Effectiveness of Low-Level Laser Therapy in Temporomandibular Disorders: A Systematic Review and Meta-Analysis

Aim: To assess the scientific evidence on the efficacy of low-level la-ser therapy (LLLT) in the treatment of temporomandibular disorders (TMD). Methods: The databases of PubMed, Science Direct, Cochrane Clinical Trials Register, and PEDro were manually and electronically searched up to February 2010. Two independent reviewers screened, extracted, and assessed the quality of the publications. A meta-analysis was performed to quantify the pooled effect of LLLT on pain and function in patients with chronic TMD. Results: The literature search identified 323 papers without overlap between selected databases, but after the two-phase study selection, only six randomized clinical trials (RCT) were included in the systematic review. The primary outcome of interest was the change in pain from baseline to endpoint. The pooled effect of LLLT on pain, measured through a visual analog scale with a mean difference of 7.77 mm (95% confidence interval [CI]: –2.49 to 18.02), was not statistically significant from placebo. Change from baseline to endpoint of secondary outcomes was 4.04 mm (95% CI 3.06 to 5.02) for mandibular maximum vertical opening; 1.64 mm (95% CI 0.10 to 3.17) for right lateral excursion and 1.90 mm (95% CI: –4.08 to 7.88) for left lateral excursion. Conclusion: Currently, there is no evidence to support the effectiveness of LLLT in the treat-ment of TMD.

laser;meta-analysis;systematic review;temporomandibular disorders;temporomandibular joint

1. Al-Ani Z, Gray R. TMD current concepts: An update. Dent Update 2007;34:278–288.

2. Bertolucci LE, Grey T. Clinical analysis of mid-laser versus placebo treatment of arthralgic TMJ degenerative joints. Cranio 1995;13:26–29.

3. Dolwick MF. The role of temporomandibular joint surgery in the treatment of patients with internal derangement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:150–155.

4. Gray RJM, Quayle AA, Hall CA. Physiotherapy in the treatment of temporomandibular joint disorders. Br Dent J 1994;176:257–264.

5. Widmalm SE. Use and abuse of bite splints. Compend Contin Educ Dent 1999;20:249–259.

6. Tsukiyama Y, Baba K, Clark GT. An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorders. J Prosthet Dent 2001;86:57–66.

7. Debar LL, Vuckovic N, Schneider J, Ritenbaugh C. Use of complementary and alternative medicine for temporomandibular disorders. J Orofac Pain 2003;17:224–236.

8. Basford JR. Low-energy laser treatment of pain and wounds: Hype, hope, or hokum? Mayo Clin Proc 1986;61:671–675.

9. Kitchen SS, Partridge CJ. A review of low level laser therapy. Physiotherapy 1991;77:161–168.

10. Hanssen HJ, Thoroe U. Low power laser biostimulation of chronic orofacial pain. A double-blind placebo controlled cross-over study in 40 patients. Pain 1990;43:169–179.

11. Belkin M, Schwarts M. New biological phenomena associated with laser radiation [review]. Health Phys 1989;56: 687–690.

12. Brunner R, Haina D, Landthaler M, Waidelich W, Braun-Falco O. Applications of laser light of low-power density. Experimental and clinical investigations. Curr Probl Dermatol 1986;15:111–116.

13. Honmura A, Ishii A, Yanase M, Obata J, Haruki E. Analgesic effect of Ga-Al-As diode laser irradiation on hyperalgesia in carrageenin induced inflammation. Lasers Surg Med 1993;13:463–469.

14. Sakurai Y, Yamaguchi M, Abiko Y. Inhibitory effect of low-level laser irradiation on LPS-stimulated prostaglandin E2 production and cyclooxygenase-2 in human gingival fibroblasts. Eur J Oral Sci 2000;108:29–34.

15. Shimizu N, Yamaguchi M, Goseki T, et al. Evidence for physiotherapy practice: A survey of the physiotherapy evidence database (PEDro). Aust J Physiother 2002;48:43–49.

16. Jarvis D, MacIver MB, Tanelian DL. Electrophysiologic recording and thermodynamic modeling demonstrate that helium-neon laser irradiation does not affect peripheral Adelta or C-fiber nociceptors. Pain 1990;43:235–242.

