TREATMENT ALTERNATIVES FOR PATIENTS WITH MASTICATORY MYOFASCIAL PAIN

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TREATMENT ALTERNATIVES FOR PATIENTS WITH MASTICATORY MYOFASCIAL PAIN EDWARD F. WRIGHT, D.D.S., M.S.; ERIC L. SCHIFFMAN, D.D.S., M.S. h

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Alternative therapies are used by many people, and the dental literature has reported that some alternative therapies are

comparable to splint therapy in the effective treatment of masticatory myofascial pain. The authors review the efficacy of alter-

native therapies and discuss their clinical implications. This

review Is intended to help dental

practitioners to select alternative therapies they can use with or instead of splint therapy for

treating patients who have a primary diagnosis of myofascial

pain.

1030 JADA, Vol. 126, July 1995

yofascial pain (MFP) is a regional, dull muscular ache characterized by localized tender spots known as "trigger points" in the involved muscle and its associated fascia. MFP is a medical condition treated by both dentists and physicians. Clinically, it may be localized to one muscle group, such as the masticatory muscles, or have a more generalized distribution throughout the body.' Practitioners should use muscle palpation to arrive at a provisional diagnosis of MFP. During palpation, practitioners should attempt to duplicate or modify the patient's pain. Note, however, that many people who do not have symptoms of MFP report pain during muscle palpation; treatment should not be prescribed for these otherwise asymptomatic patients. Also, many other disorders (both dental and medical) can cause secondary muscle pain, and these should be ruled out before the patient is treated for MFP.2 Dentists often prescribe splint therapy for masticatory MFP. Alternative therapies-including physical therapy and psychological interventions-also may be prescribed to augment the effects of splint therapy.' Because there is growing interest in alternative therapies, a number of researchers are investigating the efficacy of these treatment approaches. ALTERNATIVE THERAPIES

Eisenberg and colleagues3 reported that one in three U.S. adults used an alternative therapy in 1990. These providers of alternative care had more patient visits that year than all the primary care medical doctors in the United States. Headaches and chronic pain were the third and fourth most common conditions for which alternative therapy was sought. Alternative treatment for patients with MFP include self-management, jaw exercises, massage, trigger point compression, trigger point injections, acupuncture, relaxation therapy, biofeedback and stress management.3 5 Researchers have reported that the effectiveness of some alternative therapies is comparable to that of splint therapy.6'7 Many case reports and series also suggest their effectiveness; however, only a few randomized clinical trials have compared alternative and traditional therapies for MFP to determine their

CLINICAL PRACTICE relative efficacy. This is unfortunate, since definitive conclusions on the value of these treatments can be drawn only from clinical trials, not from case reports or series. This article compares the efficacy of alternative treatments with that of splints and provides clinical indications for the dentist to consider when managing patients with a primary diagnosis of MFP. For clarity and comparability, all splint therapies referenced in this article used flat-plane acrylic splints. EFFICACY OF ALTERNATIVE TREATMENTS

MFP patients generally have localized tender areas, known as "myofascial trigger points," in their muscles and associated fascial structures

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Patients with MFP who used stretching exercises showed a statistically significant decrease in their symptoms, a decrease in the tenderness of their masticatory muscles on palpation and an increase in their range of motion.

that are believed to be the major source of their muscle pain. Trigger points can be identified by palpating the muscle and detecting a tender area within a taut muscle band. However, sometimes palpation refers pain to a location beyond the muscle being palpated.8 Researchers debate the potential relationship between trigger points and acupuncture points. Melzack, Stillwell and Fox9 reported that 71 percent of identified trigger points were within 3 centimeters of the acupuncture points used to treat pain. However, the mechanism of treating pain using these two types of points is quite different. Trigger points are treated by inactivating them directly, while acupuncture points are stimulated to prompt the central nervous system, in turn, to release pain-relieving mediators.6"0 MFP therapies that are presumed to have a peripheral effect include applications of heat and cold, masticatory muscle exercises, physical therapy modalities, massage, trigger point compression and trigger point injections.46'10'3 Therapies presumed to have a central effect include acupuncture, relaxation therapy, biofeedback and stress management.6l14-l6

