Journal of Electromyography and Kinesiology 22 (2012) 463–468

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Journal of Electromyography and Kinesiology

journal homepage: www.elsevier.com/locate/jelekin

Effects of transcutaneous electrical nervous stimulation on electromyographic and

kinesiographic activity of patients with temporomandibular disorders: A
placebo-controlled study
Annalisa Monaco ⇑, Fabrizio Sgolastra, Irma Ciarrocchi, Ruggero Cattaneo
University of L’Aquila, Department of Health Sciences, L’Aquila, Italy

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to assess the effect of a single 60 min TENS application on sEMG and kin-
Received 25 September 2011 esiographic activity in TMD patients in remission, and to assess the sEMG and kinesiographic effect of
Received in revised form 20 October 2011 TENS in placebo and untreated groups. Sixty female subjects, selected according to the inclusion/exclu-
Accepted 12 December 2011
sion criteria, suffering from unilateral TMD in remission were assigned to one of the following group:
Group TENS, that received a single session of 60 min of TENS; Group Placebo that received a single session
of 60 min of sham TENS; Group Control, that received no treatment. Pre- and post-treatment differences
Keywords:
sEMG
in sEMG of TA, MM, SCM, and DA and interocclusal distance values within groups were tested using the
Kinesiography Wilcoxon test. Differences in sEMG and kinesiographic data, among the three groups, were assessed by
TMD Kruskal–Wallis test. Significant differences were only observed in the TENS group, for masticatory mus-
Neck muscles cles of both sides; one-way analysis of variance revealed that sEMG values of masticatory muscles of both
Mandible sides in the TENS group were significantly reduced, in comparison with placebo and control groups. Kin-
esiographic results showed that the vertical component of the interocclusal distance was significantly
increased after TENS only in the TENS group. TENS could be effective to reduce the sEMG activity of mas-
ticatory muscles and to improve the interocclusal distance of TMD patients in remission; the placebo
effect seems not present in the TENS application.
Ó 2011 Elsevier Ltd. All rights reserved.

1. Introduction that could be integrated by several questionaries used for anam-

Temporomandibular disorders (TMD) refer to a collection of
general and oro-facial conditions affecting the physiology of the
temporomandibular joint (TMJ), the masticatory muscles, and the
contiguous tissue components (NIH, 1996; Thilander et al.,
2002); even if several research have been conducted to elucidate
the aetiology of TMD, currently, its nature has not been completely
understood yet (Tartaglia et al., 2011; Epker et al., 1999; Iwasaki
et al., 2010; Santana-Mora et al., 2009). However, it is well known
that TMD could affect the neuromuscular activity of masticatory
muscles, both at rest and during functional activity, such as masti-
cation (Henrikson et al., 1998; Sato et al., 1999; Peroz and Tai,
2002; Kurita et al., 2001), determining a reduction in bite-force
and muscular fatigue; furthermore, these conditions could nega-
tively influence the global quality of life of patients (De Felício
et al., 2009; Dworkin and LeResche, 1992). Diagnosis of TMD is
mainly based on clinical examination (Klasser and Okeson, 2006),
⇑ Corresponding author. Address: University of L’Aquila, Department of Health
Sciences, Unit of Gnathology, Via Vetoio 1, 67100 L’Aquila, Italy. Tel.: +39 0862
433837.
E-mail address: annalisamonaco@yahoo.it (A. Monaco).
nestic purpose, such as RDC/TMD, or for clinical assessment.
Surface electromyography (sEMG) has been proposed as
supplemental tool in TMD diagnosis, since it could provide an
objective recording of muscular activity (Castroflorio et al., 2005;
Ferrario et al., 2007; Tartaglia et al., 2011), at rest and during
functional activity, in an in-office and non-invasive way.
Among different treatment strategies used in the treatment of
TMD, transcutaneous electrical nervous stimulation (TENS) has
been proposed (Jankelson, 1969; Jankelson and Swain, 1972; Talley
et al., 1990): it is mainly used for the antalgic effect that could pro-
duce in symptomatic patients and for the positive relaxing effect
that is exerted in the masticatory muscles (Gold et al., 1983); how-
ever, the antalgic effect of TENS application is still a debated ques-
tion, since contrasting results have been reported in literature and
the possibility of a placebo effect has been suggested (Oosterhof
et al., 2008; Rakel and Frantz, 2003; Rakel et al., 2010). In addition,
the effect of TENS application on sEMG activity of masticatory
muscles has been poorly investigated: indeed, only two study
(Rodrigues et al., 2004; Cooper and Kleinberg, 2008) investigated
the effect of TENS on sEMG activity of masticatory muscles, report-
ing a reduced sEMG activity of hyperactive muscles and an in-
creased activity of masseter muscles during maximum voluntary

