TEMPOROMANDIBULAR PAIN AND DYSFUNCTION SYNDROME

MUSCULOSKELETAL MEDICINE

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TEMPOROMANDIBULAR PAIN AND DYSFUNCTION SYNDROME History, Physical Examination, and Treatment Joseph J. Marbach, DDS

Physicians have relegated the treatment of chronic musculoskeletal facial pain to the dental realm. Ostensibly, this decision is based on the notion that the disorders require special expertise outside the scope of traditional medical training; however, there is little evidence to support this viewpoint. Those who seek care for chronic musculoskeletal pain, regardless of the anatomic site of their pain, share many demographic and clinical features.”, R1 Consider, for example, patients with musculoskeletal facial pain and those who suffer from fibromyalgia. Though these disorders are generally treated quite differently, several investigators have speculated on the possibility that the two disorders are one in the same or, at the very least, closely linked. Wo1fes2proposed four psychophysical models that could serve to link musculoskeletal face pain and fibromyalgia.R2It has also been suggested that perhaps but for the publications of Costen? the tender point sites located in the head and neck would be included among those used to arrive at the diagnosis of fibromyalgia (Fig. l).,,Costen’s series of publications created a new paradigm for treating facial pain.7 The rapid paradigmal shift that occurred more than 60 years ago resulted in a change in treatment for facial pain that continues to this day. In 1934, Costen, an otolaryngologist, described a symptom complex that became known as the temporomandibular joint (TMJ) s y n d r ~ m eCosten .~ attributed the cause of TMJ pain to the loss of posterior teeth and the resultant compression of nerve tissue in the TMJ and periarticular muscles of the face, head, and neck. Costen placed TMJ treatment squarely in the care of dentistry. This article was supported by National Institutes of Health Research Grant DE 05989 (National Institute of Dental Research).

From the Departments of Oral Pathology, Biology, and Diagnostic Sciences and Psychiatry, University of Medicine and Dentistry of New Jersey, Newark, New Jersey

RHEUMATIC DISEASE CLINICS OF NORTH AMERICA

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Figure 1. Tender point locations used for the 1990 classification criteria for fibromyalgia. Dots indicate 18 potential points. Note faces and heads, with the exception of the occipital area, do not contribute to the diagnosis of fibromyalgia. Is this logical or merely an historical accident? (Adapted from Wolfe F, Smythe HA, Yunus MB, et al: The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum 33160, 1990; with permission.)

This focus was maintained by generations of original models that evolved along dental lines. For patients who had no missing teeth to replace, a bad bite or malocclusion was thought to cause the syndrome. Later, nocturnal tooth grinding (bruxism) was added to the list of risk factors for TMJ syndrome. Despite extensive research, the origin of musculoskeletal face pain remains ~ ~ ~ k n o w n . ~ ~ Nevertheless, this article argues that there is little evidence to support the traditional dental origins that form the basis of much current practice. DEFINITIONS

Musculoskeletal face pain syndromes of unknown cause are referred to by several names. The term temporomandibular pain dysfunction syndrome (TMPDS),

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adopted by the International Association for the Study of Pain (IASP), will be employed in this article.57The IASP system is intended as a descriptive taxonomy to classify chronic pain syndromes. The IASP description of TMPDS requires tenderness in one or more muscles of mastication. In addition, clicking or popping noises in the TMJ or restricted mandibular range may be present. Neither of the latter two are necessary or sufficient for diagnostic purposes. TMPDS is characterized by muscle pain associated with localized areas of tenderness on palpation at specific tender points. Research diagnostic criteria (RDC) for facial pain have received a great deal of attenti~n.’~ Dworkin and coworker~’~ proposed RDC for a heterogeneous group of disorders known as temporomandibular disorders (TMD).”l Despite its widespread use in the dental literature, the term TMD is not used in this article. Confusion regarding the heterogeneity of the TMD population makes interpretation and replication of studies employing the term TMD difficult or imp~ssible.~~ Other Facial Pain Shddrornes

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In clinical practice, musculoskeletal face pain, such as TMPD, is confused sometimes with two other categories of facial pain disorders. The first category includes the typical neuralgias, the most common of which is trigeminal neuralgia. It is characterized by sudden, paroxysmal pain generally confined to the distribution of one or more branches of the trigeminal nerve. Other typical neuralgias are associated with acute herpes zoster, post-herpetic neuralgia, and geniculate neuralgia. The second category re ers to atypical facial pain (AFP), or atypical facial neuralgia. The definitions for1these terms are so varied as to render them useless. AFP is a diagnosis m@eJraditonaly, after excluding other possibilities for which the clinician has a physical explanation. It is used most often as a euphemism for psychiatric-based facial pain.43,44 The k i m s are specifically rejected by the IASP.58

