MYOFASCIAL PAIN-DYSFUNCTION SYNDROME

Introduction
Facial pain and its diagnosis has always posed a dilemma for the clinicians. The complex anatomy of the region compounded with the variability of symptoms involved, present a challenging situation during the management of orofacial pain. The study of temporomandibular joint appears to hold an uncommon fascination for clinicians of many disciplines. The dysfunction of this joint results in a large proportion of complaints presented to the dentists. With ever increasing refinements in diagnostic and treatment modalities, dramatic advances have been made in understanding the causes of facial pain related to joint and surrounding musculature. Still the mystery exists regarding the precise diagnosis and treatment of facial pain.

Differentiation between d$%function %$ndro e and

te !oro andibu"ar #oint !ain$ofa%cia" !ain-d$%function %$ndro e

Temporomandibular joint pain dysfunction syndrome is a term covering a variety of problems which include the entire scope of temporomandibular joint disorders originating either intra articular or extra articular1. yofascial pain!dysfunction syndrome is a psychophysiologic disease that primarily involves the muscles of mastication. The condition is characteri"ed by dull, aching, radiating pain that may become acute during use of the jaw, and mandibular dysfunction that generally involves a limitation of opening#.

Fre$uently, myofascial pain is overloo%ed as a common cause of chronic pain because of fre$uent association with joint dysfunction and other pain disorders.

Etio"o&$
The myofascial pain!dysfunction syndrome has a multicausal etiology and the %nowledge about the probable etiological factors seem to have improved over a period of time. Goodfriend &1'(()1, Costen &1'(*)1 and many others initially advocated the probable etiologies for the dysfunction syndrome. +athologies of temporomandibular joint, trauma, occlusal disharmony and many other factors have been proposed by different authors. ,ot of confusion existed until, Travell and Rinzler1 first suggested that s%eletal muscles in spasm could be the source of pain. They described about the painful areas within the muscles and called them as - Trigger areas. which were associated with pain, spasm, tenderness and dysfunction. Schwartz1 &1'//) adapted Travell0s wor% and postulated the term temporomandibular joint pain!dysfunction syndrome. 1e reported that majority of patients with pain in the region of temporomandibular joint were suffering from functional disorders involving painful spasm of masticatory musles. 1e hypothesi"ed that stress was a significant cause of clenching and grinding habits which resulted in muscle spasm. 2cclusal abnormalities were found to play a secondary role. The next significant development towards understanding this aspect of facial pain occurred when Laskin &1'3')1 presented a comprehensive explanation of the problem and proposed his !%$c'o!'$%io"o&ica" t'eor$. 1e suggested that though mechanical factors related to occlusion may

cause

this

condition

by

producing

muscular

overextension

or

overcontraction leading to muscle fatigue but psychophysiologically motivated oral habits is the fre$uent cause of painful spasm. To stress the role played by muscles, it was suggested that the term myofascial pain dysfunction syndrome is a more accurate term to describe the condition than temporomandibular joint pain!dysfunction syndrome. ,as%in pointed out the %ey elements of the theory of dysfunction(. T56S726 289, 19:7T -4ental 7rritation. +4

;S<;,98 F9T7=;5

uscular overextension

>2S+9S

uscular 2vercontraction

>2F9S<79, +976!4>SF;6<T726 S>6482 5

<ontracture

2cclusal dysharmony

4egen. 9rthritis

9ltered <hewing +attern

Etio"o&$ of t'e are t'ree ec'ani% indicate t'at

$ofa%cia" !ain-d$%function %$ndro e( A"t'ou&' t'ere o%t co on !at'wa$( T'e e*!"anation of t'i%

ean% of entr$ into t'e %$ndro e( T'e dar)er arrow% i% ter ed t'e !%$c'o!'$%io"o&ic t'eor$(