Self-management is a standard treatment for patients with MFP. Studies have shown that 60 to 90 percent of the patients report improvement in their symptoms after using only self-management.17-19 Self-management routinely includes the following actions: - resting the masticatory muscles by voluntarily limiting the activities for which the patient uses them -avoiding hard or chewy foods and refraining from activities that cause pain in the muscles of mastication such as gum chewing, overextending the jaw with yawning and undergoing prolonged dental appointments without rests; - becoming aware of and eliminating parafunctional habits -for example, changing a clenching habit by lightly resting the tongue on top of the mouth wherever it is most comfortable and keeping the teeth apart and the masticatory muscles relaxed; - applying heat or cold to the most painful masticatory areas; - using over-the-counter anti-inflammatory medications. Note: These medications can cause secondary effects, including rebound or overuse headaches and gastrointestinal upset or bleeding. If prolonged use is necessary, the dentist may need to consult a physician to monitor side effects and may need to consider other medications. Prescription anti-inflammatory medications, muscle relaxants and low-dose antidepressants also may be considered as adjunctive therapy for patients with MFP.2022 The table offers an example of a self-management handout (this one is used at the TMD Clinic, Lackland Air Force Base, Texas). STRETCHING EXERCISES

Practitioners often prescribe stretching exercises for patients with MFP. Empirically, the key to stretching is to stretch the muscle short of causing pain or aggravating the pain complaint and relax the muscles while stretching. Dall'Arancio and Fricton23 reported that when compared with a placebo control group doing sham exercises, patients with MFP who used stretching exercises showed a statistically significant decrease in their symptoms, a decrease in the tenderness of their masticatory muscles on palpation and an increase in their range of motion. Carlson and colleagues" suggested combining stretching exercises and postural relaxation for patients with MFP. They reported that following an experimentally induced stressful event, the avJADA, Vol. 126, July 1995 1031

CLINICAL PRACTICE TABLE

and back posture help you maintaiXn gd jaw posture. Try to hold your head up small pillow or rolled twel to support yoir ler bA. oid habits suh as resting your jaw on your hand or cradling the telephone against your shoulder. 4. Avoid caffeine. Caffeine stimulates your muscles to contract and, theore, become more tense. Caffeine or caffeinelike drugs are in coffee, tea, most sodas and chocolate. Decaffmeated cfee also has some caffeine. 5. Watch your habits. Avoid oral habits that put strain on the jaw muscles and joits. Theseiclude, among others, clenching the teeth; grinding the teeth (bruxism); touching or restig the teeth together; biting your cheeks, your lips or objects you put in your mouth; pushing the tongue against the teeth; and tensing the jaw. 6. Sleep smart. Avoid sleeping habits that strain your jaw muscles or joints. Don't sleep on your stomach, and if you sleep on your side, keep your neck and jaw aligned. 7. Don't open wide. Until the pain has been reduced, avoid activities that involve opening the jaw wide-yawning, yelling, prolonged dental treatments. 8. Use medications. Use anti-inflammatory and pain-reducing medications like Aleve (Syntex Laboratories), ibuprofen, Tylenol (McNeil Laboratories), aspirin (without caffeine) and Percogesic (Procter & Gamble) to reduce joint and muscle pain. Avoid medications with caffeine, such as Anacin (Whitehall), Excedrin (Bristol-Myers Squibb Company) or Vanquish (Glenbrook). erage masseter muscle surface EMG activity dropped 58 percent in the group that used stretching exercises with postural relaxation compared with a 33 percent drop in the group that used only postural relaxation. 1032 JADA, Vol. 126, July 1995

The benefits of stretching exercises appear to increase when the patient uses moist heat or cold on the area before stretching. Burgess and colleagues25 reported that a vapocoolant followed by stretching exercises (spray and stretch) with

