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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 35-38

Laser therapy for myofascial pain dysfunction syndrome


Department of Prosthodontics, D. Y. Patil University School of Dentistry, DY Patil Deemed to be University, Navi Mumbai, Maharashtra, India

Date of Submission23-Sep-2019
Date of Acceptance07-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Ankita Vikas Chitnis
29/505, A Wing, Bharat CHS, Tilak Nagar, Chembur, Mumbai - 400 089, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_39_19

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   Abstract 


Myofascial pain dysfunction syndrome (MPDS) has been a very prevalent disorder with an enigmatic etiology and even difficult treatment protocol. Patients suffering from MPDS are difficult to diagnose and require exclusion of various symptoms and signs to formulate a treatment plan. In recent years, low-level laser therapy has been advocated as an effective way to counter and alleviate the resulting pain caused due to MPDS. This article is a case report on a successful reduction of pain in a patient diagnosed with the same.

Keywords: Laser therapy, myofascial pain dysfunction syndrome, trigger points, visual analog scale


How to cite this article:
Chitnis AV, Mistry GS, Puppala P, Swarup NA. Laser therapy for myofascial pain dysfunction syndrome. J Interdiscip Dentistry 2020;10:35-8

How to cite this URL:
Chitnis AV, Mistry GS, Puppala P, Swarup NA. Laser therapy for myofascial pain dysfunction syndrome. J Interdiscip Dentistry [serial online] 2020 [cited 2020 Jul 13];10:35-8. Available from: http://www.jidonline.com/text.asp?2020/10/1/35/283535




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Role of radiologist is of paramount importance in determining and eliminating presence of any temporomandibular disorders.
  • Pharmacological intervention may be required for treating the source of pain.
  • Treatment modalities include elimination and management of parafunctional habits by a prosthodontic approach using splints.
  • Transcutaneous electric nerve stimulation (TENS) and Electrical twitch obtaining intramuscular stimulation (ETOIMS) can be used to target trigger points by engaging deep motor endplates.



   Introduction Top


Myofascial pain dysfunction syndrome (MPDS), a common term used in dental medicine to describe orofacial chronic pain, is a functional disease related to the masticatory muscles, the neural structures, and the temporomandibular joint (TMJ) structures.[1] Its specific meaning relates to a painful condition caused by myofascial trigger points (MTrPs), while the general meaning indicates a regional muscle pain syndrome that is associated with muscle tenderness. Risk factors are occlusal parafunction, gender, age, depression, and psychological and emotional trauma.[2]

Nonsteroidal anti-inflammatory drugs are the most commonly used drugs for MPDS, whereas tizanidine is considered afirst-line agent for its treatment. However, these only provide palliative treatment. A Cochrane literature review that only included randomized control trials (RCTs) also evaluated Botulinum neurotoxin Type-A in the setting of MPDS and showed a statistically significant decrease in pain intensity scores and duration.[3] Injections into MTrPs are a common and effective treatment. They employ dry needling, short- or long-acting anesthetics, or steroids; manual therapy includes deep pressure massage, stretch therapy with cold spray, superficial heat, and myofascial release. These treatment modalities, although effective, cause discomfort to the patient during the treatment. The use of high-powered ultrasound has also been explored. Transcutaneous electric nerve stimulation (TENS) uses an electrical current to stimulate nerve fibers to provide pain relief. Electrical twitch obtaining intramuscular stimulation (ETOIMS) employs an electrical current through a monopolar electromyography needle to engage deep motor endplates. Magnetic stimulation is being investigated for musculoskeletal (MSK) pain and MPDS. A 2004 RCT investigated laser versus placebo in the treatment of MPDS and its effects on serotonin, a mediator of pain. Laser treatment demonstrated a statistically significant reduction in pain and an increase in urinary excretion of serotonin degradation.[4] Laser treatment is less painful and causes minimum discomfort to the patient. A subsequent increase in the pain threshold helps in alleviating pain.

