Myofascial Pain Dysfunction Syndrome.ppt

Myofascial pain syndrome (previously known as myofascial pain and dysfunction syndrome [MPDS or MFPDS]) can occur in patients with a normal temporomandibular joint. It is caused by muscle tension, fatigue, or (rarely) spasm in the masticatory muscles. Symptoms include pain and tenderness in and around the masticatory structures or referred to other locations in the head and neck, and, often, abnormalities of jaw mobility. Diagnosis is based on history and physical examination. Conservative treatment, including analgesics, muscle relaxation, modification of parafunctional behavior (eg, teeth clenching and grinding), and use of oral appliances usually is effective.

1. MyofascialPain
DysfunctionSyndrome
(MPDS)
Presentedby
Dr. Rahul Srivastava
Professor
Rama Dental CollegeHospital
& ResearchCentre Kanpur

2. Myofascialpain dysfunctionsyndrome (MPDS)
Itisaregionalmyogenous paincondition
characterized bylocalareas offirm,
hypersensitivebandsofmuscletissueknownas
triggerpoints.
Thisconditionisalsoreferredasmyofascial
triggerpointpain.Myofascialtriggerpointpain
wasfirstdescribedbyTravellandRinzlerin
1952.

3. Etiology of MPDS
Centralnervoussystemplayssignificantrole.
Protractedlocalmusclesoreness.
Localfactors:Parafunctionalhabits,poor
postureandchilling.
Systemicfactors-Fatigue,poorphysical
condition,hypovitaminosisandviralinfections.
Increasedlevelsofemotionalstress.
Continuedsourceofdeeppaininput.

4. Occlusalinterferences.
Presence of sleep disorder.
Idiopathic trigger point mechanism.

5. Clinical Features of MPDS
Femalesmoreaffectedthanmaleswithratioof
4:1.
Affectsprimarilyyoungwomen(age20to40
years).
Presenceoftriggerpointswhichpresentaslocal
areasoffirm,hypersensitive,bandsofmuscle
tissue.

6. Four cardinal sign and symptoms:
Laskinhasproposed4cardinalsignsand
negativecharacteristicsforMPDS.
Unilateraldullpainintheearorpreauricular
regionthatcommonlyworsensonawakening.
Muscletenderness.Tendernessofoneormore
musclesofmasticationonpalpation.
ClickingorpoppingnoiseinTMJ.
Limitationofjawmovement,limitationor
deviationofthemandibleonopening.

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

8. Trigger points?
Triggerpointsarediscrete,focal,hyperirritable
spotslocatedinatautbandofskeletalmuscle.
Thespotsarepainfuloncompressionandcan
producereferredpain,referredtenderness,motor
dysfunctionandautonomicphenomena.

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. Thepainisoftendescribedasspreadingor
radiating.
Referredpainisanimportantcharacteristicofa
triggerpoint.
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
Diagnosisismadeonthebasisofclinicalfindings.
Presenceoftriggerpoints:
Triggerpointsaresmallinheadandneckregion
i.e.aboutto2to10mmandlargerinshoulder
region10to20mm.

13. Examinationofmuscleofmastication
Musclesshouldbeexaminedfortendernessusing
digitalpalpation.Musclesthatshouldbeincluded
inexaminationaremedialandlateralpterygoid,
masseter,temporalis,sternocleidomastoidand
trapezius.

14. Measurement of stress
AusefultoolisSymptomchecklist90(SCL-90).This
evaluation provides anassessment ofnine
psychologicstates.

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. Palliativetherapy
Thistherapyincludesproceduressuchasocclusal
splint,medications,homeremedies(ice,moistheat
application,exercisesandsoftdiet).

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 metaxalone400
to 800 mg every six hours or chlorzoxazone500 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-Nonsteroidalanti-inflammatory drugs
Ibuprofen should be used in doses of 400mg four
times daily.
The cyclo-oxygenaseinhibitors 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. TricyclicAntidepressant
Druglikeamitryptyllineiseffective.
Itcanbestartedwithdoseaslowas10mgatnight
anddosagecanbeincreasedto75to100mg
dependinguponpatienttolerance.
Capsaicin
Capsaicin cream (0.025% or 0.075%) can be used for
pain relief.

21. Itreleasessubstance–Pandpainrelated
neuropeptidestoreducepainperceptionand
inflammationandmustbeappliedmultipletimes
perdayforatleast2weeks.

22. B-Muscle exercise
Passivestretchingi.e.keepingthemusclefibers
relaxedwhileslowlystretchingthemuscle,
preventingitfromtighteningviathestretchreflexin
conjunctionwithmoistheat(followedbyapplication
ofice)isbeneficialfordecreasingmuscleandjoint
painandforimprovingrangesofmovement.