CLINICAL PDACTICE

Figure 1. In this study,"t application of heat followed by stretching exercises provided a greater increase in range of motion for the shoulder, compared with stretching followed by ice pack application, with moist heat application followed by stretching and ice pack application and with stretching only.

stretching exercises substantially decreased facial pain for most subjects. Lentell and colleagues26 compared the increase in the shoulder's range of motion when moist heat was applied to the area before stretching, when stretching was followed by an ice pack, when moist heat was applied before stretching followed by application of an ice pack, when only stretching was done and when no preconditioning was done (Figure 1). Lentell and colleagues reported that using heat before stretching produced a more statistically significant gain in the range of motion than stretching only (P=0.003). Although this study did not include patients with masticatory MPD, it illustrates the benefits of applying heat and ice in conjunction with stretching for muscles in general. Exercises are effective, but it takes time to explain them to the patient. A physical therapist can be particularly helpful in this situation and is the practitioner to whom dentists most commonly refer patients with MFP.27 MASSAGE

Many massage techniques can alleviate MFP. The most commonly used technique involves light stroking of the skin that gradually increases in pressure. As the stroking pressure increases, trigger points begin to stand out and are felt as nodular obstructions to the smooth flow of the stroke. With each pressure stroke, the trigger points are compressed and gradually inactivated.'0 This variety of massage has been suggested to relieve pain, increase the blood flow to the muscles and elevate the plasma endorphin levels. The

endorphin levels remain elevated for approximately 90 minutes following the massage and may be responsible for the pain relief, warmth, relaxation and well-being often reported after a massage.28 A few techniques use cold (for example, ice massage or spray and stretch with vapocoolant) and then stretch the muscles. The presumed mechanisms that inactivate the trigger points in these techniques are inhibition of pain and inhibition of spinal stretch reflexes, enabling the muscle to be stretched.10 Our experiences suggest that patients instructed in muscle massage have an effective treatment at their disposal, while those who only passively receive a massage have a temporary relief that requires them to continually return for additional massages to maintain this degree of comfort. TRIGGER POINT COMPRESSION

Techniques for inactivating trigger points through pressure have been termed "myotherapy"4 and "ischemic compression."'0 Trigger points that are only moderately active usually can be inactivated through one compressive treatment, while a chronically irritable trigger point may need several treatments. Muscles that can be compressed against bone or can be held between the fingers (for example, the anterior portion of the masseter muscle) are the best candidates for this therapy. The technique generally involves stretching the muscle just before its point of discomfort, using a thumb or knuckle to press on the trigger point, up to the limit of tolerance, and maintaining the pressure for approximately one minute. During the minute, the discomfort should decrease and the pressure being applied should be increased correspondingly. Moist heat and active muscle stretching should follow trigger point compressions. Patients can be instructed in trigger point compression, and it is an effective tool for maintaining trigger point inactivation.'0 TRIGGER POINT INJECTIONS

Trigger point injections involve injecting vasoconstrictor-free anesthetic into trigger points. Generally, this is done in muscles that are unresponsive to the techniques already discussed."2'29 Salim30 compared the effectiveness of trigger point injections with that of transcutaneous electrical nerve stimulation (TENS) in patients with MFP. The subjects received both therapies followed by passive muscle stretching. He reported that three JADA, Vol. 126, July 1995 1033

inC tiNI Al PRACTIC[

Figure 2. Trgger point InjoctIons initlally provided a substantial decrease In pain for all groups In this study.' Pain levoes Increasd over the next seven d for all groups. Howevor, they remained below the InitMal pain levels for those receing anesthesia Injectlons and Increased above Initial levels for those receiving saline Injections.

