oral medicine Editor. JAMES W. LITTLE,
D.M.D., M.S.D.
Chairman and Professor Department of Oral Diagnosis and Oral Medicine University of Kentucky Lexington, Kentucky 40506
The diagnosis and conservative treatment of myofascial pain dysfunction syndrome
-
Myofascial pain dysfunction. syndrome
845
awciiated withthetemparomadhular iAnts No. o/patients 194 48 32 274
Disorder Myofascial pain dysfunction syndrome Other TMJ-associated conditions Conditions unrelated to TMJ Total Table
rcfcrred
II. TiKJ conditions other than MPDS with symptoms related to the joint
diagnosed
in forty-eight
Disorder Osteoarthrosis Symptomless click Recurrent subluxation Rheumatoid arthritis Total
patients
No. ofpatients 26 17 : 48
E:ven when a firm diagnosis is made, the clinician is faced with another problcm, namely, the large number of different modalities of treatment. Some clinicians believe that the main problem lies in the joint itself and various types of surgery, including removal of the disc or of parts of the condyle, have been adroca.tcd.’ Others place stress on a.bnormalit,ics of the occdlusion as important, etiologic factors in the condition and advocate various forms of occlusal equilibration.” Still others have argued that the main problem lies in the masticatory musculaturc, this in turn being caused or promoted by psychological factors. They adx-oeatcx conservative therapy for the condition, directed at relieving stress and symptoms, and have claimed long-last,ing good results with this form of therapy.’ Kvtwcen Xeptcmbcr, 1972, and September, 1974, 274 patients were referred to the ljepartment of Oral Medicine Clinic at the Ilnircrsity of Western Ontario with symptoms in one or both temgoromandibular joints. Of these, 194 were (bagnosed as having myofascial pain dysfunction syndrome (RIPDS) . Of tho rcmaintler, forty-eight had othrr diseases of the temporomandibular joints or assoc4att4 structures and thirty-two had conditions which were unrelated to the joints (Table I). Ta.ble II sets out the other conditions SFC’~which wcrc associated wit,11 the t~cmporoma~~clil~ular ,joints but not diagnosed as MI’DS, and Table III etlumcrntcs the conditions Sean which wcrc completely unrelated to the tcmporonr~~ndibular joints. Thr purpose of this article is to review t,he signs, sgmpioms. radiographic finclings, and response to treatment of Ihe patients with MT’DS ar~ci to suggelrl that a large number of these pat&its will respond to conservative therapy. MYOFASCIAL
PAIN
All patients symptoms : 1
itself.
Pn,iw
DYSFUNCTION
diagnosed nwullv
Sometimes
SYNDROME
as having
nnilntcrnl
well localized.
MPDS ill
the
had one or more o-f the following
nrpanrionlar
roeinn
at other times radiating
c>r in
the
nav
to the side of the
Disorder
I
No. ofoafients
Atypical facial pain Cardiovascular accident Cervical spine lesion Chemical poisoning Fibrous band following injections Globus hystericus Needle track infection Paroxysmal migrainous neuralgia Pharyngeal abscess Pulpitis Schizophrenia Tension headache Undiagnosed neuropathy Total
Symptom
Pain Click, etc. Dysfunction (difficulty in opening and closing or deviation) Three symptoms Two symptoms One symptom Total
No. ofpatients
186 160 147 117 65 12 194
55* 5045r
40
5 F B
35 30
B
25
5 p
20
2
15 IO
Pi{/. 1 Frequency
Ined.
