Early results of low-level laser application for masticatory muscle pain: a double-blind randomized clinical study

Synthesis of temporomandibular disorders management intervention outcomes for development of core outcome sets: A systematic review

INTRODUCTION

The selection of appropriate outcomes in clinical trials and systematic reviews is a crucial factor in determining the results that are useful, reliable, and relevant for both patients and healthcare professionals. Clinicians and researchers have been encouraged to develop and apply core outcome sets (COS) to minimise the discrepancy between studies.

AIM

This systematic review is the first phase of the COS development project for clinical trials in temporomandibular disorders (COS-TMD). It aims to identify and synthesise the outcomes used in the randomised controlled trials (RCT) that evaluated the effectiveness of interventions used in TMD management.

MATERIALS AND METHODS

An electronic search was performed in several databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library and EMBASE. The eligibility criteria comprised RCT that applied any intervention to treat temporomandibular joint disorders or masticatory muscle disorders. The identified outcomes were categorised according to domains of the Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT).

RESULTS

The electronic search resulted in 1606 studies. After removing duplicates and applying the eligibility criteria, 106 RCT were included. A total of 43 studies evaluated masticatory muscle disorders, 27 evaluated temporomandibular joint disorders, and 36 analysed mixed TMD.

CONCLUSIONS

The evaluation showed significant variability in the types of outcomes and their measurement instruments. In addition, some domains such as physical and emotional functioning, participant ratings of global improvement and adverse events have been neglected when determining the effectiveness of treatments for TMD.

Effectiveness of photobiomodulation and orofacial myofunctional therapy in orofacial pain disorders. A systematic review of randomized control trials

Orofacial pain can significantly affect physical, psychological, and overall quality of life. This study aimed to compare the effectiveness of combining photobiomodulation (PBM) with orofacial myofunctional therapy (OMT) in managing orofacial pain disorders. An electronic search of randomized controlled trials in electronic databases was performed until March 2024. Randomized controlled trials (RCTs) focusing on PBM and OMT for the management of orofacial pain were included. Risk of bias across individual studies was performed using the Cochrane risk of bias tool for interventions. A total of 10 RCTs were included, out of which 7 RCTs revealed that the combined approach of PBM and OMT had a more pronounced impact on diminishing pain and enhancing functional activity in patients with orofacial disorders. One study reported significant increases in pressure pain threshold for TMJ, masseter, and anterior temporalis muscles at both sides in the post-treatment compared with the pre-treatment in both groups. The risk of bias was low in 7, moderate in 2, and high in 1 study. The efficacy of a combined modality treatment of PBM with OMT for orofacial pain disorder shows promising results. However, further randomized controlled trials with extended follow-up periods standardized PBM and OMT parameters are warranted to obtain firm conclusions.

Comparison of low-level laser therapy and standard treatment for temporomandibular disorders: An assessment of therapeutic and placebo effects

BACKGROUND

Despite extensive research on the use of low-power lasers for TMD treatment, the extent of their effectiveness remains uncertain.

OBJECTIVE

This study aimed to investigate the therapeutic or placebo effect of LLLT for TMD, and to compare it with standard treatment methods. A unique aspect of this study was the inclusion of a control group that received only standard treatment, allowing for an assessment of the placebo effect of LLLT.

METHODS

A total of 42 patients with TMD were referred to Kerman Dental School Pain Clinic and were randomly assigned to three groups: group A received LLLT, group B was a placebo group and group C was a control group that received only standard treatment. The laser groups received gallium-aluminium-arsenide laser treatment twice a week for 10 sessions. Patients' jaw movement rate indicators and VAS index were evaluated at the start of treatment, and indicators were re-recorded every week for 5 weeks. SPSS 21 was used for statistical analysis, including ANOVA and Tukey's post hoc tests for inter-group comparisons. The repeated measurement test was used to analyse the data.

RESULTS

All groups showed significant improvement in VAS indicators (p = .0001), lateral jaw movements (p = .0001), forward jaw movement (p = .007) but not for maximum mouth opening. No significant difference was observed between the groups at the end of the study (p = .000).

CONCLUSION

Our study provides insights into LLLT's effectiveness for TMD, suggesting it cannot replace standard treatment alone. These findings contribute to the literature and emphasise the importance of including a control group in future studies to assess the placebo effect of LLLT.

Effect of physiotherapeutic procedures on the bioelectric activity of the masseter muscle and the range of motion of the temporomandibular joints in the female population with chronic pain: a randomized controlled trial

INTRODUCTION

Physical therapy (PT) methods applied in dentistry are increasingly discussed nowadays. Taking into account a rapidly growing number of temporomandibular disorders (TMDs) and orofacial pain patients, it is reasonable to determine which of the available physiotherapeutic (PT) methods are more effective than others, especially in terms of their possible analgesic and myorelaxant effects.

OBJECTIVE

To assess manual and physical factors influencing pain reduction or elimination and increased muscle tension in patients with TMD; yet the influence of the applied forms of PT on the range of motion (ROM) of temporomandibular joints (TMJ).

MATERIAL AND METHODS

A randomized, parallel-group, RCT, single-blind, equi-randomized (1:1) study was conducted in DC/TMD Group Ib patients (20-45 years of age). An experimental group (G1, n = 104) and a control group without TMD (G2, n = 104) were created according to CONSORT guidelines. Diagnostic measurements were performed in both groups (mass sEMG, temporomandibular joint range of motion-ROM, pain intensity - NRS). Group G1 was randomly divided (envelope method) into 4 therapeutic groups, in which therapy was carried out for 10 days: magnetostimulation (MS), magnetoledotherapy (MLE), magnetolaserotherapy (MLA), manual therapy (MT). Each time after the therapy, ROM and NRS measurements were performed, and after the 5th and 10th day sEMG.

RESULTS

Statistically significant differences were found in the sEMG values of the masseter muscles, TMJ ROM and the pain intensity in G1 and G2 (p < 0.00). The largest decrease in sEMG (% MVC) of the masseter muscle occurred in the subgroup in which the manual therapy (MT) procedures were applied, p < 0.000. There was no clinically significant difference in and between other subgroups. There was a distinct mandible ROM increase noted in the MT group, with minimal changes in the MLA and MLE groups and no changes in the MS group. There was a clear increase in the lateral mobility of both right and left TMJ in the MT group. There were no differences in the course of the study in the MS group, and slight increases in the MLA and MLE groups. In the case of pain measurements, the greatest decrease in pain intensity was observed in the MT subgroup.