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Epidemiology

The estimated prevalence of chronic facial pain symptoms consistent with a diagnosis of TMPDS ranges from 6%, or 10.5 million adults, in a general population ample"^,^" to 12% of enrollees in a large health maintenance organization (HMO)Ro;the ratio of women to men was 2 to 1 in both samples. About 25% of both symptomatic women and symptomatic men enrolled in the HMO had sought TMPDS-related treatment during the prior 6 months. On average, the age of women seeking treatment is 38 to 40 (SD 16) years old.’ Some researchers,4 but not found that estimated prevalence rates decrease after age 60. In contrast to the 2 to 1 female-to-male prevalence ratio found in epidemiologic studies, data from facial pain specialty facilities consistently report a striking preponderance of women. Women constitute between 80% to 95% of most treated sample^.^ The gender ratio is particularly apparent for invasive treatments, such as TMJ surgery. For example, data collected between 1982 and 1991 by the National Hospital Discharge Survey (NHDS) show that the odds were more than 13 to 1 that those discharged with a TMPDS-related diagnosis would be female.z6TMPDS-related hospitalizations are usually associated with surgical treatment. As in the case of fibromyalgia, there is no satisfactory expla-

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nation for the consistently high ratio of females to males who seek care for TMPDS. REVIEW OF TREATMENTS

People suffering from TMPDS both seek and neglect to seek care for many reasons, in addition to the sensation of pain. For example, fear, social stigma, economic considerations, and stoicism can exert strong influences on care seeking behavior. Failure to identify the concerns that led the patient to act as he or she did may hamper treatment. In an attempt to provide the most comprehensive care, the treatment strategy outlined here is based on a biopsychosocial theory described by EngeP7and others.16The theory is derived from observations concerning which signs and symptoms patients perceive as deviations from health, what meanings they ascribe to these changes, and the action or inaction of the patient in response to the sum of this information. Several constructs, such as illness abnormal illness behavior,’j2and the patient’s explanatory serve as investigatory tools to study empirically the biopsychosocial theory. Embedded in this theory is the notion that patient‘s behavior toward illness is motivated by psychological and social factors in addition to biomedical considerations. This review attempts to provide the clinician with practical information for the treatment of patients with TMPDS. Many reviews of treatment, as currently practiced, are available (see reference 72). These reviews are customarily organized by treatment modality ( e g , nonsteroidal anti-inflammatory drugs [NSAIDs], tricyclic antidepressant drugs, physical therapy, tender point injections). It is sometimes difficult for clinicians to make practical use of all of this information when faced with a patient seeking treatment. For evidence, one need only observe the wide variation in the actual practice of TMPDS care.55,6o Depending on referral pattern, a patient with TMPDS who presents with virtually the identical set of signs and symptoms can undergo TMJ surgery or psychotherapy, be recommended for 3 years of orthodontic treatment, or be fitted with a $600 bite appliance. Some variation in practice patterns is inevitable because of differences in available resources, physician access to training, and the patient’s preferences; however, these variations should be small and explainable. Practice variation of the magnitude found for TMPDS is more likely to reflect the uncertainty regarding how to approach the particular medical problem. This review of treatment follows the usual sequence of an initial office visit, comprising demographics, symptom history, and physical, radiographic and laboratory examination if appropriate. Questions that explore the patient’s explanatory model are as follows: What do you think is wrong with you? Why do you think your pain started when it did? What do you think is happening to your body? What do you think about the explanation given to you by others you have consulted for the cause of your pain? Do you find it acceptable or not? Do you have any fears about the pain? What are the main problems that your pain has caused you? What do your family, friends, and coworkers think about your pain? Do you have any ideas or opinions about how this type of pain is treated? If your pain is not entirely relieved by treatment, what will you do next?

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The clinician may choose to collect much of these data indirectly by guiding and encouraging patients to express themselves. Demography As an Aid to Diagnosis

Demographic characteristics provide important clues for the differential diagnosis of chronic facial pain because many conditions present with concomitant facial, head, and neck pain. Gender and age are initial filters.’,.7, 59, 79 Recall that TMPDS is a disorder of women who start seeking help in their 20s and 30s. Because there are so many morbid conditions with facial pain symptoms, the clinician should ruLe out other conditions before arriving at a diagnosis of TMPDS, particularly in an adult male.9,58The same is true for females over the average age of 50 years old if it is their initial onset of facial pain. In the absence of a long history of TMPDS, other physical and psychological disorders should be ruled out. Generally, disorders that present with facial pain as a prominent feature, such as sinusitis, toothache, otitis, various forms of headache, and trigeminal neuralgia, differ demographically from TMPDS. If, on the other hand, the patient is between the ages of 15 and 30 years old and meets criteria for TMPDS, and for those over 20 years old, has had prior episodes of facial pain, one can proceed with an examination for TMPDS. Thus, a knowledge of the epidemiology of various chronic facial pain disorders provides an invaluable aid in arriving at a diagnosis. HISTORY

The multidimensional nature of chronic pain syndromes requires a wide variety of descriptors to identify the problem, a sort of multivariate approach to history taking. Information should be collected on nociception, pain perception, evaluation, behavioral responses, and coping. Complaint

TMPDS patients almost always report pain as the chief complaint. Determine as precisely as possible the specific location by asking the patient to point to the painful sites (Fig. 2). Patients with TMPDS usually localize pain to one or more of the muscles of ma~tication~~; the masseter muscle is the single most frequently identified muscle. It is followed, in order of frequency, by the temporalis, sternocleidomastoid, trapezius, and splenius capitis and cervical spine muscles. The pterygoid muscles are more difficult for the patient to identify because they lie deeper in the face. About a third of the patients also complain of an earache when describing a synovitis of the TMJ.36Other sites, such as those above and below the eye or in the occiput, may indicate a comorbid neuralgia.43If the signs and symptoms of TMPDS are present along with signs and symptoms clearly not those of TMPDS, look for comorbid conditions. Do not attempt to treat the entire clinical picture as one disorder. Dysfunction

Because the elevator muscles of mastication are almost always painful to move, patients with TMPDS exhibit restricted range of mandibular motion.

