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DIPLOMARBEIT

Alternative methods in the treatment of myofascial pain in case of hyperactive masticatory muscles

Alternative Methoden der Schmerzausschaltung bei Hyperaktivität der Kaumuskulatur

Zur Erlangung des akademischen Grades

Doktorin der Zahnheilkunde (Dr. med. dent.)

an der
Medizinischen Universität Wien

ausgeführt an der Prothetischen Abteilung

der Universitätszahnklinik Wien

unter der Anleitung von

Fr. DDr. Astrid Skolka, MSc

und

Fr. Dr. med. dent. Jelena Simatovic

eingereicht von
Tatiana Molodova
Matrikelnummer: 1242812

Ort, Datum:……………………… Unterschrift:………………………………

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I dedicate this thesis to my parents
Sytchik Margarita (1962-1995) and Sytchik Nikolay (1957-2007).

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Danksagung

Frau DDr. Astrid Skolka MSc, Frau Dr. med.dent. Jelena Simatovic und Frau a.o.Univ. Prof. DDr.
Martina Schmid-Schwap danke ich für die Betreuung und Unterstützung bei der Verfassung der
vorliegenden Arbeit.

Für die Korrektur und die Unterstützung bei sprachlichen Fragen bedanke ich mich bei Herrn
Anatolij Milijanovic.

Ein spezieller Dank gilt noch meinem Partner Klaus della Torre, der mich während meines
Studiums zu jeder Zeit unterstützt hat.

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Table of Content

1. ZUSAMMENFASSUNG ...…………………………………………………………………… 6
2. ABSTRACT ……………………………………………………………………...…………… 7
3. INTRODUCTION …………………………………………………………………...………... 8
3.1 Definition ……………………………………………………………………………….… 8
3.1.1 Pain ……………………………………………………………………………...…. 8
3.1.2 Chronic Pain ……………………………………………………………………….. 8
3.1.3 Chronic Pain Variations ……………………………………………………………. 8
3.1.4 Myofascial pain ……………………………………………………………………. 9
3.1.5 Orofacial Pain ……………………………………………………………………… 9
3.1.6 Bruxism ……………………………………………………………………………. 9
3.2 Scientific Background …………………………………………………………………... 10
4. FUNDAMENTALS …………………………………………………………………………. 12
4.1 Muscle Structure …………………………………………………...…………………… 12
4.2 Muscles Physiology …………………………………………………………………….. 14
4.3 Anatomy of Masticatory Muscles ……………………………………...……………….. 15
4.3.1 Masseter muscle …………………………………………………………….……. 15
4.3.2 Temporal muscle ……………………………………………….………………… 16
4.3.3 Medial pterygoid muscle ……………………………………………………….... 16
4.3.4 Lateral pterygoid muscle ……………………………………………….………… 17
4.4 Neurophysiological Background ………………………………………………………... 18
4.5 The Trigeminal Nerve …………………………………………………………………... 19
5. METHODS OF TREATMENT ………………………………………………………..……. 22
5.1 Acupuncture ……………………………………………………………………….……. 22
5.2 Botulinum toxin ………………………………………………………………..……….. 23
5.3 Biofeedback …………………………………………………………………….………. 24
5.4 Transcutaneous electrical nerve stimulation ……………………………..……………... 25
6. PROBLEMS AND QUESTIONS …………………………………………………………… 26
7. AIM …………………………………………………………………………………..……… 26

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8. MATERIAL AND METHODS …………………………………………...…………………. 27
8.1 Meta analysis ………………………………………………………………………….… 27
8.2 Literature Research ……………………………………………………………………… 28
8.3 Inclusion and Exclusion Criteria ……………………………………...………………… 29
8.4 List of studies included in meta-analysis ………………………………………………... 31
8.5 Statistical Analysis ………………………………………………………………………. 33
9. DESCRIPTIVE RESULTS …………………………………………………………………... 34
9.1 Characteristics of the included studies ………………………………...………………… 34
9.2 Quantitative description of the subgroups ………………………………………………. 36
10. DISCUSSION………………………………………………………………………………. 38
11. CONCLUSION …………………………………………………………………………….. 40
12. REFERENCES ……………………………………………………………………...……… 41
13. SUPPLEMENTS …………………………………………………………………..……….. 46
13.1 List of abbreviations ………………………………………………………………...…. 46
13.2 List of figures ………………………………………………………………………..… 47
13.3 List of tables …………………………………………………………………………… 48
13.4 Tables ………………………………………………………………………………...… 49
14. RÉSUMÉ / CV ………………………………………..………………………………….… 63

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1. ZUSAMMENFASSUNG

Ziele:
Die Lebensqualität von Patienten mit chronischen myofaszialem Schmerzsyndrom ist ziemlich
niedrig. Sie leiden unter Schlafstörungen, Schwierigkeiten bei der Mastikation, chronischen
Kopfschmerzen und Konzentrationsproblemen. Ziel dieser Arbeit ist es, nicht medikamentöse
Behandlungsmethoden des durch hyperaktive Kaumuskultur bedingten myofaszialen
Schmerzsyndroms, die Alternativen zu den „golden standard“-Therapien wie Aufbissbehelfe oder
Physiotherapie darstellen, zu erheben, einer Metaanalyse zuzuführen und somit den Therapieerfolg
dieser alternativen Methoden aufzuzeigen.

Methoden:
Die Metaanalyse ist die quantitative statistische Analyse, die die Ergebnisse einer Reihe relevanter
wissenschaftlicher Studien kombiniert, bei denen eine bestimmte Frage mit dem Ziel, bessere
Ergebnisse zu erreichen, untersucht wurde (27). Die in dieser Arbeit angewandte statistische
Untersuchung ist das Modell zufallsbedingter Effekte (random-effect model).

Ergebnisse:
Die Ergebnisse unserer Studie haben die höchstpositive Wirkung in jener Behandlungsgruppe, in
der Botulinumtoxin eingesetzt wurde, gezeigt (die durchschnittliche standardisierte Differenz ist
1.96). Obwohl auch jene Gruppe, die mittels TENS-Methode behandelt wurde, eine höchstpositive
Wirkung gezeigt hat (die durchschnittliche standardisierte Differenz ist 2.05), sind deren Ergebnisse
wegen der zu geringen Anzahl von Untersuchungen (nur 2) und Probanden nicht vergleichbar.

Fazit:
Die Ergebnisse unserer Studie zeigen den effektivsten Therapieerfolg der Schmerzbehandlung mit
Botulinumtoxin. Einschränkend muss allerdings erwähnt werden, dass aufgrund der unzureichenden
Anzahl der für unsere Kriterien relevanten Untersuchungen ein weiterer Forschungsbedarf zu
diesem Thema besteht.

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2. ABSTRACT

Objectives:
Quality of life for patients with chronic myofascial pain is quite decreased. They have troubles in
sleeping, chewing, suffer from chronic headache and have some concentration problems. Aim of
this work is to search and compare possible treatments of myofascial pain due to hyperactive
masticatory muscles, other than painkillers or “golden standard”-therapies as occlusal splints or
physiotherapy, finding alternative ways to cope with the problem of pain and to show their
effectiveness.

Methods:
Meta-analysis is a quantitative statistical analysis that combines results of a number of related
scientific studies which has examined a particular question with goal to produce better results (27).
Statistical test which was applied in this work is random-effect model.

Results:
The result of our study showed the highest positive effect in the subgroup of treatment with
botulinum toxin (average standardized difference is 1.96). Even though the subgroup of TENS
method showed a high positive effect (average standardized difference is 2.05) it cannot be
compared on the basis of a non-representative sample (just 2 studies).

Conclusion:
The result of our study showed the highest positive effect in coping with pain in the group of
botulinum toxin, but due to limited amount of study which machted our criteria the topic of our
study needs further research.

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3. INTRODUCTION

3.1 Definition

3.1.1 Pain
Pain is an unpleasant physical sensation caused by different kinds of stimulation or injury of the
sensory nerve endings. Pain sensations can range from mild or localised discomfort all the way to
agony.
It is a subjective feeling and an individual response to the cause. Pain is a valuable symptom in the
diagnostics of many disorders and diseases. Experiencing pain is influenced by physical, mental,
social and emotional factors (1).

3.1.2 Chronic pain


Chronic pain is an unpleasant sense of discomfort that continues or occurs again over a prolonged
period of time and may be caused by various clinical pathologic conditions. Chronic pain may be
less intense than acute pain. Pain sensation has both physical and emotional components. And some
factors can influence the pain sensation such as scarring or continuing psychological stress (1).

3.1.3 Chronic pain variations according the World Health Organisation (WHO)
The World Health Organisation (WHO) defines chronic pain as persistent or recurrent pain that lasts
longer than 3 months. Chronic pain also can be associated with significant emotional distress or
significant functional disability.
According to the WHO-classification of chronic pain, orofacial pain is listed as a separate diagnosis
(2).
World Health Organisation classification of chronic pain:
x chronic primary pain
x chronic cancer pain
x chronic postsurgical or posttraumatic pain
x chronic neuropathic pain
x chronic headache or orofacial pain
x chronic visceral pain
x chronic musculoskeletal pain

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3.1.4 Myofascial pain
Myofascial pain is a jaw muscle distress associated with chewing or exercise of the masticatory
muscles (1). Myofascial pain is often defined as chronic musculoskeletal pain, which can be local or
referred. Multiple trigger points are described (4).

3.1.5 Orofacial pain


Orofacial pain can be considered as pain or physical discomfort concerning the maxillofacial area.
Orofacial pain is a common symptom associated to different kinds of diseases. According to
Mosby's Dictionary of Complementary and Alternative Medicine (2005) more than 95% of
orofacial pain cases can be estimated due to dental reasons (toothache, pulpitis or dental abscess).
The second most common cause of orofacial pain is temporomandibular disorders. The remaining 5%
of pathologies of orofacial pain are rare and have different backgrounds (3).

