Review Reports - Effects of Low-Level Laser Therapy at Different Energy Densities in Patients with Temporomandibular Disorders: A Randomized Clinical Trial

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Major issues preventing publication:

English inadequate (grammar, syntax, run-on sentences, inconsistent formatting)
No sample size calculation (N=100 arbitrary, risk of underpowering)
Randomization vaguely described (no block size, allocation concealment)
Incomplete statistics (no effect sizes, 95% CIs)
No sham control ("refusers" = soft diet group)
Overly optimistic interpretation despite similar results across all groups

Comments on the Quality of English Language

The English requires urgent professional revision (Major Language Revision mandatory). It is comprehensible and functional for internal review, but inadequate for publication in MDPI Applied Sciences, with frequent errors in grammar, syntax, formatting, and academic style that distract and compromise credibility.

Author Response

We would like to thank you for your close interest and contributions to our study. We have tried to make the necessary revisions in line with your recommendations. We highlighted changes in red color in the word document (revised manuscript). If this is not the revision that you asked for, we would be glad if you could inform us about it. Finally, we are ready to make any other revisions if necessary.

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

Reviewer 1

Comment 1: English inadequate (grammar, syntax, run-on sentences, inconsistent formatting)

Response 1: The manuscript has been carefully revised to improve grammar, syntax, sentence structure, and formatting consistency throughout the text. In addition, if further language improvement is considered necessary, professional support from a scientific language editing service will be obtained.

Comment 2: No sample size calculation (N=100 arbitrary, risk of underpowering)

Response 2: The study included a total of 100 patients, with 50 patients in each main diagnostic group. Within each group, 20 patients were allocated to each laser subgroup and 10 patients to the soft-diet-only subgroup. The sample size was based on the number of eligible patients available during the study period rather than an a priori power calculation. This limitation has now been added to the manuscript.

Comment 3: Randomization vaguely described (no block size, allocation concealment)

Response 3: Patients allocated to the laser treatment groups were assigned using a computer-generated randomization list. The soft-diet-only group consisted of patients who declined active laser treatment but agreed to participate in follow-up examinations.

Comment 4: Incomplete statistics (no effect sizes, 95% CIs)

Response 4: Due to the statistical structure of the study and limitations of the original dataset, these analyses could not be performed reliably. This limitation has now been acknowledged in the manuscript, and we have interpreted the results more cautiously, emphasizing that statistical significance may not necessarily indicate clinical relevance.

Comment 5: No sham control ("refusers" = soft diet group)

Response 5: A true sham control group was not included; however, patients who declined laser therapy but agreed to follow a soft diet were used as a comparison group to evaluate treatment effects and to determine whether there was a significant difference between the laser and soft diet groups.

Comment 6: Overly optimistic interpretation despite similar results across all groups

Response 6: We have carefully revised the discussion to provide a more balanced interpretation, emphasizing that while both the laser and soft diet groups showed improvement, the results were similar across groups. We have moderated any language that might have appeared overly optimistic.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor,

Thank you for your opportunity to review the present manuscript

My comments are as follows :

This manuscript presents a randomized clinical trial investigating the effects of low-level laser therapy at different energy densities in patients with temporomandibular disorders, comparing outcomes across treatment and control groups.

The study reports improvements in pain and mandibular function across all groups, including the soft-diet control, suggesting that observed benefits may not be exclusively attributable to the laser intervention.

Overall, the findings contribute to the existing literature by highlighting the potential role of treatment parameters while also indicating the need for further controlled studies to clarify the specific efficacy of low-level laser therapy.

But there are some issues that must be must be addressed before considering it for publication

Major Issues

Please rewrite the entire introduction section in order to make it more concise and more clear.
Please rearange the sentances in the Methods section in order to be more easy to read – ex – inclusion and exclusion criteria should be with number or lines each belowe the other – x

- y

- z

- also an exclusion criteria should be children or teenagers with active growth , if not please explain why

- Please add the Placebo effect supposition in the discussion section and write the Conclusion mor appropriate to your findings. Please detail the possible placebo effect on laser therapy of TMD in the discussion section and add citations regarding this aspect.

- Please state what are the limitations of your study and what must be done in the future to overcome them . You have a lot of 50 patients , statiscally the number is too small to draw any relevant conclusions of it. This is your first limitation. There are many more, please state them.