days after treatment, 100 percent of the trigger point injection patients experienced a reduction in pain, while only 31 percent of patients using the TENS felt that their pain had been reduced. Hameroff and colleagues'3 compared the effectiveness of injections of 0.05 percent bupivacaine, 1 percent etidocaine and saline in 10 to 18 trigger points per patient in 15 patients over seven days (Figure 2). They reported that the change in the patient's average pain in the first 15 minutes decreased by 20 percent, 47 percent (P=0.009) and 58 percent (P=0.004) for the saline, bupivacaine and etidocaine groups, respectively. They reported that at 24 hours and at seven days after the injections, the saline group had a 7 percent and a 13 percent increase in pain, respectively, while the bupivacaine group had an 18 percent (P=0.003) and 7 percent (P=0.005) decrease in pain and the etidocaine group had 22 percent (P=0.006) and 12 percent (P=0.001) decrease in pain, respectively. Trigger point injections with bupivacaine and etidocaine initially caused a substantial decrease in patient's pain; over the seven days this decrease lessened, but the initial pain level was never reached. Hong' corroborated this finding and reported that with successive injections, the pain intensity continues to drop to a lower level each time. Following trigger point injections, the provider should recommend use of the spray and stretch technique, encourage the use of hot packs and have the patient move the injected muscle through its full pain-free range of motion.'0 1034 JADA, Vol. 126, July 1995

Fgure 3. Acupuncture wa inItialy sulerIo to spUnt e klt ht hower, over time, acupun abIity to control pean relae to splInt thempy%

tr

ACUPUNCTURE

Acupuncture is being used increasingly in the United States. At least 80 private insurers and Medicaid programs in some states are covering acupuncture for certain disorders. The U.S. Food and Drug Administration estimates that 9 million to 12 million acupuncture treatments are provided each year in the United States.31 The mechanism by which acupuncture relieves pain is believed to be an increase in endorphins and other central non-opioid effects.32 Patients with MFP often require several acupuncture treatments to achieve an effective outcome.n,35 Two randomized clinical trials compared the efficacy of acupuncture and splint therapy for patients with MFP (Figure 3).85 Johansson and colleaguesw provided the patients in their acupuncture group with six 30-minute sessions. At a three-month follow-up eamination, they found no significant difference between the percentage of patients reporting subjective improvement with splint therapy and with acupuncture treatments. In the second of these studies, List and HelkimoP began by providing the group of patients receiving acupuncture with six 30-minute sessions. However, they found that several patients started to improve only at the sixth treatment, so they allowed these late responders (28 percent of the group) to have eight acupuncture sessions. Immediately after the acupuncture sessions were completed (a period of six to eight weeks), a significantly larger number of the acupuncture patients than of patients in the splint group reported improvement (P<0.001; 98

CLINICAL PACTIICE

Figure 4. Both splint therapy and biofoodback can provide a significant decrease in the clinical signs of temporomandibular dysfunction.

percent and 65 percent, respectively). During the next year, the percentage of patients in the acupuncture group reporting subjective improvement decreased while the percentage of patients in the splint group reporting subjective improvement increased. The success of the acupuncture group might have been maintained if the patients had received subsequent treatments. List and Helkimo33 also reported that at the six-month follow-up, patients were able to cross over and receive the treatment of the other group. Only 17 percent of the patients who received the splint and chose to cross over to acupuncture had further subjective improvement from acupuncture. These studies suggest that acupuncture, while effective, loses some of its impact over time; they also suggest that patients who do not improve after using a splint tend not to improve with acupuncture. RELAXATION THERAPY

Relaxation therapy such as progressive muscle relaxation, yoga or meditation has been reported to produce a similar response termed "relaxation response."36'37 This response is believed to reduce increased activity of the sympathetic nervous system, decrease muscle tone, reduce anxiety and reduce the effects of stress.3v1 It also is reported to be a powerful tool against the perceptions of low self-efficacy and helplessness and many subjects describe their relaxation experiences as providing them with peace of mind, a sense of wellbeing and a feeling of control.3839 Relaxation therapy has been shown to be effective for patients who have MFP. However, the