Laskins theory is an outgrowth of wor% of Schwart" and is based on premise that +4 syndrome is primarily a result of emotional rather

than occlusal or mechanical factors. The masticatory muscle spasm is the primary factor responsible for signs and symptoms of pain!dysfunction syndrome. Spasm can be initiated in one of the three ways ? 1) muscular over extension, #) muscular overcontraction, or () muscle fatigue. The myofascial pain syndrome so produced not only causes pain and limitation of movement but also produces changes in jaw position so that teeth don0t occlude properly &occlusal disharmony). 7n addition it may also cause organic changes such as degenerative changes in the T @ and muscle contraction which is a manifestation of long!term spasm. These organic changes result in an altered chewing pattern with attendant reinforcement of the original spasm and pain. The changes in neuromuscular control of mandible produced due to occlusal disharmony has been supported by many researchers. 7rregularities in occlusion appear to be the precipitating factor in pathogenesis of +4 syndrome. 2cclusal interferences, posterior bite collapse, deep overbiteA overjet and many other factors tend to restrict movement and predispose the patients to increased parafunctional activity resulting in overuse and thus fatigue of muscles. oreover Bruno &1'B1)1 found that the resulting pain in muscles will be concentrated in areas of fascia which upon palpation demonstrated tenderness and pain and these areas were referred to as trigger areas. 9ccording to ein!erg &1'B*)1, every patient has got adaptation to

a situation which is determined by his psychological ma%e up. 7n a given patient, an occlusal interference may trigger the patient0s acute symptoms while another factor, such as emotional stress may sustain them.

The concept of -etiologic circle. is useful to understand the mechanism of T @ dysfunction.

Stress Syndrome Trigger echanism Sustaining 2cclusion

5vidence that nocturnal "arafunction may be involved in +4

echanism

syndrome stemmed from studies by Trenouth &1'BC)* who observed that jaw pain and limitation of movement were often noted to be worse on awa%ening. Christensen &1'C1)* and #emm &1'B')* demonstrated that in chronic cases of +4 syndrome, an inflammatory stage occurs in affected muscles of mastication following the classic spasm. This myositis perpetuates the symptoms of pain and dysfunction. So, it can be seen that one school of thought supported occlusal disharmony as the major etiological factor of the development of +4 syndrome, but it could not explain why pain and dysfunction are uncommon in patients with severe malocclusion. 7t is now recogni"ed that hyperactivity of muscles leading to myospasm is triggered by emotional disturbances and may be due to a combination of psychologic stress and muscle incordination secondary to malocclusion. To complete the understanding for etiology of +4 syndrome, it is

essential to eliminate the possibility of medically lin%ed factors, recent

major surgical operations or trauma to head and nec% which can give signs and symptoms of +4 syndrome.

PAT+OP+YSIOLO,Y OF MPD SYNDROME

9s explained by Tra-e"" &1'3D)/, the pathophysiology of this stress disorder of s%eletal muscles may be outlined as follows? 6oxious stimulation &due to such as mechanical, emotional, infectious, metabolic, nutritional, or a combination of these) 4evelopment of spasm &+rotective mechanism) Shortening of muscles ,ose capacity for voluntary relaxation and exhibit an overactive stretch reflex 7nvoluntary shortening of one or more muscles 5ccentric position of condyles 4isorientation of jaw movements and restricted opening of the mouth +ain &due to spasm and decreased relaxation of muscles) ore spasm of muscles 7t has been observed that whenever the pain associated with s%eletal muscle spasm is very severe, it is referred to a site from the muscle that is its source. The pain is referred from a small area of hypersensitivity located within the muscle or the fascia. These areas are termed as Trigger areas.

The response of muscles against the injury tends to gain momentum and results in a self representating cycle of spasm!pain!spasm which limits the movements and result in fibrosis of tissues.

C"inica" Feature%
Incidence. Women are affected by in the #D to *D years age group#. The patients suffering from complaint of? +ain in a "one of reference &most important problem that causes patients to see% treatment). Trigger points in muscles which cause pain on stimulation. Taut muscle band. ,imited jaw opening. 9ssociated symptoms. +resence of contributing factors for onset of pain. 6o tenderness in temporomandibular joint. Mode of On%et The patients suffering from +4 syndrome may complain of? +4 syndrome usually present with +4 syndrome more fre$uently than men,

with the ratio ranging from (?1 to /?1#. The greatest incidence appears to be

i.

Sudden onset of pain and trismus, characteri"ed by forcible contraction of muscle during biting on a hard object, overstretching of jaws, difficult tooth extraction etc.

ii.

