Laser Therapy for TMJ Problems to Improve Comfort and Mobility

INTRODUCTION

Temporomandibular joint disorder (TMJD) is a common condition affecting the temporomandibular joint (TMJ) and causing pain and discomfort. A systematic review of 21 articles reported a prevalence of TMJD of approximately 31% for adults/the elderly and 11% for children/adolescents.1 It was found that women are twice as prevalent to have TMJD than men.2 Additionally, women using either supplemental estrogen or oral contraceptives are more likely to seek treatment for TMJD issues. Based on the available statistics published, approximately one third of adult patients have some form of TMJD,1 but many of those patients may not address that with the dentist. The avoidance of broaching this problem with the practitioner may be related to several factors, including lack of understanding that the dentist can assist in pain relief; the discomfort having been present for a long period, and thus, the patient has accepted that he or she has to deal with it; and/or the patient fears an invasive procedure to treat it. Pain related to TMJD can significantly influence a patient’s quality of life.

Various treatment modalities have been utilized in dentistry for pain management and other applications, including TMJD treatment. Laser usage has been increasingly utilized for pain management both intraorally and extraorally and has been termed photobiomodulation (PBM). Regarding TMJD treatment, PBM permits a non-invasive approach to stimulate the relief of pain and improve patient comfort with predictable outcomes. PBM also allows a non-pharmaceutical approach to treatment.

Orofacial pain can have several origins that are non-dentition related. Those conditions include musculoskeletal, neurovascular, neuropathic, and psychogenic (Figure 1). TMJD pain tends to fall into the musculoskeletal region of orofacial pain. This is divided into muscular issues, joint mechanics, and arthritides. Muscular issues are divided into myalgia (muscle aches and pains), myofascial pain (a chronic condition that arises from inflammation in muscles and fascia), myositis (inflammation or swelling of the muscles), trismus (muscle spasms in the TMJ), and contracture (tightening of the muscles and tendons). Joint mechanics are classified as disc displacement at the TMJ, ankylosis of the joint due to perforation of the disc, or conditions following joint trauma from an accident or after surgical treatment of the joint. Arthritides relate to arthritic changes to the components of the joint.

Figure 1. Classification of orofacial pain.

Some dental conditions may contribute to TMJD issues. These conditions encompass a decrease in vertical dimension of occlusion (VDO) that puts the TMJ in a different position, placing strain on the muscles and tendons associated with the joint. These conditions include worn dentition in patients with their own teeth or those with a full removable prosthesis on one or both arches. These patients may require correction of the VDO issue to take pain off the joint and its associated structures.

LASER MANAGEMENT OF TMJD

Laser usage in dentistry has become the norm in various treatment modalities with applications in soft and hard tissue, depending on which laser is being utilized. The energy produced by the laser influences the tissues at which it is directed. Laser-tissue interaction is dependent upon the wavelength, tissue type, power (incident energy), and duration of exposure. With regard to the applications being discussed in this article, red to near-infrared light energy is utilized on body tissues being treated.

Various therapeutic approaches are known to reduce pain, including analgesics, corticosteroids, anti-inflammatory drugs, and phytotherapy.³Laser therapy has been shown to be an appropriate alternative to manage pain due to temporomandibular disorders.^4,5

Two terms that are used in regard to laser application are PBM and low-level laser therapy (LLLT). Essentially, those terms are interchangeable and refer to the same thing: utilizing laser energy to effect change at the cellular level and stimulate positive effects. PBM is a non-invasive, non-thermal,⁶ non-cutting treatment modality that uses low-intensity light energy to provide pain relief by producing an analgesic effect via inhibiting nociceptive signals and decreasing inflammation, thereby leading to subsequent healing.⁷ That analgesic effect will vary from patient to patient depending on how long the pain has been present and the level of pain, and multiple sessions may be required to achieve a comfort level for that particular patient. PBM’s mechanism of pain reduction relates to a blockage of action potential generation and conduction of nociceptive signals in the neurons.^8,9 The effect of pain reduction occurs through release of inflammatory mediators and alteration in lymphocyte metabolism.⁸

Another form of laser treatment, high-intensity laser therapy (HILT), has been recommended and utilized in orthopedic and physical therapy. HILT employs higher average power output (>50 mW) than LLLT (≤50 mW). HILT affords deeper tissue penetration and can produce photothermal effects.¹⁰ In contrast, LLLT operates at lower power levels, making it suitable for superficial applications.

