This document discusses the history, definition, etiology, clinical characteristics, diagnostic methods, and treatment of myofascial pain dysfunction syndrome (MPDS). Some key points: - MPDS is a pain disorder caused by trigger points in the muscles of mastication that refer pain to the head and neck. It is the most common cause of masticatory pain. - Etiology may include occlusal factors, prosthetic problems, malocclusion, psychophysiologic factors, and trauma. - Clinical characteristics include pain in the head/neck, limited jaw motion, joint noises, and tender muscles. - Treatment involves a multidisciplinary approach including medications, trigger point injections, physical

1. Guided by
-Dr. Shalu Rai
-Dr. Sapna Panjwani
-Dr. Deepankar Mishra
-Dr. Vikas Ranjan
Presented by
-Dr. Priyadershini

2. History-
• Costen (1934)- occlusal etiology in TMJ pain. (Bite raising era)
• He reported association of bite like ear pain, sinus pain, decreased hearing,
tinnitus, dizziness, burning & vertigo & occipital headaches.
• Scwartz (1956)- TMJ pain dysfunction syndrome & blamed the masticatory &
perimasticatory musculature leading towards the symptoms.
• He noted altered psychologic make up and advocated use of muscle
relaxants, restrictions of oral openings for resting the muscles.
TMJ Dysfunction Syndrome/
Myofascial Pain Dysfunction Syndrome
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

3. • Laskin (1969)- Myofascial Pain Dysfunction Syndrome.
• He implicated psychophysiologic theory stating that
psychological stress leads to myospasm & advised
tranquilizers, muscle relaxants.
Definition
• MPDS is a pain disorder, in which unilateral pain is referred
from the trigger points in myofascial structures, to the muscles
of the head and neck.
• MPDS is the most common cause of masticatory pain & limited
function for which patient seeks dental consultation & the
source of the pain treatment.

4. Etiology
• Tooth muscle theory- occlusal interference cause an alltered
proprioceptive feedback, leading to incoordination & spasm of muscles of
mastication.
• Prosthetic problems- fauty prosthesis, over closure, bilateral loss of
molar teeth, increased vertical dimentions.
• Malocclusion- by Oral habits (clenching, grinding of teeth), anxiety.
• Psychophysiologic theory- masticatory muscle spasm causes MPDS,
degenerative arthritis & contracture arthritis.
• Steep angulation of articular eminence.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

5. Micro/ macro
trauma to
muscles
Increased
tone of
musculature
Muscle fatigue &
accumulation of
metalic byproducts like
lactic acid,
prostaglandins,
bradykinines,
histamines which
lowers pH
Inolves a
psychogenic
component
which modifies
pain &
complicates the
treatment
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

6. Clinical characteristics
Laskin’s Cardinal symptoms of MPDS :-
1. Pain or discomfort anywhere about the head or neck.
2. Limitation of motion of the jaw.
3. Joint noises– grating, clicking, snapping.
4. Tenderness on palpation of the muscles of mastication.
Negative characteristics:-
1. Absence of clinical, radiographic or biochemical evidence of organic
changes in TMJ.
2. Lack of tenderness in TMJ area when palpated via external auditory
meatus.
• A zone of reference
• Trigger points in muscles
• Occasional associated symptoms
• The presence of contributing factors

7. Zone of reference
• Referral of myofascial
trigger point pain of
temporalis muscles refers
only to the maxillary teeth.

8. • The masseter refers only
to the posterior teeth.
• The digastric anterior
refers only to the
mandibular incisors.

9. Trigger points
• Trigger points exist as a localized tender areas
within taut bands of skeletal muscles &
stimulated by macro & microtraumatic episodes,
they refer a characteristic pain pattern to a
distant group of muscles, i.e. zone of reference.
• Palpation of trigger points gives a positive ‘jump
sign’.

