Journal of Prosthodontic Research

www.elsevier.com/locate/jpor

Original article
Effect of occlusal splint treatment on the temperature of
different muscles in patients with TMD
Valentim Adelino Ricardo Barão DDS, MSc*, Ana Kelly Garcia Gallo DDS, MSc,
Paulo Renato Junqueira Zuim DDS, PhD, Alicio Rosalino Garcia DDS, PhD,
Wirley Gonçalves Assunção DDS, PhD
Department of Dental Materials and Prosthodontics, Araçatuba Dental School, Univ. Estadual Paulista (UNESP), José Bonifácio,
1193, Araçatuba, São Paulo 16015-050, Brazil
Received 30 March 2010; received in revised form 29 May 2010; accepted 8 June 2010
Available online 29 June 2010

Abstract
Purpose: The aim of this study was to evaluate the effect of occlusal splint treatment on the temperature of masseter (inferior, intermediate and
superior), anterior temporal, digastric and trapezius muscles in patients with temporomandibular disorder (TMD).
Materials and methods: Thirty patients (6 male and 24 female) aged from 16 to 57 years (mean 37.8  11.4 years) were selected. The patients
were diagnosed with muscular TMD by clinical examination (application of Research Diagnostic Criteria questionnaire and physical
examination). Occlusal splints in acrylic resin were inserted in all patients with a weekly follow-up. The superficial thermography (8C) on
the both sides of the muscles was performed using a digital thermometer in a controlled temperature room. This procedure was performed before
occlusal splint insertion (patient with pain) and after the completion of the treatment (patient without pain). The data were analyzed by 2-way
repeated-measures ANOVA and means were compared by Tukey HSD test (P < .05).
Results: After occlusal splint treatment a significant increase in temperature was observed in each muscle, both in the right and left sides. When the
muscles were compared in the same period (before or after therapy) there was no significant difference among them.
Conclusion: It can be concluded that the use of occlusal splint promoted a significant increase on the muscles temperature. There was symmetry in
the temperature of muscles on the right and left sides both before and after the treatment.
# 2010 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Thermography; Temporomandibular disorder; Occlusal splint; Muscle

1. Introduction the hypothalamic thermoregulatory center. Depending on the

The muscular exercise is a function that requires both
coordination and control of the central nervous system. When
the muscle performs an activity (i.e. raise or lower the
mandible), this mechanical work requires about 20% of the
energy produced by the muscle cells [1]. The remaining energy
(80%) is released as heat in order to maintain the body
temperature so that all the biochemical reactions can be
processed and the body homeostasis can be kept. Therefore,
during a muscular exercise, an increase in thermogenesis occurs
leading to an increase in body temperature. However, the body
temperature is kept constant due to the effective participation of
* Corresponding author. Tel.: +55 18 3636 3335; fax: +55 18 3636 3245.
E-mail address: ricardo.barao@hotmail.com (V.A.R. Barão).
type of the muscular effort, metabolic changes such as greater
need of nutrients and oxygen are necessary to perform a
muscular contraction [1].
During the mastication, both the muscular blood flow and
the electrical activity increase linearly, and after vigorous
exercise the muscle suffer hyperemia [2]. This electrical
activity is also increased in the madibular rest position in
patients with bruxism [3].
Patients with temporomandibular disorders (TMD) com-
plain about masticatory muscles fatigue, muscle weakness and
pain. The main mechanism that can explain the myalgia is a
decrease in intramuscular blood flow caused by mechanical
compression of the blood vessels and metabolites accumulation
[4].
Pathological conditions in joints and muscles are often
associated with circulatory disorders and/or inflammatory