17. Skinner SM, Gage JP, Wilce PA, Shaw RM. A preliminary study of the effects of laser radiation on collagen metabolism in cell culture. Aust Dent J 1996;41:188–192.

18. Koes BW, Assendelft WJ, Van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine 1996;21: 2860–2871.

19. Bjordal JM, Couppé C, Chow RT, Tunér J, Ljunggren EA. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother 2003;49:107–116.

20. Armijo-Olivo SA, Macedo LG, Gadotti IC, Fuentes J, Stanton T, Magee DJ. Scales to assess the quality of randomized controlled trials: A systematic review. Phys Ther 2008; 88:156–175.

21. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: A survey of the physiotherapy evidence database (PEDro). Aust J Physiother 2002; 48:43–49.

22. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions 5.0.0. The Cochrane Collaboration, 2008. Available at: www.cochranehandbook.org.

23. Carvalho CM, De Lacerda JA, Dos Santos Neto FP, Cangussu MC, Marques AM, Pinheiro AL. Wavelength effect in temporomandibular joint pain: A clinical experience. Lasers Med Sci 2010;25:229–232.

24. Gül K, Onal SA. Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome. Agri 2009;21:104–112.

25. Kuan TS. Current studies on myofascial pain syndrome. Curr Pain Headache Rep 2009;13:365–369.

26. Fikácková H, Dostálová T, Navrátil L, Klaschka J. Effectiveness of low-level laser therapy in temporomandibular joint disorders: A placebo-controlled study. Photomed La-ser Surg 2007;25:297–303.

27. Dundar U, Evcik D, Samli F, Pusak H, Kavuncu V. The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: A double blind, placebo-controlled study. Clin Rheumatol 2007;26:930–934.

28. Núñez SC, Garcez AS, Suzuki SS, Ribeiro MS. Management of mouth opening in patients with temporomandibular disorders through low-level laser therapy and transcutaneous electrical neural stimulation. Photomed Laser Surg 2006; 24:45–49.

29. Kato MT, Kogawa EM, Santos CN, Conti PCR. TENS and low-level laser therapy in the management of temporomandibular disorders. J Appl Oral Sci 2006;14:130–135.

30. Cetiner S, Kahraman SA, Yücetas S. Evaluation of low-level laser therapy in the treatment of temporomandibular disorders. Photomed Laser Surg 2006;24:637–641.

31. De Medeiros JS, Vieira GF, Nishimura PY. Laser application effects on the bite strength of the masseter muscle, as an orofacial pain treatment. Photomed Laser Surg 2005;23: 373–376.

32. Kogawa EM, Kato MT, Santos CN, Conti PCR. Evaluation of the efficacy of low-level laser therapy (LLLT) and the microelectric neurostimulation (MENS) in the treatment of myogenic temporomandibular disorders: A randomized clinical trial. J Appl Oral Sci 2005;13:280–285.

33. Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain syndrome. Photomed Laser Surg 2004;22:306–311.

34. Hakgüder A, Birtane M, Gürcan S, Kokino S, Turan FN. Efficacy of low level laser therapy in myofascial pain syndrome: An algometric and thermographic evaluation. Lasers Surg Med 2003;33:339–343.

35. Hong CZ. New trends in myofascial pain syndrome [review]. Zhonghua Yi Xue Za Zhi (Taipei) 2002;65:501–512.

36. Fargas-Babjak A. Acupuncture, transcutaneous electrical nerve stimulation, and laser therapy in chronic pain. Clin J Pain 2001;17:105–113.

37. Criscuolo CM. Interventional approaches to the management of myofascial pain syndrome. Curr Pain Headache Rep 2001;5:407–411.

38. Pinheiro AL, Cavalcanti ET, Pinheiro TI, Alves MJ, Manzi CT. Low-level laser therapy in the management of disorders of the maxillofacial region. J Clin Laser Med Surg 1997;15:181–183.

39. Simunovic Z. Low level laser therapy with trigger points technique: A clinical study on 243 patients. J Clin Laser Med Surg 1996;14:163–167.