Figure 5. Both spiint therapy and blofeedback with relaxation and stress management (BF/SM) provided an initial decrease in depression, but only the patients treated with BF/SM were able to maintain this Improvement.""

practitioner cannot simply hand the patient an audiotape program and expect the patient to listen to the tape and receive the benefits of the therapy.22 Relaxation programs, including structured audiotape programs, have been shown to be effective when the patient was first instructed on their use and encouraged to use them.37 Carrington and colleagues37 reported that 86 percent of the total benefits were observed within the first six weeks. Among subjects who subjectively perceived themselves as having stress and wished to use relaxation therapy, 73 percent continued to practice relaxation five and a half months after

they began.37 BIOFEEDBACK

Biofeedback was developed in the 1960s, to give the patient an appraisal of a chosen physiologic measure (such as muscle tension, blood pressure and skin temperature). Muscle tension (EMG activity) is the measure used routinely for patients with MFP. This type of biofeedback measure has been reported to be more effective for patients with chronic non-vascular tension-type headaches than skin temperature biofeedback.42 All biofeedback studies referenced in this article used EMG biofeedback. Funch and Gale40 compared the effectiveness of biofeedback and relaxation therapy for patients with chronic temporomandibular joint disorder. They reported that the biofeedback and relaxation groups experienced an average decrease in pain of 35 percent and 56 percent, respectively. Generally, biofeedback is supplemented with reJADA, Vol. 126, July 1995 1035

~CLINICAL PRACTICE

Figure 6. While splint therapy and biofeedback with relaxation and stress management (BF/SM) provided approximately the same pain relief, splint therapy was able to provide it much faster. Combining the therapies provided even faster and greater pain relief than either were able to provide separately.16

laxation therapy to increase its effectiveness, 1 and all the other biofeedback studies presented here augmented biofeedback with relaxation. Dohrmann and Laskin` randomly assigned patients with MFP to either a group using biofeedback and relaxation or a control group. All the patients in the biofeedback group found the treatment partially or fully successful, had a decrease in their mean EMG activity and symptoms and had an increase in their mean pain-free range of motion. Over the year they were followed, only 25 percent of the patients in the biofeedback group desired further treatment compared with 72 percent of the control group. Pierce and Gale44 suggested that biofeedback was ineffective for nighttime bruxing. They treated nighttime-bruxing patients with biofeedback and relaxation and found that over a six-month period, the patients' EMG activity returned to its pre-treatment levels. The researchers speculated that biofeedback may be effective for patients with daytime parafunctional habits. Hijzen, Slangen and Van Houweligen45 did a similar randomized clinical trial for patients with MFP and concluded that biofeedback was more effective for patients with daytime parafunctional habits than for patients with nighttime parafunctional habits. Dahlstrom and Carlsson-"3 randomly assigned TMD patients to treatment with a splint or with biofeedback (Figure 4). The splint group was instructed to wear the splint only at night for six weeks; the researchers did not specify the wear 1036 JADA, Vol. 126, July 1995

instructions that were given afterwards. After one month, both the splint and biofeedback groups experienced significant decreases in their mean dysfunction scores (P<0.01) and symptoms (P<0.01), and only the subjects in the biofeedback group had a significant increase in their mean mouth opening (P<0.01). Dahlstrom and colleagues speculated that, again, biofeedback was more effective for patients with daytime parafunctional habits and nighttime wear of the splint was more effective for patients with nighttime parafunctional habits. These studies suggest that biofeedback combined with relaxation is an effective treatment for MFP patients. Our experiences suggest that the patient instructed in biofeedback must be taught to incorporate it into his or her everyday life. We believe that the combination of biofeedback and relaxation training can be especially helpful for patients who do not appear to know how to relax their muscles and/or whose symptoms increase as the day progresses. STRESS MANAGEMIENT

Brantley and Jones4' reported that 65 percent of muscle contracture headaches in their patient

