Myofascial pain dysfunction syndrome/ dental regular courses

MYOFASCIAL PAIN
DYSFUNCTION SYNDROME
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

ETIOLOGY OF MPDS
• TISSUE INJURY
Major trauma
Exposure to extreme temperature
• PHYSICAL STRESSES
Extreme fatigue
Repetitive micro trauma (Clenching & Bruxism)
Other disease processes

ETIOLOGY OF MPDS
• PREDISPOSING FACTORS
Physical deconditioning
Previous injuries
Psychological and behavioral abnormalities
Occlusal interferences
Posterior bite collapse
Deep over bite overjet
• POOR NUTRITIONAL STATUS
• GENETIC PREDISPOSITION

DIGAMMATIC RERESENTATION OF
ETIOLOGY OF MPDS
PSYCHOPHYSIOLOGIC THEORY OF MPDS
(Modified by LASKIN in 1969)

CLINICAL FEATURES--- PAIN
• Pain,Unilateral,More diffuse
• Masseter :
– jaw ache
• Temporalis :
– head ache
• Lateral pterygoid :
– Earache
– Deep pain behind eye
• Medial pterygoid :
– Difficulty in swallowing,
– Feeling of swollen gland
– Stuffiness or a full feeling in the ear

CLINICAL FEATURES --- PAIN
• Constant
• Severe on arising in the morning
• Worsens as day progresses
• Radiates to cervical region,shoulders and back

CLINICAL FEATURES --- TRIGGER
POINTS
• Tenderness in MM
• Angle of mandible
• Posterosuperior aspect masseter
• Anterior temporal region
• Over the temporal crest
• Anterior aspect of coronoid

CLINICAL FEATURES
• Limitation of jaw movement
• Inability open the mouth
• Deviation to the affected side
• Lateral excursion on affected side is affected
• Limitation correlated with pain

CLINICAL FEATURES
• Clicking or popping sound in the joint
• To summarize
• Three cardinal symptoms
• Pain, tenderness in the muscles, limitation in the opening
• Absence of clinical, radiographic, biochemical
evidence of TMJ pathology

DIAGNOSIS

DIAGNOSIS
• History
• General Body Examination
• Examination of The Face
• Examination of TMJ
• Examination of muscles of mastication and associated
cervical musculature
• Examination of the dentition and oral tissues
• Examination of remaining structures of head and neck

DIAGNOSTIC TESTS
• Clinical examination
• Muscle palpation
• Range-of-motion measurements
• Quality of motion assessment : coordination and velocity

VOLUNTARY PAIN FREE OPENING
• The voluntary pain free
opening is being measured
from the mandibular incisor to
the ipsilateral maxillary incisor
• The measurement should
also be done for maximum
voluntary opening

PASSIVE STRETCH TEST
• From the maximum voluntary opening by
applying about 2lbs to 3lbs of pressure to
lower and upper incisors with the middle
or index finger
• The amount of resistance and the tactile
feeling elicited at the most open position
is described as END FEEL
• The SOFT END FEEL exists when the
patient refuses to allow much force to be
applied because of pain
• The HARD OR SPRINGY END FEEL
exists when firm pressure is applied and
no movement results

PASSIVE STRETCH TEST
• If the patient has too much of pain to allow this
manipulation, a vapocoolant spray should be used on
the skin over the masseter and temporalis muscles. This
spray will generally block the pain transiently to allow for
better stretching

• Injection of muscles using about 1ml of a 1 % solution
PROCAINE HYDROCHLORIDE without epinephrine
• Diagnostic test to help localize the sources of pain
• Can also be done to rule out or identify the peripheral
nature of an orofacial pain problem
ANAESTHETIC NERVE AND MUSCLE
BLOCKING

THERMOGRAPHY
• Thermography is also not currently of diagnostic utility
because, at best, it only confirms the presence of altered
temperature in a painful muscle, and it is many times
less sensitive than palpation procedures

BIOPSY
• Excisional or needle biopsy of muscle tissue is not a
routine procedure and has very little applicability for the
painful disorders of the muscles of mastication

