Follow-up evaluation of 105 patients with myofascial pain-dysfunction syndrome

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Follow-up evaluation of 105 patients with myofascial pain-dysfunction syndrome Stanley R. Cohen, DMD, M S, Revere, Mass

In a private oral surgical practice, 118 patients were treated fo r signs and symptoms related to the dysfunction of the temporomandibular joint (TMJ). Except fo r one person who was treated surgically, therapy was conservative and was directed at relaxing the musculature associated with the TMJ. One hundred five patients were followed up; 91 reported no further problems or thought that the problem was under control. Fourteen had no improvement or sought treatment elsewhere.

the use o f L ask in’s 1 criteria, patients were consid ered to have m yofascial pain-dysfun ction syndrom e (MPD) if one or m ore of four findings w ere evident: pain, al­ m ost always un ilateral, in the ear or preauricular region that m ight radiate dow n to the angle of the m an­ dible, to the sid e of the neck, or to the tem poral region; m uscle regions ten ­ der to palpation, w h ich represent sites of m u scle spasm ; click in g in the tem porom andibular jo in t (patients w ith click in g were inclu ded only if other sym ptom s were present in ad­ dition to the click in g or if the patient was disturbed by others hearing the noise); lim itation of jaw function , in ­ cluding the in ab ility to open as w ide as usual. L im itation o f opening w ith ­ out click in g had usually existed for a

long tim e and the patient often had a history o f click in g or pain.

Methods of treatment P anoram ic radiographs were taken to rule out pathologic con d ition s o f the condyles; none w ere found. A fter a history w as taken and an exam ination w as m ade, the con d i­ tion of these patients was diagnosed as MPD. It w as exp lained to th e pa­ tients that m u scle spasm s were the cau se of th eir trouble, and assurance was given that the cond ition w as not life threatening. A n analogy was m ade betw een a cram p o f a leg m us­ cle and spasm in a jaw m uscle. After the explanation had b een given, con ­ tracted areas of th e m asseter, tem ­ poralis, and neck m u scles, w hich

w ere tender to palpation over the skin, w ere sprayed w ith ethyl chlorid e. If the m edial and lateral pterygoid m u scles w ere in spasm , an anesthetic was in jected intraorally. T his re lie f o f sym ptom s h elp ed to es­ tablish the p a tien t’s con fid en ce that the diagnosis w as sound; this is an im portant factor in su ccessfu l therapy. It was th en explained th at the cy cle of a precipitating factor— su ch as stress or nervous ten sio n — caused m u scle spasm , w h ich cau sed pain, w h ich in turn caused m ore ten sio n and spasm . C licking and lim itation o f opening w ere attributed to the in ­ ability of th e m u scles that open and close the jaw to w ork harm oniously together becau se som e m u scles were in spasm and the pain set up reflexes that prevented fu ll opening. Therapy was directed tow ard breaking the cycle. D iazepam was prescribed to relax the m usculature and to relax the patient. If the patient preferred, aspirin or other m u scle relaxants were substituted. As exercise relieves ten sio n and is cond u cive to relaxation , reflexrelaxation exercises w ere initiated if pain was the only sym ptom . T h e pa­ tien t w as instructed to op en h is jaw against the force of th e fist held against the chin. Contracture o f the JADA, Vol. 97, November 1978 ■ 825

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depressor m u scles o f the m andible allow ed the elevator m u scles to re­ lax. It was exp lain ed to the patient that the m u scles o f m astication are volun­ tary, striated m u scles that are under the control o f th e individ ual, as op­ posed to sm ooth, involuntary m us­ cles. P atients w ere taught to open th eir jaw s w ith th eir fingertips over the cond yles and were m ade aware of th eir opening and closin g m ove­ m ents. T h is form of therapy was found to be esp ecially help ful in overcom ing click in g and lim itation of opening. Patients were told not to do anything that would cause pain or click in g . They w ere m ade consciou s o f th eir m u scles and told to con cen ­ trate on them w h en eating and talk­ ing. T h e exercises to retrain their m u scles w ere found to be effective w hen there w as click in g and lim ita­ tion o f op ening, as w ell as pain. Ethyl chlorid e w as prescribed for selected patients so that patients could spray th eir m u scles. A p pli­ ances to prevent bruxism or m in i­ m ize its effects w ere constructed for some. Patients w ere told that th e problem m ight never be elim inated, but that it could be controlled . T hey w ere told that a recurren ce was not serious, that being aware o f the cause of MPD w as m ost im portant, and that it was under their control.