1050-6411/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jelekin.2011.12.008
464 A. Monaco et al. / Journal of Electromyography and Kinesiology 22 (2012) 463–468
clenching (Rodrigues et al., 2004); however, these studies used a
long TENS application time (from 45 to 60 min) in symptomatic
patients; furthermore, none of the studies analyzed kinesiographic
changes after TENS application.
However, to the best of our knowledge, no study comparing the
effect of TENS on sEMG and kinesiographic activity of TMD pa-
tients, as well the effect of placebo TENS, with untreated patients,
have been performed.
Therefore, the aim of the present study was to assess the effect
of a single 60 min TENS application on sEMG and kinesiographic
activity in asymptomatic TMD patients, and to assess the sEMG
and kinesiographic effect of TENS in placebo and untreated groups.
2. Materials and methods
2.1. Subjects
This study was conducted in accordance with the Declaration of
Helsinki. The Committee on Ethics in Science of the University of
L’Aquila, L’Aquila, Italy approved the study and informed consent
was obtained from each subject.
Sixty female subjects suffering from unilateral TMD in remis-
sion at least from 3 months, aged 22–30 years-old (median age =
26 years), were recruited and divided into three group: twenty pa-
tients were assigned to a single session of 60 min of TENS (Group
TENS); twenty patients undergone a single session of 60 min of
sham TENS (Group Placebo); twenty patients received a delayed
TENS treatment after the end of the study, and, therefore, this
group received no treatment during the entire duration of the
study (Group Control).
2.2. Selection criteria
Jaw elevator muscle activity can be influenced by oro-facial
pain (Svensson et al., 2004), gender (Sarlani and Greenspan,
2005), age (Fogle and Glaros, 1995), occlusion (Del Palomar et al.,
2008), and hemispheric-dominance (Pirttiniemi, 1998). For this
reason, only patients that fulfilled the following inclusion criteria
were included in the study: age less than 30 years; female gender;
right-handed (7–10 points in Edinburgh inventory; Oldfiel, 1971);
presence of complete permanent dentition, with the exception of
the third molars; normal occlusion; and diagnosis of unilateral
arthrogenous TMD on the Research Diagnostic Criteria for TMD
(RDC/TMD)(Dworkin and LeResche, 1992; Epker et al., 1999), Axis
I, groups II and III. Patients were excluded from the study if they
met one or more of the following exclusion criteria: having pace-
maker or other electrical devices, previous experience of TENS or
biofeedback, systemic diseases; history of local or general trauma;
neurological or psychiatric disorders, muscular diseases; cervical
pain; bruxism, diagnosed by the presence of parafunctional facets
and/or anamnesis of parafunctional tooth clenching and/or grind-
ing; pregnancy; assumption of anti-inflammatory, analgesic, anti-
depressant or myorelaxant drugs; fixed or removable prostheses;
fixed restorations that affected the occlusal surfaces; or previous
or concurrent orthodontic or orthognathic treatment.
2.3. sEMG, TENS and kinesiographic measurements
All examinations were performed by one examiner, who was
previously calibrated with an expert in electromyographic and kin-
esiographic recordings and TENS use. An 8-channel surface electro-
myograph with simultaneous acquisition, common grounding to
all channels, and filters of 50 Hz electromyography (K7/EMG, Myo-
tronics-Noromed, Inc., Tukwila WA, USA), with disposable elec-
trodes (Duotrode, bipolar surface electrodes Ag–AgCl, 20 mm
center to center distance, Myotronics-Noromed, Inc., Tukwila
WA, USA) was used for sEMG recording. The right masseter
(RMM), left masseter (LMM), right anterior temporal (RTA), left
