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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 512-515
Comparative efficacy of analgesic gel phonophoresis and ultrasound in the treatment of temporomandibular joint disorders


Department of Oral Medicine and Radiology, Sree Balaji Dental College and Hospital, Bharath University, Chennai, Tamil Nadu, India

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Date of Submission07-Nov-2017
Date of Decision03-Dec-2018
Date of Acceptance06-Jan-2019
Date of Web Publication18-Nov-2019
 

   Abstract 

Aim: The aim of this study is to determine the efficacy of phonophoresis in patients with temporomandibular disorders. Objective: To prove that phonophoresis could be an effective treatment modality in in patients with temporomandibular disorders. Procedure: Fifty patients diagnosed clinically and radiographically as temporomandibular disorder were randomly assigned into either of the two groups, namely, (Group A) plain ultrasound and (Group B) phonophoresis. Acoustic gel containing no pharmacological agent was applied in the ultrasound group, whereas a gel containing aceclofenac was applied in the phonophoresis group. Each group was treated three times a week for 2 weeks. The assessment of pain and inflammation both before and after treatment were done using the visual analog scale (VAS) and Creactive protein (CRP). Results: Intergroup comparison was done and analyzed statistically using independent ttest. Intragroup comparison was done using paired ttest. A significant difference in VAS scores and CRP levels before and after treatment were seen within both ultrasound phonophoresis PH groups. No significant difference was noted statistically between ultrasound and phonophoresis group. Conclusion: The results of this study suggests that though plain ultrasound as well as phonophoresis with aceclofenac gel are effective in the management of temporomandibular disorders. Phonophoresis was found be slightly superior as evident in VAS scores and CRP levels though not statistically significant.

Keywords: C-reactive protein, temporomandibular joint disorder, therapeutic ultrasound, phonophoresis, visual analog scale

How to cite this article:
Ramakrishnan SN, Aswath N. Comparative efficacy of analgesic gel phonophoresis and ultrasound in the treatment of temporomandibular joint disorders. Indian J Dent Res 2019;30:512-5

How to cite this URL:
Ramakrishnan SN, Aswath N. Comparative efficacy of analgesic gel phonophoresis and ultrasound in the treatment of temporomandibular joint disorders. Indian J Dent Res [serial online] 2019 [cited 2019 Dec 16];30:512-5. Available from: http://www.ijdr.in/text.asp?2019/30/4/512/271069

   Introduction Top


The area where the mandible articulates with the cranium, the temporomandibular joint (TMJ) is one of the most complex joints in the body. The TMJ is considered as a ginglymoarthroidal joint. The American Dental Association adopted the term temporomandibular disorders.[1] Temporomandibular disorders (TMDs) are defined by the American Academy of Orofacial Pain as “a collective term that embraces a number of clinical problems that involve the masticatory muscles, the TMJ [temporomandibular joint], and the associated structures.”[2] The TMJ, like other joints, are affected by inflammatory, traumatic, infectious, congenital, developmental, and neoplastic diseases, and it may also be caused by malocclusion, parafunctional habits such as bruxism [teeth grinding], teeth clenching, lip biting, stress, anxiety, or abnormalities of the intra-articular disk.[3],[4] The prevalence of TMDs is approximately 40% to 75%. Clicking sounds in TMJ and deviation on opening the jaw occur in approximately 50% of the patients but only 5% seek treatment.[2],[4],[5],[6] 85 to 90% of TMDs, whether articular or muscular, can be treated with noninvasive, nonsurgical, and reversible interventions.[3] Noninvasive therapies commonly used for the treatment of TMJ disorders includes occlusal splint therapy, replacement of missing teeth, correcting malocclusion, physical therapy, and psychology.[4] Physical therapy is beneficial in restoring the normal function of the TMJ, muscles of mastication, and cervical muscles, as well as in reducing inflammation and promoting repair and strength.[5]

Topical administration of NSAIDs has been considered as an alternate route for treatment of TMD to decrease the potential side effects of oral NSAIDs and for patients who are intolerant to oral medications.[7] Unfortunately, many topical drugs are absorbed through the skin very slowly. The stratum corneum provides a barrier to save the underlying layers of the epidermis from temperature, infection, chemicals, and mechanical stress.[8],[9] It has been demonstrated that ultrahigh frequency sound (ultrasound) may be used to drive chemicals into living tissues. This process is called phonophoresis. It is thought that ultrasound may increase cell membrane permeability, allowing whole molecules of a particular medication (if small enough) to be driven into the tissues.[10] The development of an ultrasound-based transferral drug delivery system has received increased attention over the past few years. Hence, this study was done to determine the efficacy of ultrasonically driven analgesic into the joint (phonophoresis), which is considered to be noninvasive and safe.