Biofeedback and relaxation training can be especially helpful for patients who do not appear to know how to relax their muscles andlor whose symptoms increase as the day progresses. population appeared to be due to minor stresses in the patients' lives. Stress management is a cognitive approach to dealing with these minor stresses, an approach in which the patients identify the stressful situations in their lives and learn coping skills to better manage these situations. " Turk, Zaki and Rudy16 added stress management to the biofeedback/relaxation therapy program (BF/SM) and randomly assigned TMD patients to a group receiving this treatment, a group receiving splint therapy and a waiting-list control group. A non-randomized fourth group was later studied in which both treatments (splint therapy and BF/SM) were combined (Figures 5 and 6). The subjects in the splint group had been instructed to wear their splints 24 hours a day for the first six weeks (except when eating) and presumably not to wear them afterwards (the re-

CLINICAL PRACTICE searchers did not specify). The members of the BF/SM group were given six weekly one-hour sessions with instructions to practice on their own. At the six-week follow-up, the pain and depression scores of all three treatment groups had decreased significantly (P<0.001). From the sixweek follow-up to the six-month follow-up, the

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Self-management has been reported to help 60 to 90 percent of the patients with TMD. Such a regimen is easy to implement and should be the first treatment the patient receives for MFP.

splint group's pain score increased significantly (P<0.04), the BF/SM group's pain score decreased significantly (P<0.03) and the combined group's pain score had no significant change. The depression scores for the splint group had a significant increase (P<0.01) while the BF/SM and combined groups had no significant changes in their depression scores. Patients who were given the combined BF/SM therapy did not experience a relapse in pain (P<0.03) or depression (P<0.03) as the splint group did at the six-month follow-up. This study suggests that BF/SM is a slow but effective therapy if used alone. If BF/SM is combined with splint therapy, improvement is as rapid as splint therapy and could prevent patients from having a relapse such as Turk and his colleagues observed when splint therapy was used alone. This study illustrates that multiple treatments can have additive effects on MFP, presumably by addressing factors that could perpetuate the disorder. BF/SM is time consuming, and the patient must be motivated to practice so maximum benefit can be obtained. SUMMARY AND CLINICAL IMPLICATIONS

This literature review suggests that MFP can be managed successfully with several different treatment strategies and that a combination of strategies may be most successful. When the practitioner determines that the patient has a primary diagnosis of MFP, therefore, the use of the biopsychosocial model to determine the most prominent contributing factors affecting the diagnosis seems most appropriate.' If the most significant component appears to be physical, then the provider may desire to limit treatment to that

provided by the dentist and/or physical therapist. If the patient's physical problem appears to have a significant behavioral or psychosocial component, the practitioner should seek an evaluation by a psychologist before determining the treatment strategy. In some cases, the practitioner may need to obtain evaluations by both a psychologist and a physical therapist before deciding on a course of treatment. The provider should discuss with the patient his or her willingness to participate in the different treatment and should work with the patient to devise a protocol to treat the patient's MFP and address any contributing factors. Throughout therapy, the practitioner must continually re-evaluate the patient's condition, because the patient's primary problem may resolve itself and a secondary problem may become evident -or the patient's problem may not be resolved because the primary diagnosis was incorrect. Any treatment protocol should include consideration of the treatment's efficacy, cost, ability to remain effective, required time commitment, discomfort to the patient and disruption to the patient's lifestyle. A summary of recommended treatments. Currently, there is no scientifically determined protocol or consensus among experts for treating patients with a primary diagnosis of MFP, but the following generalizations are based on the literature presented and the authors' experiences. - Self-management has been reported to help 60 to 90 percent of the patients with TMD. Such a regimen is easy for the patient to implement and should be the first treatment the patient receives for MFP. - Stretching exercises have been shown to decrease the muscle's EMG activity and tenderness, in addition to increasing the patient's range of motion. The benefits of these exercises can be improved if the patient warms or cools the Dr. Wright Is a area before colonel, U.S. Air stretching the Force, and Is the =;^; 33S 1E muscle. Tomporomandibular Stretching exDisorders, Lackland Schiffman

ls an

AFB, Texas. Address

Dr.

reprint requests to Dr. Wright, 83 Cross Canyon, San Antonio, Texas

assistant professor, TMJ and Cranlofacial Pain Clinic, University of Minnesota,

78247.