CONCLUSIONS

According to our results manual therapy is an effective form of treatment in patients with pain, increased masticatory muscle tension and limitation in mandible ROM. Dental physiotherapy should become an integral part of multimodal TMD patients' treatment.

What are the best parameters of low-level laser therapy to reduce pain intensity and improve mandibular function in orofacial pain? A systematic review and meta-analysis

PURPOSE

To determine the effectiveness of laser therapy for managing patients with orofacial pain (OFP). In addition, to determine which parameters provide the best treatment effects to reduce pain, improve function, and quality of life in adults with OFP.

METHODS

Systematic review. Searches were conducted in six databases; no date or language restrictions were applied. Studies involving adults with OFP treated with laser therapy were included. The risk of bias (RoB) was performed with the Revised Cochrane RoB-2. A meta-analysis was structured around the OFP type, and outcomes. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessed the overall certainty of the evidence.

RESULTS

Eighty-nine studies were included. Most studies (n = 72, 80.9%) were considered to have a high RoB. The results showed that laser therapy was better than placebo in improving pain, maximal mouth open (MMO), protrusion, and tenderness at the final assessment, but with a low or moderate level of evidence. The best lasers and parameters to reduce pain are diode or gallium-aluminum-arsenide (GaAlAs) lasers, a wavelength of 400-800 or 800-1500 nm, and dosage of <25 J/cm2.

CONCLUSIONS

Laser therapy was better than placebo to improve pain, MMO, protrusion, and tenderness. Also, it was better than occlusal splint to improve pain, but not better than TENS and medication.Implications for rehabilitationLaser therapy was found to be good in improving pain, maximal mouth opening, jaw protrusion, and tenderness at the end of the treatment.For patients with all types of temporomandibular disorders (TMDs) (myogenous, arthrogenous, and mixed), the following lasers and parameters are recommended: diode or gallium-aluminum-arsenide (GaAlAs) laser, wavelength of 400-800 or 800-1500 nm, and a dosage <25 J/cm2.For patients with arthrogenous TMDs, the following lasers and parameters are recommended: Diode laser and a wavelength between 400 and 800 nm.For patients with myogenous TMDs, the following lasers and parameters are recommended: diode laser, wavelength between 800 and 1500 nm, and dosage of <25 J/cm2.For patients with mixed TMDs, the following lasers and parameters are recommended: diode, GaAlAs, or infrared laser, a wavelength of 800-1500 nm, a dosage >100 J/cm2, and an application time between 15 and 30 s or >60 seconds.

Korean Medicine Clinical Practice Guideline Update for Temporomandibular Disorders: An Evidence-Based Approach

Many updated clinical research results have been published since the Korean Medicine Clinical Practice Guidelines (KMCPGs) for temporomandibular disorders (TMDs) were published in 2018. Therefore, it is necessary to update the existing clinical practice guidelines (CPGs). This study presents updated recommendations for TMD treatment based on current research data published up to February 2020. The draft version of the level of evidence and grade of recommendation was determined through an assessment of the risk of bias and a meta-analysis of selected literature based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The final guidelines were derived using the Delphi method. Eighteen recommendations were derived for eight items of Korean medicine treatment for TMDs. Compared with previous Korean medicine CPGs for TMDs, the grades of seven recommendations, including acupuncture, pharmacopuncture, and Chuna manual therapy, were increased. The grades of the two recommendations have been changed. Six new recommendations were added to fully reflect clinical reality. Acupuncture, pharmacopuncture, and Chuna manual therapy are recommended for TMD patients in clinical practice. Concurrent conventional conservative therapy with Korean medicine or a combination of Korean medicines should be considered in clinical practice in patients with temporomandibular disorders.

The Effect of Photobiomodulation on Temporomandibular Pain and Functions in Patients With Temporomandibular Disorders: An Updated Systematic Review of the Current Randomized Controlled Trials

Introduction: Temporomandibular disorders (TMDs) are the most prevalent non-dental origin orofacial pain conditions affecting the temporomandibular joints (TMJs) and/or orofacial muscles. Photobiomodulation therapy (PBMT) is a conservative way to improve function and reduce symptoms in TMD patients. This systematic review was conducted to update evidence about the effects of PBMT on pain intensity, TMJ movements, electromyography (EMG) activity, pressure pain threshold (PPT), and TMJ sound in patients with TMDs. Methods: A systematic literature search was conducted in Web of Science, PubMed/Medline, and Scopus databases using appropriate keywords and specific strategies from January 2000 to September 2022. Data extraction was done based on the inclusion/exclusion criteria. Results: A total of 40 studies were included. All included studies except one provided information on pain intensity; 27 studies showed a reduction in pain intensity in PBMT groups compared to control groups. Seven out of 15 studies, which reported maximum mouth opening (MMO), showed a greater MMO in PBMT groups than in placebo groups. In addition, the figures for passive maximum mouth opening (PMMO) and active maximum mouth opening (AMMO) in all the studies reporting PMMO and AMMO were higher in PBMT groups. In eight out of ten studies, lateral movement (LM) was greater in PBMT groups. Moreover, in three studies out of four, protrusive movement (PM) was reported to be greater in the PBMT group. Four out of nine studies showed a greater PPT in the PBMT group. Reduced TMJ sounds in the PBMT group were reported in two out of five studies. In addition, in most studies, no difference in EMG activity was detected between the two groups. Conclusion: This updated systematic review showed the promising effects of PBMT on the alleviation of pain and improvement in MMO. Using the infrared diode laser with a wavelength ranging between 780-980 nm, an energy density of<100 J/ cm2, and an output power of≤500 mW for at least six sessions of treatment seems to be a promising option for treating mentioned TMDs signs and symptoms based on the previously reported findings.

Efficacy of laser therapy for temporomandibular disorders: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to evaluate the efficacy of laser therapy in temporomandibular disorders (TMD).

METHODS

Randomized controlled trials (RCTs) in regard to this issue were searched in electronic databases. Three investigators independently screened the eligible studies, and the quality of the included studies was assessed according to the risk of bias tool recommended by the Cochrane handbook. The primary outcome measure was the degree of pain, reported on a visual analog scale (VAS), and the secondary outcome measures were TMJ function, including maximum active vertical opening (MAVO), maximum passive vertical opening (MPVO), left and right lateral movement (LLE, RLE). Pooled effect sizes were calculated using random effects models and 95% confidence interval (95% CI).