anterior temporal (LTA), right digastric (RDA), left digastric (LDA),
right sternocleidomastoid (RSCM), and left sternocleidomastoid
(LSCM) muscles were recorded. The sEMG recordings and muscle
activity was expressed as the root mean square (rms) of the ampli-
tude, expressed in lV (Van der Bilt et al., 2001). Kinesiographic
recordings were performed using a kinesiograph (K7/CMS; Myo-
tronics-Noromed, Inc., Tukwila, WA, USA) that measures jaw
movements with an accuracy of 0.1 mm. An array of lightweight
(113 g) multiple sensors (Hall effect) containing 8 magnetic sen-
sors, tracks the motion of a magnet (CMS Magnet; Myotronics-Nor-
omed, Inc., Tukwila WA, USA) attached at the lower interincisor
point. The kinesiograph was interfaced with a computer for data
storage and subsequent software analysis (K7 Program, Myotron-
ics-Noromed, Inc., Tukwila WA, USA).
For TENS application a J5 Myomonitor TENS Unit device (Myo-
tronics-Noromed, Inc., Tukwila, WA, USA), with disposable elec-
trodes (Myotrode SG Electrodes, Myotronics-Noromed, Inc.,
Tukwila, WA, USA) was used: this low-frequency neurostimulator
generates a repetitive synchronous and bilateral stimulus, deliv-
ered at 1.5 s intervals, with a variable amplitude of approximately
0–24 mA, a duration of 500 ls and a frequency of 0.66 Hz.
2.4. Positioning of sEMG, TENS electrodes and kinesiographic array
The electrodes determine, to a large extent, the quality of the
recordings (Tecco et al., 2011). Electrodes were positioned on the
left and right masseter muscles (LMM, RMM) and the left and
right anterior temporal muscles (LTA, RTA), as described by Cas-
troflorio et al. (2005a,b), as well as on the left and right anterior
digastric muscles (RDA, LDA) (Castro et al., 1999) and the left and
right sternocleidomastoid muscle (LSC, RSC) (Falla et al., 2002a,b),
bilaterally parallel to the muscular fibers and for sternocleido-
mastoid muscle over the lower portion of the muscle according
to Falla et al. (2002b) to avoid innervations point. A template
was used to enable the electrodes to be re-positioned in the same
position upon being repeated or if an electrode had to be re-
moved because of a malfunction. The ground electrode, which
was larger than the others and ensured very good contact with
the skin, was positioned on the subject’s forehead to ensure a
common reference to the amplifier’s differential input. The kinesi-
ographic array was mounted on the subject’s head, and the opti-
mal position of the magnet for kinematic movement recording
was monitored with the software. The two electrodes for TENS
were placed bilaterally over the cutaneous projection of the notch
of the V pair of cranial nerves, that is located between the coro-
noid and condylar process and was retrieved by manual palpation
of the zone anterior to the tragus, while a third grounding elec-
trode was placed in the center of the back of the neck (Cooper
and Kleinberg, 2008); however, since in the area of application
of TENS, fibers of VII pair of cranial nerves are present, the result
of TENS application is the motor stimulation of masticatory and
facial muscles.
2.5. Recording procedure
Electromyographic and kinesiographic recordings were con-
ducted with patients comfortably seated on a wooden chair with
a straight back; patients were asked to relax and assume a relaxed
position of the head. The measurements were performed in a silent
and comfortable environment. For sEMG recording, three consecu-
tive tracing, with a duration of 15 s, and without any interposing
phasic event, such as swallowing, voluntary movement or clench-
ing, were acquired with patient in mandible rest position (teeth
 A. Monaco et al. / Journal of Electromyography and Kinesiology 22 (2012) 463–468 465

