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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 3  |  Page : 210-216

Miseries and remedies of myofascial pain dysfunction syndrome: Comparative study


1 Department of Oral Medicine and Radiology, Career Post Graduate Institute of Dental Sciences, Lucknow, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Pacific Dental College, Udaipur, Rajasthan, India
3 Department of Conservative Dentistry and Endodontics, Career Post Graduate Institute of Dental Sciences, Lucknow, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences and Hospital, Mangalore, Karnataka, India

Date of Submission09-May-2018
Date of Acceptance18-Jul-2018
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Supratim Tripathi
Department of Conservative Dentistry and Endodontics, Career Post Graduate Institute of Dental Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_76_18

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   Abstract 


Background: Myofascial pain dysfunction syndrome (MPDS) has been recognized as the most common, nontooth-related chronic orofacial pain condition that confronts dentists. A variety of therapies have been described in literature for its management.
Objectives: This study is a prospective study carried out to evaluate the efficacy of occlusal splint therapy and compare it with transcutaneous electrical nerve stimulation (TENS) in the management of MPDS.
Materials and Methods: Sixty patients who reported to the Department of Oral Medicine and Radiology, Pacific Dental College, Udaipur, since September 2009, in the age range of 17–55 years were included in the study and were randomly assigned to two equally sized groups, A and B. Group A patients received TENS therapy, whereas Group B patients received soft occlusal splint therapy. All the patients were evaluated for pain using visual analog scale (VAS), maximum comfortable mouth opening, temporomandibular joint (TMJ) clicking, and tenderness during rest and movement, as well as for the number of tender muscles at the time of diagnosis, after the first week of initiation of therapy, and every month for 3 months of follow-up.
Results: There was a progressive decrease in VAS, number of tender muscles, TMJ clicking, and tenderness with various jaw movements, and there was a significant improvement in mouth opening in patients on occlusal splint therapy during the follow-up period when compared with TENS therapy group.
Conclusion: Occlusal splint therapy has better long-term results in reducing the symptoms of MPDS. It has better patient compliance, has fewer side effects, and is more cost-effective than TENS therapy; hence, it can be chosen for the treatment of patients with MPDS.

Keywords: Myofascial pain dysfunction syndrome, occlusal splint therapy, transcutaneous electrical nerve stimulation therapy


How to cite this article:
Tripathi P, Mathur H, Tripathi S, Saxena VS, Ahmed J. Miseries and remedies of myofascial pain dysfunction syndrome: Comparative study. J Indian Acad Oral Med Radiol 2019;31:210-6

How to cite this URL:
Tripathi P, Mathur H, Tripathi S, Saxena VS, Ahmed J. Miseries and remedies of myofascial pain dysfunction syndrome: Comparative study. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Oct 14];31:210-6. Available from: http://www.jiaomr.in/text.asp?2019/31/3/210/268280




   Introduction Top


The temporomandibular joint (TMJ) forms one of the most fascinating and complex synovial systems in the body. Movements of the TMJ are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently.[1] Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components.

Evidence indicates that temporomandibular disorders (TMDs) are most prevalent between 20 and 40 years of age and they predominantly affect women. The reason why women make up the majority of patients presenting for treatment is still unclear. In a community-based study, a greater likelihood of developing TMD was found if oral contraceptives were used and in women more than 40 years of age if estrogen replacement was used.[2]

In 1934, Costen first described a syndrome that included facial and head pain and TMJ dysfunction, which was known as TMJ pain dysfunction syndrome. Over the years, several diagnostic terms have been suggested by various authors for musculoskeletal disorders of the temporomandibular region, reflecting the different theories of etiology probably responsible for the various signs and symptoms presenting in the patients. The term myofascial pain dysfunction syndrome (MPDS) was initially coined by Laskin in 1969.[3] Even though the condition is common, it is not well understood by most dental practitioners. The reason is probably related to the diversity of views expressed and a difficulty in comprehending its natural history and symptomatology.