3.1.6 Bruxism
Definition according to EACD (European Academy of Craniomandibular Disorders):
Bruxism is a repetitive jaw-muscle activity characterised by clenching or grinding of the
teeth and/or by bracing or thrusting of the mandible. Bruxism has two distinct circadian
manifestations: it can occur during sleep and indicated as sleep bruxism or during wakefulness and
indicated as awake bruxism (30).
Aetiology of this disorder is a response to anxiety, tension (aggression or anger) and/or dental
problems (4). This condition is associated with forceful lateral or protrusive jaw movements and as
the result abrasion the chewing surface of the teeth (6).
Bruxism is typically associated with stress but may be also caused by malocclusion (39).
Symptoms of bruxism may include: different types of headache, myofascial pain, earaches,
hypersensitivity of teeth and noises as clicking in temporomandibular joints.
Further teeth damage may be recognised during a dental examination, including enamel loss of
occlusal and incisal teeth surfaces, flattened occlusal surfaces and/or fractured teeth, fillings and
crowns. Bruxism may lead to permanent teeth loss and jaw dysfunction (7).

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3.2 Scientific background

Chronic pain is a point of interest for numerous scientific studies. Among many worldwide acting
health organisations studying chronic pain the Swedish agency for health technology and
assessment of social service detected in a study Methods of Treating Chronic Pain a strong negative
correlation between pain and quality of life (8).

Furthermore, various scientific streams closely monitoring the topic of chronic headache confirm
that chronic headache may negatively affect patient's health-related quality of life (9). Headache
may negatively influence our life, and it may limit patient’s ability to work and concentration,
damage quality of sleep and limit ones everyday and social life. The scientific study „Headache and
quality of life“ claims that headache negatively influences patient’s quality of life not only during
attack phases but also during interictal periods (10).

The study “Chronical pain harms the brain” of North-western University on “Science Daily” state
that people with unrelenting pain not only suffer from the uninterrupted throbbing pain sensation,
but they also show different kind of sleep difficulties and are often depressed, anxious, experience
difficulty to concentrate and have difficulty to make simple daily routines (11).

Chronic pain of the chewing muscles can lead to the damage of an important process of receiving
and digesting meal. A study of Professor Greg M Murray of the Faculty of Dentistry at the
University of Sydney “How does pain affect jaw muscle activity? The Integrated Pain Adaptation
Model” shows that patients with temporomandibular disorders (TMD) frequently have restricted
mouth opening and reduced jaw function (12).

University of Sidney has done intense clinical research on the topic of chronic pain, one of their
studies around 2010 shows that all patients with chronic pain go through proven psychological
changes during dealing with their pain. Psychological and environmental factors also played a great
role in chronic pain and around 30% of patients showed signs of clinical depression (13).

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The publication Mental Status as a Common Factor for Masticatory Muscle Pain: A Systematic
Review detected that masticatory muscle pain (MMP) is a reason for chronic orofacial pain and has
become a considerable social problem which affects about 12–14% of the adult population.

Masticatory muscle pain condition is diagnosed 1.5–2 times more frequently with women than with
men. Even though MMP typically located on the face, jaws and area around ears, it may also radiate
to a pain sensation inside ear, teeth, head and neck (14).

Medicamentous treatment may cause harm to inner organs, such as liver, kidney and gastrointestinal
tract. The clinical research Harmful Effects of Aspirin Compounds reveal that many complications
are correlating with prolonged treatment with aspirin. Some of these complications involve damage
to various tissues and organs (particularly the gastric mucosa, the renal papilla, red blood cells and
the inner ear). It also reduces coagulation and impacts body temperature control (15).

A study in the Journal of American Clinical and Experimental Gastroenterology showed that
ibuprofen liquid capsules had the highest risk of incidence of gastroduodenal mucosal injury (16).

A team led by David Moore of Baylor College of Medicine in Houston, Texas, reported that
overdoses of acetaminophen widely used as painkiller cause severe liver damage. In the United
States painkiller overdoses cause acute liver failure in 800 patients every year; a third of which with
fatal incidence (17).

Even though it is proven that painkillers reduce pain symptoms, there is also evidence that it can do
serious damage to the cardiovascular system of patients. Investigation by the research team led by
Michèle Bally, of the University of Montreal Hospital Research Center (CRCHUM), shows that the
use of non-steroidal anti-inflammatory drugs (NSAIDs) can significantly increase a risk of having
heart attack after just a few weeks of use (18).

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4. FUNDAMENTALS

4.1 Muscle structure

Muscle
Muscle is a tissue composed of elongated fiber-cells that contract to produce movement. Anatomy
of muscle provides two main functions: contraction and stretching. Muscles may be classified as
skeletal muscle (striated), cardiac muscle or smooth muscle (Fig. 1). Muscles also variate in shape
(digastric, triangular, tricipital etc.) and colour (e.g. from white to deep red). Muscles have
additional functions as protection of the abdomen against injuries and help to upright posture (19).

Fig. 1 Muscle type tissue


(Dornalds 2000)

Some muscles are attached to bones by a strong white fibrous tissue, the tendon (Fig. 2). Others are
attached to other muscles or to the skin, for example, producing the smile, the wink and some other
facial expressions. The more proximal (fixed) attachment is called the origin, the more distal
(movable attachment) is the insertion. The narrowing part of the belly that is attached to the tendon
of origin is called the caput or head (19).

Fig. 2 Tendon and muscle fiber structure


(Asklepios Medical Atlas 2016)

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Muscle fiber

Muscle fiber is a multi- or polynuclear cell of muscle tissue, which has a cylindrical shape and
contains myofibrils that contracts when it is stimulated. The muscle fiber is enclosed in sarcomere
(20).

The classification of muscle fibers is based on the ability of contraction and on different metabolic
characteristics. Type I fibers are contracting slowly and develop low tension; they demonstrate
high oxidative and low glycolic capacity. Type II fibers have a rapid speed of activation and
develop high tension; they demonstrate low oxidative and high glycolytic capacity combined with
strength and power performance (23).

Almost all hollow internal organs such as stomach, heart, intestines and blood vessels have muscle
tissue in their structure. Muscles fibers can reach length from a few hundred thousandts of
centimetres to several centimetres. Each muscle fiber receives its own nerve impulse that provides
different kinds of motion. Each fiber cell has its small stored supply of glycogen used as fuel for
movement. The heart muscle additionally uses free fatty acids as fuel. As a signal of an impulse
travelling down the nerve, the muscle fiber changes chemical energy into mechanical energy and as
result the muscle contracts (21).

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4.2 Physiology of Muscles

The speed of human movement, the ability to maintain posture, the regulation of blood circulation,
the respiration and other processes depend on physiology of muscles. Tonus is a physiological
condition when no muscle stays completely relaxed, remains slightly contracted. It keeps bones in
place and allows a person to take different kinds of posture.
Muscles help the body performing different types of movements. A muscle which is flexing a joint
or a limb is called flexor. A muscle that extends a joint or limb is called extensor. Abductor or
levator is any muscle which pulls toward the midline or moves a limb towards main part of the
body.

To contract a muscle going through 3 different phases (Fig. 3):


1. latent period – time after a muscle got a nerve stimulation and before it starts contracting,
2. phase of tension – isometric contraction,
3. phase of relaxation.

A muscle, which contracted many times and has run out of glycogen and other stored substances
starts accumulating lactic acid and becomes unable to contract further. That condition is called
fatigue (22).

Fig. 3 Phases of muscle tension


(Collins Dictionary of Biology 2005)

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4.3. Anatomy of Masticatory muscles

Mastication is the process of grinding and chewing food into smaller pieces in the oral cavity
turning it into a food bolus. There are 4 pairs of masticatory muscles which are having an important
role in the chewing process. Masticatory muscles include:
x masseter muscle;
x temporal muscle;
x lateral pterygoid muscle;
x medial pterygoid muscle.

4.3.1 Masseter muscle


The masseter muscle (Fig. 4) is a faсial muscle that plays a major role in the chewing process and
also participates in protraction, retraction and in a side movement of the jaw. The masseter is
divided into two parts called 'superficial' and 'deep' part.
Latin language: musculus masseter (pars superficialis et pars profunda) (22).

Musculus masseter pars superficialis:


Origin: inferior border of zygomatic arch;
Insertion: angle of the mandible;
Action: it closes jaw and also participates in protraction, retraction, side movement of the jaw;
Innervation: N. massetericus (N. mandibularis).

Musculus masseter pars profunda:


Origin: inferior and medial border of zygomatic arch;
Insertion: lateral coronoid of the mandible, disc and joint capsule;
Action: limit lateral movement of the condyles, centering the condyle against the eminentia
articularis;
Innervation: N. massetericus (N. mandibularis) (23).

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Fig. 4 Masseter muscle and temporal muscle.
(The Illustrated Atlas of the Human Body by Beverly McMillan 2010)

4.3.2 Temporal muscle


Latin language: musculus temporalis (pars anterior, pars intermedia et pars posterior) (Fig. 4)
Origin: temporal line superior et inferior;
Insertion: coronoid process of the mandible and anterior border of the ramus;
Action: pars anterior- elevation, pars intermedia and pars posterior – mouth closure und retrusion;
Innervation: N. temporalis profundi (N. mandibularis) (23).

4.3.3 Medial pterygoid muscle


Latin language: musculus pterygoideus medialis (Fig. 5)
Origin: pterygoid fossa of sphenoid and tuberosity of maxilla;
Insertion: medial surface of the mandible between angle and mylohyoid groove; It forms a muscle
loop with the masseter;
Action: adduction; in unilateral activation- mediotrusion;
Innervation: N. pterygoideus medialis (N. mandibularis) (23).

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Fig. 5 Medial and lateral pterygoids muscles
(The Illustrated Atlas of the Human Body by Beverly McMillan 2010)

4.3.4 Lateral pterygoid muscle


Latin language: musclus pterygoideus lateralis (Fig. 5)

Musculus pterygoideus lateralis caput superius:


Origin: ala major ossis sphenoidalis;
Insertion: fovea pterygoidea colli mandibulae, articular disc and capsule of temporomandibular
joint;
Action: it supports lower jaw in a process of opening and closing of mouth, retrusion, laterotrusion,
it holds the disc condyle complex at the slope of the eminentia articularis, it is also active in the
resting position of the lower jaw;
Innervation: N. pterygoideus lateralis (N. mandibularis) (23).

Musculus pterygoideus lateralis caput inferius:


Origin: lamina lateralis processus pterygoidei;
Insertion: fovea pterygoidea colli mandibulae;
Action: mouth opening, protrusion, mediotrusion (unilateral activity);
Innervation: N. pterygoideus lateralis (N. mandibularis) (23).