10. Associated symptoms
Neurologic
• Tingling
• Numbness
• Blurred vision
• Twitches
• Lacrimation
Gastrointestinal
tract
• Nausea
• Vomiting
• Diarrhea
• Constipation
• Indigestion
Musculoskeletal
• Fatigue
• Tension
• Tiredness
• Weakness
Otologic
• Tinnitus
• Ear pain
• Dizziness
• Vertigo
• Diminished
hearing

11. Other criteria
• Psychologic or central etiology-
• Muscle fatigue by unusual habits & occlusal
disharmony.
• Occlusal or peripheral etiology-
• Inherent malocclusion- developmental deformities
• Acquired malocclusion
• Iatrogenic
• Intrinsic joint disorders
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

12. History of the patient
• Mode of onset, duration, frequency & quality of pain. Site &
reference point of pain.
• Time of the day, at which pain is most pronounced.
• Occupation.
• Sleeping habits.
• Parafunctional habits.
• H/O previous trauma, prolonged dental work etc.
• Family or emotional problems.
• Associated symptoms.
• Aggravating & relieving factors.
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

13. Physical examination
• Articular / joint examination
• Dental examination
• Muscular examination
• Cervical examination
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

14. Clinical examination of TMJ
• TMJ pain-
• Determined by digital palpation of the joints – when
mandible is in both stationary as well as dynamic
movement
• Finger tips placed – lateral aspect of both the joints
– feel for the lateral poles passing downwards &
forwards across articular eminence on repeated
opening & closing.
• A medial force is then applied to – record symptoms
if any in static position & then on opening & closing.
• Also, on maximal opening – fingers are rotated
slightly posteriorly to apply force on the posterior
aspect of the condyle (to evaluate posterior
capsulitis & retrodiscitis)

15. Temporalis muscle
• Palpation of the posterior, middle, and
anterior regions and tendon of the
Temporalis.
• I / o- The finger is moved up the anterior
border of the ramus until the coronoid
process and the attachment of the
tendon of the temporalis are felt.

16. Massater muscle
• Palpation of the masseter muscles at
their superior attachment to the
zygomatic arches.
• Palpation of the superficial masseter
muscles near the lower border of the
mandible.

17. • Functional manipulation
of inferior lateral
pterygoid.
• The patient is asked to protrude
against resistance provided by
the examiner.
• Functional manipulation of the
superior lateral Pterygoid is
achieved by asking the patient to
bite on at tongue blade
bilaterally.

18. Medial pterygoid
• Tell patient to open mouth wide, protrude against resistance, clench
the teeth together, and then bite on a separator when these function
causes pain then medial pterygoid muscle is involved.

19. Sternocleidomastoid
• Palpation of the sternocleidomastoid
muscle high near the mastoid process &
low near the clavicle.

20. Articular or TMJ Function and
Range of Motion:-
1. Amount of oral opening and the excursions.
2. Extent of movement
i) ROM – Range of motion
i) AROM – Active range of motion
iii) PROM – Passive range of motion
3. Palpation for tenderness.
4. Grading of click or crepitation- noises evaluation.
5. Auscultation (stethoscopic evaluation), if needed.
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

21. 1. Amount of oral opening and excursions.
• Opening path & amount of deviation should be noted.
• Early opening deviation is due to spasm lateral pterygoid
muscle of same side.
• Normal range of protrusive movement- 10mm
• Lateral excursions- normal- 10mm
• Pain or inflammation indicates one of the following
conditions
• Joint inflammation,
• muscle dysfunction.
• Anteriorly displaced disc etc
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

22. 2. Extent of movement
• ROM – Range of motion-
• Normal vertical ROM in adults is-40- 50 mm
• Hypomobility without pain gives indication for pathology.
• Measurement of maximum pain free motion is noted.
• Limited AROM with pain indicates structural restrictions by
muscular problems.
• PROM tests all inert structures.
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

23. 3. Areas of tenderness on palpation
• Simultaneous palpation of both the joints with index fingers
laterally over the joints & through the external auditory
canal in open & closed position.
• Pain is unrelated to closure in posterior joint palpation may
indicate ear problem or inflammation.
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

