This document discusses myofascial pain dysfunction syndrome (MPDS), including its etiology, clinical features, diagnosis, and treatment. MPDS is characterized by localized tender bands of muscle called trigger points that can cause referred pain patterns. It commonly affects young women and is diagnosed based on clinical findings like the presence of trigger points. Treatment involves palliative therapies like occlusal splints as well as definitive therapies like trigger point injections and dry needling.

1. Myofascial Pain
Dysfunction Syndrome
(MPDS)
Presented by
Dr. Rahul Srivastava
Professor
Rama Dental College Hospital
& Research Centre Kanpur

2. Myofascial pain dysfunction syndrome (MPDS)
It is a regional myogenous pain condition
characterized by local areas of firm,
hypersensitive bands of muscle tissue known as
trigger points.
This condition is also referred as myofascial
trigger point pain. Myofascial trigger point pain
was first described by Travell and Rinzler in
1952.

3. Etiology of MPDS
 Central nervous system plays significant role.
 Protracted local muscle soreness.
 Local factors: Para functional habits, poor
posture and chilling.
 Systemic factors - Fatigue, poor physical
condition, hypovitaminosis and viral infections.
 Increased levels of emotional stress.
 Continued source of deep pain input.

4.  Occlusal interferences.
 Presence of sleep disorder.
 Idiopathic trigger point mechanism.

5. Clinical Features of MPDS
 Females more affected than males with ratio of
4:1.
 Affects primarily young women (age 20 to 40
years).
 Presence of trigger points which present as local
areas of firm, hypersensitive, bands of muscle
tissue.

6. Four cardinal sign and symptoms:
Laskin has proposed 4 cardinal signs and
negative characteristics for MPDS.
 Unilateral dull pain in the ear or preauricular
region that commonly worsens on awakening.
 Muscle tenderness. Tenderness of one or more
muscles of mastication on palpation.
 Clicking or popping noise in TMJ.
 Limitation of jaw movement, limitation or
deviation of the mandible on opening.

7. Negative characteristics
 No radiographic evidence.
 No tenderness in TMJ area on palpation via the
external auditory meatus.

8. Trigger points?
 Trigger points are discrete, focal, hyperirritable
spots located in a taut band of skeletal muscle.
 The spots are painful on compression and can
produce referred pain, referred tenderness, motor
dysfunction and autonomic phenomena.

9. Types of trigger points
Trigger points are classified as:
 Active trigger point.
 Latent trigger point.
Active trigger point
 An active trigger point causes pain at rest.
 It is tender to palpation with a referred pain
pattern that is similar to the patient's pain
complaint.
 This referred pain is felt not at the site of the
trigger-point origin, but remote from it.

10.  The pain is often described as spreading or
radiating.
 Referred pain is an important characteristic of a
trigger point.
Latent trigger point
 A latent trigger point does not cause spontaneous
pain, but may restrict movement or cause muscle
weakness.

11.  The patient presenting with muscle restrictions or
weakness may become aware of pain originating
from a latent trigger point only when pressure is
applied directly over the point.

12. Diagnosis of MPDS
 Diagnosis is made on the basis of clinical findings.
Presence of trigger points:
Trigger points are small in head and neck region
i.e. about to 2 to 10 mm and larger in shoulder
region 10 to 20 mm.

13.  Examination of muscle of mastication
Muscles should be examined for tenderness using
digital palpation. Muscles that should be included
in examination are medial and lateral pterygoid,
masseter, temporalis, sternocleidomastoid and
trapezius.

14. Measurement of stress
A useful tool is Symptom check list 90(SCL-90). This
evaluation provides an assessment of nine
psychologic states.

15. Treatment of MPDS
Treatment of MPDS is divided in to four categories by
Weinberg. These categories are:
 Palliative therapy.
 Causative therapy.
 Adjunctive therapy.
 Definitive therapy.

16. Palliative therapy
This therapy includes procedures such as occlusal
splint, medications, home remedies (ice, moist heat
application, exercises and soft diet).

17. A- Pharmacological treatment
Drug therapy should be used on fixed dose schedule
rather than as needed for pain. Following drugs can
be used for treatment of MPDS:
1- Muscle Relaxants
Most common muscle relaxants are metaxalone 400
to 800 mg every six hours or chlorzoxazone 500 mg
every six hours.

18. Other muscle relaxants are :
 Casrisoprodol (250-350mg three times daily)
 Methocarbamol (500-1500mg 4-6 hourly)
 Orphenadrine (50mg three times daily)
 Cyclobenzaprine(5 mg three times/day).

19. 2- Nonsteroidal anti-inflammatory drugs
 Ibuprofen should be used in doses of 400mg four
times daily.
 The cyclo-oxygenase inhibitors rofecoxib (25-50
mg/day) and celecoxib (100-200mg/day).
3- Benzodiazepenes
Diazepam(2.5 to 5mg at bed time) and clonazepam
(0.25mg 2 times/day, maintenance dose 1mg/day).

