Deep Dry Needling along with Soft Splint Therapy versus only Soft Splint Therapy for Patients Suffering from Temporomandibular Myofascial Pain Dysfunction Syndrome– A Systematic Review.

Dr. Vibha Vaswani (M.D.S)*,  Dr. Sonal Shah (M.D.S)¹, Dr. Tanvi Malankar (M.D.S)² Dr.Pushkar Waknis (M.D.S, FIBOMS)³, Dr. Deeisha Gupta (M.D.S)^4, Dr. Kunal Jain (M.D.S)⁵

*Corresponding Author: Dr. Vibha Vaswani (M.D.S)*, 3rd Year Resident, Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India-411018, Orcid ID: 0000-0002-7504-7271

1. Professor, Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India-411018, Orcid ID: 0000-0001-8424-0105

2. 2nd Year Resident,  Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India-411018, Orcid ID: 0000-0003-4814-9173

3. Professor and Head of Department, Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India-411018, Orcid ID: 0000-0002-8230-6075

4. 3^rd Year Resident, Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune,India-411018, Orcid ID: 0000-0003-3044-7084

5. 3rdYear Resident, Dept. of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune,India-411018, Orcid ID: 0000-0002-7921-7362

Received Date:  March 08, 2021

Publication Date: March 11, 2021

Abstract
Occlusal stabilization splints are considered as the standard method of treatment for Myofascial Pain dysfunction Syndrome. Deep Dry Needling (DDN) of the Myofascial Trigger Points (MTrPs) of the masticatory muscles along with occlusal splints is a newer treatment modality. The objective of this study is to evaluate the effect of deep dry needling as an adjunct with stabilization splints in the treatment of patients suffering from myofascial pain dysfunction syndrome. Data search included an electronic search of PubMed, Google Scholar, EMBASE, Institutional Library and manual search of various journals. Articles in English language, published from 01/01/2000 till 31/12/2017. Comparative clinical studies, RCTs, controlled clinical trials and retrospective studies. Patients above 18 years of age, presenting with myofascial pain that underwent deep dry needling with or without occlusal splints were included in this study. Preliminary screening consisted of 298 studies, out of which 46 were selected among which 4 were duplicates. Out of 42 studies, 25 were excluded after reading the abstract. Of the 17 studies,2 were excluded and a total of 10 studies was included in qualitative synthesis with a total of 769 estimates. We concluded, occlusal splints are no doubt the gold standard for the treatment of Myofascial Pain Dysfunction Syndrome. But deep dry needling of the myofascial trigger points of the lateral pterygoid muscle, masseter and temporalis is an effective treatment modality and is maximally invasive as compared to occlusal splints. Thus, DDN with occlusal splints should be adopted as the treatment modality for Myofascial Pain Syndrome for better treatment outcomes.

KEYWORDS: Myofascial pain syndrome, Occlusal splint, Bruxism, Dry needling.

Introduction
Disorders of the temporomandibular joint are characterized by a multiplex set of conditions that reflect symptoms that not only affect the joint, but also its surrounding structures. These conditions are prevalent in approximately 10% of individuals in the adult age group with a greater female predilection.(1)  The symptoms usually fluctuate in all age groups but seem to impulsively resolve among the elderly. Pain in the head and neck region in most cases is attributed to that of the muscular origin or associated with myofascial pain of the temporomandibular joint. (2)

Myofascial trigger points (MTrPs) are localized areas of hyperalgesic zones that are usually associated with Temporomandibular joint Dysfunction (TMD). (3)  These points develop due to muscle overload or trauma anywhere in the body. Active MTrPs are associated with voluntary pain while the latent ones evoke symptoms when compressed. Palpating the trigger point or injecting it with a needle, evokes a localized initial response leading to contraction of muscle fibers in or around these MTrPs. (4)

Since patients are refractive, a standard treatment approach is not feasible and hence, a variety of therapies, either isolated or in combination are being employed. The main outcome of such treatment is focused on pain relief. Most commonly, pharmacological agents like antidepressants, benzodiazepines and muscle relaxants are used primarily for the management. Depending on the efficacy of such drugs and keeping in mind the possible side effects, their long-term administration is considered. (5)

Among the several treatments used, stabilization occlusal splints being the most beneficial are also a conservative modality that brings about an effective reduction in pain but is a reversible form of the same. Various other techniques have been employed for the same in the recent past. The beneficial effects of acupuncture is an age-old treatment that originated in China in the 16th century used in the treatment of orofacial pain has been reported. It also has been reported that the effect of acupuncture therapy is similar to that of stabilization splints. (5,6)

Focused question: Does deep dry needling along with stabilization splints enhance the treatment of Myofascial Pain Dysfunction Syndrome (MPDS)?