RESULTS

A total of 28 randomized controlled trials were included. Laser therapy had a more significant effect in terms of VAS (SMD=﹣1.88; 95% CI=﹣2.46 to﹣1.30; P<0.00001; I² =93%), MAVO (MD = 4.90; 95% CI= 3.29 to 6.50; P < 0.00001; I² =72%), MPVO (MD=5.8²; 95% CI= 4.62 to 7.01; P<0.00001; I² =40%) and RLE (MD = 0.73; 95% CI= 0.23 to 1.22; P = 0.004; I² = 0%) as compared to placebo group. However, there was no significant difference in LLE between two groups (MD= 0.35; 95% CI=﹣0.31 to 1.01; P=0.30; I² =0%).

CONCLUSIONS

Laser therapy can effectively reduce pain but have small effect on improving mandibular movement of TMD patients. More well-designed RCTs with large sample sizes are needed for further validation. And these studies should report detailed laser parameters and provide complete outcome measure data.

PROSPERO

CRD42022349719.

Low-level laser therapy in the management of muscle fatigue caused after long Endodontic procedure

Background

The masticatory muscles may undergo fatigue due to prolonged mouth opening during the endodontic procedures. Low-level laser can be used to treat muscle fatigue due its capacity to produce reactive oxygen species and improve function of mitochondria. Aim: To determine the effectiveness of low-level laser therapy in the management of masticatory muscle fatigue caused after long endodontic procedure under Local anesthesia.

Material and Methods

44 patients complaining of reduced mouth opening and pain while mouth opening, after long endodontic therapy were considered for the study and were randomly allocated into study and control group. In the study group, low-level laser was applied while patients of control group didn't receive any therapy. In the study group, Visual analogue scale (VAS) score of pain was taken after endodontic therapy, immediately after laser therapy and 4 hours after endodontic therapy. Mouth opening of the patients was measured, before and after endodontic procedure and immediately after laser therapy. In the control group, VAS score of pain was recorded immediately after endodontic therapy and 4 hours after endodontic therapy. Statistical analysis used: ANOVA test and un-paired t-test was used for the data analysis.

Results

When both groups were compared, a statistically significant (P=0.0000) reduction with fatigue was found.

Conclusions

The low-level laser can be a useful procedure immediately post long endodontic procedure causing masticatory muscle fatigue. Hence, this therapy can be considered as an add-on therapeutic procedure along with prolonged endodontic appointments to relieve the patient from the discomfort. Key words:Muscle fatigue, Masticatory muscles, Low-level laser therapy.

Efficacy of stabilisation splint and low-level laser therapy for patients with chronic closed lock from non-reducible displaced temporo-mandibular joint discs: A parallel randomised clinical trial

BACKGROUND

Stabilisation splint therapy (SST) and low-level laser therapy (LLLT) are effective-invasive treatment for temporo-mandibular disorder (TMD) patients. However, the specific efficacy of each therapy in patients with chronic closed lock (CCL) from temporo-mandibular joints (TMJ) disc displacement without reduction (DDwoR) remains unknown.

OBJECTIVES

The aim of this study was to assess and compare the efficacy of SST and LLLT alone or in combination in patients with CCL from TMJ DDwoR.

METHODS

This parallel randomised clinical trial included 42 patients who were diagnosed with CCL from TMJ DDwoR. Patients were allocated equally and randomly into three treatment groups: group I received combined SST and LLLT, group II received LLLT and group III received SST. Maximum mouth opening (MMO), visual analogue scale (VAS), muscle and joint palpation scores and time required to achieve normal state were evaluated at baseline, 1, 2, 4 weeks, 3 and 6 months after the intervention. Data were collected and analysed using SPSS software.

RESULTS

Regarding MMO and VAS, a statistically significant improvement was found between group I versus group II and versus group III at all evaluation times. Regarding muscle and joint palpation scores, a statistically significant difference was found between group I versus group III, while non-significant difference was found between group I and group II. A statistically significant faster improvement was found in group I versus group III and versus group II.

CONCLUSION

All treatment modalities can be effective in management of CCL from a TMJ DDwoR cases, but the combined SST and LLLT group seems to provide the best and quickest improvement.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05548894.

The reliability of using light therapy compared with LASER in pain reduction of temporomandibular disorders: a randomized controlled trial

BACKGROUND

Temporomandibular Disorders (TMD) refer to a group of symptoms where pain is the most leading cause to demand a treatment by the patient. Light therapies are of great importance at current times due to its biosafety and non-invasive quality when used for the management of TMD symptoms. This study aimed to evaluate the efficacy of red LED light with low-level LASER in treating TMD patients.

MATERIALS AND METHODS

A double-blind randomized clinical study was conducted and included 60 patients along 3 groups (20 for each group) presented with myofascial pain related to TMD. Patients were randomly divided into 3 groups. Group A were managed by applying the LED light device into the trigger points without switching the device on. A red LED light was given to group B for 5 min at the tender muscles. Group C were treated by using low-level LASER therapy for 30 s. Patients were evaluated for any improvements regarding the pain score, presence of trigger points, and trismus along 4 visits (1 week interval between each visit). Any side effects related to the 2 devices were also assessed.

RESULTS

Both group B and C patients showed a statistically significant improvement in the pain value (P < 0.05) at the 3rd and 4th visits when compared to group A. Regarding tenderness, there was a reduction in the number of trigger points in both study groups; however, the results were insignificant in group B. Statistics showed insignificant differences between group B & C patients regarding pain and number of trigger points at all visits (P > 0.05).

CONCLUSION

Both LED light and LASER therapies could effectively relieve pain associated with myogenic TMD as there were no important differences between their outcomes. However, the biosafety and lower cost of the LED light device compared to the LASER should also be considered. Trial Registration This clinical trial was prospectively registered (TCTR ID: TCTR20190507002) on 07/05/2019. URL: http://www.thaiclinicaltrials.org/show/TCTR20190507002.

