Guided by

-Dr. Shalu Rai

-Dr. Sapna Panjwani
-Dr. Deepankar Mishra
-Dr. Vikas Ranjan
Presented by
-Dr. Priyadershini
 TMJ Dysfunction Syndrome/
Myofascial Pain Dysfunction Syndrome
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.

Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

• 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.
 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.)
 Muscle fatigue &
Inolves a
accumulation of
psychogenic
metalic byproducts like
Micro/ macro Increased component
lactic acid,
trauma to tone of which modifies
prostaglandins,
muscles musculature pain &
bradykinines,
complicates the
histamines which
treatment
lowers pH

Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and

occlusion (5th ed.)
 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
 Zone of reference

• Referral of myofascial
trigger point pain of
temporalis muscles refers
only to the maxillary teeth.
• The masseter refers only
to the posterior teeth.

• The digastric anterior

refers only to the
mandibular incisors.
 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’.
 Associated symptoms

Gastrointestinal
Neurologic Musculoskeletal Otologic
tract

• Tingling • Nausea • Fatigue • Tinnitus

• Numbness • Vomiting • Tension • Ear pain
• Blurred vision • Diarrhea • Tiredness • Dizziness
• Twitches • Constipation • Weakness • Vertigo
• Lacrimation • Indigestion • Diminished
hearing
 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

 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

 Physical examination

• Articular / joint examination

• Dental examination
• Muscular examination
• Cervical examination

Neelima Malik, Textbook Of Oral & Maxillofacial Surgery, 2nd Edi

 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)
 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.
 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.
• 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.
 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.
Sternocleidomastoid

• Palpation of the sternocleidomastoid

muscle high near the mastoid process &
low near the clavicle.
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

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

 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

 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

 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

 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

Phase I therapy
psychophysiologic
discussion.
Home therapy (diet & Laskin and Block,
exercise)
Muscle relaxant & NSAIDs (1986)
(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,
Phase lV
biofeedback)
Psychologic
(4 to 6 weeks) 10% to 15%
counselling
resolution.
pain clinic
 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
 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.)
 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.)
 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
 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.
 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.
 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 Crystals contracts Oscillation of

(>20000 Hz) and expands by crystals produce
vibration of synthetic alternating electric pressure waves =
crystals current ultrasound waves.
 Thermal

Increase local
metabolism, circulation, Promotes
regeneration and tissue
extensibility of repair
connective tissue

Mechanical
effects

• 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.

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.
 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.
 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).
 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.
 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 Initially During

applied experience an Continued warming there After a period
directly in a uncomfortable icing will is an increase of warming a
circular motion feeling that will result in a second
without in blood flow
quickly turn mild aching application
pressure to into a burning to the tissues
the tissues. and then that assists may be
sensation.
numbness. tissue repair. desirable.

Okeson, Jeffrey P. (2003). Textbook of Management of temporomandibular disorders and occlusion (5th ed.)
 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.)
 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.)
 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.)
• 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.)
 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
 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.)
• 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.

Gustav O Kruger ; Textbook of Oral and Maxillofacial Surgery, ch 26, 6th edi; 700-756