Top

In the present study, a total of 17 female patients (56.6%) and 13 male patients (43.3%), with a high female frequency similar to the study done by Korf et al.[6] and Goulet et al.[7] are observed. This could be due to estrogen's influence on the pain felt in TMD through an effect on the dopamine system and degenerative diseases through modulation of cellular response in the TMJ.[8],[9] A study by Ribeiro-DaSilva et al.[10] suggests that a polymorphism in the estrogen receptor alpha may increase the risk of women developing TMD.[11],[12]

The present study revealed a significant reduction in VAS score in group A by 63.49% and an increase in pain-free mouth opening by 22.87%. These findings were similar to the study by Rai et al.,[13] El Fatih et al.[14] and Grieder et al.[15] have reported that this therapy was beneficial in hastening pain relief when used as an adjunct. These findings were in contrast with the study done by Lee.[16]

In a study, De Laat et al.[17] mentioned that one group receiving physical therapy showed improvement in pain parameters and range of motion in patients with myofascial pain. The present study has also shown similar results in a significant decrease in VAS scores. IID is present in 1st and 2nd weeks due to the therapeutic effects of ultrasound and nonsignificant in 3rd and 4th weeks due to static symptoms after a certain period.

In the present study, group A showed statistically more significant than group B, which is similar to the findings mentioned by FeiAne and Lund.[18],[19] The literature mentioned that increase in range of motion is attributed to stretching exercises that can enforce patient responsibilities and thereby address psychosocial factors (like coping and locus of control) can be a powerful tool, and can be considered as an adjuvant.[20]

Among the two therapies, group A showed a significant reduction in VAS score over group B in 1st and 2nd weeks, a nonsignificant decrease in VAS score in 3rd and 4th weeks, and a significant increase in IID in 3rd and 4th weeks and a nonsignificant increase in 1st and 2nd weeks. Pain relief was noticed in group A [Figure 1] and [Figure 2] patients, and significant improvement in mouth opening may be due to the therapeutic effect of ultrasound in decreasing inflammatory and pain mediators caused by changes in nerve conduction, alterations in cell membrane permeability compared to group B patients [Figure 3] and [Figure 4] (mouth exercises). These findings were similar to a recent study by Nayak et al.[21]


The mouth exercise program completely relies on patient compliance and consistency, which is the major limitation, and our study is single-centered with a limited number of participants.

Future prospects

Further studies with larger sample sizes to know the treatment's better outcome with follow-up shortly.

   Conclusion Top

When the pre- and post-treatment effects were compared, combination with ultrasound showed more improvement in pain relief and mouth opening compared to physiotherapy (mouth exercise program). This suggests that physiotherapy and ultrasound in combination were more effective in reducing the pain in TMDs compared to exercises alone.

Key message

Even though many treatments are available, ultrasound therapy (US) is easily accepted and noninvasive, which helps in neovascularization and relief of pain. US with physiotherapy showed better results and is easily accepted by patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Lee JC, Lin DT, Hong C-Z. The effectiveness of simultaneous thermotherapy with ultrasound and electrotherapy with combined AC and DC current on the immediate pain relief of myofascial trigger points. J Musculoskelet Pain 1997;5:81–90.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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