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Figure 2. Tender points (X), chief referred pain patterns (arrows),and widespread painful areas (stippled). A, Masseter muscle. B, Temporalis muscle. Illustration continued on opposite page

Range of motion is, by convention, considered restricted if the distance between the upper and lower central incisor teeth is less than 35 mm. This estimate should not be rigidly adhered to, however, for either diagnostic or treatment purposes. Clicking noises in the TMJ can be annoying. More importantly, some clinicians and even the popular press have made these noises a treatment focus. Patients seek care because of worry and fright over the potential consequences they have been told may occur from cli~king.2~ A patient’s concerns should be taken seriously, first by reassurance, then, if the patient persists, follow with conservative therapy. Epidemiologic studies indicate that rates for clicking of the TMJ can be found frequently in about 25%, and occasionally in 40%, of general population samples.29Furthermore, Magnusson et a141shows that almost half the subjects with TMJ clicking at age 15 had none at age 20 whereas half who had clicking at age 20 did not have it at age 15. At a 10-year follow-up, only one of Magnusson’s original 293 subjects reported intermittent locking, a more troublesome form of clicking that may require physical therapy (see section on treatment). The process of labeling clicking as an internal derangement (ID) and its inclusion as one of the temporomandibular spectrum disorders30 transformed simple clicking noises into IDS, an example of what Ivan Illich calls ”the medicalization of life.”32 Onset About 75% of TMPDS cases report an insidious onset; the other 25% ascribe the onset of pain usually to a trauma (e.g., physical injury, tooth grinding, dental or other surgical procedure, illness, and psychological stress).48A comparison of cases reporting traumatic versus insidious onset found no differences with regard to clinical or psychiatric status or long-term outcome.67In the absence of

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Figure 2 (Continued). C, Sternocleidomastoid muscle. capitis and splenius cervicis muscles.

D,Trapezius muscle.

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€, Splenius

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an acute traumatic injury, such as a mandibular fracture, the circumstances surrounding onset have little bearing on future course and treatment. Course The course of TMPDS is highly variable.” One year of monthly observations disclosed that average pain at the time of the monthly interview was 30 on a 0 to 100 scale. Average worst pain of the month was nearly double (57) on the same scale. The average patient had a 55-point range between the month of the highest and the lowest worst pain severity. No respondent had a consistent pattern of increase or decrease in pain during the year-long observation. The high variability was not related to therapy. The duration of the disorder correlated modestly with the average pain at the time of the interview. This suggests that TMPDS pain tends to get worse over time. Patients frequently make appointments at moments of relatively high pain intensity. Because the pain is variable, there is a chance that the intensity of a patient’s pain will be somewhat less at the time they finally visit the clinician.66 Providing the patient with a statistical rather than a psyyhological explanation for their decreased pain can reduce the potential stigma associated with the notion that the pain can be controlled merely by seeing the doctor. Much to the consternation of the patient and clinician alike, pain intensity may exacerbate just as treatment is initiated. On the other hand, the pain intensity may remit spontaneously, leaving a false impression of treatment efficacy. It has been suggested that TMPDS remits with age.I5Our own data on age derived from treated cases indicates that TMPDS is a chronic disorder and only a minority of cases achieve permanent remission.84In 1991, a clinic sample of 164 was recruited from 443 patients randomly selected from clinical records of 1013 women who had sought care from the author between 1979 and 1990 (mean year of last clinical visit with author was 1987). A diagnosis of TMPDS was the sole criterion for inclusion in the study. Less than 20%of the sample said that they considered the disorder gone, approximately 36% said the disorder was under control or in remission, and nearly 45% said that the disorder was still active. Duration Even though chronic cases may have difficulty pinpointing the onset of their disorder, they frequently report a similar historical pattern. They recall brief episodes of facial pain during their teens; during their 20s the episodes become more frequent and last longer. The mean age of onset was 32 years old in one study of chronic cases.51The age should not be confused with the mean age for research samples reported in many studies. The latter age is closer to 40 years old. Chronic cases are more likely to be represented in research studies. Most data on duration comes from patients entering specialty clinics. These samples add an additional potential for bias. Patients acquire information from clinicians that may alter the way they gauge duration. For example, patients often tell clinicians that their TMPDS started following tooth grinding.” Careful questioning discloses that many TMPDS patients report that they learned that they grind their teeth from their treating clinician. When clinicians endorse the , ~ ~can exert a strong tooth-grinding original model of TMPDS as most d 0 , 3 ~they

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influence on their patient’s beliefs. Many patients believe that if they suffer from TMPDS they must have initiated the syndrome while under stress when they started grinding their teeth. Because of such factors, self-report is a problematic method for assessing duration. Other patients, sensitive to the pejorative labeling associated with spontaneous or insidious onset, chose to ascribe the onset to a physical event. Probably the period preceding the beginning of care seeking is often reported as the date of onset. If this were so, the validity of much of the data on onset requires careful study. Prior Treatment and Aggravating and Relieving Factors