24. 4. Timing of the click
• Noted whether it is coming during opening, closing or both
should be ascertained.
• Distinct sound click
• Crepitus
• Multiple scraping, grating noises
These sound can be heard by stethoscope.
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

25. Recent diagnostic methods:-
I. TMJ arthrography.
II. Computed radiography (CR).
III. Computed Tomography (CT) scan & Magnetic
Resonance Imaging (MRI).
IV. Bone Scintigraphy- nuclear imaging
V. Single Photon Emission Computerized
Tomography (SPECT).
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

26. Laskin and Block,
(1986)
Phase I therapy
psychophysiologic
discussion.
Home therapy (diet &
exercise)
Muscle relaxant & NSAIDs
(2-4 wks)- 50% resolution
Phase Il therapy
Home therapy and
medications + bite
appliance
(2 to 4 wks) 20% to
25%resolution. Phase lll
Physiotherapy (ultrasound,
electrogalvanic stimulation)
or relaxation therapy (yoga,
biofeedback)
(4 to 6 weeks) 10% to 15%
resolution.
Phase lV
Psychologic
counselling
pain clinic

27. Medications
1. NSAIDs to reduce inflammation & pain in muscles & joint.
• Aspirin : 2 tabs 0.3 to 0.6gm/ 4 hourly.(ECOSPIRIN)
• Piroxicam: cap. 10 to 20mg /once daily.(FELDENE)
• Ibuprofen : 200 to 600mg/3 times a day.(BRUFEN)
• Pentazocine: 30 mg i.v./i.m./s.c. every 3– 4 hrs max.- 360mg. (TALWIN,
TALACEN)
2. Muscle relaxant-
• Methocarbamol : muscle relaxant- 1500mg/ 4 times a day for 2-3
days,1000mg i.v./ 8 hrly (ROBAXIN)
• Metaxalone- (SKELAXIN)
• Chlorzoxazone - (FLEXON MR)- 400 mg, 325mg, 250 mg
3. Antidepressant-
• Diazepam- (VALIUM, CALMPOSE) & chlordiazepoxide (sedative)
5 to 10mg /2 to 3 times a day.(LIBRIUM)
• Amitriptyline: - 25mg/ 3- 4 times a day or at bedtime.(ELAVIL,
VANATRIP).
Tripathi, textbook of pharmacology, 5th edi.,
Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

28. Trigger Point Injection
• A trigger point is located, trapped between
the fingers, and injected (with a short 27-
gauge needle).
• 0.5% bupivacaine with epinephrine.
• Blocks are given at 48-hour to weekly
intervals into nerve distributions and
particularly into zones of muscular trigger
foci.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

29. Therapeutic Anesthetic Block
• The auriculotemporal nerve can be blocked by
passing a 27-gauge needle through the skin just
anterior to and slightly above the junction of the
tragus and the earlobe.
• The needle is then advanced until it touches the
posterior neck of the condyle. The needle is then
repositioned in a more posterior direction behind
the posterior neck of the condyle.
• Once the neck of the condyle is felt, the tip of the
needle is carefully moved slightly behind posterior
aspect of the condyle in an anteromedial direction
to a depth of 1 cm.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

30. Physiotherapeutic modalities
1. Heat application.
• Ultrasound
• Heat lamp
• Diathermy.
2. Cryotherapy.
• Ice pack
• Vapo- coolant spray
• Ice massage
• Cold whirlpool
3. Massage with counter-irritants & vibrators.
4. Electro Galvanic Stimulation.
5. Transcutaneous Electronic Nerve Stimulator (TENS).
6. Active stretch exercises.
Mujakperuo HR, Watson M, (2010). "Pharmacological interventions for pain in patients with
temporomandibular disorders". The Cochrane Database of Systematic Reviews

31. Pathophysiologic effects of topical modalities
Scott F. Nadler, DO, FACSM, Kurt Weingand, and Roger J. Kruse, MD, The Physiologic Basis and Clinical
Applications of Cryotherapy and Thermotherapy for the Pain Practitioner Pain Physician. 2004;7:395-399.