1883-1958/$ – see front matter # 2010 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
doi:10.1016/j.jpor.2010.06.001
20 V.A.R. Barão et al. / Journal of Prosthodontic Research 55 (2011) 19–23
reactions in the synovial membrane of joints, tendons, and
connective tissues of muscles and bones. When these processes
take place, variations in skin temperature can be evaluated by
the thermography [5].
Thermography is an auxiliary beneficial technique to
diagnose orofacial diseases, to determine the disease activity
and progress, and the treatment evolution [6]. In addition, it is a
passive detection process since it does not require incidence of
radiation on the body. The circulatory system is the
predominant factor in the thermography patterns [7].
Muscular tissue temperature is dependent not only on energy
production but also blood flow [8] and room temperature [9].
An occlusion force around 25% from the total force can reduce
blood flow leading to hypothermia of the muscle [10].
Stomatognathic diseases, such as TMD and bruxism, can also
alter the temperature of the muscle [5,11,12].
Occlusal splint is considered a conservative and a reversible
therapy for patients with TMD, reducing or even eliminating
the pain. Also, this treatment reduces the electrical activity of
the anterior temporal and the masseter muscles, and provides a
balance between both sides (right and left) of the muscles [13].
Nascimento et al. [14] found a significant reduction of clinical
signs and symptoms of TMD in patients with bruxism after 60
days using occlusal splint.
Therefore, the purpose of this study was to evaluate the
effect of occlusal splint treatment on the temperature of
masseter (inferior, intermediate and superior), anterior tem-
poral, digastric and trapezius muscles in patients with TMD.
2. Materials and methods
2.1. Patient selection
Thirty patients (6 male and 24 female) aged from 16 to 57
years (mean 37.8  11.4 years) enrolled in the Center of
Diagnosis and Treatment of Temporomandibular Disorders at
Aracatuba Dental School, Brazil were selected for this study.
Only subjects with diagnosed myofascial TMD, no dental
failures and no-users of removable prosthesis were included.
Patients’ selection was performed by means of anamnesis
and clinical examination. The presence of TMD was confirmed
by the Dworkin and LeResche research diagnostic criteria
(RDC) questionnaire. The clinical examination was performed,
according to Dworkin and LeResche [15], by two examiners.
One examiner, calibrated according to the RDC/TMD standard,
and another, who received calibration training, performed the
clinical examination. In accordance with the RDC/TMD, the
clinical diagnoses are (1) a – myofascial pain without limited
opening; b – myofascial pain with limited opening, (2) a – disc
displacement with reduction; b – disc displacement without
reduction (with limited opening); c – disc displacement without
reduction (without limited opening), and (3) a – arthralgia; b –
osteoarthritis; c – osteoarthrosis.
Only patients allotted in the RDC axis 1 (myofascial pain)
and with myofascial pain on all targeted muscles (masseter,
anterior temporal, digastric and trapezius muscles) just in left
side were selected. The selected subjects were informed about
the treatment to be instituted and signed a term of informed
consent, in accordance with the recommendations of the
Human Research Ethics Committee.
At the end of the treatment, clinical examination and the
RDC questionnaire were conducted again in order to confirm
the absence of myofascial pain.
2.2. Occlusal splint fabrication
Diagnostic impressions were made using stock trays with
irreversible hydrocolloid (Hydrogum, Zhermack S.p.A.
Rovigo, Italy) then poured in type IV dental stone (Durone
IV, Dentsply Ind. e Com. Ltd, Petrópolis, RJ, Brazil). The casts
were articulated in a semi-adjustable articulator (Bio Art,
Equipamentos Odontológicos Ltd, São Carlos, SP, Brazil) using
a wax maximum intercuspation record and a face–bow transfer.
For the occlusal splint fabrication, the retentions on the
maxillary cast were relive and the occlusal splint was waxed
covering the entire maxillary arch with 2-mm thickness,
simultaneous bilateral occlusal contacts and immediate
disocclusion of the posterior teeth by the anterior teeth during
the eccentric movements of the mandible [1,16,17]. The
occlusal splint in wax was embedded with type III dental stone
(Gesso-Rio, Orlando Antonio Bussioli-ME, Rio Claro, SP,
Brazil) in a metal flask (DCL no. 6, Dentaria Campineira Ltd,
São Paulo, SP, Brazil). The wax was removed and a colorless
thermopolymerized acrylic resin (Clássico, Artigos Odontoló-
gicos Clássico, São Paulo, SP, Brazil) was packed into the flask.
After resin polymerization in boiling water the occlusal splint
was removed and polished.
After fabrication, the occlusal splints were inserted in the
subjects. The occlusal adjustments were performed using a
double-sided articulating film (Accufilm II, Parkell Inc., NY,
USA) with the patient in a supine position [18]. No polishing
procedure was accomplished after occlusal splint adjustment so
that the occlusal contacts could be preserved [16].
The subjects were instructed to use the occlusal splint daily,
during the night. Every 7 days the occlusal contacts of the
occlusal splint were re-adjusted. The occlusal contacts were
recorded in each session by photograph in order to confirm their
stabilization. After occlusal contacts stabilization the subjects
returned every 15 days.
2.3. Thermography test
Each subject was comfortably kept in a room with an
ambient temperature of 22 8C at least 30 min before the test.
Then, the temperature of the masseter (inferior, intermediate
and superior), anterior temporal, digastric and trapezius
muscles was evaluated. A digital infrared radiation thermo-
meter (TD-971 ICEL, Icel Instrs & Components Ltd, Curitiba,
PR, Brazil) was used to measure the temperature.
In the superficial portion of masseter muscle, the
temperature was measured in three parts: on its insertion (into
the angle and lower half of the lateral surface of the ramus
mandible), on its origin (zygomatic arch), and between its
insertion and origin (in the imaginary line corresponding to the
 V.A.R. Barão et al. / Journal of Prosthodontic Research 55 (2011) 19–23 21