- Please add all the patients’ Metadata (Patient by patient all variables) – Excel , Statistical Analysis etc for transparency. This is mandatory . In the tables you have the mean age , mean height etc – Please provide all the data.

- Please add a supplemental material of the model of your informed consent that was given to the patients, and also a copy of your original IRB statement for transparency.

- Please add the citation of the CONSORT guidelines also in the referance section

Minor issues – please cite every sentence in the introduction and discussion section

At the end of the introduction section you state “ Previous studies have reported … “, which studies ? please add citations

Material and Methods section you state “ the patients were informed of the possible complications … “ – please mention them

Please add the citation of the International Classification of Diseases (ICD) also in text and in the References section

How long is a session of laser therapy ? please mention it in Methods section

The references do not meet the mdpi specific reference requirements . Please rewrite all of them accordingly

Comments on the Quality of English Language

Must be improved overall

Author Response

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

Major Issues:

Comments:

Please rewrite the entire introduction section in order to make it more concise and more clear.

Please rearange the sentances in the Methods section in order to be more easy to read – ex – inclusion and exclusion criteria should be with number or lines each belowe the other – x

- y

- z

- also an exclusion criteria should be children or teenagers with active growth , if not please explain why

Response: The necessary revisions related to the above comments have been made in the manuscript.

Response: As our study did not include a true placebo group, direct evaluation of the placebo effect was not possible. However, since similar results were observed in the soft diet group, we have highlighted the potential placebo effect of laser therapy in the Discussion section.

- Please add a supplemental material of the model of your informed consent that was given to the patients, and also a copy of your original IRB statement for transparency.

- Please add the citation of the CONSORT guidelines also in the referance section

Response: The necessary revisions related to the above comments have been made in the manuscript.

Minor issues:

At the end of the introduction section you state “ Previous studies have reported … “, which studies ? please add citations

The necessary revision has been made.

Material and Methods section you state “ the patients were informed of the possible complications … “ – please mention them

By 'possible complication,' we refer to an unexpected adverse outcome, rather than a known complication of laser therapy on the joint, as no such complications have been previously reported in the literature.

Please add the citation of the International Classification of Diseases (ICD) also in text and in the References section

The necessary revision has been made.

How long is a session of laser therapy ? please mention it in Methods section

The necessary revision has been made (for 2 minutes per joint)

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript addresses a clinically relevant question regarding dose-dependent effects of LLLT in TMD management. While the topic merits investigation, several methodological concerns must be resolved before the manuscript is ready for publication.

The study is presented as a randomized clinical trial; however, control group allocation was determined by patient refusal of treatment rather than by randomization . This does not adhere to the CONSORT framework. Additionally, the absence of a sham-laser arm means that within-group improvements in VAS and range-of-motion measures cannot be specifically attributed to LLLT, as opposed to non-specific or placebo. This limitation and its implications should be explicitly acknowledged
Control subgroups comprised only ten patients each, with no a priori power calculation reported. The authors are requested to provide a prospective power calculation or to discuss its absence as a limitation.3
How was the number of sessions decided?
The stated primary objective is to determine whether energy density variations produce differential therapeutic outcomes. However, where no significant between-group differences were observed in the primary outcome. I suggest the authors present primary outcome results transparently and ensure that conclusions regarding dose-dependent effects are proportionally represented by primary outcomes; the only current emphasis is on secondary outcomes, creating a divergence in methodology and results reporting
TMD is known to fluctuate and sometimes spontaneously remit. Over a six-month follow-up, contributions from regression to the mean, spontaneous remission, and behavioral adaptation cannot be excluded. The authors are encouraged to address this limitation.
The conclusion simultaneously suggests that laser therapy "may have a placebo effect" and that its "effectiveness was confirmed." These statements are mutually contradictory. The authors are requested to adopt a coherent interpretive position
The claim that no dropout rate was applicable across a six-month, nine-session trial requires clarification. A CONSORT participant flow diagram documenting enrollment, allocation, follow-up, and analysis would be welcome.
For reproducibility and comparability with the photobiomodulation literature, the authors should report fluence (J/cm²), irradiance (W/cm²), spot size, and beam delivery mode. As they very well pointed in the discussions, “This diversity is due to variables such as the type of laser device used, wavelength, application time,frequency, repetition frequency, and laser technique”;