The clinical relevance to interdisciplinary dentistry can be seen as the radiologist's role is of paramount importance in determining and eliminating the presence of any temporomandibular disorders. Pharmacological intervention may be required for treating the source of pain. Treatment modalities include elimination and management of parafunctional habits by a prosthodontic approach using splints. TENS and ETOIMS can be used to target trigger points by engaging deep motor endplates.


   Case Report Top


The patient reported with a complaint of atypical pain on the entire face. The patient gave a history of a road traffic accident 9 years ago, developing deafness in the right ear and having advised to wear a hearing aid since then. The patient had no pain on the face immediately postaccident; however, has developed pain 2 years ago. On examination, slight deviation, no clicking, or crepitus was observed and the absence of tenderness over the TMJ.

The patient pointed out distinct points in the offending area that were spread bilaterally on the face with two points over the temporalis muscle region and two over the masseter muscle region. These points were precise and repeatable [Figure 1] and [Figure 2].
Figure 1: Trigger points marked on the right side of the face

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Figure 2: Trigger points marked on the left side of the face

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The patient was advised to undergo primary investigations; any foci of infection observed were eradicated and were advised to wear a hard splint[5] for 2 weeks. The pain only subsided on the administration of analgesics and muscle relaxants. A diagnosis of MPDS was made after ruling out any other positive findings and relief of pain only with muscle relaxants. The criteria included a diagnosis of MPDS based on at least two of the following symptoms:

  1. Dull pain in the facial region
  2. One or more masticatory muscles' tenderness
  3. Mandibular restriction or deviation on mouth opening.[6],[7]


A low-level laser therapy (LLLT) was carried out using an InGaAsP diode laser (Biolase) with a wavelength of 904 nm for 4 weeks.[8],[9] [Figure 3] Therapeutic dose was 1008 mJ for each affected region. To alleviate pain, each region was initially radiated for 60 s, 0.7 W, then to reduce inflammation, it was radiated for another 60 s, 0.7 W.[10] The patient was kept under observation, and a pain score was evaluated using the visual analog scale every 4 h every day and at 24 h, 36 h, and 48 h after every appointment. Twelve appointments were scheduled for the patient every alternate day with a waiting period when a plateau was reached in terms of the pain score. [Table 1] The power was reduced by 0.1 W after a set of two appointments.
Figure 3: Laser therapy given at the marked trigger points

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Table 1: Progress of the patient in terms of visual analog scale values

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   Discussion Top


It is important to note that clinicians have been treating MPDS based on what they believe is its underlying pathophysiology and what are considered safe and effective treatments. Travell and Simons[11] utilized the spray and stretch technique because they attributed MPDS to muscle overload. Sola and Kuitert[12] and Lewit[13] utilized saline injections and dry needling, respectively; they believed their methods mechanically disrupted the dysfunctional endplates located near the MTrP. These theories are still considered plausible and discussed today.[14] Laser therapy has been used in the treatment of MSK pain including MPDS; however, its exact mechanism of therapeutic action remains elusive. Evidence support that LLLT has significant neuropharmacological effects on the synthesis, release, and metabolism of a range of neurochemicals, including histamine, serotonin, and acetylcholine, all of them being the mediators of pain. The laser reduces cell membrane permeability for Na+ and K+ and causes neuronal hyperpolarization resulting in increased pain threshold. It helps in removing metabolites and increasing blood flow to the muscles in the painful conditions through local vasodilation. All these results in analgesic effect.[15],[16] Gur et al.[17] revealed that short-period application of LLLT is effective in pain relief, improvement of functional ability and quality of life. Mean pain values decreased more significantly in a study carried out by Hakgüder et al.[18]

There is significant contradictory evidence for the benefit of laser therapy. Waylonis et al.[19] studied clinical responses using portions of the McGill Pain Questionnaire. No statistical difference between the treatment and the placebo groups could be determined. Dundar et al.[20] suggested that although the laser therapy had no superiority over placebo groups in their study, the possibility of effectivity with another treatment regimen including different laser wavelengths and dosages (different intensity and density and/or treatment interval) cannot be excluded. However, more studies need to be carried out with a larger sample size to ascertain the definite effects of LLLT.