32. Heat application/ thermotherapy
• Thermotherapy is the therapeutic application of any substance to the body that
adds heat to the body resulting in increased tissue temperature.
• Heat therapy, which can be either superficial or deep, is like cryotherapy in that
it provides analgesia and decreased muscle tonicity.
• Unlike cryotherapy, thermotherapy increases tissue temperature, blood flow,
metabolism, and connective tissue extensibility.
• Heat therapy is delivered by three modes:
• Ultrasound
• Heat lamp
• Diathermy.
Scott F. Nadler, DO, FACSM, Kurt Weingand, and Roger J. Kruse, MD, The Physiologic Basis and Clinical
Applications of Cryotherapy and Thermotherapy for the Pain Practitioner Pain Physician. 2004;7:395-399.

33. Ultrasound therapy
• Ultrasound (US) is used for heating deep tissues.
• It is a noninvasive method which consists of
piezoelectric crystals that convert the electrical
energy to mechanical oscillation energy using
high-frequency alternating current (van der Windt,
1999).
• 2- 3 MHz – upto 3 cm deeper tissues.
US produces
(>20000 Hz)
vibration of synthetic
crystals
Crystals contracts
and expands by
alternating electric
current
Oscillation of
crystals produce
pressure waves =
ultrasound waves.

34. • Contineous or pulsed
• Both produces thermal effects
• Contineous produces more thermal energy.
• A unidirectional movement of the ultrasound field causing a micro
massage of the target tissues that increases cell diffusion which is thought
to promote tissue repair.
Thermal
Mechanical
effects
Increase local
metabolism, circulation,
regeneration and
extensibility of
connective tissue
Promotes
tissue
repair
Scott F. Nadler, DO, FACSM, Kurt Weingand, and Roger J. Kruse, MD, The Physiologic Basis and Clinical
Applications of Cryotherapy and Thermotherapy for the Pain Practitioner Pain Physician. 2004;7:395-399.

35. Pulse ratio
• Concentration of energy on time basis
• Time of machine at on : Time of machine at off
Scott F. Nadler, DO, FACSM, Kurt Weingand, and Roger J. Kruse, MD, The Physiologic Basis and Clinical
Applications of Cryotherapy and Thermotherapy for the Pain Practitioner Pain Physician. 2004;7:395-399.

36. Phonophoresis
• The use of ultrasound to enhance the delivery of topically applied
medications
• Hydrocortisone- 10% - wycort 2.5% ointment- TDS
• Ketoprofen- 10%
• Dexamethazone
• Clobetasol ointment 0.05% in orabase
• NSAIDs - diclofenac sodium gel as a coupling media (Álvarez-Soria et al.,
2008).
• 1 MHz frequency with transducer having an affective radiating Intensity of
1.5 W/ cm² in continuous mode to insure reaching the deep tissues
(Kitchen and Bazin, 2002).

37. Cryotherapy
• Cryotherapy is defined as the therapeutic application of any substance to the
body that removes heat from the body, resulting in decreased tissue
temperature.
• Ice pack
• Ice massage
• Vapo-coolant spray
• Cryotherapy decreases tissue blood flow by causing vasoconstriction, and
reduces tissue metabolism, oxygen utilization, inflammation, and muscle spasm.
• Topical cold treatment decreases the temperature of tissues to a depth
of 2 to 4 cm, decreasing the activation threshold of tissue nociceptors
and the conduction velocity of pain nerve signals causing local
anesthetic effect called cold-induced neuropraxia.
Scott F. Nadler, DO, FACSM, The Physiologic Basis and Clinical Applications of Cryotherapy and
Thermotherapy for the Pain Practitioner Pain Physician. 2004;7:395-399.