of symptoms
Table 1V shows the frequency of symptoms in the series. The most frequent s>.mptum \vas pain, iintl this was the only symptom in twelve cases. Sisf- (117) of the patients had three symptoms, and 33.5 per cent (sixty-five) hut1 two symptoms (pain and click). Sincty-three per wilt (180) of the patients hat1 muscle tenderness on palpation. Eighty-three per cent complained of a click \vhich was associatc~tl with other symptoms. Seventeen patients who had a “symptomlcss click” wcw cxcludecl from the series. It is important to note that not all symptoms wrc prcscnt when the patient \\.a~ swn. A previous history of such symptoms was recorded. Frequently, for instance, a jaw had at first cliclcetl anti ~~:en difficwlt, to opca anal then pain had fc)llOwccl j conversely, initial pain in some cases was later followecl by difficulty ill opening and/or click. Sex One-hundred and sixty-four p;ltients were women and thirty were men. This gives a ratio of 5.5 to 1, which is higher than in some series but is in keeping with the findings of most workers who clctscrihe a femiil(l prc~pond~brance for this condition.
65 60 55 50 2 45 p 40 B "0 35 lx30 El 2 25 2 20 15 10 5 0
5
10 I5 2025
30354045
5055
60
DURATION Cf SYMPTOMS (MCWHS) Fig. 2. H .istogr:w showing duratiou of symptoms incl uded had symptoms for mow than 60 month?. I
iu 191 MPW
I)atients.
cSi
and had frequently been passed from one practitioner to another for weeks 01 months before being seen. Thus, it may I)t: assumed that the interval between onset of symptoms ant1 presentation for initial consultation is less than this series would suggest. Occlusion
The occlusion \\‘a~ c~samined in all cijses, and twenty-eight of the 194 patients had an odusion abnormd enough to bc consitlercd a maloc~lnsion i VCI’~ tleep overbite, cross-bite). Psychologic
aspects
Of the total number of patients, 75 per cent, described themsrlvcs in such terms as “tense,” “ unable to delegate work,” “unable to relax,” or “undergoing stress,” a.ncl X0 per cent admitted to grinding, clenching, or other dental habits, the most common being nocturnal grinding or bruxism. The relationship of these habits to
conditions seen. It is interesting to note that many of the patients had conditions which were completely unrelitted to the TKJ, although the symptoms included p;1in in the TXJ, trismus, or other dysfunction of the TXJ. The most common TMJ condition from which RIPJ)S hat1 to be distinguished uxs osteoarthrosis. This showed an older age incidence, positive radiologic fintlings, and association with a grating sound rather than a clicking sound ill the joint. As stated earlier, patients with a symptomless (*lick were escluded from the series. The other conditions set out in the table were all sufficiently tliffcrent from MI’I)S in their presentation to make diagnosis fairly obvious. All patients tliagnos(~(1 as having RII’DS had no clinical or ratliographic evitl~n~ of organic cl&case of the TM.7. In addition, most of them, (192, or 93.4 pc’r pcxnt) had two or more of the clinical symptoms of the disorder. Only twelve patients had a single symptom (pain), and in each cast this was characteristic c>nough in nature to make the diagnosis almost certain. TREATMENT
We believe that, although the cause of the condition is probably multifactorial,” the bulk of evidence supports the importance of psychological factors in its initia.tion. For t,his reason, treatment was directed toward these factors and towartl the relief of symptoms. The condition was explained fully, and each paticnt was told that the symptoms \\-cre due to muscle spasm linked to stress. The pijtiellts were firmly reassured that, no organic disease was present. Initial trcatmcnt was based to some extent on findings. Thus, when patients admitted that they ww going through a period of psychological stress, a mild tranquilizer was given. Forty-nine patients fell into this category. For twenty-three patients. an ocdclusal splint was constructed, as there was a history of brusism or an obvious o~lnsal abnormality was present. The remainin g 122 patients receivctl pliysiotherapy, consisting of applications of ice and ultrasound7 to the region of each tcmporomandibular ,joint in IO-minute sessions three times a week foJ- 3 or 4 weeks. No patient underwent occlusal equilibration, surgery, or intra-articulnr injdions of corticosteroids. If no positive response had occurred after 4 weeks of this initial treatment, the course of physiotherapy was repeated. For those paticds who had received another form of therapy, a course of physiotherapy WBS instituted. Table V shows the number of patients who reccivcd each type of initial treatment and the number in each category who underwent a subsequent course of physiotherapy. Iuo other combinations of treatment were carried out. RESULTS