A great deal can be learned from responses to prior treatment. This is because most TMPDS cases have a history of multiple treatments by the time they arrive at a specialist’s office. As described in the section on duration, early episodes may be treated in a variety of ways under a variety of diagnostic rubrics. These interventions potentially provide a valuable guide to the clinician. For example, most patients with chronic TMPDS have been prescribed oral appliances. Controlled studies indicate that these devices have no advantage over placebo.8 Thus, devices can serve as an indicator of a patient’s placebo reactivity. A history of good response to one tricyclic antidepressant should alert the clinician to explore the same pharmacologic arena. The patient’s selfreport often proves useful as well in generating research hypotheses. For example, consistent with clinical speculation about the adverse effects of cold weather, a seasonal pattern was detected for TMPDS pain intensity.23Female patients also report more intense facial pain during premenstrual cycles. In fact, it was found that when compared with controls, chronic cases report much higher rates of premenstrual-related pains, not only in their face, but also breast tenderness or swelling, headaches, and joint or muscle pain.5zThoroughly question patients about past treatments and responses. View the patient’s self-report as a valuable source of information to predict future treatment response. Medical and Dental History

Numerous benignz’ and maligr1ant-5~conditions include facial pain as a symptom. TMPDS can be confused with disorders ranging from temporal arteritis and sinusitis to ear and tooth infections. When the symptoms of TMPDS are confused with those of a toothache, patients may undergo root canal therapy or tooth extraction. These two procedures can result in deafferentation neural44 The clinician should be alert to the possibility that a patient may simultaneously suffer from two chronic facial pain disorders. A thorough medical/dental history is essential to untangle such knotty problems. Psychiatric History

It is widely believed that personality flaws are closely associated with facial pain disorders.’* The underlying reasoning is often methodologically flawed, however. For example, even though it has been shown that, among samples of TMPDS patients, rates of depression are high compared with the general population,zz it is premature to conclude that depression is a cause of the disorder. It is also possible that depression is a consequence of facial pain or

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that both are the result of a common tertiary factor. Knowledge of only the rates of comorbidity of depression and facial pain is insufficient to determine the direction of a causal relationship. Other methodologic problems involve the source of the data. Depressed patients are likely to be over-represented as study subjects. Researchers reporting rates of depression or other psychological problems inevitably gather cohorts of chronic (not early onset) cases. Meanwhile, it is well established that depression is a risk factor for chronicity for many health conditions with known organic causes.15 Even in clinical practice, chronic patients are inevitably over-represented, leading even the most conscientious clinician to presume mistakenly that prevalence of depression is unusually high. A recent study by Dohrenwend and colleagues” nd that depression is a response to the stress of chronic facial pain. n other words, chronic facial pain is not a depressive equivalent of masked depression. Other research studies that observed patients with chronic TMPDS on a monthly basis for a full year provide strong support for the notion that there are psychological/stress-related components involved in the maintenance of Th4PDS.84Elevation in levels of distress in 1 month was associated with higher levels of pain in the next month; the reverse, pain l@adingto higher distress levels, was not observed. It may be that pain produces a more immediate increase in distress levels that went undetected with monthly observations. These findings do not, however, help identify the cause of TMPDS. Recall that one cannot assume that identical factors influence both the cause and maintenance of chronic TMPDS. It is important when questioning patients about their psychiatric history and symptoms of depression to tell them that depression did not cause their disorder, but may affect their recovery just the same.

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Social History Since EngeP7called for the “new medical model” that he termed biopsychosociul, the social component of his model has received relatively little attention among algesiologists (pain specialists). Even though social institutions, such as insurance companies and the Drug Enforcement Agency, regulate and influence the clinical decision process, pain medicine has to date failed to investigate thoroughly how clinical practice is inexorably bound in a social construction. By definition, chronic pain is a fairly constant experience of discomfort that accompanies its sufferer in all social situations. The invisibility of chronic pain provides the pain-afflicted person with a certain amount of discretion in deciding whether or not to allow the pain to become a relevant topic in any interaction. Pain patients practice a type of situational secrecy. For example, pain patients will reveal the pain when it serves them in socially sanctioned situations, such as interactions with health care workers, in an effort to receive treatment, or under certain circumstances with family and friends, thereby receiving support and understanding. These same people will conceal the pain if they judge that revealing it will be potentially damaging to their interests, such as when they seek or wish to maintain employment. On a more intimate level, they may decide to conceal the fact that vigorous sexual activity increases pain if they see this disclosure as damaging to a marriage or other relationship. Besides negotiating social interactions, chronic pain poses a potent social dilemma for those who experience it and for those who compose the social network of the sufferer. In the absence of an easily identifiable lesion, people with pain rely on biomedical experts to validate their claims of discomfort through laboratory tests and other medical procedures. Some sources of pain