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4.4 Neurophysiological background

Trigeminothalamic pathways to the cortex


Nerve impulses for the somatic sensation from the face, the nasal cavity, the oral cavity and the
teeth rise along the trigeminothalamic pathway to the cerebral cortex (Fig. 6). As well as the other
somatosensory pathways, the trigeminothalamic pathway consists of three neuron sets (24).

First order neurons spread from somatic sensory receptors in the face, the nasal cavity, the oral
cavity and the teeth through the trigeminal nerve into the pons. A part of the first order neurons
makes synapses in the pons with parts of the second order neurons. The other part raises into the
medulla with second order neurons, which crosses to the opposite side of the pons and the medulla
and ascends as the trigeminothalamic tract to the ventro-posterior nucleus of the thalamus. Third
order neurons project their axons to the primary somatosensory area on the same side of the
cerebral cortex as the thalamus (24).

Fig.6 The trigeminothalamic pathway


(Essentials of Oral Histology and Embryology. 2000, Mosby.)
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4.5 Trigeminal Nerve

The trigeminal nerve is the fifth cranial nerve, also called nervus trigeminus (latin language),
trifacial nerve, trigeminus. It is the largest and the most complex of the 12 cranial nerves. This
nerve has sensory and motor functions, the sensory part being responsible for the sensibility of the
face. The trigeminal nerve transmits sensory and tactile informations to the face and the head, also
stimulates muscles and activates mastication. It has three different divisions: the ophthalmic branch,
the maxillary branch and the mandibular branch, which innervate the corresponding parts of the
face (Fig. 7).

Fig. 7 Trigeminal areas of innervation


(Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, 2003)

These three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2) and the mandibu-
lar nerve (V3) are converging in the trigeminal ganglion also called gasserian ganglion or semilunar
ganglion, located in the Meckels cave.

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The Gasserian ganglion (Fig. 8) is a group of nerve cells located outside the nervous system, the
large flattened sensory root ganglion of the trigeminal nerve that lies within the skull and behind the
orbit (19).

Fig. 8 Trigeminal ganglion and trigeminal nerve branches


(Mosbys Medical Dictionary 2009)

The ophthalmic nerve is the first branch of the trigeminal nerve and is also called nervus
ophthalmicus. Its major branches are the nasociliary, the frontal and the lacrimal nerves. It is a
sensory nerve including mostly general somatic afferent fibers that transmit sensory informations
from the eyeball, the skin of the upper face and anterior scalp, the upper part of the nasal cavity and
the air cells to the central nerve system (1).

The maxillary nerve is the second main branch of the nervus trigeminus. It is supplying the
innervation to certain parts of the face, the mucosa of the nose and the cheeks, it also innervates the
upper teeth and the gingiva. The major branches are the zygomatic nerve, the infraorbital and the
middle meningeal nerves (6).

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The mandibular nerve is the largest of the three branches of trigeminal nerve and it has sensory
and motor fibers. The major sensory branches are the auriculotemporal, the lingual and the inferior
alveolar nerves, which innervate the lower teeth, the skin of the lower lip, the gingiva and the lower
jaw. The major motoric branches which innervate the muscles of mastication are the lateral
pterygoid, the masseteric, the buccal and the deep temporal nerves (2).

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5. METHODS OF TREATMENT

5.1 Acupuncture

Acupuncture is a form of alternative medicine (35) based on needle insertion in specific points of
human body, called acupoints (25). This method of therapy is fundamental element of traditional
chinese medicine. Acupuncture is also widespread in Europe and most often used for pain relief
(36).

The name originates from Latin and literally means “inserting needles” – Latin „acus” – needle and
„punctura” – to needle/to stick needles.

A broader definition of acupuncture therefore includes various techniques of acupoints stimulation


(25), using:
x needles
x heating/cauterization
x acupressure
x electro-acupuncture
x photopuncture or laser therapy

The World Health Organization (WHO) recommends acupuncture as an effective treatment for over
forty medical problems, including allergies, respiratory conditions, and gastrointestinal disorders,
among others (7).

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5.2 Botulinum toxin or Botox

Botulinum toxin is one of seven type-specific, immunologically differentiable exotoxins (A, B, C1,
C2, D, E, F and G) produced by Clostridium botulinum. It causes paralysis in high doses, but is
used medically in small, localised doses to treat disorders associated with involuntary muscle
contraction and spasms (7).

All the serotypes interfere with neural transmission by blocking the release of acetylcholine, which
is the principal neurotransmitter at the neuromuscular junction. Intramuscular application of
botulinum toxin acts at the neuromuscular junction to provoke muscle paralysis by inhibiting the
release of acetylcholine from presynaptic motor neurons (26).

Botox was very popular in cosmetic industry due to its effect to prevent or dissolve muscle spasm.
However after the report of William J. Binder in 2000 that patients who had cosmetic injections
around the face reported relief from chronic headache (37), Botulinum toxin became a very
interesting way of struggling with myogenous chronic pain.

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5.3 Biofeedback

Biofeedback, or applied psychophysiological feedback, is a patient-guided treatment that permits an


individuum to control muscle tension, pain, body temperature, brain waves and other bodily
functions and processes through relaxation, visualization and other cognitive control techniques
(38).

The name biofeedback refers to the biological signals that are feedback, or returned, to the patient in
order for the patient to develop techniques to control them (38).

Biofeedback has been successfully used in treating different kinds of disorders and their symptoms,
including temporomandibular disorders (TMD), chronic pain, epilepsy, attention deficit
hyperactivity disorder (ADHD), migraine headaches, anxiety, depression and sleep disorders. Also
illnesses caused by stress is also a target for biofeedback therapy. Some types of headaches, eating
disorders, high blood pressure, bruxism, post-traumatic stress disorder, all these pathologies may be
treated successfully by showing and teaching patients the ability to relax and release both aspects
muscle and mental tension (38).

This method of therapy is provided with the help of a device and a computer program; some of the
devices can measure more than 20 parameters and the computer program can offer a wide range of
therapeutical approaches.

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5.4 Transcutaneous electrical nerve stimulation (TENS)

TENS is a non-invasive method of pain control, applied to relieve chronic or acute pain by the
application of electric impulses to the nerve endings. This method is done through electrodes placed
on the skin and attached to a stimulator by flexible wires. The generated electric impulses are
similar to those of the body but different enough to block transmission of pain signals to the brain
(1).

Different techniques are used to struggle with different methods of pain relief.
The three main ways are:
x convential TENS
x acupuncture-like TENS
x intense TENS

The method of TENS supports the interruption of pain impulses from the periphery to the central
nervous system by increasing the production of endorphins and improving blood supply to the
affected part. The increased circulation supports the healing process and helps reducing muscle
spasm (5).

Transcutaneous electrical nerve stimulation is a treatment method which patients can apply non-
ambulatory at home – low complexity of use and small size of devices easily operated by patients
themselves.

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6. PROBLEMS AND QUESTIONS

Low life quality becomes an issue for patients with chronic myofascial pain. They suffer from
sleeping disorder and chronic headache; their oral motorics are compromised; on top their ability to
concentrate and perform precise work is limited. As we can see in the scientific background of this
meta-analysis, numerous studies argued that painkillers and anti-inflammatory medication do not
cure the cause but reduce the symptoms with relatively high incidence of side effects.
There are two different therapy concepts which proved their good therapeutic effect and which can
be considered as standard for the treatment of myofascial pain: the use of intraoral appliances and
physiotherapy, each one alone or in combination (58), (59), (60), (61).
The aim of this work is, however, to focus on the alternative methods of treatment and to analyse
their outcome.
There are two central questions for our study:
Which alternative treatment methods of myofascial pain caused by hyperactive masticatory muscles
exist? And which ones show a better result in comparison?

7. AIM

Aim of this work is to search and compare treatments of myofascial pain due to hyperactive masti-
catory muscles and to find alternative ways to reduce pain avoiding risk of side effects.
The method to investigate our aim is the meta-analysis (random-effects model).

26
8. MATERIAL AND METHODS

8.1 Meta-analysis

Meta-analysis is a quantitative statistical analysis that combines the results of a number of related
scientific studies which has examined a particular question with goal to produce better results (27).
The introduction of the term meta-analysis is dated to the mid-seventies of the XXth century, where
the psychologist Gene V. Glass, first modern statistician, in his speech addressed to the American
Educational Research Association assigned to the method he developed the term of “meta-analysis”.
He defined meta-analysis as "analysis of analysis". This method uses a statistical approach to
combine the results from multiple studies in an effort to increase power over individual studies (28).

The meta-analysis has been used to give more insight into following topics:
x overall effectiveness of interventions (e.g., psychotherapy, outdoor education);
x relative impact of independent variables (e.g., the effect of different types of therapy);
x strength of relationship between variables.

Meta-analysis often combined with a systematic literature review (literature research) allows the
identification and categorisation of the relevant evidence.

Steps in the meta-analysis are:


1. Formulate research questions
2. Collection of relevant investigations
3. Coding and evaluation of investigations
4. Data analysis
5. Presentation and interpretation of results

Statistical test applied in this work is random- effect model.

27
8.2 Literature Research

Search is performed in the following databases:


x PubMed
x Ovid-Medlinne(r)
x EMBASE
x EBM Reviews- Cochrane Database of Systematic Reviews

Search strategy for PubMed:


1. alternative treatment or alternative therapy 422.769
2. #1 AND myofacial pain 797
3. #2 AND hyperactive masticatory muscles OR bruxism 14
4. #3 OR botulinum toxin OR botox 19.292
5. #4 OR biofeedback 31.815
6. #5 OR TENS 51.665
7. #6 OR acupuncture 75.493
8. #7 and stomatognathic system 2.068
9. #8 and masticatory muscles 495
10. limit to human 457
11. limit to adult 18 + year old 318
12. limit to english and german 303
13. limit to last 10 years 118

After thorough study and text reading of all the 118 scientific articles found via PubMed only 17
were chosen for statistical evaluation (Fig. 9). The detailed analysis of the reasons why scientific
articles were not included in our study is listed in table 1 (detailed analysis of scientific articles
found via PubMed) in the supplement.