Results of follow-up O f 118 patients follow ed up, 97 (82% ) were fem ales. (In their study of 4 91 patients, Schw artz and Cobin2 found that 83 % w ere fem ales.) Seventy-three o f the 118 patients (more than 6 2% ) were fem ales younger than 40 years (Table 1). Con­ tact w ith 13 patients was not made. Intervals o f six m onths to 12 years had elapsed betw een initiation of treatm ent and follow -up contact. P a­ tien ts were contacted by telephone and asked if they w ere still having sym ptom s. If sym ptom s were still present, the p atient was asked if there was im provem ent or if the problem w as under control. T hose who thought that there was no im prove­ m ent or that th e cond ition was not 826 ■ JADA, Vol. 97, November 1978

under control were asked if treatment had been sought elsewhere. Sixty-five persons (62% ) reported that they had no further problems. Twenty-six patients (25% ) had recur­ ring symptoms, but either had im­ proved or had the problem under control. Fourteen of the 105 (13% ) thought they were no better or had sought treatment elsewhere after therapy (Table 2). One patient had been involved in an automobile accident. There was no fracture, but the patient had pain and limitation of opening that did not respond to conservative treat­ ment. A high condylectomy was later performed through a preauricular approach. The patient had been free of symptoms for 12 years. This was the only surgical procedure per­ formed on the 118 patients. Two of the persons who reported that they were no better had had surgery performed by others. One had no improvement after surgery.

dysfunction always implies an occlusal problem, and once the dys­ function is established, it becomes a source of stress in itself, and as such becomes self-perpetuating.” He al­ so said,4(P232) “The cause of these symptoms is occlusal disharmony and its resultant pathologic occlu­ sion. Therefore, it is necessary to in­ tegrate the treatment of the dentition in the plan of treatment as soon as practical.” Glickman5 wrote, “Ab­ normal occlusal function is the prin­ cipal cause of temporomandibular joint disorders.” Studies have shown that more than 80% of patients with MPD are females.2 If abnormal occlusal dys­ function was the principal cause, why do not more males, who have as many occlusal disharmonies as females, have problems? In an examination of about 2,000 males in a Veterans Administration hospital, Loiselle6 reported that, despite the finding of many occlusal dishar­ monies (including overclosure), none was considered to have dys­ function of the temporomandibular joint (TMJ). Edentulous persons, in spite of overclosure, rarely have MPD. Those who wear dentures, with decreased vertical dimension or other occlusal problems, rarely have disturbances of the TMJ. Solberg and co-workers7 found that pain and dysfunction of the TMJ arose from increased muscle tension

Discussion Although Costen syndrome3 has been universally discredited, the etiology of the myofascial paindysfunction syndrome continues to be controversial. Emphasis on occlusion as the cause of painful, limited open­ ing continues. Shore4(P123) wrote, “However, temporomandibular joint

T ab le 1 ■ Age and sex of 118 patients who were treated. Age at first visit (yr) Younger than 20 20 to 30 30 to 40 40 to 50 50 to 60 Older than 60 Total

Male 7 7 3

Female 16 42 15

1 1 2 21

10

9 5 97

T able 2 ■ Results of treatment of 105 patients who were followed. Age at first visit (yr) Younger than 20 20 to 30 30 to 40 40 to 50 50 to 60 Older than 60 Total

No further problems Male 3 5 3

Female 11

18 11

3

1 1 1

6 2

14

51

Improved or Treatment failed under control or no improve­ ment Male Female Male Female 2 1 1 4 2 12 0 5 0 0 0 0