Objective
To evaluate the effect of deep dry needling (DDN) as an adjunct along with stabilization splints for treating MPDS.

Materials and Methods

Inclusion criteria :

1. Articles appearing in literature from 01/01/2000 to 31/12/2017 (18 years).

2. Patients presenting with Myofascial (Orofacial) Pain with or without Bruxism.

3.Articles in English language only.

Exclusion criteria :

 1.Animal studies.

 2.Patients below 18 years of age.

 3.Case reports, review articles, letter to the editor.

 PICO

 P = Patients suffering from MPDS.

 I = Occlusal splint and Deep dry needling.

C = Effect of DDN and/or occlusal splint therapy in patients with or without bruxism. 

O = Pain

Information Sources

An extensive search of the literature was published from 01.01.2001 till 31.12.2017 was carried out. Electronic search engines like Pubmed, Google Scholar, EMBASE, institutional library and the bibliography of studies that were included were included. In addition, only studies that were carried out in humans were looked at.

Search (Table 1)

Please refer to attached figure 2

Search Strategies (Table 2)

Please refer to attached figure 3 

Search Engines

Pub Med 

Google Scholar 

EMBASE

Institutional Library

Study Selection

Preliminary screening consisted of 298 studies. The studies were screened and only 46 were included as per the eligibility criteria. 4 were found to be duplicates. 25 studies were excluded after reading the abstract. 2 were excluded because they were not in English. Thus, a total of 15 studies were included in the qualitative analysis with a total of 769 estimates.

Data were extracted independently by VV and the data extraction was confirmed by invigilators SS and PW. At first, the studies were screened by title and abstracts, the second step of screening consisted of obtaining full-text articles when they fulfilled the eligibility criteria. Any disagreement between the two reviewers was resolved after discussion. After this, a data extraction sheet was prepared.

Data Collection Process

A standard pilot form in excel sheet was initially used. Data extraction was done and the form was reviewed by an expert and finalized for all the articles.

Data

1.         Study ID

2.         Author – Name of the author(s)

3.         Location – Place where the study was conducted

4.         Year of publication – The year in which the study was published

5.         Study Design – Retrospective/ Prospective/ Comparative

6.         Setting –Hospital/ Out Patient Department

7.         Sample size

8.         Intervention – Type of minimally invasive technique

9.         Study group – Type of population included in the study

10.       Control – Conventional technique

11.       Results – Result of the study

12.       Remarks – Comment of authors (VV, SS, PW)

Results

Refer to attached Figure 1

STUDY CHARACTERISTICS: Table 1 and Table 2

Discussion

As there is no fixed line of management for patients suffering from myofascial pain due to their refractive nature, a variety of treatment modalities are being employed either individually or in combination. For patients suffering from MPDS, pain relief is the desired treatment outcome. In the recent past, acupuncture (deep dry needling) has been discovered to be an efficient therapeutic alternative for conditions causing chronic pain. It is known that occlusal splints are used as an effective mode of treatment for MPDS. This review however discusses the efficiency of the combination of DDN and occlusal splints in the treatment of MPDS.

Thomas List and Martti Helkino (7)  in January 1992 published a prospective study to evaluate the effectiveness of the combination of acupuncture and occlusal splints in the management of MPDS by means of subjective and/or clinical assessment. A total of 110 patients among which 23 were male and 87were female patients and those who presented with 6 months of history of MPDS were included in the study. After random allocation to three groups, viz acupuncture, occlusal splints and control they were assessed before and immediately after treatment. It was observed that treatment acupuncture and occlusal splints showed statistically significant effectiveness and thus concluded that they are a good treatment modality for temporomandibular myofascial pain.