The authors are encouraged to clarify whether the DC/TMD served as the operational diagnostic framework, and to distinguish this from ICD-10 classification, which functions as an administrative coding system rather than a validated research diagnostic instrument. No further diagnostic details are given other than “ The inclusion criteria were diagnosis of DDwR and myalgia based on symptoms and clinical and radiographic findings.” I consider this to be insufficient
I suggest citing some recent systematic reviews/meta-analyses on the subject and discussing their results in comparison with this study; as it is currently, the references body could be updated and improved a little.

All the best,

Author Response

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

1. The study is presented as a randomized clinical trial; however, control group allocation was determined by patient refusal of treatment rather than by randomization . This does not adhere to the CONSORT framework. Additionally, the absence of a sham-laser arm means that within-group improvements in VAS and range-of-motion measures cannot be specifically attributed to LLLT, as opposed to non-specific or placebo. This limitation and its implications should be explicitly acknowledged.

Patients allocated to the laser treatment groups were assigned using a computer-generated randomization list. The soft-diet-only group consisted of patients who declined active laser treatment but agreed to participate in follow-up examinations.

2. Control subgroups comprised only ten patients each, with no a priori power calculation reported. The authors are requested to provide a prospective power calculation or to discuss its absence as a limitation.

The study included a total of 100 patients, with 50 patients in each main diagnostic group. Within each group, 20 patients were allocated to each laser subgroup and 10 patients to the soft-diet-only subgroup. The sample size was based on the number of eligible patients available during the study period rather than an a priori power calculation. This limitation has now been added to the manuscript.

3. How was the number of sessions decided?

The number of treatment sessions was determined based on the session intervals reported in the literature, and was set close to the average of those previously published protocols.

4. The stated primary objective is to determine whether energy density variations produce differential therapeutic outcomes. However, where no significant between-group differences were observed in the primary outcome. I suggest the authors present primary outcome results transparently and ensure that conclusions regarding dose-dependent effects are proportionally represented by primary outcomes; the only current emphasis is on secondary outcomes, creating a divergence in methodology and results reporting

We have moderated the statements emphasizing the effectiveness of laser therapy in the manuscript. It is now clarified that the soft diet group also showed similar improvements.

5. TMD is known to fluctuate and sometimes spontaneously remit. Over a six-month follow-up, contributions from regression to the mean, spontaneous remission, and behavioral adaptation cannot be excluded. The authors are encouraged to address this limitation.

The necessary revision has been made.

6. The conclusion simultaneously suggests that laser therapy "may have a placebo effect" and that its "effectiveness was confirmed." These statements are mutually contradictory. The authors are requested to adopt a coherent interpretive position

The necessary revision has been made.

7. The claim that no dropout rate was applicable across a six-month, nine-session trial requires clarification. A CONSORT participant flow diagram documenting enrollment, allocation, follow-up, and analysis would be welcome.

Although there were some participants who discontinued the study, they were excluded from the analysis according to the predefined criteria, and therefore the number of participants in each group remained unaffected.

8. For reproducibility and comparability with the photobiomodulation literature, the authors should report fluence (J/cm²), irradiance (W/cm²), spot size, and beam delivery mode. As they very well pointed in the discussions, “This diversity is due to variables such as the type of laser device used, wavelength, application time,frequency, repetition frequency, and laser technique”.

The necessary revision has been made.

9. The authors are encouraged to clarify whether the DC/TMD served as the operational diagnostic framework, and to distinguish this from ICD-10 classification, which functions as an administrative coding system rather than a validated research diagnostic instrument. No further diagnostic details are given other than “ The inclusion criteria were diagnosis of DDwR and myalgia based on symptoms and clinical and radiographic findings.” I consider this to be insufficient

The inclusion criteria were a diagnosis of DDwR and myalgia based on symptoms and clinical and radiographic findings, and patients who had not received any previous TMJ treatment and had no systemic diseases. The necessary revision has been made.

10. I suggest citing some recent systematic reviews/meta-analyses on the subject and discussing their results in comparison with this study; as it is currently, the references body could be updated and improved a little.