Multiple studies have demonstrated an improvement in pain and function when PBM or HILT is utilized when musculoskeletal disorders are present.^11-16 With regard to TMJD pain and issues with the associated muscles, LLLT (PBM) and HILT have been reported to be effective in reducing overall subjective perception of myofascial pain.^17,18

Studies have reported that use of LLLT and HILT in TMJD patients was a highly effective, non-invasive therapeutic method.^18,19 LLLT can be considered as a treatment modality or supplemental approach for management of acute and chronic TMJD. However, patients with acute TMJD are likely to have a better outcome than those with long-standing chronic pain issues.²⁰ A study reported that LLLT may be useful for patients with TMJD-related pain, especially those with long-standing pain.²¹ Some TMJD patients may present with a complaint of tinnitus, which has been associated with this condition in some patients. LLLT has been demonstrated to provide relief from those symptoms as the trigger points identified in TMJD are treated. Some patients report that tinnitus associated with their TMJD has been helped by LLLT.²²

The use of LLLT has been reported to result in improvement in maximal mouth-opening, and reductions in pain and chewing difficulty were reported as statistically significant compared to a control placebo group with no active laser treatment. Statistically significant improvements were also detected with a reduction in the number of trigger points.²³ LLLT or HILT is an option for those patients who have trismus and postoperative pain following mandibular third molar surgery or other treatment that resulted in the patient keeping open for an extended period of time.^24-26 The use of LLLT with an Nd:YAG laser may be an efficient way to manage orofacial pain in TMJ disk displacement patients, thus providing pain relief and reducing their recovery time.^27,28

Additionally, a meta-analysis showed the LLLT had better short-term efficacy than transcutaneous electric nerve stimulation (TENS) in the treatment of pain caused by TMJD.²⁹ Another study stated that the healing effect of HILT with pulsed Nd:YAG laser therapy was significantly higher than TENS in patients with TMJ disc displacement with reduction.³⁰ LLLT was compared with splint therapy for treatment of pain related to TMJD and was found to be equally effective.³¹ When splint therapy is being utilized, the lead author has found that LLLT is a good augmentation in the management of acute pain either before the splint is delivered or during splint therapy when pain arises.

TREATMENT PROTOCOL

Examination and Diagnosis of TMJD

The first appointment consists of interviewing the patient to determine his or her symptoms related to the TMJ and its associated structures (muscles, the joint, and teeth). A comprehensive medical history is taken to determine any contributory factors that could be involved in the pain present, such as arthritis, past history of head and neck trauma, and/or neck issues.

A complete exam is performed of the intraoral and extraoral areas. Any dental factors that may be contributory are noted. Those could include missing posterior dentition (not replaced by prosthetics), worn teeth, mobile teeth, and periodontal issues. A standardized form is utilized to record the findings (Figure 2). The examination should include how many millimeters the patient can open in active and passive opening, protrusive motions, and lateral motions to the left and right before discomfort results. Active opening is defined as the patient opening as wide as possible before any sensation may be felt in the TMJ, whereas passive opening is defined as opening normally without straining. The patient’s ability to open fully and any deviation of the mandible upon opening are noted. When opening in a straight vertical direction, does the mandible deviate to one side? Any noted deviation is drawn on the diagram on the form. Any noise or palpation changes at the joint are noted upon opening. Intraorally, the condition of the dentition and the occlusal contacts in all positions are noted.

Figure 2. Form for patient evaluation examination when evaluating the TMJ and associated structures.

Extraorally, the muscles are palpated on the sides of the face and neck. Trigger points are spots where the patient feels discomfort when light pressure is applied, which aids in determining what the cause may be (Figures 3 and 4). Trigger points are muscular in nature and identify which muscle is contributing to the pain the patient has indicated has led him or her to seek attention. A standardized form is utilized to record the trigger points identified during the examination (Figure 5). When recording trigger points on the form, when pain is felt, it is indicated in red with different symbol notation based on whether the pain is mild, moderate, or severe (Figure 6). When palpation refers pain to a different area, that is then indicated in green with an arrow indicating the path of pain. The area the pain is referred to is then circled on the chart. An example of how this would be recorded is shown in Figure 7.

Figure 3. Cervical myofascial trigger points and the area affected by each point.

Figure 4. Trigger points on the skull and the originating source.

Figure 5. Form for documentation of trigger points to be used during the TMJ examination.

Figure 6. Palpation guidelines for documentation of trigger points on the form (“CC” = “chief complaint”).

Figure 7. Example of documented trigger points on the form during a patient TMJ examination.

Deviation of the mandible is also examined, and this will allow for the identification of issues on one side vs bilaterally. A patient with no issues in the joint or associated musculature will be able to open in a straight vertical direction with a maximum opening of 40 to 60 mm, depending on skull size (Figure 8). Deflection to one side on opening indicates the issue is originating on the side that the jaw is deviating to as that joint or muscles are the cause of the issues. Under normal conditions, the patient should be able to move the jaw 7 to 12 mm laterally to the right and left when maximally open. If that is not possible, it indicates TMJD issues either in the joint or facial muscles or a combination of the 2. If the patient’s TMJD issues are bilateral, then no deviation may be seen, and limited opening is present before discomfort presents. When an issue is present unilaterally in the joint, and a click is noted when opening, a deviation to the side at mid-opening presents at the click, and then the jaw moves back to the midline as it fully opens (Figure 9).