28
Search strategy for Medline, Cochrane Database of Systematic Reviews, Embase via OVID:
1. Alternative methods or alternative therapy 11.811
2. Myofascial pain or orofacial pain or oromyofacial pain 4.552
3. Bruxism 2.365
4. Botulinum toxin or Botox 13.485
5. Acupuncture 25.777
6. TENS (transcutaneous electrical nerve stimulation) 4.320
7. Biofeedback 9.680
8. Masticatory muscles 8.571
9. #2 and #3 98
10. #1 or #4 or #5 or #6 or #7 or #9 63.831
11. #8 and #10 284
12. limit #11 to humans, adults 19+ and full text 12

After thorough study and text reading of all the 12 scientific articles found via OVID only 1 was
chosen for statistical evaluation (Fig. 9). The detailed analysis of the reasons why scientific articles
were not included in our study is listed in table 2 (detailed analysis of scientific articles found via
OVID) in the supplement.

8.3 Exclusion and Inclusion Criteria

Exclusion criteria:
x studies on children 0-18 years old
x studies without abstract
x studies which are not written in english and/or german
x studies which were done on animals
x reviews

Inclusion criteria:
x studies not older than 15 years
x studies which are done on human

29
Graphic presentation of literature research via PubMed and Ovid:

Databases research:
- PubMed: 118
- Medline, Cochrane Database of
Systematic Reviews and Embase
Via Ovid: 12

n=130

Unrelated studies: 110ated


studies:
n = 110

Full-text articles
assessed for eligibility:F
articln=20ed for eligibility:
n = 20

Full-text articles excluded:


no information about VAS
n=2xt articles excluded:
no information about VAS

Sudies included in meta-analysis:

n=18dies included in
meta-analysis:
n = 18

Fig. 9 Literature research via PubMed and Ovid

30
8.4 List of studies included in meta-analysis

1. Efficacy of botulinum toxin in treating myofascial pain and occlusal force characteristics of
masticatory muscles in bruxism (40).
2. Efficacy of botulinum toxin therapy in treatment of myofascial pain (41).
3. Short-term transcutaneous electrical nerv stimulation reduces pain and improves the masti-
catory muscle activity in temporomandibular disorder patients: a randomized controlled trial
(42).
4. Effectiveness of botulinum toxin type A for the treatment of chronic masticatory myofascial
pain: A case series (43).
5. Effects of myofascial trigger point dry needling in patients with sleep bruxism and tem-
poromandibular disorders: a prospective case series (44).
6. The efficiency of botulinum toxin type A for the treatment of masseter muscle pain in pa-
tients with temporomandibular joint dysfunction and tension-type headache (45)
7. Could acupuncture be useful in the treatment of temporomandibular dysfunction? (46).
8. Deep dry needling of trigger points located in the lateral pterygoid muscle: efficacy and
safety of treatment for management of myofascial pain and temporomandibular dysfunction
(47).
9. Changes in masticatory function after injection of botulinum toxin type A to masticatory
muscles (48).
10. Contingent electrical stimulation inhibits jaw muscle activity during sleep but not pain in-
tensity or masticatory muscle pressure pain threshold in self-reported bruxers: a pilot study
(49).
11. Use of the Grindcare device in the management of nocturnal bruxism: a pilot study (50).
12. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum
toxininjections and fascial manipulation technique (51).
13. Integration of rehabilitation and acupuncture in the treatment of a professional musician
with temporomandibular joint dysfunction (52).
14. EMG analysis after laser acupuncture in patients with temporomandibular dysfunction
(TMD). Implications for practice (53).
15. Laser acupuncture for myofascial pain of the masticatory muscles. A controlled pilot study
(54).

31
16. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles (55).
17. Immediate effects of microsystem acupuncture in patients with oromyofacial pain and cra-
niomandibular disorders (CMD): a double-blind, placebo-controlled trial (56).
18. Effect of conventional TENS on pain and electromypgraphic activity of masticatory muscles
in TDM patients (57).

32
8.5 Statistical analysis

The Visual Analogue Scale (VAS) is a popular tool for the measurement of pain. A variety of
statistical methods are applied for its analysis (29). Usually the Visual Analogue Scale is a
measurement instrument of pain intensity with a range from 0 till 10. So the patient can indicate the
demanded pain level. To analyse the different methods of treatment according their effectiveness
VAS was chosen as operationalization target criteria for our study.
The difficulty we faced was that in 3 articles from 18 not the universal VAS from 0 to 10 was used
but scales from 0 to 5 or from 0 to 4 or from 0 to 100. In order to be able to make the calculation all
3 examples were transformed on the range of values from 0 to 10.

To observe the change of the result between different methods of treatment 1 month was chosen as
time criteria.

Missing Data: in 2 studies focused on therapeutic effect of Botulinum toxin the detailed values of
results were missing and only graphically represented mean values and standard deviations can be
considered.

Building of homogeneous subgroups:


In order to keep the results comparable the following subgroups were formed:
x botulinum toxin group
x acupuncture group
x TENS group
x biofeedback group
x dry needling group
x control group

For continuous outcomes the standardized mean difference (SMD) was calculated and random-
effect model to calculate the results was used. All statistical analysis were performed with help of a
software program - the statistical software R version 3.5.2 Core Team 2018 (R Foundation for
Statistical Computing, Vienna, Austria).

33
9. DESCRIPTIVE RESULTS

9.1 Characteristics of the included studies

Table 4 shows the number of patients in examination and the number of patients in the control
group. Overall 496 participants were examined in the 18 studies included in this meta-analysis.
5 studies from 18 gave no information about the gender distribution of their study population, but in
the remaining 15 studies were enrolled 270 female and 82 male participants.

mean (sd)
study group n male female baseline after 1.month
Delaine Rodrigues (2004) TENS 19 19 5.75 (1.41) 1.32 (1.05)
I.Simma (2008) acupuncture 11 11 4.05 (3.4) 16.5 (33)
I.Simma (2008) control group (placebo) 12 12 4.1 (3.4) 30 (28.5)
Joannis Katsoulis (2009) laser acupuncture blind verum 7 1 6 6.43 (2.51) 28.43 (21.95)
Joannis Katsoulis (2009) blind placebo 4 0 4 6.83 (2.22) 22 (18.35)
Yoshi F. Shenn (2009) real acupuncture 16 7.4 (1.3) 5.8 (2.1)
Yoshi F. Shenn (2009) sham acupuncture 12 7.3 (0.8) 6.5 (2.8)
Hotta PT (2010) laser acupuncture 10 4.2 (0) 3.1 (NA)
Emma K Hunter (2011) acupuncture 1 1 7 (0) 4 (NA)
L.Guarda-Nardini (2012) Botulinum 15 11 4 7.3 (1.1) 5.2 (2.1)
L.Guarda-Nardini (2012) Fascial Manipulation 15 11 4 6 (2) 2.1 (1.4)
Park HU (2013) Botulinum in Masseter 20 8 12 9.05 (0.85) 6.92 (2.38)
Park HU (2013) Botulinum in Masseter and Temporalis 20 8 12 8.84 (0.96) 5.22 (2.17)
R.Needham (2013) biofeedback 19 10 9 6.2 (0) 4.85 (NA)
Cassia Maria Grillo (2014) control group (splint) 20 20 6.41 (1.89) 1.19 (1.59)
Cassia Maria Grillo (2014) acupuncture 20 20 5.96 (1.29) 1.09 (1.29)
Conti (2014) control group 8 1 7 5 (0.9) 4.1 (0.9)
Conti (2014) biofeedback 7 2 5 4.8 (1.6) 3.3 (1.6)
Luis/Miguel Gonzalez (2015) dry needling 24 5 19 5.65 (2.52) 1.92 (1.18)
Luis/Miguel Gonzalez (2015) control group 24 5 19 5.1 (3.88) 2.1 (5.37)
Luis/Miguel Gonzalez (2015) dry needling 24 5 19 6.75 (2.53) 2.15 (2.5)
Luis/Miguel Gonzalez (2015) control group 24 5 19 6.15 (7.02) 2.85 (6.6)
Blasco-Bonora (2016) dry needling 17 6 11 6.88 (1.04) 1.92 (1.89)
Ferreira (2016) control group 20 5.7 (3.1) 4.4 (3)
Ferreira (2016) TENS 20 5.7 (3.9) 3.4 (2.6)
Malgorzata Pihut (2016) Botulinum 42 4.86 (1.84) 1.21 (1.12)
Chaurand (2017) Botulinum 11 11 8.48 (0.57) 6.78 (0.57)
Chaurand (2017) conservative therapy 11 11 8.48 (0.57) 8.02 (0.57)
J.Baker (2017) Botulinum 19 4 15 8.1 (1.9) 2.7 (2.6)
Varsha A Jadhao (2017) Botulinum 8 7.6 (2.26) 3.55 (1.19)
Varsha A Jadhao (2017) control group (placebo) 8 8 (1.6) 3.85 (0.88)
Varsha A Jadhao (2017) control group (placebo) 8 8 (1.8) 3.8 (0.9)

Tab. 4 Characteristics of included studies (with transformed mean and standard deviation (sd))

34
Table 5 shows the results of SMD calculation for each study (except for 3 studies: Emma K Hunter
(2011), R. Needham (2013) and Hotta PT (2010)), so the improved performance can be represented.

