Low level laser therapy of
tinnitus - a case for the dentist?
Jan Tunér DDS, Swedish Laser-Medical Society
Tinnitus is a debilitating condition with an increasing incidence, especially
among the young generation, due to intensive sound levels at concerts
and in headsets. It is, however, not solely a problem of the modern
world. The condition is described in papyrus documents dating back 600
BC. Some famous historic persons have suffered from tinnitus, such as
Martin Luther, Jean-Jaques Rousseau and Ludwig van Beethoven. It is
estimated that roughly one person in ten is affected by tinnitus of
some degree. The origin of tinnitus is controversial. It is claimed
that tinnitus is located in the inner ear but also that it actually
is situated in the brain cortex, as evidenced by PET-scanning. It is
reasonable to beleive that the condition can have several origins and
that one of these then is of interest to the dentist. Low level lasers
have been claimed to have a therapeutic effect on tinnitus and vertigo.
In these cases the irradiation has been directed towards the cochlea.
Low level laser therapy (LLLT) is also reported to be useful in the
treatment of temporo-mandibular disorders (TMD). Furthermore, some patients
are cured from their tinnitus when a proper TMD therapy has been performed.
It now also appears that low level lasers can be used to advantage in
the treatment of TMD-related tinnitus, and without actually irradiating
the inner ear.
LOW LEVEL LASERS
Since the beginning of the 80's low level lasers have become increasingly
popular as an additional treatment possibility in many professions,
such as chiropractors, naprapaths and physiotherapists but not so much
in traditional medicine and dentistry. In spite of more that 100 positive
double blind studies there remains a sceptical attitude. In dentistry
alone, more than 90% of the published studies show positive results.
It is true that several studies have failed to show any result, but
it is not uncommon for such studies to contain serious flaw . And
it is not to be expected that any dosage or any wavelength of low level
laser will produce a biological response.
Low level lasers are generally in the visible - near visible range of
the spectrum. The most common types are HeNe (633 nm), InGaAlP (630-685
nm), GaAlAs (780-870 nm) and GaAs (904 nm). Power output in the beginning
ranged from 1-10 mW. With the advent of less expensive diodes the power
has increased considerably and GaAlAs lasers are now available with
power of even 1 000 mW (1 Watt). Increased dosage and power density
have proven to be important and the clinical results have consequently
been improved. Suitable dosage varies depending on the condition and
the depth of the target tissue, but generally 4-20 J/cm2 are applied.
Red laser light is optimal for superficial conditions such as mucosa
and skin whereas infrared is better for pain and deeper lying conditions
because of its superior penetration.
Biological responses of cells to laser irradiation are suggested 
to occur due to physical and/or chemical changes in photoacceptor molecules,
components of the respiratory chain like cytochrome c oxidase and NADH-dehydrogenase.
Hypotheses about primary mechanisms at the interface of laser irradiation
and tissue are redox properties alterations, NO release, superoxide
anion reactions, singlet oxygen production and local transient heating
of chromophores. Further, secondary processes are triggered where the
mechanisms are performed "in the dark". Thus, distant effects
can be obtained far from the irradiated area. The redox-regulation mechanism
may explain the positive effect of tissues characterized by acidosis
LOW LEVEL LASER OF TINNITUS - THE LITERATURE
Low level laser therapy (LLLT) has been suggested as a possible therapy
for tinnitus. Several studies have used Ginkgo biloba infusions in combination
with LLLT, the former being a widespread but not well documented therapy
for tinnitus. The number of studies are few and they will be briefly
described in the following.
Witt  is one of the pioneers in this field, but to the knowledge
of the author his results have not been published in any peer-review
journal. Witt combines infusion of Gingko biloba (Egb 761, 17.5 mg dry
extract per 5 ml amouple)) and laser. This may be a favourable combination
but an evaluation of the contribution of the laser is not possible.
More than 500 patients have been treated since 1989 and Witt claims
that more than 60% of the patients have reached a considerable or total
relief . The laser used is a combination of HeNe 12 mW/GaAs 5 x 10 mW.
Treatment technique not stated.
Swoboda  did not find any significant effect of Gingo/laser. However,
the ginkgo infusion used was at a homeopathic level (D3 = 1:1000 dilution),
acc. to Witt.