Later in June 1992, Thomas List and Martti Helkino (8)  published a follow-up study pertaining to the use of acupuncture and occlusal splints. Among those 110 patients who participated in the first study, 30 were lost to follow up and among the 80 patients who participated in the follow up by filling the questionnaires showed that 68% of patients treated with occlusal splints and 57% of patients treated with acupuncture showed a positive response to additional treatment modalities as compared to those who were not treated with either acupuncture and/or occlusal splints. Thus they concluded that a combination of acupuncture and occlusal splints is an effective treatment modality and suggested that more studies should be carried out to prove the same.

Mona Al-Saad and Riyadh Akeel (9)  in the year 2001 published a prospective study that compared the electromyographic (EMG) activity level and clinical presentations in patients with myelogenous TMDs that were treated with two different types of occlusal devices. 11 participants were divided into two groups, wherein one group was treated with usual flat plane occlusal devices and the second group was treated with anatomic splints. The gravity of signs and symptoms were assessed and the EMG activity of the masseter muscle was recorded and the values were evaluated prior to treatment and were subsequently followed up at regular intervals up to 4 weeks following the delivery of the occlusal device. The EMG was also recorded in 7 normal patients as a control group. It was observed that all patients showed a reduction of reported and clinically found muscle pain, with not much a difference between both the groups. Thus, they concluded that both types of occlusal devices are beneficial to patients suffering from TMD.

Gavish A. et al (10) in the year 2002 published a prospective study that evaluated the usefulness of the stabilization appliance to reduce the morbidity in MPDS patients and compared the unpleasant experience through the chewing test between the two groups, with and without splints. 37 participants who presented with aggravating pain and symptoms took part in this study and were divided into two groups among which 21 received the splint for nocturnal use and the remaining 16 were equally watched upon clinically without the splint. They were then made to perform a chewing test succeeded by a period of rest and their pain intensity was assessed on a VAS scale over a period of 2 months followed by the same tests again. It was noted that the level of pain at baseline prior to the chewing test was high in both groups. Hence, they concluded that the splint had a more therapeutic effect.

Ingalill Bergstrom, Thomas List and Tomas Magnusson (11)  in February 2008 published a long-term follow-up study of 18- 20 years of the study carried out in 1992 by Thomas List and Martti Helkino7,8. 55 patients who received therapy then participated in this study and readily filled the questionnaire. Among 87% of patients who presented with temporomandibular disorder earlier, decreased to 38% and also the incidence of headaches reduced significantly. Patients gave positive feedback to the treatment they received and hence authors concluded that the combination of occlusal splints and acupuncture is effective.

Cheryl Ritenbaugh et al (6)  in June 2008 published a prospective study to assess the feasibility and acceptability of two different medicinal treatments for MPDS compared to specialty care. 160 women in the age group of 25-55 years participated in this study. Patients were exposed to all modes of treatment. Patients were assessed on their self-reported facial pain and interference with routine day-to-day chaos. It was observed that the patients showed significantly better responses to both the medicinal treatments as compared to specialty care. Hence the authors concluded that there are potential benefits of medicinal treatments over specialty care in treating TMDs.

F Alencar JR. and A. Becker (12)  in the year 2009 compared the benefit of different occlusal splints in relation to clinical counseling and in managing MPDS. The study consisted of 42 patients that were randomly put into three clinical categories using different splints. Their assessment over a period of 3 months showed equal treatment outcomes with respect to all three types of splints. Thus, they concluded that patient counseling and motivation play a major role in the treatment outcome.

Camero J. F. et al (13) assessed the effects of dry needling over MTrPs in the masseter muscle in 12 female patients suffering from MPDS. Treatment was provided in 2 visits; the first visit being deep dry needling into the MTrP of the masseter muscle and the other visit being sharp dry needling in the most painful site of the temporomandibular region (placebo). Patients were assessed on basis of Pressure Pain Threshold (PPT) over the masseter muscle TrP and mandibular condyle and painless active jaw opening pre-and post-intervention. Statistically significant beneficial effects were noted in the DDN sessions. Thus authors concluded that DDN of MTrPs in the masseter muscle helped in maximal pain- free jaw opening and increase in PPT

Faith Ozkan et al (14)  conducted a study in the year 2011 consisting of fifty patients that were put into two groups of 25 each. Group 1 was treated with splints and the patients in Group 2 were treated with TrP injections combined with splint therapy. Positive improvement was observed in both groups. However, the group treated with combination therapy showed a more noted reduction in the VAS scores, at follow-up. They concluded that trigger point injection therapy in combination with splint therapy is efficient in the management of MPDS as compared to that of only stabilization splints.