study estimate SE CI
J.Baker (2017) - Botulinum 2.32 0.43 [1.48, 3.16]
L.Guarda-Nardini (2012) - Botulinum 1.22 0.40 [0.43, 2.01]
L.Guarda-Nardini (2012) - Fascial Manipulation 2.20 0.48 [1.27, 3.13]
Varsha A Jadhao (2017) - Botulinum 2.12 0.66 [0.83, 3.41]
Varsha A Jadhao (2017) - control group (placebo) 3.04 0.80 [1.48, 4.60]
Varsha A Jadhao (2017) - control group (placebo) 2.79 0.76 [1.31, 4.27]
Cassia Maria Grillo (2014) - acupuncture 3.70 0.54 [2.65, 4.76]
Cassia Maria Grillo (2014) - control group (splint) 2.93 0.47 [2.01, 3.85]
Yoshi F. Shenn (2009) - real acupuncture 0.89 0.37 [0.16, 1.62]
Yoshi F. Shenn (2009) - sham acupuncture 0.38 0.41 [-0.43, 1.18]
Emma K Hunter (2011) - acupuncture [, ]
Park HU (2013) - Botulinum in Masseter 1.17 0.34 [0.49, 1.84]
Park HU (2013) - Botulinum in Masseter and Temporalis 2.11 0.40 [1.33, 2.90]
Malgorzata Pihut (2016) - Botulinum 2.37 0.29 [1.81, 2.94]
I.Simma (2008) - acupuncture -0.51 0.43 [-1.36, 0.34]
I.Simma (2008) - control group (placebo) -1.23 0.45 [-2.12, -0.35]
R.Needham (2013) - biofeedback [, ]
Joannis Katsoulis (2009) - lasser accupuncture blind verum -1.32 0.61 [-2.51, -0.12]
Joannis Katsoulis (2009) - blind placebo -1.01 0.79 [-2.56, 0.54]
Luis/Miguel Gonzalez (2015) - dry needling 1.86 0.35 [1.18, 2.55]
Luis/Miguel Gonzalez (2015) - control group 0.63 0.30 [0.05, 1.21]
Luis/Miguel Gonzalez (2015) - dry needling 1.80 0.35 [1.12, 2.48]
Luis/Miguel Gonzalez (2015) - control group 0.48 0.29 [-0.10, 1.05]
Delaine Rodrigues (2004) - TENS 3.49 0.53 [2.44, 4.53]
Ferreira (2016) - TENS 0.68 0.33 [0.04, 1.32]
Ferreira (2016) - control group 0.42 0.32 [-0.21, 1.04]
Hotta PT (2010) - lasser accupuncture [, ]
Blasco-Bonora (2016) - Dry needling 3.17 0.53 [2.13, 4.22]
Conti (2014) - biofeedback 0.88 0.57 [-0.24, 1.99]
Conti (2014) - control group 0.95 0.54 [-0.10, 2.00]
Chaurand (2017) - conservative therapy 0.78 0.45 [-0.10, 1.65]
Chaurand (2017) - Botulinum 2.87 0.64 [1.61, 4.12]

Tab. 5 SMD calculation


(estimate-standard mean difference calculation / SE - standard error / CI - confidence interval)

Table 6 demonstrates the results of SMD calculation for the subgroups and shows the highest scores
in the TENS subgroup and in the botulinum toxin subgroup.

subgroups k estimate SE CI Z p-value


Botulinum 7 1.96 0.24 [1.49, 2.44] 8.14 .000
Control 12 0.98 0.33 [0.32, 1.63] 2.93 .003
TENS 2 2.05 1.40 [-0.70, 4.80] 1.46 .144
Acupuncture 4 0.70 0.97 [-1.21, 2.60] 0.72 .474
Biofeedback 1 0.88 0.57 [-0.24, 1.99] 1.54 .123
Dry needling 3 2.18 0.37 [1.44, 2.91] 5.82 .000

Tab. 6 SMD results for subgroups


(k - amount of studies included in subgroup / estimate-standard mean difference calculation /
SE - standard error / CI - confidence interval / Z - Z-test/ p-value - probability value)

35
9.2 Quantitative description of the subgroups
Detalied list of the results according to the subgroups (Fig.10)

x Botulinum toxin subgroup:


7 studies were summarized with a number of participants from 8 to 42. In total, 135 patients were
included in the calculation. Average standardized difference is 1.96 [1.49; 2.44] on the VAS scale
with heterogeneity of 56%. This positive effect of botulinum was confirmed by z-statistics
(z = 8.1, p <.0001).
x TENS subgroup:
2 studies were summarized and in total, 39 participants were included in the calculation. Average
standardized difference is 2.05 [-0.70; 4,80] on the VAS scale with heterogeneity of 95%. This
positive effect of TENS was confirmed by z-statistics (z =1.46, p <.144).
x Acupuncture subgroup:
4 studies were summarized with a number of participants from 1 to 20. In total, 65 patients were
included in the calculation. Average standardized difference is 0.70 [-1.21; 2.60] on the VAS scale
with heterogeneity of 94%. This positive effect of acupuncture was confirmed by z-statistics
(z = 0.72, p <.474).
x Biofeedback subgroup:
1 study was summarized in total and 7 participants were included in the calculation. Average
standardized difference is 0.88 [-0.24; 1.99] on the VAS scale with no applicable heterogeneity
because of amount of studies. This positive effect of biofeedback was not confirmed by z-statistics.
x Dry needling subgroup:
3 studies were summarized with a number of participants from 17 to 24. In total, 65 patients were
included in the calculation. Average standardized difference is 2.18 [-1.44; 2.92] on the VAS scale
with heterogeneity of 63%. This positive effect of dry needling was confirmed by z-statistics
(z = 5.82, p <.000).
x Control subgroup:
12 studies were summarized with a number of participants from 4 to 24. In total, 166 patients were
included in the calculation. Average standardized difference is 0.98 [0.32; 1.63] on the VAS scale
with heterogeneity of 85%. This positive effect of control group was confirmed by z-statistics
(z = 2,93, p <.003).

36
Fig. 10 Forest Plot

37
10. DISCUSSION

Numerous studies have investigated the topic of myofascial pain caused by hyperactive masticatory
muscles. Several treatment methods - differing painkillers - are offered in practice including ad-
vanced laser acupuncture (31) and Botox (32). Intraoral appliances and physiotherapy, stand-alone
or in combination, can be considered as “golden” standard in the treatment of myofascial pain (58),
(59), (60), (61). In this work we were focused on searching alternative methods or alternative treat-
ments and on analysis of their outcome. Further, we examined most popular alternative ways of
myofascial pain therapy. General limitation of our study is a low number of researched studies fit-
ting defined criteria. As a consequence there were only few studies, which we were able to compare.

Aim of this work was to search and compare other possible pain treatments and finding alternative
ways to reduce pain avoiding risk of side effects. Searched databases contained 5 different therapy
methods other than standardways of dealing with hyperactive masticatory muscles: botulinum toxin,
acupuncture, dry needling, TENS and biofeedback. It is important to highlight that not all included
studies had results of follow up longer than one month. In order to standardise 1-month period was
chosen as a time criteria and in order to set comparison standard of all included studies in our meta-
analysis. The meta-analysis showed the positive effect in the subgroup of treatment with Botulinum
toxin; positive effect of the other subgroups can be discussed with limitation due to small study
sample.

Despite scrupulous research of all relevant literature databases only 18 studies had quantitative
description of pain before and after the applied treatment, which is another limitation to our study.
In 3 out of 18 criteria matching studies it was not possible to measure the effect size due to
impossibility to establish standard deviation of studied samples. The result of meta-analysis showed
the positive effect in the subgroup of treatment with botulinum toxin (average standardised
difference 1.96). Even though the subgroup of TENS showed also a highly positive effect (average
standardised difference 2.05) it cannot be used for comparison on the basis of an insufficiently large
sample of studies (just 2) and participants therein.
The amount of studies we found for the subgroup of Transcutaneous Electrical Nerve Stimulation
(TENS) can also show how restricted the use of this method of therapy is in dental practice. For the
subgroup of dry needling (average standardised difference 2.18) we reached the same conclusion as

38
for subgroup TENS: the amount of study shows that this method is not popular in dealing with
temporomandibular disorders despite demonstrated highly positive results and a high potential of
this method. The subgroup of acupuncture despite of recognised healing effect on muscle spasm
treatment in the alternative medicine shows lower result – average standardized difference 0.70 – in
comparison with Botulinum toxin. That result may be due to short time criteria we selected to
compare studies – 1 month. Time of action for Botulinum toxin is approximately 4-5 days (33) in
contrast to time of action for acupuncture, which may be immediate but mostly accumulates after
couple of sessions (34).

There are studies that show no effect but also studies with positive and negative effects in our meta-
analysis. Most of them were showing a slight improvement after applying therapy as shown in
figure 10 (Forest Plot). Also control group, in general, demonstrated a positive effect, which,
however, cannot be clearly measured in the individual studies due to the high variability of results.

A large number of investigations did not match our criteria on the basis of no available information
about pain syndrome improvement or non-measurable information about pain. But out of 18 studies
included in meta-analysis 3 contained different VAS scales to evaluate level of pain before and after
treatment (i.e. VAS scale 0-4 versus VAS scale 0-5), which we had to standardise in order to
compare. An example of linear VAS transformation is in Supplement of this study. Small inaccuracy
in the calculation is due to linear transformation of the VAS scores.

Our study shows that there is a big potential in application of alternative ways to treat
temporomandibular disorders. Even though a large number of studies did not completely match our
criteria (24 studies) on basis of no available information about quantitative description of pain level
before and after therapy, the topic of investigation in them did research alternative ways of
treatment TMD on basis of electromyography comparison.

Botulinum toxin treatment demonstrates a good result in our study. It opens up a subject for further
comparison: is the therapeutic effect of Botulinum toxin treatment comparable with the therapeutic
effect of conservative treatment-methods? To answer this question additional examinations are
needed.

39
11. CONCLUSION

Botulinum toxin method proved to help patients with myofascial or orofacial pain. This method
increasingly used over the last 18 years may become a dominating alternative method for pain relief.
This may be especially true if the conservative way of treatment does not significantly improve pain
scores in helping to stabilise patients.

The result of our study showed the positive effect in coping with pain in the group of Botulinum
toxin treatment, but due to limited amount of studies matching our criteria the topic of our study
requires further investigation.

