CRANIOMANDIBULAR FUNCTION A:ND DYSFUNCTTON

SECTION EDITOR
GEORGE A. ZARB

Diagnosis and treatment of myofacial

pain-dysfunction (MPD) syndrome
Daniel M. Laskin, D.D.S., M.S., and Sanford Block, D.D.S., LL.B.**
Medical College of Virginia, School of Dentistry, Richmond, Va., and University of Illinois, College of I)cntihtr, _
Chicago, 111.

M yofacial pain-dysfunction
psychophysiologic
(MPD) syndrome is a
disease that primarily involves the
muscles of mastication.* The condition is characterized
by dull, aching, radiating pain that may become acute
during use of the jaw, and mandibular dysfunction that
generally involves a limitation of opening.
Generally the condition involves only one side of the
face and, upon examination, tenderness can usually be
elicited in one or more of the muscles of mastication or
their tendinous attachments. Although headache is fre-
quently mentioned as a symptom, the only type of
headache that may be directly or indirectly part of the
syndrome is muscle spasm or tension headache, with
other types being coincidental findings. The same is true
for such complaints as diminished hearing, tinnitus,
burning tongue, and neuralgic pains. Although MPD
syndrome starts as a functional disorder, it can ultimate-
ly lead to organic changes in the temporomandibular
joint (TMJ) and the masticatory muscles, and even
cause possible alterations in the dentition.
MPD syndrome is believed to be a stress-related
disorder.*, * It is hypothesized that centrally induced
increases in muscle tension, frequently combined with
the presence of parafunctional habits such as clenching
or grinding of the teeth, result in muscle fatigue and
spasm that produce the pain and dysfunction. Similar
symptoms, however, occasionally can also result from
muscular overextension, muscle overcontraction, or trau-
ma (Fig. 1).
Women are affected by MPD syndrome more fre-
quently than men, with the ratio in various reports
ranging from 3:l to 5:l. 5,6 Although the condition can
occur in children, the greatest incidence appears to be in
the 20 to 40 years age group.
MAKING THE DIAGNOSIS
Because the cardinal signs and symptoms of MPD
syndrome are similar to those produced by many organic
*Professor and Chairman, Department of Oral and Maxillofacial
Surgery and Director of the TMJ and Facial Pain Research Center,
Medical College of Virginia, School of Dentistry.
**Assistant Professor of Oral and Maxillofacial Surgery, University of
Illinois, College of Dentistry; Director of Dentistry and Oral
Surgery. Swedish Convenant Hospital, Chicago, Ill.
problems involving the TMJ, as well as by a variety of
nonarticular conditions, the diagnosis of this syndrome
can be difficult, requiring a careful history and a
thorough clinical evaluation. Radiographs may also be
helpful. These may include periapical views of the teeth
and screening views (transcranial, transpharyngeal, or
panoramic) of the TMJs. If the screening views of the
TMJs show some abnormality, tomographic views arc
usually advisable. Arthrography can also be useful in
determining the position of the meniscus when an
internal derangement of the TMJ is being considered.
Depending upon the suspected condition, other radio-
graphic views of the head and neck, C:T scans, and
scintigraphy may be needed to establish a final diagno-
sis. In addition, certain laboratory tests may be helpful in
some instances These include the complete blood cell
count if an infection is suspected; serum calcium, phos-
phorous, and alkaline phosphatase measurements for
possible bone disease; serum uric acid determination for
gout; serum creatinine and creatine phosphokinase levels
as indicators of muscle disease; and erythrocyte sedimen-
tation rate, rheumatoid factor, and latex fixation tests for
suspected rheumatoid arthritis. Elec?romyography can
be used to evaluate muscle function. Psychologic evalua-
tion and psychometric testing are good research tools, but
have little diagnostic value other than determining the
presence of any associated abnormal behavioral charac-
teristics.
Two major groups of conditions must be considered in
the differential diagnosis of MPD syndrome: the nonar-
titular problems that can mimic MPD syndrome, and
the various pathologic disorders of the TMJ that may
sometimes also produce similar signs and symptoms.
Nonarticular problems include conditions that produce
pain resembling that of MPD syndrome (Table I) and
those that produce mainly limitation nf jaw opening
(Table II).
The pathologic conditions involving the TMJ are the
same as those that involve other joints of the body (Table
III). However, because in young patients the articular
surface of the mandibular condyle also serves as a
growth site, any pathologic condition involving the joint
that alters the condylar surface will also have an effect
upon mandibular and, subsequently, facial growth.
Thus, pathologic conditions occurring in this region