Minneapolis.

ercises are easy to do, not time consuming for

the patient and

JADA, Vol. 126, July 1995 1037

~~ICINICAL PRACTICE should be prescribed if self-management does not control the signs and symptoms of MFP. - Massage and trigger point compression are effective techniques for increasing the muscle's vasodilation and temporarily inactivating trigger points. The dentist can teach patients these techniques. However, such instruction can be time consuming. This is one reason the dentist should consider referral to a physical therapist to accomplish this. In addition, when the patient has a limited range of motion or pain with a normal range of motion, a physical therapist may use other physical therapy modalities that dentists may not have access to. The goal of these passive treatments must be to allow the patients to reach a point where they can perform the care on their own. - Persistent trigger points rarely are resistant to the previously noted interventions, but when they are, they can be treated with direct injection. This may result in an immediate decrease in symptoms; however, symptoms usually return, at a lesser level, over a week or two. This procedure is usually followed by the spray-and-stretch technique, administration of hot packs and active range-of-motion exercises. Trigger point injections are invasive, bear certain risks and are recom-

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Acupuncture has been reported to be as effective as splint therapy in relieving MFP symptoms, but it appears to lose its impact over time.

mended only after exercises and other physical therapy modalities have failed to achieve a lasting effect. - Acupuncture has been reported to be as effective as splint therapy in relieving MFP symptoms, but it appears to lose its impact over time. Acupuncture therapy usually involves multiple treatments with periodic follow-up treatments to maintain its effectiveness. It may be appropriate as an adjunctive therapy if other therapies have proved inadequate. - Studies suggest that biofeedback, relaxation techniques and stress management are effective treatments for patients who have significant behavioral or psychosocial contributing factors.16"383946 Biofeedback and relaxation have been shown to be effective in reducing primary daytime parafunctional habits but not in reducing primary 1038 JADA, Vol. 126, July 1995

nighttime parafunctional habits. Patients with nighttime parafimctional habits usually experience an increase in their pain when they first awaken, while patients with daytime parafunctional habits feel an increase in their pain during the day or evening. Several studies speculated that patients with daytime parafunctional habits benefit the most from biofeedback with relaxation and patients with nighttime parafinctional habits benefit the most from splints. We have observed that patients with daytime parafunctional habits also benefit from a splint worn during the day if their splint is used to increase their awareness, and thus their control, of their parafunctional habits. Biofeedback with relaxation is a timeconsuming treatment, and the patient must be taught to use it effectively in everyday life. The patient must be motivated to practice the therapyStress management teaches coping skills to deal with stressful situations in the patient's life. Turk and his colleagues'6 suggested that stress management combined with biofeedback, relaxation and splint therapy would increase the patient's rate of improvement and decrease relapse that may occur with splint therapy alone. This therapy is time consuming and the patient must be motivated to practice it. CONCLUSION

Currently, we can only speculate on which therapies would provide the most effective outcome for MFP patients with diverse biological, behavioral and psychosocial contributing factors. However, when a variety of contributing factors is present and the patient does not respond to self-management, an evaluation by a dentist, physical therapist and psychologist is appropriate to determine which intervention or combination of interventions would be most beneficial for the patient. As additional research becomes available, our recommendations are likely to change. We hope this review will help practitioners select appropriate alternative therapies to combine with their traditional therapies and thus improve the treatment outcome for their patients with MFP. . The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinions or official policies of the American Dental Association or its subsidiaries or of the U.S. Air Force or the U.S. Department of Defense.

The authors thank Dr. James Fricton of the University of Minnesota for his assistance with this article.

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