38. Cold application
• Ice pack or direct ice massage encourages the
relaxation of muscles that are in spasm and thus
relieves the associated pain.
Ice should be
applied
directly in a
circular motion
without
pressure to
the tissues.
Initially
experience an
uncomfortable
feeling that will
quickly turn
into a burning
sensation.
Continued
icing will
result in a
mild aching
and then
numbness.
After a period
of warming a
second
application
may be
desirable.
During
warming there
is an increase
in blood flow
to the tissues
that assists
tissue repair.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)

39. Use of vapocoolent spray
• Vapocoolant sprays do not penetrate tissue as does
ice, and therefore it is likely that the reduction in pain
is more associated with the stimulation of cutaneous
nerve fibers that in turn shut down the smaller pain
fibers (the C fibers).
• Ethyl chloride and fluoromethane.
• Applied from a distance of 1 or 2 feet for 5 sec.
• After the tissue has been rewarmed, the procedure
can be repeated.
• A towel can be used to protect eyes, ears, nose,
mouth.
• When myofascial (trigger point) pain is present, a
technique described as “spray and stretch” is used.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

40. Electrogalvanic stimulation therapy
• Uses the principle that electrical stimulation
cause muscle contraction.
• EGS uses a high-voltage, low-amperage,
monophasic current of varied frequency.
• A rhythmic electrical impulse is applied to
the muscle, creating repeated involuntary
contractions and relaxations.
• The intensity and frequency of these can be
varied according to the desired effect, and
they may help to break up myospasms, as
well as increase blood flow to the muscles
and leads to a reduction of pain in
compromised muscle tissues.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)

41. Transcutaneous Electrical Nerve Stimulation.
• TENS produces a continuous stimulation of cutaneous
nerve fibers at a subpainful level.
• This uses a low-voltage, low-amperage, biphasic
current of varied frequency and is designed primarily for
sensory counterstimulation in painful disorders.
• When a TENS unit is placed over the tissues of a
painful area, the electrical activity decreases pain
perception.
• When the intensity of a TENS unit is increased to the
point that motor fibers are activated, this becomes an
EGS unit that is no longer used for pain control but
instead for muscle relaxation.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)

42. • During TENS, pulsed currents are generated by
a portable pulse generator and delivered across
the intact surface of the skin via conducting pads
called electrodes.
• The conventional way of administering TENS is
to use electrical characteristics that selectively
activate large diameter ‘touch’ fibres (Aβ) without
activating smaller diameter nociceptive fibres
(Aδ and C).
• Evidence suggests that this will produce pain
relief in a similar way to ‘rubbing the pain better’.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)

43. Acupuncture
• Acupuncture involves stimulation of the body at certain
points. During a treatment, thin steel needles are inserted
into the skin, then manipulated gently by hand or with light
electrical stimulation.
• Treatment is short (6 week)
• Acupuncture needles stimulate the nervous system by
releasing natural painkillers such as endorphins and
serotonin.
• Each patient responds to acupuncture differently. Some
people notice an immediate improvement, while some need
several treatments to experience the full effect.
• The British Dental Acupuncture Association reported that
about 70% of patients show some benefit.
Gustav O Kruger ; Textbook of Oral and Maxillofacial Surgery, ch 26, 6th edi; 700-756

44. Biofeedback Training
• The patient is encouraged to assume a relaxed
position in a comfortable, quiet setting.
• The electromyographic sensors are attached to the
masseter muscle.
• A finger sensor may also be used to monitor
temperature and/or galvanic skin response.
• The patient is instructed to relax the muscles as
much as possible.
•The computer monitor provides immediate feedback regarding the success in
reducing the muscle activity.
•After several training sessions the patient becomes aware of effective relaxation
and is encouraged to accomplish this without the biofeedback unit.
Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and
occlusion (5th ed.)

45. Gustav O Kruger ; Textbook of Oral and Maxillofacial Surgery, ch 26, 6th edi; 700-756
• Significant control over pain and other sensory complains
may be gained through psychophysiological techniques such
as yoga, meditation, biofeedback, hypnosis, and
psychotherapy.
• Hypnosis is another paraphysiological technique with
primary action on pain tolerance thresholds for the control
of chronic facial pain. Carefully selected patients may, with
training in autosuggestion, come to effectively deny or
accept their pain.
• Counselling and psychotherapy should be included in the
overall treatment.