not in contact). During the recordings, each subject was asked to
keep his/her eyes closed, maintaining light contact between his/
her lips. The participants received these instructions before the
recordings. For each patient, sEMG was recorded before and 1 h
after the single application of the TENS, while kinesiographic
measurements were recorded before and immediately after the
application of TENS. In the placebo group, patients were not in-
structed about the effect of TENS and, even if the electrodes were
placed as in the TENS group, no electricity was delivered to the
electrodes. In the control group patients were monitored at base-
line and after 1 h and received no treatment.
For kinesiographic recording, the patients were asked to close
their eyes and, starting from the mandible rest position, to oc-
clude teeth; after 2 s from occlusal contact, the patients were
asked to quickly open and return in occlusal contact (tap–tap
phase); for each patients at least 3 consecutive tap–tap phase
were recorded; the achievement of occlusal contact during each
tap–tap phase was assumed as the presence on the vertical com-
ponent (Fig. 1, Line blue) of the kinesiographic tracing of an hor-
izontal line located at the same height of first occlusal contact
(Fig. 1). After the tap–tap phase, the patients remain in the habit-
ual occlusion position for at least 1 s, then, they were asked to
protrude the mandible. Kinesiographic recording was started at
the end of the TENS session; the effect of TENS on kinesiographic
tracing could be observed in Fig. 1: indeed, in the mandible rest
position, in vertical, anterior–posterior and lateral tracks it is
possible to see a series of intermittent spikes that correspond to
the movements of the mandible, that are induced by TENS
application.
For kinesiographic measurements, the interocclusal distance
was recorded in its threedimensional component: verticality (de-
fined as the difference between basal and the highest level of the
blue line) (Fig. 1), anterior-posteriority (defined as the difference
between basal and highest level of the red line) (Fig. 1), and verti-
cality/anterior-posteriority (V/AP) ratio.
2.6. Statistical analysis
Statistical analysis was performed using STATA 10 (StataCorp LP,
College Station, TX, USA). The level of significance was assumed
to be p 6 0.01 for all tests. Assessment of examiner reliability was
performed using k statistics, assuming k = 0.61 as an acceptable
agreement score (Landis and Koch, 1977a,b). The Shapiro–Wilk test
indicated a non normal distribution of sEMG and kinesiographic
data, therefore, pre- and post-treatment differences in sEMG and
kinesiographic values within groups were tested using the Wilco-
xon test. Differences in sEMG and kinesiographic data, among the
three groups, were assessed by Kruskal–Wallis one-way analysis
of variance. Kinesiographic and sEMG data are expressed as means
and standard deviations (SD).
3. Results
The assessment of inter-examiners agreement revealed an
excellent reliability (k = 0.91). At baseline, no significant differ-
ence in sEMG and kinesiographic measurements was observed
among the three groups. At 1 h, a reduction in sEMG values
was observed for all investigated muscles in TENS and placebo
group; in the control group only RMM, LDA and RDA showed a
reduction; however, significant differences pre- and post-treat-
ment were only observed in the TENS group, for masticatory
muscles of both sides; one-way analysis of variance revealed that
sEMG values of masticatory muscles of both sides in the TENS
group were significantly reduced, in comparison with placebo
and control groups (Table 1). Kinesiographic results showed that
the vertical component of the interocclusal distance was signifi-
cantly higher after TENS, in the TENS group; furthermore, this dif-
ference was also significant if compared with placebo and control
group (Table 2).