4

2

4 1 2 22

0 0 0 1 2

0 1 1 1 12

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caused by emotional factors. Half of their patients showed signs of anx­ iety. They found no significant dif­ ference in occlusion between the symptomatic and the control groups. Tw enty-five patients w ith MPD w ere treated w ith m ock equ ilibration (nonocclud ing surfaces o f the teeth w ere ground) by G oodm an and oth ers.8 Strong, positive assurance w as given. S ixteen reported com ­ plete re lie f o f sym ptom s, and the n in e who reported som e positive ef­ fect w ere treated w ith other m ethods. Several disorders o f th e TM J m ay require surgery. C hronic d islocation, ankylosis, tum ors, deform ities, and traum atic in ju ries could ben efit from surgical intervention. How ever, few patients w ith MPD, in w hom the cau se is p rin cip ally in the m u scles, w ould ben efit from surgery rather than conservative therapy. Agerberg and Lundberg9 used arthrogram s to follow 12 patients w ho underw ent TM J surgery (two were undergoing th eir second surgical procedures). Condylectom ies w ere perform ed on two of the 12 patients in addition to excisio n o f the m eniscu s, w h ich was done on all 12. Agerberg and Lundberg con clu d ed that there w as a clin ica l im provem ent, although this w as not apparent in arthrogram s, and that TM J surgery for MPD w as a last resort. Y ale and co-w orkers10 have show n that there is sign ifican t variability in the size and shape o f norm al hum an m andibular cond yles. M arkovic and R osenberg11 found only n in e o f 100 patients w ith MPD had bony changes w hen their cond y les were exam ined by lam in ographic radiographs. G reene and M arkovic12 used co n ­ servative and reversible treatm ents, inclu d ing m ed ication, bite plates, physical therapy, and cou nseling, for 32 fem ales w ith MPD in w hom re­ sults of radiographic fin d ings in volv­ ing the TM J were abnorm al (none had ankylosis, neoplasm , m ajor traum a, or the like). Follow -up show ed consid erable or total im ­ provem ent in 26 o f 3 0 patients. G reene and M arkovic con clu d ed that bony abnorm alities observed on radiographs m ight be unrelated to the p atien t’s su bjective sym ptom s.

Radiographic ev id ence o f inflam ­ m atory or d egenerative changes can­ not be relied on fo r diagnosis or in treatm ent p lanning for patients w ith MPD. R oss13 w rote, “ the m ost com m on cause of pain and d ysfunction o f the tem porom andibular jo in t is destruc­ tive occlu sal fo rce.” He and oth ers,14 w ith sim ilar points of view , treat the problem prim arily by alteration of the occlusion. Our m ethods of treat­ m ent focus on spasm o f m asticatory m uscles as the prim ary cau se of MPD w ith secondary roles played by the d entition and jo in t. Y avelow and co-w orkers15 said, ‘ ‘self-perpetuating pain to d ysfunction to pain cycle m ust be interrupted by therapy, but the choice of treatm ent depends on the c lin ic ia n .” T h eir treatm ent did not inclu de irreversible procedures, such as occlu sal grinding, m outh re­ habilitation, prosth etic appliances, surgical procedures, or the in jection of steroids or sclerosin g solutions. In 1954, S ch w artz16 reported the treatm ent of 20 patients w ith painful, lim ited opening. T h e con d ition in nin e of ten w ho received ethyl chlorid e treatm ent im proved or was com pletely relieved. In eight o f ten w ithout treatm ent, th e cond ition did not im prove. A fter observations of m ore than 2 ,5 0 0 patients at a TM J clin ic , Schw artz and C hayes17 w arned that occlu sal interferences may be caused by eith er dysfunction o f m uscles or abnorm al tooth rela­ tionships, that occlu sal interferences are n ot causative in them selves but m ay be a result of con d itions as­ sociated w ith ten sio n , and that treatm ent to elim in ate interferences m ay aggravate the conditions. In a double-blind study, G reene and L askin 18 show ed im provem ent in MPD sym ptom s for 58% of the pa­ tients w hen m eprobam ate w as given; the cond ition of 31 % im proved w ith a placebo. The investigators reported that subjective factors, such as pain, im proved m ore w ith th is treatm ent than did objective sym ptom s, such as click in g . In another study by Laskin and G reene,19 on ly a placebo was used along w ith verbal and nonver­ bal assurances, inclu d ing optim istic predictions of success. W hen the

doctor-patient relationship was stressed, the condition in 52% im­ proved with placebo treatment. These findings support the role of psychological factors in the cure of MPD. Lupton20 reported that not only was there a significant relationship between psychological factors and nonorganic TMJ dysfunction, but also that the psychological factors were amenable to treatment; treat­ ment resulted in relief of physical symptoms as well as psychological improvement. Rothwell21 used the Eyesenck Personality Inventory, a psychological instrument, to evalu­ ate a group with MPD. He found that those with MPD symptoms that were difficult to treat scored higher in neuroticism than others. Moulton22 said that the best therapy results if patients are han­ dled conservatively by the first doc­ tor who sees them. Only necessary treatment should be performed until there is less anxiety and less muscle spasm. She thought that the most re­ calcitrant patients were those who had found doctors who promised complete cures and who promised a mechanical way to lift the barriers of pain. These patients sought others who offered relief by mechanical methods. Recently, there have been several reports of the use of biofeedback training in treatment of MPD.23,24 Two British psychologists25 taught relaxation exercises to four patients with MPD, with beneficial results. They hypothesized that MPD was similar to tension headaches. Bio­ feedback training is similar to re­ training exercises in that the pa­ tient’s consciousness of activities of his muscles is raised, and control of muscular activity is thereby reestab­ lished.