20. Tricyclic Antidepressant
 Drug like amitryptylline is effective.
 It can be started with dose as low as 10mg at night
and dosage can be increased to 75 to 100mg
depending upon patient tolerance.
Capsaicin
 Capsaicin cream (0.025% or 0.075%) can be used for
pain relief.

21.  It releases substance –P and pain related
neuropeptides to reduce pain perception and
inflammation and must be applied multiple times
per day for at least 2 weeks.

22. B- Muscle exercise
Passive stretching i.e. keeping the muscle fibers
relaxed while slowly stretching the muscle,
preventing it from tightening via the stretch reflex in
conjunction with moist heat (followed by application
of ice) is beneficial for decreasing muscle and joint
pain and for improving ranges of movement.

23. C- Counter stimulation of muscle
There are two methods for reducing muscular pain:
1. Repetitive action on trigger point with a mode of
counter stimulation.
2. Muscle rehabilitation through active and passive
stretching and postural exercises to restore the
muscle to normal length, posture and range of
motion.

24. Spray And Stretch
Non-invasive technique for counter stimulation. It
involves cooling the skin with fluoromethane, ethyl
chloride, spray and then gently stretching the involve
muscle to perform spray and stretch therapy.

25. Pressure and Massage
Increased pressure applied to the trigger point can
also relieve pain. Pressure is increased to about 20
pounds and is maintained to 30 to 60 seconds.

26. Trigger Point Injections
Procaine diluted to 0.5% with saline has been
recommended because of its low toxicity to the
muscle, but lidocaine (2% without vasoconstrictor) is
also used.
Injections are often given to muscle group in series of
weekly treatments for 3 to 5 weeks.

27. D- Adjunctive therapy
Consist of treatment modalities that augment and
assist definitive or causative type of treatment for
TMD. It includes:
1- Physiotherapy
It is combination of physical therapy, massage
therapy and electro modalities. Both passive and
active treatments are commonly included as part of
therapy.

28. Posture therapy is also useful to avoid forward head
positions that are thought to adversely affect
mandibular posture and masticatory muscle.
2- Electrotherapy
Is a part of adjunctive therapy; modalities includes
electrogalvanic stimulation, ultrasound, low level
laser and infra red.

29. 3- Electrogalvanic stimulation
It utilizes negative polarity over a painful, swollen
area. The negative charge produces alkaline effect
within the tissues, denaturing proteins and produces
vasodilatation of the capillaries.

30. 4-Transcutaneous Electrical Nerve Stimulation (TENS)
TENS supposedly blocks pain signals being carried
over the small, unmyelinated C fibers by forcing the
large myelinated A fibers to carry a light touch
sensation. It may provide pain relief by physiologic
effects of rhythmic muscle movement.

31. 5- Ultrasound
It is a method of producing deep heat more
effectively that the patient could achieve by using
surface warming. These mechanical vibrations
produce heat and vasodilatation by increasing the
tissue temperature.
6- Iontophoresis
Is a process in which ions in solutions are driven
through intact skin by using a direct current between
two electrodes. It uses ultrasonic energy to drive a
medication deep into the tissue.

32. 7- Low level laser
Laser therapy includes nitric oxide synthesis, which
causes the endothelial linings of capillaries to dilate,
improving circulation in the area.
8- Infra red radiation
It produces vasodilatation of capillary bed by
initiating the synthesis of nitric oxide, improving
circulation and decreasing swelling.

33. 9- Acupuncture (dry needling) and Percutaneous
electrical nerve stimulation (electro-acupuncture or
PENS) also beneficial in pain management.
Stress management in MPDS
Integrating behavioral therapy and relaxation
techniques in chronic pain management in MPDS are
effective.

34. Difference between trigger points and tender points:
Trigger points Tender points
Local tenderness, taut band,
local twitch response, jump sign
Local tenderness
Singular or multiple Multiple
May occur in any skeletal
muscle.
Occur in specific locations that
are symmetrically located
May cause a specific referred
pain pattern
Do not cause referred pain, but
often cause a total body increase
in pain sensitivity

35. References
1- Okeson JP. Management of Temporomandibular
Disorders and Occlusion 5th edition publisher
Elsevier 2002
2- Srivastava R, Devi P, Jyoti B Temporomandibular
Joint Imaging CBS publisher and Distributor pvt
ltd;2014

36. 3- Greenberg MS, Glick M Orofacial Pain and
Temporomandibular Disorders.Oral Medicine
Diagnosis & Treatment Burket’s 10th edition
Hamilton, Ontario, BC Decker Inc 271-300.
4- American Academy of Orofacial Pain. Guidelines
for Assesments, Diagnosis and Management, Chicago:
Quintessence; 1996. Available from:
http://www.quintpub.com/PDFs/book_preview/B4139.p
df

37. 5- Zarb GA, Carlsson GE. Temporomandibular Joint
Function and Dysfunction, Copenhagen, Germany:
Munksaard; 1979. p. 230.
6- Gozler S Myofascial Pain Dysfunction Syndrome:
Etiology, Diagnosis, and Treatment
http://dx.doi.org/10.5772/intechopen.72529