Journal of Oral Rehabilitation 2002 29; 858–863
Effect of occlusal splint and transcutaneous electric
nerve stimulation on the signs and symptoms of
temporomandibular disorders in patients with bruxism
A . A L V A R E Z - A R E N A L , L . M . J U N Q U E R A , J . P . F E R N Á N D E Z ,
I . G O N Z Á L E Z & S . O L A Y University of Oviedo Dental School, Asturias Central Hospital, Spain
SUMMARY A crossed-design experimental study has
been made involving simple blind paired data and
random assignment to treatment, with the aim of
evaluating the action of an occlusal splint with
transcutaneous electric nerve stimulation (TENS)
upon the manifestations of temporomandibular
disorders (TMD) in patients with bruxism. The
prevalence of TMD in the 24 patients with bruxism
was 62Æ5%%; the corresponding severity, as deter-
mined by the pantographic reproducibility index
Introduction
The association between temporomandibular disorders
(TMD) and bruxism has often been commented in the
literature (Allen, Rivera-Morales & Zwemer, 1990;
Molina et al., 1997). In a series of 86 patients with
bruxism, Yustin et al. (1993) found 89Æ6% to have
symptoms of TMD. Sjöholm, Polo and Alihanka (1992)
in turn recorded joint and muscle tenderness in almost
half of their bruxing patients, with a 25% incidence
of headache and joint clicking. According to some
authors, bruxism contributes to the development of
TMD (Abraham et al., 1992; Kampe et al., 1997).
However, others have observed no such association
between bruxism and TMD (Marbach et al., 1990;
Kieser & Groeneveld, 1998).
The most widely accepted treatment approach for both
bruxism and TMD is conservative and reversible manage-
ment including occlusal devices (splints), behavioural
techniques, and pharmacological and physical proce-
dures – the indicated therapeutic combination depend-
ing on the particular symptoms involved and ⁄ or the
predominant influence of one aetiological factor or other.
ª 2002 Blackwell Science Ltd
(PRI), was mild (mean value: 20Æ71). Clicking and
pain in the lateral pterygoid muscle were the most
frequent clinical manifestations. The occlusal splint
and TENS did not significantly improve the signs
and symptoms of TMD in these patients with
bruxism.
KEYWORDS: temporomandibular disorders, bruxism,
treatment approach, occlusal splint treatment,
TENS treatment
In the case of bruxism, it may be considered that
while no conservative treatment modality is superior to
any other, the occlusal splint is the most widely used
option. The manifestations of TMD are markedly
improved by these devices, even when the bruxing
habit persists (Major & Nebbe, 1997). This has been
demonstrated in non-bruxing individuals who never-
theless have been diagnosed with TMD (Skeppar &
Nilner, 1993). Pain, tenderness of the masticatory
muscles and myogenic headache are the symptoms
that appear to improve significantly in both noc-
turnal bruxing patients subjected to splint therapy
(Sheikholeslam, Holmgren & Riise, 1993) and in
individuals with TMD but no bruxing behaviour (Long,
1995). In contrast, however, joint noises (clicking) tend
to persist despite treatment (Sheikholeslam et al., 1993;
Yap, 1998).
Transcutaneous electric nerve stimulation (TENS)
has been described in the literature as a form of
treatment for bruxism, although the results obtained
have not been contrasted. On the other hand, TENS is
habitually employed in patients with TMD (Talley et al.,
1990), in view of its analgesic and muscle relaxing
858
 EFFECT OF OCCLUSAL SPLINT AND TENS ON THE SIGNS AND SYMPTOMS OF
TMD
effect, with positive results (Gold, Greene & Laskin,
1983).
A crossed-design experimental study has been made
involving simple blind paired data and random assign-
ment to treatment, with the aim of evaluating the
action of an occlusal splint with TENS upon the
manifestations of TMD in patients with bruxism, and
assessing the differences between grinders and clench-
ers. The conduction of such a study is justified by the
scant and contradictory information available in the
literature regarding the effect of an occlusal splint with
TENS upon bruxing patients.
Materials and methods
The bruxing patients were selected from among the
students in Dental School of the University of Oviedo
(Spain) and the patients from private dental clinics. The
inclusion criterion was bruxing behaviour, diagnosed
via anamnesis and ⁄ or a questionnaire and clinical
examination.
Although a total of 32 subjects were initially inclu-
ded, eight abandoned the study for different reasons –
leaving a final 24 individuals with an average age of
36Æ5 years (15 males and nine females). Thirteen were
clenchers and 11 grinders. The study procedure was
explained to the subjects and informed consent was
obtained in all cases.
Each patient was subjected to joint and muscle
palpation (temporal, masseter, lateral and medial
pterygoid, digastric, sternocleidomastoid and trapezius)
by a single expert explorer. Palpation was bilateral
and simultaneous, following the habitual protocol and
recommendations. The presence of pain and ⁄ or ten-
derness was scored as follows: + (mild), ++ (moderate),
and +++ (severe or intense). Temporomandibular joint
(TMJ) palpation was in turn performed adopting an
external and posterior approach. Joint noises associated
with oral opening and closing were evaluated using a
stethoscope.
Patients with joint and muscle tenderness and ⁄ or
joint clicks were diagnosed of TMD. A Pantronic
electronic pantograph* was used to determine the
severity of TMD in terms of the pantographic repro-
ducibility index (PRI) reading provided by the appar-
atus.
*Denar, Anaheim CA, USA.
ª 2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 858–863
859
A transparent thermopolymerizing acrylic mandibu-
lar occlusal splint was prepared for each patient via the
classical technique, following the fitting of models in a
semiadjustable articulator†. The occlusal surface was
smooth and level with point-form contacts, in centric
relation, of the functional and non-functional anta-
gonist cuspids of the posterior teeth. In the anterior
sector of the splint the contacts of the anterior teeth
were less pronounced, and the inclined planes for the
canine and protrusive guides were well defined, to
provide immediate disocclusion of the posterior teeth
during mandibular eccentric movements. The patients
wore the splint 24 h a day, except during meals, for a
period of 45 days.
The TENS was in turn carried out with a BNS-40
portable unit‡, following the instructions of the manu-
facturer. This is a low-frequency neurostimulator
that generates stimuli at a fixed rate (one every 1Æ5 s),
with a duration of 500 ms and a variable amplitude of
0–25 mA. Each TENS session lasted 45–60 min,
and each patient underwent 15 sessions (one every
2 days). A session was always carried out prior to
any exploration.
The data corresponding to each study variable were
recorded before and after treatment. A resting period of
a month and a half was observed between the two
treatments (i.e. occlusal splint and TENS) – the order of
the treatments being randomized for each patient.
The descriptive statistical study comprised the calcu-
lation of frequencies and the central tendency and
dispersion measures for each study variable. The
Mann–Whitney U-test and chi-square tests with Yates
correction and the Fisher exact test were applied where
indicated, for the comparison of independent variables.
Paired data were analyzed by means of the Friedman
and Wilcoxon tests. The SPSS statistical package (ver-
sion 6Æ0.1) for Windows was used throughout.
Results
Table 1 shows that 15 patients presented TMD at the
initial evaluation – a figure that increased to 19 after
treatment (although the difference was not significant).
The TMD severity was mild, with a mean panto-
graphic reproducibility index (PRI) of 20Æ71. The
grinders scored highest up to moderate TMD severity
†
Dentatus ARL, Hägersten, Sweden.
‡
Myotronics Inc., Seattle, WA, USA.
860 A . A L V A R E Z - A R E N A L et al.