Application of photobiomodulation for chronic pain-related TMD on pain points versus pre-established points: Randomized clinical trial

Photobiomodulation therapy (PTB) is a therapeutic possibility for temporomandibular disorders (TMD), but its effectiveness and protocols for use remain controversial. This study is a RCT that compared the effectiveness of PTB on pain points of the masticatory muscles and TMJs, located through palpation versus application of pre-established points in women with painful TMD, diagnosis by DC/TMD (Diagnostic Criteria for Temporomandibular Disorders - Brazilian Portuguese version). Therefore, a total sample of 54 women, aged between 18 and 60 years, was investigated. Volunteers were randomly randomized and PTB was applied in four different groups with a dose of 4 J and 6 J divided into pre-established application points (PE - G1) and pain points (PD - G2) - Groups 4PE, 4PD, 6PE and 6PD. Four laser applications were performed with a wavelength of 780 nm, one session per week, totaling one month of therapy. The following assessments were performed: DC/TMD, Brief Pain Inventory (BPI), McGill Questionnaire - Short Version (SF-MPQ) and Pain Intensity, Visual Analogue Scale (VAS). Friedman's test was used for within-group comparisons, while the Mann-Whitney test was used for between-group comparisons (p < 0.05). According to the results, laser application on pain points (G2) was more effective. McGill's results showed that regardless of dose, the pain point application group had better outcomes (p = 0.004). Pain intensity evaluation (last days) also showed that application at the pain points was more effective regardless of dose (p = 0.0002). Medians and interquartile deviations showed overall that PTB was more effective at pain points, with a trend towards better outcomes at the 6 J dose. Therefore, it can be concluded that in women with chronic painful TMD, the application of PTB at pain points is more effective than the application at pre-established points. Therefore, individualized PTB protocols are proposed, based on examination palpation of the masticatory structures.

Effectiveness of conservative therapeutic modalities for temporomandibular disorders-related pain: a systematic review

PURPOSE

The aim of this systematic review was to evaluate the effectiveness of conservative different therapeutic modalities for temporomandibular disorders (TMD) pain.

MATERIALS AND METHODS

An electronic systematic search was conducted in the MEDLINE (PubMed) database to identify the randomized clinical trials (RCTs) published between 2001 and 2021. The following, simple or multiple conjunctions, search keywords were selected: TMD pain, TMD management or conservative treatment or treatment strategies and TMD pain, therapeutic modalities or interventions and TMD. Studies included must have patients older than 18 years, with painful TMD, which diagnosis was performed by Research Diagnostic Criteria for TMD or Diagnostic Criteria for TMD. Outcome variables were pain relief and post treatment pain intensity reduction. Data were analysed with non-parametric tests and the level of significance was set at p<.05.

RESULTS

Out of 1599 articles obtained, 28 RCTs fulfilled all selection criteria and were included. The results of this study show that there was a significant decrease in short-term post-treatment TMD pain with the use of occlusal splint alone or in combination with other therapeutic modalities when compared with the control group. Statistically significant differences were also detected between laser and photobiomodulation group and the control, in short-term treatment TMD-related pain.

CONCLUSIONS

The primary findings of the present systematic review showed that the occlusal splint alone or combined with other therapeutic intervention presented positive effect on short-term TMD pain reduction. Secondary outcome suggests that laser and photobiomodulation therapy had, also, a significant role in short term pain relief.

Efficacy of rehabilitation on reducing pain in muscle-related temporomandibular disorders: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients with temporomandibular disorders (TMD) mostly suffer from muscle-related pain. Several conservative interventions have been suggested as treatments for TMD in the last years.

OBJECTIVE

The aim of this systematic review with meta-analysis was to assess the efficacy of rehabilitative approaches in reducing pain in patients with muscle-related TMD.

METHODS

PubMed, Scopus, and Web of Science were systematically searched from inception until April 28th, 2021 to identify randomized controlled trials (RCTs) presenting: patients with painful muscle-related TMD; rehabilitative approaches as interventions; placebo or sham treatment as comparisons; pain intensity, using visual analogue scale as outcome. A meta-analysis was performed to evaluate the overall effect on painful muscle-related TMD patients. PROSPERO registration number of this systematic review is CRD42021251904.

RESULTS

Out of 1997 papers suitable for title/abstract screening, 189 articles were assessed for eligibility. Sixteen RCTs were included and most of them (n= 6, 37.5%) investigated the effects of the laser therapy. The meta-analysis revealed that rehabilitative interventions had a significant overall effect size (ES) of 1.44 (p< 0.0001) in decreasing pain in patients with muscle-related disorders.

CONCLUSION

Findings of this systematic review with meta-analysis suggested that rehabilitative approaches might be effective in reducing pain in muscle-related TMD patients. However, the low number of RCTs evaluating conservative approaches might impair the synthesis of evidence regarding the different techniques, calling for caution in the interpretation of these results.

Can Photobiomodulation Support the Management of Temporomandibular Joint Pain? Molecular Mechanisms and a Systematic Review of Human Clinical Trials

This study aims to point out the correlation between photobiomodulation (PBM) targets and effects and management of temporomandibular disorders (TMDs) pain using diode lasers with infrared wavelengths ranging from 780 up to 980 nanometers (nm). A systematic search of multiple electronic databases was done to identify the clinical trials published between 1st January 2010 and 18th December 2021. The included studies were limited to human subjects who had TMD pain, involving two genders with age > 18 years, and were treated with PBM using a diode laser (780–980 nm) as a non-pharmacological therapy to decrease the intensity of the pain associated to TMDs. The risk of bias for included studies was assessed using the Cochrane RoB tool (for randomized studies). The methodologic quality was rated using the Delphi list. The findings suggest that PBM is an effective tool in alleviating TMDs’ pain and increasing the range of movement in patients with Axis 1 of TMDs. However, TMDs’ pain related to underlying pathology cannot be solely treated by PBM. The causative factors must be treated first. Studies displaying the highest quality Delphi score may represent a suggested PBM therapy protocol to follow for TMDs pain management.