Table 1
Two-way repeated-measures ANOVA for the temperature of muscles from the right side.
Source of variation df SS MS P value F value
*
Time 1.0 47.23 47.23 <0.0001 383.7
Muscle 5.0 8.870 1.774 0.2948 1.235
Interaction 5.0 0.2486 0.04971 0.8457 0.4039
Samples (repeated) 174.0 250.0 1.437 <0.0001* 11.67
Residue (error) 174.0 21.42 0.1231

Total 359.0 327.8

*
P < .05 denotes statistically significant difference.

Table 2
Two-way repeated-measures ANOVA for the temperature of muscles from the left side.
Source of variation df SS MS P value F value
*
Time 1.0 48.99 48.99 <0.0001 386.9
Muscle 5.0 3.664 0.7329 0.6026 0.7290
Interaction 5.0 0.2689 0.05378 0.8311 0.4247
Samples (repeated) 174.0 174.9 1.005 <0.0001* 7.939
Residue (error) 174.0 22.03 0.1266

Total 359.0 249.9

*
P < .05 denotes statistically significant difference.

occlusal plane). For the anterior temporal muscle, temperature Table 3

Means and standard deviations of temperature (8C) for the muscles from the
was measured at a point distanced 15 mm from the posterior
right side as affected by the occlusal splint treatment.
supraorbital border. In the digastric muscle the temperature was
performed on the anterior belly at a point distanced 10 mm Muscles Time
from its origin. In the trapezius muscle the temperature was Initial Final
performed 15 mm from its insertion in the posterior direction. Inferior masseter 33.56 (0.94) A a 34.35 (0.84) A b
In all muscles, thermography was evaluated on both right and Intermediate masseter 33.26 (0.86) A a 34.06 (0.79) A b
left sides. Each temperature analysis was performed twice in Superior masseter 33.43 (0.76) A a 34.10 (0.80) A b
each measurement time. Therefore, two times before occlusal Anterior temporalis 33.56 (0.92) A a 34.25 (0.83) A b
splint treatment and two times after treatment. A mean value of Digastric 33.77 (0.87) A a 34.45 (0.87) A b
Trapezius 33.34 (1.09) A a 34.05 (0.96) A b
two measurements was calculated.
In all temperature measurements, the thermometer was Different uppercase letters within column denote group differences that are
positioned at 10 mm from each muscle surface. Thermography statistically significant (P < .05). Different lowercase letters within row denote
group differences that are statistically significant (P < .05).
was performed before and after occlusal splint treatment. The
follow-up of patients was 3.2  1.01 months.
splint treatment), respectively. It can be observed that occlusal
2.4. Statistical analysis splint treatment statistically increased the muscles’ temperature
(Tables 3 and 4). Indeed, there was no statistical significant
Data were evaluated by 2-way repeated-measures analysis difference among the muscles in the same period (initial or
of variance (ANOVA). Means were compared by Tukey HSD final) for both sides (Tables 3 and 4).
test (P < .05). Comparing the side of each muscle, no statistical significant
difference (P > 0.05, Tukey HSD test) was noted between right
3. Results (non-painful muscles) and left (painful muscles) sides both
before and after occlusal splint treatment.
Considering the right side of the muscles, ANOVA showed a
statistical significant difference for the time factor (before and 4. Discussion
after occlusal splint treatments) (Table 1). However, no
statistical significant difference was observed among the With regard to the different methods used to examine the
muscles and in the interaction between time and muscles stomatognathic system, thermography presents several advan-
(Table 1). The same behavior was exhibited for the muscles on tages such as non-radiation emission, non-invasiveness, and
the left side (Table 2). low cost. Some authors [5,6,11,19–22] stated that the
Tables 3 and 4 displayed the mean temperature of the thermography is a record of the heat produced by facial