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defy explanation by these investigations. When this happens, the person with pain is placed firmly in a situation ripe for pejorative labeling. These labels, in turn, lead pain sufferers to experience alienation and self-doubt, placing them in a situation vulnerable to potentially inappropriate but "legitimizing" treatments. It has been suggested that the quest for legitimation is the chief reason why people undergo procedures such as TMJ surgery.53 Thus, as part of the social history, the clinician should inquire as to how the pain has affected vocational and recreational functioning. One should also determine the patient's perception of former clinicians' causal models. Were they told their pain was stress induced? Did this result in stigmatization as a consequence? PHYSICAL EXAMINATION

After taking the history, a physical examination begins with a full face and profile view of the patient to check for swelling and asymmetry. Complaints of numbness or paresthesia and motor dysfunction should be followed by a neurologic consultation. Mandibular Movements

Ask the patient to open his or her mouth. Place a caliper or one end of a wooden tongue depressor between the midline of the upper and lower central incisors and record the measurement. Normal range is about 35 to 40 mm.".l 3 If marked restriction is evident, there are two possibilities. The more common is that painful muscles restrict motion. In this case, the patient can usually point to the painful site. Typically, the site of pain will be one or more of the major elevator muscles of mastication, the masseter or temporalis muscles (see Fig. 2). Because over 80% of TMPDS cases report unilateral pain, most patients will deviate to the left or right when attempting to open their mouths. The second cause of restriction can be due to restriction in TMJ motion. The latter may accompany muscle restriction, but in the case of non-TMPDS disorders, may be due to a localized synovitis, and more rarely, to a mechanical locking of the disk. Bony or fibrous ankylosis is also an uncommon cause of restricted range of mandibular motion. Improperly healed mandibular fractures and systemic disease (i.e., rheumatoid arthritis, ankylosing spondylitis) may account for painless restricted mandibular range that does not respond to active stretch.35 Those with clicking of the TMJ may show irregular or uncoordinated movements during mouth opening. The patient should be reassured about the benign nature of the clicking noises. Some patients who click can open their mouths to a range in excess of 55 mm. A wide range of mouth opening is rarely a source of clinical problems. Palpation

The masticatory muscles are examined bilaterally for size, rigidity, and the s~~ a detailed location of painful areas (see Fig. 2). Travel1 and S i m ~ n describe method for palpation of the face, head, neck, and shoulder muscles. Some advocate palpation of the internal and external pterygoid muscles intraorally. The mucous membranes in the mouth are tender to fairly light pressure. Because

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of this, there are major questions about the reliability and validity of intraoral palpation because of the potential for high rates of false-positive findings (k = 0.27). This is not a clinical problem because rarely do patients report pain solely in the internal and external pterygoid muscles. Palpate the lateral aspect of the mandibular condylar heads with the teeth together and the distal aspect with the teeth apart. This is done by placing the index finger just anterior to the tragus of the ears. Palpation by way of the external auditory meatus (placing the pinky finger in the ear) adds no additional information and is routinely quite unpleasant, even for someone without a tender TMJ. Auscultation

Much has been made regarding the significance of TMJ sounds. Two sounds, clicking and crepitus, can be detected by manual palpation or by stethoscope. Clicking sounds vary in amplitude so that they may be apparent only to the subject. Clicking is commonly associated with so-called disk derangements; however, arthrotomographic examination shows that displaced disks are not routinely accompanied by sounds.68Crepitus is not associated with TMPDS, but most commonly indicates degenerative changes. If is usually encountered in the elderly and in younger persons with a history of physical trauma to the mandible. Radiographic and Laboratory Examination

Criteria for TMPDS specifically rejects pathologic TMJ radiographic findings. Epidemiologic data report that so-called displaced disks are found in as many as 42% of those surveyed. Thus, the position of the disks as determined by radiographs should be considered an epiphenomenon with regard to TMPDS. There are as yet no known markers for TMPDS detectable by laboratory examination. TREATMENT

Multiple symptoms require multiple concurrent treatment. When considering treatment, bear in mind that there is a need for clinical trials, especially for many of the most widely employed TMPDS treatments. By the time the clinician has collected the history and performed the physical examination, he or she should also have a knowledge of the patient's explanatory model. It is often not enough to arrive at a diagnosis, correct as it may be, to achieve a successful therapeutic intervention with TMPDS patients. Like the twin serpents of Hermes' caduceus, treatment requires both knowledge and wisdom. The formula recited by the ill at the temple of Hermes was not "Hermes please heal me" but rather "Hermes which god do I pray to?" The school of Hippocrates viewed illness as caused by an imbalance of the endogenous humors (dyskrasia)." They distinguished many such humoral disharmonies. Because it was believed that each imbalance caused a distinctive pain, pain itself served as a useful diagnostic tool for the healer-priest. This concept has contemporary relevance in the treatment of chronic pain because of the need to

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individualize treatment by integrating the biologic findings with the patient’s explanatory ‘model. The following treatment strategy reflects the fact that neither the cause nor pathogenesis of TMPDS is known. In light of this, the guiding principle of therapy is that irreversible treatments, such as bite alteration or surgery of the TMJ, should be replaced by more conservative treatment. Physical Therapy: Exercises