THE JOURNAL OF PROSTHETIC DENTISTRY 75


MUSCULAR
STRESS __t HY PERACTIVITY
MUSCULAk
Fig. 1. Etiology of myofacial pain-dysfunction (MPD) syndrome. (Modified from Laskin
DM: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969.)
manifest themselves differently than in other joints of the
body.
Because a large number of conditions can produce
signs and symptoms similar to those of MPD syndrome,
establishing an accurate diagnosis can be extremely
difficult at times. However, careful attention to the
details of history taking and physical examination, and
the use of this information as a guide to eliminating
unrelated conditions, can facilitate the process.
TREATMENT OF MPD SYNDROME
Management of MPD syndrome is founded on certain
basic principles that include the establishment of an
accurate diagnosis, gradual escalation of therapy, and
avoidance of irreversible forms of treatment. It is also
based on the clinicians understanding that MPD syn-
drome is a psychophysiologic disease and that the results
of treatment must be considered in the light of placebo
effects9-2and the contributions of a good doctor-patient
relationship. 13,14This means that treatment should be
geared toward management rather than a definitive cure
inasmuch as the causes of a psychophysiologic disorder
may be more difficult to eliminate than those of a disease
of microbiologic origin. Finally, the ability of patients to
understand and accept the psychophysiologic basis for
the disease is essential in their ultimately dealing with
the problem.
Several different treatments have been recommended
for MPD syndrome, ranging from structural alterations
to psychotherapy. The following is a discussion of
various therapeutic modalities that have been used
successfully by many clinicians in the management of
patients with MPD syndrome and have fulfilled the
requirement of not producing irreversible structural
76
LASKIN AND BLOCK
- Dental Irritation
FATIGUE
changes. This discussion will be followed by a treatment
plan explaining the proper use of these modalities.
Initial explanation of the problem
The first step in the management of patients with
MPD syndrome is to provide them with some under-
standing of their problem. Because patients often have
difficulty accepting a psychophysiologic explanation for
their disease, the initial discussion should deal with the
issue of muscle fatigue and spasm as the cause of the pain
and dysfunction, delaying consideration of stress and
psychologic factors until the condition has improved and
the patients confidence has been gained. Relating the
symptoms to specific masticatory muscles helps the
patient to understand the reason for the type and location
of the pain; for example, headache from the temporal
muscle, jaw ache from the masseter muscle, discomfort
when swallowing from the medial pterygoid muscle, and
earache from the lateral pterygoid muscle. Assuring the
patient that he or she does not have cancer or arthritis
can help relieve anxiety about the persistence of the
symptoms.
Therapeutic modalities
There are a number of simple yet effective things that
the patient can do at home to reduce muscle fatigue,
spasm, and pain, increase mandibular mobility, and
restore good masticatory function. These include proper
diet, the limitation of jaw movement, avoidance of
parafunctional habits, and use of heat and massage.
There are other specific treatment modalities that
require professional administration or prescription.
Therapy at home. The diet should be of a soft,
nonchewy character. Food should be cut into small
JULY 1986 VOLUME 56 NUMBER 1
DIAGNOSIS AND TREATMENT OF MPD SYNDROME

Table I. Differential diagnosis of nonarticular conditions mimicking pain of MPD syndrome

.-____ _____- ---_ ~. - ..~ ~-.-..---
Disorder Limitation Muscle tenderness Diagnostic features
Pulpitis No No Mild to severe ache or throbbing, intcrmlttent
or constant; aggravated by thermal changes;
eliminated by dental anesthesia; positive x-ray
findings
Pericoronitis Yes Possible Persistent mild to severe ache: diltigxliv
swallowing; possible fever; local
inflammation; relieved with dent,4 anesthesia
Otitis media No No Moderate to severe earache, pain cimstant,
fever; usually history of upper rt*+ratory
infection; no relief with dental arrcsthesia
Parotitis Yes No Constant aching pain, worse when eating;
pressure feeling; absent sallvar!, Itow. ear lobe
elevated; ductal suppuration
Sinusitis No No Constant aching or throbbing, w~~r;e when
change head position; nasal dis<hargtt; often
molar pain not relieved bv dent<)! anesthesia
Trigeminal neuralgia No No Sharp stabbing pain of shor; duratron: trigger
zone; pain follows nerve pathu.iv, older age
group; often relieved by denta! ant>sthesx
Atypical (vascular) neuralgia No No Diffuse throbbing or burning pain <>,tlong
duration; often associated autonc,m~c
symptoms; no relief with drntJ1 .lnrsthesia
Temporal arteritis No No Constant throbbing preauricu!ar JXIL~; arterl
prominent and tender; low grdd? fever: may
have visual problems, clcv,ltcsd ~~~drmentation
ra tr
Trotters syndrome Yes No Aching pain in ear, side of fact, I~~wer law;
(nasopharyngeal carcinoma) deafness; nasal obstruction ~:t~r.~l~-a!
lymphadenopathy
Eagles syndrome (elongated No No Mild to sharp stabbing pain in e,~r, throat,
styioid process) retromandible; provoked by swaiiowing,
turn,ng head, carotid comprc:ss;on, usually
posttonsillectomy, stylold pr<~ts-, longer than
2.5 cm