The references have been carefully reviewed and updated in response to the comment.

Reviewer 4 Report

Comments and Suggestions for Authors

The topic is clinically relevant, and the study attempts to address an important gap—lack of consensus on optimal laser parameters and includes a reasonable sample size (n=100), but there are methodological concerns, inconsistencies in interpretation, and clarity issues.

INTRODUCTION

The authors provide an updated review of the state of the art.

MATERIALS AND METHODS

There are methodological limitations affecting validity.

The “control” group is not a true control: patients self-selected by refusing treatment; and this introduces selection bias and undermines randomization.

No placebo/sham laser group, which is essential in LLLT trials due to strong placebo effects.

So you cannot confidently attribute effects to LLLT vs placebo or natural recovery.

There are Randomization and Allocation Bias, because you state:“patients who refused treatment… were assigned to the control group”. So this breaks: randomization integrity and allocation concealment.

This creates systematic differences in patient motivation, expectations, and behavior.

No dropout claim is unrealistic. Statement: “no dropout rate was applicable” . In a 6-month clinical trial, 0% dropout is highly unusual.

Were all patients followed completely?

Were missing data handled?

There are some statistical issues: multiple comparisons without clear correction strategy (despite mentioning Bonferroni) and overemphasis on within-group significance rather than between-group differences.

the authors did an overinterpretation of dose effect. There aren’t strong evidence for dose-response.

There aren’t a CONSORT flow diagram.

WRITING, CLARITY AND TERMINOLOGY CONSISTENCY

There are some redundancy and overly long sentences and occasional grammatical issues. Example: “clearly defined and applied bilaterally…” → incomplete phrasing

Use consistent naming: LLLT vs PBM (photobiomodulation)

TABLES

They are very dense and hard to interpret: they doesn’t highlighting significant comparisons and no adding effect sizes.

RESULTS

There are overinterpretation of results.

DISCUSSION

The authors should expand on: natural course of TMD; placebo/contextual effects; and psychosocial factors.

CONCLUSIONS

There is a logical inconsistency between results ans conclusion.

Results: “Comparable and favorable improvements were achieved in both laser therapy and soft diet group”. Conclusion: “Effectiveness of the laser therapy was confirmed” - these statements contradict each other.

There are contradictory conclusions.

ETHICS CONSIDERATIONS

Trial registration date appears after study start: Registered 12/10/2024, but study conducted 2022–2024

Author Response

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

No placebo/sham laser group, which is essential in LLLT trials due to strong placebo effects.

So you cannot confidently attribute effects to LLLT vs placebo or natural recovery.

This creates systematic differences in patient motivation, expectations, and behavior.

Comment: No dropout claim is unrealistic. Statement: “no dropout rate was applicable” . In a 6-month clinical trial, 0% dropout is highly unusual.

Were all patients followed completely?

Were missing data handled?

Response: Although there were some participants who discontinued the study, they were excluded from the analysis according to the predefined criteria, and therefore the number of participants in each group remained unaffected.

the authors did an overinterpretation of dose effect. There aren’t strong evidence for dose-response.

There aren’t a CONSORT flow diagram.

WRITING, CLARITY AND TERMINOLOGY CONSISTENCY

There are some redundancy and overly long sentences and occasional grammatical issues. Example: “clearly defined and applied bilaterally…” → incomplete phrasing

Use consistent naming: LLLT vs PBM (photobiomodulation)

TABLES

They are very dense and hard to interpret: they doesn’t highlighting significant comparisons and no adding effect sizes.

RESULTS

There are overinterpretation of results.

DISCUSSION

The authors should expand on: natural course of TMD; placebo/contextual effects; and psychosocial factors.

Comment:

CONCLUSIONS

There is a logical inconsistency between results ans conclusion.

There are contradictory conclusions.

Response: The necessary revision has been made.

Comment:

ETHICS CONSIDERATIONS

Trial registration date appears after study start: Registered 12/10/2024, but study conducted 2022–2024

Response: The study was conducted after obtaining local ethical approval. As clinical trial registration is a relatively recent requirement in our country, the registration was completed on 12/10/2024, following local regulations, although the study was conducted between 2022 and 2024.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Several aspects require revision before the paper can be considered for publication.