Nonpharmacological Interventions for Pain in Patients with Temporomandibular Joint Disorders: A Systematic Review

This systematic review aimed to compare the efficacy of nonpharmacological therapies for painful temporomandibular joint disorders. The protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020171364). The search was performed on the electronic databases PubMed, Google Scholar, Clinical Trials, and Web of Science. The eligibility criteria were randomized controlled trials in patients diagnosed with painful temporomandibular joint disorders comparing the pain relief between conventional treatment and nonpharmacological therapies such as acupuncture, physiotherapy, low-level laser, and massage. Fourteen articles were included in this review. At the overall bias of the studies included, 71.42% exhibited some concerns and 28.57% had high risk. The efficacy of nonpharmacological interventions was found to be moderate in the short term and variable in the long term for pain reduction in patients with temporomandibular joint disorders. The evidence pointed out that acupuncture, laser therapy, and physiotherapy are potentially useful interventions for pain relief in patients with temporomandibular joint disorders. However, there is a lack of consistency and short-term follow-up in the studies to determine the lasting of such effect.

Effects of low-level laser photobiomodulation on the masticatory function and mandibular movements in adults with temporomandibular disorder: a systematic review with meta-analysis

PURPOSE

To review the effects of low-level laser photobiomodulation on masticatory function and mandibular movements in adults with temporomandibular disorder.

RESEARCH STRATEGIES

Search in PubMed, Web of Science, Scopus, EMBASE, Cochrane, LILACS, ScienceDirect, and Google Scholar, using the following descriptors: "temporomandibular joint disorders", "low-level light therapy", "low-level laser therapy", "mastication", and "mandible".

SELECTION CRITERIA

Randomized clinical trials in adults with temporomandibular disorder, using low-level laser and assessing the mastication and mandibular movements.

DATA ANALYSIS

Firstly, the titles and abstracts of all retrieved studies were read. Then, only the studies selected in the first stage were read in full and assessed regarding eligibility. After the selection, the characteristics, methodological quality, and quality of evidence of the studies included in the review were analyzed. In the meta-analysis, the mean amplitude of mouth opening was considered as a measure of intervention effect.

RESULTS

The 10 articles included in the review had quite different results one from the other, especially regarding the amplitude of mouth opening, while the mastication was assessed in only one of them. Most studies had a high risk of bias, demonstrating a low methodological quality. Significantly higher results for photobiomodulation were identified in the six studies included in the meta-analysis.

CONCLUSION

Due to the scarcity in the literature, there is not enough evidence of the effects of low-level laser photobiomodulation on mastication. As for the mandibular movements, this intervention presented significant results, particularly in the amplitude of mouth opening.

The efficacy of low-level diode laser versus laser acupuncture for the treatment of myofascial pain dysfunction syndrome (MPDS)

Background

Methods

Results

Conclusion

Clinical evaluation of single and repeated sessions of photobiomodulation with two different therapeutic wavelengths for reducing postoperative sequelae after impacted mandibular third molar surgery: a randomized, double-blind clinical study

The effects of the number of photobiomodulation (PBM) sessions on the postoperative inflammatory process remain controversial. The current literature comparing single and repeated PBM sessions is limited.

The hierarchy of different treatments for myogenous temporomandibular disorders: a systematic review and network meta-analysis of randomized clinical trials

The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo.  At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling  therapy (71.2%, moderate quality), and occlusal appliances  (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances  (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments.  This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances  . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.

Comparative effectiveness of low-level laser therapy with different wavelengths and transcutaneous electric nerve stimulation in the treatment of pain caused by temporomandibular disorders: A systematic review and network meta-analysis

OBJECTIVE

To assess the efficacy of low-level laser therapy (LLLT) with different wavelengths and transcutaneous electric nerve stimulation (TENS) and explore the optimal wavelength range of laser application in the treatment of pain caused by temporomandibular disorders (TMD).

METHODS

An electronic search on PubMed, Cochrane Library, Embase, Scopus and Web of Science was undertaken to identify the randomised clinical trials (RCTs) published from database inception to 16 April 2021, aiming to compare the effects of LLLT with different wavelengths (632.8-672 nm, 780-904 nm, and 910-1100 nm) or TENS or placebo group on TMD patients pain reduction. In addition, manual search of the studies was performed. The reviewers assessed the risk of bias of individual studies with the Cochrane risk of bias tool and excluded the RCTs with a high risk of bias in any field. Meanwhile, the reviewers, after performing the network meta-analysis, assessed the quality of evidence, which contributed to network estimate via the GRADE framework.

RESULTS

Twenty-seven RCTs with 969 patients with TMD were included. In the meta-analysis, all treatment groups showed an overall improvement in pain scores, when compared with the placebo group. LLLT with wavelength ranging from 910 nm to 1100 nm produced more pain relief in the visual analogue scale (VAS) immediately after treatment [mean difference (MD) = 4.68, 95% confidence interval (CI):(3.08,6.28)]. After one-month follow-up, LLLT with wavelength ranging from 910 nm to 1100 nm also showed superior pain-relieving effects [MD = 3.61, 95% CI: (-1.77, 8.99)]. However, no significant difference was observed. Based on the SUCRA ranking, L3 ranked first immediately after treatment and 1 month later.

CONCLUSION

The results of the meta-analysis showed the LLLT had better short-term efficacy than TENS in the treatment of pain caused by TMD. Better results can be achieved with higher wavelengths. Therefore, we recommended to treat TMD using LLLT with wavelength ranging from 910 nm to 1100 nm.

Role of Photobiomodulation Therapy in Modulating Oxidative Stress in Temporomandibular Disorders. A Systematic Review and Meta-Analysis of Human Randomised Controlled Trials

This systematic review and meta-analysis (PROSPERO registration; ref CRD 42020198921) aimed to govern photobiomodulation therapy (PBMT) efficacy in temporomandibular disorder (TMD). PRISMA guidelines and Cochrane Collaboration recommendations were followed. Differences in pain reduction assessment by qualitative measurement with visual analogue scale pain (VAS), pressure threshold (PPT) and maximum mouth opening (MMO) were calculated with 95% confidence intervals and pooled in a random effects model with a subgroup analysis, evaluating the role of follow-up duration. Heterogeneity was analysed using Q and I² tests. Publication bias was assessed by visual examination of funnel plot symmetry. Qualitative analysis revealed 46% of the 44 included studies showed a high risk of bias. Meta-analysis on 32 out of 44 studies revealed statistically significant intergroup differences (SSID) for VAS (SMD = -0.55; 95% CI = -0.82 to -0.27; Z = 3.90 (p < 0.001)), PPT (SMD = -0.45; 95% CI = -0.89 to 0.00; Z = 1.97 (p = 0.05)) and MMO (SMD = -0.45; 95% CI = -0.89 to 0.00; Z = 1.97 (p = 0.05)), favouring PBMT compared to control treatment strategies. Sensitivity analysis revealed SSID (SMD = -0.53; 95% CI = -0.73 to -0.32; Z = 5.02 (p < 0.0001)) with low heterogeneity (Τ² = 0.02; χ² = 16.03 (p = 0.31); I² = 13%). Hence, this review, for first time, proposed suggested recommendations for PBMT protocols and methodology for future extensive TMD research.