pieces so that excessive chewing is not necessary. Jaw
motion should be limited and wide opening, such as
when yawning, should be avoided. Yawning should be
consciously controlled or restricted by placing the hand
under the chin or by bending the head down so the chin
touches the chest.
Parafunctional habits, such as clenching or grinding
the teeth, should be avoided. Although patients are
usually aware of a grinding habit, many clench their
teeth unconsciously. They should be instructed to check
for clenching and to remember to keep their teeth apart
if they recognize such activity. Anterior splints that
prevent occlusion of the posterior teeth can also be used
to eliminate clenching and grinding, particularly during
sleep.O Other parafunctional habits such as fingernail
biting, lip biting, cheek biting, and holding pipes or
cigars in the mouth for prolonged periods must also be
avoided since these habits also can induce masticatory
muscle fatigue.
Heat and massage are beneficial to patients with
MPD syndrome. Moist heat applications should be used
for a half hour at least twice daily. These applications
should be placed over the involved masticatory muscles
for 10 minutes, followed by a S-minute pause, and then
reapplied two more times in the same manner. Between
heat applications, mild exercise using hinge motion
within the limit of pain may be used to maintain muscle
function. Massage using a moderate kneading motion
over the involvled area will also aid the return of venous
blood, lymph, and catabolites into the main circulation
and help reduce muscle pain and spasm.
Short-term medication. Because muscle spasm and
pain are part of the MPD syndrome, muscle relaxants
and analgesic drugs can help to resolve the problem.,
Spasm produces pain that in turn produces more spasm;
muscle relaxant drugs can interrupt this vicious cycle.
However, they are more effective if used in conjunction
with a pain-relieving medication. Generally, only a mild
analgesic is needed. If patients state that they require a
narcotic, drug dependency or a wrong diagnosis should
be considered. Examples of analgesics that may be used
effectively are: aspirin, 10 gr buffered or coated, three

THE IOURNAL OF PROSTHETIC DENTISTRY 77

 LASKIN AND BLOCK

Table II. Differential diagnosis of nonarticular conditions producing limitation of mandibular

movement
Muscle
Disorder Pain tenderness Diagnostic features

Odontogenic Yes Yes Fever; swelling; positive x-ray findings; tooth

infection tender to percussion; pain relieved and
movement improved with dental anesthesia
Nonodontogenic Yes Yes Fever; swelling; negative dental findings on
infection x-ray; dental anesthesia may not relieve pain
or improve jaw movement
Myositis Yes Yes Sudden onset; movement associated with pain;
areas of muscle tenderness; usually no fever
Myositis ossificans No No Palpable nodules seen as radio-opaque areas
on x-ray; involvement of nonmasticatory
muscles
Neoplasia Possible Possible Palpable mass; regional nodes may be
enlarged; may have paresthesia; x-ray may
show bone involvement
Scleroderma No No Skin hard and atrophic; mask-like faces;
paresthesias; arthritic joint pain; widening
of periodontal ligament
Hysteria No No Sudden onset after psychological trauma; no
physical findings; jaw opens easily under
general anesthesia
Tetanus Yes No Recent wound; stiffness of neck; difficulty
swallowing; spasm of facial muscles;
headache
Rxtrapyramidal No No Patient on antipsychotic drug or
reaction phenothiazine tranquilizer; hypertonic
movement; lip smacking; spontaneous
chewing motions
Depressed Possible No History of trauma; facial depression; positive
zygomatic arch x-ray findings
Osteochondroma No No Gradual limitation; jaw may deviate to
coronoid unaffected side; possible clicking sound on
process jaw movement; positive x-ray findings

times a day; acetaminophen, 650 mg, three times a day;
or propoxyphene (Darvocet-N 100) 1 to 2 tabs, three
times a day.
The benzodiazepines are the drugs most often pre-
scribed as muscle relaxants. These agents also have
tranquilizing properties that can be beneficial in reliev;
ing tension. The best known and most widely used
benzodiazepine is diazepam (Valium), which is pre-
scribed in the range of 2 mg three times a day to 5 mg
four times a day. l5 A gain, it should be taken in conjunc-
tion with an analgesic for the best effect. As an alterna-
tive to diazepam, meprobamate may be used in a dosage
of 400 mg three times a day. The use of drugs with only
muscle relaxant properties and no sedative or tranquil-
izing effects, such as carisoprodol (Soma) or methocarba-
ma1 (Robaxin), have generally not been successful for
the treatment of MPD syndrome.
Patients with long-standing MPD syndrome and
proven depression may benefit from the use of an
antidepressant drug. l6 These drugs have many autonom-
ic side effects that may discourage the patient from
taking them. The most commonly used antidepressant
drugs are the tricyclic antidepressants, of which amitrip-
tyline (Elavil) is the best example. It is generally
prescribed in an initial dose of 25 mg at bedtime and
gradually increased to 75 mg at bedtime. The beneficial
effects are derived from mood elevation and the drugs
analgesic properties. It should be used for at least 2
months because it may take as long as a month to reach
its maximum therapeutic effect. If it is necessary to
continue beyond this time, it is often better to place the
patient under a physicians care for the depression.
Because there are a variety of side effects that may
accompany the use of the antianxiety and antidepressant
drugs, as well as various medical contraindications to
their use, they should not be prescribed without famil-
iarity with these potential hazards.
Splint therapy. When the previously described forms
of home therapy have not been completely successful, or
there is a history or suspicion of a tooth clenching or
grinding habit, splint therapy should be considered.
Numerous types have been used but the Hawley-type