Patients were reassessed from the stand-point of symptoms from 16 to 44 months following their first visit and they were placed in one of three categories : (1) those who wcrc still having symptoms which required treatment; (2) those who were having occasional problems which required no treatment; and (3) those who were completely free of all symptoms. Table V summarizes the findings for each of the three treatment combinations. Of 194 patients seen, thirty-six (18.6 per cent) still had problems requiring t,roatment~, seventy-six (39 per cent) had no symptoms whatsoever, and eighty-
Initial treatment
No. ofpattents in each category of initial treatment
Physiotherapy Occlusal splint Tranquilizer Total
122 23 - 49 194
No. ofpatients receiving course of physiotherapy after one month
/
61 :s 103
A
C‘ategor), Of result5 1 El 1
C
22 7 I 36
54 9 18 xl
45* 7 24 75
Category ofresult
MPDS MPDS (oost-iniurvl .. _~ Total
A
B
C’
Total
24 12
15
13 2
174* 20 194
6
diaries ofdaihactirities aadofpain respo~ises ia~21 attempt toisolate situpI I ~NillS RhlCh I~~vsred toP~O&VG thQ musde tension andsuhse~umt pain.Incon-
junction with a psychologist, the ljatient was then encouraged to define one or more “stress-inducing” situations from his pain diary. The psychologist then instructcd the patient in relevant coping skills to handle the stressful situations more cffectivclg. Results after eight weekly sessions indicated that all but one of the subjects showed rnarkcd improvement on both objective and subjective m~~asures. A complete description of this approach and its outcome is reported elsewllerc ,.I” CONCLUSIONS
The age and sex distributions of the series arc much in keeping with those described in other articlts.1.1l1 All patients were treated by conservative methods. With these modalities of treatment, a substantial proportion of patients (75 per cellt) rcccivcd relief to the extent that no further treatment was necessary; 38 per cent had no symptoms whatsoever. In the group w-hero these conservative methods of treatment proved incffectire, a substantial amount of relief was ol)tainetl in a significant number of patients following the use of relaxation and col)ing skills training. The rationale for the use of these methods is based on the theory that persons respond to stressful life situations with an “unconscious” or subliminal constriction of specific n~usclc groups. Factors determining which, if Andy, muscle groups a.re affcctetl arc unclear, but there is some evidence to suggest that this type of subliminal muscle constriction is seen in the frontalis, trapezius, alltl temporalis muscles as well as in the masseter.” Jl’ith prolonged constriction of the muscle, spasm becomes more likely. When this o~urs in frontalis, trapczius, or tcmporalis muscles, it is labeled by the patient as “hcatlachc.” 1Vhen it occurs in the massetcr or ptcrygoid muscles, it is called “jaw pain.” The trea,tment approach growin, v out of this theoretical framework would then rcyuire a two-pronged attack : 1. The therapist would enable the patient to become more aware of the muscle constriction causing the discomfort. Hc would then teach the patient how to relax this muscle or group of muscles. Hence, biofeedback and rclasation training would be given. 2. The therapist would enable the patient to clearly identify his stressful lift situations and to cope with them more effectively. Hence, the pain diary and coping skills training (for example, assertive skill training) would be given. It might be argued that all methods of therapy used in the treatment of MI’IE have some effect mentioned in 1 or 2 above, even if this is indirect, or unintentional. We suggest that our results compare favorably with those obtained when more
REFERENCES I. 2. ::. i. 5. 6. i. 8. 9. IO.
Il. 12. Reading, A., :lud Martin, J. 140: 201-205, 1976.
X. : Tllc~ Trwtmcwt
Repmt requests lo: Dr. Ralph I. Brooke Drpwtment of Oral Medicine Paculty of Dentistry Tllo University of Western Ontario London, Ontario, Cau:~cla
of Mandil~ul:rr
J)ysfuuctiou
I’ain,
Br. Ihar~t.