The signs and symptoms of MPDS vary, but generally the patient will complain of one or more of the following: pain in the region of the TMJ and mandibular elevators, tenderness in the region of one or both joints, TMJ sounds (clicking or crepitation), restricted jaw opening, disturbed chewing patterns, and locking of the jaw.

Muscle pain is one of the most common presenting symptoms and primarily involves the jaw muscles, but sometimes cervical muscles are also involved. Pain may radiate over the ipsilateral side of the face, jaw, and neck. Headaches related to MPDS is often caused by muscular tension of the jaw muscles.[2]


   Materials and Methods Top


Subjects

This prospective study was conducted in the Department of Oral Medicine and Radiology, Pacific Dental College and Hospital Udaipur. Subjects were selected from a consecutive series of patients with MPDS from the Department of Oral Medicine with approval of protocol from the institutional ethical committee. All procedures were in accordance with the ethical standards of the responsible committee.

Inclusion and exclusion criteria

The diagnosis was made based on the signs and symptoms of MPDS, as outlined by Laskin, that is,

  • Unilateral, dull pain in the ear or preauricular region that is commonly worse on awakening.
  • Tenderness of one or more muscles' mastication on palpation.
  • Limited or deviation of mandible on opening
  • Clicking or popping noise in TMJ.


Patients with newly diagnosed MPDS satisfying Laskin's criteria were included in the study.

The following patients were excluded from the study:

  • Patients who were unwilling or unable to participate in the study and attend all planned follow-up evaluation for any reason.
  • Patients with occlusal disharmony, taking orthodontic treatment, and undergoing occlusal corrections.
  • Patients suffering from any form of arthritis affecting TMJ such as osteoarthitis and rheumatoid arthritis confirmed using appropriate radiographs and blood investigations.
  • Patients with internal disk derangements.
  • Patients suffering from psychological disorders and under treatment from a psychiatrist for pain in the TMJ region.


Screening procedure

A total of 60 patients diagnosed with MPDS were selected for the study and divided into two groups of 30 each based on different treatment modalities. These groups were subsequently subdivided into two subgroups of 10 patients each according to the visual analog scale (VAS).

A detailed history of each patient was recorded at the time of diagnosis regarding onset, duration, and progress of symptoms. Pain characteristics such as type, nature, and severity were noted. Pain response to jaw activities such as mastication, phonation, and deglutition were also recorded.

Intensity rates of pain were recorded on a VAS, 10-mm long continuum. The extremes were labeled as no pain and worst possible pain. Following history and subjective assessment of VAS, maximum comfortable mouth opening and thorough examination of TMJ and the muscles of mastication were done [Figure 1].
Figure 1: Diagnostic instruments

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TMJ was palpated from the lateral and posterior aspects. Clicking and jaw deviation during opening and closing were assessed. Joint tenderness at rest and during jaw movements (opening, closing, right lateral, left lateral, protrusive, and retrusive) was done. Muscle tenderness was assessed by means of digital palpation of accessible muscles, resistance testing, and functional manipulation of muscles. The tenderness in the muscle was recorded as being present or absent.

Group assignment

Group A consisting of 30 patients (three subgroups of 10 patients each) received transcutaneous electrical nerve stimulation (TENS) with an intensity of 1–8 V, 9–16 V, and above 17 V, respectively, based on their VAS scores for 10 min. The total period of treatment varied from 5 to 7 days. Patients were made to sit on the dental chair. The electrodes were placed over the area of maximum muscle tenderness. The machine was switched on and the intensity was increased slowly to ensure that pain does not arise because of passage of electric current [Figure 2] and [Figure 3].
Figure 2: Lateral view of the patient

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Figure 3: Transcutaneous electric nerve stimulation machine

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Group B comprised 30 patients (three subgroups of 10 patients each) treated with occlusal splint therapy to be done everyday for 4, 6, and 12 h, respectively, depending on their VAS scores, for a period of 3 months. Patients were instructed to wear the splint at night to take care of parafunctional habits, if any. In both the groups, subjective and objective assessments were evaluated at the time of diagnosis, after the first week of initiation of therapy, and every month for 3 months of follow-up.