78 JULY 1986 VOLUME 56 NUMBER 1

DIAGNOSIS AND TREATMENT OF MPD SYNDROME

Table III. Differential diagnosis of temporomandibular joint disease

Disorder Pain Limitation Diagnostic features
Agenesis No Yes Congenital; usually unilateral; mandible
deviates to affected side; unaffected side
long and flat; severe malocclusion; often
ear abnormalities; x-ray shows iondylar
deficiency
Condylar hypoplasia No No Congenital or acquired; affected side has
short mandibular body and ra,mus. fullness
of face, deviation of chin; body of
mandible elongated and face fl,lt on
unaffected side; malocclusion; x-ray shows
condylar deformity, antegonial notching
Condylar hyperplasia No No Facial asymmetry with deviation of chin to
unaffected side; cross-bite malocclusion;
prognathic appearance; lower border of
mandible often convex on affected side;
x-ray shows symmetrical enlargement of
condyle
Neoplasia Possible Yes Mandible may deviate to affected side; x-rays
show enlarged, irregularly shaped condyle
or bone destruction depending on type of
tumor; unilateral condition
Infectious arthritis Yes No Signs of infection; may be part of systemic
disease; x-ray may be negative early, later
can show bone destruction; fluctuance may
be present; pus may be obtained on
aspiration; usually unilateral
Rheumatoid arthritis Yes Yes Signs of inflammation; findings in other
joints (hands, wrists, feet, elbows, ankles);
pos.1tive laboratory tests; retarded
mandibular growth in children; anterior
open bite in adults; x-rav shows bone
destruction; usually bilateral
Traumatic arthritis Yes Yes History of trauma; x-ray negative except for
possible widening of joint space; local
tenderness; usually unilateral
Degenerative Yes Yes Unilateral joint tenderness; often crepitus;
arthritis TM1 may be only joint involved, x-ray may
be negative or show condylar flattening,
lipping, spurring, or erosion
Ankylosis No Yes Usually unilateral but can be bilateral; may
be history of trauma; young patient may
show retarded mandibular growth; x-rays
show loss of normal joint architecture
Internal disk Yes Yes Pain exacerbated by function; clicking on
derangement opening, or opening limited to under 25
mm with no click; positive arthrographic
findings; may be history of trauma: usually
uni :ateral

upper anterior splint is probably the most effective
because it prevents occlusion of the posterior teeth and
thereby prevents most forms of parafunctional activity.
The anterior platform should be flat and nonguiding and
should produce minimal separation of the occlusal
surfaces (approximately 2 mm). The splint should not be
worn continuously since supereruption of the posterior
teeth can occur. Generally, it is worn at night and for 5
to 6 hours during the day. The specific periods of use
during the daytime hours depends on the history of the
symptoms. Usually it is worn in the afternoon and early
evening. The patient should be instructed not to dench
against the splint and to rest the teeth lightly against the
platform only when necessary.
When a Class 11 malocclusion exists, it will be
necessary to u.se a maxillary splint with full occlusal
coverage. This type of splint can also be used in patients
who grind but do not clench their teeth or in those who