P. C. R. Conti* et al (15)  tested a hypothesis that treatment with intraoral devices with a variety of occlusal configurations was beneficial in the management of myofascial pain. 51 patients were analyzed and then divided into 3 categories viz, Group 1 (full coverage acrylic stabilization occlusal splint); Group 2 (anterior device nociceptive trigeminal inhibitory (NTI) system), and Group 3 (psychiatric guidance for behavioral changes and self-care (control group)). Patients were followed up to 3 months regularly and were evaluated using the VAS and PPT of the masticatory muscles. It was noted that Group 1 showed a marked improvement in pain at the first follow-up (2 weeks) whereas for groups 2 and 3, this progress was delayed up to a maximum of 3 months. Hence they concluded that behavioral changes are beneficial, however, the adjunctive use of occlusal devices produces an earlier improvement.

Emad T. Daif (16)  in the year 2012 assessed the effect of occlusal splint therapy on the EMG activity of masticatory muscles in TMD patients with myofascial pain and to check for a possible relationship between this effect and the treatment outcome. 40 patients participated in this study and were divided into two equal groups amongst which one was treated by occlusal splints for 6 months, while the second one controlled. A clinical assessment and surface EMG for masticatory muscles were performed at baseline, and then 6 months later. It was observed that 85% of the group treated with splints completely recovered or improved clinically while only 20% of the control group had little improvement. They concluded that occlusal splints could eradicate or improve the signs and symptoms of patients with myofascial pain.

Mario Vicente-Barrero et al (17)  in the year 2012 evaluated the results of applying acupuncture or occlusal splints in the treatment of MPDS patients. The study included 20 patients and results were evaluated by means of the VAS, measurements of mouth opening and lateral deviation of the jaw in millimeters, and assessment of sensitivity to pressure on different points in the temporomandibular myofascial region before and 30 days after treatment. It was noted that patients treated with splints showed a reduction in subjective and objective pain, as well as increased mouth opening and those with acupuncture, showed pain reduction in the short term and improvements in all of the evaluated parameters. Hence, they concluded that acupuncture was an effective complement and/or acceptable alternative to splints in the treatment of MPDS.

Luis-Miguel Gonzales-Perez et al (18)  in the year 2012 evaluated the usefulness of DDN in the treatment of MPDS. 36 patients were included in this study. Differences in pain with a VAS scale and range of mandibular movements before and after intervention were studied and pain reduction was significantly greater as compared to baseline. On basis of the findings in their study, they concluded that DDN in the TrPs in the external pterygoid muscle can be beneficial in the management of patients with MPDS.

Luis-Miguel Gonzalez-Perez et al (19)  in the year 2015 determined whether DDN of TrPs in the Lateral Pterygoid Muscle (LPM) would greatly reduce pain and improve function, compared with methocarbamol/paracetamol medication. The study consisted of 48 patients with chronic myofascial pain located in the LPM that were assigned to one of the two groups. The test group received three applications of needling once per week consecutively for three weeks, while control group patients were given two tablets of a methocarbamol/paracetamol combination every 6 hours for 3 weeks and were assessed pre-treatment, and up to 8 weeks after finishing the treatment. The DDN group had better levels of pain reduction. The evaluation of efficacy was assessed by both patients/investigators and was noted that results were better for the last group. Some patients who received combination drug treatment described unpleasant side effects (mostly drowsiness). Thus, they concluded that DDN of the TrPs in the LPM showed better efficiency in reducing pain and improving maximum mouth opening, laterality and protrusion movements, compared with methocarbamol/paracetamol treatment.