D.M.D., M.S.D.
Chairman and Professor Department of Oral Diagnosis and Oral Medicine University of Kentucky Lexington, Kentucky 40506
The diagnosis and conservative treatment of myofascial pain dysfunction syndrome
-
Myofascial pain dysfunction. syndrome
845
awciiated withthetemparomadhular iAnts No. o/patients 194 48 32 274
Disorder Myofascial pain dysfunction syndrome Other TMJ-associated conditions Conditions unrelated to TMJ Total Table
rcfcrred
II. TiKJ conditions other than MPDS with symptoms related to the joint
diagnosed
in forty-eight
Disorder Osteoarthrosis Symptomless click Recurrent subluxation Rheumatoid arthritis Total
patients
No. ofpatients 26 17 : 48
E:ven when a firm diagnosis is made, the clinician is faced with another problcm, namely, the large number of different modalities of treatment. Some clinicians believe that the main problem lies in the joint itself and various types of surgery, including removal of the disc or of parts of the condyle, have been adroca.tcd.’ Others place stress on a.bnormalit,ics of the occdlusion as important, etiologic factors in the condition and advocate various forms of occlusal equilibration.” Still others have argued that the main problem lies in the masticatory musculaturc, this in turn being caused or promoted by psychological factors. They adx-oeatcx conservative therapy for the condition, directed at relieving stress and symptoms, and have claimed long-last,ing good results with this form of therapy.’ Kvtwcen Xeptcmbcr, 1972, and September, 1974, 274 patients were referred to the ljepartment of Oral Medicine Clinic at the Ilnircrsity of Western Ontario with symptoms in one or both temgoromandibular joints. Of these, 194 were (bagnosed as having myofascial pain dysfunction syndrome (RIPDS) . Of tho rcmaintler, forty-eight had othrr diseases of the temporomandibular joints or assoc4att4 structures and thirty-two had conditions which were unrelated to the joints (Table I). Ta.ble II sets out the other conditions SFC’~which wcrc associated wit,11 the t~cmporoma~~clil~ular ,joints but not diagnosed as MI’DS, and Table III etlumcrntcs the conditions Sean which wcrc completely unrelated to the tcmporonr~~ndibular joints. Thr purpose of this article is to review t,he signs, sgmpioms. radiographic finclings, and response to treatment of Ihe patients with MT’DS ar~ci to suggelrl that a large number of these pat&its will respond to conservative therapy. MYOFASCIAL
PAIN
All patients symptoms : 1
itself.
Pn,iw
DYSFUNCTION
diagnosed nwullv
Sometimes
SYNDROME
as having
nnilntcrnl
well localized.
MPDS ill
the
had one or more o-f the following
nrpanrionlar
roeinn
at other times radiating
c>r in
the
nav
to the side of the
Disorder
I
No. ofoafients
Atypical facial pain Cardiovascular accident Cervical spine lesion Chemical poisoning Fibrous band following injections Globus hystericus Needle track infection Paroxysmal migrainous neuralgia Pharyngeal abscess Pulpitis Schizophrenia Tension headache Undiagnosed neuropathy Total
Symptom
Pain Click, etc. Dysfunction (difficulty in opening and closing or deviation) Three symptoms Two symptoms One symptom Total
No. ofpatients
186 160 147 117 65 12 194
55* 5045r
40
5 F B
35 30
B
25
5 p
20
2
15 IO
Pi{/. 1 Frequency
Ined.
of symptoms
Table 1V shows the frequency of symptoms in the series. The most frequent s>.mptum \vas pain, iintl this was the only symptom in twelve cases. Sisf- (117) of the patients had three symptoms, and 33.5 per cent (sixty-five) hut1 two symptoms (pain and click). Sincty-three per wilt (180) of the patients hat1 muscle tenderness on palpation. Eighty-three per cent complained of a click \vhich was associatc~tl with other symptoms. Seventeen patients who had a “symptomlcss click” wcw cxcludecl from the series. It is important to note that not all symptoms wrc prcscnt when the patient \\.a~ swn. A previous history of such symptoms was recorded. Frequently, for instance, a jaw had at first cliclcetl anti ~~:en difficwlt, to opca anal then pain had fc)llOwccl j conversely, initial pain in some cases was later followecl by difficulty ill opening and/or click. Sex One-hundred and sixty-four p;ltients were women and thirty were men. This gives a ratio of 5.5 to 1, which is higher than in some series but is in keeping with the findings of most workers who clctscrihe a femiil(l prc~pond~brance for this condition.