Most patients with TMPDS suffer from mild (approx. 30 mm) to moderate (20-30 mm) restricted range of mandibular movements. This results from pain in the e vator muscles of mastication (e.g., masseter, temporalis, medial pterygoid). Se 5 ere restricted range of mandibular movements, or trismus (<15 mm), is uncom on in TMPDS. Exercises often reverse restricted mandibular range. The rate o improvement is usually correlated with chronicity. The following exercise is used to increase range of mandibular motion:

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1. Open and close mouth (wide) 10 times 2. Place fist under chin and open mouth against resistance three times 3. Repeat steps 1 and 2 a total of three times 4. Repeat this exercise sequence three to four times a day before meals

If ethyl chloride spray has been prescribed, the patient should use it before beginning the exercise. This exercise employs as its first step “active stretch,” and as its second step ”reflex relaxation.” The latter forces the elevators to tracting in response to an exaggerated force appearing to emanate relinquis in the depre sor muscles, but here actually the result of borrowed muscle strength from the arm. Assure the patient that the more force is applied without causing py at the chin, the less painful the mouth-opening motion will be. This is the same phenomenon observed when an outstretched arm rises after force has been applied downward and then is abruptly removed. Uncoordinated movements sometimes are associated with an audible clicking noise. This noise is annoying, even sometimes alarming, to the patient. The following describes the exercise found effective for the elimination or control of clicking noises:

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1. With mouth closed, place the front portion of the tongue on roof of mouth (against the palate) as far back as possible. Press the tongue hard against the roof (palate). Do not c u d the tongue. 2. While keeping the tongue pressed hard against the roof of the mouth, slowly open mouth and hold in place for 10 seconds. Remember that the tongue is positioned with the mouth closed and then the mouth is opened while keeping the tongue in place. 3. Rest for 10 seconds then repeat steps 1 and 2 six times before each meal (3 times per day) for the first 2 days. 4. After doing the exercise for 2 days, increase the number of times to 12 times before each meal (3 times per day) for a total of 36 times. 5. After doing the exercise 12 times (3 times per day) for 2 days, increase to 18 times before each meal (3 times per day) for a total of 54 times. 6. Patient should continue with exercises (18 times, 3 times per day) for the duration of time specified

A side effect is that at the beginning of the exercise period the patient may

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experience some soreness in front of the ear on the affected side. Once the exercise regimen has taken effect, this soreness should go away. The coordination exercise mobilizes the left and right external pterygoid muscles to contract simultaneously. Because these muscles insert on the TMJ disk, the maneuver will pull the disks forward and downward, thereby avoiding wedging one of the disks between the mandibular condyle and the eminence of the temporal bone. During jaw opening, this wedging action gives way to a rapid release accompanied by a clicking sound of various amplitude.

Vapocoolant Sprays

Prior to exercising, many patients apply vapocoolant sprays, chloroethane, or chlorofluorocarbon to the affected site. Instructions for the use of vapocoolant sprays are as follows:

1. Spray is highly flammable and should not be sprayed near any flame. 2. Make sure that the nozzle is fine or medium, depending on instructions. These are the only sizes that are acceptable. 3. Spray only in a well-ventilated room. Do not inhale. 4. Stand or sit while using spray; do not lie down, the spray is heavier than air

and will collect near the floor. 5. Cover eyes and ears while spraying. If spraying is done alone, place a piece of cotton in the ear of the side being sprayed. 6. Spray each side for 10 seconds. Pause for 15 seconds. Repeat 3 times. If both sides are to be sprayed, remember to spray each side a total of three times. 7. If exercises have been prescribed, remember .bo use the ethyl chloride spray before starting the exercise. 8. Spray may be used anytime during acute-painful episodes. Some patients can use the spray themselves, but most need assistance. The topical anesthetic reduces pain, thus permitting more efficient muscle stretching.77Written instructions are provided to patients. IM Injections

The local injection of tender points74is well established.” Routinely, local anesthetics, such as 2% lidocaine hydrochloride (duration, 1 hour) or 0.5% bupivacaine hydrochloride (duration, 2 to 3 hours), are employed. Routinely, 25-gauge, 5/8 inch needles are used. Relief may last initially only coincident with the duration of the anesthetic; however, with repeated injections, relief is often sustained for long periods. Local corticosteroid IM injection, usually in combination with a local anesthetic, was introduced in the early 1950s. Thirty years of experience finds that this therapy is still controversial. Conclusions regarding the effectiveness of steroids suffer from a paucity of controlled Variables such as multiple routes of administration, drugs, dose, duration, and disorder contribute to lack of knowledge. Nevertheless, Gray and colleagues27and the author’s experience indicate that local corticosteroids reduce pain and improve function in many patients with TMPDS. IM therapy can reduce reliance on systemic analgesics and anti-inflammatory drugs. Selected patients can enjoy a better quality of life