   Conclusion Top


Although mixed data are available regarding the efficacy of laser treatment for the treatment of MPDS, a significant amount of studies show a noteworthy reduction in the pain associated with the same. The patient showed a considerable amount of pain reduction (80%) during the course of the treatment after which a plateau was obtained. The patient has been advised to maintain regular follow-up and will be assessed for any further developments in symptoms or absence of the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gözler S. Myofascial pain dysfunction syndrome: Etiology, diagnosis, and treatment. Temporomandibular Joint Pathology – Current Approaches and Understanding. London: IntechOpen Limited; 2018.  Back to cited text no. 1
    
2.
Palla S. Trigger points as a cause of orofacial pain. J Musculoskelet Pain 2004;12:29-36.  Back to cited text no. 2
    
3.
Malanga GA, Gwynn MW, Smith R, Miller D. Tizanidine is effective in the treatment of myofascial pain syndrome. Pain Physician 2002;5:422-32.  Back to cited text no. 3
    
4.
Ceylan Y, Hizmetli S, Siliǧ 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;24:260-3.  Back to cited text no. 4
    
5.
Boero RP. The physiology of splint therapy: A literature review. Angle Orthod 1989;59:165-80.  Back to cited text no. 5
    
6.
Lynch M, Brightman V. Burket's Oral Medicine. 9th ed. Philadelphia: JB Lippincott; 1994. p. 312-14, 327-28.  Back to cited text no. 6
    
7.
Eversole LR, Machado L. Temporomandibular joint internal derangements and associated neuromuscular disorders. J Am Dent Assoc 1985;110:69-79.  Back to cited text no. 7
    
8.
Kulekcioglu S, Sivrioglu K, Ozcan O, Parlak M. Effectiveness of low-level laser therapy in temporomandibular disorder. Scand J Rheumatol 2003;32:114-8.  Back to cited text no. 8
    
9.
Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ Orthop Rheumatol 2015;2. pii: 00068.  Back to cited text no. 9
    
10.
Azizi A, Sahebjamee M, Lawaf S, Jamalee F, Maroofi N. Effects of low-level laser in the treatment of myofascial pain dysfunction syndrome. J Dent Res Dent Clin Dent Prospects 2007;1:53-8.  Back to cited text no. 10
    
11.
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams &Wilkins; 1983.  Back to cited text no. 11
    
12.
Sola AE, Kuitert JH. Myofascial trigger point pain in the neck and shoulder girdle; report of 100 cases treated by injection of normal saline. Northwest Med 1955;54:980-4.  Back to cited text no. 12
    
13.
Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;6:83-90.  Back to cited text no. 13
    
14.
Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial trigger points then and now: A historical and scientific perspective. PM R 2015;7:746-61.  Back to cited text no. 14
    
15.
Raman A, Srividhya S, Kumar M, Laxman A, Kumar M, Kailasam S. Low level laser therapy: A concise review on its applications. J Indian Acad Oral Med Radiol 2013;25:291-3.  Back to cited text no. 15
  [Full text]  
16.
Motwani MB, Balpande AS, Pajnigara NG, Pajnigara NG, Shweta G, Iyer NC. Role of low-level laser therapy in treatment of orofacial pain: A systematic review. J Adv Clin Res Insights 2016;3:56-9.  Back to cited text no. 16
    
17.
Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S. Efficacy of 904 nm gallium arsenide low level laser therapy in the management of chronic myofascial pain in the neck: A double-blind and randomize-controlled trial. Lasers Surg Med 2004;35:229-35.  Back to cited text no. 17
    
18.
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;33:339-43.  Back to cited text no. 18
    
19.
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;69:1017-20.  Back to cited text no. 19
    
20.
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;26:930-4.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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