The literature review remains somewhat descriptive. The authors should provide a more critical synthesis of the evidence and better justify the choice of the specific laser parameters tested in the study.

The methodology is not described in sufficient detail. The randomization process and allocation concealment are unclear, and the blinding procedures are not fully explained. Ethical approval and informed consent are reported appropriately, but the manuscript should also clarify whether the trial was prospectively registered and whether CONSORT recommendations were fully followed.

The statistical analysis is not ideal for a longitudinal randomized trial. The use of multiple separate nonparametric tests across several time points and outcomes increases the risk of type I error. A repeated-measures or mixed-effects approach would be more appropriate, and the handling of multiple comparisons should be clarified.

The Results section is difficult to read and does not clearly highlight the main findings. The manuscript would benefit from a clearer synthesis of the clinically relevant outcomes.

The Discussion is informative but should be more critical. The fact that improvement was also seen in the control group weakens the attribution of effects specifically to low-level laser therapy. Alternative explanations such as placebo effect, natural recovery, regression to the mean, and the influence of soft diet should be discussed more explicitly. The claim that a specific energy density may represent an optimal dose is not convincingly demonstrated.

The Conclusion is too strong in relation to the data. The manuscript suggests that the effectiveness of laser therapy has been confirmed, but the results do not clearly show superiority over the control condition. The conclusion should be toned down and aligned more carefully with the findings.

Comments on the Quality of English Language

Author Response

Dear Editor:

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

Several aspects require revision before the paper can be considered for publication.

The literature review has been revised to provide a more critical synthesis of the available evidence. Additionally, the rationale for the selected laser parameters has been clarified and supported with relevant literature in the revised manuscript.

The Methods section has been revised to provide a more detailed description of the randomization process, allocation concealment, and blinding procedures. Additionally, information regarding trial registration has been clarified, and the manuscript has been updated to ensure compliance with CONSORT recommendations.

We acknowledge that repeated separate nonparametric tests across multiple time points may increase the risk of Type I error and that a repeated-measures or mixed-effects model could provide a more robust analytical framework for longitudinal data. In the present study, nonparametric tests were chosen due to the non-normal distribution of the outcome variables at several time points, as confirmed by normality assessments. Given this distributional limitation and the relatively small sample size, we opted for a conservative approach using nonparametric methods.

The Results section is difficult to read and does not clearly highlight the main findings. The manuscript would benefit from a clearer synthesis of the clinically relevant outcomes.

In the revised manuscript, the Results section has been reorganized to improve clarity and readability. Specifically, we have streamlined the presentation of outcomes and highlighted the most clinically significant findings at the beginning of each subsection. Redundant statistical details have been reduced, and the main effects of the intervention on pain reduction, functional improvement, and temporomandibular joint outcomes are now more clearly emphasized.

In the revised manuscript, the Discussion section has been substantially revised to adopt a more critical and balanced interpretation of the findings. We now explicitly address that improvements observed in both the intervention and control groups may be influenced by several non-specific factors, including the placebo effect, natural disease course, regression to the mean, and the potential therapeutic impact of soft diet and reduced functional load on the temporomandibular joint.

In the revised manuscript, the Conclusion has been carefully toned down and aligned with the actual findings. We have removed any implication of definitive effectiveness or superiority of low-level laser therapy. Instead, the conclusion now emphasizes that both the laser and control (soft diet) groups showed significant improvements, without clear evidence of superiority of laser therapy.

Reviewer 2 Report

Comments and Suggestions for Authors

It is fine for me. Now it can be accepted.

Best regards,

Comments on the Quality of English Language

Must be improved overall

Author Response

We sincerely thank the reviewer for the time and effort devoted to evaluating our manuscript. We are grateful for the constructive comments provided, which have contributed to improving the overall quality of the study.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the revised manuscript. While the authors have made efforts to address the previous concerns which I appreciate, I still have some firm suggestions for the sake of scientific rigor and overall quality of the study:

1. Please provide the completed CONSORT checklist as a supplementary file, as per standard reporting requirements for randomized controlled trials.

2. The choice of 9 sessions should be explicitly justified by citing relevant literature that supports this as an adequate and appropriate intervention duration. I kindly request the authors to provide the corresponding references in the Materials and Methods section.