THE JOURNAL OF PROSTHETIC DENTISTRY 79


must wear a splint 24 hours a day, because the occlusion
will remain stable. The platform must be flat so as not to
lock or guide the mandible into either an anterior or
retruded position. This is not a functional splint and
should not be worn during eating.
All splints must be adjusted periodically during treat-
ment to eliminate premature tooth contacts that may
occur as the masticatory muscles relax and return the
jaw and teeth to a more normal relationship.
Physical therapy. The various forms of physical
therapy recommended for use in patients with MPD
syndrome are directed at reducing muscle tension and
spasm and improving jaw function, and include ultra-
sound, electrogalvanic stimulation, and cryotherapy.
Ultrasound produces vibrations within the tissue that
cause particle collision and the release of energy. This
energy reaction results in the production of heat. The
physiologic effect of this deep heat and vibration is a
reduction in muscle tension and an increase in tissue
elasticity. There are also mild analgesic and anti-
inflammatory actions as a result of improved circula-
tion.
In MPD syndrome the treatment is used over the
masseter and the temporalis muscles. The sound head is
moved slowly to avoid excessive heat build up. A
maximal tolerable level is recommended and this is
adjusted according to the area of application. A tolerance
will develop during the treatment and greater intensities
may then be applied. The applications last 10 to 15
minutes and can be given twice daily. Muscle tenderness
usually resolves in 1 to 2 weeks. Care must be taken not
to apply this therapy when there is acute inflammation,
and it must not be used in patients with vascular
insufficiency, over malignant areas, over metallic
implants, or in patients with cardiac pacemakers.
High voltage electrogalvanic stimulation involves the
use of a monophasic, pulsed direct current applied
through an electrode placed on the skin over the involved
muscle. The muscle can be activated at frequencies
ranging from 4 to 80 pulses per second. Treatment is
usually applied for 10 to 15 minutes 2 to 3 times a week.
The electrical stimulation of the muscle increases circu-
lation, reduces pain and spasm, and increases resistance
to fatigue. It has been shown to be effective in improving
the range of motion and diminishing pain in patients
with MPD syndrome.19
The use of cold (cryotherapy) reduces tissue tempera-
ture, causes local analgesia, has anti-inflammatory
effects, and can diminish muscle spasm. The analgesic
effects are due to a decrease in end organ activity and
pain fiber conduction. In addition, the cold-mediating
nerve fiber input creates increased activity at,the spinal
gate and reduces the influence of the pain fibers. The
cooling effect also creates vasoconstriction and reduces
myoneural transmission and neuromuscular activity.
80
LASKIN AND BLOCK
The use of cold, or cryotherapy, in the treatment of
MPD syndrome is useful in the acute phases of the
disorder. A vapor-coolant svay (ethyl chloride or fluo-
rimethane) is applied over the involved masticatory
muscles. Because of the volatile nature of the sprays, care
must be taken to protect the eyes and ears. The bottle is
held 1 to 1% feet away from the target muscle and the
spray is applied in a circular motion for 10 seconds. The
spray is stopped when slight frosting appears on the
skin. Immediately after the application, a red area will
be present. The procedure is repeated two more times,
with a lo-second interval in between. The mandible is
then mobilized by gently stretching to the maximal
tolerated opening. Care should be taken not to produce
excessive pain during this exercise. The mandibular
range of motion should improve and the patient should
experience less pain and stiffness after the treatment.
The application should be repeated twice daily for 2 to 3
days. If no improvement is noted in this period, cryother-
apy should be discontinued.
Ice packs can also be beneficial in the acute phase of
MPD syndrome. The cold applications are used for 10
to 15 minutes, removed, and reapplied after 5 to 10
minutes. This can be repeated 3 to 4 times daily.
Moderate stretching exercise is instituted after the
treatment. As with the vapor-coolant sprays, the use of
ice packs also helps reduce pain and stiffness.
Relaxation therapy. Because MPD syndrome is
basically a problem related to increased muscle tension
and spasm, any technique designed to induce muscle
relaxation should be helpful. Among the modalities that
have proven to be effective are biofeedback,2,20 condi-
tioned relaxation,2x 22and hypnosis.23s24
Electromyographic biofeedback involves supplying the
patient with visual or auditory information about the
moment-to-moment contractile status of the muscle
being monitored. The patient then concentrates on
relaxing the muscle and, if effective, this is reflected by a
corresponding reduction in the level of the graphic
representation or the audible sound. The patient thus
learns to produce muscle relaxation. Although the proce-
dure concentrates on only one muscle at a time, learning
to reduce its activity has a generalized relaxing effect.
The auditory electromyographic biofeedback unit is
used by placing an electrode over the affected masticato-
ry muscle. The patient sits comfortably in a semireclin-
ing position. Earphones are placed on the patient and the
machine is adjusted to a beginning level. When the
patient clenches or tenses the masticatory muscles, the
EMG activity increases causing a louder audible
response. The patient is then instructed to relax, creating
a reduction in EMG activity that is reflected by a
lowering of the sound. The sensitivity of the machine is
increased gradually and the patient has to achieve a
greater state of relaxation to maintain or reduce the
JULY 1986 VOLUME 56 NUMBER 1
DIAGNOSIS AND TREATMENT OF MPD SYNDROME
audible feedback. The biofeedback is used for two
30-minute sessions each week for 6 weeks. The patient is
instructed to practice the relaxed state at home each
night for the same length of time. This therapy requires
continued practice to maintain the reduced muscle
activity. Patient response to biofeedback is generally
good as a feeling of self-control and positive motivation
becomes apparent.
Conditioned relaxation is similar to biofeedback in its
end result but differs in that the patient does not have the
benefit of a feedback indicator. This is actually an
advantage because the person does not become dependent
upon a machine to indicate relaxation, but instead
develops a definite awareness of how the state of
relaxation actually feels. The patients are taught to
contract and relax the various muscles of the body,
including the muscles of mastication, learning to appre-
ciate the contrast between the two states.
Conditioned relaxation can be taught by the clinician,
or the patient can learn it by using instructional audio-
cassette tapes. In the latter instance, the patient should
still have personal instruction initially to assure that the
instructions are understood.
The use of an altered state of consciousness to induce
relaxation, such as produced by hypnosis, transcendental
meditation (TM), and yoga, can also be useful in the
treatment of MPD syndrome. Although TM and yoga
can be self-taught, altered consciousness definitely
requires instruction from a trained hypnotherapist.
Hypnosis may not only aid in the reduction of tension,
but can also be used to eliminate parafunctional habits
such as fingernail biting, lip or cheek biting, and
bruxism
Anesthetic injections. The injection of local anesthet-
ics into the tender and painful areas in the masticatory
and cervical muscles has been used for diagnostic (estab-
lishing the source of the pain) and therapeutic (relieving
myospasm) purposes in patients with MPD syndrome.*
Essential in the use of this technique is a thorough
knowledge of the anatomy of the region to be injected.
The local anesthetic should not contain epinephrine or
other vasoconstrictors. The injection is done under
aseptic conditions and with the use of proper aspiration
technique. Generally, no more than 0.5 cc is injected in
each region. Care must be taken to avoid the main
branches of the facial nerve, and the patient should be
warned that a temporary (2 to 3 hour) paresis or
paralysis of some of the facial muscles may occur despite
all precautions.
If the diagnosis is correct, the local anesthetic injection
will relieve the pain and reduce the muscle spasm.
During this time, the mandible can be gently exercised to
stretch the muscles and improve mobility. Massage is
also helpful in producing muscle relaxation. The proce-
dure can be repeated several times within a week, if
THE JOURNAL OF PROSTHETIC DENTISTRY
effective; thereafter other, less invasive forms of treat-
ment such as ultrasound or cryotherapy should be used
to reduce the myospasm because too frequent injection
can be injurious to the muscle.6
Transcutaneous electrical nerve stimulation. The
use of transcutaneous electrical nerve stimulation
(TENS) is based on the concept that stimulation of the
cutaneous branches of the fifth nerve creates an inhibito-
ry effect on the trigeminal spinal tract nucleus and
thereby not only reduces awareness of pain but also
helps indirectly to induce muscle relaxat ion.:, Patients
are treated by placing the electrode directly over the area
of most discomfort (care in avoiding main branches of
the facial nerve will reduce the twitching effect). Thera-
py sessions last 30 minutes and should be repeated daily.
Patients can be taught to use portable units at home and
may then perform several treatments each day. Analge-
sics may be used to aid in further reducing periods of
discomfort between sessions.
Final explanation of the problem
When patients with MPD syndrome begin to show
improvement of their symptoms and have gained confi-
dence in the doctors ability to deal with their problem, it
is advisable to discuss with them the relationship
between stress and muscular pain-dysfunction symp-
toms. Five concepts should be presented to the patient in
this discussion. First, they must realize that MPD
syndrome is a psychophysiologic disease. Second, they
must be made to understand that this does not imply that
their symptoms are imaginary, but that psychologic
stress can cause physical disorders. The gastric ulcer is
another example of a psychophysiologic disease that is
easily understood by the patiem. Third, they must
understand that stress can be related to pleasant as well
as unpleasant life situations. Realizing this often makes
it easier for pa.tients to identify stress in their lives. It is
not essential that the clinician be told about the patients
problems; what is important is that the patient identifies
them and makes an effort to cope with them in a healthy
manner. Fourth, the patient should be told how stress
can result in centrally generated increases in muscle
activity and pa.rafunctional habits such ;IS clenching and
grinding of the teeth, and how this ieads to muscle
fatigue, spasm, pain, and dysfunction. Finally, patients
should be made aware that it may not be possible to
provide a permanent cure for the problem, but that they
can learn to manage it in a satisfactory manner by
controlling stress and by using the recommended forms
of simple therapy at the first sign of recurrent symp-
toms.
Psychologic counseling
Each indivilduals reaction to stress is related to the
state of his emotional health. Most pa.tients are able to
81
 LASKIN AND BLOCK