=radual onset characteri"ed by appearance of abnormal sounds in the joint followed by pain and limited jaw motion. imbalance or asymmetry of face. ajor precipitating factor may be strain of muscles due to occlusal

iii.

ay be associated with oral foci of infection, respiratory infection, or acute emotional stress.

Tri&&er !oint% / Tri&&er 0one% / Tri&&er area%

yofascial pain is characteri"ed by pain referred from few hypersensitive areas termed as trigger areas A "ones. 9 trigger point is defined as a locali"ed tender area in taut band of s%eletal muscle, tendon or ligaments. +oints occur fre$uently in head, nec%, shoulder, lower bac%. 9ny pressure on these areas may initiate pain referred to distant areas &called as "one of reference). Trigger areas develop due to direct A indirect trauma &parafunctional habits) to muscles, due to wea%ening of muscles &nutritional disturbances, lac% of exercise, structural disharmony etc.). Trigger points range from #./mm in diameter and may be active or latent.

'

 +alpating trigger points with deep finger pressure, elicits alteration in pain, in the "one of reference or causes radiation of pain towards the "one of reference. +atients behavioural reaction to firm palpation of trigger points is a distinguishing characteristic of myofascial pain and is termed a positive Ejump sign0. This reaction may include? a. Withdrawal of head. b. Wrin%ling of face or forehead and desensation of s%in. 7n locating an active trigger point, jump sign should be elicited.

Si&n% and %$ !to % of $ofa%cia" !ain% are often acco !anied b$ ot'er !at'o"o&ica" condition% and ot'er !rob"e % %uc' a%.
a) $eurologic % Tingling, numbness, blurred vision and excess lacrimation. b) Gastrointestinal % 6ausea, constipation and indigestion. c) &usculoskeletal % Fatigue, tension, stiff joints and muscle twitching. d) 'tologic sym"toms % Tinnitus, ear pain and diminished hearing. e) 'ther sym"toms % Scratchy sensation, teeth sensitivity, increased salivation, increased sweating and s%in flushing.

1D

Mana&e ent of MPD S$ndro e

I Dia&no%i% of t'e condition The cardinal signs and symptoms of those produced by many organic +4 syndrome are similar to problems involving the

temporomandibular joint and other non!articular conditions. Therefore, a careful history and thorough examination may be helpful in diagnosing the condition. 8adiographs may be helpful in diagnosing the condition if it has affected the bony structure also. F rays include ? Transcranial, transpharyngeal, panoramic views, <.T. scans and can provide reliable diagnosis of the condition. 9rthrography can be useful in determining the position of meniscus &when internal derangement of temporomandibular joint is being considered). 1( Certain "ab te%t% are 'e"!fu" 7f infection is suspected. For bone diseases. For gout. 7ndicators of muscle disease. For rheumatoid arthritis. For muscle function evaluation. For behavioural responses. 87 with arthroscopy

<omplete blood cell count Serum calcium, phosphorous and al%aline phosphatase measurement. Serum uric acid determination. Serum ceratinine and creatine phospho%inase levels. 5S8, 8heumatoid factor, ,atex fixation test. 5 = +sychologic evaluation and psychometric testing.

11

Differentia" dia&no%i% of MPD %$ndro e

a) $on articular conditions that mimic &() syndrome G +ulpitis, +ericoronitis, 2titis media, +arotitis, Sinusitis, Trigeminal neuralgia, 9typical &vascular) neuralgia, Temporal arthritis, Trotters syndrome, 5agle0s syndrome. b) $on articular conditions "roducing limitation of mandi!ular movement ! 2dontogenic infection, 6on!odontogenic infection, yositis, yositis ossificans, 6eoplasia, Scleroderma, 1ysteria, Tetanus, 5xtra pyramidal reaction, 4epressed "ygomatic arch, 2steochondroma. c) )ifferential diagnosis of tem"oromandi!ular *oint disease G 9genesis, <ondylar 7nfectious arthritis, hypoplasia, <ondylar hyperplasia, 6eoplasia, 8heumatoid arthritis, Traumatic arthritis,