Low-level laser therapy in temporomandibular joint disorders: a systematic review

Temporomandibular joint disorders (TMDs) encompass a wide array of ailments affecting the temporomandibular joint (TMJ), muscles of mastication, and the allied structural framework. Myofascial pain, internal derangement of the joint, and degenerative joint diseases constitute the majority of TMDs. TMDs usually have a multifactorial etiology, and treatment modalities range from conservative therapies to surgical interventions. Low-level laser therapy (LLLT) has evolved as an efficient non-invasive therapeutic modality in TMDs. Previously conducted systematic reviews and meta-analyses have shown variable results regarding the efficiency of LLLT in TMJ disorder patients. Hence, this systematic review was carried out as an attempt to evaluate the efficacy of LLLT in the treatment of temporomandibular joint disorder patients.

Effects of photobiomodulation associated with orofacial myofactional therapy on temporomandibular joint dysfunction

PURPOSE

To investigate the influence of photobiomodulation associated with orofacial myofunctional therapy (OMT) in patients with temporomandibular muscle disorders (TMD).

METHODS

Randomized, blinded trial clinical study with a sample of eleven women with muscle TMD divided into two groups. The experimental group (EG) consisted of five women submitted to orofacial myofunctional therapy associated with photobiomodulation, and the control group (CG) consisted of six women submitted to orofacial myofunctional therapy associated with inactive photobiomodulation (placebo). The intervention was performed in the following twelve sessions: one evaluation, ten speech therapy sessions associated with photobiomodulation, and one reevaluation. For outcomes, investigation on pain perception using the visual analogue scale (VAS), investigation of palpation sensitivity with the research diagnostic criteria for temporomandibular disorders (RDC/TMD), and quality of life (QOL) verification through oral health impact profile - short form (OHIP-14) were considered.

RESULTS

The EG increased measurements of mandibular movements of opening and protrusion and improved in the evaluation of QOL.

CONCLUSION

Orofacial myofunctional therapy, when associated with photobiomodulation, contributed to increase the range of mandibular movements, with important improvements in the perception of quality of life and with significant improvement in the painful conditions of volunteers with TMD.

Placebo and nocebo response magnitude on temporomandibular disorder-related pain: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review (SR) was to answer the following question: "In adult patients with temporomandibular disorder (TMD)-related pain, what is the placebo or nocebo effect of different therapies?"

METHODS

A SR was performed with randomised clinical placebo-controlled trials on diagnosed painful TMD studies from five main databases and from three grey literature. Studies included must have sample older than 18 years, with painful TMD, which diagnosis was done by Research Diagnostic Criteria (RDC/TMD) or Diagnostic Criteria (DC/TMD).

RESULTS

Out of 770 articles obtained, 42 met the inclusion criteria for qualitative and 26 for quantitative analysis. Meta-analysis indicated mean variation on pain intensity for placebo therapy was higher on laser acupuncture with 45.5 mm point reduction, followed by avocado soya bean extract with 36 mm and amitriptyline 25 mg with 25.2 mm. Laser showed a 29% of placebo effect, as well medicine with 19% and other therapies with 26%. Possible nocebo effect of 8% pain increase was found for intra-articular injection of Ultracain.

CONCLUSIONS

Based on the available data, the placebo response could play a major effect on TMD pain management and may be responsible from 10% to 75% of pain relief. Laser acupuncture, avocado soya bean and amitriptyline promoted the higher placebo effect. Possible nocebo effect was found only for Ultracain injection with 8%.

CLINICAL RELEVANCE

Clinicians could apply such evidence to optimise pain management and judgement about treatment efficacy, and researches may find it useful when designing their investigations.

Low-level laser therapy modulates demyelination in mice

There are no effective therapies for remyelination. Low-level laser therapy (LLLT) has been found advantageous in neurogenesis promotion, cell death prevention, and modulation of inflammation in central and peripheral nervous system models. The purpose of this study was to analyse LLLT effects on cuprizone-induced demyelination. Mice were randomly distributed into three groups: Control Laser (CTL), Cuprizone (CPZ), and Cuprizone Laser (CPZL). Mice from CPZ and CPZL groups were exposed to a 0.2% cuprizone oral diet for four complete weeks. Six sessions of transcranial laser irradiation were applied on three consecutive days, during the third and fourth weeks, with parameters of 36 J/cm², 50 mW, 0.028 cm² spot area, continuous wave, 1 J, 20 s, 1.78 W/cm² in a single point equidistant between the eyes and ears of CTL and CPZL mice. Motor coordination was assessed by the rotarod test. Twenty-four hours after the last laser session, all animals were euthanized, and brains were extracted. Serum was obtained for lactate dehydrogenase toxicity testing. Histomorphological analyses consisted of Luxol Fast Blue staining and immunohistochemistry. The results showed that laser-treated animals presented motor performance improvement, attenuation of demyelination, increased number of oligodendrocyte precursor cells, modulated microglial and astrocytes activation, and a milder toxicity by cuprizone. Although further studies are required, it is suggested that LLLT represents a feasible therapy for demyelinating diseases.

Can the severity of orofacial myofunctional conditions interfere with the response of analgesia promoted by active or placebo low-level laser therapy?

OBJECTIVE

To analyze the influence of orofacial myofunctional condition (OMC) on pain perception, temporomandibular disorders (TMD) severity, and the response to low-level laser therapy (LLLT) in women with painful TMD.

METHODS

Seventy-eight women, 59 with TMD, received active laser (30) or placebo (29), with 19 controls. OMC, TMD severity, pain intensity, and pressure pain threshold (PPT) were assessed at different times during the masticatory test: before treatment (LLLT dose: 780nm), during, and after 30 days.

RESULTS

No correlation was found between OMC and pain perception or TMD severity (p > 0.05). The active and placebo LLLT showed reduction of pain during chewing and better recovery levels during the rest period (p > 0.05), without differences between OMC groups.