65 60 55 50 2 45 p 40 B "0 35 lx30 El 2 25 2 20 15 10 5 0
5
10 I5 2025
30354045
5055
60
DURATION Cf SYMPTOMS (MCWHS) Fig. 2. H .istogr:w showing duratiou of symptoms incl uded had symptoms for mow than 60 month?. I
iu 191 MPW
I)atients.
cSi
and had frequently been passed from one practitioner to another for weeks 01 months before being seen. Thus, it may I)t: assumed that the interval between onset of symptoms ant1 presentation for initial consultation is less than this series would suggest. Occlusion
The occlusion \\‘a~ c~samined in all cijses, and twenty-eight of the 194 patients had an odusion abnormd enough to bc consitlercd a maloc~lnsion i VCI’~ tleep overbite, cross-bite). Psychologic
aspects
Of the total number of patients, 75 per cent, described themsrlvcs in such terms as “tense,” “ unable to delegate work,” “unable to relax,” or “undergoing stress,” a.ncl X0 per cent admitted to grinding, clenching, or other dental habits, the most common being nocturnal grinding or bruxism. The relationship of these habits to
conditions seen. It is interesting to note that many of the patients had conditions which were completely unrelitted to the TKJ, although the symptoms included p;1in in the TXJ, trismus, or other dysfunction of the TXJ. The most common TMJ condition from which RIPJ)S hat1 to be distinguished uxs osteoarthrosis. This showed an older age incidence, positive radiologic fintlings, and association with a grating sound rather than a clicking sound ill the joint. As stated earlier, patients with a symptomless (*lick were escluded from the series. The other conditions set out in the table were all sufficiently tliffcrent from MI’I)S in their presentation to make diagnosis fairly obvious. All patients tliagnos(~(1 as having RII’DS had no clinical or ratliographic evitl~n~ of organic cl&case of the TM.7. In addition, most of them, (192, or 93.4 pc’r pcxnt) had two or more of the clinical symptoms of the disorder. Only twelve patients had a single symptom (pain), and in each cast this was characteristic c>nough in nature to make the diagnosis almost certain. TREATMENT
We believe that, although the cause of the condition is probably multifactorial,” the bulk of evidence supports the importance of psychological factors in its initia.tion. For t,his reason, treatment was directed toward these factors and towartl the relief of symptoms. The condition was explained fully, and each paticnt was told that the symptoms \\-cre due to muscle spasm linked to stress. The pijtiellts were firmly reassured that, no organic disease was present. Initial trcatmcnt was based to some extent on findings. Thus, when patients admitted that they ww going through a period of psychological stress, a mild tranquilizer was given. Forty-nine patients fell into this category. For twenty-three patients. an ocdclusal splint was constructed, as there was a history of brusism or an obvious o~lnsal abnormality was present. The remainin g 122 patients receivctl pliysiotherapy, consisting of applications of ice and ultrasound7 to the region of each tcmporomandibular ,joint in IO-minute sessions three times a week foJ- 3 or 4 weeks. No patient underwent occlusal equilibration, surgery, or intra-articulnr injdions of corticosteroids. If no positive response had occurred after 4 weeks of this initial treatment, the course of physiotherapy was repeated. For those paticds who had received another form of therapy, a course of physiotherapy WBS instituted. Table V shows the number of patients who reccivcd each type of initial treatment and the number in each category who underwent a subsequent course of physiotherapy. Iuo other combinations of treatment were carried out. RESULTS