40. Hansson TL. Infrared laser in the treatment of craniomandibular disorders, arthrogenous pain. J Prosthet Dent 1989; 61:614–617.

41. Bezuur NJ, Habets LL, Hansson TL. The effect of therapeutic laser treatment in patients with craniomandibular disorders. J Craniomandib Disord 1988;2:83–86.

42. Waylonis GW, Wilke S, O’Toole D, Waylonis DA, Waylonis DB. Chronic myofascial pain: Management by low-output helium-neon laser therapy. Arch Phys Med Rehabil 1988; 69:1017–1020.

43. Katsoulis J, Ausfeld-Hafter B, Windecker-Gétaz I, Katsoulis K, Blagojevic N, Mericske-Stern R. Laser acupuncture for myofascial pain of the masticatory muscles. A controlled pilot study. Schweiz Monatsschr Zahnmed 2010;120:213–225. 44. Carrasco TG, Guerisoli LD, Guerisoli DM, Mazzetto MO. Evaluation of low intensity laser therapy in myofascial pain syndrome. Cranio 2009;27:243–247.

45. Shirani AM, Gutknecht N, Taghizadeh M, Mir M. Low-level laser therapy and myofacial pain dysfunction syndrome: A randomized controlled clinical trial. Laser Med Sci 2009;24:715–720.

46. Mazzetto MO, Carrasco TG, Bidinelo EF, De Andrade Pizzo RC, Mazzetto RG. Low intensity laser application in temporomandibular disorders: A phase I double-blind study. Cranio 2007;25:186–192.

47. Ceylan Y, Hizmetli S, Silig Y. The effects of infrared laser and medical treatments on pain and serotonin degradation products in patients with myofascial pain syndrome. A controlled trial. Rheumatol Int 2004;24:260–263.

48. Tullberg M, Alstergren PJ, Ernberg MM. Effects of low-power laser exposure on masseter muscle pain and micro-circulation. Pain 2003;105:89–96.

49. Bertolucci LE, Grey MS. Clinical comparative study of microcurrent electrical stimulation to midlaser and placebo treatment in degenerative joint disease of the temporomandibular joint. Cranio 1995;13:116–120.

50. Bertolucci LE, Grey MS. Clinical analysis of mid-laser vs placebo treatment of arthralgic TMJ degenerative joints. Cranio 1995;13:26–29.

51. Gray RJM, Quayle AA, Hall CA, Schofield MA. Physiotherapy in the treatment of temporomandibular joint disorders: A comparative study of four treatment methods. Br Dent J 1994; 176:257–261.

52. Carrasco TG, Mazzetto MO, Galli Mazzetto R, Mestriner W. Low intensity laser therapy in temporomandibular disorder: A phase two double-blind study. Cranio 2008;26:274–281.

53. Conti PCR. Low level laser therapy in the treatment of temporomandibular disorders (TMD): A double-blind pilot study. Cranio 1997;15:144–149.

54. Da Cunha LA, Firoozmand LM, Da Silva AP, Esteves SA, De Oliveira W. Efficacy of low-level laser therapy in the treatment of temporomandibular disorder. Int Dent J 2008; 58:213–217.

55. De Abreu Venancio R, Camparis CM, De Fatima Zanirato R. Low intensity laser therapy in the treatment of temporomandibular disorders: A double-blind study. J Oral Rehabil 2005;32:800–807.

56. Emshoff R, Bösch R, Pümpel E, Schöning H, Strobl H. Low-level laser therapy for treatment of temporomandibular joint pain: A double-blind and placebo-controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:452–456.

57. Kulekcioglu S, Sivrioglu K, Ozcan O, Parlak M. Effectiveness of low-level laser therapy in temporomandibular disorder. Scand J Rheumatol 2003;32:114–118.

58. Gam AN, Thorsen J, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: A meta-analysis. Pain 1993;52:63–66.

59. Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain 2003;106:337–345.

60. Turk DC, Dworkin RH, McDermott MP, et al. Analyzing multiple endpoints in clinical trials of pain treatments: IMMPACT recommendations. Initiative on methods, measurement, and pain assessment in clinical trials. Pain 2008;139: 485–493.