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as a consequence of the appropriate use of local steroids. With careful use, complications, such as infection, injury to neighboring structures, and undesirable systemic effects, are rare. Improvement from IM steroid/anesthetic therapy generally begins within 24 hours and may persist initially for as much as 1 week. Considering the chronic nature of TMPDS, this treatment meets the criteria of safe, effective, brief, and economic management. In one study, 73% of the 436 patients with TMPDS were treated with local injections of cortic~steroids.~" No known complications were reported among those receiving the steroid/anesthetic therapy. The following steps can be used in most cases. Fill the 3-mL, 25-gauge, 5/8 inch syringe with 0.5 mL (2 mg) of dexamethasone sodium phosphate, 1 mL 2% lidocaine, and 1.5 mL of 0.5% bupivacaine to make a total of 3 mL of solution. The author almost always sprays the area to be injected with chloroethane (ethyl chloride) far about 5 seconds or until the skin just starts to acquire a white coating. Then immediately insert the needle into the tender point. Do not move the needle about, but inject slowly. Intravenous injection is easily avoided by routine aspiration. Always aspirate. Depending on the number of injection sites, more syringes may be necessary. The additional syringes should contain only lidocaine and bupivacaine. Between one and six IM injections with an average of three injections per patient visit are routinely used. With exceptions, visits are scheduled at least 1 week apart. Vasoconstrictor drugs, such as epinephrine, are not ordinarily used; however, selected patients (about 10%) benefit from the long-lasting local anesthetic effect vasoconstrictor drugs provide. Selection of such patients comes with knowledge of the individual patient and medical status. See Figure 2 for an indication of the most common sites of needle entry for TMPDS cases. A detailed atlas is available illustrating the injection technique for each muscle involved in TMPDS.77 Bite Adjustment

Many TMPDS cases undergo dentally focused treatments; however, controlled studies fail to assign a significant role to dental occlusion or missing teeth in the cause or maintenance of TMPDS.65,6q These dental treatments range from bite adjustments carried out on the natural teeth to extensive prosthetic dental reconstruction (caps and bridgework). Other common treatments include oral appliances and orthodontic movement of teeth.65, Control groups have demonstrated that many people have missing teeth, malocclusions,2xand grind their teeth at night, but do not suffer from face pain, and vice versa.54Nevertheless, the traditional relationship between TMPDS and dental treatment remains strong. Patients with TMPDS report that their physicians frequently referred them to dentists by implication sanctioning a dental form of treatment. A note of caution should be sounded regarding bite adjustment or, as it is sometimes called, bite coruection. Bite adjustment commits a subset of patients to a permanent state of discomfort and distress because they cannot adapt to their altered bite. The complex anatomy of the biting surfaces of teeth is for all practical purposes nonreproducible, even when records of the teeth in the form of dental molds are available. These sufferers seek out dentist after dentist in a vain attempt to have their bites restored. They can be diagnosed once the pattern of care seeking for bite correction appears. Counsel here consists of discouraging them from pursuing a succession of invariably unsuccessful treatment^.^^ Far from bizarre, somatosensory experiences corresponding to the sensation that

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one's bite is not correct are almost universal. Most people who have undergone restorative dental treatment are familiar with the delicate perceptual assessments associated with the final adjustments of even a single dental filling. lntraoral Appliances to Counter Tooth Grinding

Given the overwhelming clinical acceptance that tooth grinding plays a large role in TMPDS,33,39 treatment is often directed at interrupting the hyperactive muscle activity that is believed to be a consequence of grinding. This is thought to be achieved through the use of occlusal appliances, such as bite guards or occlusal splits. Oral appliances have been widely advocated6 and are the most widely used treatment for TMPDS even though there is no evidence that they are e f f e ~ t i v e . ' ~In, ~fact, ~ as with many other objects placed in the mouth (i.e., pencils, pipes, and chewing gum), when appliances are worn, people tend to chew them. Epidemiologic data cast some doubt on the role of tooth grinding or bruxism in TMPDS. In particular, men have higher tooth attrition scores7oeven though women more often show signs and symptoms of TMPDS. Many patients with TMPDS do not grind, and many habitual tooth grinders do not report symptoms of TMPDS. Several controlled clinical trials found that occlusal appliances are no more effective than placebo at reducing the pain associated with TMPDS.8 Despite their widespread use, an evidence-based medicine approach does not support the use of oral appliances. Oral Drug Treatment

When evaluating studies on the effectiveness of medications, recall that the pain intensity associated with TMPDS varies widely within relatively short periods of time. This makes it difficult to tell whether a reduction in pain is caused by a prescribed medication or reflects instead the normal variation of pain for the Conclusions regarding treatment efficacy require longterm observation. NSAlDs

The few well-controlled studies indicate that, in the case of TMPDS, daily use of NSAIDs provides little benefit in relation to the risk of well-known sideeffects.*OA 4-week trial of ibuprofen 2400 mg per day proved no more effective than placebo." The same lack of effect was documented with piroxicam 20 mg daily.24Only relatively few patients with TMPDS benefit from the long-term use of NSAIDs. Patients, however, report short-term relief with high doses of NSAIDs. Opioids and Narcotic Analgesics

There are few controlled studies to guide the clinician; therefore clinical experience with tolerance, addiction, and physical dependence is extremely important.63The chronic administration of opioids has been successfully employed in otherwise recalcitrant cases. Success is measured by a report of a decrease in pain intensity, the achievement of a steady-state dose, and improve-