Partheniadis-Stumpf  also failed to find any effect from the combined
ginkgo (6 ml Tebonin) infusion and laser. However, the laser was applied
at a distance of one cm above the mastoid. The non-contact mode reduces
penetration considerably and the mastoid is not ideal for reaching the
Plath  treated 40 tinnitus patients with 50 mg Ginkgo biloba. 20
patients received sham laser irradiation, 20 real laser. A HeNe 12 mW/GaAs
5 x 15 mW GaAs laser was used, irradiation procedure approximately the
same as for Partheniadis-Stumpf. In this study, 50% of the patients
reported a reduction of the tinnitus of more than 10 dB, compared with
5% in the control group, in both self-assessment and audiometric findings.
A similar study has been performed by von Wedel . 155 patients were
treated with Ginkgo infusion (5 ml Syxyl D3) and laser. The outcome
was negative. No information about the type of laser, treatment technique
or dosage is given, making an evaluation impossible.
Shiomi  has investigated the effect of infrared laser applied directly
into the meatus acusticus, 21 J, once a week for 10 weeks. The result
of this non-controlled study is as follows: 26% of the patients reported
improved duration, 58% reduced loudness and 55% reported a general reduction
The same author  has also examined the effect of light on the cochlea,
using guinea pigs. Direct laser irradiation was administred to the cochlea
through the round window and the amplitude of CAP was reduced to 53-83%
immediately after the onset of irradiation. The amplitude then returned
to the original level. The results of this investigation suggest that
LLLT might lessen tinnitus by suppressing the abnormal excitation of
the 8th nerve or the organ of Corti.
More or less the same parameters were used in a controled study by
Mirtz  but in this case there was no significant effect.
Wilden   has applied a different method where the dose has
been increased considerably. A set consisting of one HeNe laser and
three powerful GaAlAs lasers is used, covering a large area over and
around the ear, in the non-contact mode. Doses between 3.000 and 5.000
J are given each session. Laser is applied as a monotherapy. More than
800 patients have been treated with this concept and positive effects
are reported, even for vertigo. Recent injuries in "the disco generation"
are more easily treated than long-term chronic conditions. In a separate
study  Wilden reports improvment of the hearing capacity of these
patients, as evaluated by audiometry.
Beyer  has performed a very exact ex-vivo laser penetration study.
Based on these findings it was possible to calculate the energy needed
to obtain a dose of 4 J/cm2 in the cochlea itself. 30 patient were treated
five times within 2 weeks. One group was irradiated with 635 nm diode
laser, the other with 830 nm diode laser. By self-assessment around
40% of the patients reported a slight to significant attenuation of
the tinnitus loudness of the irradiated ear. This study has been followed
by a double blind study.
Prochazka  has evaluated the effect of combined Egb 761 Ginkgo
infusion and laser in a double blind study. 37 patients were divided
into three groups. One group had Egb 761 only, one Egb761 and placebo
laser, one Egb761 and real laser, 830 nm. The results in the three groups
were as follows: no effect 29/26/19, less than 50% relief 44/48/29,
more than 50% relief 18/26/36, no more tinnitus 9/0/26. Irradiation
was performed over the mastoid and over the meatus acusticus, twice
a week, 8-10 sessions, total 175 J.
Rogowski  divided a group of 32 tinnitus patients into one group
receiving LLLT and one receiving a placebo procedure. Dose, wavelength
and treatment technique not stated in the available English abstract.
The effect was evaluated through VAS. Within the patient group transiently
evoked otoacoustic emissions (TEOAE) were measured before, during and
after therapy. No significant difference between laser and placebo was
found in annoyance or loudness of the tinnitus and in changes of TEOAE
amplitude. These results indicate that there is no relationship between
the effect of low-power laser and changes in cochlear micromechanics.
A few other indications in otorhinolaryngology have been treated with
low level lasers, even with intravenous irradiation. [17-20]
It is obvious that the available literature on laser therapy of tinnitus
is scarse and ambiguous. Some studies have used a combination of Ginkgo
and laser, others laser as monotherapy. Differences in wavelengths,
pulsing, dosage and treatment technique makes a firm evaluation impossible.
However, the positive results reported in some studies do merit attention
and further research. Recent clinical experience also suggests that
the doses necessary for successful outcome of the therapy have to be
increased considerably. Tinnitus is a grave condition, sometimes leading
to suicide. It is also an increasing problem and the existing treatment
modalities offered to tinnitus patients are not very effective. Young
persons suffering from acoustic chocks (concerts, discos) can be more
successfully treated with laser therapy. Understandably enough, a long
standing condition in elderly persons is a severe condition taking 10-20
sessions to influence.