40
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Bruxism: A Literature Review. J Indian Prosthodont Soc. 2010 Sep; 10(3): 141–148.
Published: 22 Jan 2011. doi: 10.1007/s13191-011-0041-5.
40. Jadhao VA, Lokhande N, Habbu SG, Sewane S, Dongare S, Goyal N. Efficacy of botulinum
toxin in treating myofascial pain and occlusal force characteristics of masticatory muscles
in bruxism. Indian J Dent Res. 2017 Sep-Oct;28(5):493-497. doi:
10.4103/ijdr.IJDR_125_17.
41. Chaurand J, Pacheco-Ruíz L, Orozco-Saldívar H, López-Valdés J. Efficacy of botulinum
toxin therapy in treatment of myofascial pain. Journal Oral Science. 2017; 59(3):351-356.
doi: 10.2334/josnusd.16-0614.
42. Ferreira AP, Costa DR, Oliveira AI, Carvalho EA, Conti PC5 Costa YM, Bonjardim LR.
Short-term transcutaneous electrical nerve stimulation reduces pain and improves the
masticatory muscle activity in temporomandibular disorder patients: a randomized
controlled trial. Journal of Applied Oral Science. 2017 Mar-Apr;25(2):112-120. doi:
10.1590/1678-77572016-0173.
43. Baker JS, Nolan PJ. Effectiveness of botulinum toxin type A for the treatment of chronic
masticatory myofascial pain: A case series. Journal of the American Dental Association.
2017 Jan;148(1):33-39. doi: 10.1016/j.adaj.2016.09.013. Epub 2016 Oct 27.
44. Blasco-Bonora PM, Martín-Pintado-Zugasti A. Effects of myofascial trigger point dry
needling in patients with sleep bruxism and temporomandibular disorders: a prospective
43
case series. Acupuncture in Medicine. 2017 Mar;35(1):69-74. doi: 10.1136/acupmed-2016-
011102. Published: 3 Oct 2016.
45. Pihut M, Ferendiuk E, Szewczyk M, Kasprzyk K, Wieckiewicz M. The efficiency of
botulinum toxin type A for the treatment of masseter muscle pain in patients with
temporomandibular joint dysfunction and tension-type headache. Journal of Headache and
Pain. 2016;17:29. doi: 10.1186/s10194-016-0621-1. Published: 24 Mar 2016.
46. Grillo CM, Canales Gde L, Wada RS, Alves MC, Barbosa CM, Berzin F, de Sousa Mda L.
Could Acupuncture Be Useful in the Treatment of Temporomandibular Dysfunction? Journal
of Acupuncture and Meridian Studies. 2015 Aug;8(4):192-9.
doi:10.1016/j.jams.2014.12.001. Published 8 Dec 2014.
47. Luis-Miguel Gonzalez-Perez, Pedro Infante-Cossio, Mercedes Granados-Nunez, Francisco-
Javier Urresti-Lopez, Ricardo Lopez-Martos, and Pablo Ruiz-Canela-Mendez. Deep dry
needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of
treatment for management of myofascial pain and temporomandibular dysfunction.
Med Oral Patol Oral Cir Bucal. 2015 May; 20(3): e326–e333.
Published online 7 Feb 2015. doi: 10.4317/medoral.20384
48. H. U. Park, B. I. Kim, S. M. Kang, S. T. Kim, J. H. Choi, H. J. Ahn. Changes in masticatory
function after injection of botulinum toxin type A to masticatory muscles. Published: 08
November 2013. https://doi.org/10.1111/joor.12111
49. Conti PC, Stuginski-Barbosa J, Bonjardim LR, Soares S, Svensson P. Contingent electrical
stimulation inhibits jaw muscle activity during sleep but not pain intensity or
masticatory muscle pressure pain threshold in self-reported bruxers: a pilot study. Oral
Surgery, Oral Medicine, Oral Pathology and Oral Radiology. Published: Jan 2014;117(1):45-
52. doi: 10.1016/j.oooo.2013.08.015.
50. Needham R1, Davies SJ. Use of the Grindcare device in the management of nocturnal
bruxism: a pilot study. British Dental Journal. Published: Jul 2013; 215(1):E1. doi:
10.1038/sj.bdj.2013.653.
51. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw
muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial
manipulation technique. The Journal of Craniomandibular Practice. 2012 Apr; 30(2):95-102.
52. Hunter EK. Integration of rehabilitation and acupuncture in the treatment of a professional
musician with temporomandibular joint dysfunction. Acupuncture in Medicine: Journal of
the British Medical Acupuncure Society. 2011 Dec; 29(4):298-301. doi:
10.1136/aim.2010.003889. Epub: 16 Jun 2011.

44
53. Hotta PT, Hotta TH, Bataglion C, Bataglion SA, de Souza Coronatto EA, Siéssere S, Regalo
SCH. EMG analysis after laser acupuncture in patients with temporomandibular
dysfunction (TMD). Implications for practice. Complementary Therapies in Clinical Practice.
2010 Aug;16(3):158-160. doi: 10.1016/j.ctcp.2010.01.002. Epub 2010 Jan 27.
54. Katsoulis J1, 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 Monatsschrift Zahnmedizin. 2010;120(3):213-25.
55. Shen YF, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for
myofascial pain of the jaw muscles. Journa of Orofacial Pain. 2009 Fall;23(4):353-9.
56. I. Simma J. M. Gleditsch L. Simma E. Piehslinger. Immediate effects of microsystem
acupuncture in patients with oromyofacial pain and craniomandibular disorders (CMD): a
double-blind, placebo-controlled trial. Published: 30 October 2009 British Dental Journal
volume 207, E26.
57. Delaine Rodrigues, Anamaria Oliveira Siriani, Fausto Bérzin. Effect of conventional TENS
on pain and electromyographic activity of masticatory muscles in TMD. Brazilian Oral
Research 2004;18(4):290-5.
58. Qvintus V, Suominen AL, Huttunen J, et al. Efficacy of stabilisation splint treatment on
facial pain - 1-year follow-up. Journal of oral rehabilitation. 2015;42:439-46.
59. Dao TT, Lavigne GJ, Charbonneau A, et al. The efficacy of oral splints in the treatment of
myofascial pain of the jaw muscles: a controlled clinical trial. Pain. 1994;56:85-94.
60. Martins WR, Blasczyk JC, Aparecida Furlan de Oliveira M, et al. Efficacy of
musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A
systematic review with meta-analysis. Manual therapy. 2016;21:10-7.
61. Calixtre LB, Moreira RF, Franchini GH, et al. Manual therapy for the management of pain
and limited range of motion in subjects with signs and symptoms of temporomandibular
disorder: a systematic review of randomised controlled trials. Journal of oral
rehabilitation. 2015;42:847-61.

45
13. SUPPLEMENTS

13.1 List of abbreviations

1. RCTs Randomised Controlled Trials


2. WHO World Health Organisation
3. EACD European Academy of Craniomandibular Disorders
4. TMD Temporomandibular Disorders
5. MMP Masticatory Muscle Pain
6. CRCHUM University of Montreal Hospital Research Center
7. NSAIDs Non-steroidal Anti-inflammatory Drugs
8. ADHD Attention Deficit Hyperactivity Disorder
9. TMJ Temporomandibular Joint
10. TENS Transcutaneous Electrical Nerve Stimulation
11. VAS Visual Analogue Scale
12. SMD Standardised Mean Diơerence
13. estimate Standard Mean Difference calculation
14. SE Standard Error
15. CI Confidence Interval
16. Z Z-Test
17. p-value Probability Value
18. k Amount of Studies Included in Subgroup

46
13.2 List of figures

Fig. 1 Muscle type tissue


Fig. 2 Tendon and muscle fiber structure
Fig. 3 Phases of muscle tension
Fig. 4 Masseter muscle and temporal muscle
Fig. 5 Medial and lateral pterygoids muscles
Fig. 6. The trigeminothalamic pathway
Fig. 7 Trigeminal areas of innervation
Fig. 8 Trigeminal ganglion and trigeminal nerve branches
Fig. 9 Literature research via PubMed and Ovid
Fig. 10 Forest Plot

47
13.3 List of tables

Table 1 detailed analysis of scientific articles found via PubMed


Table 2 detailed analysis of scientific articles found via Ovid
Table 3 systematic review of included studies in meta-analysis (Excel).
Table 4 characteristics of included studies (with transformed mean and standard deviation)
Table 5 SMD calculation
Table 6 SMD result for subgroups

48
13.4 Tables

Table 1 (The detailed analysis of scientific articles found via PubMed)

Name of the researched articles (PubMed List) inc. not reason n°


inc.
1. One-Year Relapse of Mandibular Distraction for The object of study
Hemifacial Microsomia Using Masseteric Botulinum - is postoperative
Toxin Type A Injections. pain.

2. Complications of botulinum toxin injection for mas- The object of study


seter hypertrophy: Incidence rate from 2036 treatments - is the masseter
and summary of hypertrophy.
causes and preventions.

3. A new target for the treatment of trigeminal neuralgia The object of study
with - is the masticatory
botulinum toxin type A. activity.

4.Effectiveness, Safety, and Predictors of Response to No information


Botulinum Toxin Type A in Refractory Masticatory - about VAS.
Myalgia: A Retrospective Study.

5. Efficacy of botulinum toxin in treating myofascial


pain and occlusal force characteristics of masticatory + 1
muscles in bruxism.

6. Efficacy of botulinum toxin therapy in treatment of


myofascial pain. + 2

7. Evaluation of articular disc loading in the temporo- The object of study


mandibular joints after prosthetic and pharmacological - is the masticatory
treatment in model studies. activity.

8. Self-Rated Communication-Related Quality of Life The object of study


of Individuals With Oromandibular Dystonia Receiving - is the facial area
Botulinum Toxin Injections. but not the mastica-
tory muscles.
9. First case of anaphylaxis after botulinum toxin type - The object of study
A injection. is the facial area
but not the mastica-
tory muscles.
49
10. Acute visual loss after botulinum toxin A injection The object of study
in the masseter muscle. - is the masseter
hypertrophy.
11. Short-term transcutaneous electrical nerve stimula-
tion reduces pain and improves the masticatory muscle + 3
activity in temporomandibular disorder patients: a ran-
domized controlled trial.

12. Effectiveness of botulinum toxin type A for the


treatment of chronic masticatory myofascial pain: A + 4
case series.

13. Mandibular Rim Trilogy with Botulinum Toxin The object of study
Injection: Reduction, Projection, and Lift. - is the masseter
hypertrophy.
14. Ultrastructural changes in human masseter muscles The object of study is
after botulinum neurotoxin a injection. - structural change in
skeletal muscle.
15. High-density EMG Reveals Novel Evidence of Al- The object of study
tered Masseter Muscle Activity During Symmetrical - is the facial area
and Asymmetrical Bilateral Jaw Clenching Tasks in but not the mastica-
People With Chronic Nonspecific Neck Pain. tory muscles.