Fabrication and adjustment of the occlusal splint

An alginate impression of the maxillary and mandibular arches was made. A soft occlusal splint was fabricated using Biostar vaccum former [Figure 4] from a 3-mm-thick, soft polyvinyl sheet. The splint was then separated from the cast with a laboratory knife/scissors, the edges were smoothed, and the palatal area was removed. The splint was then disinfected with 2% gluteraldehyde and placed in the patient's mouth to check for retention [Figure 5]. A carbide bur was used to remove the excess material from the imprint to develop the desired occlusal pattern. The soft splint was then polished with pumice, disinfected, and the appliance was then placed in the patient's mouth [Figure 6].
Figure 4: Biostar vacuum former

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Figure 5: Frontal view of occlusal splint

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Figure 6: Biostar polyvinyl sheet with maxillary cast

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Statistical analysis

The VAS scores [Table 1], number of tender muscles [Table 2], TMJ tenderness, TMJ clicking, maximum comfortable mouth opening [Table 3], and within the groups were compared with the help of the analysis of variance test. P < 0.05 was considered to be significant.
Table 1: Comparison of visual analog scale of Groups A, B, and C at the time of diagnosis and during follow-up using ANOVA

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Table 2: Comparison of muscle tenderness of Groups A, B, and C at the time of diagnosis and during follow-up using ANOVA

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Table 3: Comparison of mouth opening of Groups A, B, and C at the time of diagnosis and during follow-up using ANOVA

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   Results Top


In the mild group, VAS score for pain intensity showed significant reduction in Group A (TENS therapy) than that in Group B (occlusal splint therapy). The number of tender muscles, TMJ tenderness, and TMJ clicking showed significant reduction in Group B compared with that in Group A, but mouth opening showed the same level of improvement in Groups A and B during 3 months of treatment follow-up.

In the moderate group, VAS scores for pain intensity, number of tender muscles, TMJ tenderness, and TMJ clicking showed significant reduction in Group B compared with Group A, [Table 4] but mouth opening showed the same significant reduction in Groups A and B and showed the same improvement during the 3 months of treatment follow-up.
Table 4: Comparison of temporomandibular joint clicking of Groups A, B, and C at the time of diagnosis and during follow-up using ANOVA

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In the severe group, VAS scores for pain intensity, number of tender muscles, TMJ clicking, and TMJ tenderness showed [Table 5] significant reduction in Group B compared with that in Group A, but mouth opening showed improvement in Group A during the 3 months of treatment follow-up when compared with Group B.
Table 5: Comparison of temporomandibular joint tenderness of Groups A, B, and C at the time of diagnosis and during follow-up using ANOVA

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   Discussion Top


Various treatment modalities for TMD have been tried and tested over time. Choosing a specific conservative treatment modality for patients with MPDS depends on clinicians' expertise, patient presentation, and elimination of possible etiologic factors.

This study evaluates the efficacy of occlusal splint therapy in the management of MPDS in comparison to TENS therapy. In this study, in the mild group, 50% of the patients in Group A had complete remission in VAS scores, and the remaining 50% had significant reduction. About 30% of the patients in Group B had complete remission in VAS scores, and the remaining 70% had significant reduction. Tsuga et al.[4] concluded that 87% of their patients had reduced TMJ pain; VAS reduction was seen in 50% and clicking was reduced in 70% of the patients in response to occlusal splint therapy when patients were followed up for 4 weeks.