Fig. 1. Kinesiographic track. Ver (Verticality/Blue line) refers to vertical component of the interocclusal distance; AP (Anterior-Posteriority/Red line) refers to anterior–
posterior component of interocclusal distance. Lat (Laterality/Green line) refer to lateral component of interocclusal distance. Line at the beginning of the track refers to basal
position of the mandible at rest position (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).
466 A. Monaco et al. / Journal of Electromyography and Kinesiology 22 (2012) 463–468

Table 1
Values of sEMG activity in the TENS, placebo and control group.

TENS PLACEBO CONTROL

Baseline 1h Baseline 1h Baseline 1h
LTA 2.79 (1.69) 1.62 (1.08)a,b 2.74 (1.39) 2.32 (1.65) 2.69 (1.25) 3.18 (1.93)
RTA 2.87 (1.76) 1.71 (1.13)a,b 2.83 (1.57) 2.56 (1.95) 2.93 (1.57) 3.36 (1.67)
LMM 1.59 (0.91) 1.17 (0.64)a,b 1.45 (1.11) 1.29 (1.04) 1.37 (1.19) 1.39 (1.26)
RMM 1.47 (1.01) 1.11 (0.77)a,b 1.43 (1.23) 1.31 (1.11) 1.51 (1.19) 1.42 (1.33)
LSM 2.44 (1.81) 2.23 (2.40) 2.42 (1.63) 2.38 (1.71) 2.19 (1.30) 2.38 (1.97)
RSM 2.28 (1.74) 2.24 (2.74) 2.41 (2.11) 2.36 (1.64) 2.46 (1.92) 2.65 (1.81)
LDA 1.99 (1.17) 1.79 (1.11) 1.83 (0.95) 1.79 (0.89) 1.79 (0.76) 1.64 (0.68)
RDA 2.16 (1.26) 1.95 (1.25) 1.97 (1.17) 1.85 (1.14) 1.94 (1.35) 1.89 (1.09)

Letters refer to significant change end of follow-up-baseline (a) or among groups (b).

Table 2
Kinesiographic values in the TENS, placebo and control group.

TENS PLACEBO CONTROL

Baseline After TENS Baseline After TENS Baseline After TENS
Verticality 1.23 (0.72) 3.03 (1.17)a,b 1.19 (0.71) 1.28 (1.28) 1.25 (0.79) 1.27 (1.09)
Anterior-posteriority 0.61 (0.36) 0.78 (0.51) 0.54 (0.51) 0.61 (0.33) 0.59(0.44) 0.64 (0.39)
V/AP Ratio 2.36 (1.18) 4.42 (3.06) 2.31 (1.09) 2.29 (1.26) 2.24 (1.18) 2.09 (1.46)

Letters refer to significant change end of follow-up-baseline (a) or among groups (b).