3. The statement — "Although there were some participants who discontinued the study, they were excluded from the analysis according to the predefined criteria, and therefore the number of participants in each group remained unaffected" — implies that the initial enrollment exceeded the 100 participants ultimately reported. In the interest of scientific rigour and transparent reporting, the authors are strongly encouraged to clearly state the initial number of enrolled participants and provide a detailed account of how the final sample of 100 was reached, ideally through a CONSORT flow diagram. Failure to do so may raise concerns regarding reporting bias, which would negatively impact the overall quality assessment of the study.

4.Diagnostic Criteria for DDwR and Myalgia: The authors' efforts to revise this section are appreciated; however, the current wording remains insufficiently specific. The authors are requested to either explicitly enumerate the symptoms, clinical signs, and radiographic criteria used to establish the diagnoses of DDwR and myalgia, or to reference a validated diagnostic methodology in the Materials and Methods section. Vague descriptions are not acceptable for a study in which diagnostic accuracy is central to the research design.

5. The reference list does not appear to have been updated as previously requested. The authors are asked to ensure that all references are current, relevant, and consistent with the revised manuscript content.

Author Response

Dear Editor:

We are looking forward to receiving your comments.

Best regards

Emil MAHAMMADLI, DDS

Department of Oral and Maxillofacial surgery, Faculty of Dentistry,

Karadeniz Technical University, Trabzon/Turkey

Please provide the completed CONSORT checklist as a supplementary file, as per standard reporting requirements for randomized controlled trials.

The CONSORT checklist has been added as a supplementary file.

The choice of 9 sessions should be explicitly justified by citing relevant literature that supports this as an adequate and appropriate intervention duration. I kindly request the authors to provide the corresponding references in the Materials and Methods section.

The choice of 9 sessions was based on previously published studies reporting similar treatment protocols for TMD. Several studies have demonstrated that low-level laser therapy applied over multiple sessions (generally ranging between 6 and 12 sessions) is effective in reducing pain and improving function in TMD patients. Therefore, 9 sessions were selected as an appropriate and adequate intervention duration in line with the existing literature. Relevant references have been added to the Materials and Methods section.

The statement — "Although there were some participants who discontinued the study, they were excluded from the analysis according to the predefined criteria, and therefore the number of participants in each group remained unaffected" — implies that the initial enrollment exceeded the 100 participants ultimately reported. In the interest of scientific rigour and transparent reporting, the authors are strongly encouraged to clearly state the initial number of enrolled participants and provide a detailed account of how the final sample of 100 was reached, ideally through a CONSORT flow diagram. Failure to do so may raise concerns regarding reporting bias, which would negatively impact the overall quality assessment of the study.

The initial sample size was determined based on a previous study (Kulekcioglu et al., 2003) and a corresponding sample size calculation. During the recruitment process, patients who did not meet the study criteria were excluded and replaced with newly recruited eligible participants. Therefore, the final sample consisted of 100 patients who met all inclusion criteria and completed the study. This process has now been clarified in the manuscript, and a CONSORT flow diagram has been added to ensure transparent reporting.

Diagnostic Criteria for DDwR and Myalgia: The authors' efforts to revise this section are appreciated; however, the current wording remains insufficiently specific. The authors are requested to either explicitly enumerate the symptoms, clinical signs, and radiographic criteria used to establish the diagnoses of DDwR and myalgia, or to reference a validated diagnostic methodology in the Materials and Methods section. Vague descriptions are not acceptable for a study in which diagnostic accuracy is central to the research design.

The diagnostic criteria for DDwR and myalgia have been revised and clearly defined in the Materials and Methods section. A validated diagnostic methodology (DC/TMD) has been referenced, and the relevant clinical and diagnostic criteria have been explicitly stated

The reference list does not appear to have been updated as previously requested. The authors are asked to ensure that all references are current, relevant, and consistent with the revised manuscript content.

The reference list has been carefully reviewed, updated, and expanded to ensure that all citations are current, relevant, and consistent with the revised manuscript

Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

With the changes made by the authors, the article is minimally acceptable for publication.

Author Response

We thank the reviewer for the careful evaluation of our manuscript and for acknowledging the revisions made. We appreciate the constructive feedback provided throughout the review process, which has helped us improve the quality and clarity of our work.