TMJ clicking in Group B also showed significant reduction when compared with Group A during the 3 months of treatment follow-up. In the moderate group, 20% of the patients in Group B had complete remission, and the remaining 80% had significant reduction. Patients of Groups A and B also had significant reduction. Around 10% of the patients of Group A and 20% of the patients of Group B had complete remission in TMJ clicking, but there was no significant reduction noticed in Group A patients. Block et al.,[5] in their study in 1978, also found that after 6 weeks of using soft splints, 74% of the patients had complete or almost complete remission of their TMD symptoms. Kovaleski and De Boever [6] have also shown significant reduction in clicking in response to occlusal splint therapy when patients were followed up for 2 months. Harkins et al.[7] found that 74% of the patients with soft splints had reduction in facial myalgia and reduction in or elimination of TMJ clicking. Madani and Mirmortazavi [8] measured in terms of the VAS score, and the mean improvement was 48 ± 25.26 mm (81.35%) for group I (anterior positioning splint therapy), 24.50 ± 21.46 mm (40.16%) for group II (physical therapy), and 40.71 ± 34.30 mm (75.99%) for group III (combined therapy of anterior positioning splint and physical therapy).

In this study, in the mild group, 2 of 10 patients in Group A had complete reduction in muscle tenderness and the remaining 8 had significant reduction; 6 of 10 patients in Group B had complete reduction in muscle tenderness and the remaining 4 had significant reduction. In the moderate group, 3 of 10 patients in Group A had complete reduction in muscle tenderness and the remaining 7 had significant reduction; 6 of 10 patients in Group B had complete reduction in muscle tenderness and the remaining 4 had significant reduction. In the severe group, 3 of 10 patients in Group A had complete reduction in muscle tenderness and the remaining 7 had significant reduction; 9 of 10 patients in Group B had complete reduction in muscle tenderness and the remaining 1 had significant reduction.

In the mild group, 3 of 10 patients in Group A had complete reduction in TMJ tenderness and the remaining 7 had significant reduction; 7 of 10 patients in Group B had complete reduction in TMJ tenderness and the remaining 3 had significant reduction. In the moderate group, 3 of 10 patients in Group A had complete reduction in TMJ tenderness and the remaining 7 had significant reduction; 5 of 10 patients in Group B had complete reduction in TMJ tenderness and the remaining five had significant reduction. In the severe group, 4 of 10 patients in Group A had complete reduction in TMJ tenderness and the remaining 6 had significant reduction; 6 of 10 patients in Group B had complete reduction in TMJ tenderness and the remaining 4 had significant reduction. Keng [9] found that 83.3% of patients showed muscular pain and tenderness around the joint area in response to occlusal splint therapy during the 3-month follow-up.

Kovaleski and De Boever [6] have also shown significant reduction in clicking, TMJ, and muscle tenderness in response to occlusal splint therapy when patients were followed up for 2 months. Tsuga et al.[4] concluded that 87% of their patients had reduced TMJ pain; VAS reduction was seen in 50% and clicking was reduced in 70% of the patients. Harkins et al.[7] found that 74% of the patients with soft splints had reduction in facial myalgia and reduction in or elimination of TMJ clicking. This will relax the elevator and positioning muscles and contribute to the reduction of abnormal muscle hyperactivity.[10]

In the mild group, 7 of 10 in Group A and 9 of 10 patients in Group B had improvement in mouth opening and the remaining had no improvement. In the moderate group, 7 of 10 patients in Group B, 8 of 10 patients had improvement in mouth opening and the remaining had no improvement. In the severe group, 7 of 10 patients in Group A and 9 of 10 patients in Group B had improvement in mouth opening and the remaining had no improvement. Suvinen and Reade [11] have also shown a 7.4-mm improvement in mouth opening after splint therapy. Occlusal splint therapy decreased the pain and tenderness in the muscles and joints of the patients in this study, apparently allowing an increase in their maximal mouth opening. Núñez et al.[12] reported significant improvement in the range of motion for both low-level laser therapy (LLLT) and TENS therapy observed immediately after treatment. Comparing the two methods, the values obtained after LLLT were significantly higher than those obtained after TENS.