Figure 8. Under normal conditions, the patient should be able to open fully to a maximum of 40 to 60 mm without discomfort in a straight motion with no deviation and be able to shift the mandible 7 to 12 mm laterally when fully open without discomfort.

Figure 9. Documentation of variations on mandibular path when opening the jaws.

Trigger points, maximum opening, and jaw deviation should be rechecked at the start of each treatment session to note what, if any, changes have occurred and if the treatment area needs to be modified.

Laser Treatment

Treatment recommendations are discussed with the patient, who is educated on the use of the laser for therapy. Treatment will consist of 3 to 5 treatment sessions that are spaced one week apart. Upon acceptance of treatment, a consent form is reviewed and signed by the patient.

In session 1, biostimulation utilizing high-intensity laser therapy (HILT) is performed with the laser. The PerioLase MVP-7 pulsed Nd:YAG laser (Millennium Dental Technologies) is set at 4.0 W, 100 µsec, 200 mJ, and 20 Hz (Figure 10). Although the peak power at these settings is 2,000 W, the free-running pulse configuration of this particular laser yields a short duty cycle (0.2% at these parameters), which minimizes thermal accumulation within tissues^16,32 when the fiber tip delivery system is held away from the tissue and moved in a circular motion over the target area. In addition, in non-contact mode, the Nd:YAG laser wavelength can penetrate several millimeters deep, depending on the tissue.³³ The result is the delivery of the desired amount of photonic energy to deeper tissues in a short time.³⁴

Figure 10. PerioLase MVP-7 (Millennium Technologies) screen showing settings for TMJ treatment.

A 360-µm fiber tip is placed in the laser’s handpiece. The tip is used in a non-contact manner, keeping the laser fiber tip 4 to 6 in from the skin. The patient is informed that he or she will feel warmth and should indicate what he or she is sensing. This will indicate how far from the surface the tip is to be placed. Should the patient indicate the area feels hot, the tip is backed away slightly until he or she indicates that it feels warm but not hot. Should the patient not be feeling warmth when the tip is close to the surface, the power output is increased incrementally on the laser until the patient indicates warmth is felt. As the HILT reduces the pain at the trigger points, the laser power may need to be increased to maximize treatment benefits at subsequent sessions.

The tip is applied over each trigger point that was identified during the examination (Figure 11). When the laser beam is activated, the tip is moved in a circular motion to apply HILT to the area surrounding the trigger point. Following completion at a trigger point, typically 5 to 7 minutes, the next trigger point on that side of the head and face is treated. Once those are completed, the trigger points on the opposite side of the head and face are treated to complete the session.

Figure 11. Tip of the laser being used over trigger points as the patient opens to his or her maximum.

At subsequent sessions, the patient is interviewed to determine whether he or she has noted any improvements in the discomfort he or she initially presented with, which is noted in the chart. The trigger points previously noted are checked by palpation to determine whether sensitivity has improved at each point. The technique described in session 1 is repeated in the second session and subsequent sessions. Sessions are repeated at one-week intervals until symptoms are eliminated or further improvement is not noted between sessions. The patient is then seen at 3-month recall sessions to maintain the results. Should the patient not have any return of symptoms after his or her second 3-month recall session, he or she can be discontinued from recall treatment and instructed to schedule a treatment session should any symptoms return. Some patients may require continuing long-term recall sessions every 3 months to maintain their comfort levels and prevent the return of worsening pain and discomfort.

CASE EXAMPLES

Case 1

A 60-year-old male presented with severe jaw discomfort, difficulty in chewing, and pain and tightness in the jaws bilaterally. A review of his medical history noted cardiac issues, diabetes, hypertension, depression and anxiety, and elevated cholesterol. The patient was currently taking medications for hypertension and anxiety along with medications to lower cholesterol and manage diabetes. He was a clencher and grinder and would continue the habits all day.

A physical exam was performed, and acute distress with facial asymmetry with no swelling or enlarged lymph nodes was noted. The intraoral exam showed generalized attrition of teeth due to grinding. A myofascial evaluation was performed, and masseter muscle pain was noted bilaterally. A review of the systems (ROS) noted that it was significant for body and jaw movements with pain in the neck and back. A screening evaluation of cranial nerves was within normal limits (WNL). A range of motion (ROM) test noted moderate pain, and a click was detected on the left TMJ and crepitus was needed on the right TMJ. The diagnosis based on the clinical findings was myofascial pain in the masseter muscles.