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ment in the patient’s vocational or social activity. Careful patient selection for opioid therapy is critical. The clinician should carefully select chronic pain cases for whom other treatments have failed to control their pain adequetly. Those patients should also be chosen who pose little risk of developing an addiction (e.g., no history of licit or illicit drug addiction, employed, no character disorder, and cognitively capable of entering into an agreement with the clinician regarding the parameters of narcotic use and abuse). Clinicians should be acquainted with the distinction between addiction and physical dependence. The selection of opioid, dose, and route of administration must be made on a case-by-case basis. Oral drugs include sustained release morphine, meperidine, and butalbital in addition to aspirin and caffeine. Transdermal fentanyl is effective in selected cases. Intranasal, or so-called sphenopalatine, ganglion blocks showed cocaine to be superior to both lidocaine (active placebo) and saline (inactive placebo) in the relief of TMPDS pain.so The intranasal route of drug administration is undergoing renewed research interest. Antidepressants

Antidepressant drugs are effective in the treatment of a wide variety of pain disorders, including TMPDS. Studies suggest that these drugs act independently of an antidepressant role as evidenced by their effectiveness at low doses (mean 23.6 mg for pain versus mean 129 mg for depres~ion).~’ The two most widely effective and studied antidepressant drugs for the relief of pain are amitriptyline and imipramine. Doses begin as low as 10 mg at bedtime and, if necessary, are gradually raised in 10-mg increments to 30 to 40 mg. Analgesic effects generally occur within a few days. The main complaints of patients are sedation, constipation, and dry mouth. Clinical experience with the newer generation of selective serotonin re-uptake inhibitor (SSRIs) class of antidepressant drugs indicates that they should be avoided in TMPDS. Anecdotal reports from numerous TMPDS cases suggest agitation may result from SSRIs, even at low doses. Citalopram, an SSRI, was not found to differ from placebo in the treatment of fibromyalgia.61There is older literature establishing the efficacy of monamine oxidase inhibitor drugs (phenelzine, tranylcypromine) in the treatment of orofacial pain.38Dietary restrictions and side effects associated with the use of these drugs have limited their acceptance. Muscle Relaxants and Minor Tranquilizers

In the short-term, diazepam and related drugs frequently result in effective relief of muscle spasm.I0Long-term use of these mostly benzodiazepine derivatives may result in tolerance and increasing escalation of dose with troublesome side effects. Unlike the case with opioids, it is more difficult to maintain patients on a steady dose of a benzodiazepine; however, many patients with TMPDS find various degrees of relief from benzodiazepine derivatives on a relatively low (diazepam [Valium], 5 mg bid; clonazepam [Klonopin], 0.5 mg bid or tid) dose and do not escalate their intake. Surgery

Although considerable controversy surrounds the indications for surgery, as many as 5% of patients treated for TMPDS undergo surgery involving the TMJ.lZOn June 4, 1992, the congressional committee responsible for overseeing

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the Food and Drug Administration and the National Institutes of Health conducted hearings that focused on the high rates of morbidity associated with TMJ surgery, particularly those surgeries that employ alloplastic The evidence presented to the committee confirmed that neither the safety nor the efficacy of many types of TMJ surgery had been established. Surgery of the TMJ may be indicated in cases of tumor or ankylosis. Fortunately, tumors are rare, and true TMJ ankylosis is also rare and easily identified. There are few indications for open joint surgery, such as condylotomy, diskectomy, and alloplastic or autogenous replacements and grafts, given its high rates of morbidity? Even less invasive procedures, such as arthroscopy, have not yet had clinical trials done to argue that their benefit is worth the potential risk.2,31, 78 In any case, these surgical procedures do not represent alternative treatment routes for most clinicians. The view traditionally held by oral surgeons, that failure of more conservative treatments is one indication for ~urgery,2~ does not appear to be warranted given the high rates of morbidity and the lack of demonstrated efficacy of surgery. SUMMARY A stepwise method for treating TMPDS is presented. Step 1-start patient on a regimen of chloroethane or chlorofluorocarbon spray and exercise. Step 1A-if a clicking joint is the chief complaint, start with click exercise. Step 1B-if restricted mouth opening is the chief complaint, start with range of motion exercise; employ exercises sequentially, not simultaneously. Step 2-if pain is moderate to severe, start with amitriptyline 10 mg at bedtime, increasing the dose in 10-mg increments to 40 mg. Step 3-for nonresponders, add injections of tender points with lidocaine and consider a trial of a different tricyclic. Step &for nonresponders, consider a trial of tender point injections combining dexamethasone with local anesthetic. Start by injecting the three most painful tender points with 0.5 mL of a solution of 1 mg of dexamethasone combined with two thirds bupivacaine and one third lidocaine to reach the desired volume. Repeat injections, varying the sites as required. Do this once weekly for 4 to 6 weeks for an adequate trial. This regimen can be continued for an extended period of time with appropriate precautions in place. The value of judgment-free psychosocial support cannot be overemphasized. Patients with TMPDS are faced with long-term problems of pain management. An understanding clinician can provide the sustained support required to prevent the cycle of ever more invasive treatments with their potential for harm. ACKNOWLEDGMENTS I wish to thank Dr. Karen Raphael and Rochelle Stem, Esq., for their comments on prior drafts of this paper.

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Address reprint requests to Joseph J. Marbach, DDS Department of Oral Pathology, Biology and Diagnostic Services University of Medicine and Dentistry of New Jersey 110 Bergen Street University Heights Newark, NJ 07103-2400