I I I 1
Phase I (24 wke) Phase cut therapy
Accurate diagnosis Final explanation
Initial explanation Symptoms eliminated Instructions for self-management
Home therapy Follow-up appointment
Medications

Symptoms persist

Symptoms eliminated
Continue home therapy and medications

I
Symptom,5 persist
L
I I I
Phase III (4-6 wks)
Continue home therapy and medications Symptoms eliminated
Reevaluate splint
Initiate physical therapy
Initiate relaxation therapy
I I

Symptomf persist

*I

1
Psychological
counseling
I 1
Consultation Referral to center

Fig. 2. Management of MPD syndrome.

understand the relationship of stress to physical illness,
can identify stressful situations in their lives, and are
able to cope effectively with these stresses once an
explanation has been provided. A few patients, however,
either are unable to recognize stressful conditions or are
unable to cope with them in an appropriate manner.
There are also some who have sufficient psychological
gain from their illness to consciously or unconsciously
not wish to get well. Such patients will be refractory to
all forms of treatment. Referral of these individuals to a
qualified psychologist or psychiatrist for counseling is in
order.29s30During this time, however, the dentist should
also continue treatment so that the patient does not get
the impression that the problem has only a psychological
component.
Specific treatment plan (Fig. 2)
Once a definitive diagnosis of MPD syndrome has
been made, the patient begins the first phase of therapy.
In mild cases this period, which can last from 2 to 4
weeks, involves an initial explanation of the problem and
the initiation of therapy at home. In more severe cases,
an analgesic drug and a muscle relaxant are added to the
regime. If the patient responds favorably, first the
analgesic and then the muscle relaxant are discontinued.
Depending on the history of when the symptoms are
worse, the drugs are initially decreased either at night or
during the daytime. Home therapy is also gradually
eliminated. The patient is given a full explanation
regarding suspected etiology of the problem and instruc-
tions for further self-management. The patient should be
told to return for care if symptoms recur and cannot be
quickly controlled by the previously used procedures. In
addition, a specific appointment for future follow-up
should be given.
If the initial therapy fails and reevaluation confirms
the original diagnosis and indicates that the patient has
been compliant, treatment is escalated to the second
phase, which consists of the introduction of a splint in
addition to continuation of the previous treatment
modalities. This phase can last as long as 4 weeks. If the
regimen is successful, medications are gradually reduced
and then stopped, and use of the splint is also gradually
eliminated. If the patients symptoms had been worse in
the morning upon awaking, the splint is now worn only
at night; if the symptoms had increased as the day
progressed, the splint is worn only in the daytime.
Unless the patient is engaging in excessive parafunction-