In our study, the occlusal splint therapy did not result in any significant reduction in the VAS scores immediately after 7 days of treatment, but significant and progressive reduction in VAS scores was seen in the third (last) month of treatment follow-up. This indicates that the occlusal splint causes a slow and steady improvement in TMJ symptoms in TENS therapy. This is in agreement with the conclusions of Raphael et al.,[13] who found that occlusal splints had decreased the VAS scores and the number of painful muscles during a 6-week follow-up study in patients with myofascial pain. The results showed a progressive decrease in VAS scores, the number of tender muscles, TMJ tenderness, and TMJ clicking.


   Conclusion Top


The conventional soft occlusal splint therapy is a much safer and effective mode of a conservative line of therapy in comparison to TENS therapy in patients with MPDS. The advantages of occlusal splint therapy include reversible therapy, better results, fewer side effects, cost-effectiveness, and better patient compliance than TENS therapy. The occlusal splint may also have placebo effects. This study concludes that occlusal splint therapy shows better results when compared with TENS in the management of MPDS over a long-term period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Okeson JP. Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003. p. 260.  Back to cited text no. 1
    
2.
Bruce Blasberg, Eli Eliav, Martin S. Greenberg, Orofacial pain and temporomandibular disorders. Temporomandibular Disorders: Burket's Oral Medicine Diagnosis and Treatment. Part. 3. 10th ed., Ch. 10. 2008, 257-87.  Back to cited text no. 2
    
3.
Seligman DA, Pullinger AG. The role of intercuspal occlusal relationships in temporomandibular disorders: A review. J Craniomandib Disord 1991;5:96-106.  Back to cited text no. 3
    
4.
Tsuga K, Akagawa Y, Sakaguchi R, Tsuru H. A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for specific symptoms of temporomandibular joint dysfunction syndrome. J Prosthet Dent 1989;61:610-3.  Back to cited text no. 4
    
5.
Block SL, Apfel M, Laskin DM. The use of a resilient rubber bite appliance in the treatment of MPD syndrome. J Dent Res 1978;57:92.  Back to cited text no. 5
    
6.
Kovaleski WC, De Boever J. Influence of occlusal splints on jaw postion and musculature in patients with temporomandibular joint dysfunction. J Prosthet Dent 1975;33:321-7.  Back to cited text no. 6
    
7.
Harkins S, Marteney JL, Cueva O, Cueva L. Application of soft occlusal splints in patients suffering from clicking temporomandibular joints. Cranio 1988;6:71-6.  Back to cited text no. 7
    
8.
Madani AS, Mirmortazavi A. Comparison of three treatment options for painful temporomandibular joint clicking. J Oral Sci 2011;53:349-54.  Back to cited text no. 8
    
9.
Keng SB. Myofacial pain dysfunction syndrome: A clinical study. Singapore Med J 1982;23:97-101.  Back to cited text no. 9
    
10.
Dylina TJ. A common-sense approach to splint therapy. J Prosthet Dent 2001;86:539-45.  Back to cited text no. 10
    
11.
Suvinen T, Reade P. Prognostic features of value in the management of temporomandibular joint pain-dysfunction syndrome by occlusal splint therapy. J Prosthet Dent 1989;61:355-61.  Back to cited text no. 11
    
12.
Núñez SC, Garcez AS, Suzuki SS, Ribeiro MS. Management of mouth opening in patients with temporomandibular disorders through low-level laser therapy and transcutaneous electrical neural stimulation. Photomed Laser Surg 2006;24:45-9.  Back to cited text no. 12
    
13.
Raphael KG, Marbach JJ, Klausner JJ, Teaford MF, Fischoff DK. Is bruxism severity a predictor of oral splint efficacy in patients with myofascial face pain? J Oral Rehabil 2003;30:17-29.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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