Diagnosis

• Sleep disorder (diagnosed by a sleep expert after referral)
• TMJ movement disorders
• Myofascial pain of the masticatory and cervical muscles

Laser therapy, as outlined in the protocol described previously, was performed over 3 treatment sessions. The laser was used to deliver 2,100 J per side with a light dose of 74 J/cm2, and an area of 6 cm was treated at each of the trigger points identified (Figure 12). Clinical results, as noted in Figure 13, found significant improvement in comfort between sessions 1 and 2, with further improvement between sessions 2 and 3 with increased ability to open after each session. Visual analogue scale (VAS) was recorded at each session to monitor pain levels and improvement in TMJD (Figure 14). VAS records endpoints on a scale of zero to 10, with zero being no pain and 10 being extreme pain as defined by the patient.^31,35 Active and passive improvement replicated comfort improvement, and the patient indicated less facial tightness, greater range of motion, and an absence of the pain he initially presented with. Clicking remained but was no longer contributing to discomfort. A mouthguard was recommended to the patient to prevent further wear from his grinding and aid in prevention of further TMJD issues.

Figure 12. Laser setting used on Case 1 for each of the 3 treatment sessions and the area treated.

Figure 13. Clinical results for Case 1 after the 3 treatment sessions and showing improvement in range of motion (left) and a decrease in pain (right).

Figure 14. The VAS pain scale allowing the patient to indicate his or her level of pain.

Case 2

A 76-year-old male presented with moderate discomfort and pain in the jaws bilaterally and a complaint of tightness in the TMJ bilaterally and pain on chewing. He reported daily constant pain that started 3 to 4 weeks prior. A review of his medical history noted cardiac issues, hypertension, elevated cholesterol, and previous sinus surgery. The patient was currently taking lisinopril for his hypertension and Plavix to lower his risk of further heart attacks since his prior event. No contributory habits were noted.

A physical exam was performed, and acute distress with facial asymmetry was noted, with no swelling or enlarged lymph nodes. The intraoral exam was WNL. A myofascial evaluation was performed, and masseter muscle pain was noted bilaterally (Figure 15). An ROS noted that it was significant for body and jaw movements with pain in the neck and back; dry mouth was noted, as was numbness in and around the nose. A screening evaluation of cranial nerves was WNL. ROM noted moderate pain, and a click was detected on the left TMJ and crepitus was detected on the right TMJ. The diagnosis based on the clinical findings was TMJ arthralgia with movement disorders and myofascial pain in the masseter muscles.

Figure 15. Identification of trigger points in Case 2.

Laser therapy, as outlined in the protocol described previously, was performed over 3 treatment sessions. The laser was used to deliver 2,006 J per side with a light dose of 63 J/cm2, and an area of 6.5 cm was treated. A lower dose was utilized based on the patient indicating sensations of warmth as the activated laser was used at the trigger points (Figure 16). Clinical results, as noted in Figure 17, found significant improvement in comfort between sessions 1 and 2 with further improvement between sessions 2 and 3. Active and passive improvement resulted in an increase in comfort, and the patient indicated less facial tightness was present with improvement in facial symmetry with a resolution in the pain during chewing that was felt prior to treatment. Less clicking and crepitus was noted following completion of the laser treatments.

Figure 16. Laser setting used on Case 2 for each of the 3 treatment sessions and the area treated.

Figure 17. Clinical results for Case 2 after the 3 treatment sessions, showing improvement in range of motion (left) and a decrease in pain (right).

CONCLUSION

TMJD issues are a common occurrence, and often, patients in the dental practice do not make the dentist aware of the symptoms they are having. This may relate to patients feeling that it is not something the dentist can assist them in managing or that it is something they just need to deal with on their own. Laser treatment has been demonstrated through HILT to relieve pain associated with the muscles of the face and associated structures of the TMJ. The cases presented discuss identification of the trigger points and how to treat them with the Nd:YAG laser to decrease pain and improve the ability to open the mouth and restore comfortable function.

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ABOUT THE AUTHORS

Dr. Palayam received his DDS degree from the University of Colorado School of Dental Medicine, combining his lifelong passions for medicine and computer technology, and emerged as a revolutionary force in contemporary dentistry. He is one of only a handful of dentists in the state of Massachusetts trained on LANAP, an advanced laser-assisted periodontal osseous surgery, and LAPIP, an implant surgical protocol, along with 3D CBCT. He can be reached at sathish.palayam@gmail.com.

Dr. Kurtzman is in private general dental practice in Silver Spring, Md; a former assistant clinical professor at the University of Maryland in the department of Restorative Dentistry and Endodontics; and a former American Academy of Implant Dentistry Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, implant surgery, removable and fixed prosthetics, and periodontics and has published more than 880 articles globally, as well as several ebooks and textbook chapters. He can be reached at dr_kurtzman@maryland-implants.com.

Disclosure: Dr. Palayam reports no disclosures. Dr. Kurtzman received compensation for co-writing this article.