muscles on the right and left sides as affect by the time (occlusal vessels. However, for others [6,12,20,23–25] the heat comes
22 V.A.R. Barão et al. / Journal of Prosthodontic Research 55 (2011) 19–23
Table 4
Means and standard deviations of temperature (8C) for the muscles from the left
side as affected by the occlusal splint treatment.
Muscles Time
Initial Final
Inferior masseter 33.60 (0.73) A a 34.32 (0.70)
Intermediate masseter 33.41 (0.76) A a 34.23 (0.72)
Superior masseter 33.50 (0.70) A a 34.26 (0.66)
Anterior temporalis 33.64 (0.51) A a 34.34 (0.51)
Digastric 33.58 (0.89) A a 34.35 (0.85)
Trapezius 33.37 (0.96) A a 34.02 (0.89)
Different uppercase letters within column denote group differences that are
statistically significant (P < .05). Different lowercase letters within row denote
group differences that are statistically significant (P < .05).
from the cellular metabolism during muscular activity. The
measurement of the skin temperature can be beneficial in
determining both activity and progress of disease, and also to
monitor the progress of the treatment.
Berry and Yemm [26], Johansson et al. [5] and Kawano et al.
[12] showed that stomatognathic system diseases alter the
temperature of the compromised structures, and produce an
abnormal facial thermograms as can be seen in myofacial pain
syndromes, myositis, muscle-ligament injuries, joint disorders,
inflammation, motor and sensorial disorders, and bruxism.
These findings corroborate with the results of the present study,
since the temperature was changed after muscular disorder
treatment (Tables 3 and 4).
After treatment, the patients exhibited a significant increase
in temperature of all muscles. Changes in the rest position due
to tooth clenching, related or not to emotional stress, the subject
performs an isometric contraction of the mandibular elevator
muscles. This can make the muscle more sensitive, and in
extreme cases, may lead to spontaneous pain. This muscular
condition seems to be related to the vasoconstriction caused by
the muscular structure stiffness as a result of muscle
hyperactivity. Therefore, the proper transport of nutrients
and metabolites is impeded, which can cause accumulation of
subproducts responsible for triggering the pain [1]. Since there
is less blood supply, the muscular temperature tends to be
reduced, as observed in the current study. After occlusal splint
insertion, an increase of temperature was noted probably
because the blood supply returned to normal levels. This
observation is in agreement with other authors [11,26–28] who
found a normal muscular temperature after TMD therapy.
According to Gratt and Sickles [21] the thermal patterns of
the stomatognathic system present a high level of symmetry
between the two sides (right and left) in asymptomatic patients.
The authors [21] also verified that the temperature variation
between both sides in temporomandibular joint and some facial
areas is very small and below 0.2 8C; therefore, sometimes is
hard to differ thermal changes among illnesses. However,
Kawano et al. [12] found asymmetry of the surface temperature
of the body in asymptomatic patients. In present study, the
temperature was symmetric both before and after the treatment.
Berry and Yemm [26] observed a range of 5 8C in different
areas of the same side of the face and small difference between
the sides in asymptomatic patients. However, in patients with
TMD, the authors found that the affected masseter exhibited
higher temperature than the non-affected masseter. The authors
believe that the muscular temperature can be influenced by
either the hyperactivity or hyperemia.
A b
The differences in temperature between the right and left
A b sides of the muscle, both in adults and children, have different