4. Discussion no additional study is available in literature, the placebo effect in

In the present study, the effect of TENS on sEMG activity and
kinesiographic pattern of patients with TMD in remission was
investigated; the results suggest that TENS is effective in reducing
the activity at rest of masseter and anterior temporalis muscles,
and in increasing the interocclusal distance. These results are in
agreement with those achieved by other studies (Rodrigues et al.,
2004; Cooper and Kleinberg, 2008): Cooper and Kleinberg (2008)
analyzed the effects of TENS on the sEMG activity, as well on the
symptoms of 313 patients suffering from symptomatic TMD: this
study found that TENS application reduced the sEMG activity of
masticatory muscles, as well as symptoms; however, even if the ef-
fect of TENS on sEMG values were evaluated before and immedi-
ately after the TENS application, changes in symptoms were
evaluated after one and three months, during which patients
underwent a treatment with orthosis; therefore, it is difficult to
state if the reduction of symptoms should be attributed to the
TENS application or to the orthosis treatment. However, Rodrigues
et al. (2004) evaluated the effect of TENS on sEMG activity and pain
of 19 patients suffering from TMD: a significant reduction on pain
level, as well on the sEMG activity of anterior temporalis muscles,
at rest, was observed. Accordingly, the results of the present study
showed that TENS application led to significant reduction in the
electromyographic activity of masticatory muscles, in patients
with TMD; however, it should be stressed that Cooper and Klein-
berg (2008) and Rodrigues et al. (2004) enrolled patients with
painful TMD; in the present study, instead, only patients with
TMD in remission were enrolled; the time of TENS application in
the present study was similar to that of Cooper and Kleinberg
(2008). However, it is difficult to state what is the time of
application that provide the great effect on the sEMG activity, since
no study comparing different times of TENS application is
available.
Interestingly, even if a slight but not significant reduction in
electromyographic and kinesiographic activity was observed in
the placebo group, no real placebo effect was observed: indeed,
the results of sEMG, as well of kinesiography, indicated that the
differences in the placebo group were not significant if compared
with control group, that received no treatment. However, since
TENS treatment should be further analyzed.
Even if surface EMG has been widely used in the clinical manage-
ment of TMD patients, it is not considered a reliable method for diag-
nosis and monitoring of TMD yet (Castroflorio et al., 2008; Klasser
and Okeson, 2006; Suvinen and Kemppainen, 2007). Indeed, several
shortcomings in the clinical application of this technique still limit
its use in the clinical practice: the most important problems relate
to the normalization/standardization of surface EMG recording,
since to compares EMG recordings among different subjects it is nec-
essary to relate all measurements to the electrical muscle activity
detected during some standardization recording, like a maximum
voluntary contraction (Tartaglia et al., 2011); however, in the cur-
rent study, the sEMG activity was assessed with patients at rest po-
sition, that has been suggested to be more reliable in asymptomatic
patients (Suvinen et al., 2003).
Due to the noise inherent with sEMG, a valuable attention and a
careful effort were made to obtain clean and reproducible standard
records. Approximately 10% of the electrodes required careful relo-
cation after new degreased, dry, jelly, and electrode fixation; how-
ever, to obtain a reliable and sure sEMG recording, the reliability of
signal captation of each electrodes was tested by a noise test soft-
ware (K7 Program, Myotronics-Noromed, Inc., Tukwila WA, USA):
only when software gave the absence of noise (corresponding to
the value provided by the software of 0.0), sEMG recording was
started.
Considering the strict and rigorous inclusion/exclusion criteria
used in the selection of patients, it seems to be reasonable that
the homogeneity of the sample enhances the internal validity of
the study; some dependent variables, such as age, ethnicity, gen-
der, hemispheric-dominance, missing teeth, occlusal alteration,
as well as the presence of systemic condition that could affect
the activity of muscles, nervous system and joints, have been ex-
cluded to homogenize both groups under study; these strict selec-
tion criteria behaved a drastic decrease in the sample size.
In conclusion, the present study support the effectiveness of a
single 60 min session of TENS in reducing the sEMG activity of
masseter and anterior temporalis muscles in patients with unilat-
eral TMD; additionally, the TENS application could increase the
vertical component of the interocclusal distance.
 A. Monaco et al. / Journal of Electromyography and Kinesiology 22 (2012) 463–468
5. Conclusion
Based on the finding of the present study, the application of a
single session of 60 min of TENS could reduce the sEMG activity
of masticatory muscles, and increase the interocclusal distance.
No evidence of placebo effect was detected. However, considering
that no additional study is available to compare the effect of TENS
with placebo, further studies are needed to confirm the findings of
the present study.
Conflict of interest
The authors declare that they have no conflict of interests.
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Annalisa Monaco received the D.D.S. degree from
the School of Dentistry, University of L’Aquila,
L’Aquila, Italy, in 1988, and the M.S. degree in
orthodontics from the University of L’Aquila, in 1992.
She has been a Researcher in dental diseases with
University of L’Aquila since 1998. She is currently an
Assistant Professor of gnathology in the School of
Dentistry, University of L’Aquila. Since 1999, she is
responsible of clinical service of Orthodontics. Her
research interests include electromyographic and
kinesiographic evaluation of stomatognathic appa-
ratus and functional aspects of orthodontic and
temporomandibular disorders. She is the author of
more than 60 scientific papers in these fields.
Fabrizio Sgolastra received his D.D.S. at L’Aquila
University, School of Dentistry in 2008. He also
attended a Ph.D. course. He is a staff member in the
research group and resident of the Department of
Health Science, at University of L’Aquila. He is
author of scientific papers in various field of Den-
tistry.
468 A. Monaco et al. / Journal of Electromyography and Kinesiology 22 (2012) 463–468
Irma Ciarrocchi received her D.D.S. at L’Aquila
University, School of Dentistry in 2008. She also
attended a Ph.D. course. She is a staff member in the
research group of Gnatology directed by Prof.
Annalisa Monaco at the same University. She is
actually a Resident in the Department of Health
Science, University of Laquila.
Ruggero Cattaneo received the M.S. degree in
medicine from the University of Milan, Milan, Italy,
in 1985. He worked in the neuromuscular field with
particular interest to surface electromyography
(sEMG). He is currently with the University of
L’Aquila, L’Aquila, Italy. His current research inter-
ests include the use of sEMG in dentistry, the
upgrading of clinical dental evaluation using sEMG.
He is the author of more than 20 scientific papers in
these fields.