DISCUSSION

The perception of pain and severity of TMD are not correlated with the OMC, and the response of analgesia promoted by active LLLT or placebo is not associated with OMC.

Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial

The effectiveness of photobiomodulation (PBM) and manual therapy (MT), alone or combined (CT), were evaluated in pain intensity, mandibular movements, psychosocial aspects, and anxiety symptoms of temporomandibular disorder (TMD) patients. Fifty-one TMD patients were randomly assigned to three groups: the PBM group (n = 18), which received PBM with 808 nm, 100 mW, 13.3 J/cm2, and 4 J per point; the MT group (n=16) for 21 minutes each session on masticatory muscles and temporomandibular joint TMJ; and the CT group (n = 17), applied during twelve sessions. Seven evaluations were performed in different moments using visual analogue scale (VAS), Research Diagnosis Criteria for Temporomandibular Disorders (RDC/TMD) Axis I and II, and Beck anxiety inventory (BAI). All groups demonstrated reductions in pain and improvement in jaw movements during treatment and at follow-up (< 0.001). The assessment of psychosocial aspects of TMD, comparing baseline and follow-up in all treatment groups, revealed that treatment did not promote modification in the intensity of chronic pain (p > 0.05). However, depression symptoms showed a reduction in PBM and CT groups (p≤0.05). All treatments promoted reduction in physical symptoms with and without pain and enhancement of jaw disabilities (p ≤ 0.05). MT promotes improvement in 5 functions, PBM in 2, and CT in 1 (p < 0.001). BAI analysis revealed that all treatments lead to a reduction in anxiety symptoms (p≤0.05). All protocols tested were able to promote pain relief, improve mandibular function, and reduce the negative psychosocial aspects and levels of anxiety in TMD patients. However, the combination of PBM and MT did not promote an increase in the effectiveness of both therapies alone.

Low-Level Laser Therapy for Temporomandibular Disorders: A Systematic Review with Meta-Analysis

Objectives

We systematically reviewed randomized controlled trials (RCTs) of the effect of low-level laser therapy (LLLT) versus placebo in patients with temporomandibular disorder (TMD).

Methods

A systematic search of multiple online sources electronic databases was undertaken. The methodological quality of each included study was assessed using the modified Jadad scale, and the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

Results

A total of 31 RCTs were included. Total modified Jadad scale scores showed that the methodological quality was high in 30 studies and low in 1 study. Combining data from all clinically heterogeneous studies revealed positive effects of LLLT on pain relief, regardless of the visual analogue scale (VAS) score or the change of VAS score between the baseline and the final follow-up time point, while dosage analyses showed discrepant results about the effects of high or low doses for patients with TMD. Follow-up analyses showed that LLLT significantly reduced pain at the short-term follow-up. Temporomandibular joint function outcomes indicated that the overall effect favored LLLT over placebo.

Conclusion

This systematic review suggests that LLLT effectively relieves pain and improves functional outcomes in patients with TMD.

Electromyographic evaluation of a low-level laser protocol for the treatment of temporomandibular disorder: a randomized, controlled, blind trial

[Purpose] Problems involving the temporomandibular joint and associated structures can lead to temporomandibular disorder (TMD). The aim of the present study was to evaluate muscle activity in individuals with a diagnosis of TMD before and after treatment with low-level laser therapy (LLLT) through the use of electromyography (EMG). [Subjects and Methods] Male and female individuals aged 14 to 23 years were evaluated. TMD was determined by a clinical examination and the administration of the Research Diagnostic Criteria for Temporomandibular Disorders, followed by the evaluation of sensitivity to palpation of the masseter and anterior temporal muscles as well as the EMG determination of muscle activity. The participants were randomly allocated to an active LLLT group (n=9) and sham group (n=7). Twelve sessions of LLLT were conducted using a wavelength of 780 nm, energy density of 25 J/cm², power of 50 mW, power density of 1.25 W/cm² and a 20-second exposure time or sham LLLT. Muscle activity was determined prior to treatment and after the last session. [Results] During the isometric evaluation of the masseter and anterior temporal muscles, an increase in the mean EMG signal was found in the group submitted to active LLLT. When evaluated individually, some participants in the active LLLT group demonstrated a reduction in muscle activity, but no significant differences were found in the mean EMG signal between the initial and final evaluations. [Conclusion] Further studies with a larger sample size are needed to confirm the present findings.

Effect of high-frequency bio-oxidative ozone therapy for masticatory muscle pain: a double-blind randomised clinical trial

To evaluate the effect of bio-oxidative ozone application at the points of greatest pain in patients with chronic masticatory muscle pain. A total number of 40 (40 women, with a mean age of 31·7) were selected after the diagnosis of myofacial pain dysfunction syndrome according to the Research Diagnostic Criteria for temporomandibular disorder (RDC/TMD). The patients were randomly divided into two groups: patients received the ozone therapy at the point of greatest pain, ozone group (OG; n = 20); patients received the sham ozone therapy at the point of greatest pain, placebo group (PG; n = 20). Ozone and placebo were applied three times per week, for a total of six sessions. Mandibular movements were examined, masticator muscles tenderness were assessed and pressure pain threshold (PPT) values were obtained. Subjective pain levels were evaluated using visual analogue sale (VAS). These assessments were performed at baseline, 1 month and 3 months. Ozono therapy decreased pain intensity and increased PPT values significantly from baseline to 1 month and 3 months in OG compared with PG. PPTs of the temporal (OG = 24·85 ± 6·65, PG = 20·65 ± 5·43, P = 0.035) and masseter (OG = 19·03 ± 6·42, PG = 14·23 ± 2·95, P = 0.007) muscles at 3 months of control (T2) were significantly higher in the OG group. PPT value of the lateral pole was also significantly higher at T2 in the OG group (OG = 21·25 ± 8·43, PG = 15·35 ± 4·18, P = 0.012). Mandibular movements did not show significant differences between treatment groups except right lateral excursion values at T2 (OG = 8·90 ± 1·77, PG = 6·85 ± 2·41, P = 0.003); however, OG demonstrated significantly better results over time. Overall improvements in VAS scores from baseline to 3 months were OG 67·7%; PG 48·4%. Although ozone therapy can be accepted as an alternative treatment modality in the management of masticatory muscle pain, sham ozone therapy (placebo) showed significant improvements in the tested parameters.