Conclusions and summary A follow-up study of 118 patients

was performed to determine the ef­ fect of various conservative treat­ ments for MPD after six months to 12 years. Of the patients, 8 2% were females; 62 were females younger than 40

Cohen : MYOFASCIAL PAIN-DYSFUNCTION SYNDROME ■ 827

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years old. During treatment, patients were made aware of muscle spasm, and consciousness of the role of mus­ cles in MPD was raised. Of 105 patients who were con­ tacted, 65 had no further problems, 26 thought the problem was im­ proved and under control, and 14 had not improved or had sought treatment elsewhere. Musculature and psychological factors play major roles in the MPD syndrome.

9. A gerberg, G., an d Lu ndberg, M . C hanges in th e tem p o ro m a n d ib u la r jo in t after su rgical treatm ent. A ra d io lo g ic follo w -u p stud y. Oral Surg 3 2 :8 6 5 D ec 1 9 7 1 . 10. Y a le ,

S .H .;

A llis o n ,

B.D .;

and

H auptfu eh rer, J.D. A n e p id em io lo g ica l a ssess­ m en t o f m an d ib u lar co n d y le m orp h olo gy . O ral Su rg 2 1 :1 6 9 F eb 1 9 6 6 .

2 2 . M o u lto n , R.E. E m o tion al fa cto rs in nono rg a n ic tem p orom an d ibu lar jo in t pain . D ent C lin N A m 6 0 9 Nov 1 9 6 6 . 2 3 . C arlsso n , S .G .; G ale, E.N .; and O h m an , A. T rea tm e n t o f te m p orom an d ibu lar jo in t sy n ­ drom e w ith b io fee d b a ck train in g . JAD A 9 1 :6 0 2 Sep t 1975. 2 4 . S o lb erg ,

W .K .,

and

R ugh,

J.D.

fee d b a ck -in d u ced m u scle rela x a tio n used in

C orrected la m in a g ra p h ic ev alu ation o f th e T M J

th e trea tm en t o f bru xism . J D ent R es 5 2 (sp ecial is s u e ):7 8 a bstract no 7 8 F eb 1 9 7 3 .

in 1 0 0 M PD p atien ts. J D en t Res 5 2 (sp ecia l issu e ):76 abstract no. 7 0 F eb 1 9 7 3 . 12. G reen e, C .S ., an d M ark ov ic, M .A . R e­ sp o n se to n o n su rg ica l treatm en t o f p atien ts w ith p o sitiv e ra d io g ra p h ic fin d in g s in th e tem ­ po ro m an d ib u lar jo in t. J O ral Surg 3 4 :6 9 2 Aug 1976.

2 5 . R ead in g, A., and Raw , M. T h e treatm ent o f m a n d ib u la r d y sfu n ctio n pain . P o ssib le a p ­ p lica tio n o f p sy ch o lo g ica l m ethods. B r D ent J 1 4 0 :2 0 1 M arch 16, 1 9 7 6 .

1 3 . R o ss, I.F . O c clu s io n , a co n cep t for th e 1. L a sk in , D .M . E tio lo g y o f th e paind y sfu n ctio n sy n d ro m e. JA D A 7 9 :1 4 7 Ju ly 1 9 69. 2. S ch w a rtz , L .L ., and C obin , H .P. Sy m p tom s a sso cia ted w ith th e tem p o ro m an d ib u lar jo in t. S tu d y o f 4 9 1 cases. O ral Surg 1 0 :3 3 9 M arch 1957. 3. C oston , J.B . Sy n d ro m e o f ear an d sin us sy m p tom s d ep en d en t u p o n distu rbed fu n ctio n o f tem p o ro m an d ib u lar jo in t. A n n O to l R h in ol an d L aryn g o l 4 3 :1 M arch 19 3 4 . 4. S h o re ,

N .A .