   Materials and Method Top


Institutional Ethical clearance was obtained for performing the study (Ref: SBDCECM105/13/33). Fifty subjects with chronic TMJ pain not relieved by analgesics were included based on the clinical and radiographical diagnosis. Patients with allergy to aceclofenac gel, pregnancy, epilepsy, bleeding disorders, liver, kidney damage, skin disorders like psoriasis and skin abrasions, and patients on steroid therapy were excluded. The patients were randomly divided into two groups of 25 each (Group A and Group B). Group A of 25 patients received plain therapeutic continuous ultrasound [Figure 1], and Group B of 25 patients received analgesic gel phonophoresis. Each group was treated three times a week for 2 weeks using a probe frequency of 1 MHz, intensity 1.5 w/cm 2 for 8 min [Figure 2]. The visual analog scale (VAS) and C-reactive protein values (CRP) levels were used to monitor changes in intensity of pain and inflammation. The intensity of pain was evaluated before and after treatment using VAS. The CRP values were measured before and after treatment by immunoturbidometry.
Figure 1: Patient receiving plain continuous ultrasound

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Figure 2: Patient receiving analgesic gel phonophoresis

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   Results Top


Ultrasound can be used to reduce pain and inflammation in selected musculoskeletal conditions. The addition of analgesic gel to ultrasound greatly improved the efficacy of treatment. Phonophoresis with analgesic gel as a coupling agent gives good results in the treatment of TMDs. The results suggested that both treatment modalities have been effective in reducing the symptoms of the subjects. The patients reported a decrease in pain (VAS). There was a significant decrease in inflammation (CRP levels), which was measured before and after the treatment. These changes are especially noteworthy as the patients had chronic pain for more than 3 months not relieved by analgesics.

[Table 1] shows a statistically significant difference (P = 0.000) in VAS scores and CRP levels before and after the treatment in Group A. [Table 2] shows a statistically significant difference (P = 0.000) in VAS scores and CRP levels before and after the treatment in Group B. [Table 3] shows that there was no statistically significant difference in the VAS scores and CRP levels after treatment bet. Group A and Group B which signifies that though phonophoresis is a better treatment modality, continuous ultrasound is a good treatment modality.
Table 1: Mean difference in VAS scores and CRP levels before and after treatment of group A (continuous ultrasound)

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Table 2: Mean difference in VAS scores and CRP levels before and after treatment of Group B (Phonophoresis)

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Table 3: Intergroup comparison between group A (continuous ultrasound) and Group B (phonophoresis)

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   Discussion Top


Transdermal drug delivery through the use of topically applied agents has been used in the treatment of systemic conditions such as motion sickness, hypertension, and angina, as well as for the local treatment of musculoskeletal injuries. The use of physical modalities such as ultrasound enhances the delivery of topically applied compounds. The potential advantage of this technique is that it is noninvasive, minimizes the risk of hepatic and renal injury from drug elimination, and is well tolerated by the patients.[11] Ultrasound causes temperature elevations of 4–5°C at depths of 8 cm. This level of heating is attainable at an intensity of approximately 1.5 w/cm 2 or higher, which causes an increase in cell permeability.[12] The present study was designed to evaluate the efficacy of phonophoresis using an analgesic gel with proven ultrasound transmission. The results were judged by VAS scores and CRP levels. VAS proved to be an effective technique for the measurement of intensity of pain. The scores were quick and easy to use and a valid technique for evaluation of subject's pain as it is related to self-selected functional activity. Further, CRP seems to be a sensitive marker of inflammation in this study. This was in accordance with the study by strummer et al.[13],[14],[15] They found that the severity of pain was associated with serum concentrations of high sensitivity C reactive protein (hsCRP), a sensitive marker of low-grade systemic inflammation in patients with osteoarthritis.[16]

In our study, even though both the groups showed significant improvement, Phonophoresis group seems to be a little superior than ultrasound group, which was evident in the improvement of clinical symptoms. A number of other variables which were kept constant in this study including the frequency, intensity of ultrasound, the mode of US (continuous vs. pulsed), duration of treatment, and transmission of ultrasound through different agents with varying drug concentrations requires further investigation to get a better understanding of this technique.