Effects of low-level laser therapy on burning mouth syndrome

To investigate low-level laser therapy (LLLT) applied to treat burning mouth syndrome (BMS). This prospective, comparative, partially blinded, single-centre, clinical trial of GaAlAs Laser, with 815 nm wavelength, included 44 BMS patients divided randomly into three groups: Group I (n = 16): GaAlAs laser 815 nm wavelength, 1 W output power, continuous emissions, 4 s, 4 J and fluence rate 133·3 J cm^-2 ; Group II (n = 16): GaAlAs infrared laser, 815 nm wavelength, 1 W output power, continuous emissions, 6 s, 6 J and fluence rate 200 J cm^-2 ; Group III (n = 12) placebo group, sham laser. All groups received a weekly dose for 4 weeks. Pain intensity was recorded using a 10-cm visual analogue scale; patients responded to the oral health impact profile (OHIP-14), xerostomia severity test and the hospital anxiety-depression scale (HAD). These assessments were performed at baseline, 2 and 4 weeks. LLLT decreased pain intensity and improved OHIP-14 scores significantly from baseline to 2 weeks in groups I and II compared with the placebo group. No statistically significant differences were found from 2 to 4 weeks. Overall improvements in visual analogue scale (VAS) scores from baseline to the end of treatment were as follows: Group I 15·7%; Group II 15·6%; Group III placebo 7·3%. LLLT application reduces symptoms slightly in BMS patients.

Effects of oral motor exercises and laser therapy on chronic temporomandibular disorders: a randomized study with follow-up

This study investigated the efficacy of combining low-level laser therapy (LLLT) with oral motor exercises (OM-exercises) for rehabilitation of patients with chronic temporomandibular disorders (TMDs). Eighty-two patients with chronic TMD and 20 healthy subjects (control group) participated in the study. Patients were randomly assigned to treatment groups: GI (LLLT + OM exercises), GII (orofacial myofunctional therapy-OMT-which contains pain relief strategies and OM-exercises), and GIII (LLLT placebo + OM-exercises) and GIV (LLLT). LLLT (AsGaAl; 780-nm wavelength; average power of 60 mW, 40 s, and 60 ± 1.0 J/cm²) was used to promote analgesia, while OM-exercises were used to reestablish the orofacial functions. Evaluations at baseline (T1), after treatment immediate (T2), and at follow-up (T3) were muscle and joint tenderness to palpation, TMD severity, and orofacial myofunctional status. There was a significant improvement in outcome measures in all treated groups with stability at follow-up (Friedman test, P < 0.05), but GIV did not show difference in orofacial functions after LLLT (P > 0.05). Intergroup comparisons showed that all treated groups had no difference in tenderness to palpation of temporal muscle compared to GC at follow-up (Kruskal-Wallis test, P < 0.01). Moreover, GI, GII, and GIII showed no difference from GC in orofacial functional condition (T2 and T3) while they differed significantly from GIV (P < 0.01). In conclusion, LLLT combined with OM-exercises was more effective in promoting TMD rehabilitation than LLLT alone was. Similar treatment results were verified with the OMT protocol.

The effect of laser and botulinum toxin in the treatment of myofascial pain and mouth opening: A randomized clinical trial

This study conducted a randomized clinical trial in 15 patients, who sought care at the Dental Clinic of the University of Passo Fundo, in order to compare the use of low-level laser and botulinum toxin in the treatment of myofascial pain and whether they alter the mouth opening of patients with temporomandibular disorder. The patients were divided into two groups: the Laser group received low-level GaAlAs laser, 100mW of power at a wavelength of 830nm in continuous light emission; and the Toxin group received 30U of botulinum toxin type A (BTX-A) in the first session, and 15U after fifteen days. The assessments were performed by measuring pain with Visual Analogue Scale (VAS), and mouth opening with a digital caliper. Data were submitted to Student's t test at 5% significance level. Regarding pain symptoms, the results indicate that groups treated with laser and toxin registered 7U in VAS, at day 5 the scores were 4.75 and 4.86U, respectively. The laser worked faster (day 12) at 2.75U, and the group treated with BTX-A registered 2.86U at day 30. Both therapies investigated were effective in reducing pain, but the effect of low-level laser was faster than the use of BTX-A. Both treatments showed no statistically significant improvement in mouth opening.

A randomized pilot study to assess the safety and the value of low-level laser therapy versus clonazepam in patients with burning mouth syndrome

Comparison between low-level laser therapy (LLLT) and clonazepam for treating burning mouth syndrome (BMS) patients has never been documented; the aim of this study was to assess the effects of LLLT photobiomodulation versus medical therapy with clonazepam on BMS. Thirty-three patients (25 female, 8 male, mean age = 67.12) were randomly allocated to two different groups: the first one (group A, 18 patients) underwent two laser irradiation sessions weekly for 5 weeks, whereas the second one (group B, 15 patients) received topical clonazepam therapy [half a tablet (2 mg) in the mouth without swallowing for 3 min, three times a day for 21 days]. LLLT was delivered with a continuous wave 980-nm aluminum gallium arsenide (AlGaAs) diode laser and the output of 300 mW, delivering a Fluence of 10 J/cm(2), using a "spot technique," with an average power density of about 1 W/cm(2). The laser probe was held perpendicularly at a distance of about 2 mm from the mucosa. Visual analogue scale (VAS), McGill Pain Questionnaire, present pain intensity (PPI), and Oral Health Impact Profile (OHIP-49) assessed sensation of pain. Hospital Anxiety and Depression Scale and Geriatric Depression Scale assessed levels of anxiety and depression. Twelve weeks after the end of treatment, patients treated with LLLT experienced a decrease in pain sensation reported for all the parameters analyzed: VAS (P = 0.004), McGill Pain Questionnaire (P = 0.002), PPI (P = 0.002), and OHIP-49 (P = 0.010). The group treated with clonazepam had less favorable results for VAS (P = 0.33), McGill Pain Questionnaire (P = 0.005), PPI (P = 0.013), and OHIP-49 (P = 0.25). Levels of anxiety and depression did not change statistically in any groups (P > 0.05). Comparing the two groups, LLLT appeared to be superior in improving pain perception, but statistically only at 8 weeks after the end of the protocol proposed (P = 0.026). Based on this preliminary trial, LLLT is capable of reducing the symptoms of patients with BMS with a constant and long-lasting effect, experienced since the end of the first applications.