LASER THERAPY OF TMD
The following is an account of some studies published in the field of
low level laser therapy for TMD.
Hansson  studied the effects of GaAs laser on arthritis of the temporo-mandibular
joint. The author stresses that lasers are not an alternative to conventional
treatment, but that it seems possible to reduce healing periods and
more quickly reduce inflammation.
Bezuur and Hansson  treated a group of 27 patients suffering from
long-term problems related to TMD with a GaAs laser. The treatment was
administered over the joint on five consecutive days. 80% of the 15
patients with arthrogenous pain experienced total pain relief. The maximum
jaw-opening ability increased during the treatment period, and continued
to increase during the year that the group was monitored. The group
suffering from myogenic problems also improved, both in terms of pain
and jaw-opening ability. The effect here was, however, much lower. As
the muscles were not treated, it is assumed that this group also had
undiagnosed arthritis. The reduction of joint sounds may possibly have
been due to an increase of metabolism in articular cell structures,
e.g. an activation of the synovial membrane, producing more synovial
Eckerdal  reports on the clinical experience of a 5-year non-controlled
study of perioral neurapathias. The treated diagnoses were trigeminal
neuralgia, atypical facial pain, paresthesias, and TMD pain. Of these
diagnoses, the TMD pain group was the most successful one. At the end
of treatment, 73% of the patients (N = 40) had a good response, at six
months still 73%, and at one year 70%. 10 J/cm2 was applied to the joint
over 4-8 sessions.
In a study comprising 75 cases, Bradley  found LLLT effective as
a monotherapy when treating acute joint pain (less than eight weeks
duration). In more chronic cases, without bone changes on X-ray, LLLT
was used as an adjunct to splints and the like. In osteoarthritic cases,
LLLT can be almost as useful as intra-articular steroids.
Bradley  used GaAs laser acupuncture when treating a small group
of patients suffering from TMJ pain dysfunction syndrome who had not
responded to treatment with a bite splint or psychotropic medicine.
Needle acupuncture was used in a comparative group. Both types of acupuncture
can be studied with thermography. Biostimulation was observed to yield
vascular effects which locally resemble the vascular effects achieved
with needle acupuncture, although it takes more time for laser stimulation
to take effect. Both forms of acupuncture were more effective on known
acupuncture points than on randomly chosen points. St 6 was used throughout
as a "known acupuncture point".
Kim  divided a group of 36 patients with maxillary joint problems
into three therapy groups. The patients were treated with bite splints,
GaAlAs laser treatment, or laser acupuncture. The treatment results
were compared after two and four weeks with a check on status before
treatment. The following conclusions were drawn: The patients' subjective
discomfort was reduced in both the bite splint and laser treatment groups.
The improvement in the laser group was much greater than in the bite
splint group. Clinically observable symptoms showed a significant reduction
in all groups, but the group treated with laser light responded faster
to treatment than the other groups. EMG activity gradually decreased
in all the groups - and without any great difference between groups.
Laser treatment had more beneficial effects than bite splints, while
laser acupuncture produced the poorest results.
Lopez  treated a group of 168 patients with problems related to
TMD with a combination of bite splints and HeNe laser. An obvious improvement
could be observed in 52 of the patients after a single treatment. After
ten treatments, 90% of the patients had improved. No further improvement
was brought about in the other 10% by administering further treatments.
The laser treatment was given directly over the maxillary joint - 6
mW for five minutes (1.8 J). The extent of healing was inspected using
a tomographic X-ray before treatment and after six months. At that point,
healing had advanced to a stage usually seen after 12 to 18 months when
only a bite splint is used. In a group of 88 patients with pains in
the jaw muscles, pain was alleviated for up to six hours, but without
lasting results. The author concluded that HeNe lasers are effective
as a complementary method to bite splints when treating arthrosis and
arthritis, but that this wavelength is not optimal for myogenic pain.
Hatano  used a GaAlAs laser to study the effect on palpation pain
in 15 patients with TMD. A 30 mW laser was used for 3 minutes (5.4 J)
in the area of one temporo-mandibular joint. The other side served as
control. Palpation score was estimated directly after irradiation and
at 20, 40, and 60 minutes after irradiation. There was a significant
decrease in palpation pain with better values at 20, 40, and 60 minutes
than directly after irradiation.
Bertolucci  compared two groups of patients (16+16) receiving physical
therapy for mandibular dysfunction. One group received sham irradiation,
the other GaAs during three weeks. The results were as follows (treatment
group/placebo group): change in pain 40.25/1.56; change in vertical
opening 1.35/-0.05; change in left and right deviation 3.78/0.62.
