Oral & Maxillofacial Surgery Fifth Year

1. Myofascial Pain
Dysfunction Syndrome
Dr. Wael M. Talaat
Assistant Professor of Oral & Maxillofacial Surgery
University of Dammam

2. Myogenous TMD (muscle-related)

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Usually caused by overwork, fatigue or tension
of the jaw and other muscles in the head and
neck.
This type of TMD commonly causes jaw ache,
toothache, headache and/or an ache in the back
of the neck.

3. Myofascial pain disorders
Six categories
1. Myositis
Acute inflammation with pain, edema and decreased
ROM. Usually secondary to overuse, but no infection
or trauma seen
TX: rest, NSAIDs
2. Muscle Spasm
Acute contraction from overuse, overstreching
Tx: rest, NSAIDs, massage, heat, relaxants


4. 3. Contracture
- End stage of untreated muscle spasm
- Due to fibrosis of muscle and connective tissue
- Tx: NSAIDs, massage, vigorous physical therapy,
occasional surgical release of scar tissue
4.Hysterical trismus
- Decreased ROM
- Psychosocial etiology
- More common in females


5. 5. Fibromyalgia
Diffuse, systemic process with firm, painful bands
(trigger points)
Usually seen in weight bearing muscles
Often associated sleep disturbance
More common in females
 Diagnostic criteria
- trigger points
- known path of pain for trigger points


6. 6. Collagen vascular disorders
-- Sjogren’s Syndrome
autoimmune
xerostomia, xeropthalmia with keratitis
sometimes muscle and joint pain , including the TMJ
diagnose with minor salivary gland biopsy

-- SLE
autoimmune, butterfly rash, fever, rheumatoid arthritis
-- Scleroderma
autoimmune characterized with gradual muscle and joint
pain, tightening of skin
limited jaw expansion with pain may be initial presentation

7. Etiology
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The ETIOLOGY of MPDS is multifactorial.
Commonly accepted cause is BRUXISM
resulting from stress & occlusion being an
aggravating factor.
MPDS can also result from internal joint
problems, such as disc displacement disorders,
or degenerative joint disorders.

8. 
When the pain source is purely in the muscles
it has been termed: „Myofascial pain dysfunction‟
( MPDS ) by Laskin.

However, when the TMJ itself is also involved, it
is called „TMJ pain dysfunction syndrome‟ by
Schwartz

9. Myofascial Pain Dysfunction Syndrome
( MPDS )
The MPD syndrome is :
•
•
•
Common cause of TMJ pain
Psycho-physiologic disease involving muscles of
mastication.
Stress-related disorder.
There is an increase in mandibular muscle tension
in tandem with teeth grinding and/or clenching
resulting in spasm, pain, and dysfunction.

10. The condition is characterized by:

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- PAIN - unilateral, dull, aching pain, which increases with
muscular activity, and progressively worsens towards the end of
the day.
- Patients experience limitation of mouth opening.
- Complaints associated with referred pain include
* headache
* earache, tinnitus
* burning tongue
* sometimes decreased hearing.


11. Increased stress levels result in poor habits, like :
- bruxism,
- clenching of teeth, and even
- excessive gum chewing.
leading to muscular overuse, fatigue and spasm,
and subsequently pain.

12. Many symptoms may not appear
related to TMJ itself. They are:
•
Headache:
Pain becomes worse while opening and closing
the jaw.
Exposure to cold weather or air-conditioned air
may increase muscle contraction and facial
pain.

13. •
Ear pain:
•
Pts with TMJ disorder notice ear pain but there
are no signs of infection.
•
The ear pain is usually described as being in front
of or below the ear.
•
Because of this -many a times, patients are
treated for a presumed ear infection, which can
often be distinguished from TMJ by an associated
hearing loss or ear drainage.
Because ear pain occurs so commonly, ENT
specialists are frequently called on to make the
diagnosis of a TMJ disorder.
•

14. •
Sounds:
Grinding, crunching, clicking, or popping sounds
are common in patients with a TMJ disorder.
These sounds may or may not be accompanied by
increased pain.

15. •
Dizziness:
A majority of patients with a TMJ disorder
report a vague dizziness or imbalance
(vertigo).
The cause of this type of dizziness is not well
understood.