82 JULY 1966 VOLUME 56 NUMBER 1

DIAGNOSIS AND TREATMENT OF MPD SYNDROME
al activity while asleep, it should be possible to gradually
eliminate use of the splint entirely. Bruxism patients,
however, may need to continue using the splint indefi-
nitely in order to remain asymptomatic. Before dismiss-
al, the same instructions given to those successfully
managed in the first phase of treatment are given to these
patients.
Most patients will respond favorably to the second
phase of therapy; for those who do not, however, further
escalation of treatment is indicated. In the third phase of
treatment, which may last from 4 to 6 weeks, the splint
should be reevaluated to be sure that it has been properly
adjusted to the occlusion and that the correct vertical
opening has been established. If these procedures fail,
the anterior splint can be converted to provide full
occlusal coverage. Although the splint may not prevent
clenching, it does provide greater stability for the man-
dible. Physical therapy and relaxation therapy are
introduced, and home therapy and medications are
continued. If the symptoms subside, medications are
stopped first, then the physical therapy, and then the use
of the splint. Finally, the restrictions of home therapy
are discontinued, but the patient may need to continue
practicing his relaxation technique for an indefinite
period. The same final explanation and instructions
described for patients successfully treated in phase one
are given before dismissal.
If all of the previous approaches fail, and there is no
question about the diagnosis, psychologic counseling
should be recommended. If there is doubt about the
prognosis, the patient should first be referred for appro-
priate consultation and reevaluation. Possible consul-
tants may include the oral and maxillofacial surgeon, the
neurologist, and the otolaryngologist. Another alterna-
tive is to refer patients with recalcitrant MPD syn-
dromes to a TMJ center or pain clinic because they
generally require a multidisciplinary approach for suc-
cessful management.
SUMMARY
The successful management of patients with MPD
syndrome is dependent on establishing an accurate
diagnosis and using proper therapy based on an under-
standing of the etiology of the disorder. Establishing an
accurate diagnosis is accomplished by taking a careful
history, doing a thorough examination, and having a
knowledge of the various other conditions that can
produce signs and symptoms similar to those of MPD
syndrome. Using proper therapy is related to recognition
that MPD syndrome is a stress-induced psychophysio-
logic disease originating in the muscles of mastication
and not an organic disease arising in the temporomandi-
bular joint. Thus, therapy should be directed at reducing
stress, relaxing tense jaw muscles, and creating an
awareness by the patient of the causes of the problem,
THE JOURNAL OF PROSTHETIC DENTISTRY
rather than at analyzing occlusion, measuring joint
spaces, and producing irreversible structural changes in
the dentition and the articulation. Because good results
can be achieved with these uncomplicated, reversible
forms of therapy,3, 32it is important that the clinician
does not succumb to an unproven fad or use of an
irreversible procedure that will not achieve better
results.
REFERENCES
1. Laskin DM: Etiology of the pain-dvstunt ira,n ryndrorne. J Am
Dent Assoc 79:147, 1969.
2. Greene CS: Myofascial pain-dysfunction :;yndrome. lhe evolu-
tion of concepts. In Sarnat BG, Laskin Dhl, eds: The Temporo-
mandibular Joint, ed 3. Springfield. Ii! 1979, Charles C
Thomas, Pub], pp 277-288.
3. Yemm R: Tmemporomandibular dysfunction .md masseur muscle
response to (experimental stress. Br Dent J 127~508, 1969,
4. Yemm R: A comparison of the electrical actwitv of masseter and
temporal muscles of human wbjrrts durincr vxperimcntal stress.
Arch Oral Viol l&269, 1971.
5. Carlsson GE, Magnusson T, Wedel A. SCI wry of panents seen
at a department of Stomatognathlc Physiiv!oc?;v,Swed Dent J
69:115, 1976.
6. Butler JH. Folke LE, Brandt CL.: A desc->pi\e survry of signs
and symptoms associated with the myofasc~al pain-dvsfunction
syndrome. J Am Dent Assoc 9Oz62.5,f97!1.
7. Helms CA, Katzberg RW, Manzione JV: Computed tomogra-
phy. In Helms CA, Katzberg RW, Dolw:tk MF, eds: Internal
Derangements of the Temporomandibular Joint. San Francisco,
1983, Radiology Research and Education boundation.
8. Goldstein HA, Bloom CY: Detection of deqcnerative disease of
the temporomandibular joint bv bone stin~ircr,~phy. J Nwl Med
21:928, 1980.
9. Greene CS, Laskin DM: Meprobamate therapy for the myofas-
cial pain-dysfunction (MPD) syndromt: A double-blind walua-
tion. J Am Dent Assoc 82587, 1971
10. Greene CS. Laskin DM: Splint therap\ IOI thr myofascial
pain-dysfunction (MPD) svndromr I\ ~miwtalive study. J Am
Dent Assoc 84642, 1972.
11. Goodman P, Greene CS, Laskin DM: Response of patients with
myofascial pain-dysfunction syndrome to mock equilibration. J
Am Dent Assoc 92:755, 1976.
12. Dohrmann II, Laskin DM: An evaluation of rlcctromyographic
biofeedback in the treatment ot myofasri.-11 pain-dysfunction
syndrome. J Am Dent Assoc 96:656. 197?,.
13. Laskin DM, Greene CS: Influence of the doctor-patienr relation-
ship on placebo therapy for patient< wirh rnyofascial pain-
dysfunction (MPD) syndrome. J Am I !cn~ Assoc 85:892,
1972.
14. Greene CS: Myofascial pain-dysfunction syndrome: Nonsurgical
treatment. In Sarnat BG, Laskin DM, editors: The Temporo-
mandibular Joint. ed 3. Springfield. I I 1179, Charles C
Thomas, pub], pp 315-334.
15. Greene CS, Laskin DM: Therapeutic c-ltects of diazepam
(Valium) and sodium salicylate in myofw ial pain-dysfunction
(MPD) patients. 1972 (IADR abstr No. IQ?).
16. Gessel AH: Electromyographic biofeedback :md tricyclic antide-
pressants in myofascial pain-dysfunction syndrome: Psychologi-
cal predicators of outcome. J Am Dent Awrc 91:1048, 1975.
17. Kraus HT: Muscle tension and the trmpl)r~)mandibular joint. J
PROSTHET DENT 13:950. 1963.
18. Lehman .JF. De Lateur B~J, Warrw (r ;. Stonebridge JB:
83