16. The Anatomical Basis of Paradoxical Masseteric The object of study


Bulging after Botulinum Neurotoxin Type A Injection. - is the location of
anatomical points
for Botulinum tox-
in injections.
17. Surgical intervention for oromandibular dystonia- The object of study
related limited mouth opening: Long-term follow-up. - is the dystonia re-
lated masticatory
pain.
18. The efficacy of two formulations of botulinum toxin The object of study
type A for masseter reduction: a split-face comparison - is the masseter
study. hypertrophy.

19. Achieving Ideal Lower Face Aesthetic Contours: The object of study
Combination of Tridimensional Fat Grafting to the Chin - is the masseter
with Masseter Botulinum Toxin Injection. hypertrophy.

20. Effects of myofascial trigger point dry needling in


patients with sleep bruxism and temporomandibular + 5
disorders: a prospective case series.

50
21. Anatomical recommendations for safe botulinum The object of study
toxin injection into temporalis muscle: a simplified re- - the location of ana-
producible approach. tomical points for
Botulinum toxin
injections.
22. Effective Botulinum Toxin Injection Guide for The object of study
Treatment of Temporal Headache. - the location of ana-
tomical points for
Botulinum toxin
injections.
23. Diverse Effects of 3 Selective Serotonin Reuptake The object of study
Inhibitors on Bruxism in a Depressive Patient Treated - is the masticatory
With Botox Therapy: A Case Report. activity.

24. Optimal duration of ultra low frequency- The object of study


transcutaneous electrical nerve stimulation (ULF- - is the masticatory
TENS) therapy for muscular relaxation in neuromuscu- activity.
lar occlusion: A preliminary clinical study

25. The efficiency of botulinum toxin type A for the


treatment of masseter muscle pain in patients with tem- + 6
poromandibular joint dysfunction and tension-type
headache.

26. Recurrent parotid swelling secondary to masseter The object of study


muscle hypertrophy: a multidisciplinary diagnostic and - ist he masseter
therapeutic approach. hypertrophy.

27. Bilateral hypertrophy of masseteric and temporalis The object of study


muscles, our fifteen patients and review of literature. - ist he masseter
hypertrophy.
28. Comparison of clinical marking and ultrasound- The object of study
guided injection of Botulinum type A toxin into the - is the Botulinum
masseter muscles for treating bruxism and its cosmetic toxin and its cos-
effects. metic effect.

29.Short-Term Sensorimotor Effects of Experimental The object of study


Occlusal Interferences on the Wake-Time Masseter - is the occlusal in-
Muscle Activity of Females with Masticatory Muscle terference.
Pain.

30. A Pilot Study on the Treatment of Posterior Cheek The object of study
Enlargement in HIV+ Patients With Botulinum Toxin - ist he masseter
A. hypertrophy.
51
31. Management of oromandibular dystonia on a chorea The object of study
acanthocytosis: a brief review of the literature and a - is the dystonia re-
clinical case. lated masticatory
problem.
32. Effect of a repeated jaw motor task on masseter The object of study
muscle performance. - is the masticatory
activity.
33. Sleep bruxism possibly triggered by multiple sclero- The object of study
sis attacks and treated successfully with botulinum - is the bruxism but
toxin: Report of three cases. not the mascatory
muscles.
34. Ensuring Restorative Success With Bruxism Test- - No full text of the
ing. study.

35. Could Acupuncture Be Useful in the Treatment of


Temporomandibular Dysfunction? + 7

36. Management of sleep bruxism in adults: a qualita- The object of study


tive - is the bruxism but
systematic literature review. not the masticatory
muscles.
37. Rehabilitation and functional recovery after masse- The object of study
teric-facial nerve anastomosis. - is the facial area
but not the mastica-
tory muscles.
38. Effect of a second injection of botulinum toxin on The object of study
lower facial contouring, as evaluated using 3- - is the Botulinum
dimensional laser scanning. toxin and ist cos-
metic effect.
39. The correlation between surface electromyography The object of study
and bite force of mastication muscles in Asian young - is the masticatory
adults. activity.

40. Deep dry needling of trigger points located in the


lateral pterygoid muscle: Efficacy and safety of treat- + 8
ment for management of myofascial pain and temporo-
mandibular dysfunction.

41. The risorius muscle: anatomic considerations with The object of study
reference to botulinum neurotoxin injection for masse- - is masseter hyper-
teric hypertrophy. trophy.

52
42. Lower facial remodeling with botulinum toxin type The object of study
A for the treatment of masseter hypertrophy. - is masseter hyper-
trophy.
43. Use of onabotulinumtoxinA in post-traumatic oro- The object of study
mandibular dystonia. - is the dystonia re-
lated masticatory
problem.
44. Electromyogram biofeedback training for daytime The object of study
clenching and its effect on sleep bruxism. - is the masticatory
activity.
45. The topographic anatomy of the masseteric nerve: A The object of study
cadaveric study with an emphasis on the effective zone - is choice of ana-
of botulinum toxin A injections in masseter. tomical points for
Botulinum toxin
injections.
46. Botulinum toxin injection for bruxism associated The object of study
with brain injury: case report. - is bruxism but not
the masticatory
muscles.
47. Classification of masseter hypertrophy for tailored The object of study
botulinum toxin type A treatment. - is the masseter
hypertrophy.
48. Effect of tongue position on masseter and tempora- The object of study
lis electromyographic activity during swallowing and - is the masticatory
maximal voluntary clenching: a cross-sectional study. activity.
49. Thirty-year follow-up of a TMD case treated based The object of study
on the neuromuscular concept. - is the masticatory
activity.
50. Osteopenic consequences of botulinum toxin injec- The object of study
tions in the masticatory muscles: a pilot study. - is the masticatory
activity.
51. Surface raw electromyography has a moderate dis- The object of study
criminatory capacity for differentiating between healthy - is the masticatory
individuals and those with TMD: a diagnostic study. activity.

52. Effects of botulinum toxin on jaw motor events dur- The object of study
ing sleep in sleep bruxism patients: a polysomnographic - is the masticatory
evaluation. activity.

53. The use of botulinum toxin in the treatment of the The object of study
consequences of bruxism on cervical spine musculature. - are spinal muscles.

53
54. Repeated clenching causes plasticity in corticomotor The object of study
control of jaw muscles. - is the masticatory
activity.
55. Changes in masticatory function after injection of
botulinum toxin type A to masticatory muscles. + 9

56. Contingent electrical stimulation inhibits jaw mus-


cle activity during sleep but not pain intensity or masti- + 10
catory muscle pressure pain threshold in self-reported
bruxers: a pilot study.

57. Oromandibular dystonia: long-term management The object of study


with botulinum toxin. - is the dystonia re-
lated masticatory
problem.
58. Painful unilateral temporalis muscle enlargement: The object of study
reactive masticatory muscle hypertrophy. - is masseter hyper-
trophy.
59. Treatment of posterior cheek enlargement in human The object of study
immunodeficiency virus-positive individuals with botu- - is masseter hyper-
linum toxin A. trophy.

60. The effect of tongue position and resulting vertical The object of study
dimension on masticatory muscle activity. A cross- - is the masticatory
sectional study. activity.

61. Use of the Grindcare® device in the management of


nocturnal bruxism: a pilot study. + 11

62. RimabotulinumtoxinB versus OnabotulinumtoxinA The object of study


in the treatment of masseter hypertrophy: a 24-week - is the masseter
double-blind randomized split-face study. hypertrophy.

63. Comparison between sensory and motor transcuta- The object of study
neous electrical nervous stimulation on electromyo- - is the masticatory
graphic and kinesiographic activity of patients with activity.
temporomandibular disorder: a controlled clinical trial.

64. Botulinum toxin injection for management of tem- The object of study
poromandibular joint clicking. - is the TMJ.

54
65. Efficacy and safety of incobotulinum toxin A in The object of study
periocular rhytides and masseteric hypertrophy: side- - is the masseter
by-side comparison with onabotulinum toxin A. hypertrophy.

66. Influence of visual feedback on force-EMG curves The object of study


from spinally innervated versus trigeminally innervated - are spinal muscles.
muscles.

67. Somatosensory input and oromandibular dystonia. - The object of study


is the dystonia re-
lated masticatory
problem.
68. Botulinum injection for the management of myofas- No information
cial pain in the masticatory muscles. A prospective out- - about VAS.
come study.

69. Myofascial pain of the jaw muscles: comparison of


short-term effectiveness of botulinum toxininjections + 12
and fascial manipulation technique.

70. Oral sensorimotor integration in adults who stutter. - The object of study
is the facial area
but not the mastica-
tory muscles.
71. Hemimasticatory spasm treated with microvascular The object of study
decompression of the trigeminal nerve. - is the masticatory
muscles activity.
72. Forces, movements and reflexes produced by push- The object of study
ing human teeth. - is the masticatory
muscles activity.
73. Paradoxical bulging of muscle after injection of The object of study
botulinum neurotoxin type A into hypertrophied masse- - is the masseter
ter muscle. hypertrophy.

74. Effects of transcutaneous electrical nervous stimula- The object of study


tion on electromyographic and kinesiographic activity - is the masticatory
of patients with temporomandibular disorders: a place- activity.
bo-controlled study.

75. Obstructive parotitis secondary to an acute masse- - The object of study


teric bend. is the masseter
hypertrophy.

55
76. The influence of auditory and visual information on The object of study
the neuromuscular control of chewing crispy food. - is the facial area
but not the maste-
catory muscles.
77. Chronic orofacial pain (OFP) of different origin. A - The object of study
case report. is masseter hyper-
trophy.
78. Myositis ossificans traumatica of the temporalis The object of study
muscle: a case report and diagnostic considerations. - is posttrauma.

79. Abobotulinum toxin A and onabotulinum toxin A The object of study


for masseteric hypertrophy: a split-face study in 25 Ko- - is the masseter
rean patients. hypertrophy.

80. Integration of rehabilitation and acupuncture in the


treatment of a professional musician with temporoman- + 13
dibular joint dysfunction.

81. Phosphatidylcholine/deoxycholate lipolysis and The object of study


hyaluronic acid augmentation to enhance nonsurgical - is the masseter
lower facial contouring using botulinum toxin type A. hypertrophy.