   Conclusion Top


Both treatment modalities are effective and safe for patients with temporomandibular disorders. However, phonophoresis may be particularly helpful in patients with gastric problems who are sensitive to any systemic form of NSAIDs, as well as the elderly population in whom the use of NSAIDs is considered to increase the risk of gastric, renal, and cardiac events.

Limitation

The results reflect the short-term effects of phonophoresis or ultrasound therapy. Long-term effectiveness has not been evaluated. For a more definitive answer on the use of phonophoresis and therapeutic ultrasound in TMDs, large randomized controlled trials with long-term follow-up is required.

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.
Okeson JP. Functional anatomy and biomechanics of temporomandibular joint. In: Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis: Missouri Mosby; 2003. p. 6-7.  Back to cited text no. 1
    
2.
Klasser GD, Greene CS. The changing field of temporomandibular disorders: What dentists need to know. J Can Dent Assoc 2009;75:49-53.  Back to cited text no. 2
    
3.
Scrivani SJ, Keit DA, Kaban LB. Temporomandibular disorders. N Engl J Med 2008;359:2693-705.  Back to cited text no. 3
    
4.
Venkateswaran S, Annamalai PR, Divya L Yamin J. Diagnosis & management of temporomandibular joint disorders: What the medical and dental practitioners should know. Chettinad Health City Medical Journal 2013;2:52-9.  Back to cited text no. 4
    
5.
Romero-Reyes M, Uyanik JM. Orofacial pain management: Current perspectives. J Pain Res 2014;7:99-115.  Back to cited text no. 5
    
6.
Dimitroulis G. Temporomandibular disorders: A clinical update. BMJ 1998;317:190-4.  Back to cited text no. 6
    
7.
Senye M, Mir CF, Morton S, Thie NM. Topical non steroidal anti inflammatory medications for treatment of temporomandibular degenerative pain: A systemic review. J Orofac Pain 2012;26:26-32.  Back to cited text no. 7
    
8.
Aldwaikat M, Alarjah M, Willis J, Mason T. Sonophoresis effect on the permeation of metronidazole using 3d skin equivalent. Int J Pharm Sci Res 2013;4:205-14.  Back to cited text no. 8
    
9.
Mohamed Faisal CK, Sumila M, Mathias L, Ajith S. Comparative study on the effectiveness of low level Laser therapy versus phonophoresis in the Management of lateral epicondylitis. The Nitte University Journal of Health Sciences 2013;3:35-44.  Back to cited text no. 9
    
10.
Antich TJ. Phonophoresis: The principles of the ultrasonic driving force and efficacy in treatment of common orthopaedic diagnosis. J Orthop Sports Phys Ther 1982;4:99-102.  Back to cited text no. 10
    
11.
Klaiman MD, Shrader JA, Danoff JV, Hicks JE, Pesce WJ, Ferland J Phonophoresis vs Ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc 1998;30:1349-55.  Back to cited text no. 11
    
12.
Griffin JE, Echternach JL, Price RE. Patients treated with ultrasonic driven hydrocortisone and with ultrasound alone. Phys Ther 1967;47:594-601.  Back to cited text no. 12
    
13.
Sturmer T, Brenner H, Koenig W, Günther KP. Severity and extent of osteoarthritis and low grade systemic inflammation as assessed by high sensitivity C-reactive protein. Ann Rheum Dis 2004;63:200-5.  Back to cited text no. 13
    
14.
Stürmer T, Raum E, Buchner M, Gebhardt K, Schiltenwolf M, Richter W, et al. Pain and high sensitivity C reactive protein in patients with chronic low back pain and acute sciatic pain. Ann Rheum Dis 2005;64:921-5.  Back to cited text no. 14
    
15.
Huntley JS, Kelly MB. C-reactive protein: A valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain. Emerg Med J 2005;22:602-3.  Back to cited text no. 15
    
16.
Park CH, Lee SH. Investigation of high-sensitivity C-reactive protein and erythrocyte sedimentation rate in low back pain patients. Korean J Pain 2010;23:147-50.  Back to cited text no. 16
    

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Correspondence Address:
Dr. Nalini Aswath
Mathuram, Plot 161, Door No. 5, 5th Street, Murugu Nagar, Velachery, Chennai - 42, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_634_17

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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