A b point of view in the literature. Some relates this temperature
A b difference as a consequence of failure in thermostat installa-
A b tion, difference in vascularity, anatomical and physiological
A b
differences, biological difference between individuals, and
variation in room temperature [5]. Different temperature
between both sides is more pronounced in children and can be
related to the thermoregulatory mechanism, which is
influenced by the increased oxygen consumption, low cardiac
debit and presence of adipose tissue, as well as the tissue
micro-circulation [29]. All these situations are more likely to
occur in subjects aged between 7 and 11 years, mainly in the
masseter muscle [29]. Some authors [5,30,31] found that the
mean temperature of the masseter muscle in asymptomatic
patients was around 34.4 8C, while in patients with arthritis
was significant lower (33 8C). These findings are in accordance
with the present study since prior to treatment the temperature
of the muscles was around 33.5 and 34.2 8C after occlusal
splint treatment.
According to Johansson et al. [5] the temperature of the
muscles can be affected by the amount of time that the subject
spent in the room. However, in the present study this variable
was controlled since all patients were maintained during 30 min
in a controlled temperature room prior to thermography test.
The skin place where the temperature is measured is another
relevant aspect [5]. For this reason, the present study
standardized the exactly place in each muscle where the
temperature was measured.
The limitations of the present study are the small number of
subjects, and only one type of TMD was investigated.
Therefore, additional studies are required to evaluate the
muscular temperature changes in patients with different types
of TMD as affected by different therapies.
5. Conclusion
Within the limitations of this study, the following conclu-
sions were drawn:
 Occlusal splint therapy statistically increased the temperature
of the masseter (inferior, intermediate, superior), anterior
temporal, digastric, and trapezius muscles in patients with
muscular temporomandibular disorder.
 There was symmetry in the temperature of muscles on the
right and left sides both before and after the treatment.
Conflict of interest statement
The authors claim to have no financial interest, directly or
indirectly, in any entity that is commercially related to the
products mentioned in this article.
 V.A.R. Barão et al. / Journal of Prosthodontic Research 55 (2011) 19–23
References
[1] Okeson J. Management of temporomandibular disorders and occlusion,
6th ed., St. Louis: Mosby; 2008.
[2] Möller BM. Craniomandibular disorders and mastigatory muscle function.
Scan J Dent Res 1992;100:32–8.
[3] Tsolka P, Felon MR, McCullock AJ, Preskel HW. A controlled clinical,
eletromyographic and kinesiographic assessment of craniomandibular
disorders in women. J Orofac Pain 1994;8:80–90.
[4] Rugh TC. Pathophysiology of pain. In: Rugh TC, Patton HD, Woodbury
JW, Towe AL, editors. Neurophysiology. Philadelphia: Saunders; 1965. p.
345–63.
[5] Johansson A, Kopp S, Haraldson T. Reproducibility and variation of skin
surface temperature over the temporomandibular joint and masseter
muscle in normal individuals. Acta Odontol Scand 1985;43:309–13.
[6] Kopp S. Constancy of clinical signs in patients with mandibular dysfunc-
tion. Community Dent Oral Epidemiol 1977;5:94–8.
[7] Irwin JW, Savara BS, Bartley MH, Rau JA. Intraoral thermography. Oral
Surg Oral Med Oral Pathol 1971;32:724–30.
[8] Nadel ER. Effects of temperature on muscle metabolism. Biochem Exerc
1983;13:134–43.
[9] Brengelmann G, Brown AC. Temperature regulation. In: Rush TC, Patton
HD, editors. Physiology and biophysics. Philadelphia: W.B. Saunders;