Paloma Maria Blasco- Bonora and Aitor Martin-Pintado-Zugasti (20) in the year 2016 evaluated the effects of DDN on MTrPs of the masseter and temporalis on PPT, pain-free maximal jaw opening and TMD related disability in 17 patients with sleep bruxism and MPDS and each patient received intervention in the masseter and temporalis MTrPs. Assessments were made before treatment, immediately after treatment and at 1-week follow-up. Jaw disability was assessed using the Jaw Disability Checklist (JDC) at baseline and at 1-week post-treatment only. Thus they concluded that DDN of the active MTrPs in the masseter and temporalis in the patients with MPDS and SB was associated with immediate and 1-week improvements in pain sensitivity, jaw opening and TMD-related disability.

All our studies were conducted between the years 2001 and 2017. Of the 15 studies, 7 were prospective, 5 were comparative and 3 were follow-up studies and showed global distribution. A total of 769 patients suffering from Myofascial Pain Syndrome were treated using conventional occlusal stabilization splints or by DDN or by DDN along with occlusal splints. Amongst the 6 studies that used occlusal splints with or without behavioral counseling for patients suffering from Myofascial TMD; 1 study did not include a comparison group; 2 studies concluded that behavioral changes alone could help relieve myofascial pain effectively but 3 studies proved that occlusal splints helped to relieve myofascial pain effectively. And among the remaining 6 studies, that used DDN, 3 studies that used DDN with occlusal splints proved that Acupuncture along with occlusal splints proved to be a compliment in the treatment of MPDS.

Limitations

We found that 6 studies used minimally invasive techniques i.e. occlusal stabilization splints, of which 1 study did not have a comparison group and 2 studies proved that behavioral changes were effective alone. 4 studies talked about DDN of MTrPs of the muscles of mastication, and 1 study proved that DDN proved to be a complement to the conventional stabilization splint therapy in the treatment of MPDS. The parameters used for assessing the outcome of treatment were different in all studies. The number of studies carried out talking about the two treatment modalities in combination is inconsequential; thus making the choice is debatable.

Conclusion

On thorough comparison of the results, we conclude that occlusal splints are no doubt the gold standard for the treatment of Myofascial Pain Dysfunction Syndrome along with behavioral changes.

But Deep Dry Needling of the Myofascial Trigger Points of the Lateral Pterygoid Muscle, Masseter and Temporalis is an effective treatment modality and is maximally invasive as compared to occlusal splints; and DDN with Occlusal Splints should be adopted as the treatment modality for Myofascial Pain Syndrome for better treatment outcomes.

Future Implications

One of the drawbacks of this systematic review is that there are very few articles that support combination therapy for MPS. This represents an opportunity for future research in which a long-term multi-centric, prospective, randomized controlled trial can be undertaken with a comparison of occlusal splints alone and occlusal splints with deep dry needling in the treatment of MPS to help enhance treatment outcomes.

Conflict of Interest: None

Funding: No.

References

1.Gonzalez-Perez LM, Infante-Cossio P, Granados-Nunez M, Urresti-Lopez FJ, Lopez-Martos R, Ruiz-Canela-Mendez P. “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”. Medicina oral, patologia oral y cirugia bucal. 2015 May;20(3):e326.

2.Roldán-Barraza C, Janko S, Villanueva J, Araya I, Lauer HC. “A systematic review and meta-analysis of usual treatment versus psychosocial interventions in the treatment of myofascial temporomandibular disorder pain”. J Oral Facial Pain Headache. 2014 Jul 1;28(3):205-2.

3.Blasco-Bonora PM, Martín-Pintado-Zugasti A. “Effects of myofascial trigger point dry needling in patients with sleep bruxism and temporomandibular disorders: a prospective case series. Acupuncture in Medicine”. 2017 Feb;35(1):69-74.

4.Roldán-Barraza C, Janko S, Villanueva J, Araya I, Lauer HC. “A systematic review and meta-analysis of usual treatment versus psychosocial interventions in the treatment of myofascial temporomandibular disorder pain”. J Oral Facial Pain Headache. 2014 Jul 1;28(3):205-2.