Table 1. Temporomandibular disorders (TMD) and pantographic total sample. In no case were crepitants identified. The
reproducibility index (PRI) in bruxing patients occlusal splint improved the percentage of joints with
clicks to a greater extent than TENS, although here
TMD
again the difference was not statistically significant
No Yes PRI value (Table 2).
n 9* 15* 20Æ71* Only two or three patients referred pain in either
5† 19† 18Æ00† temporomandibular joint (TMJ), in the temporal region
5‡ 19‡ 14Æ75‡ (headache), neck or nape region, or in other cranio-
Grinding 6* 5* 27Æ18* facial zones. Following treatments, only one patient
3† 8† 21Æ81† referred pain in the neck or nape region (Table 3).
4‡ 7‡ 15Æ09‡ Tenderness to muscle or joint palpation was likewise
Clenching 3* 10* 15Æ23* irrelevant, as can be seen in Table 4. Of all the muscles
2† 11† 14Æ76† explored, the lateral pterygoids were most often hyper-
1‡ 12‡ 14Æ46‡ sensitive, with over two-thirds of the patients referring
P-value ns ns 0Æ003 for *; ns tenderness in this zone; an intensity of (+++) was
for † and ‡ recorded in almost half of the cases. The clenchers were
*Before treatment. the most affected group, although no significant differ-
†
After treatment with occlusal splint. ences were observed with respect to the grinders. The
‡
After TENS treatment. occlusal splint and TENS failed to improve muscle or
ns: Not significant. joint tenderness. Indeed, as can be seen in Table 4, pain
in response to muscle palpation actually increased after
(27Æ18), with significant differences versus the clenc- the treatments.
hers. On comparing the PRI after treatment, the
application of TENS was seen to reduce the PRI scores
Discussion
slightly with respect to the fitting of an occlusal splint –
although the difference was not statistically significant. The results of the present study indicate an association
During opening and closing of the mouth, clicks between bruxism and TMD, regardless of whether the
involving one joint or the other were recorded in 10 diagnosis is established by clinical exploration or via the
patients. Reciprocal clicking was observed in 25% of the PRI. Over 60% of the bruxing patients presented TMD.