1966. p. 1050–69.
[10] Monteiro AA. Blood flow changes in human masseter muscle elicited by
voluntary isometric contraction. In: Doctoral thesis. Sweden: University
of Lund; 1990.
[11] Berry DC, Yemm R. A further study of facial skin temperature in patients
with mandibular dysfunction. J Oral Rehabil 1974;1:255–64.
[12] Kawano W, Kawazoe T, Tanaka M, Hikida Y. Deep thermometry of
temporomandibular joint and masticatory muscle regions. J Prosthet Dent
1993;69:216–21.
[13] Ferrario VF, Sforza C, Tartaglia GM, Dellavia C. Immediate effect of a
stabilization splint masticatory muscle activity in temporomandibular
disorder patients. J Oral Rehabil 2002;29:810–5.
[14] Nascimento LL, Amorim CF, Giannasi LC, Oliveira CS, Nacif SR, Silva
Ade M, et al. Occlusal splint for sleep bruxism: an electromyographic
associated to Helkimo Index evaluation. Sleep Breath 2008;12:275–80.
[15] Dworkin SF, LeResche L. Research diagnostic criteria for temporoman-
dibular disorders: review, criteria, examinations and specifications, cri-
tique. J Craniomandib Disord 1992;6:301–55.
[16] Barker DK. Occlusal interferences and temporomandibular dysfunction.
Gen Dent 2004;52:56–61.
23
[17] Tecco S, Festa F, Salini V, Epifania E, D’Attilio M. Treatment of joint pain
and joint noises associated with a recent TMJ internal derangement: a
comparison of an anterior repositioning splint, a full-arch maxillary
stabilization splint, and an untreated control group. Cranio 2004;22:
209–19.
[18] Fu AS, Mehta NR, Forgione AG, Al-Badawi EA, Zawawi KH. Max-
illomandibular relationship in TMD patients before and after short-term
flat plane bite plate therapy. Cranio 2003;21:172–9.
[19] Hunter AM, St. Clair Gibson A, Mbambo Z, Lambert MI, Noakes TD. The
effects of heat stress on neuromuscular activity during endurance exercise.
Plregers Arch 2002;444:738–43.
[20] Christensen LV, Mohamed SE. Effects of topical cooling on isometric
contractions of the human masseter muscle. Arch Oral Biol 1984;29:635–9.
[21] Gratt BM, Sickles EA. Thermographic characterization of the asymptom-
atic temporomandibular joint. J Orofac Pain 1993;7:7–14.
[22] Hidaka O, Yanagi M, Takada K. Changes in masseteric hemodynamics
time-related to mental stress. J Dent Res 2004;83:185–90.
[23] Morimoto T, Takada K, Hijiya H, Yasuda Y, Sakuda M. Changes in facial
skin temperature associated with chewing efforts in man: a thermografic
evaluation. Arch Oral Biol 1991;36:665–70.
[24] Ariji Y, Sakuma S, Kimura Y, Kawamata A, Toyama M, Kurita K, et al.
Colour Doppler sonographic analysis of blood-flow velocity in the human
facial artery and changes in masseter muscle thickness during low-level
static contraction. Arch Oral Biol 2001;46:1059–64.
[25] Gavin TP. Clothing and thermoregulation during exercise. Sports Med
2003;33:941–7.
[26] Berry DC, Yemm R. Variations in skin temperature of the face in normal
subjects and in patients with mandibular dysfunction. Br J Oral Surg
1971;8:242–7.
[27] Burdette BH, Gale EN. The effects of treatment on masticatory muscle
activity and mandibular posture in myofascial pain-dysfunction patients. J
Dent Res 1988;67:1126–30.
[28] Roark AL, Glaros AG, O’Mahony AM. Effects of interocclusal appliances
on EMG activity during parafunctional tooth contact. J Oral Rehabil
2003;30:573–7.
[29] Tegelberg A, Kopp S. Skin surface temperature over the temporomandib-
ular joint and masseter muscle in healthy children and adolescents. Acta
Odontol Scand 2002;60:271–5.
[30] Tegelberg A, Kopp S. Skin surface temperature over the masseter muscle in
individuals with rheumatoid arthritis. Acta Odontol Scand 1988;46:151–8.
[31] Kopp S, Haraldson T. Skin surface temperature over the temporomandib-
ular joint and masseter muscle in patients with craniomandibular disorder.
Swed Dent J 1988;12:63–7.