Heating of joint structures by ultrasound. Arch Phys Med
Rehabil 49:28, 1968.
19. Eisen RG, Kaufman A, Greene CS: Evaluation of physical
therapy for MPD syndrome patients. J Dent Res 63(Special
issue):344, 1984.
20. Carlsson SG, Gale EN, ohman A: Treatment of temporomandi-
bular joint syndrome with biofeedback training. J Am Dent
Assoc 91:602, 1975.
21. Gessel AH, Alderman MM: Management of myofascial pain-
dysfunction syndrome of the temporomandibular joint by tension
control training. Psychosomatics 12:302, 1971.
22. Olson RE, Greene CS, Solar S: Comparison of two relaxation
methods for the treatment of MPD syndrome. J Dent Res
59(Special issue A):518, 1980 (Abstr No. 996).
23. Price A, Stallard RE: Hypnotic therapy for MPD. J Dent Res
55128, 1974 (Abstr No. 296).
24. Tarte JS, Spiegel H: The role of hypnosis in the treatment of
craniomandibular dysfunction. In Gelb H, editor: Clinical Man-
agement of Head, Neck and TMJ Pain and Dysfunction.
Philadelphia, 1977, WB Saunders Co, pp 401-442.
25. Travel1 JG, Simons DG: Myofascial pain and dysfunction: The
trigger point manual. Baltimore, 1983, Williams & Wilkins
co.
26. Benoit PW, Belt WD: Some effects of local anesthetic agents on
skeletal muscles. Exp Nemo1 34:264, 1972.
Discriminative ability of the TMJ Scale: Age and
gender differences
T. F. Lundeen, D.M.D., MS.,* S. R. Levitt, M.D., Ph.D.,** and M. W. McKinney,
University of North Carolina, School of Dentistry, and North
North Carolina Central University, Durham, N.C.
T he concept of a single TMJ syndrome of temporo-
mandibular joint disorder has been replaced with a series
of diagnostic categories such as internal derangements,
arthritic disorders, and muscle hyperactivity disorders.
These diagnostic categories need to be carefully defined
on the basis of clinical symptomatology and pathogene-
sis. A standardized assessment method is necessary to
make useful comparisons between the different disorders
as well as between different studies. Reliable and
proved testing methods that provide standardized and
*Associate Director, Pain Program, and Associate Professor, Depart-
ment of Operative Dentistry, University of North Carolina, School
of Dentistry.
**Clinical Assistant Professor, Department of Psychiatry, University
of North Carolina, School of Medicine, and Pain Resource Center,
Inc., Durham, N.C.
***Professor, Department of Public Administration, North Carolina
Central University, and Pain Resource Center, Inc., Durham,
N.C.
84
LASKIN AND BLOCK
27. Block SL, Laskin DM: The effectiveness of transcutaneous nerve
stimulation (TNS) in the treatment of unilateral MPD syn-
drome. J Dent Res 59(Special issue):519, 1980 (Abstr No.
999).
28. Gold N, Greene CS, Laskin DM: TENS therapy for treatment
of MPD syndrome. J Dent Res 62~244, 1983.
29. Pomp AM: Psychotherapy for the myofascial pain-dysfunction
(MPD) syndrome: A study of factors coinciding with remission. J
Am Dent Assoc 89:629, 1974.
30. Marback JJ, Dworken SF: Chronic MPD, group therapy and
psychodynamics. J Am Dent Assoc 90:827, 1975.
31. Greene CS, Laskin DM: Long-term evaluation of conservative
treatment of myofascial pain-dysfunction syndrome. J Am Dent
Assoc 89:1365, 1974.
32. Greene CS, Laskin DM: Long-term evaluation of conservative
treatment of myofascial pain-dysfunction syndrome: A compara-
tive analysis. J Am Dent Assoc 107:235, 1983.
Reprint requests to:
DR. DANIEL M. LASKIN
MEDICAL COLLEGE OF VIRGINIA
SCHWL OF DENTISTRY
Ph.D.***
Carolina Memorial Hospital, Chapel Hill, N.C., and
quantitative methods for patient assessment have been
developed in other disciplines, especially clinical psy-
chology. We have used these methods to develop a
diagnostic tool called the TM J Scale., *
The TM J Scale is a 974tem questionnaire developed
specifically for the assessment of TMJ disorders (Pain
Resource Center Inc., Durham, N.C.). The question-
naire produces scores on 10 clinically important symp-
tom scales associated with TMJ disorders. There are
five physical symptom scales, three psychosocial scales, a
non-TMJ disorder scale, and a global scale. The five
physical symptom scales include pain report, palpation
pain, malocclusion, joint dysfunction, and range of
motion limitation. The psychosocial scales include psy-
chologic factors, stress, and chronicity. The non-TMJ
scale is designed to detect the presence of other oral and
facial problems. The global scale is a general predictor of
the presence of a TMJ disorder. Each of the symptom
scales functions independently. The global scale was
JULY 1986 VOLUME 56 NUMBER 1