ELECTROMYOGRAPHY(EMG)
• EMG may be a useful tool in the evaluation of muscle
function
• Pain is not diagnosed with use of EMG
• At best, EMG can detect the presence of abnormal
protective muscle activity occurring with jaw movement
in patients with trismus
• EMG can also be used to monitor the level of jaw muscle
activity during sleep to document the presence of active
bruxism

JAW TRACKING
• As with EMG, jaw tracking procedures are not diagnostic
of a painful disorder of masticatory muscles
• Abnormal movements can usually be recognized
clinically, and use of a millimeter ruler is a sufficiently
accurate way to document the range of maximum jaw
movements

TREATMENT OF MPDS
• Education
• Self-care
• Physical therapy
• Intra-oral appliance therapy
• Behavioral/Relaxation technique
• Pharmacotherapy

EDUCATION
• Explanation of diagnosis and treatment
• Reassurance about good prognosis, recovery
• Explanation of patient’s and doctors roles in therapy
• Information to enable patient to perform self care

SELF CARE AND HABIT REVERSAL
• Attention to jaw activities that are unrelated to function
– Tooth clenching
– Jaw posturing habits
– Jaw muscle tensing
– Leaning on the jaw
• Restful jaw postures
• Habit control
• Dispensing set of instructions to focus attention on habits

SELF CARE AND HABIT REVERSAL
• Application of moist heat for 15-20 min twice daily
• Range of motion exercises within comfort zone
• Use of ice for control /relief of pain (10 min/2 hr)

PHYSIOTHERAPY
• To relieve pain,
• Reduce muscle spasm
• Achieve relaxation
• Improve joint mobility and muscle action
• Restore full function to musculoskeletal system

PHYSIOTHERAPY
• Education regarding biomechanics of the jaw, neck,
head posture
• Passive modalities
– Heat and cold therapy
– Ultrasound
– LASER
– TENS
• Range of motion exercises (active and passive)
• Posture therapy
• Passive stretching, general exercise, conditioning
program

PHYSIOTHERAPY
MOIST HEAT
• More therapeutic than dry heat
• Vasodilatation
• Increases blood flow to area
• Utilized before manipulative therapy

ELECTROGALVANIC STIMULATION
• Positive and negative current delivered to target area
• High frequency pulsations : relax spastic muscles
• Rhythmic contractions : increase circulation, reduce
edema
• Re-educate abnormally functioning muscle

ULTRA SOUND
THERAPEUTIC USES ARE DUE TO
• Elevation of temperature within tissues
• Increased vasodilatation and waste removal
• Stimulation of metabolism
• Increased cell membrane permeability and improved gas
exchange
• Reduced conductivity of insonated nerves and resultant
decrease in pain transmission.
• Mechanical movements producing a micro massage
(Pulsed ultrasound accentuates the mechanical effects).

APPLICATIONS OF ULTRASOUND
• Production of deep heat at the joints
• Treatment of joint contracture by increasing the stretch
of muscle spasm and tendonitis
• Facilitation of stretch of soft tissues by decreasing the
viscosity of collagen
• Decreasing firing of type III muscle spindles
• Facilitation of breaking calcium deposits in bursitis

TENS
• Two modes of action are theorized for its efficacy. First
one being based on the gate control theory of pain,
• The second theory is based on the putative production of
endogenous opiates when subjected to certain types of
electrical stimulation

OTHER METHODS
• ACUPRESSURE : Target organ stimulated by pressure
• Auriculotherapy : points in the ear corresponding to the
organ
• Reflexology : points in feet
• Kinesiology
• Clinical extension of neuromuscular physiology
• Proprioceptors and their effect on normal muscle
function and strength

ACUPUNCTURE
• Based on premises that human body has energy centres
• Balance : state of health
• Inserting fine needles specific points on body
• Points correspond to specific organ

OCCLUSAL SPLINT THERAPY
Splint therapy may be defined as the art and science of
establishing neuromuscular harmony in the masticatory system and
creating a mechanical disadvantage for parafunctional forces with
removable appliances.
• TYPES OF OCCLUSAL SPLINT
• The two most common
– Centric relation
– Anterior repositioning splint.
• Others include the
– Anterior bite plane,
– Posterior bite plane,
– Pivoting splint soft or resilient splint