4egenerative arthritis, 9n%ylosis, 7nternal dis% derangement. 7t is not possible to discuss signs and symptoms of these conditions at this juncture but a careful evaluation should rule out these conditions. II Treat ent of MPD %$ndro e The treatment of +4 syndrome should be geared towards +4 syndrome.

complete management rather than symptomatic cure. Several treatment modalities have been recommended for 1(

Initia" e*!"anation of t'e !rob"e The patients should be explained about the problem and its probable

etiology. The psychophysiologic factor shouldn0t be stressed while explaining the problem because patient may not accept it. 7nitial discussion

1#

should deal with muscle fatigue, spasm and explaination about the condition. 2( a. T'era!eutic oda"itie% of treat ent

Therapy at home 7nta%e of soft diet with small cut pieces. @aw motion should be limited and wide opening should be avoided. +arafunctional habits such as clenching, grinding should be avoided &although patients are unaware of these habits, they should be instructed to chec% for clenching). 2ther habits such as fingernail biting, lip biting etc. should be avoided. hour twice daily. assage of the affected area using moderate %neading motion. This helps in return of venous blood, lymph and catabolites and reduces muscle pain and spasm. 7ntermediate moist heat application for half an

b.

Short term medication uscle relaxants and analgesics can be used.

! pines #mg!/mg $id &4ia"epam) ! te *DDmg tid

:en"odia"e

! spirin 1Dgm tid.

eproboma

! cetaminophen 3/Dmg tid. +ropoxyphene 1!# tabs tid.

9ntidepressant drugs &for patients with long standing +4 syndrome and proven

1(

depression). Tricyclic antidepressants #/mg G B/mg at bed time c. considered. used? i. Stabili"ation splint. ii. 8elaxation splint. iii. 8esilient splint. iv. +ivoting splint. .awleys type upper anterior splint is most effective because it prevents occlusion of posterior teeth and thereby prevents parafunctional activity. 7t is worn at night and /!3 hours of day. Shouldn0t be worn continuously as it results in supraeruption of posterior teeth. +latform of the splint should be flat. d. i) Physical therapy ;ltrasound produces 9ccording to +awazoe,- * types of splints are Splint therapy 7f previously described forms of therapy are not successful or there is hAo tooth clenching etc., splint therapy should be

vibrations within the tissue that cause particle collision and release of energy. This results in production of heat and vibration which reduces the muscle tension and increase in tissue elasticity. given twice daily for 1!# wee%s. oreover there is mild analgesic and anti!inflammatory action. ,asts for 1D!1/ minutes,

1*

ii)

1igh voltage electrogalvanic stimulation involves the use of monophasic, pulsed direct current applied through an electrode placed on s%in over the involved muscle. ! 9ctivated at fre$uencies from *!CD pulse per second, for 1D!1/ minutes, #!( times a wee%. Stimulation of muscle increases circulation, reduces pain and spasm

and increases resistance to fatigue. iii) <ryotherapy &cold therapy) spasm. vasoconstriction, neuromuscular activity. Hapour coolant spray &such as ethyl chloride or fluorimethane) is applied over the involved muscle by spraying for 1D seconds. 8epeated for two more times with 1D seconds interval. andible is mobili"ed by gently stretching to maximum opening &also termed as spray and stretch activity). of 7ce pac%s can be useful in acute phases +4 syndrome. <old application is used for 1D!1/ minutesI removed and reapplied after / to 1D minutes, (!* times daily. e. Relaxation therapy : :ecause +4 syndrome is <ooling reduces effect also transmission creates and 8educes tissue temperature, causes local analgesia and has anti!inflammatory effects and diminishes muscle

myoneural

basically a problem related to increased muscle tension and spasm, any

1/

techni$ue designed to induce muscle relaxation should be helpful. 9mong the modalities that have proven to be effective are biofeedbac%, conditioned relaxation and hypnosis. i3 4iofeedbac) 5 = biofeedbac%

involves supplying the patient with visual or auditory information about the moment to moment contractile status of muscle being monitored. The patient then concentrates on relaxing the muscle and is reflected by reduction in level of graphic representation or audible sound. The biofeedbac% is used for two (D!minutes sessions each wee% for 3 wee%s. Clarke and +ardachi &1'BB)C used biofeedbac% method in B patients suffering from +4 syndrome and achieved success by controlling parafunctional habits. )ohrmann and Laskin &1'BC)B noted significant reduction in massetric 5 = levels of patients treated with biofeedbac%. ii3 Conditioned re"a*ation . Similar to biofeedbac% in its end results but differs in that the patients do not have the benefit of a feedbac% indicator. iii) treatment of +4 syndrome. 2ther methods are hypnosis, transcendental mediation &T ) and yoga can also be useful in the

13

f.