T em p o ro m an d ib u lar jo in t

d y sfu n ctio n and o cclu s a l eq u ilib ratio n , ed 2. P h ila d e lp h ia , J. B . L ip p in co tt, 19 7 6 . 5. G lick m a n , I. C lin ica l p eriod on to log y ; pre­ v en tio n , d iag n o sis, and treatm en t o f p eriod on ­ ta l d ise a se in th e p ra ctice o f g en eral dentistry,

clin ic ia n . S t. Lo u is, C. V. M o sb y C o ., 1 9 7 0 , p 8 3 . 1 4 . R am fjo rd ,

S .P .

D y sfu n ction al

THE AUTHOR

tem ­

p o ro m an d ib u lar jo in t a n d m u scle pain . J P ro s­ th et D ent 1 1 :3 5 3 M a rch -A p ril 1 961. 1 5 . Y av elo w , I.; F o rster, I.; and W in in g er, M. M an d ib u lar re lea rn in g . O ral Surg 3 6 :6 3 2 N ov 19 7 3 . 16. S ch w artz , L.L . E th y l ch lo rid e treatm ent o f lim ited , p a in fu l m a n d ib u la r m ovem ent. JAD A 4 8 :4 9 7 M ay 195 4 . 17. S ch w a rtz , L., an d C h ayes, C.M . F a cia l p a in and m an d ib u lar d y sfu n ctio n . P h ila d e l­ p h ia, W . B. Sau n d ers Co., 1 9 6 8 , p 3 37. 18. G reen e, C .S ., an d L ask in , D .M . M ep ­ ro bam ate th erap y for th e m y o fa scia l paind y sfu n ctio n (M PD) sy nd ro m e: a d o u b le-blin d ev alu atio n . JA D A 8 2 :5 8 7 M arch 1 9 7 1 . 1 9 . L ask in , D .M ., and G reen e, C .S. In flu en ce

COHEN

ed 4 . P h ila d e lp h ia , W . B . S au n d e rs C o., 1 9 72, p 847. 6. L o is e lle , R .J. R e latio n o f o cclu s io n to tem ­ p o ro m a n d ib u lar jo in t d y sfu n ctio n : th e pros-

th erap y fo r p a tie n ts w ith m y o fa scia l p ain -

th o d o n tic v iew p o in t. JA D A 7 9 :1 4 5 Ju ly 1 9 69. 7. S o lb erg , W .K .; F lin t, R .T .; and B ran tn er,

d y sfu n ctio n (M PD) sy nd ro m e. JAD A 8 5 :8 9 2 O ct 19 7 2 .

J.P . T em p o ro m an d ib u lar jo in t p ain and dys­

20. L u p ton , D.E. P sy ch o lo g ica l asp ects o f

D en tistry, B o sto n , and c h ie f o f th e d en ­ tal serv ice, C h elsea M em orial and

fu n ctio n : a c lin ic a l study o f em o tion al and o c c lu s a l co m p o n e n ts. J P ro sth et D ent 2 8 :4 1 2

tem p o ro m an d ib u la r jo in t d y sfu n ctio n . JA D A 7 9 :1 3 1 Ju ly 1 9 6 9 .

G rover M an or H osp itals. H e also h as a p riv a te p ra ctice . A d dress requests for

O ct 1 9 7 2 .

2 1 . R o th w e ll, P. S . P e rso n a lity and te m ­ p o ro m an d ib u lar jo in t d y sfu n ctio n . O ral Surg 3 4 :7 3 4 Nov 19 7 2 .

re p rin ts to Dr. C ohen at 1 6 P lea sa n t S t,

8. G oodm an , P .; G reene, C .S .; and L ask in , D .M . R e sp o n se of p atien ts w ith m y ofascial p a in -d y sfu n ctio n synd rom e to m o ck eq u ilib ra­ tio n . JA D A 9 2 :7 5 5 A p ril 1 9 7 6 .

828 * JADA, Vol. 97, November 1978

B io ­

11. M ark ov ic, M .A ., and Rosen berg, H.M.

of th e d o cto r-p atien t re la tio n sh ip on p lacebo

Dr. C ohen is a ssista n t c lin ic a l p rofes­ sor o f oral and m a x illo fa cia l surgery, H enry M. G oldm an S ch o o l o f G raduate

R evere, M ass 0 2 1 5 1 .