Patients were reassessed from the stand-point of symptoms from 16 to 44 months following their first visit and they were placed in one of three categories : (1) those who wcrc still having symptoms which required treatment; (2) those who were having occasional problems which required no treatment; and (3) those who were completely free of all symptoms. Table V summarizes the findings for each of the three treatment combinations. Of 194 patients seen, thirty-six (18.6 per cent) still had problems requiring t,roatment~, seventy-six (39 per cent) had no symptoms whatsoever, and eighty-
Initial treatment
No. ofpattents in each category of initial treatment
Physiotherapy Occlusal splint Tranquilizer Total
122 23 - 49 194
No. ofpatients receiving course of physiotherapy after one month
/
61 :s 103
A
C‘ategor), Of result5 1 El 1
C
22 7 I 36
54 9 18 xl
45* 7 24 75
Category ofresult
MPDS MPDS (oost-iniurvl .. _~ Total
A
B
C’
Total
24 12
15
13 2
174* 20 194
6
diaries ofdaihactirities aadofpain respo~ises ia~21 attempt toisolate situpI I ~NillS RhlCh I~~vsred toP~O&VG thQ musde tension andsuhse~umt pain.Incon-
junction with a psychologist, the ljatient was then encouraged to define one or more “stress-inducing” situations from his pain diary. The psychologist then instructcd the patient in relevant coping skills to handle the stressful situations more cffectivclg. Results after eight weekly sessions indicated that all but one of the subjects showed rnarkcd improvement on both objective and subjective m~~asures. A complete description of this approach and its outcome is reported elsewllerc ,.I” CONCLUSIONS
The age and sex distributions of the series arc much in keeping with those described in other articlts.1.1l1 All patients were treated by conservative methods. With these modalities of treatment, a substantial proportion of patients (75 per cellt) rcccivcd relief to the extent that no further treatment was necessary; 38 per cent had no symptoms whatsoever. In the group w-hero these conservative methods of treatment proved incffectire, a substantial amount of relief was ol)tainetl in a significant number of patients following the use of relaxation and col)ing skills training. The rationale for the use of these methods is based on the theory that persons respond to stressful life situations with an “unconscious” or subliminal constriction of specific n~usclc groups. Factors determining which, if Andy, muscle groups a.re affcctetl arc unclear, but there is some evidence to suggest that this type of subliminal muscle constriction is seen in the frontalis, trapezius, alltl temporalis muscles as well as in the masseter.” Jl’ith prolonged constriction of the muscle, spasm becomes more likely. When this o~urs in frontalis, trapczius, or tcmporalis muscles, it is labeled by the patient as “hcatlachc.” 1Vhen it occurs in the massetcr or ptcrygoid muscles, it is called “jaw pain.” The trea,tment approach growin, v out of this theoretical framework would then rcyuire a two-pronged attack : 1. The therapist would enable the patient to become more aware of the muscle constriction causing the discomfort. Hc would then teach the patient how to relax this muscle or group of muscles. Hence, biofeedback and rclasation training would be given. 2. The therapist would enable the patient to clearly identify his stressful lift situations and to cope with them more effectively. Hence, the pain diary and coping skills training (for example, assertive skill training) would be given. It might be argued that all methods of therapy used in the treatment of MI’IE have some effect mentioned in 1 or 2 above, even if this is indirect, or unintentional. We suggest that our results compare favorably with those obtained when more
REFERENCES I. 2. ::. i. 5. 6. i. 8. 9. IO.
Il. 12. Reading, A., :lud Martin, J. 140: 201-205, 1976.
X. : Tllc~ Trwtmcwt
Repmt requests lo: Dr. Ralph I. Brooke Drpwtment of Oral Medicine Paculty of Dentistry Tllo University of Western Ontario London, Ontario, Cau:~cla
of Mandil~ul:rr
J)ysfuuctiou
I’ain,
Br. Ihar~t.