Anesthetic injections ;seful in extremely painful conditions. The injection of ,9 into tender and painful areas in muscle has been used for diagnostic and therapeutic purposes in patients with +4 syndrome.

D./cc of ,9 that does not contain epinephrine or other vasoconstrictors are used. g. Transcutaneous Electrical Ner e Stimulation TENS The use of T56S is based on the concept that stimulation of cutaneous branches of fifth nerve &trigeminal) creates an inhibitory effect on the trigeminal spinal tract nucleus, thus reducing the awareness of pain and relaxing the muscles. Therapy lasts (D minutes and should be repeated daily. 777. Final explanation of problem. When patients with +4 syndrome begin to show improvements of +4

their symptoms and have gained confidence in doctors ability to deal with their problem, the relationship between stress and syndrome should be discussed and explained. 7H. +sychologic <ounseling 9 group of patients are sometimes not able to identify and understand relationship between stressAstrain and +4 syndrome and are unable to cope with stressful conditions. Such patients should be referred to psychologists or psychiatrist for counseling.

1B

+sychological interventions are aimed at reducing high level of muscle tension or modifying the environment. Treatment of contributing factors should be carried out.

1C

Su

ar$
The +4 syndrome is a psychophysiologically altered condition

involving the muscles of mastication and cervical group of muscles. The condition characteri"ed by dull aching, radiating pain often results in muscle spasm and restricted movements. 9n accurate diagnosis is accomplished by careful history ta%ing and thorough examination. The application of proper therapy is related to the understanding that +4

syndrome is a stress induced psychophysiologic disease originating in muscles and not a temporomandibular joint disorder. Thus, the therapy should be directed towards reducing stress, rehabilitating the occlusion and relaxing the muscles to alleviate the condition.

1'

Reference%
1) Prosthet. "ent.# ** ? *(C, 1'CD. #) syndrome. !. Prosthet. "ent.# /3 ? B/, 1'C3.
()

Mi)'ai" M(5 Ro%en +( ? 1istory and etiology of myofascial pain!dysfunction syndrome. !.

La%)in

D(M(5

Sanford

4( ? 4iagnosis and treatment of myofascial pain!dysfunction & +4)

La%)in D(M( ? 5tiology of

the pain!dysfunction syndrome. !. Am. "ent. Assoc.# B' ? 1*B, 1'3'.

*) ', +hiladelphia, 1''B, ,ippincott G 8aven. /) Prosthet. "ent.# 1D ? B*/, 1'3D. 3)

L$nc' M(A(5 4ri&'t an

6(7(5 ,reenber& M(S( ? :ur%et0s oral medicine? 4iagnosis and treatment. 5d.

Tra-e""

7(

Temporomandibular joint pain referred from muscles of the head and nec% . !.

8awa0oe Y(, 8otani +(5

+a ada T( and Ya ada S( ? 5ffect of occlusal splints on the electromyographic activities of masseter muscles during maximum clenching in patients with myofascial pain!dysfunction syndrome. !. Prosthet. "ent.# *( ? /BC, 1'CD.

B)

Do'r ann R(7(5 La%)in

D(M( ? 9n evaluation of electromyographic biofeedbac% in the treatment of myofascial pain!dysfunction syndrome. !. Am. "ent. Assoc. '3 ? 3/3, 1'BC.

#D

C)

C"ar)e N(,(5 8ardac'i 4(7( ? The treatment of myofascial pain!dysfunction syndrome using the biofeedbac% principle. !. Periodont.# *C ? 3*(, 1'BB.

#1