5.Gavish A, Winocur E, Ventura YS, Halachmi M, Gazit E. “Effect of stabilization splinttherapy on pain during chewing in patients suffering from myofascial pain”. Journal of oral rehabilitation.2002 Dec; 29(12):1181-6.

6.Ritenbaugh C, Hammerschlag R, Calabrese C, Mist S, Aickin M, Sutherland E, Leben J, DeBar L, Elder C, Dworkin SF. “A pilot whole systems clinical trial of traditional Chinese medicine and naturopathic medicine for the treatment of temporomandibular disorders”. The Journal of Alternative and Complementary Medicine. 2008 Jun 1;14(5):475-87.

 7.List T, Helkimo M, Andersson S, Carlsson GE. “Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders”. Part I. A comparative study. Swedish dental journal. 1992;16(4):125-41.

8.List T, Helkimo M. “Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders: II. A l-year follow-up study”. Acta Odontologica Scandinavica. 1992 Jan 1;50(6):375-85.

9.Al-Saad M, Akeel R. “EMG and pain severity evaluation in patients with TMD using two different occlusal devices”. International Journal of Prosthodontics. 2001 Jan 1; 14 (1).

10.Gavish A, Winocur E, Ventura YS, Halachmi M, Gazit E. “Effect of stabilization splinttherapy on pain during chewing in patients suffering from myofascial pain”. Journal of oral rehabilitation.2002 Dec; 29(12):1181-6.

11.Bergström I, List T, Magnusson T. “A follow-up study of subjective symptoms of temporomandibular disorders in patients who received acupuncture and/or interocclusal appliance therapy 18–20 years earlier”. Acta Odontologica Scandinavica. 2008 Jan 1;66(2):88-92.

12.Alencar Jr F, Becker A. “Evaluation of different occlusal splints and counselling in the management of myofascial pain dysfunction”. Journal of oral rehabilitation. 2009 Feb;36(2):79-85.

13.Fernández-Carnero J, La Touche R, Ortega-Santiago R, Galan-del-Rio F, Pesquera J, Ge HY, Fernández-de-las-Peñas C. “Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders”. Journal of orofacial pain. 2010 Jan 1;24(1):106.

14.Ozkan F, Cakir Ozkan N, Erkorkmaz U. “Trigger point injection therapy in the management of myofascial temporomandibular pain”. Agri- The Journal of The Turkish Society of Algology. 2011 Jul;23(3):119-25.

15.Conti PC, De Alencar EN, da Mota Correa AS, Lauris JR, Porporatti AL, Costa YM. “Behavioural changes and occlusal splints are effective in the management of masticatory myofascial pain: a short?term evaluation”. Journal of oral rehabilitation. 2012 Oct;39(10):754-60.

16.Daif ET. “Correlation of splint therapy outcome with the electromyography of masticatory muscles in temporomandibular disorder with myofascial pain”. Acta Odontologica Scandinavica. 2012 Jan 1;70(1):72-7.

17.Vicente-Barrero M, Yu-Lu SL, Zhang B, Bocanegra-Pérez S, Durán-Moreno D, López- Márquez A, Knezevic M, Castellano-Navarro JM, Limiñana-Cañal JM. “The efficacy of acupuncture and decompression splints in the treatment of temporomandibular joint pain- dysfunction syndrome”. Medicina oral, patologia oral y cirugia bucal. 2012 Nov;17(6):e1028.

18.Gonzalez-Perez LM, Infante-Cossio P, Granados-Nuñez M, Urresti-Lopez FJ. “Treatment of temporomandibular myofascial pain with deep dry needling”. Medicina oral, patologia oral y cirugia bucal. 2012 Sep;17(5):e781.

19.Gonzalez-Perez LM, Infante-Cossio P, Granados-Nunez M, Urresti-Lopez FJ, Lopez-Martos R, Ruiz-Canela-Mendez P. “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”. Medicina oral, patologia oral y cirugia bucal. 2015 May;20(3):e326.

20.Blasco-Bonora PM, Martín-Pintado-Zugasti A. “Effects of myofascial trigger point dry needling in patients with sleep bruxism and temporomandibular disorders: a prospective case series. Acupuncture in Medicine”. 2017 Feb;35(1):69-74.

Volume 2 Issue 4 April 2021

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