FUNCTIONS OF OCCLUSAL
SPLINTS
1. To relax the muscles,
2. To allow the condyle to seat in centric relation,
3. To provide diagnostic information,
4. To protect teeth and associated structures from bruxism,
5. To mitigate periodontal ligament proprioception and
6. Cognitive Awareness

PRINCIPLES OF SPLINT
• Cover all teeth on the arch the appliance is seated on
• Adjust to achieve simultaneous contact - opposing teeth
• Adjust to a stable comfortable mandibular posture
• Avoid changing mandibular position
• Avoid long term continuous use

BEHAVIORAL AND RELAXATION
TECHNIQUES
• Relaxation therapy
• Meditation
• Hypnosis
• Biofeedback
• Cognitive-behavioral therapy

RELAXATION TECHNIQUES
• Decrease sympathetic activity
• Deep methods
– Autogenic training : Imagining a peaceful environment and
comforting bodily sensations
– Meditation: Self-directed practice for relaxing the body and
calming the mind
– Progressive muscle relaxation: reducing muscle tone in major
muscle groups
• AIMS
– Comforting body sensation
– Calming the mind
– Reducing muscle tone

RELAXATION TECHNIQUES
• Brief methods for relaxation
– Self controlled relaxation : PMR, Autogenic training
– Paced breathing
– Deep breathing
• Hypnosis
• Selective or diffuse focus to induce relaxation
• Does not effect endorphin production
• Effect on catecholamines is not known
•

COGNITIVE AND BEHAVIORAL
THERAPIES
• Cognitive and behavioral therapies
– Changes the pattern of negative thoughts
– Block pain from entering consciousness
• Frontal limbic attention system
• Preventing impulses from thalamus to cortex

BIOFEEDBACK
• Continuous feed back by
– Monitoring electrical activity of muscle
– Monitoring peripheral temperature
• Relaxation exercises aimed at reducing the temperature

PHARMACOTHERAPY
• NSAIDs
• Acetaminophen
• Muscle relaxants
• Antianxiety agents
• Tricyclic antidepressants
• Clonazepam

PHARMACOTHERAPY
• NSAIDs : Celecoxib, Etoricoxib
• Period of 2 weeks
• Less g.i irritation
• Nabumetone, Naproxen, Diclofenac
• Diclofenac gel (pluronic lecithin organogel)
• Capsaicin cream (0.025% or 0.075%)

PHARMACOTHERAPY
• Antianxiety agents :
– Sedation
– Acute exacerbations of muscle pain
• Muscle relaxants
• Sedative
• Tricyclic antidepressants

PATHOPHYSIOLOGY OF THE
MASTICATORY MUSCLES
Muscular shortening
(Calcium excess shortening)
Prolonged sustained and muscular contraction
Disruption of delicate sarcoplasmic reticulum
Release of free calcium ions that are stored within
Remove regulatory proteins &
yields actin-myosin complexing

Shortened muscles experience increase in metabolic
demands due to more actin and myosin
Depletion of ATP
(Muscular fatigue)
Actin myosin binding intensified
(ATP depletion shortening)
Mechanical interruption of blood flow through
this area of biochemical derangement
Vasoconstriction decrease of oxygen in the affected
muscular fibres (shift to anaerobic metabolism)

Anaerobic metabolism causes propagation of decreased pH
& accumulation of Nocigenic and Spasmogenic
by-products called the “BIOGENIC AMINES” like serotonin,
histamines, kinins & prostaglandins
Activation of group III and group IV
muscle nociceptive fibres
PAIN
Pain and further exaggerated central response (reflex
response phenomenon) creates increased accumulation of
biogenic amines & intensified vasoconstriction
Local twitch response & jump signs of myofascial trigger
pointswww.indiandentalacademy.com

The constant biochemical cycle results in the production of
spasmogenic amines (biogenic amines)
Three staged casual theory Calcium pump inactivation, ATP
depletion & increase in free Ca++
(creating vicious , deteriorative biochemical cycle)
Becomes impossible for muscular fibres to reabsorb the
free calcium ions back into the sarcoplasmic reticulum
In addition intensified vasoconstriction of central origin
coupled with Mechanical vasoconstriction will cause
ultimate inactivation of the ATP-dependent calcium pump

DIAGRAMMATIC
REPRESENTATION

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