Table 2. Clicks recorded in temporomandibular joints (TMJ)

Right TMJ Left TMJ Either TMJ

Oral opening Oral opening Oral opening Oral opening Oral opening Oral opening
or closing and closing or closing and closing or closing and closing

n 11* 5* 10* 5* 10* 6*

8† 9† 6† 10† 7† 10†
9‡ 10‡ 9‡ 10† 9‡ 10‡

Grinding 6* 2* 5* 2* 6* 2*
4† 3† 4† 3† 4† 3†
4‡ 5‡ 4‡ 5‡ 4‡ 5‡

Clenching 5* 3* 5* 3* 4* 4*
4† 6† 2† 7† 3† 7†
5‡ 5‡ 5‡ 5‡ 5‡ 5‡

P-value ns ns ns

*Before treatment.
†
After treatment with occlusal splint.
‡
After TENS treatment.
ns: Not significant.

ª 2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 858–863

 EFFECT OF OCCLUSAL SPLINT AND TENS ON THE SIGNS AND SYMPTOMS OF 861
TMD
Table 3. Pain sensitivity (tenderness) referred by the patients In the present study, the occlusal splint and TENS
increased the percentage of individuals with TMD. This
Some Temporal Neck or Other
is in conflict with the findings of the literature, where
TMJ (temples) nape zones
splint treatment is unanimously considered to improve
n 2* 2* 3* 2* TMD in both bruxing (Sheikholeslam et al., 1993) and
0† 0† 0† 0†
non-bruxing subjects (Naeije & Hansson, 1991). This
0‡ 0‡ 1‡ 0‡
discrepancy could be explained by the criterion used to
Grinding 0* 1* 3* 1* diagnose TMD, the fluctuating severity of the signs and
0† 0† 0† 0†
symptoms (which can change on a weekly or even daily
0‡ 0‡ 1‡ 0‡
basis), intra-observer variability, and the questionabil-
Clenching 2* 1* 0* 1*
ity of the PRI – despite its apparent consistency (Beard,
0† 0† 0† 0†
Clayton & Myers, 1984; Clayton & Beard, 1986).
0‡ 0‡ 0‡ 0‡
In the same line, most of the patients in our series
P-value ns ns ns ns
referred no muscle or joint pain, and palpation elicited
*Before treatment. no pain response except in the lateral pterygoid
†
After treatment with occlusal splint. muscles. The literature reports a 50% (Yustin et al.,
‡
After TENS treatment. 1993) and even 90% (Sheikholeslam et al., 1993)
ns: Not significant.
incidence of headache and tenderness in the temporal
region and in the temporal and masseter muscles,
This percentage coincides with those reported by other among bruxing individuals. However, our findings do
authors (Lundh et al., 1985; Allen et al., 1990), and is not support the hypothesis found in the literature that
even lower than the percentage described in relation to bruxism contributes to cause or sustain TMD (Abraham
nocturnal bruxism (Abraham et al., 1992; Yustin et al., et al., 1992; Kampe et al., 1997). In any case, over two-
1993). Nevertheless, it should be taken into account thirds of the bruxing individuals suffered pain in the
that while some authors point to a relation between lateral pterygoid muscles – these being considered the
bruxism and TMD, others have observed no such muscles fundamentally associated with TMD.
association (Marbach et al., 1990; Kieser & Groeneveld, Of note in the present study was the observation
1998). In any case, the initial TMD in our series was that one-third of the patients showed painful hyper-
mild, as assessed by the PRI, and remained so after both sensitivity in the sternocleidomastoid and trapezius
treatments. muscles – suggesting the existence of an alteration in