82. Assessment of sleep parameters during contingent The object of study


electrical stimulation in subjects with jaw muscle activi- - is the masticatory
ty during sleep: a polysomnographic study. activity.

83. Incidental aggravation of venous malformation after The object of study


botulinum toxin type a injection for reducing benign - is masseter hyper-
masseteric hypertrophy. trophy.

84. Effect of botulinum toxin type A injection on lower The object of study
facial contouring evaluated using a three-dimensional - is the Botulinum
laser scan. toxin and its cos-
metic effect.
85. Masseteric hypertrophy: considerations regarding The object of study
treatment planning decisions and introduction of a novel - is the masseter
surgical technique. hypertrophy.

86. Effect of electromyogram biofeedback on daytime The object of study


clenching behavior in subjects with masticatory muscle - is the masticatory
pain. activity.

56
87. Mandible changes evaluated by computed tomogra- The object of study
phy following Botulinum Toxin A injections in square- - is the Botulinum
faced patients. toxin and its cos-
metic effect.
88. Surgical management of persistent oromandibular The object of study
dystonia of the temporalis muscle. - is the dystonia re-
lated masticatory
problem.

89. Effect of Botulinum Toxin on Pressure Pain Thre- The object of study
shold and EMG Power Spectrum of Masseter Muscle - is the masticatory
During Sustained Fatiguing Contraction activity.

90. Lateral pterygoid muscle dystonia. A new technique The object of study
for treatment with botulinum toxin guided by electro- - is the dystonia re-
myography and arthroscopy. lated masticatory
problem.
91. EMG analysis after laser acupuncture in patients
with temporomandibular dysfunction (TMD). Implica- + 14
tions for practice.

92. Intraoperative muscle electrical stimulation for ac- The object of study
curate positioning of the temporalis muscle tendon dur- - is facial paralysis
ing dynamic, one-stage lengthening temporalis myop- related masticatory
lasty for facial and lip reanimation. changes.

93. Botulinum toxin type A for the treatment of hyper- The object of study
trophy of the masseter muscle. - is the masseter
hypertrophy.
94. Intramuscular nerve distribution of the masseter The object of study
muscle as a basis for botulinum toxin injection. - is the masseter
hypertrophy.
95. Persistent idiopathic facial pain: multidisciplinary The object of study
approach and assumption of comorbidity. - is idiopathic facial
pain.
96. Effects of myogenous facial pain on muscle activity The object of study
of head and neck - is the masticatory
muscles activity.
97. Effectiveness of transcutaneous electrical nerve sti- The object of study
mulation and microcurrent electrical nervestimulation in - is the masticatory
bruxism associated with masticatory muscle pain - a activity.
comparative study.

57
98. Topography of the masseter muscle in relation to The object of study
treatment with botulinum toxin type A. - are the anatomical
points for Botuli-
num toxin injec-
tions.
99. Laser acupuncture for myofascial pain of the masti-
catory muscles. A controlled pilot study. + 15

100. Neurogenic temporomandibular joint dislocation The object of study


treated with botulinum toxin: report of 4 cases. - is the TMJ.

101. Botox facial slimming/facial sculpting: the role of The object of study
botulinum toxin-A in the treatment of hypertrophic - is the masseter
masseteric muscle and parotid enlargement to narrow hypertrophy.
the lower facial width.

102. Treatment of masseteric hypertrophy with botuli- The object of study


num toxin: a report of two cases. - is the masseter
hypertrophy.
103. Evaluation and selecting indications for the treat- The object of study
ment of improving facial morphology by masseteric - is the Botulinum
injection of botulinum toxin type A. toxin and its cos-
metic effect.
104. Monitoring masseter muscle evoked responses The object of study
enables faster tracheal intubation. - is intubation.

105. Acupuncture and temporomandibular disorders: a The object of study


3-month follow-up EMG study. - is the masticatory
activity.
106. Botulinum toxin type A for the treatment of sia- The object of study
lorrhoea in amyotrophic lateral sclerosis: a clinical and - is the facial area
neurophysiological study. but not the mastica-
tory muscles.
107. Randomized clinical trial of acupuncture for myo-
fascial pain of the jaw muscles. + 16

108. Immediate effects of microsystem acupuncture in


patients with oromyofacial pain and craniomandibular + 17
disorders (CMD): a double-blind, placebo-controlled
trial.

58
109. Oromandibular dystonia and hormonal factors: The object of study
twelve years follow-up of a case report. - is the dystonia re-
lated masticatory
problem.
110. Bilateral temporalis hypertrophy. - The object of study
is the masseter
hypertrophy.
111. Muscle weakness after repeated injection of botu- The object of study
linum toxin type A evaluated according to bite force - is the masseter
measurement of human masseter muscle. hypertrophy.

112. Unilateral masseter muscle hypertrophy: morpho- The object of study


functional analysis of the relapse after treatment with - is the masseter
botulinum toxin. hypertrophy.

113. Long-term efficacy of botulinum toxin type A for The object of study
the treatment of habitual dislocation of the temporo- - is the TMJ.
mandibular joint.

114. Botulinum toxin B increases mouth opening in The object of study


patients with spastic trismus. - is stroke and trau-
matic related mas-
ticatory changes.
115. Effect of botulinum toxin type A injection into The object of study
human masseter muscle on stimulated parotid saliva - is effect of Botuli-
flow rate. num toxin on flow
of saliva.
116. Mandibular angle ostectomy for Chinese women: The object of study
approaches and extent determined by cephalometric - is the aesthetic sur-
analysis. gery.

117. Masseter muscle reduction procedure with radio- The object of stu-
frequency coagulation. - dyis the masseter
hypertrophy.
118. Management of dystonia of the lateral pterygoid The object of study
muscle with botulinum toxin A. - is the dystonia re-
lated masticatory
problem.

59
Table 2 (The detailed analysis of scientific articles found via Ovid)

Name of the researched articles (Ovid list) inc. not reason n°


inc.
1. A pilot study on the Treatment of posterior cheel The object of study
enlargement in HIV + Patients with B´botulinum toxin A. - is muscle
hypertrophy.
2. Prolonging the duration of masseter muscle reduction The object of study
by adjusting the masticatory movements after the - is muscle
treatment of masseter muscle hypertrophy with hypertrophy.
botulinum toxin type A injection.

3. Treatment of posterior cheek enlargement in human The object of study


immune-deficiency virus- positive induviduals with - is muscle
botulinum toxin A. hypertrophy.

4. Botulinum toxin type A in the healing of ulcer The object of study


following oro-mandibular dyskinesia in the a patient in a - is dyskinesia
vegetative state. related masticatory
problem.
5. Botulinum toxin in closed treatment of madibular The object of study
condylar fracture. - is fracture related
masticatory
muscles.
6. Successful treatment of postpolio tinnitus with type a The object of study
botulinum toxin. - is not the
masticatory
muscles.
7. Effect of conventional TENS on pain and
electromyographic activity of masticatory muscles in + 1
TMD patients.

8. Botulinum toxin in a case of hemimasticatory spasm The object of study


with severe worsening during pregnancy. - is the masticatory
activity.
9. Botulinum toxin A in patients with oromandibular The object of study
dystonia: long-term follow-up. - is dystonia related
masticatory
problem.
10. Botulinum toxin in the management of paradoxical of The object of study
jaw muscles. - is the masticatory
activity.
11. Pathophysiology of hemimasticatory spasm. - The object of study
is the masticatory
activity.
12. Hemimasticatory spasm: clinical and The object of study
electrophysiologic abservtions. - is the masticatory
activity.

60
Table 3. Systematic review of included studies in meta-analysis (Excel).

61
Example of VAS transformation
Linear transformation to a 10-stage VAS scale ሺܸ‫ܵܣ‬ଵ଴ ሻ:
Following calculation was applied for 0-4 VAS scale ሺܸ‫ܵܣ‬ସ ሻ
ܸ‫ܵܣ‬ସ
ܸ‫ܵܣ‬ଵ଴ ൌ ‫Ͳͳ כ‬
Ͷ
ܸ‫ܵܣ‬ସ ܸ‫ܵܣ‬ଵ଴
0 0
1 2.5
2 5
3 7.5
4 10

Following calculation was applied for 0-5 VAS scale ሺܸ‫ܵܣ‬ହ ሻ


ܸ‫ܵܣ‬ହ
ܸ‫ܵܣ‬ଵ଴ ൌ ‫Ͳͳ כ‬
ͷ
ܸ‫ܵܣ‬ହ ܸ‫ܵܣ‬ଵ଴
0 0
1 2
2 4
3 6
4 8
5 10

Following calculation was applied for 0-100 VAS scale ሺܸ‫ܵܣ‬ଵ଴଴ ሻ


ܸ‫ܵܣ‬ଵ଴଴
ܸ‫ܵܣ‬ଵ଴ ൌ
ͳͲ
ܸ‫ܵܣ‬ଵ଴଴ ܸ‫ܵܣ‬ଵ଴
0 0
10 1
30 3
50 5
70 7
100 10

62
14. RÉSUMÉ / CV

Persönliche Daten

Name Tatiana Molodova


Geburtsdatum 25.08.1987
Staatangehörigkeit Weissrussland
Adresse Schopenhauerstrasse 73/8, 1180 Wien
E-Mail tessdahling@gmail.com

Ausbildung

02/2013-12/2019 MedUniWien, Österreich


09/2005-06/2010 Medizinische Universität, Dentistry Department, Minsk, Weissrussland.
09/2003-05/2005 Schule Nummer 137, Minsk, Weissrussland
09/1994-05/2003 Schule Nummer 2 mit der Fremdsprache Englisch als Schwerpunkt,
Beryoza, Weissrussland

Weitere Fähigkeiten und Kenntnisse

x Teilnahme am International Congress in Medical Acupuncture ICMART


mit eigenem Thema 2009
x Penn Endo Global Symposium Vienna 2014
x Ausbildung bei der Firma Erkodent Düsseldorf 2014 (Schienentherapie)
x Ausbildung bei der Firma Swiss Dental Academy 2016
(Parodontitis Management, Mundhygiene mit modernsten Methoden)

Fremdsprachen

x Deutsch und Englisch - fließend


x Russisch - Muttersprache

63