23. C-Counter stimulation of muscle
Therearetwomethodsforreducingmuscularpain:
1.Repetitiveactionontriggerpointwithamodeof
counterstimulation.
2.Musclerehabilitationthroughactiveandpassive
stretchingandposturalexercisestorestorethe
muscletonormallength,postureandrangeof
motion.

24. SprayAndStretch
Non-invasivetechniqueforcounterstimulation.It
involvescoolingtheskinwithfluoromethane,ethyl
chloride,sprayandthengentlystretchingtheinvolve
muscletoperformsprayandstretchtherapy.

25. PressureandMassage
Increasedpressureappliedtothetriggerpointcan
alsorelievepain.Pressureisincreasedtoabout20
poundsandismaintainedto30to60seconds.

26. TriggerPointInjections
Procainedilutedto0.5%withsalinehasbeen
recommended becauseofitslowtoxicitytothe
muscle,butlidocaine(2%withoutvasoconstrictor)is
alsoused.
Injectionsareoftengiventomusclegroupinseriesof
weeklytreatmentsfor3to5weeks.

27. D-Adjunctivetherapy
Consistoftreatmentmodalitiesthataugmentand
assistdefinitiveorcausativetypeoftreatmentfor
TMD.Itincludes:
1-Physiotherapy
Itiscombination ofphysicaltherapy,massage
therapyandelectromodalities.Bothpassiveand
activetreatmentsarecommonlyincludedaspartof
therapy.

28. Posturetherapyisalsousefultoavoidforwardhead
positionsthatarethoughttoadverselyaffect
mandibularpostureandmasticatorymuscle.
2-Electrotherapy
Isapartofadjunctivetherapy;modalitiesincludes
electrogalvanicstimulation,ultrasound,lowlevel
laserandinfrared.

29. 3-Electrogalvanicstimulation
Itutilizesnegativepolarityoverapainful,swollen
area.Thenegativechargeproducesalkalineeffect
withinthetissues,denaturingproteinsandproduces
vasodilatationofthecapillaries.

30. 4-TranscutaneousElectricalNerveStimulation(TENS)
TENSsupposedlyblockspainsignalsbeingcarried
overthesmall,unmyelinatedCfibersbyforcingthe
largemyelinatedAfiberstocarryalighttouch
sensation.Itmayprovidepainreliefbyphysiologic
effectsofrhythmicmusclemovement.

31. 5-Ultrasound
Itisamethodofproducingdeepheatmore
effectivelythatthepatientcouldachievebyusing
surfacewarming.Thesemechanical vibrations
produceheatandvasodilatationbyincreasingthe
tissuetemperature.
6-Iontophoresis
Isaprocessinwhichionsinsolutionsaredriven
throughintactskinbyusingadirectcurrentbetween
twoelectrodes.Itusesultrasonicenergytodrivea
medicationdeepintothetissue.

32. 7-Lowlevellaser
Lasertherapyincludesnitricoxidesynthesis,which
causestheendothelialliningsofcapillariestodilate,
improvingcirculationinthearea.
8-Infraredradiation
Itproducesvasodilatationofcapillarybedby
initiatingthesynthesisofnitricoxide,improving
circulationanddecreasingswelling.

33. 9-Acupuncture (dryneedling)andPercutaneous
electricalnervestimulation(electro-acupunctureor
PENS)alsobeneficialinpainmanagement.
Stressmanagement inMPDS
Integratingbehavioraltherapyandrelaxation
techniquesinchronicpainmanagement inMPDSare
effective.

34. Differencebetweentriggerpointsandtenderpoints:
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-OkesonJP.Management ofTemporomandibular
DisordersandOcclusion5theditionpublisher
Elsevier2002
2-SrivastavaR,DeviP,JyotiBTemporomandibular
JointImagingCBSpublisherandDistributorpvt
ltd;2014

36. 3-GreenbergMS,GlickMOrofacialPainand
Temporomandibular Disorders.Oral Medicine
Diagnosis&Treatment Burket’s10thedition
Hamilton,Ontario,BCDeckerInc271-300.
4-AmericanAcademyofOrofacialPain.Guidelines
forAssesments,DiagnosisandManagement,Chicago:
Quintessence; 1996. Available from:
http://www.quintpub.com/PDFs/book_preview/B 4139.p
df

37. 5-ZarbGA,CarlssonGE.Temporomandibular Joint
FunctionandDysfunction,Copenhagen, Germany:
Munksaard;1979.p.230.
6-GozlerSMyofascialPainDysfunctionSyndrome:
Etiology, Diagnosis, and Treatment
http://dx.doi.org/10.5772/intechopen.72529