16. •
Ringing in the ear (Tinnitus):
For unknown reasons, patients with a TMJ disorder
experience noise or ringing in the ear (tinnitus).
More than half of those patients, will have resolution
of their tinnitus after successful treatment of their
TMJ.

17. Diagnosis

Clinical exam:
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Compare both sides of the jaw, face and head for symmetry
Feel the TMJs, jaw bones and head and neck muscles to find
painful areas
Inspect the gums, mouth tissue and teeth for disease and
excessive tooth wear facets from bruxism
Look for jaw deviation on opening
Listen for joint noises
Measure mouth opening and check side-to-side movements

18. PHYSICAL EXAMINATION
Systemic evaluation of muscles of mastication
1. Symmetry
2. Muscular hypertrophy
3. Palpation for presence of tenderness ,spasm or
trigger point


20. PHYSICAL EXAMINATION
Evaluation of TMJ tenderness and noise
1.point of tenderness
2.form of joint noise : clicking or crepitus


22. PHYSICAL EXAMINATION
Measurement of range of jaw motion
3.5 cm in vertical
1 cm in protusively and laterally


24. 
Clinical signs on examination of myofacial
dysfunction include:
1. Limitation of jaw opening (normal range is at least 35
mm as measured from lower to upper anterior teeth)
2. Palpable spasm of facial muscles
3. Clicking or popping sound in the TMJ
4. Tenderness on palpation of the TMJ via the external
auditory meatus
5. Crepitus over the joint
6. Lateral deviation of the mandible.

25. Management
The aim of management should be:
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Control the factors that worsen TMD
Decrease harmful pressure or “loading” on the joints
Restore jaw function
Help resume regular daily activities
Pain reduction techniques

26. The treatment of myofascial pain
dysfunction syndrome is divided into
four phases.

-
Phase I treatment is initiated upon diagnosis, and
consists of :
educating the patient on muscle fatigue and
spasm as the cause of pain and dysfunction. It
helps to explain referred pain.
- the avoidance of clenching and grinding is
emphasized
- a soft diet is instituted.

27. •
NSAIDs are prescribed, with or without a muscle relaxant.
The most commonly used agents are
Diazepam (2-5 mg twice a day)
and
Ibuprofen (400 mg thrice a day).
Naproxen (500 mg twice daily)
and
Celecoxib (100 mg twice daily)
•
•
Moist Heat therapy + stretch massage helps to relieve the pain
& relax the joint and muscles.
50% of patients will obtain significant relief in 2-4 weeks.

28. Phase II therapy is initiated if Phase one
treatment fails.
• Medications are continued, but a custom made
oral orthopaedic acrylic appliance (splint) is added.
• These include occlusal splints, bite guards and night
guards.
• These appliances helps prevent muscle overuse, including
bruxism.
• Some of the common occlusal splints used in clinical
practice are:
1. Centric relation splint.
2. Anterior repositioning splint.
3. Soft or resilient splint.
4. Anterior bite plane.
5. Posterior bite plane.

29. •
The appliance is usually worn at night, but can
also be worn during the day, if necessary.
•
Care should be taken to instruct the patient not
to wear the appliance at all times, as the
posterior teeth may become displaced.
•
If the patient remains asymptomatic, the
appliance is discontinued.
If symptoms return, the appliance may be
resumed at night, and its use continued as long
as necessary.
•

30. Phase III Therapy
Phase III includes
•
•
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Physiotherapy of the muscle groups, including
Ultrasonic therapy, Electro galvanic stimulation,
TENS.
Recently, it has been reported that pulsed radio
frequency energy therapy (PRFE) in patients with
TMJ arthralgia is safe and effective and also
increases mandibular motion.
These therapies focus beams of heat, sound or
radio waves into the TMJ to increase blood flow
and relieve pain.

31. Phase IV Therapy
•
Phase IV involves
•
Psychological counseling to identify stress factor and
referral to a TMJ center. The TMJ center employs
psychological counseling and trigger-point injections,
for treatment.
•
Biofeedback helps patients to recognize times of
increased muscle activity and spasm, and provides
methods to help control them.
•
In preliminary studies, Botulinum toxin has been
used successfully to treat various pain syndromes,
including TMDs.

32. Thank You