Interleukin-1b in the synovial fluid is associated with TMD pain .
In a study by Shimizu , GaAlAs laser light influenced the production
of this substance.
Ivanov  treated 109 patients with temporomandibular joint arthritis
and arthrosis with an HeNe laser (12 mJ/cm2, 3-7 treatments). 89% of
the patients reported clinical improvement.
In a double blind study by Sattayut , the higher doses (20 J per
point, 300 mW) were clearly more effective than 4 J and 60 mW . In this
study GaAlAs was used as monotherapy. Following a period of 2-4 weeks
after therapy (3 sessions in one week) there was an average of 52% reduction
of pain as assessed by SSI pain questionaire.
CMD, TMD, LLLT AND TINNITUS
It has been know for decades that patients with temporo-mandibular joint
dysfunction (TMD) and crano-mandibular disorders (CMD) also may have
tinnitus problems, and that there is a connection between the two.
In a book by Myrhaug , the author underlines the fact that there
are two muscles in the inner ear which are innervated by two facial
nerves. M. tensor tympani is innervated by n. trigeminus and m. stapedius
is innervated by n. facialis. Intensive action in the masticatory muscles
could therefore influence these two small muscles as well and thereby
cause the tinnitus sensation.
Bjorne  compared a group of 31 patients suffering from Ménière's
disease with a control group, matched for sex and age. The patients
in the Ménière group had statistically significant more
signs of crano-mandibular disorders, such as tenderness to palpation
upon the masticatory muscles, of the temporo-mandibular joint, upper
part of the trapezius in the area of the atlas, the axis and the third
In a second study by Bjorne  24 of the 31 patients from the previous
study were compared with 24 control subjects regarding the frequency
of signs and symptoms of cervical spine disorders. Symptoms of cervical
spine disorders as head and neck/shoulder pain, and signs as limitations
in side-bending and rotation movements were more frequent in the patient
group as well as tenderness to palpation of the neck muscles. 39% of
the Ménière patients could influence their tinnitus, both
sound level and pitch, by protrusion or lateral movement of the mandible
or by clenching their teeth. 75% of the patients could trigger their
attacks of vertigo by extension, flexion or side-rotation of the head
A correlation between tinnitus and tension of the lateral pterygoid
muscle has also been found . Further correlation between signs and
symptoms of TMD and tinnitus is indicated in studies by Rubenstein 
and Ciancaglini .
Wong  reports that the styloid process and its attachments are
often the center of TMD problems and that no less than 11 symptoms have
been observed in connection with soft tissue lesions in this region,
one of them being tinnitus. The muscular symptoms are suitable for low
level laser therapy acc. to the authors.
There is reason to beleive that a subgroup of the tinnitus (and vertigo)
patients actually have a primary crano-temporo-mandibular dysfunction
problem and that the tinnitus sensation is a secondary phenomenon. A
greater awareness of this possibility and a closer cooperation between
otorhinologists and dentists would probably reduce the problems of the
patients in this subgroup. The size of this group is unknown, since
the CMD relation is seldom diagnosed, nor treated. The correlation between
Mènière's disease and CMD seems to be more frequent than
the correlation between an isolated tinnitus problem and CMD.
Some of these patients in the mentioned subgroup can change the intensity
or pitch of their tinnitus by clenching or opening their mouth wide,
and in some cases even by changing the position of their head. Irradiating
a muscle involved in the creation of the tinnitus phenomenon can alter
the carachter of the tinnitus. This offers a possibility of an initial
diagnosis of the type of tinnitus. It is not unusal for the tinnitus
sensation to disappear temporarily after laser irradiation. Repeated
irradiation can keep the patient free of tinnitus and also make the
patient more aware of the hypertension in the muscles.
CMD/TMD is a very common condition and the suggested treatment modalities
are multifold. Occulsal splints and elimination of occlusal interferences
are standard procedures but the scientific documentation of these, and
other treatment modalities are still poor, although the clinical experience
seems to verify their effectiveness.
The concept of treating tinnitus and vertigo patients through occlusal
stablisation is not new but so far not very much explored. Adding low
level laser irradiation to this therapy is even less explored and there
is very little research. The objective of this article is not to give
precise recommendations about treatment procedures but rather to put
the light on the possibility for the dentist to improve the quality
of life of many vertigo and tinnitus patients and that the dentist could
play an important role in this treatment. Further research is warranted.
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