Table 4. Muscle and joint hypersensitivity to palpation

Some Temporal or Coronoid Lateral Medial

TMJ masseter process pterygoid pterygoid Digastric Sternocl. Trapezius

n 4* 4* 10* 17* 8* 1* 7* 6*
4† 7† 15† 19† 9† 1† 7† 6†
4‡ 7‡ 13‡ 18‡ 8‡ 0‡ 7‡ 6‡

Grinding 1* 1* 4* 7* 5* 0* 2* 3*
1† 1† 7† 4† 4† 0† 2† 1†
0‡ 2‡ 4‡ 7‡ 5‡ 0‡ 0‡ 2‡

Clenching 3* 3* 6* 10* 3* 1* 5* 3*
3† 6† 8† 15† 5† 1† 5† 5†
4‡ 5‡ 9‡ 11‡ 3‡ 0‡ 7‡ 4‡

P-value ns ns ns ns ns ns ns ns

*Before treatment.
†
After treatment with occlusal splint.
‡
After TENS treatment.
ns: Not significant.

ª 2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 858–863

862 A . A L V A R E Z - A R E N A L et al.
the positioning and balancing of the head and neck as a
result of bruxism and ⁄ or occlusal alterations, with
sustained contraction of these muscles to ensure hori-
zontal gaze and normal stomatognathic function (Gola,
Chossegros & Orthieb, 1992). In one of the few studies
to perform electromyographic recordings with assess-
ment of sternocleidomastoid pain sensitivity, Kohno,
Yoshida and Freesmeyer (1992) showed this muscle to
be more active on the working than on the balancing
side, and during mandibular movements to right and
left, in eccentric bruxism. According to these authors,
the observed muscle pain would be attributable to
occlusal interferences, contacts under hyper-balancing
conditions, and bruxing activity.
In the present study, the occlusal splint and TENS
were unable to control or reduce painful muscle and
joint hypersensitivity. Most authors consider that
occlusal splints provide relief symptoms in close to
90% of patients with bruxism (Sheikholeslam et al.,
1993) or TMD (Suvinen & Reade, 1989; Naeije &
Hansson, 1991; Yatani et al., 1998). Myogenic headache
and hypersensitivity of the masticatory muscles are the
manifestations that improve most significantly (List
et al., 1992; Turk, Hussein & Rudy, 1993). In contrast,
tenderness of the coronoid process usually persists
(Sheikholeslam et al., 1993), as also suggested by our
findings. However, Magnusson and Carlsson (1980)
question the action of occlusal splints, since they
observed no significant reduction in joint pain in their
series of patients with TMD.
The literature accepts that occlusal splint failure to
control pain is associated with the existence of psycho-
logical and mood alterations (Suvinen & Reade, 1989).
In the present study, we believe the cause of ineffec-
tiveness to have been the mild nature and scant
symptoms of TMD in most of the bruxing individuals.
Joint sounds (clicks), considered to be the second
most frequent sign of TMD, were only moderately
prevalent in our series – clicking being recorded in
almost half of the bruxing patients (with reciprocal
clicking in 25% of these cases). These data agree with
the observations of other authors (Yustin et al., 1993),
and are similar to those referred in patients with TMD
and in the asymptomatic population (Wabeke et al.,
1989; Dibbets & Van der Weele, 1992; Pöllmann, 1993).
Thus, we believe that bruxism is not an important
factor in the establishment and development of joint
sounds. The scant improvement in such sounds recor-
ded in our study – with even a qualitative increase as
ª 2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 858–863
reflected by the enhanced reciprocal clicking observed
after occlusal splint treatment and TENS – confirms
the findings of other authors (Lundh et al., 1985;
Sheikholeslam et al., 1993; Yap, 1998). However, we
cannot affirm that stabilization splints are ineffective for
controlling joint noises, as many studies have reported
a decrease or weakening of such sounds in a large
percentage of patients with TMD (Chong-Shan &
Hui-Yun, 1989; Skeppar & Nilner, 1993).
Conclusions
1. The prevalence of TMD was 62Æ5% in the bruxing
population studied – the PRI showing a predominance
of mild cases.
2. Painful hypersensitivity of the joints and masticatory
muscles was irrelevant in our series.
3. Clicking and pain affecting the lateral pterygoid
muscle and coronoid process were the most prevalent
findings in our patients.
4. Occlusal splint treatment and TENS failed to improve
the signs and symptoms of TMD in the bruxing
individuals.
5. No significant differences were observed between
clenchers and grinders among the bruxing population,
either before or after treatment.
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Correspondence: A. Alvarez-Arenal, Escuela de Estomatologtı́a, Uni-
versidad de Oviedo, Catedrático José Serrano s ⁄ n. 33009, Oviedo,
Spain.
E-mail: junquera@sci.cpd.uniovi.es